Heart Failure (Cardiac Insufficiency): Therapy

The variety of diseases that can underlie heart failure results in different therapeutic approaches. For example, cardiac arrhythmias can be treated by means of antiarrhythmic drugs, while heart valve disease can be treated by surgical valve replacement. Therefore, individualized therapy is always necessary. Patients with decompensated heart failure should be hospitalized if hypotension (blood pressure below normal), worsening renal function, altered state of consciousness, resting dyspnea/breathlessness at rest (tachypnea/increased respiratory rate at rest, possibly O2 saturation < 90%), or hemodynamically relevant arrhythmias – including new onset atrial fibrillation (AF) and acute coronary syndrome – are present. Other indications for immediate hospitalization include: repeated ICD shocks, significant electrolyte shifts (hyponatremia, hypokalemia, or hyperkalemia), new-onset or decompensated comorbidity (eg, pneumonia), and decompensation of the underlying disease (eg, acute coronary syndrome, ischemia, valvular defects, etc).

General measures

  • Daily weight monitoring (if weight increases: > 1 kg per day or 2 kg within 3 days or more than 2.5 kg per week → physician consultation)
  • Independent needs-adapted adjustment of the diuretic dose (“drainage medication”) (in case of dyspnea/breathlessness, weight gain of > 2 kg within 3 days, edema/water retention).
  • Weight reduction in BMI (body mass index; body mass index, BMI) > 30 and heart failure with preserved ejection fraction (ejection fraction); no weight reduction in moderate and severe heart failure.
  • Nicotine restriction (refraining from tobacco use) – smoking cessation if necessary.
  • Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day) or alcohol restriction (renunciation of alcohol) in alcohol toxic cardiomyopathy (heart muscle disease).
  • Complementary physical training: patients who have stable chronic heart failure may benefit from regular physical activity, such as cycling. The recommendation also applies to patients after decompensation or with severe heart failure. This reduces further hospitalizations due to worsening symptoms (rehospitalization rate). [Physical exercise is now a Class 1A recommendation for patients with heart failure.]
  • Bed rest only in acute or decompensated heart failure (see above).
  • Leisure activities and intimate life
    • Sauna: A Finnish proverb says: “The sauna is the pharmacy of the poor”. It reduces the risk of sudden cardiac death (PHT), has a beneficial effect on ventricular arrhythmias (cardiac arrhythmias originating in the ventricle/potentially life-threatening; rate of ventricular tachycardia ↓), and improves NYHA stage (scheme for grading heart failure/heart failure; BNP levels ↓). Furthermore, sauna has a positive effect on systolic and diastolic blood pressure. The frequency of angina pectoris attacks (“chest tightness”; sudden pain in the heart area) decreases.Conclusion: for patients after a myocardial infarction (heart attack) sauna does not seem to be dangerous.
    • Sports: see below sports medicine
    • Intimate life: Blood pressure only increases to 160/90 mmHg during the sexual act, and pulse rate to 120/min – after which it takes only two to three minutes for heart rate and blood pressure to recover. For patients who can perform moderate physical activity (energy expenditure of 3 to 5 METs* ) without experiencing angina, dyspnea (shortness of breath), cyanosis (blue discoloration of the skin), arrhythmias, or ST-segment depression (may indicate insufficient blood flow to the myocardium/cardiac muscle) can have sex pleasurably. The same is true for patients with NYHA stages I and II and for implantable cardioverter defibrillator (ICD; pacemaker) wearers.
  • Night rest
    • Orthopnea (a state of extreme respiratory distress in which sufficient breathable air reaches the lungs only when the upper body is upright) is exacerbated when patients lie on their left side. The cause of this is that the additional “preload” on the left part of the heart, which must pump blood from the pulmonary to the systemic circulation, is increased in the left-sided position.This results in blood congestion in the lungs, which causes dyspnea (shortness of breath).The right-sided position, on the other hand, is said to have a calming effect on the autonomic nervous system.Notes: Because patients frequently turn in bed (Greek : trepo) to get air (pneuma), the symptom is called trepopnea.Preload is defined as end-diastolic volume in the ventricle (blood volume present at the end of diastole after maximum filling of a ventricle (heart chamber)) and the preload of the myocardium (heart muscle) produced by it.
  • Review of permanent medication due topossible effect on the disease present.
  • Regular medication
  • Possible avoidance of sun exposure (e.g., amiodarone therapy).
  • Travel recommendations:
    • Air travel is contraindicated for patients with resting dyspnea (shortness of breath at rest).
    • No travel at altitudes >1,500 m [maximal aerobic capacity decreases by 1% per 100 meters above 1,500 meters].
    • No hot or humid climate
    • Short flights; long flights can lead to dehydration (lack of fluids), peripheral edema (water retention) and thrombosis (formation of blood clots)
    • Recommendations for air travel, depending on the stage of heart failure according to the NYHA (New York Heart Association) classification:
      • Stage I: no restriction on fitness for air travel.
      • Stage III: limited fitness for travel; patient should receive oxygen.
      • Stage IV: the patient should fly only exceptionally and with medical and oxygen accompaniment; in decompensated heart failure, flight is prohibited altogether

