Health Care Maintenance Issues

All patients with the clinical syndrome of HF who abuse tobacco, alcohol, or illicit drugs should be counseled to stop. For such patients, these recommendations carry even greater potential benefit than they do in the general population.55 Nicotine has vasoconstrictor activity, which can worsen hemodynamics and antagonize vasodilator effect. Transdermal nicotine preparations do not appear to significantly increase cardiovascular risk, even in high-risk patients, although physician-monitored use is advisable. Additional pharmacologic aids for tobacco withdrawal, such as bupropion, have not been associated with exacerbation of HF.

Alcohol-induced dilated cardiomyopathy is generally associated with chronic daily consumption of at least 70 g of ethanol. Alcohol alters myocardial metabolism in many ways, significantly affecting fatty acid composition of the sarcolemma. Confounding nutritional and vitamin deficiencies coexist in chronic alcoholism and may adversely affect ventricular function. Renal magnesium and potassium wasting are enhanced. In the Studies of Left Ventricular Dysfunction (SOLVD) trials, a positive relationship was found between light to moderate alcohol intake and significant increases in serum markers of inflammation, shown to correlate with adverse clinical outcome.

The potential for reversal of ventricular remodeling and normalization of LVEF with cessation of alcohol ingestion are well recognized and correlate with improved prognosis. For patients who are not suspected of having an alcohol-induced cardiomyopathy, there is controversy regarding the impact of small amounts of alcohol. Light to moderate alcohol consumption (1-2 drinks per day) does not appear to alter the risk for HF in patients with LV dysfunction after myocardial infarction or to alter outcomes in patients with HF.56,57

Pulmonary congestion and pulmonary hypertension increase the risk of lung infection. Therefore, administration of pneumococcal vaccine and annual influenza vaccines is highly recommended in HF patients, as is counseling patients to seek early evaluation for potentially serious infections. Additional vaccines, such as hepatitis and specific immunization matching foreign travel standards, should be given if appropriate. Maintenance of tetanus toxoid vaccination is prudent in all patients with HF.

There are few indications for infective endocarditis (IE) prophylaxis because the risk of IE due to dental or other procedures is quite low compared to the prevalence of bacteremia due to activities of daily living, such as chewing and teeth brushing.58 Prophylaxis should follow American Heart Association/American College of Cardiology (AHA/ACC) guidelines in the setting of valvular heart disease when applicable. 58 Whether functional mitral regurgitation resulting from LV chamber and valve ring dilation carries the same attributable risk as that of primary valvular disorders is unclear from available data, although most experts would recommend treatment. When a patient has an implanted intravascular device, such as a pacemaker or automated internal cardiac defibrillator, most electrophysiologists recommend antibiotic prophylaxis under the same conditions as valvular heart disease, at least for the first 3 months after implantation.

The need for analgesic medication for musculoskeletal complaints is common in HF patients, partially because HF is predominantly a disease of the elderly.59 Unsuspected use of NSAID products may explain worsening renal function, hyperkalemia, fluid retention, or hypertension among HF patients. NSAID use has been implicated in the onset of HF symptoms in the elderly, perhaps unmasking underlying ventricular dysfunction.60 The use of cyclooxygenagase-2 inhibitors has been associated with a higher risk of hospitalization for HF, although some studies indicate that celecoxib appears safer than rofecoxib.61,62 All patients should be instructed to avoid the use of these products, unless all other treatment modalities have been exhausted. When these agents are prescribed, there should be careful clinical monitoring and laboratory assessment of renal function.

The risk of gout is increased in HF patients. Diuretic use, obesity, renal impairment, and alcohol consumption are additional risk factors. Colchicine and corticosteroids are preferred to NSAIDs as initial therapy for acute attacks.