CONTINUING EDUCATION An ARB may be added if the patient remains symptomatic on an ACE inhibitor and beta blocker. If an aldosterone receptor antagonist is not indicated, the combination of an ARB, ACE and aldosterone receptor antagonist can be harmful.6,8,9 Hydralazine and isosorbide dinitrate are used in combination in African Americans with NYHA II-IV and HFrFF already receiving GDMT with an ACE inhibitor and beta blocker.6,9 It may also be useful in combination in those who cannot tolerate ACE or ARB.6,9 Anticoagulants are used in chronic HF patients with permanent, persistent, paroxysmal atrial fibrillation and any risk for cardioembolic stroke. They are not recommended in patients with:
Device Therapy for Management of Heart Failure Sudden cardiac death (SCD) is a risk for those with HFrEF and systolic dysfunction due to ventricular tachyarrhythmias. An implantable cardioverter defibrillator (ICD) can be considered in patients receiving GDMT for at least three to six months. Expected survival with good functional status is at least one year.6 Repeated use of these devices can reduce health-related quality of life (HRQOL) leading to post-traumatic stress syndrome.6 Cardiac resynchronization therapy (CRT) can improve ventricular function due to increased QRS interval by: • Improving ventricular contractile function; • Diminishing secondary mitral regurgitation; and • Reversing ventricular remodeling.6
• HF (HFrEF) without AF; • A prior thromboembolic event; and • A cardoembolic source. The selection of anticoagulant should be individualized and based on risk, cost, tolerability, drug interactions, and personal preference.
As with ICD use, GDMT and diuretics to control fluid are essential.6 An ICD is recommended for primary prevention of sudden cardiac death (SCD) for some patients with HFrEF that are > 40 days post-MI who are receiving GDMT with: • LVEF < 35 percent; NYHA class II or III with greater than one-year life expectancy; or
The I(f ) channel inhibitor, ivabradine, may benefit those hospitalized with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF < 35 percent) who are: • Receiving GDMT with a beta blocker at maximum tolerated dose; and • In sinus rhythm with a heart rate of > 70bpm at rest.9 Digoxin may be of benefit to decrease hospitalizations and improve symptoms in some.6,9 Omega -3 fatty acids have also been cited for use in both HFrEF and HFpEF to reduce mortality and cardiovascular events. Statins are of no benefit if exclusively HF, nor are hormonal therapies.6,9 For patients that present with HFpEF, the pathway is not as clear. Control of hypertension using beta blockers, ACE inhibitors, or ARB – as well as use of diuretics to alleviate symptoms and manage fluid overload are the first line of defense.6,9 Coronary revascularizations may be done in patients with coronary artery disease (CAD) and angina symptoms (e.g., chest pain and shortness of breath) or with myocardial ischemia causing characteristic HFrEF and management of atrial fibrillation (AF).6,9 Aldosterone receptor antagonists can be considered in some patients with EF ≥ 45 percent, elevated BNP levels HF hospital admission within the year, and glomerular filtration rate > 30 mL/min. ARB may be used to decrease hospitalizations.6,9 Nitrates, unless HF was accompanied by symptomatic CAD, did not improve quality of life or activity.6,9 Use of phosphodiesterase-5 inhibitors (e.g., sildenafil, vardenafil) did not improve quality of life or activity either, and nutritional supplements were shown to be of no benefit.6,9
• LVEF < 30 percent, NYHA class I with greater than one year life expectancy.6 ICD placement may not prolong survival in an unstable patient, those with frequent hospitalization, or frailty and comorbidities such as renal issues or malignancies.6 Cardiac resynchronization therapy (CRT) is indicated in those who are receiving GDMT with: • LVEF < 35 percent; • Sinus rhythm; • Left bundle branch block (LBBB) with a QRS duration of >150 ms and NYHA class II or III or ambulatory class IV6
CRT may be used in those who are receiving GDMT with: • LVEF < 35 percent; • Sinus rhythm; • Non-left bundle branch block with QRS duration >150 ms and NYHA class III/ambulatory class IV 6
or • LVEF < 35 percent; • Sinus rhythm; • Left bundle branch block with a QRS duration 120-149 ms; and NYHA class II or class III or ambulatory class I6 or • Patients with AF and LVEF < 35 percent; • Needing ventricular pacing; and • Atrioventricular nodal ablation or medication for rate control to provide ventricular pacing.6 or
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