Cardiac Failure - Nonpharmacologic Treatment

A. Case Management, Diet, and Exercise Training

Thirty to 50 percent of congestive heart failure patients who are hospitalized will be readmitted within 3-6 months. Strategies to prevent clinical deterioration, such as case management, home monitoring of weight and clinical status, and patient adjustment of diuretics, can prevent rehospitalizations and should be part of the treatment regimen of advanced heart failure.

Patients should routinely practice moderate salt restriction (2-2.5 g sodium or 5-6 g salt per day). More severe sodium restriction is usually difficult to achieve and unnecessary because of the availability of potent diuretic agents.

Exercise training improves activity tolerance in significant part by reversing the peripheral abnormalities associated with heart failure and deconditioning.

In severe heart failure, restriction of activity may facilitate temporary recompensation. However, in stable patients, a prudent increase in activity or a regular exercise regimen can be encouraged. Indeed, a gradual exercise program is associated with diminished symptoms and substantial increases in exercise capacity.

B. Coronary Revascularization

Since underlying coronary artery disease is the cause of heart failure in the majority of patients, coronary revascularization may both improve symptoms and prevent progression. However, trials have not been performed in patients with symptomatic heart failure. Nonetheless, patients with angina who are candidates for surgery should be evaluated for revascularization, usually by coronary angiography. Noninvasive testing for ischemic but viable myocardium may be a more appropriate first step in patients with known coronary disease but no current clinical evidence of ischemia. The benefit of evaluating patients with heart failure of new onset without angina or prior myocardial infarction is limited. In general, bypass surgery is preferable to PTCA in the setting of heart failure because it provides more complete revascularization.

C. Biventricular Pacing (Resynchronization)

Many patients with heart failure due to systolic dysfunction have abnormal intraventricular conduction that results in dyssynchronous and hence inefficient contractions. Several studies have evaluated the efficacy of "multisite" pacing, using leads that stimulate the right ventricle from the apex and the left ventricle from the lateral wall via the coronary sinus. Patients with wide QRS complexes (generally = 140 ms), reduced ejection fractions, and severe symptoms have been evaluated. Results from studies with up to 6 months of follow-up have reported an increase in ejection fraction and improvement in symptoms and exercise tolerance. Definitive data on mortality or morbidity are not yet available. Nonetheless, this appears to be a promising therapeutic approach in patients who remain symptomatic despite aggressive medical therapy. Devices that combine biventricular pacing and ICD capabilities are also available.