Congestive heart failure chronic pharmacotherapy: Difference between revisions
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==Diuresis: First step in the management of heart failure== | ==Diuresis: First step in the management of heart failure== | ||
Begin by rapidly improving the symptoms of heart failure (within hours to days) by the use of [[diuretics]]. [[Diuretics]] reduce excess volume that accumulates with [[heart failure]] and decrease [[pulmonary edema]] that causes symptoms of [[dyspnea]] and [[orthopnea]]<ref name="pmid20653715">{{cite journal| author=Michael Felker G| title=Diuretic management in heart failure. | journal=Congest Heart Fail | year= 2010 | volume= 16 Suppl 1 | issue= | pages= S68-72 | pmid=20653715 | doi=10.1111/j.1751-7133.2010.00172.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20653715 }} </ref>. [[Lasix]] 20 to 40 mg PO daily is a conventional starting dose, but in some patients, [[torsemide]] may have better | Begin by rapidly improving the symptoms of heart failure (within hours to days) by the use of [[diuretics]]. [[Diuretics]] reduce excess volume that accumulates with [[heart failure]] and decrease [[pulmonary edema]] that causes symptoms of [[dyspnea]] and [[orthopnea]]<ref name="pmid20653715">{{cite journal| author=Michael Felker G| title=Diuretic management in heart failure. | journal=Congest Heart Fail | year= 2010 | volume= 16 Suppl 1 | issue= | pages= S68-72 | pmid=20653715 | doi=10.1111/j.1751-7133.2010.00172.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20653715 }} </ref>. [[Lasix]] 20 to 40 mg PO daily is a conventional starting dose, but in some patients, [[torsemide]] may have better a better choice due to more predictable absorption. Once a day dosing of a given [[diuretic]] is preferred to twice a day dosing at a lower dose. A rise in [[BUN]] and [[Cr]] may reflect a reduction in renal perfusion, and further [[diuresis]] should only be undertaken with careful monitoring of renal function. The patient should weigh themselves each morning at the same time on the same scale, and the [[diuretic]] dosing should be adjusted to maintain a constant weight. | ||
:*'''Simultaneous with number 1''' | :*'''Simultaneous with number 1''' | ||
::*[[Congestive heart failure treatment of underlying causes|Treat the underlying cause of heart failure]] such as [[ischemic heart disease]], [[hypertension]], and [[valvular heart disease]]. | ::*[[Congestive heart failure treatment of underlying causes|Treat the underlying cause of heart failure]] such as [[ischemic heart disease]], [[hypertension]], and [[valvular heart disease]]. | ||
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::*Treat with vaccines for [[influenza]] and [[pneumococcus]] <ref name="pmid21271169">{{cite journal| author=Martins Wde A, Ribeiro MD, Oliveira LB, Barros Lda S, Jorge AC, Santos CM et al.| title=Influenza and pneumococcal vaccination in heart failure: a little applied recommendation. | journal=Arq Bras Cardiol | year= 2011 | volume= 96 | issue= 3 | pages= 240-5 | pmid=21271169 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21271169 }} </ref>. | ::*Treat with vaccines for [[influenza]] and [[pneumococcus]] <ref name="pmid21271169">{{cite journal| author=Martins Wde A, Ribeiro MD, Oliveira LB, Barros Lda S, Jorge AC, Santos CM et al.| title=Influenza and pneumococcal vaccination in heart failure: a little applied recommendation. | journal=Arq Bras Cardiol | year= 2011 | volume= 96 | issue= 3 | pages= 240-5 | pmid=21271169 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21271169 }} </ref>. | ||
<ref name="pmid14610160">{{cite journal |author=Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM |title=Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both |journal=[[The New England Journal of Medicine]] |volume=349 |issue=20 |pages=1893–906 |year=2003 |month=November |pmid=14610160 |doi=10.1056/NEJMoa032292 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa032292?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-29}}</ref> | <ref name="pmid14610160">{{cite journal |author=Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM |title=Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both |journal=[[The New England Journal of Medicine]] |volume=349 |issue=20 |pages=1893–906 |year=2003 |month=November |pmid=14610160 |doi=10.1056/NEJMoa032292 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa032292?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-29}}</ref> | ||
==ACE Inhibition and Angiotensin Receptor Blockade: Second step in the management of heart failure== | ==ACE Inhibition and Angiotensin Receptor Blockade: Second step in the management of heart failure== | ||