* Metabolic equivalent of task (MET); 1 MET ≡ energy expenditure of 4.2 kJ (1 kcal) per kilogram of body weight per hour).

Conventional nonsurgical therapeutic methods

  • In cases of proven obstructive sleep apnea (sleep-related breathing disorder in which repeated obstructions of the upper airway occur during sleep due to the flaccid base of the tongue), a CPAP mask (respiratory mask with Continuous Positive Airway Pressure; this is a form of ventilation that combines the patient’s spontaneous breathing with a permanent positive airway pressure (PEEP)) is required!In patients with systolic heart failure, treatment is by means of Adaptive Servo Ventilation (ASV). Inhalation and exhalation pressures are determined for each breath. When breathing is stable, the device provides only minimal pressure support. This produces better results than CPAP (“continuous positive airway pressure“): the number of breathing episodes decreases more significantly and heart function improves more. Notice: In one study, heart failure patients with central sleep apnea were studied with and without this ventilatory aid. It was found for sure that mortality (death rate) actually increased in heart failure patients when they were ventilated by ASV (34.8% versus 29.3%; HR 1.28; P = 0.01 and 29.9% versus 24.0%; HR 1.34; P = 0. 006).CONCLUSION: Adaptive servo ventilation is contraindicated (“not indicated” or “prohibited”) for patients with systolic heart failure in stages NYHA II-IV and predominant central sleep-disordered breathing.
  • Implantable cardioverter defibrillator (ICD) – this is a miniaturized automatic defibrillator; it can be used to terminate cardiac arrhythmias such as ventricular fibrillation and ventricular flutter (defibrillation) and ventricular tachycardia, atrial fibrillation and atrial flutter (cardioversion) by delivering targeted electrical shocks. This serves to reduce the risk of sudden cardiac arrest (SCA); for indications, see ICD (implantable cardioverter defibrillator).Note: The authors of PROLONG recommend waiting a certain time before implanting an ICD in patients with newly diagnosed heart failure, as the left ventricular ejection fraction often recovers under optimized pharmacotherapy. They recommend wearing a defibrillator vest during this time instead. They showed that after a three-month transition period with the wearable defibrillator vest, 88 patients (58%) met the indication for ICD implantation. After six months, this was true for only 58 patients (38%). The defibrillator vest induced adequate shocks due to ventricular tachycardia/ventricular fibrillation in 11 patients (7%), two of them after the first three months.A randomized trial of the defi vest is awaited.
  • Cardiac resynchronization therapy: pacemaker procedure to resynchronize cardiac contraction for patients with heart failure (NYHA stages III and IV) when drug therapy has been exhausted:
    • In patients with left bundle branch block, the procedure significantly reduces heart failure-related hospitalization (hospitalization) and cardiovascular and all-cause mortality (all-cause mortality rate).
    • For resynchronization therapy to be successful, the pacing ratio must be as high as possible.
    • Detailed information on cardiac re-synchronization can be found under the topic of the same name.

Legend

  • ACCF: American College of Cardiology Foundation
  • AHA: American Heart Association
  • NYHA: New York Heart Association

Vaccinations

The following vaccinations are advised, as infection often leads to decompensation and hospitalization:

  • Influenza vaccination
  • Pneumococcal vaccination

Note: Patients with chronic heart failure who participated in annual influenza vaccination had an 18% reduced cardiovascular mortality risk (risk of death).

Nutritional Medicine

  • Nutritional counseling based on nutritional analysis
  • Observance of the following nutritional medical recommendations:
    • Patients with heart failure should consume as little salt as possible (<3 g per day). It is believed that in this way the dose of diuretics can be reduced, which could also mitigate undesirable side effects.
    • Fluid intake in patients with grades III-IV (NYHA) should be about one to 1.5 liters per day; patients with grades I-II may drink up to two liters per day.
    • High protein intake is considered an independent factor for better survival in patients with heart failure, presumably because protein leads to increased muscle development. However, further studies are needed to provide information on the proportion of protein intake to total daily energy.
  • See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
  • Detailed information on nutritional medicine you will receive from us.

