Practical Approaches for the Treatment of Chronic Heart Failure: Frequently Asked Questions, Overlooked Points and Controversial Issues in Current Clinical Practice
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1 Practical approaches for the treatment of chronic heart failure: Frequently asked questions, overlooked points and controversial issues in current clinical practice Yüksel Çavuşoğlu, Hakan Altay1, Ahmet Ekmekçi2, Mehmet Eren2, Mehmet Serdar Küçükoğlu3, Sanem Nalbantgil4, İbrahim Sarı5, Timur Selçuk6, Ahmet Temizhan6, Dilek Ural7, Jean Marc Weinstein8, Dilek Yeşilbursa9, Mehmet Birhan Yılmaz10, Mehdi Zoghi4, Sinan Aydoğdu6, Merih Kutlu11, Necla Özer12, Mahmut Şahin13, Lale Tokgözoğlu12 Department of Cardiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir-Turkey; 1Department of Cardiology, Faculty of Medicine, Başkent University, İstanbul-Turkey; 2Department of Cardiology, Siyami Ersek Hospital, İstanbul-Turkey; 3Department of Cardiology, İstanbul University, Cardiology Institute, İstanbul-Turkey; 4Department of Cardiology, Faculty of Medicine, Ege University, İzmir-Turkey; 5Department of Cardiology, Faculty of Medicine, Marmara University, İstanbul-Turkey; 6Department of Cardiology, Ankara Türkiye Yüksek İhtisas Hospital, Ankara-Turkey; 7Department of Cardiology, Faculty of Medicine, Kocaeli University, Kocaeli-Turkey; 8Department of Cardiology, Faculty of Medicine, Ben Gurion University, Bersheva-Israel; 9Department of Cardiology, Faculty of Medicine, Uludağ University, Bursa-Turkey; 10Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas-Turkey; 11Department of Cardiology, Faculty of Medicine, Karadeniz Teknik University, Trabzon-Turkey; 12Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara-Turkey; 13Department of Cardiology, Faculty of Medicine, 19 Mayıs University, Samsun-Turkey ABSTRACT Heart failure (HF) is a progressive disorder associated with impaired quality of life, high morbidity, mortality and frequent hospitalization and affects millions of people from all around the world. Despite further improvements in HF therapy, mortality and morbidity remains to be very high. The life-long treatment, frequent hospitalization, and sophisticated and very expensive device therapies for HF also leads a substantial economic burden on the health care system. Therefore, implementation of evidence-based guideline-recommended therapy is very important to overcome its worse clinical outcomes. However, HF therapy is a long process that has many drawbacks and sometimes HF guidelines cannot answers to every question which rises in everyday clinical practice. In this paper, commonly encountered questions, overlooked points, contro- versial issues, management strategies in grey zone and problems arising during follow up of a HF patient in real life clinical practice have been addressed in the form of expert opinions based on the available data in the literature. (Anatol J Cardiol 2015: 15 Suppl 2; 1-60) Keywords: algorithm, drugs, heart failure, strategies, therapy 1.0 Introduction – Lale Tokgözoğlu (1) which is higher than Western countries. 85% of HF patients in the U.S. and Europe are 65 years of age or over. The average Heart failure (HF) is one of the most common causes of mor- age of HF in our country is lower than that of Europe (2). It is tality and hospitalizations in adults and is gradually becoming estimated that these numbers will rise with our aging population. a global epidemic. Currently, approximately 26 million adults Heart failure causes major costs to the healthcare economy live with HF in the world. It is estimated that this number will owing to life-long treatment, frequent hospitalization, and so- increase substantially with aging populations. Even though the phisticated and very expensive device therapies. Almost 1-3% prevalence is not clearly known in our country, absolute HF of total healthcare costs are spent for the management of HF in prevalence in adults was found to be 2.9% in the HAPPY Study Western Europe. Address for Correspondence: Dr. Yüksel Çavuşoğlu, Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, 26480, Eskişehir-Turkey Phone: +90 222 239 29 79 E-mail: [email protected] ©Copyright 2015 by Turkish Society of Cardiology - Available online at www.anatoljcardiol.com DOI:10.5152/AnatolJCardiol.2015.6767 Çavuşoğlu et al. 2 Practical approaches for the treatment of chronic heart failure Anatol J Cardiol 2015; 15 Suppl 2: 1–60 Heart failure is a progressive and irreversible disorder. generally accepted that excess sodium intake increases hospi- Therefore, prevention of HF is of great importance. Primarily, talization by causing fluid retention in the body. it is required to control the risk factors of HF and the leading In a meta-analysis in which six randomized trials were evalu- underlying causes. If the disease has settled in, it