After diuretics are started or at the same time you can begin the use of an [[ACE inhibitors]] <ref name="pmid1117548">{{cite journal| author=Shiokawa Y| title=Proceedings: Streptococcus surveys in Ryukyu Islands, Japan. | journal=Jpn Circ J | year= 1975 | volume= 39 | issue= 2 | pages= 168-71 | pmid=1117548 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1117548 }} </ref>. An example would be to start [[lisinopril]] 5 mg Q day. Every one to two weeks, the dose would be escalated to achieve a target dose of 15 to 20 mg Q day. [[ACE inhibitors]] are initiated before a beta blocker because they achieved their hemodynamic effects more rapidly, and they are less likely to cause a decline in hemodynamic function. If an [[ACE inhibitor]] is not tolerated, then an [[angiotensin receptor blocker]] [[ARB]] is started. Although there is some data to suggest that [[aspirin]] blunts the hemodynamic effect of [[ACE inhibitors]], there is no data to suggest that [[aspirin]] reduces the clinical efficacy of [[ACE inhibitors]] in [[heart failure]] patients. Aspirin should be administered to patients with [[ischemic heart disease]], but not to patients without it. | After diuretics are started or at the same time you can begin the use of an [[ACE inhibitors]] <ref name="pmid1117548">{{cite journal| author=Shiokawa Y| title=Proceedings: Streptococcus surveys in Ryukyu Islands, Japan. | journal=Jpn Circ J | year= 1975 | volume= 39 | issue= 2 | pages= 168-71 | pmid=1117548 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1117548 }} </ref>. An example would be to start [[lisinopril]] 5 mg Q day. Every one to two weeks, the dose would be escalated to achieve a target dose of 15 to 20 mg Q day. [[ACE inhibitors]] are initiated before a beta blocker because they achieved their hemodynamic effects more rapidly, and they are less likely to cause a decline in hemodynamic function. If an [[ACE inhibitor]] is not tolerated, then an [[angiotensin receptor blocker]] [[ARB]] is started. Although there is some data to suggest that [[aspirin]] blunts the hemodynamic effect of [[ACE inhibitors]], there is no data to suggest that [[aspirin]] reduces the clinical efficacy of [[ACE inhibitors]] in [[heart failure]] patients. Aspirin should be administered to patients with [[ischemic heart disease]], but not to patients without it. |
Revision as of 15:48, 29 April 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Assistant editor-in-chief Rim Halaby
Overview
There are several goals in the chronic management of systolic heart failure. The management of diastolic heart failure is discussed elsewhere. The first goal is to treat the patient's symptoms of heart failure and to improve the patient's exercise tolerance and quality of life. The use of diuretics and regular assessment of the patient's weight helps in avoiding excess body fluids that are associated with dyspnea and orthopnea. Another goal of the chronic treatment of heart failure is to decrease the rate of hospitalization and mortality. To achieve the second goal, patients with chronic heart failure should be administered an ACE inhibitor (or ARB if they are ACE intolerant) and a beta blocker. If the patient remains symptomatic, additional therapy may be advised such as an aldosterone antagonist.
Diuresis: First step in the management of heart failure
Begin by rapidly improving the symptoms of heart failure (within hours to days) by the use of diuretics. Diuretics reduce excess volume that accumulates with heart failure and decrease pulmonary edema that causes symptoms of dyspnea and orthopnea[1]. Lasix 20 to 40 mg PO daily is a conventional starting dose, but in some patients, torsemide may have better a better choice due to more predictable absorption. Once a day dosing of a given diuretic is preferred to twice a day dosing at a lower dose. A rise in BUN and Cr may reflect a reduction in renal perfusion, and further diuresis should only be undertaken with careful monitoring of renal function. The patient should weigh themselves each morning at the same time on the same scale, and the diuretic dosing should be adjusted to maintain a constant weight.
- Simultaneous with number 1
- Treat the underlying cause of heart failure such as ischemic heart disease, hypertension, and valvular heart disease.
- Treat other non cardiac diseases that might contribute to the symptoms of heart failure such as diabetes and hyperthyroidism[2].
- Treat with a low salt diet[3]
- Follow the patient's weight to check for fluid overload
- Treat with vaccines for influenza and pneumococcus [4].
