Drugs for Heart Failure

[green4sam]

I have been recently diagnosed with heart failure caused by nonischemic cardiomyopathy.  I have an EF of about 30-35% and am 100% pacemaker dependent.  The medications I am currently taking are lisinopril 2.5, Coreg 9.75, demadex 100 mg per day, amiodarone 200 mg, and various supplements for electrolyte replacement.  Are there other medications that could be helpful?  When is spirolactone used?  Why would a beta blocker be helpful since I have a pacemaker that controls my heart rate?  Why are they increasing the coreg every two-three weeks?  The cardiologist has been very careful with increasing the coreg.  My BP is around 100/60 but my pressure is alway pretty low.  I still have 1-2+ edema and shortness of breath with activity.

[browneyes211]

hi my name is pamela i'm 26 and i was born with a heart problem that has gotton real bad in the last 4 year's. i now have cardiomyopathy and i had a B V pacer put in on march 11th of 2002.it has helped me some what but there are day's when i don't feel that this is helping me at all.i was told almosted 2 year's ago that i might need a heart transplant in about 7 year's or so. that was the most scare thing that i had to hear being so young. i had a baby girl in march of 2000 and that is what made my heart get weaker then it was. i now had to get my tubed tied because they said if i was ever to have anymore babies it may kill me so they were not gonna take any chance's with the health that i have. i got to a really good hospital it is HUP it is in philadelphia pa,i had went to childrend's hospital of philadelphia until i was 24 then they said they my health was getting pretty bad so they sent me to a heart failur doctor over at penn he is such a great doctor he really take's his time with me and i understand what he said's to me and understand's me.

   thank you  pam age 26 from PA,

[CCF-M.D.-MJM]

CMS approved payment for both ischemic and nonischemic cardiomyopathies.  There is good data that ICDs help with both conditions.

[green4sam]

I am not sure you will see this but in case you do...I was told that ICDs are automatic for 30% or less in patients with ischemic cardiomyopathy.  Mine is nonischemic.  Is that true?  I understood that it is likely to be approved next year by CMS.  So, if I am not inducible now, I could be a candidate next year..My EP said we would need to cross that when the time comes which is unfortunate from my perspective.  Once is enough of this.

[CCF-M.D.-MJM]

Ask some questions about the EP study.  CMS recently approved payment for ICDs in patients with EF 30 or less.  If your EF is 30 or less you will not need an EP study.

It's not that EP study takes that long or adds much to the procedure, but why do it if its already approved.

Thanks for posting and take care.

[green4sam]

Dr. MJM,

This was a very excellent answer.  Thank you so very much.  I do not have a Bi-V pacer but they are planning to have one implanted in the next couple of weeks.  The old wires have to be removed so it has been more difficult to schedule.  They are also considering an ICD but will need to do electrophysiology studies first.  

Thanks so much for your valuable information.

[CCF-M.D.-MJM]

Hi Sam,

Sorry to hear about your recent health problems.

People with heart failure benefit from having blood pressure as low as they can tolerate--often in 85-90 systolic (top number) range.

Your heart is weaker than it should be--that is why you are short of breath and have the swelling.  Your systolic blood pressure is the resistance against your heart each time it pumps.  You want the a blood pressure low enough to reduce the work on your heart and high enough to provide nutrients and remove waste from your vital organs.  One way to do this is through the medications you are already one and your that your doctors is diligently increasing.

The coreg serves two purposes.  One is to control your blood pressure and reduce the work on your heart.  The second has to do with Coregs mechanism of effect--it is a beta blocker.  Beta receptors are stimulated by adrenaline (epinephrine) and acts to increase the strength of your hearts contraction.  Studies show a strong survival benefit for taking medications in this class, Coreg has the best data to date to suggest a survival benefit, even when compared with other beta blockers.

Once you are on the highest dose of Coreg that you will tolerate, you doctor will likely increase your lisinopril next to the maximum dose you can tolerate.  Once you are on maximal medical management with lisinipril (class of medication called : ace inhibitor or ACEI) and Coreg, and if  you are stil having significant symptoms, it may be appropriate to add spironolactone (aldactone).  This medications is additive to the ACEI, working in the same mechanistic pathway but further down the chain.  It a subgroup of patients with CHF, spironolactone improves outcomes long term.

The pacemaker is another issue.  If you are having significant symptoms from your heart failure, make sure you pacemaker is a "biventricular pacemaker."  70% of people with class III-IV heart failure (meaning heart failure significantly impacts you abiltiy to move around and do your daily activities) improve with a biventricular pacemaker.

There is also recent data that shows defibrillators improve survival in patients with EF 30% or less.

I hope this helps and answer some of your questions.

Good luck.