Sports Medicine

  • Endurance training (cardio) and strength training (muscle) [physical training is now a Class 1A recommendation for patients with heart failure]
    • Exercise training should be initiated only in clinically stable patients. Potential contraindications should be ruled out before starting exercise training [guidelines: ESC]:
      • Unstable heart disease
      • Severe lung disease that has not been optimally treated
      • Hypotension (low blood pressure) or hypertension (high blood pressure) at rest or during exercise
      • Worsening of heart failure symptoms.
      • Myocardial ischemia (reduced blood flow to the heart muscle) despite exercise training (exercise training may be possible here up to the ischemia threshold/threshold of reduced blood flow).
  • In addition to general physical activity, defined bicycle ergometer training under pulse control is required. For all stable patients, cycling 3 to 5 times per week for 20 to 45 minutes each time at 60-70% heart rate reserve exhaustion (= intensity of exercise).Heart rate reserve (according to Karvonen) = heart rate at rest + (maximum heart rate – resting heart rate) x intensity of exerciseMaximum heart rate (MHF, HFmax) = 220 – ageResult:
    • On average, such training improves NYHA stage by one level and maximal oxygen uptake by approximately 20%.
    • In patients with heart failure with preserved ejection fraction/ejection fraction (= diastolic heart failure; diastole is the flaccidity and thus blood inflow phase; English : “heart failure with preserved ejection fraction” (HFPEF)), which represent about 60% of cases of heart failure, structured training programs already after 3 months show an increase in maximum oxygen uptake under load of about 3 ml/kgKG/min.
  • Exercise recommendations for chronic heart failure (HF) classified by pump function:HFrEF:
    • HFrEF: “Heart Failure with reduced Ejection Fraction”; heart failure with reduced ejection fraction (= systolic heart failure; synonym: isolated systolic dysfunction): Moderate continuous training (MCT) in patients with systolic heart failure (left ventricular ejection fraction < 35%) in the usual MCT mode (60-70% of MHF) compared with aerobic high-intensity interval training (HIIT; intensity at 90-95%) showed a better effect on cardiac structure in terms of “reverse remodeling.” In terms of maximal oxygen uptake, there was no significant difference in the two groups.
    • HFmrEF: “Heart Failure mid-range Ejection Fraction”; “mid-range” heart failure: physical training has a positive effect on maximal oxygen uptake under exercise (VO2max or peak VO2) and on quality of life in heart failure patients who have an ejection fraction (percentage of blood volume ejected from a ventricle during a cardiac action) that is still approximately preserved.
    • HFpEF: “Heart Failure with preserved Ejection Fraction”; heart failure with preserved ejection fraction (= diastolic heart failure; synonym: diastolic dysfunction): especially patients with diastolic heart failure in the advanced to the most severe stage benefited from regular exercise mainly by an improvement in quality of life.
  • In heart failure patients with atrial fibrillation (AF), treadmill or bicycle ergometer training showed no beneficial effect on clinic-free survival or all-cause mortality (death rate). However, the benefit of training exists for heart failure patients without VHF.VHF patients benefited in cardiorespiratory parameters to a similar extent as heart failure patients with sinus rhythm.
  • Strength training (dynamic strength loading) 2 to 3 times per week should be added; high isometric components should be avoided.
  • Preparation of a fitness or training plan with suitable sports disciplines based on a medical check (health check or athlete check).
  • Detailed information on sports medicine you will receive from us.

Physical therapy (including physiotherapy)

  • Infrared sauna (infrared cabin; Waon therapy) – form of heat therapy developed by the University of Kagoshima, Japan: Patient sits in an infrared dry sauna at 60 °C for 15 minutes; core body temperature is thus raised by 1.0-1.2 °C; patient then rests in bed wrapped in blankets for half an hour. Frequency of treatment: five times a weekResults of a meta-analysis:
    • Improvements in the severity of heart failure according to NYHA classifications in patients in the sauna groups compared with the control groups.
    • Sauna significantly lowered BNP compared with the control group. (MD = -124.62; 95% CI = -198.09 to -51.14, I2 = 37%, P = 0.0009)BNP is mainly formed in the atria; it increases when the pressure in the heart increases; elevated levels indicate heart failure.
    • Increase in ejection fraction (EF; ejection fraction of the heart) in patients with sauna intervention.

Psychotherapy

Complementary treatment methods