ACE Inhibition and Angiotensin Receptor Blockade: Second step in the management of heart failure
After diuretics are started or at the same time you can begin the use of an ACE inhibitors [6]. An example would be to start lisinopril 5 mg Q day. Every one to two weeks, the dose would be escalated to achieve a target dose of 15 to 20 mg Q day. ACE inhibitors are initiated before a beta blocker because they achieved their hemodynamic effects more rapidly, and they are less likely to cause a decline in hemodynamic function. If an ACE inhibitor is not tolerated, then an angiotensin receptor blocker ARB is started. Although there is some data to suggest that aspirin blunts the hemodynamic effect of ACE inhibitors, there is no data to suggest that aspirin reduces the clinical efficacy of ACE inhibitors in heart failure patients. Aspirin should be administered to patients with ischemic heart disease, but not to patients without it.
If a patient cannot tolerate a an ACE inhibitor (develops a cough), then an Angiotensin II receptor blocker can be administered. The effectiveness of this approach was demonstrated for candesartan in the CHARM Alternative trial [7]. In general, ARBs are as effective or slightly less effective than ACE inhibitors in the treatment of congestive heart failure.[8][9] It is a class 2a recommendation to substitute an ARB as an alternative to ACE inhibitors if the patient is already taking an ARB for another indication.[10]
The efficacy of adding an ARB to an ACE inhibitor was assessed in the CHARM Added trial[11]. While there was a reduction in the composite primary endpoint in the study, there was no reduction in mortality. Furthermore, the VALIANT trial demonstrated that an ARB should not be added to an ACE inhibitor in the post MI setting. These results for ARBs are in contrast to the results of the EMPHASIS HF trial showed that the addition of eplerenone (an aldosterone antagonist) to ACE inhibition improved clinical outcomes including mortality among patients with class II or III heart failure with a reduced LVEF.[12] Thus, based upon the mortality benefit observed in the EMPHASIS HF trial, an aldosterone antagonist rather than and ARB should be added to an ACE inhibitor in patients with NYHA class II heart failure and an LVEF < 30%, in the post-MI patient who has and LVEF < 40% who has heart failure symptoms or diabetes, and the patient with class III or IV heart failure who has an LVEF < 35%.
"Triple therapy", the combined use of an ACE inhibitor, an ARB and an aldosterone antagonist is a relative contraindication.
Beta blockers: Third step in the management of heart failure
Once you have achieved a stable dose of a diuretic and an ACE inhibitor, then one of the three beta blockers that have been associated with improved survival (carvedilol, metoprolol succinate or bisoprolol) can be added and the dose titrated based upon the patient's tolerance. You should avoid beta-blockers with intrinsic sympathomimetic activity (pindolol or acebutolol). It should be noted that the 35% reduction in one year mortality observed in meta-analyses of beta-blockers in heart failure was when these drugs were added to ACE inhibitors[13]. There are no direct comparisons of the various beta-blockers, but some data does suggest that carvedilol may improve LVEF more than the others, but it may not be as well tolerated due to its vasodilatory properties. If the patient has been over diuresed, they may not tolerate the addition of a beta blocker.
- Relative contraindications to beta-blocker administration include the following:
- Asthma or bronchospasm
- Hypotension resulting in poor end organ perfusion or symptoms
- Bradycardia or heart block (first degree heart block with a PR interval > 0.24, second degree heart block, third degree heart block
- Peripheral arterial disease with limb ischemia at rest
- Moderate or greater peripheral edema
- Recent intravenous inotropic therapy
Given the potential for hemodynamic complications, the initiation of beta-blockers is best undertaken by an individual or center specializing in heart failure management. The patient should be aware of potential side effects, and should be aware that it may take one to three months for the beta-blockers to improve heart failure symptoms. THerapy is initiated with very low doses, and the dose of the beta-blocker should be doubled every two weeks until the target dose is achieved or symptoms prevent further dose escalation.
- Carvedilol: Initial dose 3.125 mg twice daily, target dose 25 to 50 mg twice daily
- Metoprolol succinate: Initial dose 12.5 mg daily, target dose 200 mg daily
- Bisoprolol: Initial dose 1.25 mg daily, target dose 5 to 10 mg daily
Weight gain or peripheral edema that is not responsive to diuresis may require a reduction in the dose of beta-blockers.
Aldosterone antagonism: Fourth step in the management of heart failure
An aldosterone antagonist can be added to the regimen of 'select' patients. These selected patients include:
- Class II heart failure and a left ventricular ejection fraction (LVEF) < 30%
- Class III/IV heart failure and a LVEF <35%
- Post ST segment elevation MI and a LVEF < 40% who have either symptomatic heart failure or diabetes.
