Skip to main content
SpringerLink
Log in

Treatment of heart failure with decreased left ventricular ejection fraction

  • Original Articles
  • Published:
Comprehensive Therapy

Original Article

Class I recommendations for treating patients with current or prior symptoms of heart failure with reduced left ventricular ejection fraction (LVEF) include using diuretics and salt restriction in individuals with fluid retention. Use angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and angiotensin II receptor blockers if intolerant to ACE inhibitors because of cough or angioneurotic edema. Nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and calcium channel blockers should be avoided or withdrawn. Exercise training is recommended. Implant cardioverter-defibrillator (ICD) is recommended in individuals with a history of cardiac arrest, ventricular fibrillation, or hemodynamically unstable ventricular tachycardia. ICD is indicated in patients with ischemic heart disease for at least 40 d post-myocardial infarction or nonischemic cardiomyopathy, an LVEF of 30% or less, New York Heart Association (NYHA) class II or III symptoms on optimal medical therapy, and an expectation of survival of at least 1 yr. Cardiac resynchronization therapy should be used in individuals with an LVEF of 35% or below, NYHA class III or IV symptoms despite optimal therapy, and a QRS duration greater than 120 ms. An aldosterone antagonist can be added in selected patients with moderately severe to severe symptoms of heart failure who can be carefully monitored for renal function and potassium concentration (serum creatinine should be ≶2.5 mg/dL in men and ≶2.0 mg/dL in women; serum potassium should be <5.0 mEq/L).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hunt SA, Abraham WT, Feldman AM, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult-summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). Developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation. Endorsed by the Heart Rhythm Society. J Am Coll Cardiol 2005; 46:1116–1143.

    Article  Google Scholar 

  2. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). Developed in collaboration with the International Society for Heart and Lung Transplantation. Endorsed by the Heart Failure Society of America. J Am Coll Cardiol 2001; 38: 2101–2113.

    Article  CAS  PubMed  Google Scholar 

  3. Aronow WS, Ahn C, Kronzon I. Prognosis of congestive heart failure after prior myocardial infarction in older men and women with abnormal versus normal left ventricular ejection fraction. Am J Cardiol 2000;85:1382–1384.

    Article  CAS  PubMed  Google Scholar 

  4. Lee DS, Tu JV, Juurlink DN, et al. Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA 2005;294:1240–1247.

    Article  CAS  PubMed  Google Scholar 

  5. Aronow WS, Ahn C. Frequency of congestive heart failure in older persons with prior myocardial infarction and serum low-density lipoprotein cholesterol ≥125 mg/dL treated with statins versus no lipid-lowering drug. Am J Cardiol 2002;90:147–149.

    Article  CAS  PubMed  Google Scholar 

  6. Aronow WS, Ahn C. Elderly diabetics with peripheral arterial disease and no coronary artery disease have a higher incidence of new coronary events than elderly nondiabetics with peripheral arterial disease and prior myocardial infarction treated with statins and with no lipid-lowering drug. J Gerontol: Med Sci 2003;58A: M573-M575.

    Article  Google Scholar 

  7. The CONSENSUS Trial Study Group. Effect of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N EnglJ Med 1987;316:1429–1435.

    Article  Google Scholar 

  8. Cohn J, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991;325:303–310.

    Article  CAS  PubMed  Google Scholar 

  9. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293–302.

    Article  Google Scholar 

  10. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet 1993;342:821–828.

    Google Scholar 

  11. Garg R, Yusuf for the Collaborative Group on ACE Inhibitor Trials. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995;273:1450–1456.

    Article  CAS  PubMed  Google Scholar 

  12. Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation 1999;100:2312–2318.

    Article  CAS  PubMed  Google Scholar 

  13. CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999;353:9–13.

    Article  Google Scholar 

  14. MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999;353: 2001–2007.

    Article  Google Scholar 

  15. Packer M, Coats AJS, Fowler MB, et al. Effect of carvedilol on survival in chronic heart failure. N Engl J Med 2001;344:651–658.

    Article  Google Scholar 

  16. Flather MD, Shibata MC, Coats AJS, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005;26:215–225.

    Article  CAS  PubMed  Google Scholar 

  17. Aronow WS, Ahn C, Kronzon I. Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction ≥40% treated with diuretics plus angiotensin-converting-enzyme inhibitors. Am J Cardiol 1997;80:207–209.

    Article  CAS  PubMed  Google Scholar 

  18. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology: W. J. Remme and K. Swedberg (Co-Chairmen). Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22:1527–1560.

