Q & A With the Expert on: Congestive Heart Failure

Q: How should a 78-year-old woman with congestive heart failure (CHF) after myocardial infarction be treated?

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Case Presentation 
A 78-year-old functionally independent woman has a 10-year history of hypertension and dyslipidemia. She developed CHF after an acute myocardial infarction 3 months ago. She has a nonproductive cough when lying down and New York Heart Association (NYHA) class III symptoms (dyspnea with less than ordinary activity). Her current medications include furosemide 40 mg daily, ramipril 10 mg twice daily, rosuvastatin 20 mg daily, diltiazem CD 240 mg daily, and aspirin 81 mg daily.

Physical examination in her physician’s office reveals a blood pressure in the standing and sitting positions in the right brachial artery of 128/78 mm Hg and 130/80 mm Hg, respectively, and in the left brachial artery of 126/76 mm Hg and 128/78 mm Hg, respectively. The pulse is regular with a rate of 96 beats per minute. The respiratory rate is 20 per minute. The patient’s weight has increased 5 pounds over the past month, and she now weighs 130 pounds. Physical examination is normal except for a left ventricular third heart sound heard at the point of maximum apical impulse. The cardiac rhythm is regular with a ventricular rate of 98/minute.

Her fasting blood sugar, hemoglobin, hematocrit, blood urea nitrogen, serum creatinine, sodium, potassium, chloride, carbon dioxide, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides are normal. A 12-lead electrocardiogram shows sinus rhythm with a ventricular rate of 96/minute, an old Q-wave anterior myocardial infarction, and a QRS duration of 110 msec. A chest roentgenogram shows mild pulmonary vascular congestion. A 2-dimensional echocardiogram reveals a left ventricular ejection fraction (LVEF) of 37%.

How should this woman have her CHF managed?
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A: Patients with pulmonary vascular congestion due to CHF may not have pulmonary rales heard at the lung bases. Of 50 patients with chronic CHF and a pulmonary capillary wedge pressure ≥ 22 mm Hg, 48 (96%) had a left ventricular third heart sound, 25 (50%) had increased jugular venous pressure, 8 (16%) had pulmonary rales, and 10 (20%) had peripheral edema.¹

Ramipril, rosuvastatin, and aspirin should be continued as prescribed in this woman with CHF, a reduced LVEF, and prior myocardial infarction. The dose of furosemide should be increased to 60 mg daily. Salt restriction and use of diuretics are American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) class I indications for treating CHF.² Treatment of hypertension and dyslipidemia and use of angiotensin-converting enzyme (ACE) inhibitors are also class I indications.²

Diltiazem should be stopped in this woman since it exacerbates CHF in patients with CHF and a reduced LVEF³ and increases mortality in patients with pulmonary congestion and a reduced LVEF after myocardial infarction.⁴ Calcium-channel blockers, nonsteroidal anti-inflammatory drugs, and most antiarrhythmic drugs should not be used in patients with CHF and a reduced LVEF.²

This patient needs the addition of a beta blocker such as metoprolol CR/XL or carvedilol to treat her CHF.^2,5,6 Beta blockers should be initiated in a low dose such as carvedilol 3.125 mg twice daily or metoprolol CR/XL 12.5 mg daily in patients with NYHA class III or IV CHF or 25 mg daily in patients with NYHA class II CHF.⁷ The dose of beta blockers should be doubled at 2- to 3-week intervals, as tolerated, with the maintenance dose reached over 3 months. The maintenance dose should be metoprolol CR/XL 200 mg once daily or carvedilol 25 mg twice daily (50 mg twice daily if the patient weighs more than 187 pounds).⁷ During titration, the patient should be monitored for CHF symptoms, fluid retention, hypotension, and bradycardia. If there is worsening of symptoms, the dose of diuretics or ACE inhibitors should be increased. If necessary, the dose of beta blockers can be temporarily reduced.

Patients with mild-to-moderate CHF should be encouraged to participate in regular physical activity such as walking in order to improve functional status and reduce symptoms.²

Some additional ACCF/AHA class I indications for treating CHF with a reduced LVEF are not indicated at this time: the use of angiotensin receptor blockers in patients who cannot tolerate ACE inhibitors because of cough, rash, or angioneurotic edema; use of an aldosterone antagonist; use of isosorbide dinitrate plus hydralazine; use of an implantable cardioverter-defibrillator; and use of cardiac resynchronization therapy.² Use of these therapies is discussed extensively elsewhere.^2,7

Low-dose digoxin could be prescribed for this woman if symptoms persisted after optimal treatment with diuretics, beta blockers, and ACE inhibitors. The 2005 ACCF/AHA guidelines and the 2009 ACCF/AHA guidelines for treating CHF with a reduced LVEF recommend the use of digoxin with a class IIa indication to reduce CHF hospitalization in patients with persistent symptoms despite optimal medical management.² A post-hoc subgroup analysis of data from women with a decreased LVEF in the Digitalis Investigation Group (DIG) study showed at 37-month follow-up that compared with placebo, digoxin significantly increased the risk of death among women by 23% (absolute increase in mortality of 4.2%).⁸ A post-hoc subgroup analysis of data from all 1366 women with CHF in the DIG study showed that digoxin significantly increased mortality by 20%.⁹ Another post-hoc subgroup analysis of data from all 1366 women with CHF in the DIG study showed that digoxin significantly increased mortality by 80% if the serum digoxin level was 1.2 ng/mL or more, but mortality was only increased by 5% (NS) if the serum digoxin level was 0.5-1.1 ng/mL.¹⁰

The author reports no relevant financial relationships.