Treatment of dilated cardiomyopathy

The main goals of treatment of dilated cardiomyopathy are: correction of chronic heart failure, timely administration of anticoagulants and antiplatelet agents for the prevention and treatment of thromboembolic complications in case of atrial fibrillation, treatment of arrhythmias, including life-threatening ones, improvement of quality of life, and increase in the patient’s life expectancy.

Patients with dilated cardiomyopathy should be hospitalized if:

• newly identified signs of heart failure to clarify its genesis (including DCM);
• complication of the course of DCM with the appearance of life-threatening rhythm disturbances;
• progressive heart failure, impossibility of outpatient treatment;
• the occurrence of acute coronary insufficiency, acute left ventricular failure (cardiac asthma, pulmonary edema);
• the addition of complications of CHF: pneumonia, rhythm disturbances, systemic embolism, etc.;
• symptomatic hypotension, fainting.

If signs of dilated cardiomyopathy are detected, the patient should be advised to quit drinking alcohol, smoking, and to normalize body weight, limit consumption of table salt (especially in case of edema syndrome). Adequate physical activity corresponding to the patient's condition is also recommended. In case of development of ventricular extrasystole, it is necessary to exclude provoking factors (coffee, alcohol, smoking, late bedtime).

Drug treatment of dilated cardiomyopathy

Considering that the leading clinical syndrome in dilated cardiomyopathy is heart failure, the basis of treatment should be the prescription of ACE inhibitors and diuretics. ACE inhibitors not only increase the left ventricular ejection fraction, increase the tolerance of patients to physical activity and in some cases improve the functional class of circulatory failure, but also improve the life expectancy, reduce mortality, and increase survival in patients with a low ejection fraction. Therefore, ACE inhibitors are first-line drugs in the treatment of patients with CHF. The use of these drugs is indicated at all stages of symptomatic heart failure associated with systolic myocardial dysfunction.

According to some data, beta-blockers improve the prognosis and general condition of the patient. It is recommended to start treatment with small doses. Drugs from the beta-blocker group, affecting the hyperactivation of the sympathoadrenal system, have shown the ability to improve hemodynamics and the course of heart failure, have a protective effect on cardiomyocytes, reduce tachycardia and prevent rhythm disturbances.

Treatment of heart failure should be carried out in accordance with the National Guidelines for the Diagnosis and Treatment of CHF.

Malignant ventricular arrhythmias are the leading cause of sudden cardiac death in patients with dilated cardiomyopathy. However, in patients with advanced disease, bradyarrhythmias, pulmonary embolism and other vessels, and electromechanical dissociation may account for up to 50% of cardiac arrests. The Working Group on Sudden Death at the European Society of Cardiology (2001) recommended using the following markers of sudden death in dilated cardiomyopathy:

• sustained ventricular tachycardia (class I evidence);
• syncopal states (class I evidence);
• decreased left ventricular ejection fraction (class IIa evidence);
• non-sustained ventricular tachycardia (IIB evidence class);
• induction of ventricular tachycardia during electrophysiological examination (class III evidence).

In case of sinus tachycardia, symptomatic treatment is carried out with beta-blockers or verapamil, starting with minimal doses.

Patients with ventricular extrasystole have an increased risk of sudden death, but antiarrhythmic drugs do not improve the prognosis in asymptomatic cases with a diagnosis of "DCM" or in the presence of only palpitations. In case of symptoms of left ventricular failure, beta-blockers are added to the treatment. In case of high-grade ventricular extrasystole, amiodarone, sotalol, and class Ia antiarrhythmic drugs are used.

In the presence of ventricular tachycardia and hemodynamically significant disorders (syncope, presyncope, arterial hypotension), an unfavorable prognosis of the disease should be assumed. It is recommended to prescribe treatment with amiodarone, which reduces mortality by 10-19% in patients with a high risk of sudden death, and it is also necessary to consider the need for implantation of a cardioverter or defibrillator. In patients with persistent ventricular tachycardia and dilated cardiomyopathy when heart transplantation is impossible, the main method of treatment is implantation of a cardioverter or defibrillator.

The choice of method for stopping a paroxysm of ventricular tachycardia is determined by the state of hemodynamics: if it is unstable, synchronized cardioversion is performed (discharge power of 200 J). With stable hemodynamics, intravenous administration of lidocaine is recommended (bolus + continuous infusion). If there is no effect, amiodarone or procainamide is administered. If ventricular tachycardia persists, synchronized cardioversion is performed (discharge power of 50-100 J).

In atrial fibrillation, the treatment tactics depend on its form (paroxysmal, persistent, permanent). Thus, in the development of paroxysmal atrial fibrillation and the presence of a frequent ventricular rhythm, signs of heart failure that do not quickly respond to pharmacological agents, immediate electrical cardioversion is indicated. Drug or electrical cardioversion for rapid restoration of sinus rhythm is indicated in patients with a newly detected episode of atrial fibrillation. In patients with cardiomegaly, i.e. DCM, restoration of sinus rhythm in permanent atrial fibrillation is contraindicated. If drug or electrical cardioversion is ineffective, ventricular rate control is performed in combination with antithrombotic treatment [indicated in case of atrial fibrillation and left ventricular dysfunction (presence of chronic heart failure, left ventricular ejection fraction less than 35%). To control heart rate in permanent atrial fibrillation, a combination of cardiac glycosides and beta-blockers is more effective.

Surgical treatment of dilated cardiomyopathy

Surgical treatment of dilated cardiomyopathy (heart transplant, cardiomyoplasty, use of an artificial left ventricle) is indicated when medication is ineffective, but is rarely performed, mainly in young and middle-aged patients.

Heart transplantation is indicated in cases of progressively increasing heart failure and if DCM has developed in a patient under 60 years of age.

The main alternative to heart transplantation today is the use of circulatory support devices, which are called artificial ventricles.