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Treating Heart Failure Due to Dilated Cardiomyopathy

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Updated July 27, 2014

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The treatment of dilated cardiomyopathy (DCM) - the most common form of heart failure - has improved dramatically over the past several years.

Unfortunately, studies show that many patients with DCM are not receiving the treatments they ought to be receiving. For this reason it is important for you to be aware of the treatment of DCM - if only to make sure your doctor is covering all the bases.

Treat the Underlying Cause

The first rule in treating DCM is to identify and treat the underlying cause. Treating the underlying cause can often slow, stop, or even reverse the progression of DCM. You can read here about the many causes of DCM.

Drug Treatment of DCM

Beta blockers Beta blockers reduce the excess stress on the failing heart, and have been proven to significantly improve the overall heart function, symptoms, and survival of patients with DCM. Coreg (carvedilol), Toprol (metoprolol), and Ziac (bisoprolol), are the beta blockers most commonly used in DCM. While beta blockers can produce weakness and fatigue, when used carefully they are well tolerated by most people with DCM.

Diuretics Diuretics, or "water pills," are a mainstay of therapy for patients with heart failure. These drugs increase the elimination of water through the kidneys, and reduce the fluid retention that often occurs in DCM. Commonly used diuretics include Lasix (furosemide) and Bumex (bumetanide). Their chief side effect is that they can cause low potassium levels, which can lead to cardiac arrhythmias.

ACE inhibitors ACE (angiotensin converting enzyme) inhibitors have proven to be very effective in improving both the symptoms and survival in patients with heart failure. The chief side effects are cough or low blood pressure, but most patients with DCM tolerate ACE inhibitors well. Commonly used ACE inhibitors include Vasotec (enalapril), Altace (ramipril), Accupril (quinapril), Lotensin (benazepril) and Prinivil (lisinopril).

Angiotensin II receptor blockers (ARBS) are drugs that work similarly to ACE inhibitors. They can be used in patients with DCM who cannot take ACE inhibitors. ARBS that have been approved for heart failure include Atacand (candesartan) and Diovan (valsartan).

Aldosterone antagonists Aldactone (spironolactone) and Inspra (eplerenone) are aldosterone antagonists, another class of drugs convincingly shown to improve survival in some patients with heart failure. In patients with reduced kidney function, these drugs can cause dangerously high levels of potassium, so they need to be used with great caution if kidney function is not normal.

Hydralazine plus nitrates For patients with DCM who have persistent symptoms despite beta blockers, ACE inhibitors and diuretics, using the combination of hydralzaine plus an oral nitrate (such as isosorbide) can significantly improve outcomes.

Digoxin While in past decades Lanoxin (digoxin) was considered a mainstay in the treatment of heart failure, its actual benefits in treating DCM now seem to be marginal, and many doctors prescribe it only if the more effective medications do not appear to be adequate.

Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (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, to improve the efficiency of the heart. 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 DCM and a complete or partial bundle branch block should be considered for CRT.

Preventing Sudden Death - Implantable Defibrillator Therapy

Unfortunately, patients with moderate to severe DCM have an increased risk of sudden cardiac death from ventricular arrhythmias. The implantable cardioverter defibrillator (ICD) has been shown to significantly reduce mortality in certain patients with DCM and significantly reduced left ventricular ejection fractions. If you have DCM, you should discuss with your doctor whether an ICD is something that ought to be considered in your case.

Cardiac Transplantation

Success with cardiac transplantation has improved remarkably over the last 20 years. However, due to the drastic nature of the therapy, and to the fact that donor hearts are in very short supply, heart transplantation is reserved for the very sickest patients with heart failure. It is noteworthy, however, that most heart transplant centers have found that many patients referred to them with "end-stage heart failure" have actually never received the aggressive therapy they need - and when aggressive therapy is instituted they improve substantially and no longer require heart transplantation.

Experimental Therapy

A lot of research is being done to determine whether gene therapy or stem cell therapy might be beneficial in patients with DCM. While both of these experimental treatments show some promise, they are very early in the evaluation process, and are not generally available for patients with DCM. You can read here about gene therapy and stem cell therapy for DCM.

Summary

Studies continue to show that a majority of patients with heart failure due to DCM are not receiving all the therapy they ought to be receiving. For this reason, if you or a loved one has this condition you should make sure you are familiar with all the recommended treatments which are discussed in this article. And don't be shy about discussing them with your doctor, since, in this case it truly is a matter of life and death.

Sources:

Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dickstein K, Cohen-Solal A, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29:2388.

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