Dilated Cardiomyopathy

Treatment

Medications

Medications commonly are prescribed to treat the congestive heart failure associated with dilated cardiomyopathy. These medications may include the following:

• Anti-inflammatory agents – In cases of suspected myocarditis, intravenous immunoglobulin (IVIG), a concentrated preparation of antibodies, is commonly given shortly after the diagnosis is made to try to combat the immune reaction and inflammation. Steroids are sometimes given as well to try to quiet the immune response against the heart. However, these medicines don’t always help.
• Diuretics – These medications reduce the volume of blood in the body by increasing the need to urinate and eliminate fluids from the body. With less blood to pump, the burden on the heart is reduced. Diuretics, such as furosemide, are among the medications that help the body rid itself of excess fluids.
• Beta blockers – These medications are commonly used to reduce blood pressure. However, in the treatment of heart failure, these are used to blunt the body’s complex excessive adrenaline/hormone responses (neurohormonal response) that can actually worsen the heart failure.
• Afterload reducers – These medications allow blood to flow to the body and tissues easier. In oral form, these include ACE inhibitors (the names of these medications usually end in “pril”) or angiotensin receptor blockers (ARB). In intravenous form, this may include milrinone.
• Inotropes – These medications help the heart to contract better. Digoxin is an oral medication that’s sometimes used for sick hearts. In cases of severe heart dysfunction, IV medications given by a continuous infusion, such as milrinone or dobutamine, might be used.
• Antiarrhythmics – These medications are used to help control heart rhythm and to reduce abnormal heartbeats.
• Neprilysin inhibitors – Entresto, the first of this relatively new class of blood pressure drugs, was approved in 2015 by the U.S. Food & Drug Administration (FDA) to treat heart failure.
• SGLT2 inhibitors – These medications are FDA approved for use with diet and exercise to lower blood sugar in adults with type 2 diabetes. Along with slowing the progression of kidney disease and lowering the risk of kidney failure and death in people with kidney disease and type 2 diabetes, SGLT inhibitors are also effective at reducing heart failure. Medicines in the SGLT2 inhibitor class include canagliflozin, dapagliflozin, and empagliflozin.

MitraClip and Pascal

MitraClip and Pascal implantation are innovative, less-invasive treatment options for inoperable or high-risk patients with severe functional mitral regurgitation due to DCM. MitraClip and Pascal have a tiny clip that grasps the mitral valve's two leaflets to create two smaller openings rather than one large opening, which reduces blood from flowing backward (regurgitating). The clip is placed in the heart using a slender catheter tube. The catheter is threaded up to the heart through a vein in the groin, and the clip is then moved into position directly over the center of the mitral valve's leaflets using ultrasound guidance. Then the catheter is removed from the patient's body, leaving the clip behind.

Mechanical heart support

If the heart function continues to deteriorate to a critical level, medications alone may be insufficient. Mechanical measures to support heart function, called ventricular assist devices, may be used as a bridge to heart transplantation. These devices are surgically attached to the heart itself. Some of these devices create pulsations similar to the natural heart. Others propel blood continuously and efficiently, though without pulsations. In adults, some of these devices can be placed within the body. However, due to the smaller body size of infants and children, these devices sometimes can’t be completely implanted within the body. In some situations, the patient may be placed on a machine called extracorporeal membrane oxygenation (ECMO). This is a heart-lung bypass machine that supports these organs completely. Many risks are associated with mechanical support of the heart, including severe infections and blood clots.

Heart transplantation

If the damage to the heart is permanent and unrecoverable, heart transplantation may be considered. However, the supply of donor hearts is much smaller than the number of people who might need them. The sickest patients are given the highest priority in receiving a transplanted heart. This results in long waiting times for a heart to become available for many patients. Many people don’t survive during this waiting period. The hearts must be matched to the patient regarding blood type and other immune markers. However, for some in early infancy, blood-type matching might not be necessary (ABO-incompatible transplant) since the baby's immune system may still be immature.

Heart transplantation isn’t a cure—a lifetime of continuous medical care is necessary due to the possibility of rejection of the transplanted heart. Numerous medications to suppress the immune system are necessary. This immune suppression may allow certain kinds of cancer to become more prevalent or infections to develop. The transplanted heart also has a limited lifespan, likely due to chronic low-grade attacks from the body. Coronary artery disease (CAD) can be accelerated in transplant patients. Some people whose transplanted hearts have worn out may be able to receive another transplant; however, the lifespan of this heart is typically a fraction of the previously transplanted heart.