Treatment focuses on improving the symptoms and preventing the progression of the disease. Reversible causes of heart failure also need to be addressed (e.g.
infection, alcohol ingestion, anemia,
thyrotoxicosis,
arrhythmia, and hypertension). Treatments include lifestyle and pharmacological modalities, and occasionally various forms of device therapy. Rarely, cardiac transplantation is used as an effective treatment when heart failure has reached the end stage.
Acute decompensation In
acute decompensated heart failure, the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that
airway, breathing, and circulation are adequate. Immediate treatments usually involve some combination of vasodilators such as
nitroglycerin, diuretics such as
furosemide, and possibly
noninvasive positive pressure ventilation.
Supplemental oxygen is indicated in those with oxygen saturation levels below 90%, but is not recommended in those with normal oxygen levels in the normal atmosphere.
Chronic management The goals of treatment for people with chronic heart failure are prolonging life, preventing acute decompensation, and reducing symptoms, allowing for greater activity. Heart failure can result from a variety of conditions. In considering therapeutic options, excluding reversible causes is of primary importance, including
thyroid disease,
anemia, chronic
tachycardia,
alcohol use disorder,
hypertension, and dysfunction of one or more
heart valves. Treatment of the underlying cause is usually the first approach to treating heart failure. In most cases, though, either no primary cause is found or treatment of the primary cause does not restore normal heart function. In these cases,
behavioral,
medical and
device treatment strategies exist that can provide a significant improvement in outcomes, including the relief of symptoms, exercise tolerance, and a decrease in the likelihood of
hospitalization or death. Breathlessness rehabilitation for
chronic obstructive pulmonary disease and heart failure has been proposed with exercise training as a core component. Rehabilitation should also include other interventions to address shortness of breath including the psychological and educational needs of people and the needs of caregivers.
Iron supplementation appears to reduce hospitalization but not all-cause mortality in patients with iron deficiency and heart failure.
Advance care planning The latest evidence indicates that advance care planning (ACP) may help to increase documentation by medical staff regarding discussions with participants and improve an individual's depression. This involves discussing an individual's future care plan, preferences, and values. The findings are, however, based on low-quality evidence. Remote monitoring can be effective to reduce complications for people with heart failure.
Lifestyle Behavior modification is a primary consideration in chronic heart failure management programs, with
dietary guidelines regarding
fluid and
salt intake. Fluid restriction is important to reduce fluid retention in the body and to correct the hyponatremic status of the body. Thirst is a common and burdensome symptom for patients to cope with. Chewing gum is an effective intervention to relieve thirst in patients experiencing heart failure, although patient acceptability remains an issue.
Exercise and physical activity Exercise should be encouraged and tailored to suit an individual's capabilities. A meta-analysis found that center-based group interventions delivered by a physiotherapist help promote physical activity in HF. There is a need for additional training for physiotherapists in delivering behavior change intervention alongside an exercise program. An intervention is expected to be more efficacious in encouraging physical activity than the usual care if it includes
Prompts and cues to walk or exercise, like a phone call or a text message. It is helpful if a trusted clinician provides explicit advice to engage in physical activity (
Credible source). Another highly effective strategy is to place objects that will serve as a cue to engage in physical activity in the person's everyday environment (
Adding object to the environment; e.g., exercise step or treadmill). Encouragement to walk or exercise in various settings beyond CR (e.g., home, neighborhood, parks) is also promising (
Generalisation of target behavior). Additional promising strategies are
Graded tasks (e.g., gradual increase in intensity and duration of exercise training),
Self-monitoring,
Monitoring of physical activity by others without feedback,
Action planning, and
Goal-setting. The inclusion of regular physical conditioning as part of a
cardiac rehabilitation program can significantly improve
quality of life and reduce the risk of hospital admission for worsening symptoms, but no evidence shows a reduction in mortality rates as a result of exercise. Home visits and regular monitoring at heart-failure clinics reduce the need for hospitalization and improve
life expectancy.