    Article  Google Scholar 

  19. Granger CB, McMurray JJV, Yusuf S, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003;362:772–776.

    Article  CAS  PubMed  Google Scholar 

  20. Aronow WS. Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure. Cardiol in Review 2006; 14:108–124.

    Article  Google Scholar 

  21. Aronow WS. Exercise therapy for older persons with cardiovascular disease. Am J Geriatr Cardiol 2001;10:245–252.

    Article  CAS  PubMed  Google Scholar 

  22. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Eng J Med 1995;333:1190–1195.

    Article  CAS  Google Scholar 

  23. Knight BP, Goyal R, Pelosi F, et al. Outcome of patients with nonischemic cardiomyopathy and unexplained syncope treated with an implantable defibrillator. J Am Coll Cardiol 1999;33:1964–1970.

    Article  CAS  PubMed  Google Scholar 

  24. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Eng J Med 2005;352:225–237.

    Article  CAS  Google Scholar 

  25. Aronow WS. CRT plus ICD in congestive heart failure. Use of cardiac resynchronization therapy and an implantable cardioverterdefibrillator in heart failure patients with abnormal left ventricular dysfunction. Geriatrics 2005;60 (2):24–28.

    PubMed  Google Scholar 

  26. Cleland JGF, Daubert J-C, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Eng J Med 2005;352:1539–1549.

    Article  CAS  Google Scholar 

  27. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med1999;341:709–717.

    Article  CAS  PubMed  Google Scholar 

  28. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309–1321.

    Article  CAS  PubMed  Google Scholar 

  29. Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004;351:2049–2057.

    Article  CAS  PubMed  Google Scholar 

  30. Aronow WS. Race, drugs, and heart failure. Geriatrics 2005;60(7):8–9.

    PubMed  Google Scholar 

  31. The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336: 525–533.

    Article  Google Scholar 

  32. Rich MW, McSherry F, Williford WO, et al. Effect of age on mortality, hospitalizations and response to digoxin in patients with heart failure: the DIG Study. J Am Coll Cardiol 2001;38:806–813.

    Article  CAS  PubMed  Google Scholar 

  33. Rathore SS, Wang Y, Krumholz HM: Sex-based differences in the effect of digoxin for the treatment of heart failure. N Eng J Med 2002;347:1403–1411.

    Article  CAS  Google Scholar 

  34. Rathore SS, Curtis JP, Wang Y, et al. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA 2003;289:871–878.

    Article  CAS  PubMed  Google Scholar 

  35. Ahmed A, Aban IB, Weaver MT, et al. Serum digoxin concentration and outcomes in women with heart failure: a bi-directional effect and a possible effect modification by ejection fraction. Eur J Heart Failure 2006;8:409–441.

    Article  CAS  Google Scholar 

  36. Aronow WS. Digoxin or angiotensin converting enzyme inhibitors for congestive heart failure in geriatric patients. Which is the preferred treatment? Drugs Aging 1991;1:98–103.

    Article  CAS  PubMed  Google Scholar 

  37. O’Connor CM, Gattis WA, Uretsky BF, et al. Continuous intravenous dobutamine is associated with an increased risk of death in patients with advanced heart failure: insights from the Flolan International Randomized Survival Trial (FIRST). Am Heart J 2000; 138:78–86.

    Article  Google Scholar 

  38. McMurray J, Pfeffer MA. New therapeutic options in congestive heart failure. Part II. Circulation 2002;105:2223–2228.

    Article  PubMed  Google Scholar 

  39. Gheorghiade M, Gattis WA, O’Connor CM, et al. Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. JAMA 2004;291:1963–1971.

    Article  CAS  PubMed  Google Scholar 

  40. Publication Committee for the VMAC Investigators. Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure. A randomized controlled trial. JAMA 2002;287:1531–1540.

    Google Scholar 

  41. Teerlink JR, Massie BM. Nesiritide and worsening of renal function. The emperor’s new clothes? Circulation 2005; 111:1459–1461.

    Article  PubMed  Google Scholar 

  42. Sackner-Bernstein JD, Skopicki HA, Aaronson KD. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation 2005;111:1487–1491.

    Article  CAS  PubMed  Google Scholar 

  43. Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure. A pooled analysis of randomized controlled trials. JAMA 2005;293:1900–1905.

    Article  CAS  PubMed  Google Scholar 

  44. Athanasuleas CL, Stanley AW Jr, Buckberg GD, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV. J Am Coll Cardiol 2001;37:1210–1213.

    Article  Google Scholar 

  45. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–1443.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine, Department of Medicine, New York Medical College, Valhalla, NY

    Wilbert S. Aronow MD

Authors
  1. Wilbert S. Aronow MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wilbert S. Aronow MD.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Aronow, W.S. Treatment of heart failure with decreased left ventricular ejection fraction. Compr Ther 32, 218–225 (2006). https://doi.org/10.1007/BF02698066

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02698066

Keywords

Search

Navigation