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Dr Diana R Holdright

Consultant Cardiologist

Dr Diana Holdright

Drug Therapy - Heart Failure

Heart failure develops when the heart can no longer adequately perform its function, which is to pump blood efficiently around the body. It is a common condition, affecting 1-2% of the adult population, rising to 6-10% of people aged 65 years and over, which is costly to society, and potentially disabling and life-threatening to the patient. There are many causes of heart failure, such as a heart attack, valve disease or inherited condition, and it is also associated with high blood pressure and diabetes, all of which should be treated in their own right. 

Fortunately there are several types of drug which have been proven to improve symptoms, quality of life and prognosis; drug therapy is usually a life-long commitment, with fine tuning of drugs and their doses over the years. Beyond that there are also specific treatments such as resynchronisation therapy, implantable cardioverter-defibrillators (ICDs) and heart surgery, which will be of benefit in selected individuals. The most common type of heart failure is called systolic heart failure, when the main pumping chamber of the heart cannot squeeze so effectively. Increased stiffness of the heart muscle is an increasingly recognised cause of heart failure, especially in older women, and is called diastolic heart failure or “heart failure with preserved ejection fraction”, since, although the heart can pump well, it cannot relax and fill effectively.

When the heart muscle is not pumping effectively, pressure can build up within the lungs and the chambers of the heart, creating the sensation of breathlessness and sometimes leading to fluid retention and swelling.  Diuretics, somewhat inappropriately referred to as water tablets, can ease the sensation of breathlessness and reduce fluid retention by causing salt and water to be excreted by the kidneys. Examples include furosemide and bumetanide, which shortly after ingestion cause a significant volume of urine to be produced, lasting one to several hours. ACE inhibitors and angiotensin receptor blockers (ARBs) help heart muscle function, improve symptoms, reduce the need for hospital admission and improve outlook; unfortunately a minority of patients develop an irritating tickly cough with ACE inhibitors, although this ceases upon stopping the drug. Beta blockers such as carvedilol and bisoprolol similarly reduce symptoms and the need for hospital admission, and are associated with a reduction in mortality; remarkably until the seminal trials of beta blockers in the treatment of heart failure in the late 1990s and early 2000s, beta blockers were thought not only to be contraindicated in heart failure but positively dangerous. Blockade of the hormone aldosterone with drugs like spironolactone or eplerenone is beneficial in more advanced cases of heart failure. Some patients, in particular African-Americans, have been shown to benefit from vasodilator drugs, such as hydralazine.  Digoxin, one of our oldest cardiac drugs, still plays a role in some patients. Patients in atrial fibrillation should be considered for warfarin, which reduces the likelihood of clot formation and stroke. Vaccination against influenza and pneumococcal infection is recommended in all heart failure patients since they are prone to infection and may tolerate it poorly.

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Drug Therapy - Heart FailureDrug Therapy - Heart Failure