Treating Heart Failure Patients

Over the last 10 years, the therapeutic approach to Heart Failure (HF) has undergone considerable change. The objective of current treatment strategies is not only for symptomatic improvement, but to focus increasingly on preventing the transition of asymptomatic cardiac dysfunction to symptomatic heart failure, modulating progression of heart failure and reducing mortality.² The important point, however, is that treatment of HF is most effective when prescribed at an early stage.⁴

Up to one-third of patients with nonischemic cardiomyopathy complain of chest pain, which may suggest angina or may be atypical in nature. Because coronary revascularization would play a role in the management of these patients if their chest pain were related to the presence of coronary artery disease, coronary angiography is generally recommended in these circumstances to define the presence or absence of large vessel coronary obstruction. ¹

Studies have shown that coronary artery bypass grafting has been shown to improve symptoms and survival in patients with HF and angina, although patients with severe symptoms of HF or markedly reduced ejection fractions were not included in these trials. However, these controlled trials have not addressed the issue of whether coronary revascularization can improve clinical outcome in patients with HF who do not have angina.¹

Because revascularization is recommended in individuals with ischemic chest pain regardless of the degree of ischemia or viability, there would be appear to be little role for noninvasive cardiac testing in such patients. Clinicians should proceed directly to coronary angiography in patients with angina and impaired ventricular function.¹

One-third of patients with HF due to left ventricular dysfunction have normal coronary arteries on coronary angiography and in such individuals, myocardial disorders are responsible for the development of cardiomyopathy. While most patients with a cardiomyopathy have no identifiable causative factor (i.e., idiopathic dilated cardiomyopathy), the cardiomyopathy in some patients is related to:¹

• A systemic disorder (e.g., hyperthyroidism, hemochromotosis or hypocalcemia)
• Exposure to a cardiotoxic agent (alcohol, cocaine, anthracycline, or trastuzumab)
• Presence of myocardial inflammation or infiltration (which can be diagnosed with endomyocardial biopsy)

For more information on treating specific stages of heart failure, click on the following topics:
Patients at High Risk for Developing Left Ventricular Dysfunction (Stage A)
Patients with Left Ventricular Dysfunction Who Have Not Developed Symptoms (Stage B)
Patients With Left Ventricular Dysfunction With Current or Prior Symptoms (Stage C)
Patients with Refractory End-Stage HF (Stage D)

References