Heart Failure: Principles of Treatment

Patients who get a heart attack must seek treatment as early as possible
Heart Failure: Principles of Treatment
"HF also leads to repeated hospitalisation and each hospitalisation is a burden on the society besides making the patient sicker and closer to eventual death."File/ GK

Heart failure (HF) is a common medical problem seen at all ages. Elderly people are more prone to it. Heart failure means inadequate pumping functioning of the heart. It leads to congestion in the lungs because of pooling of blood which translates into cough and shortness of breath.

In advanced cases subject is unable to walk but in early cases there is limitation like inability to climb stairs etc because of shortness of breath. The reduced output of blood which supplies nutrients to the body including muscles leads to fatigue, weakness and lassitude.

HF also leads to repeated hospitalisation and each hospitalisation is a burden on the society besides making the patient sicker and closer to eventual death. Heart failure is also a common cause of sudden death because of heart rhythm becoming chaotic.

Commonest cause of heart failure is following a heart attack (myocardial infarction). This leads to reduction in loss of muscle and which results in a lowering of left ventricular ejection fraction (LVEF). The normal LVEF is more than 50%. Patients with LVEF less than 40% are those with systolic heart failure.

The symptoms of these patients are very variable from mild to severe. All of them need aggressive treatment to keep them going with minimal symptoms, prevent hospitalization and death.

Despite several advances in managing heart failure the mortality continues to be un acceptably high. It is 10% for hospitalised patients. 20-25% at the end of 1 year after diagnosis and 42 -50% at the end of 5 years.

The burden of heart failure in the community is huge. According to a conservative estimate at least 1 % of the population has HF. This would mean at least 1- 1.5 lack patients in our UT and 13 – 15 lack patients in India.

Advances in treatment:

We have come a long way since the days of digitalis and water pills and injections which was the only thing available till 1986, when a ray of hope began with an American Veterans Administration Trial (VAHFT) showing that a drug combination of Hydralazine and isosorbide di-nitrate improved the survival modestly.

The real advances in the drug treatment came with the studies showing the beneficial role of angiotensin receptor blocking drugs like Enalapril in improving the survival. This group of drug has been consistently being used and improvements lead to the development of agents like VYMADA (Angiotensin receptor neprilysin inhibitors , ARNI).

This was followed by the demonstration that beta blocking drugs like metoprolol and carvedilol were also very useful in reducing the mortality by up to 30%. This development happened in 1996 and is a very well accepted therapy now.

Another drug called Spironolactone (Aldactone) was introduced over and above the previously mentioned therapies to further reduction in mortality in 1999.

Recently a group of drugs used in treating diabetes by eliminating sugar through urine (Sodium-Glucose Linked Transport-2 inhibitors) has been shown to further improve the survival. These drugs named: Dapagliflozin and empagliflozin are available easily in markets under prescriptions.

Recently another drug belonging to a different group (Guanylate cyclase stimulator) VERICIGUAT has been made available in Europe and USA. It should come to Indian markets soon. It has been shown to reduce hospitalizations in patients with HF.

Associated Problems and Device Therapies:

At least one third of patients with HF have associated problems like left bundle branch block (LBBB) in ECG which further deteriorates the functioning of heart. In addition, patients with LVEF < 35% are prone to cardiac arrest leading to sudden death.

All of them are candidates for implantation of an implantable defibrillator which recognizes and delivers a shock to revive the patient immediately after a cardiac arrest. Patients who additionally have LBBB need a special device which in addition to ICD need a resynchronization device to improve the heart function (CRTd).

Given the magnitude of the problem, providing these devices can be a big financial burden and even developed countries find it very difficult to cope with.

Surgical procedures are only recommended in patients with valve related problems and are usually high risk unless done early in the natural course of disease.

Four Pillars of Heart Failure Management

Besides the general measures of heart failure treatment like bed rest, limited activities, salt and fluid restriction the drug management is extremely important.

These drugs need to be started early and within 4 weeks all eligible patients should be on the 4 classes of drugs. (ACEI/ARNI, Beta Blockers, SGLT2 inhibitors and Aldosterone antagonists).

With the availability of the 5th drug Vericiguat the quality of life of these sick patients and their needing admissions would further come down.

How to Prevent Heart failure:

Seeing the dismal future for patients once having acquired HF the preventive measures assume prime importance. The modifiable risk factors of HF are; Smoking, High blood pressure, High bad cholesterol levels, high blood pressure, Diabetes and Obesity.

Recognizing these factors early and getting effective treatment is the key. Besides a good life style from young ages, reducing stress, adequate sleep, healthy diet rich in fruits and vegetables and regular exercise as a habit go a long way to keep the heart healthy.

Patients who get a heart attack must seek treatment as early as possible. Gauri Kaul Foundation has a mission: NO HEART ATTACKS-2025”. It is an effort in this direction.

Tailpiece:

Heart Failure is a common problem especially in elderly population with a poor prognosis, about 50% dying within 5 years of its diagnosis. Prevention is the key; by having a good active life style from young ages and getting treatment for the causative factors early.

There have been several developments in the drug and device-based treatments. These developments however can improve the survival only modestly and reduce need for frequent hospitalisation.

Best thing thus is to avoid getting it or at least postpone it by several decades.

Prof Upendra Kaul Founder Director Gauri Kaul Foundation, Recipient of Padma Shri and Dr B C Roy Award

Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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