Primary prevention
Primary prevention is important for those at risk for HF (stage A) and for those with pre-HF (stage B).[7]
HF is the final pathway for a wide array of pathophysiological processes. Interventions that reduce the risk of development of any cardiovascular disease will ultimately reduce the incidence of HF.[95][96] Thus, key public health targets are prevention of development of underlying causes and comorbidities: hypertension, diabetes, dyslipidaemia, obesity (i.e., metabolic syndrome), and ischaemic heart disease.
Lifestyle modifications, such as increasing physical activity, reducing tobacco, alcohol, and recreational drug use, and reducing daily salt intake, and proper medical treatment of established diseases such as hypertension, diabetes, and coronary artery disease, are expected to help reduce incident HF.[7][95][96][97][98]
The US Preventive Services Task Force recommends that adults at increased risk of cardiovascular disease are offered behavioural counselling interventions to promote a healthy diet and physical activity; those not at high risk may also be considered for behavioural counselling interventions.[99][100]
The American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines recommend additional measures for those with pre-HF (stage B) to prevent or delay progression to symptomatic HF. Patients with pre-HF and left ventricular ejection fraction (LVEF) ≤40% should receive ACE inhibitors and beta-blockers; angiotensin-II receptor antagonists should be used if the patient is intolerant to ACE inhibitors and has had a recent myocardial infarction.[7] Drugs that can cause or potentiate heart failure should be avoided, if possible. In patients with LVEF <50%, thiazolidinediones and nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) are not recommended. Thiazolidinediones increase the risk of heart failure, including hospitalisations; negative inotropic effects of nondihydropyridine calcium-channel blockers may be harmful.[7]
Secondary prevention
Risk factor modification is the key to preventing or delaying the onset of overt clinical heart failure. Physicians are advised to:
Monitor blood pressure as closely as necessary to meet targets based on guidelines. The American College of Cardiology/American Heart Association guidelines recommend a target of <130/80 mmHg for patients with HFrEF, avoiding the use of nitrates.[315]
Monitor volume status (daily weights and adjustment of diuretic dose as necessary).
Pursue revascularisation in patients with coronary artery disease, when appropriate; aggressive medical management of ischaemia is advised.
Maintain adequate rate control in patients with tachyarrhythmias (e.g., atrial fibrillation); if there is difficulty in achieving rate control or there is substantial symptom burden from the arrhythmia, rhythm control, and maintenance of sinus rhythm should be considered. Anticoagulation should be considered in all patients with atrial fibrillation (based on validated clinical risk score, such as CHA2DS2-VASc) unless contraindicated. Very aggressive rate control (especially with beta blockers) should be avoided, as patients may have significant LA dysfunction with low stroke volume and inability to increase stroke volume during exercise.
Use sodium-glucose cotransporter-2 (SGLT2) inhibitor for management of hyperglycaemia in patients with diabetes.[314]
Optimise HF therapies in patients with chronic kidney disease.[314]
Treat obstructive sleep apnoea if present.
Promote weight loss in overweight patients. Surgically induced weight loss may be considered in patients with class III obesity (BMI 40 or above).
Encourage tobacco and alcohol discontinuation.
Encourage regular aerobic exercise and consider cardiac rehabilitation when appropriate.
Use of this content is subject to our disclaimer