Treatment of Chronic Heart Failure aims to relieve symptoms, to maintain a euvolemic state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e.g.spironolactone).
ACE inhibitor therapy is recommended for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure.ACE inhibitors improve symptoms, decrease mortality and reduce ventricular hypertrophy. Angiotensin II receptor antagonist therapy,particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy.
Diuretic therapy is indicated for relief of congestive symptoms. Several classes are used, with combinations reserved for severe heart failure:
* Loop diuretics (e.g. furosemide) – most commonly used class in CHF, usually for moderate CHF.
* Thiazide diuretics (e.g. hydrochlorothiazide) – may be useful for mild CHF, but typically used in severe CHF in combination with loop diuretics, resulting in a synergistic effect.
* Potassium-sparing diuretics (e.g.Spironolactone) – used first-line use to correct hypokalaemia.
As with ACEI therapy, the addition of a β-blocker can decrease mortality and improve left ventricular function. Several β-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, nebivolol and extended-release metoprolol.
Digoxin (a mildly positive inotrope and negative chronotrope), once used as first-line therapy, is now reserved when the adequate control is not achieved with an ACEI, a beta blocker and a loop diuretic.There is no evidence that digoxin reduces mortality in CHF, although some studies suggest a decreased rate in hospital admissions.It is contraindicated in cardiac tamponade and restrictive cardiomyopathy.
