You can do more to slow the progression of heart failure

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Applied Evidence

You can do more to slow the progression of heart failure

J Fam Pract. 2009 March;58(3):122-128

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References

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2. Lloyd-Jones DM, Larson MG, Leip EP, et al. Framingham heart study. Lifetime risk for developing congestive heart failure. Circulation. 2002;106:3068-3072.

3. Burt CW, Schappert SM. Ambulatory care visits to physicians offices, hospital outpatient departments, and emergency departments: United states, 1999-2000. Vital Health Stat 13. 2004;157:1-70

4. Levit K, Stranges E, Ryan K, et al. HCUP facts and figures, 2006: Statistics on Hospital-based Care in the United States. Rockville, MD: Agency for Healthcare Research and Quality, 2008. Available at: http://www.hcup-us.ahrq.gov/reports.jsp. Accessed February 9, 2009.

5. Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels–Nomenclature and Criteria for Diagnosis. 6th ed. Boston: Little, Brown and Company; 1964.

6. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation. 2005;112:e154-e235.

7. Doust J, Lehman R, Glasziou P. The role of BNP testing in heart failure. Am Fam Physician. 2006;74:1893-1898.

8. Maisel A, Krishnaswamy P, Nowak R, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161-167.

9. Maisel AS. B-type natriuretic peptide (BNP) levels: diagnostic and therapeutic potential. Rev Cardiovasc Med. 2001;2(suppl 2):S13-S18.

10. Dao Q, Krishnaswamy P, Kazanegra R, et al. Utility of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol. 2001;37:379-385.

11. Philbin EF, Rocco TA, Jr, Lindenmuth NW, et al. Systolic versus diastolic heart failure in a community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors. Am J Med. 2000;109:605-613.

12. Piepoli MF, Flather M, Coats AJ. Overview of studies of exercise training in chronic heart failure: the need for a prospective randomized multicentre European trial. Eur Heart J. 1998;19:830-841.

13. Coats AJ, Adamopoulos S, Meyer TE, et al. Effects of physical training in chronic heart failure. Lancet. 1990;335:63-66.

14. Feldman RD, Zou G, Feagen BG, et al. The STITCH Investigators. The Simplified Treatment Intervention to Control Hypertension (STITCH) trial: A cluster randomized controlled trial of a step-care algorithm using initial fixed dose combination therapy for the management of hypertension. Presented at Scientific Sessions 2007 of the American Heart Association, November 4-7, 2007; Orlando, Fla.

15. Chobanian A, Bakris G, Black H, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Hypertension. 2003;42:1206-1252.

16. Brookes L. Hypertension highlights: new drug algorithms, new drug approvals, new drugs. Available at: http://canadiancpd.medscape.com/viewarticle/568786_print. Accessed January 27, 2009.

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18. Vantrimpont P, Rouleau JL, Wun CC, et al. For the SAVE Investigators. Additive beneficial effects of beta-blockers to angiotensin converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) study. J Am Coll Cardiol. 1997;29:229-236.

19. Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289:1652-1658.

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22. The ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547-1559.

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Early interventions: Get patients moving

For all patients with stable HF—and those at high risk of developingit—behavioral modification is a key component of treatment. Lifestyle intervention should be directed at weight loss and diet, including control of salt intake; increased physical activity; and smoking cessation.

FAST TRACK

Diagnostic testing for HF may include a 12-lead electrocardiogram, echocardiography, and a posterior-anterior/lateral chest x-ray.

Don’t shy away from exercise. Although many physicians hesitate to prescribe exercise to patients with HF, physical activity should be a routine recommendation for all but the most debilitated patients.⁶ Regular exercise has been shown to decrease symptoms, increase functional capacity, and improve the quality of life, with benefits comparable to those of pharmacotherapy.^6,12,13

Studies of the beneficial effects of exercise were based on sustaining 40% to 70% of maximum capacity for 20 to 45 minutes, 3 to 5 days a week.⁶ A good walking program—of at least 30 minutes 4 to 5 days each week—should not be difficult for patients to maintain.

BP treatment guidelines: The old and the new

As noted earlier, controlling hypertension is crucial, not only to prevent HF but to attenuate its progress. But blood pressure management is suboptimal in the United States, with many patients failing to achieve recommended levels of pressure reduction. It’s been suggested that the complexity of standard treatment guidelines may be part of the problem.

STITCH step care is a newer option. Researchers designed the Simplified Treatment Intervention to Control Hypertension (STITCH) Trial, a cluster randomized study of patients at multiple family medicine clinics in Canada, to evaluate whether a simplified step-care algorithm would yield better results.

The STITCH algorithm has 4 treatment steps:

Step 1: Initiate therapy by pairing a diuretic with either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).

Step 2: Increase combination therapy to the highest dose tolerated.

Step 3: Add a calcium channel blocker and increase to the highest tolerated dose.

Step 4: Add a non-first-line antihypertensive agent (alpha-blocker, beta-blocker, or spironolactone).

Researchers found that after 6 months, 64.7% of patients on the STITCH protocol had achieved target blood pressure, compared with 52.7% of those whose treatment was based on the Canadian Hypertension Education Program (CHEP) guidelines (P=.03).¹⁴ The CHEP protocol is similar to that of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7);¹⁵ both offer numerous options for initial treatment.¹⁶

In presenting the STITCH results at the 2007 annual meeting of the American Heart Association, the lead author described the use of a simple step-care approach as “an important way forward in the treatment of hypertension [which] may be a paradigm for managing a range of chronic diseases.”¹⁶ Yet the STITCH algorithm has yet to be widely embraced; outside of the research community, most US physicians are relying on the JNC 7 guidelines.

FAST TRACK

Only 3 beta-blockers are approved for use in patients with HF in the United States: bisoprolol, carvedilol, and metoprolol succinate.

ACC/AHA recommendations indicate that for patients at stage A—that is, those with conditions strongly associated with, and at high risk for, HF—management of hypertension should conform to national standards such as JNC 7. The JNC 7 guidelines recommend the use of a thiazide diuretic as the initial drug of choice for patients with essential hypertension. For those with diabetes, ACE inhibitors and ARBs are the first-line antihypertensive agents of choice.

Glucose control is also essential for stage A patients with diabetes. Treatment of lipid disorders and pharmacotherapy for metabolic syndrome are also recommended for stage A patients, as needed.

Treatment escalates as HF progresses

ACE inhibitors, ARBs, and beta-blockers are the preferred pharmacologic interventions for patients at stage B—those who have structural heart disease strongly associated with HF but are not yet symptomatic. Anyone who has had a myocardial infarction (MI) should be started on a beta-blocker and an ACE inhibitor, ACC/AHA recommends, unless a contraindication exists.⁶ Similarly, any patient with a reduced ejection fraction should be started on an ACE inhibitor regardless of symptoms.⁶

The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated a 23% relative risk (RR) reduction with the use of an ACE inhibitor in patients with coronary artery disease, peripheral vascular disease, or diabetes, compared with patients receiving a placebo.¹⁷ The importance of a beta-blocker was established in a subanalysis of the Survival and Ventricular Enlargement Trial (SAVE), which found that patients taking beta-blockers in addition to an ACE inhibitor had a 32% RR reduction in progression of HF, compared with patients on an ACE inhibitor alone.¹⁸