Evaluation and Management of Heart Failure
BETHESDA, MD -- Physicians now have more and better information
about heart failure to provide the most effective treatment
for the three million Americans who suffer from this condition,
say the American College of Cardiology (ACC) and the American
Heart Association (AHA). Heart failure is the end result of
other disorders, such as heart attack or high blood pressure,
that reduce the pumping power of the heart, thereby limiting
the amount of blood that can be circulated throughout the body.
The
two organizations have joined to provide information on the
newest advances and a consensus for the treatment of heart
failure in the report entitled "ACC/AHA Guidelines for the
Evaluation and Management of Heart Failure." The guidelines
appear in the November 1 issues of the Journal of the American
College of Cardiology and AHA's Circulation.
According
to John F. Williams, Jr., MD, chair of the heart failure guidelines
committee, "The development of these guidelines is significant
because of the frequency with which heart failure is encountered
and the often negative prognosis that awaits patients. However,
there is hope for those with heart failure because of recent
advances in the understanding of the causes of heart failure
and the new developments in therapy." Dr. Williams is the
director of Wishard Memorial Hospital in Indianapolis.
The
guidelines take into consideration that there is a spectrum
of diseases that contribute to heart failure, requiring different
management of various patient groups. Thesepatient groups
include those with diabetes, high blood pressure, narrowed
arteries, a history of heart attack, heart defects present
at birth, heart valve defects, and heart muscle damage. Evaluation
and management of acute heart failure (acute -- very serious,
high risk), chronic and stabilized acute heart failure (chronic
-- slow and stable progression of disease), and heart failure
in the fetus, infant, and child are each addressed separately
in the guidelines.
The
guidelines confirm that a drug commonly known as an ACE inhibitor
(angiotensin converting enzyme) is the cornerstone of treatment
for patients with heart failure due to reduced pumping power,
whether or not they are displaying symptoms. Nitrates and
other vasodilators (family of drugs that open up the arteries)
are recommended when ACE inhibitors are not tolerated. Because
patients with symptomatic heart failure are more likely to
retain sodium, a diuretic (promotes removal of water by the
kidneys) usually is indicated. The committee suggests that
the use of diuretics should be tailored to the symptoms of
each patient. Digoxin (increases pumping ability of the heart)
is recommended when the patient does not respond to maximally
tolerated doses of ACE inhibitors and diuretics, as well as
in patients with certain heart rhythm problems.
The
use of beta-blockers are also examined in the report, concluding
that the drugs, especially ones with combined beta-blocker
and vasodilator activity, are promising but should remain
investigational. Beta-blockers slow the heartbeat, decrease
the blood pressure, and reduce the contraction strength of
the heart. The committee recommends that physicians use beta-blockers
for the treatment of high risk, post-acute heart attack patients
if tolerated. In addition, the committee concluded that calcium
channel blockers generally are not of proven benefit to patients
with heart failure and may be harmful.
The
guidelines recommend that patients with acute heart failure
should most likely be hospitalized. Initial diagnostic testing
should be limited to those tests necessary to exclude underlying
causes that would require special therapeutic procedures.
Patients with acute heart failure and evidence of an acute
heart attack should be considered for urgent cardiac catheterization,
coronary arteriography and definitive interventional procedures.
If these procedures cannot be done immediately, clot-dissolving
drugs should be considered.
Also
outlined in the document is the treatment of the fetus, infant,
and child with heart failure, noting that the leading causes
of the condition are significantly different from those in
the adult. For example, unlike the adult, the causes of heart
failure in infancy are due largely to congenital (present
at birth) heart disease. The recommendations for the pediatric
group, therefore, are directed more to specific causes of
heart failure than for adults. Children with heart failure
differ from adults in two major ways: 1) there are maturational
differences that improve from early fetal gestation to the
adult, making the disorders of the cardiovascular system more
likely to have an effect on an immature individual, and 2)
there are congenital, structural, and genetic causes in the
fetus, infant, and child that are either modified by adulthood
or lead to early death.
"Like
all ACC/AHA guidelines," says Dr. Williams, "these are not
rigid requirements, but recommendations based on a comprehensive
review of scientific research. The committee was very aware
of cost implications and geographical limitations and considered
these in our deliberations. However, our primary goal was
to develop guidelines to assist physicians in delivering the
best care possible to those with heart failure."
The American College of Cardiology, a 23,000-member
nonprofit professional medical society and teaching
institution, is dedicated to fostering optimal cardiovascular
care and disease prevention through professional education,
promotion of research, leadership in the development
of standards and guidelines, and the formulation of
health care policy.
Copyright ©
1999 American College of Cardiology
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