How Dilated Cardiomyopathy Is Treated

Treating dilated cardiomyopathy (DCM), a form of heart failure, typically is a multi-pronged endeavor. Lifestyle measures targeted to preventing further damage to the heart, such as following a heart-healthy diet and getting more exercise, are key.

When these steps are not enough to improve the health and function of the heart, prescription medications may be in order. Among the drugs most often used to treat dilated cardiomyopathy are beta blockers, diuretics, and angiotensni-converting enzyme inhibitors (ACE inhibitors). A pacemaker or other implantable device may be necessary for treating severe dilated cardiomyopathy.

Lifestyle

Dilated cardiomyopathy (a form of heart failure in which the left ventricle becomes enlarged) can be treated by adjusting your diet, activity level, and making other lifestyle changes. These measures will not "cure" your condition, but they are likely to prevent it from worsening.

Eat a Heart-Healthy Diet

This means focusing on foods known to help protect the cardiovascular system while limiting those that contribute to issues such as atherosclerosis. The Mediterranean Diet is an easy-to-follow example. It focuses on:

• An abundance of fresh fruits and vegetables at every meal
• Legumes, including lentils and beans
• Foods high in monounsaturated fats—including nuts, seeds, and olive oil
• Low to moderate consumption of red wine
• High-fiber grains, including whole grain, oatmeal, and barley
• Use of leans cuts of poultry in some dishes
• Moderate consumption of fish—including fish high in healthy omega-3 fats, such as salmon and anchovy
• Low consumption of refined sugars
• Low consumption of red meat
• Low to moderate use of dairy products, including milk, yogurt, and certain cheeses, such as Parmesan and feta cheeses

Maintain a Healthy Weight

Weight loss can have a dramatic impact on long-term mortality in people with heart failure. This is especially true for those who are obese, meaning they have a body mass index (BMI) of 30 or more.

At the same time, it doesn't take a dramatic loss of weight to positively affect cardiovascular health. According to a 2015 study in Translational Behavioral Medicine, losing just 5% to 10% of total body weight is associated with better cardiovascular health. Obesity is tied to a number of chronic conditions, including heart failure.

Exercise

Most people with chronic heart failure are encouraged to do non-competitive aerobic exercise. The American Heart Association recommends at least 30 minutes per day (150 minutes per week) of moderate-intensity exercise, such as gardening, brisk walking, dancing, or doubles tennis, or 15 minutes per day (75 minutes per week) of vigorous-intensity exercise, such as running, swimming laps, hiking uphill, or singles tennis. Weight-lifting generally is not recommended. Get the green light from your healthcare provider before starting a new exercise program.

Quit Smoking

Smoking can exacerbate heart problems by contributing to damage to the arteries. Secondhand smoke can be just as harmful, as carbon monoxide can take the place of oxygen in the blood, causing it to pump harder to supply your system with vital oxygen.

If you smoke, there are numerous approaches to kicking the habit, from quitting cold turkey to using nicotine gum or other products.

Medications

If you've been diagnosed with dilated cardiomyopathy, lifestyle measures may mitigate your condition but they likely will not be sufficient. Most people with heart failure take some type of medication, or even a combination of drugs.

Beta-Blockers

Beta-blockers take excess stress off the heart by slowing heart rate, lowering blood pressure, and reducing the levels of harmful substances created in response to heart failure. In addition to being a mainstay treatment for DCM, these drugs are prescribed for heart attack, angina, congestive heart failure, atrial fibrillation, and hypertension (high blood pressure).

Beta blockers most often prescribed for dilated cardiomyopathy include Coreg (carvedilol), Toprol (metoprolol), and Ziac (bisoprolol). Side effects include dizziness, low blood pressure, fatigue, cold hands and feet, headache, and digestive issues.

Diuretics 

Diuretics, or "water pills," are a standard therapy for heart failure. Their purpose is to help reduce fluid retention and edema that often occurs in DCM by causing you to urinate more often. They also help some patients breathe more easily.

Commonly used diuretics include Lasix (furosemide) and Bumex (bumetanide). A potential side effect of diuretics is low potassium levels, which can lead to cardiac arrhythmias. Others include fatigue, light-headedness, and muscle cramps.

ACE Inhibitors

ACE inhibitors block angiotensin-converting enzyme, which the body makes in response to heart failure and that has the effect of narrowing blood vessels. ACE inhibitors also help dilate blood vessels to allow for a freer flow of blood.

Among the ACE inhibitors prescribed most often are Vasotec (enalapril), Altace (ramipril), Accupril (quinapril), Lotensin (benazepril) and Prinivil (lisinopril). Side effects of ACE inhibitors may include a cough, a salty or metallic taste, rash, or dizziness caused by low blood pressure.

Angiotensin II Receptor Blockers (ARBS)

ARBS are drugs that work similarly to ACE inhibitors. They can be prescribed for people with DCM who cannot take ACE inhibitors. ARBS that have been approved for heart failure include Atacand (candesartan) and Diovan (valsartan).