Medication Quadruple medical therapy using a combination of
angiotensin receptor-neprilysin inhibitors (ARNI),
beta blockers,
mineralocorticoid receptor antagonists (MRA), and
sodium/glucose cotransporter 2 inhibitors (SGLT2 inhibitors) is the standard of care as of 2021 for heart failure with reduced ejection fraction (HFrEF). There is no convincing evidence for pharmacological treatment of heart failure with preserved ejection fraction (HFpEF). Medication for HFpEF is symptomatic treatment with diuretics to treat congestion. is associated with improved survival, fewer hospitalizations for heart failure exacerbations, and improved quality of life in people with heart failure. European guidelines published by ESC in 2021 recommends that ARNI should be used in those who still have symptoms while on an ACE-I or
ARB,
beta blocker, and a
mineralocorticoid receptor antagonist. Use of the combination agent ARNI requires the cessation of ACE-I or ARB therapy at least 36 hours before its initiation. The mortality benefits of beta blockers in people with systolic dysfunction who also have
atrial fibrillation is more limited than in those who do not have it. If the ejection fraction is not diminished (HFpEF), the benefits of beta blockers are more modest; a decrease in mortality has been observed, but reduction in hospital admission for uncontrolled symptoms has not been observed. In people who are intolerant of ACE-I and ARB or who have significant kidney dysfunction, the use of combined
hydralazine and a long-acting nitrate, such as
isosorbide dinitrate, is an effective alternate strategy. This regimen has been shown to reduce mortality in people with moderate heart failure. It is especially beneficial in the black population.
Other medications Second-line medications for CHF do not confer a mortality benefit.
Digoxin is one such medication. Its narrow therapeutic window, a high degree of toxicity, and the failure of multiple trials to show a mortality benefit have reduced its role in clinical practice. It is now used in only a small number of people with refractory symptoms, who are in atrial fibrillation, and/or who have chronic hypotension. Diuretics have been a mainstay of treatment against symptoms of fluid accumulation, and include diuretics classes such as
loop diuretics (such as
furosemide),
thiazide-like diuretics, and
potassium-sparing diuretics. Although widely used, evidence on their efficacy and safety is limited, except for
mineralocorticoid antagonists such as
spironolactone. Anemia is an independent factor in mortality in people with chronic heart failure. Treatment of anemia significantly improves the quality of life for those with heart failure, often with a reduction in severity of the NYHA classification, and also improves mortality rates. The
European Society of Cardiology recommends screening for iron deficiency and treating with
intravenous iron if deficiency is found.
Implanted devices In people with severe cardiomyopathy (left ventricular ejection fraction below 35%), or in those with recurrent VT or malignant arrhythmias, treatment with an automatic implantable cardioverter-defibrillator (AICD) is indicated to reduce the risk of severe life-threatening arrhythmias. The AICD does not improve symptoms or reduce the incidence of malignant arrhythmias but does reduce mortality from those arrhythmias, often in conjunction with antiarrhythmic medications. In people with left ventricular ejection (LVEF) below 35%, the incidence of
ventricular tachycardia or
sudden cardiac death is high enough to warrant AICD placement. Its use is therefore recommended in
AHA/
ACC guidelines. CCM is approved for use in Europe, and was approved by the Food and Drug Administration for use in the United States in 2019. About one-third of people with an
LVEF below 35% have markedly altered conduction to the ventricles, resulting in dyssynchronous depolarization of the right and left ventricles. This is especially problematic in people with left bundle branch block (blockage of one of the two primary conducting fiber bundles that originate at the base of the heart and carry depolarizing impulses to the left ventricle). Using a special pacing algorithm, biventricular
cardiac resynchronization therapy (CRT) can initiate a normal sequence of ventricular depolarization. In people with LVEF below 35% and prolonged QRS duration on ECG (LBBB or QRS of 150 ms or more), an improvement in symptoms and mortality occurs when CRT is added to standard medical therapy. However, in the two-thirds of people without prolonged QRS duration, CRT may be harmful.
Surgical therapies People with the most severe heart failure may be candidates for
ventricular assist devices, which have commonly been used as a bridge to heart transplantation but have been used more recently as a destination treatment for advanced heart failure. Coronary bypass surgery may also be used to move blood around clogged arteries in cases when heart failure is caused by arterial blockages. In select cases, heart transplantation can be considered. While this may resolve the problems associated with heart failure, the person must generally remain on an immunosuppressive regimen to prevent rejection, which has its own significant downsides. A major limitation of this treatment option is the scarcity of hearts available for transplantation.
Palliative care People with heart failure often have significant symptoms, such as chest pain and shortness of breath.
Palliative care should be initiated early in the HF trajectory, and should not be an option of last resort. Palliative care can not only provide symptom management, but also assist with advanced care planning, goals of care in the case of a significant decline, and making sure the person has a medical
power of attorney and discussed his or her wishes with this individual. A 2016 and 2017 review found that palliative care is associated with improved outcomes, such as quality of life, symptom burden, and satisfaction with care. Without transplantation, heart failure may not be reversible and heart function typically deteriorates with time. The growing number of people with stage IV heart failure (intractable symptoms of fatigue, shortness of breath, or chest pain at rest despite optimal medical therapy) should be considered for palliative care or
hospice, according to American College of Cardiology/American Heart Association guidelines. ==Prognosis==