Heart Failure State Management

Pharmacist Focus On Preventing Heart Failure

by Darrell Hulisz, RPh, PharmD
Associate Professor of Family Medicine
Case Western Reserve University, School of Medicine
and Katherine Salay
Pharmacy Intern, Ohio Northern University

Nearly 6 million people in the United States have heart failure (HF), and the annual incidence for those over 65 years of age is estimated to be 10 per 1000. Because HF is difficult to treat, preventing it is imperative. Fortunately, research has identified numerous risk factors associated with the development of left ventricular (LV) remodeling, LV dysfunction, and HF. Prevention of HF and its preceding conditions should be focused on cardiovascular risk factor reduction. Lifestyle modification and drug therapy interventions are both important components of HF prevention.

The management of hypertension is critical in preventing HF since approximately 75% of people with HF have a history of high blood pressure. The goal of antihypertensive therapy is to maintain blood pressure <140/90, and <130/80 for those patients with diabetes or renal disease. Numerous antihypertensive medications have been shown to help prevent the development of HF, including angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, and diuretics. Another important component of the management of hypertension is diet. The Dietary Approaches to Stop Hypertension (DASH) diet has been shown to decrease rates of HF. The DASH diet recommends foods that are low in sodium and high in fiber, potassium, calcium, and magnesium. Sodium intake should be restricted to <1500mg/day.

Coronary artery disease (CAD), including prior myocardial infarction (MI) is also a major risk factor for HF. Those patients who have a history of MI are 8-10 times more likely to develop HF than those who do not. While it is unknown if hyperlipidemia directly contributes to the development of HF, it is associated with CAD. Thus, it should be appropriately managed to prevent CAD and subsequent HF. The goals for the management of hyperlipidemia for preventing HF are consistent with the National Cholesterol Education Program (NCEP) Guidelines.

Other known modifiable risk factors for the development of HF include diabetes mellitus, obesity, poor diet, and physical inactivity. Diabetes should be managed according to the recommendations from the American Diabetes Association. Obesity is defined as a body mass index (BMI) > 30 kg/m2, so the initial goal is to maintain a BMI less than this value, but the American Heart Association suggests that an ideal BMI is 25-27 kg/ m2. Even more important to preventing HF than reducing BMI may be minimizing waist circumference. Increasing physical aerobic activity to 20-30 minutes, 3-5 times a week, and improving diet can help accomplish this. Eating at least 4 servings of fruits and vegetables per day and at least 1 serving of breakfast cereal per week has shown to decrease the lifetime risk of developing HF. Excessive alcohol consumption and smoking are two additional risk factors that can be managed with lifestyle modifications. The Heart Failure Society of American recommends that men limit alcohol intake to 2 drinks per day, and women to 1 drink per day. They also recommend smoking cessation for the entire population.

In addition to risk factor management, the use of ACE inhibitors and beta-blockers is an essential component of HF prevention. The benefit of these medications goes beyond their role in managing hypertension. ACE inhibitors have demonstrated the ability to reduce HF risk by as much as 26% in patients that are at high risk for developing the disease, including those with CAD, peripheral vascular disease, stroke, and diabetes, and thus should be used in these populations. ARBs are an appropriate alternative for those patients who do not tolerate ACE inhibitors. Beta-blockers are recommended for use in patients with a history of MI to reduce recurrent MI, mortality, and development of HF because of their ability to decrease cardiac ischemia and remodeling. In the first year after an MI, beta-blockers demonstrated a 25-45% risk reduction for the development of HF.

Although HF is a common disease in the United States, many risk factors for its development have been identified. The focus of its prevention should be risk factor reduction, as well as the appropriate use of pharmacologic interventions.

Join Darrell on Tuesday, February 14th from 11:00 AM – 12:00 PM Eastern Time as he presents the Live webinar "Heart Failure, Your Patient's & Advancements in Drug Therapies". Purchase at the special sale price of $18.00!!

References:

Arnold JM, Yusuf S, Young J, Mathew J, Johnstone D, Avezum A, et al. Prevention of heart failure in patients in the heart outcomes prevention evaluation (HOPE) study. Circulation 2003;107:1284-90.
Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 2001;357:1385-90.
Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16:e1-194.
Levitan EB, Wolk A, Mittleman MA. Consistency with the DASH diet and incidence of heart failure. Arch Intern Med 2009;169:851-7.
Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischemic attack. Lancet 2001;358:1033-41.
Roger VL, Go AS, Lloyd-James DM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation 2011;123:18-209.

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Heart Failure State Management

Pharmacist Focus On Preventing Heart Failure

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