Individual Patient Considerations

Individualizing the approach to HF begins with knowledge of the type of HF. Specific pharmacologic treatments are different for HF with systolic dysfunction compared to HF due to diastolic dysfunction. Most large clinical trials that have influenced the treatment of HF have only included patients with systolic dysfunction. Many of these trials have supported the acceptance of ACE inhibitors and more recently, beta-blockers, as the most effective life-saving treatments in the long-term management of HF due to systolic dysfunction. These trials have been summarized in a recent consensus report on the management of HF. In comparison to the large evidence base for treating systolic dysfunction there is minimal data available to guide the treatment of HF due to diastolic dysfunction. The specific treatment approaches to diastolic dysfunction are discussed separately.

Optimizing the treatment of etiologic and comorbid conditions for each HF patient may significantly improve ventricular function and HF symptoms. Special attention should be given to surgical correction of significant valvular disease when appropriate and revascularization with transluminal angioplasty, stent placement, or surgical bypass when indicated. Ventricular rate control and conversion to sinus rhythm may improve ventricular function for patients with atrial fibrillation and HF.

A number of noncardiac comorbid conditions may have an impact on the clinical course of HF and should be carefully assessed and treated in each HF patient. Dyspnea, exercise intolerance, nighttime cough, and other symptoms of COPD may be misinterpreted as HF symptoms. Renal insufficiency influences fluid and electrolyte problems in HF and may limit usefulness or lead to changes in dosing for HF medications, particularly ACE inhibitors and diuretics. Significant arthritis may further limit physical activity and worsen the skeletal muscle changes that occur in HF patients. NSAIDs that are often used to treat the inflammatory process can worsen HF and should be avoided. Depression and poor social support have been shown to be important predictors of clinical outcomes, hospitalizations, and deaths among patients with ischemic heart disease. Smoking cessation should be encouraged. Patients with a component of LV dysfunction caused by alcohol abuse may show significant functional improvement with abstention from alcohol. Hypothyroidism or hyperthyroidism may aggravate HF symptoms. Nephrotic syndrome and/or hypoalbuminemia may worsen volume overload in HF.

One of the factors influencing drug selection is a HF patient’s volume status. Although ACE inhibitors should be considered first line therapy for chronic HF due to systolic dysfunction, the initial presentation of the HF patient with pulmonary and systemic congestion dictates acute treatment with diuretics to lessen fluid overload and rapidly improve symptoms.