While attempting to identify and stabilize the underlying cause, treatment should be instituted to minimize the symptoms of heart failure and to optimize the efficiency of the failing heart. The mainstay of treatment has been and remains medication, but transplant surgery has saved thousands of lives, and new medical devices are being developed to treat cardiomyopathy and heart failure.
Drugs
Digitalis. Digitalis agents (digoxin is the most common form) improve the force of heart muscle contraction by increasing the amount of calcium inside cardiac cells. If digoxin helps this condition, its effect seems to be marginal. Also, a recent study suggests that digoxin might actually be detrimental in women who have heart failure. Click here to read about the risks of digitalis in women with heart failure.Diuretics. Diuretics, or “water pills,” increase the elimination of sodium through the kidneys. Eliminating sodium reduces the fluid retention that occurs in heart failure, helps rid the lungs of the excess fluids that cause shortness of breath, and helps reduce leg swelling. Most patients who have experienced an episode of heart failure are placed on daily therapy with diuretics.
ACE inhibitors. ACE (angiotensin converting enzyme) inhibitors act to dilate blood vessels in the body. This is extremely important, because in heart failure the body responds by constricting blood vessels, and the constriction of blood vessels greatly increases the work of the heart. Of the many vascular dilating drugs that have been tried, ACE inhibitors have proven to be the most effective in improving both the symptoms and the outcome of patients with heart failure. Virtually every patient with heart failure should be on an ACE inhibitor.
Beta blockers. Beta blockers are drugs that block the effect of adrenaline on the body. Since adrenaline “drives” the heart, until recently it was felt that beta blockers should not be used in patients with heart failure, for fear that the loss of the adrenaline-mediated drive would be detrimental. But in recent years it has become established that beta blockers not only help heart failure, but also improve survival in patients with heart failure. Doctors today should make every effort to place virtually every patient with heart failure on beta blockers.
Cardiac transplantation.
Heart transplantation has progressed remarkably over the last 20 years. Today, almost 90% of heart transplant recipients survive for at least one year after transplant, and up to 75% survive for five years. Because of the scarcity of donors (only 2000 people a year receive heart transplants in the U.S.), this therapy is limited to the very sickest patients – those whose expected survival without transplantation is measured in months.Antiarrhythmic therapy.
Unfortunately, patients with moderate to severe dilated cardiomyopathy have a significantly increased risk of sudden death from ventricular arrhythmias. Also unfortunately, antiarrhythmic drugs have never been shown to reduce that risk. The implantable defibrillator has been shown to significantly reduce mortality in certain subsets of patients with cardiomyopathy, particularly in those with prior heart attacks. A recently published trial (the MADIT II trial) has shown that patients with prior heart attacks whose ejection fractions are less than 30% have a significantly improved survival when they receive implantable defibrillators.Cardiac resynchronization therapy (CRT).
CRT is a new form of treatment for some patients with dilated cardiomyopathy. CRT is a form of cardiac pacing that stimulates both ventricles (right and left) simultaneously. (Standard pacemakers stimulate only the right ventricle.) The purpose of CRT is to coordinate the contraction of the ventricles, which improves the efficiency of the heart, and increases the amount of blood pumped with each heart beat. Recent studies with CRT show that this therapy, in appropriately selected patients, results in substantial improvements in cardiac function and symptoms, reduces hospitalizations, and prolongs life. Any patient with dilated cardiomyopathy and a complete or partial bundle branch block should be considered for CRT. Click here to read more about CRT.
