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Medical Author:

Daniel Lee Kulick, MD, FACC, FSCAI

Daniel Lee Kulick, MD, FACC, FSCAI

Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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In this Article

• Congestive heart failure facts
• What is congestive heart failure?
• What causes congestive heart failure?
• What are the symptoms of congestive heart failure (CHF)?
• How is congestive heart failure diagnosed?
• What is the treatment of congestive heart failure?
• Lifestyle modifications
• Medications
• Heart transplant
• Other mechanical therapies
• What is the long term outlook for patients with congestive heart failure?
• What are the areas of new research in congestive heart failure?
• Patient Comments: Congestive Heart Failure - Lifestyle Changes
• Patient Comments: Congestive Heart Failure - Causes
• Patient Comments: Congestive Heart Failure - Symptoms
• Patient Comments: Congestive Heart Failure - Prognosis
• Patient Comments: Congestive Heart Failure - Treatment
• Find a local Cardiologist in your town
• Congestive Heart Failure Index

Until recently, the selection of medications available for the treatment of congestive heart failure was frustratingly limited and focused mainly on controlling the symptoms. Medications have now been developed that both improve symptoms, and, importantly, prolong survival.

Angiotensin Converting Enzyme (ACE) Inhibitors

ACE inhibitors have been used for the treatment of hypertension for more than 20 years. This class of drugs has also been extensively studied in the treatment of congestive heart failure. These medications block the formation of angiotensin II, a hormone with many potentially adverse effects on the heart and circulation in patients with heart failure. In multiple studies of thousands of patients, these drugs have demonstrated a remarkable improvement of symptoms in patients, prevention of clinical deterioration, and prolongation of survival. In addition, they have been recently been shown to prevent the development of heart failure and heart attacks. The wealth of the evidence supporting the use of these agents in heart failure is so strong that ACE inhibitors should be considered in all patients with heart failure, especially those with heart muscle weakness.

Possible side effects of these drugs include:

• a nagging, dry cough,
  
  
• low blood pressure,
  
  
• worsening kidney function and electrolyte imbalances, and
  
  
• rarely, true allergic reactions.

When used carefully with proper monitoring, however, the majority of individuals with congestive heart failure tolerate these medications without significant problems. Examples of ACE inhibitors include:

• captopril (Capoten),
  
  
• enalapril (Vasotec),
  
  
• lisinopril (Zestril, Prinivil),
  
  
• benazepril (Lotensin), and
  
  
• ramipril (Altace).

For those individuals who are unable to tolerate the ACE inhibitors, an alternative group of drugs, called the angiotensin receptor blockers (ARBs), may be used. These drugs act on the same hormonal pathway as the ACE inhibitors, but instead block the action of angiotensin II at its receptor site directly. A small, early study of one of these agents suggested a greater survival benefit in elderly congestive heart failure patients as compared to an ACE inhibitor. However, a larger, follow-up study failed to demonstrate the superiority of the ARBs over the ACE inhibitors. Further studies are underway to explore the use of these agents in congestive heart failure both alone and in combination with the ACE inhibitors.

Possible side effects of these drugs are similar to those associated with the ACE inhibitors, although the dry cough is much less common. Examples of this class of medications include:

• losartan (Cozaar),
  
  
• candesartan (Atacand),
  
  
• telmisartan (Micardis),
  
  
• valsartan (Diovan),
  
  
• irbesartan (Avapro), and
  
  
• olmesartan (Benicar).

Beta-blockers

Certain hormones, such as epinephrine (adrenaline), norepinephrine, and other similar hormones, act on the beta receptor's of various body tissues and produce a stimulative effect. The effect of these hormones on the beta receptors of the heart is a more forceful contraction of the heart muscle. Beta-blockers are agents that block the action of these stimulating hormones on the beta receptors of the body's tissues. Since it was assumed that blocking the beta receptors further depressed the function of the heart, beta-blockers have traditionally not been used in persons with congestive heart failure. In congestive heart failure, however, the stimulating effect of these hormones, while initially useful in maintaining heart function, appears to have detrimental effects on the heart muscle over time.

