Many therapies can be effective, but care must be individualized.
Modern treatments for heart disease have saved many people. Some of them, however, now live with heart failure—a heart that does not function well. Blood from the body is constantly returning to the heart and then being pumped out to the body. A “failing” heart either resists the inflow of blood, struggles to pump it out, or both.
About half of people with heart failure have an impaired pump, meaning one or both of the heart’s larger chambers, the ventricles, eject only a fraction of the blood that they should during each heartbeat. This is called a low ventricular ejection fraction (EF). Fortunately, medications and devices can help many people with this form of heart failure enjoy a good quality of life for many years.
“When I started a heart failure clinic 30 years ago, few patients lived more than five years, and most patients with advanced heart failure died within two years. Now, I see patients with advanced heart failure living 20 years,” says Dr. Lynne Warner Stevenson, a heart failure specialist at Harvard-affiliated Brigham and Women’s Hospital.
Multiple clinical trials have identified the most effective therapies in controlling symptoms and preventing death. But because these trials are performed in carefully controlled populations, not all therapies work for everyone. Dr. Stevenson says two main medication families are known to be widely effective for heart failure with low EF, with additional medications and heart rhythm devices being useful in certain people.
As the heart relaxes between beats (diastole), the right (R) and left (L) ventricles fill with blood. When it contracts (systole), it pushes out most—but not all—of the blood that filled the ventricles.
Cornerstones of therapy
ACE inhibitors or ARBs, plus beta blockers. These drugs reduce stress hormones that can cause further weakening of the heart muscle and disease progression. They also decrease the amount of work required for the heart to pump effectively.
“Everyone with low EF should be on both medications, if they can tolerate them. Starting these drugs early will prolong the phase of their disease in which they feel good and have good quality of life. However, many patients do not tolerate these drugs in the high-dose combinations used in clinical trials,” says Dr. Stevenson. For example, ACE inhibitors and ARBs can cause a dry cough, while beta blockers can make some people feel drowsy.
If you have fluid retention
Diuretics. Diuretics such as furosemide and torsemide help the body eliminate excess fluid that can cause swelling or shortness of breath. Although the reasons why heart disease impairs the body’s ability to maintain fluid balance are complex, most people who require a diuretic need it indefinitely. “This is one of the most important drugs to individualize, since the optimal dose can vary from 10 milligrams [mg] to 400 mg a day, depending on how well the kidneys are working,” says Dr. Stevenson.
Additional drugs to consider
Hydralazine-nitrate. This combination of blood pressure–lowering medications can be added when someone taking an ACE inhibitor or ARB plus a beta blocker continues to have severe symptoms. The combination was studied extensively in African Americans with heart failure, many of whom experienced increased survival and quality of life and a decrease in the number of hospitalizations. Since that time, it has proved useful in people of other races.
Eplerenone or spironolactone. These agents primarily decrease the formation of abnormal fibers that make the heart stiffer and less elastic, although they also help eliminate excess fluid. People who take these drugs are at higher risk for developing very high potassium levels, which can be fatal. Kidney function must be carefully reviewed before either agent is prescribed, and both kidney function and potassium levels must be monitored during therapy.
Useful in specific cases
Cardiac resynchronization therapy (CRT). Sometimes called biventricular pacing, CRT is very useful in hearts with a specific electrical pattern that indicates poorly coordinated contractions of the left and right sides of the heart, which may worsen heart failure symptoms. CRT synchronizes the contractions of the right and left ventricles for optimal pumping power. CRT has a modest effect on survival, decreases hospitalizations, and greatly increases quality of life for these people. “This device-based therapy is truly a remarkable step forward, and the only therapy we can offer that makes more than half of patients feel better almost immediately,” says Dr. Stevenson.
Implantable cardioverter-defibrillator (ICD ). ICDs provide a lifesaving shock to prevent cardiac arrest when a heart rhythm becomes dangerously fast and erratic. In people with heart failure who have survived a cardiac arrest, an ICD offers substantial benefits for survival and peace of mind. For prevention of sudden death in people who have not had a near-fatal rhythm disturbance, ICDs offer a modest but significant survival benefit in some, but with consequences in others.
“If you give 100 people with heart failure an ICD and monitor them for five years, seven will be saved by the ICD, 30 will have died anyway, 10 will have received a shock they didn’t need, and 10 will have had a problem with the lead that required surgery or hospitalization,” says Dr. Stevenson.
In addition, the device must be turned off in people who develop a terminal disease in order for them to have a peaceful, comfortable, dignified death.
“If you are 80 years old with heart failure, I would generally not encourage you to get an ICD. Unless you have already survived a cardiac arrest, it is not very likely to prolong your life, and can cause complications,” she says.
Share the decision
If you have heart failure with low EF, choosing the treatments that are right for you is something you and your doctor should do as a team.
“When it comes to individualizing medications and devices, everyone is different. Not everyone wants or can tolerate every therapy. Make sure your life goals guide your care,” says Dr. Stevenson.
“Our job is to make good decisions based on clinical trial data and individualize them through our own experience and by listening to what each patient wants. That’s why we call medicine an art,” she says.