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 pathophysiologic 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, dyslipidemia, obesity (i.e., metabolic syndrome), and ischemic 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 behavioral counseling interventions to promote a healthy diet and physical activity; those not at high risk may also be considered for behavioral counseling 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 (MI).[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 hospitalizations; negative inotropic effects of nondihydropyridine calcium-channel blockers may be harmful.[7]
The table that follows summarizes recommendations for primary prevention of heart failure taken from the AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.[7]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Stage A: at risk for heart failure
Without current or previous symptoms/signs of heart failure, and without structural heart disease, or cardiac biomarkers of stretch or injury; this includes people with: hypertension, atherosclerotic CVD (cardiovascular disease), diabetes, metabolic syndrome and obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy or family history of cardiomyopathy; note that in the general population, validated multivariable risk scores can be useful to estimate subsequent risk of incident heart failure
With hypertension
Intervention
Blood pressure control
Optimize blood pressure control using lifestyle interventions +/- antihypertensive medication to reduce blood pressure in line with published clinical guidance on management of hypertension.
Goal
Prevention of symptomatic heart failure
With cardiovascular disease (CVD)
Intervention
Optimal management of CVD
Ensure that the patient is receiving recommended interventions to optimize CVD control in line with published clinical guidance on management of CVD.
Goal
Reduced future risk of heart failure
With type 2 diabetes, with established CVD or high CVD risk
Intervention
Sodium-glucose cotransporter-2 (SGLT2) inhibitor
In addition to interventions to optimize guideline-based care for type 2 diabetes, an SGLT2 inhibitor is recommended in this group.
Goal
Prevention of hospitalization for heart failure
With exposure to cardiotoxic agents
Intervention
Referral for multidisciplinary evaluation
Refer for multidisciplinary evaluation and management; the specialist team may initiate monitoring strategies including serial monitoring of LVEF or biomarkers to identify subclinical cardiac injury.
The team may also recommend use of cardioprotective agents, and/or temporary or permanent interruption of the cardiotoxic drug.
Goal
Reduced risk of progression to heart failure
First-degree relative with genetic or inherited cardiomyopathy; and positive genetic screening result
Intervention
Genetic counseling, plus referral for guideline-directed management of specific cardiomyopathy subtype
Prompt consideration of treatment is recommended.
Genetic testing contributes to risk stratification and may guide treatment selection including use of:
defibrillators for primary prevention of sudden death, and
exercise limitation for hypertrophic cardiomyopathy and the desmosomal variants.
Consultation with a trained counselor before and after genetic testing is recommended to help the patient understand and weigh the implications of possible results for their own lives and those of family members, including the potential for discrimination on the basis of genetic information.
Goal
Decreased heart failure progression and sudden death
Stage B: pre-heart failure
Without current or previous symptoms/signs of heart failure but with evidence of at least one of the following: structural heart disease (reduced left or right ventricular systolic function; reduced ejection fraction, reduced strain; ventricular hypertrophy; chamber enlargement; wall motion abnormalities; valvular heart disease); evidence of increased filling pressures (by invasive hemodynamic measurements, or noninvasive imaging suggesting elevated filling pressures [e.g., doppler echocardiography]); with risk factors and increased levels of natriuretic peptide (BNP ≥35 pg/mL, NT-proBNP ≥125 pg/mL) or persistently elevated cardiac troponin, in the absence of competing diagnoses resulting in such biomarker elevations such as acute coronary syndrome, CKD, pulmonary embolus, or myopericarditis.
With hypertension
Intervention
Blood pressure control
Optimize blood pressure control using lifestyle interventions +/- antihypertensive medication to reduce blood pressure in line with published clinical guidance on management of hypertension.
Goal
Prevention of symptomatic heart failure
With CVD
Intervention
Optimal management of CVD
Ensure that the patient is receiving recommended interventions to optimize CVD control in line with published clinical guidance on management of CVD.
Goal
Reduced future risk of heart failure
With type 2 diabetes, with established CVD or high CVD risk
Intervention
SGLT2 inhibitor
In addition to interventions to optimize guideline-based care for type 2 diabetes, an SGLT2 inhibitor is recommended in this group.
Goal
Prevention of hospitalization for heart failure
With elevated BNP or NT-proBNP (BNP ≥35 pg/mL, NT-proBNP ≥125 pg/mL)
Intervention
Referral for cardiovascular team-based care
Refer people with elevated natriuretic peptide biomarkers to a cardiovascular specialist for diagnostic evaluation and treatment.
Goal
Prevention of development of LV dysfunction (systolic or diastolic) or new-onset heart failure
With exposure to cardiotoxic agents
Intervention
Referral for multidisciplinary evaluation
Refer for multidisciplinary evaluation and management; the specialist team may initiate monitoring strategies including serial monitoring of LVEF or biomarkers to identify subclinical cardiac injury.
The team may also recommend use of cardioprotective agents, and/or temporary or permanent interruption of the cardiotoxic drug.
Goal
Reduced risk of progression to heart failure
First-degree relative of a person with genetic or inherited cardiomyopathy, or with personal history of nonischemic cardiomyopathy; and with positive genetic screening result
Intervention
Genetic counseling, plus referral for guideline-directed management of specific cardiomyopathy subtype
Prompt consideration of treatment is recommended.
Genetic testing contributes to risk stratification may guide treatment selection including use of:
defibrillators for primary prevention of sudden death, and
exercise limitation for hypertrophic cardiomyopathy and the desmosomal variants.
Consultation with a trained counselor before and after genetic testing is recommended to help the patient to understand and weigh the implications of possible results for their own lives and those of family members, including the potential for discrimination on the basis of genetic information.
Goal
Decreased heart failure progression and sudden death
With a history of myocardial infarction (MI) or acute coronary syndrome (ACS)
Intervention
Statin
Offer a statin to all those in this group (with pre-heart failure) who have a recent or remote history of MI or ACS.
Goal
Prevention of symptomatic heart failure and adverse cardiovascular events
With LVEF ≤40%
Intervention
ACE inhibitor (or angiotensin-II receptor antagonist) plus a beta-blocker
In people with LVEF ≤40%, the combination of an ACE inhibitor plus a beta-blocker is typically recommended for those both with and without a history of MI.
For those with a recent MI and LVEF ≤40% who are intolerant to an ACE inhibitor, an angiotensin-II receptor antagonist is recommended as an alternative to an ACE inhibitor.
Goal
Prevention of symptomatic heart failure and mortality
ACE inhibitor: prevent symptomatic heart failure and reduce mortality.
Angiotensin-II receptor antagonist: prevent symptomatic heart failure and reduce mortality.
Beta-blocker: prevent symptomatic heart failure, and reduce mortality (in those with a history of MI or ACS).
>40 days post-MI, with LVEF ≤30%; with reasonable chance of survival >1 year
Intervention
Implantable cardioverter defibrillator (ICD)
In patients who are at least 40 days post-MI, and who have a LVEF ≤30% and New York Heart Association (NYHA) class I symptoms while receiving guideline-directed medical therapy and have a reasonable expectation of meaningful survival for greater than a year, an ICD is recommended.
Goal
Primary prevention of sudden cardiac death (SCD) to reduce total mortality
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.[330]
Monitor volume status (daily weights and adjustment of diuretic dose as necessary).
Pursue revascularization in patients with coronary artery disease, when appropriate; aggressive medical management of ischemia 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 hyperglycemia in patients with diabetes.[278]
Optimize HF therapies in patients with chronic kidney disease.[278]
Treat obstructive sleep apnea 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.
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