Annals of Long Term Care

“Our treatment of folks in end-stage heart disease surely needs some improvement,” said the senior public health analyst in the Department of Health and Human Services (HHS). Recalling her thoughts as her mother entered advanced heart failure (HF), she said she felt the care was not well managed. It was troubling to her, and she is knowledgeable about medical treatment and how to deal with the medical system, much more so than the average person. For most others, it can be even more troublesome.

What the HHS official was concerned about was more the management than the treatment, if one limits the word “treatment” to drugs and procedures. Of course, treatment does include more than drugs and procedures, but in advanced HF, it is easy to focus on that with which we as providers are most comfortable (ie, drugs and procedures). (This is not unique to HF; in one study, only 10% of published treatment guidelines had “significant palliative care” content.1) It is good to be reminded that there is more to treatment, especially in advanced HF. One approach is to consider two domains: drugs and procedures; and patient and caregiver quality of life.

Drugs and Procedures
Heart failure used to be considered simply decreased mechanical pumping action of the heart, often due to inadequate oxygen supply from narrowed heart arteries. Now it is understood to be a complex neurohumoral phenomenon. The HF complex includes increased cytokines, such as tumor necrosis factor and interleukin 6, which cause discomfort and cachexia; changes in pulmonary compliance that cause stiffer lungs; and brain dysfunction unrelated to hypoxia.2

As a disease, HF can produce three different presentations, each with important drug and procedure differences. Aronow3 recently outlined these differences. In brief, systolic failure is characterized by poor forward pumping of the ventricles. Drugs often used include diuretics, angiotensin-converting enzyme inhibitors (ACEIs), beta blockers (BBs), and aldosterone antagonists (if certain conditions are met). Digitalis may be used, especially if rate control is needed, although one study showed digitalis to be detrimental in patients 85 years and older.4 While, in general, calcium channel-blocking drugs (CCBs) are avoided, vasoselective CCBs may be acceptable.

Diastolic failure is characterized by stiffness of the ventricles, with slower filling in diastole. Diuretics are used cautiously if at all. Digitalis is avoided if the patient is in sinus rhythm. CCBs are acceptable.

Mixed failure has both components. Drug treatment requires a delicate balance that recognizes the principles for each component.

Treatments can also be described by heart failure stage:3

Stage A encompasses people at high risk for HF, without manifest heart damage. Treatment is aimed at prevention, and ACEIs and aspirin may be useful in many conditions.

Stage B is the level at which some structural change has become manifest, such as coronary artery obstruction or valvular dysfunction. Treatment is aimed at repairing the damage (eg, revascularization) and BB and ACEI drugs.

Stage C encompasses symptoms with physical activities. Treatment includes repair, vigorous control of diet and blood pressure, emphasis on regular systematic physical activity, careful monitoring of potassium, magnesium, and other electrolytes, and consideration of warfarin use.

Stage D is marked by symptoms at rest, despite maximum treatment. It includes all of Stage C therapies, and possibly other drugs. Nesiritide has been used, but recent studies suggest it does not provide significant benefit.5 More radical interventions such as heart transplant and ventricular assist devices are sometimes considered.

Dyspnea is usual in stage D. Suggestions to treat dyspnea include acetaminophen with codeine for mild dyspnea, and oral morphine for moderate to severe dyspnea.