Posted: January 5th, 2024

Initial Palliative Treatment for Heart Failure

Initial Palliative Treatment for Heart Failure
Heart failure is a widespread medical condition affecting millions worldwide in which the heart muscle is unable to sufficiently pump blood to meet the body’s needs. While there is no cure, palliative care aims to relieve symptoms and maximize quality of life through a combination of lifestyle changes, medications, devices and monitoring. This paper discusses initial palliative approaches for heart failure.
Lifestyle Modifications
Non-pharmacological lifestyle modifications are usually the first line of treatment for heart failure and help control symptoms. Weight management through a heart-healthy diet and exercise program is important, as excess weight places extra strain on the heart. The American Heart Association recommends regular moderate physical activity, when tolerated, to strengthen the heart and improve its pumping ability over time. Limiting sodium intake to less than 2,300 mg per day prevents fluid retention issues. Moderate alcohol consumption, if any, is recommended. Quitting smoking is also advised as it damages the heart and lungs. Stress management techniques such as relaxation exercises and counseling help some patients reduce stress levels.
Diuretics
Diuretics, also known as “water pills,” are usually the first drug treatment prescribed to help relieve symptoms of fluid retention and edema. They work by increasing the amount of sodium and water excreted through urine. Common diuretics used include furosemide, torsemide, metolaz. Common diuretics used include furosemide, torsemide, metolazone and bumetanide. Close monitoring of weight, blood pressure and electrolyte levels is needed, as too aggressive diuresis can lead to dehydration and electrolyte imbalances like hypokalemia. Potassium supplements may be needed if levels become too low.
ACE Inhibitors and ARBs
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are mainstay medications for symptomatic relief and reducing mortality in heart failure. They work by blocking the renin-angiotensin-aldosterone system (RAAS), a hormone system that causes blood vessels to narrow and retain sodium and water. Common ACE inhibitors include enalapril, lisinopril and ramipril. Popular ARBs are losartan, valsartan and candesartan. Side effects may include cough, dizziness and hyperkalemia. Baseline and periodic kidney function and electrolyte tests are recommended when initiating and adjusting dosages.
Beta Blockers
Beta blockers, such as carvedilol, metoprolol succinate and bisoprolol, are beneficial in heart failure treatment by slowing the heart rate and reducing its workload and oxygen needs. They also help control blood pressure and symptoms of fluid retention. Initiation and up-titration requires close monitoring by a healthcare professional due to the potential for low blood pressure and other side effects. However, beta blockers have been shown to reduce hospitalizations and improve survival when used appropriately under medical guidance in stable heart failure patients.
Aldosterone Antagonists
Aldosterone antagonists such as spironolactone and eplerenone may be added for more advanced cases to counter the effects of the mineralocorticoid aldosterone, part of the RAAS. Aldosterone causes the body to retain sodium and fluid. They are generally well-tolerated but can cause hyperkalemia, especially when combined with ACE inhibitors or ARBs, requiring periodic monitoring.
Digoxin
Digoxin is an older medication that may help control heart rate and improve symptoms in patients with atrial fibrillation or flutter. However, its use has diminished some as other heart failure drugs have become available. It has a narrow therapeutic window and requires therapeutic drug monitoring due to the risk of toxic effects like arrhythmias with higher levels.
Anticoagulants
For heart failure patients with a history of or risk factors for blood clots, anticoagulant medications help prevent dangerous clots. Warfarin is an older vitamin K antagonist that requires regular monitoring and dietary restrictions. Newer direct oral anticoagulants like apixaban, rivaroxaban, edoxaban, and dabigatran have more predictable effects without routine monitoring or dietary changes but are more expensive.
Device Therapies
Some heart failure patients may benefit from device-based therapies like implantable cardioverter defibrillators and cardiac resynchronization therapy. ICDs help prevent sudden cardiac death from life-threatening arrhythmias. CRT synchronizes the contractions of both lower chambers of the heart to improve pumping efficiency in those with a specific heart rhythm problem.
Non-pharmacological Approaches
Other non-drug approaches can help manage symptoms and quality of life. Limiting excess fluid intake prevents overload. Elevating the head of the bed helps drainage. Wearing compression stockings may ease leg swelling and discomfort. Supplemental oxygen may be needed for some patients. Caregiver support is important as heart failure progresses. Palliative care specialists can address psychological, social and spiritual issues as well as advance care planning goals of care discussions.
Monitoring and Follow-up
Close monitoring by a healthcare team is key, as medication dosages may need adjustments based on symptoms, weight changes and lab tests. Outpatient visits every 3-6 months allow assessment of treatment response and progression. Home weight monitoring alerts to potential fluid retention issues. Blood tests check electrolytes, kidney function and medication levels periodically or as needed. Wearable devices or telemonitoring programs may facilitate remote monitoring and early intervention for some stable patients. Hospitalization may be required for worsening symptoms, fluid overload or other problems despite optimal medical therapy. The goals shift to stabilization with intravenous diuretics and other treatments before resuming oral medications. Advanced care planning is recommended to ensure patient values and preferences are honored as the disease progresses.
Prognosis
While there is no cure for heart failure, palliative treatment aims to prevent hospitalizations and allow patients to enjoy the highest possible quality of life for as long as possible. Prognosis depends on the underlying cause and severity of cardiac dysfunction, response to treatment, and presence of other medical conditions. On average, about 50% of people with heart failure will live for at least 5 years after diagnosis. Those with mild symptoms tend to do better. Advanced directives ensure patient autonomy is maintained in serious illness.
Conclusion
A multidisciplinary approach combining lifestyle changes, medications, devices and monitoring optimizes palliation of heart failure symptoms and outcomes. Regular reassessment allows adjustment of the treatment plan based on disease progression. Supportive care addresses whole-person needs. With appropriate initial palliative treatment, many patients enjoy years of reasonable quality living with this chronic condition.
References
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., Falk, V., González-Juanatey, J. R., Harjola, V. P., Jankowska, E. A., Jessup, M., Linde, C., Nihoyannopoulos, P., Parissis, J. T., Pieske, B., Riley, J. P., Rosano, G. M., Ruilope, L. M., Ruschitzka, F., … Document Reviewers. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European Journal of Heart Failure, 18(8), 891–975. https://doi.org/10.1002/ejhf.592
Krum, H., & Abraham, W. T. (2009). Heart failure. The Lancet, 373(9667), 941–955. https://doi.org/10.1016/S0140-6736(09)60236-1
Savarese, G., & Lund, L. H. (2017). Global Public Health Burden of Heart Failure. Cardiac Failure Review, 3(1), 7–11. https://doi.org/10.15420/cfr.2016:25:2
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T., Januzzi, J. L., Johnson, M. R., Kasper, E. K., Levy, W. C., Masoudi, F. A., McBride, P. E., McMurray, J. J. V., Mitchell, J. E., Peterson, P. N., Riegel, B., … Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 62(16), e147–e239. https://doi.org/10.1016/j.jacc.2013.05.019

Check Price Discount

Study Notes & Homework Samples: Emergency Department Overload: Making Changes Despite Conflicting Input »Deep Learning for Disease Diagnosis: A Practical Approach