JOHN R. MCCONAGHY, MD STEVEN R. SMITH, MS, RPH, BCPS Toledo, Ohio From the Toledo Hospital Family Practice Residency, Toledo, Ohio. The authors report no competing interests. All requests for reprints should be addressed to John R. McConaghy, MD, Associate Director, Toledo Hospital Family Practice Residency, 2051 W. Central Ave, Toledo, OH 43606. E-mail: John.McConaghy.MD@ProMedica.org.
Antiplatelet therapy and anticoagulation. Patients with HF have an increased risk for thromboembolic events of 1.6% to 3.2% per year.33 One systematic review concluded that antiplatelet therapy is not useful in preventing thromboembolism in patients with HF in sinus rhythm and may even be harmful.34 Another systematic review also concluded that the data do not support the routine use of anticoagulants (eg, warfarin) in patients with HF and sinus rhythm.35 Anticoagulation may be beneficial, however, if there is echocardiographic visualization of a left ventricular thrombus or in cases of “severe” HF or concomitant atrial fibrillation.35
Nonpharmacologic management
Dietary sodium restriction. There is consensus that dietary sodium restriction is important in the treatment of HF36 and is recommended in published guidelines.8,37 Sodium restriction assists with fluid volume control and minimizes the dosages of HF drugs used. These recommendations are based on the retention of sodium and water in symptomatic HF. No studies, however, have examined the effect of dietary sodium restriction on morbidity or mortality, either alone or in combination with pharmacologic treatments.
Exercise training. Moderate exercise training improves quality of life and decreases mortality in patients with stable chronic HF. A recent RCT demonstrated a decrease in mortality (NNT = 4 for 14 months) and hospital readmission for HF (NNT = 5) with only moderate exercise on a stationary bicycle (60% of maximum exercise capacity) for 2 to 3 hours per week.38 Other studies have demonstrated improvements in physiologic markers39 and in quality-of-life ratings with short-term, symptom-limited exercise.40
Multidisciplinary or case-management approach. A case-based or disease-management approach to patients with HF decreases the frequency of unplanned and repeat hospitalizations, increases functional status, and increases quality of life.41 Even a single in-home visit by a clinical pharmacist and a nurse results in fewer unplanned readmissions and fewer days of hospitalization up to 18 months after discharge.42,43 A small study of 27 patients in a Veterans Affairs hospital demonstrated that patient instruction in the self-monitoring of weight and blood pressure, combined with frequent telephone follow-up from a nurse, lowered repeat hospitalizations over 1 year, with the effect more pronounced in patients with more severe NYHA classifications.44 A large RCT demonstrated that a multidisciplinary management approach (intensive patient education about HF and its treatment, dietary assessment and instruction, medication analysis and elimination of unnecessary medications, and telephone and home visit follow-up) results in fewer hospitalizations (NNT = 5 for 3 months) and reduced costs of care.45
Treatments that have no benefit or are harmful
Calcium-channel blockers. Although some of the newer, longer-acting calcium-channel blockers (CCBs) appear to be safe in the treatment of heart failure,46-49 no trials are available demonstrating that they lower mortality, decrease hospitalizations, or improve quality of life in patients with a failing heart. Older, short-acting CCBs can worsen HF.50
Positive inotropic therapy. Intermittent positive inotropic therapy, either orally (milrinone) or intravenously (dobutamine), should be avoided. Although short-term studies have shown some increase in cardiac function and symptoms,51 long-term studies demonstrate no mortality benefit.52 One RCT of milrinone demonstrated an increase in mortality (NNH = 17 for 5 months), an increased rate of hospitalization for worsening HF (NNH = 20), and more serious side effects (NNH = 25).53
Prognosis
Despite the increased longevity in Western developed nations and increased survival from coronary artery disease over recent decades, the overall prognosis of HF has improved very little.6,54 Mortality data derived from several different sources, the largest being the Framingham Heart Study,2,55 have shown that HF remains highly lethal, with a 5-year survival rate of 25% in men and 38% in women with NYHA II–IV heart failure. Mortality data from the placebo arms of intervention trials show an average 1-year mortality of 18%.9,17,19,20,56 A recent population-based study of patients with a new diagnosis of HF showed survival rates of only 62% at 12 months and 57% at 18 months.57 Despite these dismal population-based data, predicting the likelihood of survival in individuals with HF is largely unreliable.8 Estimating individual prognosis is only somewhat useful in making end-of-life care and hospice decisions for patients with very advanced HF. Table 2 summarizes specific prognostic factors for patients with HF.
TABLE 2 Factors that affect prognosis in patients with heart failure (HF)
Increasing age and age older than 55 years decreases survival
Framingham data: survival rates of older women are twice as long as those of older men despite significant age difference (women: 72 years; men: 68 years).
Women are underrepresented in HF trials and frequently have HF associated with diastolic dysfunction. Women rate their quality of inpatient care lower than men do.
African Americans have higher mortality rates and higher rates of recurrent hospitalization
HF affects approximately 3% of all African Americans. They develop symptoms at an earlier tage. The disease progresses more rapidly than in whites. African Americans are underrepresented in HF trials.
No difference in 6-month cardiac and all-cause mortality between family physician or generalist and cardiologist care
Family physician or generalist: Twofold increased risk of readmission in 6 months; tend to overestimate risks of ACE inhibitors and therefore under-prescribe them.
Cardiologist (as attending or consultant): Increased testing, hospital lengths of stay, and hospital charges, but better patient-perceived quality of life.
