[CRT-FORUM] 19E Management for heart failure. Dr. Perez Riera

[CRT-INFO]

Dear Colleague Antonio Triana from Cuba:
In HF treatment we have several approaches: Diet and lifestyle measures,
pharmacologica approach, devises, and surgeries.

I) DIET AND LIFESTYLE MEASURES
1) Physical activity, Moderate when symptoms are mild or moderate; or
bed rest when symptoms are severe.
2) If sleep apnea is identified, treat with CPAP, BiPAP, dental
appliances or surgery. Sleep apnea is an under recognized risk factor for HF
3) Weight reduction – through physical activity and dietary
modification, as obesity is a risk factor for HF and LVH.
4) Monitor weight - this is a parameter that can easily be measured at
home. Rapid weight increase is generally due to fluid retention.
5) Sodium restriction – excessive sodium intake may precipitate or
exacerbate HF, thus a "no added salt" diet (60–100 mmol total daily intake)
is recommended for patients with CHF. More severe restrictions may be
required in severe CHF.
6) Fluid restriction – patients with CHF have a diminished ability to
excrete free water load. Hyponatremia frequently develops in decompensated
heart failure due to the effects of excess circulating neuroendocrine
hormones. While the activation of the renin-angiotensin-aldosterone axis due
to decreased renal perfusion promotes both sodium and water retention, the
activation of atrial natriuretic peptide due to atrial stretch favors sodium
excretion, and the activation of antidiuretic hormone due to peripheral
baroreceptors that sense hypotension as well as due to the activation of the
sympathetic nervous system favors water retention alone, leading to
disproportionately more water retention than sodium retention. The severity
of the hyponatremia during an episode of decompensated heart failure can be
predictive of mortality. Generally water intake should be limited to 1.5 L
daily or less in patients with hyponatremia, though fluid restriction may be
beneficial regardless in symptomatic reduction.

II) PHARMACOLOGICA APPROACH. They include:
1) Angiotensin-converting enzyme (ACE) inhibitors
2) Angiotensin II (A-II) receptor blockers (ARBs).
3) Beta blockers: mainily carvedilol
4) Positive inotropes: Digoxin, phosphodiesterase inhibitors,
dobutamine.
5) Loop Diuretics: furosemide, bumetanide.
6) Aldosterone antagonists. spironolactone (Aldactone) and eplerenone
(Inspra).
7) Thiazide diuretics (e.g. hydrochlorothiazide, chlorthalidone,
chlorthiazide) – may be useful for mild CHF, but typically used in severe
CHF in combination with loop diuretics, resulting in a synergistic effect.
8) BiDil medication: is a single pill that combines hydralazine and
isosorbide dinitrate — both of which dilate and relax the blood vessels.
BiDil increases survival when added to standard therapy in black people with
advanced heart failure. This is the first drug studied and approved for a
specific racial group.
9) Recombinant neuroendocrine hormones Nesiritide, a recombinant form
of B-natriuretic peptide, is indicated for use in patients with acute
decompensated HF who have dyspnea at rest. Nesiritide promotes diuresis and
natriuresis, thereby ameliorating volume overload. It is thought that, while
BNP is elevated in HF, the peptide that is produced is actually
dysfunctional or non-functional and thereby ineffective. Extreme caution is
required when using nesiritide in patients with both HF and concurrent
morbidities such as renal dysfunction.

III) DEVISES
Implantable cardioverter-defibrillators (ICDs).
Cardiac resynchronization therapy (CRT) or biventricular pacing.
CRT combined with an ICD to shock a person out of life-threatening
arrhythmias, such as VT /VF. The worse the left ventricle, the higher the
risk for sudden death secondary to these arrhythmias.
Left ventricular assist devices (LVADs).Another current treatment involves
the use of LVADs are battery-operated mechanical pump-type devices that are
surgically implanted on the upper part of the abdomen. They take blood from
the LV and pump it through the aorta. LVADs are becoming more common and are
often used by patients who have to wait for heart transplants.
Enhanced external counterpulsation (EECP). This noninvasive technique has
been used as a treatment for heart-related chest pain, and researchers are
studying this treatment to see if it's beneficial for people with heart
failure. Inflatable pressure cuffs are placed on the calves, thighs and
buttocks. These cuffs are inflated and deflated in sync with your heartbeat.
The theory is that EECP increases blood flow back to the heart
The Acorn CorCap Mesh-like constraint devices such as aim to improve
contraction efficacy and prevent further remodeling. Clinical trials are
underway.
Myosplint device Another technique which aims to divide the spherical
ventricle into two elliptical halves

IV) SURGERIES
1) LV remodeling: The aim of the procedures is to reduce the LV diameter
(targeting Laplace's law and the disease mechanism of HF), improve its shape
and/or remove non-viable tissue. These procedures can be performed together
with:
2) Mitral Valve repair

3) Valve replacement

4) Coronary artery bypass

5) Partial left ventriculectomy or Batista procedure.

6)Two-directional cavopulmonal anastomosis (TDCPA) for the surgical
treatment of congenital heart failure (CHF) in certain complex forms of CHF
and in patients at risk of poor outcome of Fontan surgery may be used as the
final stage of hemodynamic correction.

7) Orthoptic heart transplantation: PROGNOSIS: the prognosis for heart
transplant patients following the orthotopic procedure has greatly increased
over the past 20 years, and as of May 30, 2008, the survival rates were as
follows
1 year: 87.5% (males), 85.5% (females)
3 years: 78.8% (males), 76.0% (females)
5 years: 72.3% (males), 67.4% (females)

8 Heterotopic procedure: the patient's own heart is not removed before
implanting the donor heart. The new heart is positioned so that the chambers
and blood vessels of both hearts can be connected to form what is
effectively a 'double heart'. The procedure can give the patients original
heart a chance to recover, and if the donor's heart happens to fail (eg.
through rejection), it may be removed, allowing the patients original heart
to start working again. Heterotopic procedures are only used in cases where
the donor heart is not strong enough to function by itself (due to either
the patients body being considerably larger than the donor's, the donor
having a weak heart, or the patient suffering from pulmonary hypertension).

9) Cardiomyoplasty is a surgical procedure in which healthy muscle from
another part of the body is wrapped around the heart to provide support for
the failing heart. Most often the latissimus dorsi muscle is used for this
purpose. A special pacemaker is implanted to make the skeletal muscle
contract.

All the best
Andrés Ricardo Pérez Riera MD chief of electrovectorcardiology sector ABC
Faculty of Medicine (FMABC), Discipline of Cardiology, Foundation of ABC
(FUABC), Santo André, São Paulo, Brazil.
> What is the current management for heart failure?
>
> "antonio triana" <atriana at infomed.sld.cu>
> Cuba
>


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee