Heart Failure – Systolic Dysfunction [2006 update]

Purpose, Audience, Authors, and Acknowledgements

Over the past decade, the understanding of HF has changed dramatically.  The most common cause of HF remains an ischemic insult.  This insult initiates a cascade of events mediated by neurohormonal influences that adversely affect the heart.  Unlike some disease entities for which there are no therapies, in HF there are numerous pharmacologic and lifestyle interventions that can improve mortality.  The fact that so many treatments are available has resulted in confusion among those who treat HF patients about how and in whom to initiate and titrate therapy.  Health care systems have targeted HF as a medical condition needing better disease-based management because of its prevalence and its management costs.  Additionally, the vast information regarding new treatments available for HF patients has resulted in variation in the management of this condition across specialties and health systems and under use of medications that have been proven effective.  Treatment guidelines have evolved to improve the standardization of care using evidence-based approaches.  This guideline-based, self-study activity provides practical guidance to clinicians about managing heart failure due to systolic dysfunction.  A framework of symptom severity guides pharmacologic treatment of these patients. 

Key points include:

• Confirm the etiology as systolic dysfunction.
• ACE inhibitors and beta blockers are underutilized and should be administered to appropriate patients.
• Aldosterone agonists improve mortality and should be considered for appropriate patients. 

New information in this updated guideline includes:

• BNP can be used to help determine the likelihood that dyspnea is caused by heart failure.
• Aldosterone antagonists (low dose) are now indicated among symptomatic patients recently post MI.
• Beta blockers may be used among selected patients who have rest dyspnea (NYHA IV).
• Isordil-hydralazine may be indicated for African-American patients who remain symptomatic despite background therapy (i.e., ACE inhibitors, beta blockers, and diuretics).
• ARB’s may be indicated for patients who remain symptomatic despite background therapy (i.e., ACE inhibitors, beta blockers, and diuretics).
• Many HF patients are on multiple medications with potential interactions and complications.  For example, use aldosterone antagonist (e.g., spironalactone) with caution in renal insufficiency and monitor closely for hyperkalemia.
• Referral to cardiology or electrophysiology for device therapy may be indicated in selected patients with an EF <35%.

This self-study activity is appropriate for primary care clinicians and other health care providers diagnosing and treating heart failure in adults.

Team Leader
	William E. Chavey, MD Family Medicine
Team Members
	Barry E. Bleske, PharmD Pharmacy R. Van Harrison, PhD Medical Education Robert V. Hogikyan, MD, MPH Geriatric Medicine Sean K. Kesterson, MD General Medicine John M Nicklas, MD Cardiology
Author Disclosures
	Team Member Company Relationship Barry Bleske, PharmD Abbott Astra Zeneca Scios Consultant Consultant   Research Support Consultant William Chavey, MD SmithKline Beecham Consultant Speakers Bureau Van Harrison, PhD   (None) Rogert Hogikyan, MD   (None) Sean Kesterson, MD   (None) John Nicklas, MD GlaxoSmithKline NitroMed Consultant Consultant

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