Most people in the hospital for heart failure don't get sent home with a drug that could prevent a return visit, a study finds. The drug is spironolactone, a water pill. This drug helps to prevent fluid buildup in the lungs, blood and elsewhere in people with heart failure. It has been shown to reduce hospital stays and deaths. But it also can be dangerous in some people, such as those with kidney problems. The study included 201 hospitals. More than 12,500 patients were eligible to receive spironolactone. But only about one-third received the pills. Guidelines for doctors have recommended this drug for heart failure since 2005. The study appeared in the Journal of the American Medical Association. The Associated Press wrote about it October 21.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Heart failure is an old term. In fact, it does not mean that your heart is actually failing. It does mean that your heart is not pumping blood in a forward direction. Therefore, fluid backs up into your lungs and the rest of your body.

Heart failure is diagnosed based upon a set of symptoms and signs. The primary symptoms of heart failure include:

• Shortness of breath, especially with exertion
• Decreased ability to exercise
• Fatigue
• Swelling of the feet and ankles

To decide whether you have heart failure, your doctor will need to examine you. The doctor will:

• Listen to your lungs for signs of fluid buildup
• Listen to your heart for extra sounds and heart murmurs often found in heart failure
• Examine your feet and ankles to confirm fluid buildup there

The term heart failure no longer fits as well as it did centuries ago. Today, about one-half of the people with heart failure actually have hearts that pump very strongly. Their problem is that the left ventricle, the main chamber of the heart, is too stiff. This does not allow the chamber to fill completely with blood before each heartbeat. Therefore, pressure builds up behind the left ventricle. The left ventricle gets its blood from the upper chamber of the heart, called the left atrium. And the left atrium gets blood after it has passed through the lungs.

Fluid leaks out into the lungs and later into other parts of the body, usually the feet and ankles.

The other cause of heart failure is a heart that has become weak. It can't pump blood out as strongly as it should.

The study reported in today's Journal of the American Medical Association (JAMA) found that many people with heart failure are not receiving the best treatment.

What Changes Can I Make Now?

The common causes of heart failure in the United States are coronary artery disease, high blood pressure, diabetes and excess use of alcohol.

Following the same healthy lifestyle that is used to prevent coronary artery disease can prevent or delay most cases of heart failure. A healthy lifestyle includes:

• Healthy diet
• Regular exercise
• Limited or no use of alcohol
• Control of body weight and blood pressure

If you have been diagnosed with heart failure, make sure you know which type you have. This is determined by an echocardiogram. In one form of heart failure, the heart does not pump effectively. This is called systolic dysfunction. In the other type of heart failure, the heart is too stiff. This is called diastolic dysfunction, or heart failure with preserved systolic function.

The treatments for each type do differ. For example, the drug studied in today's JAMA article is called spironolactone (Aldactone). It is a special type of water pill (diuretic) that helps the body hold on to potassium. Most diuretics, especially the ones used to treat heart failure, cause the body to lose potassium.

Spironolactone should be considered for treatment of all people with the systolic dysfunction type of heart failure. Some people with diastolic dysfunction might benefit from it, too. However, spironolactone has not been proven to improve this type of heart failure.

The ideal drug treatment for heart failure caused by systolic dysfunction (the weak heart) should include the following:

• An angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB)
• A combination of isosorbide (Isordil) and hydralazine -- This treatment appears to be especially effective in people of African heritage. It also can be used by people who cannot tolerate an ACE inhibitor or an ARB.
• A beta blocker
• Spironolactone

What Can I Expect Looking to the Future?

Drug treatment for heart failure caused by systolic dysfunction is well known. However, for diastolic heart failure, caused by a stiff heart, the best treatment has not been as well defined. There are two main goals in this type of heart failure:

• Allow some relaxation of the left ventricle, but not too much
• Decrease blood pressure to allow more blood to move forward as it should.

Researchers will continue to try to find out more about the best ways to treat both diastolic and systolic heart failure.