Practice recommendations
- Use B-type natriuretic peptide (BNP) levels as an aid not only in the diagnosis of heart failure (HF), but to track its progression as well (A).
- Prescribe exercise training for patients with stable heart failure; exercising at 40% to 70% of maximum capacity for 20 to 45 minutes several times a week offers benefits on par with pharmacotherapy (A).
- Consider using the Simplified Treatment Intervention to Control Hypertension (STITCH) algorithm for hypertensive patients or those who are at risk of developing HF; this step-care strategy is effective in treating hypertension, a leading cause of HF (C).
- Consult a specialist before prescribing both an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin receptor blocker (ARB) for a patient with advanced HF; studies of combination therapy for this patient population have had mixed results (C).
Strength of recommendation (SOR)
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
Family physicians are all too familiar with heart failure (HF). This debilitating condition accounts for approximately 3.4 million outpatient visits to US physicians annually,1 and fully two-thirds of HF patients are cared for by primary care physicians.2
A host of comorbid conditions—coronary artery disease, valvular heart disease, diabetes, dyslipidemia, metabolic syndrome, obesity, chronic renal insufficiency, and hypertension chief among them—contribute to the development of HF.3 Of these, hypertension is the most important factor. In more than 75% of cases, high blood pressure precedes HF,1 and an individual’s lifetime risk of developing HF is strongly associated with poor blood pressure control.4 Hypertension is the most significant controllable factor in the management of HF as well. Because of the nexus between hypertension and HF, we encourage physicians to think of these 2 conditions as a single entity—and to recognize that a reduction of even a few millimeters of mercury can have huge clinical benefits.
This review, which highlights a recently tested hypertension algorithm along with other recent developments and long-established treatment strategies, will help you do everything possible to slow the progression of this debilitating and deadly disease.
BNP’s increasing role in evaluating heart failure
A diagnosis of HF in patients with known heart disease is based on functionality and symptoms, assessed with the help of 2 classification schemes5,6 ( TABLE 1 ) and a variety of tests. (Patients who present with the signs and symptoms of HF but no evidence of the comorbid conditions typically associated with it should be screened for other, noncardiac causes—human immunodeficiency virus, hepatitis C, hemochromatosis, hypothyroidism, and substance abuse among them.6 )
Diagnostic testing. Baseline serum chemistries include a complete blood count, urinalysis, electrolytes, magnesium, blood urea nitrogen, creatinine, and blood glucose levels, and liver and thyroid function tests.
B-type natriuretic peptide (BNP), a homeostatic marker secreted by the heart in an attempt to maintain stable blood pressure and plasma volume and avoid fluid retention, is increasingly recognized as an important aid, not only in diagnosing HF but in gauging its severity, managing symptoms, and determining the prognosis.7,8 BNP concentrations <80 pg/mL have been found to have a negative predictive value of 98%, and are also highly sensitive (98%) and specific (98%) for the diagnosis of HF.9,10
Testing may also include a 12-lead electrocardiogram as well as a posterior-anterior/lateral chest x-ray. Echocardiography is often used to evaluate left ventricular function and ejection fraction6 —a key to establishing whether the patient has systolic (reduced ejection fraction) or diastolic (preserved ejection fraction) HF.
An ejection fraction ≤40% is characteristic of systolic HF, which affects approximately 60% of patients with heart failure11 and is the focus of the following discussion of treatments.
TABLE 1
Classifying heart failure: 2 systems
| NEW YORK HEART ASSOCIATION |
| Class I: No limitation of physical activity; ordinary activity does not cause undue fatigue or dyspnea. Class II: Slight limitation of activity; comfortable at rest, but ordinary physical activity results in fatigue or dyspnea. Class III: Marked limitation in activity. Class IV: Unable to carry on any physical activity without symptoms; symptoms present even at rest. |
| AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION |
| Stage A: Conditions strongly associated with heart failure (HF); at high risk of HF. No identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves; no signs or symptoms of HF. Stage B: Structural heart disease strongly associated with HF, but no known signs or symptoms. Stage C: Current or prior symptoms of HF associated with underlying structural heart disease. Stage D: Advanced structural heart disease, with marked symptoms of HF at rest despite maximal medical therapy. Specialized interventions required. |
| Sources: Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels–Nomenclature and Criteria for Diagnosis. 6th ed. 1964;5 Hunt et al. Circulation. 2005.6 |