20.6: Heart Failure VI: Adjunct Therapies

Additional therapies for treating patients with heart failure (HF) may include procedural interventions, supplemental oxygen, the management of sleep disorders, and nutritional therapy.

Procedural Interventions

• Implantable Cardioverter-Defibrillator: For patients at risk of life-threatening arrhythmias due to severe left ventricular dysfunction, an Implantable Cardioverter-Defibrillator (ICD) can detect and terminate these arrhythmias, preventing sudden cardiac death and improving survival rates. ICDs are typically indicated for patients with an ejection fraction (EF) of 35% or less who have symptomatic HF or have experienced cardiac arrest due to ventricular arrhythmia.
• Cardiac Resynchronization Therapy (CRT): Patients with HF who do not respond to standard therapy and have a prolonged QRS duration on their ECG may benefit from Cardiac Resynchronization Therapy (CRT). CRT involves using a biventricular pacemaker to synchronize the contractions of the left and right ventricles, improving cardiac function and reducing heart failure manifestations by correcting electrical conduction abnormalities.
• Intra-Aortic Balloon Pump (IABP): In the ICU, mechanical cardiac assist devices, like an intra-aortic balloon pump, can temporarily manage worsening HF. The IABP increases coronary blood flow to the heart muscle and decreases the heart's workload through counterpulsation, benefiting hemodynamically unstable patients by reducing pulmonary artery pressures and systemic vascular resistance (SVR) and improving cardiac output (CO).
• Ventricular assist devices (VADs): Ventricular assist devices (VADs) are mechanical pumps that support the heart's function in patients with severe heart failure, ensuring adequate blood flow throughout the body.
• Ultrafiltration: Ultrafiltration, or aquapheresis, is an alternative intervention for patients with severe fluid overload that is resistant to diuretic therapy. A dual-lumen central IV catheter is inserted, and the patient's blood is circulated through a bedside filtration machine. Liters of excess fluid are removed from the intravascular volume over several hours, monitored by indicators of volume status such as filtration fluid output, blood pressure, and hemoglobin levels.
• Hemodialysis: Hemodialysis can be used to manage volume overload in patients with renal failure.

Supplemental Oxygen

As HF progresses, oxygen therapy may become necessary based on the severity of pulmonary congestion and resulting hypoxia. Some patients require supplemental oxygen only during periods of physical activity.

Management of Sleep Disorders

Sleep disorders, including sleep apnea, are common in heart failure patients. A sleep study should be performed, and if obstructive sleep apnea (OSA) is diagnosed, Continuous Positive Airway Pressure (CPAP) may be recommended. CPAP improves sleep quality, reduces apneic episodes and daytime sleepiness, and enhances nocturnal oxygenation in HF patients with OSA.

Nutritional Therapy

A low-sodium diet (no more than two grams per day) and avoiding excessive fluid intake are usually recommended, though studies differ on the effectiveness of sodium restriction. Patients should learn which foods are low and high in sodium and how to read food labels. Patients with mild to moderate HF typically do not need fluid restrictions, but those with stage D HF and persistent fluid retention may require them. To monitor fluid status, patients should weigh themselves daily at the same time, before breakfast, using the same scale and wearing the same type of clothing and should reach out to their healthcare provider if they experience a weight gain of 3 lb (1.4 kg) over two days or 3-5 lb (2.3 kg) over a week.