Aldosterone Antagonists

This class of drugs has convincingly been shown to improve survival for some people with heart failure. and often is used in conjunction with an ACE inhibitor or ARB drug) and beta blockers. However, these medications can cause significant hyperkalemia (high potassium levels) and should not be taken by people whose kidneys do not function normally. Examples include Aldactone (spironolactone) and Inspra (eplerenone).

Hydralazine Plus Nitrates

For people with DCM who have reduced ejection fraction (a measure of how much blood the left ventricle of the heart is able to pump out during each beat) despite the use of beta-blockers, ACE inhibitors, and diuretics, combining hydralazine, a blood pressure drug, plus an oral nitrate such as isosorbide may help.

Neprilysin Inhibitor

The first of this relatively new class of blood pressure drugs, Entresto, was approved to treat heart failure by the Food and Drug Administration (FDA) in 2015. It combines the ARB valsartan with a neprilysin inhibitor (sacubitril). Early studies with Entresto have been quite promising, and some experts believe it ought to be used in place of an ACE inhibitor or ARB.

Ivabradine

Ivabradine is a drug that is used to slow the heart rate. It is used for conditions such as inappropriate sinus tachycardia in which the heart rate is dramatically elevated. People with DCM also can have resting heart rates that are substantially higher than is considered normal, and there is evidence that reducing that elevated heart rate with ivabradine may improve outcomes.

Digoxin

While in past decades digoxin (a compound from the Digitalis plant genus) was considered a mainstay in treating heart failure, its actual benefit in treating DCM now seems to be marginal. Most healthcare providers prescribe it only if the more effective medications do not appear to be adequate.

Inotropic Drugs

Inotropic drugs are intravenous medications that push the heart muscle to work harder and thus pump more blood. They are reserved for more severe cases of heart failure, as they have been associated with significantly increased mortality. Examples include milrinone and dobutamine.

Blood Thinners

Drugs like aspirin or warfarin can help prevent blood clots. Side effects include excessive bruising or bleeding.

Sodium-Glucose Co-Transporter-2 Inhibitors (SGLT2 inhibitors)

This is the newest class of drugs added to the armamentarium to treat heart failure. Jardiance (empagliflozin) was approved by the FDA in 2022 to treat heart failure regardless of ejection fraction. The drug was initially used to treat diabetes, but it was found to significantly reduce the risk of cardiovascular death and hospitalization for heart failure in adults.

Implantable Devices

People with moderate to severe DCM have an increased risk of sudden cardiac death from ventricular arrhythmias and may require an implantable device to maintain a normal heart beat.

• Cardiac resynchronization therapy (CRT): Uses a specialized pacemaker that stimulates both the right and left heart ventricles simultaneously. (Standard pacemakers stimulate only the right.) It is especially indicated for DCM patients who have an abnormality in the heart’s electrical conducting system called left bundle branch block (LBBB) in which the right and left ventricles beat out of synch.
• Implantable cardioverter defibrillator: An ICD monitors heart rhythm and delivers electrical shocks when needed to control abnormal heartbeats, including those that cause the heart to stop. ICDs have been shown to significantly reduce mortality in certain people with DCM who have significantly reduced left ventricular ejection fractions.
• Left ventricular assist device (LVAD): A mechanical implant attached to the heart to help it pump. LVADs usually are considered after less invasive approaches are unsuccessful.

Surgery

Because of the drastic nature of the procedure and the short supply of donor hearts, the only procedure used to treat heart failure, a heart transplant (cardiac transplantation), is reserved for the sickest patients.

Transplantation is considered the gold standard treatment for patients with advanced heart failure, but there are numerous considerations. A heart transplant recipient must take drugs for the rest of their lives to depress their immune systems, so the body does not view the new heart as a foreign body and attack it.  Recovery from a transplant takes several months and may involve cardiac rehabilitation. Most patients are able to leave the hospital within a few weeks of the surgery and return to their normal activities within six weeks of surgery.

Experimental Therapy

Gene therapy or stem cell therapy might be beneficial in people with DCM.

• Gene Therapy: Researchers hope that by placing a normal copy of a gene into a human cell in order to change how that cell functions. Based on limited clinical trials, gene therapy aimed at changing the cardiac phenotype in patients with heart failure and reducing ejection fraction seems safe with relatively few adverse immunologic responses, arrhythmias or other adverse events.
• Stem Cell Therapy: In this therapy, based on the idea that stem cells, often harvested from bone marrow, can repair and regenerate damaged heart tissue, stem cells are inserted into the heart using a catheter. It has not been proven fully safe and beneficial, however. 

Summary

If you've been diagnosed with DCM, you should know that there are many treatment approaches, ranging from simple lifestyle changes to the most invasive treatment of heart transplantation. Eating healthy foods and getting regular exercise are among the most effective ways to prevent the condition altogether as well as to mitigate it. In addition, numerous drug therapies and devices can help you live an active life.