is important ated, very low-sodium diet (1.8 gr/day) was reported to increase to implement the guidelines recommended therapy. Inadequate the rate of all-cause mortality (RR 1.95, 1.66 vs. 2.29) and hos- treatment or incompliance with treatment increases mortality. pitalization (RR 2.10, 1.67 vs. 2.64). Even though studies in this Almost 17-45% of hospitalized HF patients die within one year. aspect mainly include patients with systolic HF, there are also It is possible to increase survival with compliance to guideline observational studies reporting favorable effects of DASH diet recommendations and the right treatment. In these patients, on diastolic functions in hypertensive patients who have HF with treatment is a long process that has many difficulties. The guide- preserved ejection fraction (6). lines sometimes cannot answers to every question which rises There is data showing that in patients presenting with acute in everyday clinical practice regarding problems, controversial decompensated HF, fluid (maximum 800 mL/day) and sodium issues and managing complications. In this grey zone, clinical (maximum 800 mg/day) restriction has no effect on weight-loss experience comes into prominence in decision-making. or clinical improvement (7). Acute HF is a clinical syndrome in In this paper, we aimed to adress controversial issues, com- which various neurohormonal and triggering factors are involved monly encountered questions, overlooked points, new drugs, in the pathophysiology and salt restriction should not be gener- management strategies in grey zone and problems arising dur- alized in all groups in acute HF. ing follow up of a HF patient in real life clinical practice in the Clinical effect of sodium amount in diet in HF shows a U- form of expert opinions based on the available data in the lit- shape curve effect (excess consuming and excess restriction erature. are harmful) rather than linear relationship (8). A low salt diet is represented by daily sodium consumption of 2-3 grams (1-2 2.0 What are the targets of therapy in heart failure? – Yüksel Çavuşoğlu flat teaspoon of salt). HF guidelines recommend that HF patients consume less salt than the normal population (Table 2). Recom- mendations for the daily amount of sodium consumption vary de- Basic treatment targets in chronic HF are reducing mortality and re-hospitalization, relieving symptoms and signs, increasing pending on the type of HF (systolic or diastolic), accompanying functional capacity and improving quality of life (3, 4). In most of diseases, New York Heart Association (NYHA) functional class the major HF trials, all-cause mortality, mortality from HF, cardio- and severity of the disease (3). In patients with systemic conges- vascular mortality and sudden deaths are targeted as primary tion, salt restriction is strongly recommended. and secondary mortality outcomes. Similarly, in these major HF The American Heart Association restricts daily sodium in- trials, in addition to HF re-hospitalization, cardiovascular hospi- take with 1.5 gr/day in asymptomatic stage A and B HF patients talization and all-cause hospitalizations were investigated. Al- in which hypertension and cardiovascular disease usually play though symptom control, functional capacity and quality of life a role in etiology. In symptomatic stage C and D HF patients, have been evaluated as secondary endpoints in many studies, daily sodium intake is recommended to be <3 gr/day (4). Guide- they are referred as basic treatment targets in the follow-up of lines recommendations for daily sodium restriction are shown these cases. In addition to these basic targets, slowing, stop- in Table 2. ping or reversing disease progression, controlling congestion, Table 1. Targets of therapy in heart failure reducing the levels of natriuretic peptide levels, increasing peak oxygen consumption, providing an increase in a 6-min walk Basic targets distance, providing a decrease in left ventricular systolic and Controlling symptoms and signs diastolic volumes, reducing the emergency service and hospi- Reducing mortality tal admissions are among the targets to be achieved in clinical Reducing re-hospitalization follow-up (Table 1). Increasing functional capacity 3.0 General recommendations – Mehdi Zoghi Improving quality of life Clinical targets 3.1 Is salt restriction necessary? If so, how much? Slowing, stopping or reversing disease progression There is no strong evidence regarding the benefit of salt re- Controlling congestion striction in HF based on randomized, controlled trials. There are Decreasing natriuretic peptide levels studies showing that salt restriction is necessary (5), however, Increasing peak oxygen consumption there is also data showing that it has no benefit. It is suggested Providing an increase in a 6-min walk distance that a salt-free diet may