Treatment of Heart Failure

Advanced Therapies for the Treatment of Heart Failure

Despite the progress in treatments for patients with heart failure (HF), many have a decline in function and worse symptoms. Patients may need to be hospitalized if their symptoms do not respond to changes in medications. This is called Acutely Decompensated HF (ADHF). When the heart is weaker, the body holding on to fluid causes problems. Symptoms include swelling of the feet, legs and/or belly and having more shortness of breath. Nausea and not feeling like eating are also common. Many have low blood pressure making them feel dizzy or faint. They may also have cold hands and feet. Many times these symptoms respond to a course of treatment in the hospital and patients feel much better upon discharge.

Sadly, some patients do not improve to the point where they can go home on oral medications alone. Some people with HF are brought to the hospital many times with ADHF. Or they no longer are able to take their HF meds because they make them feel worse. These patients may need more advanced treatments.

Advanced treatments provide support to people with a failing heart. They are termed "advanced" because they are more complex than taking pills, having a pacemaker, and changing lifestyle. ADHF treatment consists of three options: constant intravenous (IV) medications, mechanical circulatory support (partial or total artificial hearts), and heart transplants. These treatments can only be ordered by special HF doctors who care for others with this type of HF.

Continuous IV medications are chosen for patients who feel better when getting these meds in the hospital and who feel worse when they are stopped. These meds help the heart pump better. The two reasons that these medications are used are as a "bridge" to transplant and as palliative treatment. Palliative care is focused on easing the stress, pain and symptoms of a severe or chronic illness. Palliative care may be given even when treatments are still underway to cure the illness. The goal is to improve your quality of life.

Patients waiting for a heart transplant must wait until a matched donor organ is ready and need to be in the best shape they can be for the surgery. These medications help the heart to keep the blood flowing to all the organs. Some patients are not able to have a transplant, and these drugs are used to keep the patient out of the hospital and to improve their comfort.

In order to receive these meds the patient must have a long-term IV (usually a line placed in one of the large veins) and a good support system to help. Insurances and Medicare support this service. It is started in the hospital where measures of your heart function and pressures are watched to see if the meds help. After going home, the patient is followed by a home health nurse and pharmacist who will teach the patient and family how to care for the IV, the pump, the medicine, and change the dressings.

For some patients, IV meds are not enough. These patients may need mechanical circulatory support, or heart pumps, to help keep the blood pumping to organs. There are three types of support—short-term, as a bridge to transplant and as lasting treatment. Short-term support allows very ill patients to get better after an event such as a heart attack or heart surgery. These patients remain in an Intensive Care Unit.

Longer support may be needed for patients either as a bridge to transplant or as lasting treatment. Bridge to transplant support can be given either to the left side of the heart (which pumps blood to the body) or to both sides. Pumps also can replace the heart. Some patients with left sided support, also known as LVAD ( Left Ventricular Assist Device), can be sent home after getting over surgery. Patients are able to do most things with the pump while at home. Patient must have a good support system that will help them care for the pump. Insurances and Medicare support this service at approved facilities.

Some patients may need support to both sides of their heart. Options for these patients are few. One option is to replace the pumping chambers of the heart with a total artificial heart. Now, patients needing an artificial heart must stay in the hospital, but this may change in the near future. Most insurances and Medicare support this service at an approved transplant facility.

Lasting support is a heart pump for patients who cannot have a transplant. There are two devices that have been approved by the Food and Drug Administration for this use—the HeartMate I & II. These patients must have a good social support system to help them care for the pump. They are sent home from the hospital and can do most things that they enjoy. Most insurances and Medicare support this service at approved facilities.

Heart transplantation is the final option for ADHF. Heart transplantation has been performed since the late 1960s and has been shown to be a very good treatment for end-stage HF. Heart transplant patients can expect to live up to ten to twenty years after their transplant. Some patients live longer. Sadly, the number of donor hearts is only about 2200 each year in the United States. Having a transplant means that patients and their support system must be active partners in their care for the long term.

Patients go through a detailed work-up before being chosen for a heart transplant. Many special team members and doctors meet with the patient to decide if this treatment is right for you. Besides their heart problems, patients must be healthy, without a lot of other health issues, and have a good social support system. This team includes transplant coordinators, social workers and psychologists as well as the special HF doctors and surgeons. Patients who smoke or abuse drugs or alcohol will not get a heart transplant. If someone has other health issues that may shorten life or affect the quality of life, they may not get a heart transplant. These include high blood sugar, vessel problems in your legs or arms, cancer, or infection throughout the body. Most insurance and Medicare will pay for a heart transplant at an approved facility.