Heart failure guidelines : strategies for implementation

A 50-year-old man is evaluated during a routine follow-up office visit for heart failure, which was diagnosed 1 year ago. A stress test at the time of diagnosis was negative for ischemia. At his most recent evaluation 4 months ago, an echocardiogram showed left ventricular enlargement and hypertrophy, a left ventricular ejection fraction of 40%, and no significant valvular disease. An electrocardiogram was unchanged, showing left ventricular hypertrophy but no evidence of previous myocardial infarction. The patient is currently asymptomatic, and his medications are hydrochlorothiazide and lisinopril.

On physical examination, heart rate is 85/min and blood pressure is 135/85 mm Hg. There is no jugular venous distention or peripheral edema. The lungs are clear. There is a soft S4 but no murmur.

Which of the following medications should be added to the patient's regimen?
A Carvedilol
B Digoxin
C Diltiazem
D Losartan
E Spironolactone

Key Points
* An angiotensin-converting enzyme inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients with low ejection fractions.
* Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.

Answer and Critique (Correct Answer = A)

Treatment with an angiotensin-converting enzyme (ACE) inhibitor and a β-blocker is indicated for all patients with any degree of systolic heart failure, including this asymptomatic patient with a low ejection fraction, because treatment with both agents has been shown to reduce morbidity and mortality.

Losartan, an angiotensin-receptor blocker (ARB), is an acceptable alternative in a patient who cannot tolerate an ACE inhibitor, but there is no benefit to adding an ARB to an ACE inhibitor. Calcium-channel blockers are indicated in patients with heart failure who have hypertension or angina that is not adequately controlled with an ACE inhibitor or β-blocker. First-generation calcium-channel blockers, such as nifedipine, diltiazem, and verapamil, cause a reactive increase in sympathetic activity in response to peripheral vasodilatation and negative inotropic effects, whereas second-generation calcium-channel blockers, such as amlodipine, are more vasoselective, less cardiodepressant, and do not appear to have a deleterious effect on outcome in patients with heart failure. Spironolactone and digoxin are not indicated for patients with asymptomatic systolic heart failure. Spironolactone reduces mortality in patients with severe symptomatic heart failure (New York Heart Association class III or IV) and a left ventricular ejection fraction ≤35%. Digoxin alleviates symptoms and reduces hospitalizations related to heart failure, but has not been shown to reduce mortality.
Bibliography

1. O’Connor CM. The new heart failure guidelines: strategies for implementation. Am Heart J. 2007;153:2-5. [PMID: 17394896]

Systolic Heart Failure

A 58-year-old man is evaluated in the office for a 3-month history of shortness of breath with exertion. He has a 10-year history of hypertension and type 2 diabetes mellitus but no history of coronary artery disease. His medications are extended-release metoprolol, aspirin, metformin, and atorvastatin.

On physical examination, blood pressure is 165/92 mm Hg and heart rate is 88/min. Jugular venous pressure is 10 cm H2O. Bibasilar crackles are present, cardiac rhythm is regular, and an S3 is present. Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy. Laboratory test results include potassium of 4.2 meq/L and creatinine of 1.0 mg/dL. An echocardiogram is ordered, and furosemide is prescribed.

The patient returns the following week with resolution of his symptoms. His blood pressure at this visit is 130/78 mm Hg, his heart rate is 65/min, jugular venous pressure is 4 cm H2O, lungs are clear, and the S3 is absent. The echocardiogram shows left ventricular hypertrophy, reduced systolic function, and inferior wall hypokinesis.

Which of the following is the most appropriate medication change at this time?
A Change metoprolol to carvedilol
B Start digoxin
C Start lisinopril
D Start spironolactone

Key Point
Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.

Answer and Critique (Correct Answer = C)

Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of the level of the ejection fraction or functional status unless there are contraindications (including hyperkalemia, acute renal failure, or a history of angioedema).

Sustained-release metoprolol and carvedilol are both approved for heart failure treatment in the United States. Currently, there is no definitive evidence indicating whether one is better than the other for the treatment of heart failure. Digoxin improves symptoms and reduces hospitalizations for patients with heart failure but is not indicated for patients with asymptomatic heart failure in the absence of other indications (such as rate control for atrial fibrillation). Spironolactone is indicated for patients with heart failure who have severe symptoms (New York Heart Association class III or IV).
Bibliography

1. Dagenais GR, Pogue J, Fox K, Simoons ML, Yusuf S. Angiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet. 2006;368:581-8. [PMID: 16905022]