However, studies have demonstrated an impressive clinical benefit of beta-blockers in improving heart function and survival in individuals with congestive heart failure who are already taking ACE inhibitors. It appears that the key to success in using beta-blockers in congestive heart failure is to start with a low dose and increase the dose very slowly. At first, patients may even feel a little worse and other medications may need to be adjusted.

Possible side effects include:

• fluid retention,
  
  
• low blood pressure,
  
  
• low pulse, and
  
  
• general fatigue and lightheadedness.

Beta-blockers should generally not be used in people with certain significant diseases of the airways (for example, asthma, emphysema) or very low resting heart rates. While carvedilol (Coreg) has been the most thoroughly studied drug in the setting of congestive heart failure, studies of other beta-blockers have also been promising. Research comparing carvedilol directly with other beta-blockers in the treatment of congestive heart failure is ongoing. Long acting metoprolol (Toprol XL) is also very effective in individuals with congestive heart failure.

Digoxin

Digoxin (Lanoxin) has been used in the treatment of congestive heart failure for hundreds of years. It is naturally produced by the foxglove flowering plant. Digoxin stimulates the heart muscle to contract more forcefully. It also has other actions, which are not completely understood, that improve congestive heart failure symptoms and can prevent further heart failure. However, a large-scale randomized study failed to demonstrate any effect of digoxin on mortality.

Digoxin is useful for many patients with significant congestive heart failure symptoms, even though long-term survival may not be affected. Potential side effects include:

• nausea,
  
  
• vomiting,
  
  
• heart rhythm disturbances,
  
  
• kidney dysfunction, and
  
  
• electrolyte abnormalities.

These side effects, however, are generally a result of toxic levels in the blood and can be monitored by blood tests. The dose of digoxin may also need to be adjusted in patients with significant kidney impairment.

Diuretics

Diuretics are often an important component of the treatment of congestive heart failure to prevent or alleviate the symptoms of fluid retention. These drugs help keep fluid from building up in the lungs and other tissues by promoting the flow of fluid through the kidneys. Although they are effective in relieving symptoms such as shortness of breath and leg swelling, they have not been demonstrated to positively impact long-term survival.

Nevertheless, diuretics remain key in preventing deterioration of the patient's condition thereby requiring hospitalization. When hospitalization is required, diuretics are often administered intravenously because the ability to absorb oral diuretics may be impaired, when congestive heart failure is severe. Potential side effects of diuretics include:

• dehydration,
  
  
• electrolyte abnormalities,
  
  
• particularly low potassium levels,
  
  
• hearing disturbances, and
  
  
• low blood pressure.

It is important to prevent low potassium levels by taking supplements, when appropriate. Such electrolyte disturbances may make patients susceptible to serious heart rhythm disturbances. Examples of various classes of diuretics include:

• furosemide (Lasix),
  
  
• hydrochlorothiazide (Hydrodiuril),
  
  
• bumetanide (Bumex),
  
  
• torsemide (Demadex),
  
  
• spironolactone (Aldactone), and
  
  
• metolazone (Zaroxolyn).

One particular diuretic has been demonstrated to have surprisingly favorable effects on survival in congestive heart failure patients with relatively advanced symptoms. Spironolactone (Aldactone) has been used for many years as a relatively weak diuretic in the treatment of various diseases. Among other things, this drug blocks the action of the hormone aldosterone.

Aldosterone has many theoretical detrimental effects on the heart and circulation in congestive heart failure. Its release is stimulated in part by angiotensin II (see ACE inhibitors, above). In patients taking ACE inhibitors, however, there is an "escape" phenomenon in which aldosterone levels can increase despite low levels of angiotensin II. Medical researchers have found that spironolactone (Aldactone) can improve the survival rate of patients with congestive heart failure. In that the doses used in the study were relatively small, it has been theorized that the benefit of the drug was in its ability to block the effects of aldosterone rather than its relatively weak action as a diuretic (water pill). Possible side effects of this drug include elevated potassium levels and, in males, breast tissue growth (gynecomastia).

Another aldosterone inhibitor is eplerenone (Inspra).