What is the treatment for congestive heart failure (CHF) with pulmonary hypertension?

Treatment of Congestive Heart Failure with Pulmonary Hypertension

The primary treatment for congestive heart failure (CHF) with pulmonary hypertension must focus on optimizing management of the underlying heart failure condition through aggressive therapy for heart failure with reduced systolic function, including ACE inhibitors/ARBs, beta-blockers, and diuretics, while addressing any contributing factors to pulmonary hypertension. 1

Understanding CHF with Pulmonary Hypertension

• Pulmonary hypertension (PH) occurs in 60-80% of patients with heart failure and is associated with high morbidity and mortality 2
• PH in heart failure correlates with increased left ventricular end-diastolic pressure and can occur in both heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) 2
• PH in heart failure has two components:
  • A reversible component related to elevated cardiac filling pressures
  • A less reversible component due to pulmonary vasculature remodeling and vasoconstriction 2

First-Line Management Approach

Optimize Heart Failure Treatment

• Repair of valvular heart disease when indicated 1
• Aggressive therapy for heart failure with reduced systolic function 1
• ACE inhibitors or ARBs are cornerstone therapies for CHF with PH:
  • Enalapril is indicated for treatment of symptomatic CHF, usually in combination with diuretics 3
  • These medications improve symptoms, increase survival, and decrease hospitalization frequency 3, 4
• Beta-blockers reduce cardiovascular events and mortality in patients with hypertension and heart disease 5
  • Target resting heart rate between 50-60 beats per minute 5
  • Carvedilol, metoprolol succinate, and bisoprolol have demonstrated mortality benefits 5, 4

Diuretic Therapy

• Diuretics are rapidly acting agents that improve congestion and decrease filling pressures 6
• Optimize volume status, which may require invasive monitoring in severe heart failure 1
• Thiazide or thiazide-type diuretics are first choice for BP control and prevention of heart failure 5
• Loop diuretics should be reserved for more severe heart failure or renal impairment 5

Additional Agents to Consider

• Aldosterone antagonists are beneficial in patients with heart failure symptoms 5
• Hydralazine/isosorbide dinitrate should be considered as an addition to standard therapy in African American patients with advanced heart failure 5
• Digitalis improves hemodynamics and symptoms by increasing inotropy and slowing heart rate in atrial fibrillation 6

Management of Pulmonary Hypertension Component

Identify and Treat Contributing Factors

• Identify and treat concomitant disorders that may contribute to PH, including COPD, sleep apnea syndrome, and pulmonary embolism 1
• Control risk factors for cardiovascular diseases and features of metabolic syndrome 1

Considerations for PAH-Specific Therapies

• Currently, there is no strong evidence supporting the use of pulmonary arterial hypertension (PAH) therapies in PH due to left heart disease 1
• Short-term studies using prostanoids, endothelin receptor antagonists (ERAs), and phosphodiesterase-5 inhibitors (PDE-5i) have shown improvements in hemodynamics, exercise capacity, and symptoms, but have significant methodological limitations 1
• Sildenafil has shown promise in selected patients:
  • In a randomized trial, sildenafil improved exercise capacity and quality of life in patients with systolic heart failure and secondary PH 7
  • The improvement in peak VO2 correlated directly with baseline pulmonary vascular resistance 7
  • However, sildenafil is only FDA-approved for treatment of WHO Group I pulmonary arterial hypertension, not PH due to heart failure 8

Advanced Therapies for Refractory Cases

• Left ventricular assist device (LVAD) implantation has been shown to lower pulmonary pressures through LV unloading 1
• Lung transplantation should be considered soon after inadequate clinical response on maximal medical therapy 1
• Balloon atrial septostomy may be considered where available after failure of maximal medical therapy 1

Important Cautions and Monitoring

• Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to negative inotropic effects that may worsen heart failure symptoms 5
• Avoid clonidine and moxonidine due to potential increased mortality in heart failure 5
• Monitor for electrolyte abnormalities, particularly with diuretic therapy 1
• Target blood pressure <130/80 mmHg, with more aggressive targets (<120/80 mmHg) in selected patients 5
• Regularly assess response to therapy with clinical evaluation, echocardiography, and possibly right heart catheterization in selected cases 1

Non-Pharmacological Interventions

• Sodium restriction is important for management of both hypertension and LV dysfunction 5
• Exercise training, with careful monitoring, reduces recurrent cardiac events in patients with LV dysfunction 5
• Address lifestyle modifications including management of dyslipidemia, diabetes mellitus, obesity, and smoking cessation 5