Treating chronic heart failure

Chronic heart failure is usually first treated with medications. They are generally taken in tablet form.

Which medications are suitable will also depend on the type of heart failure you have. Studies have shown that some medications can increase your life expectancy if you have heart failure with reduced pumping capacity. The medications prevent complications and relieve the symptoms, and can prevent hospital stays.

• ACE inhibitors: The names of the active ingredients in ACE inhibitors end in “-pril.” They are usually prescribed for heart failure where the heart pumps less blood, whether with or without symptoms. The typical side effects include coughing and low blood pressure.
• Angiotensin 1 receptor blockers (also called AT1 receptor blockers): The word “sartan” is found in the active ingredient names. That is why these drugs are often referred to as sartans. They are suitable for people who don’t tolerate ACE inhibitors, perhaps because they cause troublesome coughing.
• Angiotensin receptor-neprilysin inhibitors, or ARNI: This is a standard combination of the angiotensin 1 receptor blockers and the active ingredient sacubitril . They are used for people who have symptoms. If you have already been prescribed an ACE inhibitor (or sartan), it will be replaced by this ARNI combination. The possible side effects are low blood pressure and dizziness.
• Beta blockers: The active ingredient names end in “-olol” or “-ilol.” These medications reduce blood pressure and slow the heart rate. That takes more strain off the heart and can prevent an abnormal heartbeat. Beta blockers are recommended in all stages of the disease. But people without symptoms are usually only given them if they have high blood pressure or their heart failure was caused by heart attack. Side effects can include heart rhythm problems, low blood pressure, and breathing problems.
• Mineralcorticoid receptor antagonists: These include spironolactone and eplerenone. They are diuretics (increase urination). That reduces blood pressure and takes the strain off the heart. They are only suitable for people who have symptoms because of heart failure. Possible side effects are headache, impaired kidney function, low blood pressure, and poor blood salt concentration (electrolytes).
• SGLT2 inhibitors: These medications were first mainly used to treat people with type 2 diabetes, because they can also lower blood sugar. But it has been found that SGLT2 inhibitors also extend life in people with heart failure who don't have diabetes. The active ingredient names end in “-gliflozin.” The possible side effects include sugar and fat metabolism disorders, frequent urination, urinary tract infections, and dizziness.

These medications are sometimes also offered to people with heart failure whose hearts still largely have full pumping capacity. Studies suggest that SGLT2 inhibitors can also help them. It’s not clear whether the other medications listed above can also increase life expectancy in these people.

Other substances taken in addition to the medications listed here can be a good idea. There is not actually any proof that they increase life expectancy in people with heart failure, but they can relieve symptoms and improve quality of life. Some are only recommended in addition to the drugs already mentioned if someone also has certain other medical conditions. Others are an alternative, e.g. if beta blockers are not tolerated.

• Diuretics: These drugs increase urination. That reduces blood pressure and takes the strain off the heart. In particular, they are a good idea if the heart failure has already caused water retention, like in the legs. Side effects can be frequent urination, impaired kidney function, or poor blood salt concentration (electrolytes).
• Iron supplements: Some people who have heart failure develop an iron deficiency, too. That can be treated with iron tablets or infusions.
• Ivabradine: Like beta blockers, ivabradine slows the heart rate and is additionally prescribed for advanced heart failure if beta blockers are not able to slow the pulse enough. People who don’t tolerate beta blockers can take ivabradine instead. One possible side effect is the heart rate becoming too slow.
• Cardiac glycosides, also called digitalis: These medications reduce blood pressure and can strengthen the heart. But it is easy to take a dose that is a little too high. That increases the risk of side effects such as nausea and an abnormal heartbeat. That is why they are especially suited for people who have atrial fibrillation if the pulse can’t be reduced by beta blockers only. Cardiac glycosides are also an option if the heart failure causes symptoms, but other medications aren't tolerated or can no longer be taken in higher doses.
• Vericiguat (guanylate cylase simulator): This drug is used for advanced heart failure with reduced pumping capacity and symptoms, but only if the heart failure has gotten worse despite treatment and has maybe meant you had to go to hospital. Vericiguat is taken in tablet form. Possible side effects are headache, low blood pressure, or digestion problems.

People with heart failure have a higher risk of life-threatening heart rhythm disorders such as ventricular tachycardia and sudden cardiac death. Implantable cardioverter-defibrillators (ICD) can prevent that.

People with a weakened heart are usually given the device if they have already had a dangerous heart rhythm disorder. That prevents a further attack and its effects. In some people, the part of the heart where the heart rhythm disorder started is destroyed (ablated) in a medical procedure.

An ICD can also be a good idea for people with heart failure who haven’t had ventricular tachycardia. It is recommended if the heart pumps much less blood into the body than a healthy heart (reduced pumping capacity) and symptoms develop during physical exertion. If the heart failure was caused by a heart attack, doctors usually wait for at least six weeks and then check the heart’s functions again before an ICD is an option.

People can only have the surgery if they permanently take all of the necessary medications and have a life expectancy of over one year.

When a healthy heart beats, the different parts of the heart contract in a very precise sequence; first the two atria, then the two ventricles at the same time. That can get muddled up with heart failure. The already reduced “beating power” of the heart is then further restricted.

A type of pacemaker can then be fitted that makes sure that all parts of the heart muscle contract in the right “synchronized” sequence. That is why the treatment is called cardiac resynchronization therapy (CRT). The precondition here is again that you permanently take all of the necessary heart medications.

CRT is recommended if the heart failure is accompanied by reduced pumping capacity and symptoms, where the heart does beat regularly (sinus rhythm) but the electrical impulses are partly blocked in the ventricles. CRT can also be an option if somebody has ventricular fibrillation in addition to heart failure with reduced pumping capacity and symptoms.

If the heart beats too slowly, CRT can also set a faster rhythm, like a normal pacemaker.

If necessary, the doctor can program the device so that it works like an implantable defibrillator and quickly stops a life-threatening heart rhythm disorder by sending out electrical impulses.

If the heart muscle is so weak that the treatments described above are not enough, the only other option is a heart transplant. The diseased heart is removed, and a healthy donor heart is implanted. The procedure is complex and associated with risks such as bleeding, oxygen deficiency, nerve and blood vessel damage and anesthetic problems. It is usually only performed if you don’t have any other severe medical conditions and have a good chance of survival after the surgery. Whether it's the right step for you personally depends on your own beliefs, goals and preferences.

Medication has to be taken permanently to make sure the donor heart is not attacked by your own immune system (rejection reaction). The medication can increase your risk of infections.

It usually takes weeks or months to find a suitable donor heart and have it transplanted. Until then, you can be connected to machines that carry out the heart and lung functions outside the body. But they are not a permanent solution.

There is also the possibility of removing the diseased heart and replacing it with an artificial heart. It is connected with the large blood vessels and regularly pumps blood through the body. Ventricular assist devices (VADs) can be used if the weakened heart is supposed to remain in the body, for instance because the doctors assume that the heart failure will get better again.