- The Serum potassium must be under 5.0 meq/li and the glomerular filtration rate (GFR) should be > 30 cc per minute
A requirement for aldosterone antagonist is that the patient's renal function and potassium can be carefully monitored. Eplerenone has fewer endocrine side effects (1%) than spironolactone (10%), but is more costly. A reasonable strategy is to initiate therapy with spironolactone at a dose of 25 to 50 mg daily, and then switch to eplerenone at a dose of 25 to 50 mg daily if endocrine side effects develop.
Risk factors for the development of hyperkalemia on an aldosterone antagonist
- Triple therapy with an ACE inhibitor and angiotensin II receptor blocker makes this combination a contraindication
- Higher doses of either an ACE inhibitor or an angiotensin receptor blocker (ARB)
- Hyperkalemia prior to initiation of spironolactone
- Comorbidities such as diabetes and chronic renal insufficiency
- Higher NYHA heart failure class
- Concomitant administration of beta blockers, nonsteroidal anti-inflammatory drugs )NSAIDs) or potassium supplements
- A daily dose of Spironolactone greater than 50 mg
The combination of hydralazine and a nitrate: Fifth step in the management of heart failure
The combination of hydralazine and a nitrate (particularly among black patients) can be added if the patient continues to have symptoms on a diuretic,ACE inhibitor (or ARB in the intolerant patient) and a beta blocker. The initial dose is isosorbide dinitrate 20 mg three times a day along with hydralazine 25 mg three times a day. The dose(s) can be increased every 2 to 4 weeks to a target dose of isosorbide dinitrate 40 mg three times a day and hydralazine 75 mg three times a day.
- Shown below is an image that summarizes the steps in the chronic management of patients with heart failure.
References
- ↑ Michael Felker G (2010). "Diuretic management in heart failure". Congest Heart Fail. 16 Suppl 1: S68–72. doi:10.1111/j.1751-7133.2010.00172.x. PMID 20653715.
- ↑ DeGroot WJ, Leonard JJ (1970). "Hyperthyroidism as a high cardiac output state". Am Heart J. 79 (2): 265–75. PMID 4903771.
- ↑ Evangelista LS, Shinnick MA (2008). "What do we know about adherence and self-care?". J Cardiovasc Nurs. 23 (3): 250–7. doi:10.1097/01.JCN.0000317428.98844.4d. PMC 2880251. PMID 18437067.
- ↑ Martins Wde A, Ribeiro MD, Oliveira LB, Barros Lda S, Jorge AC, Santos CM; et al. (2011). "Influenza and pneumococcal vaccination in heart failure: a little applied recommendation". Arq Bras Cardiol. 96 (3): 240–5. PMID 21271169.
- ↑ Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM (2003). "Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both". The New England Journal of Medicine. 349 (20): 1893–906. doi:10.1056/NEJMoa032292. PMID 14610160. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Shiokawa Y (1975). "Proceedings: Streptococcus surveys in Ryukyu Islands, Japan". Jpn Circ J. 39 (2): 168–71. PMID 1117548.
- ↑ Granger CB, McMurray JJ, Yusuf S, Held P, Michelson EL, Olofsson B, Ostergren J, Pfeffer MA, Swedberg K (2003). "Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial". Lancet. 362 (9386): 772–6. doi:10.1016/S0140-6736(03)14284-5. PMID 13678870. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Jong P, Demers C, McKelvie RS, Liu PP (2002). "Angiotensin receptor blockers in heart failure: meta-analysis of randomized controlled trials". Journal of the American College of Cardiology. 39 (3): 463–70. PMID 11823085. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Pitt B, Poole-Wilson PA, Segal R, Martinez FA, Dickstein K, Camm AJ, Konstam MA, Riegger G, Klinger GH, Neaton J, Sharma D, Thiyagarajan B (2000). "Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial--the Losartan Heart Failure Survival Study ELITE II". Lancet. 355 (9215): 1582–7. PMID 10821361. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ McMurray JJ, Ostergren J, Swedberg K, Granger CB, Held P, Michelson EL, Olofsson B, Yusuf S, Pfeffer MA (2003). "Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial". Lancet. 362 (9386): 767–71. doi:10.1016/S0140-6736(03)14283-3. PMID 13678869. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B (2011). "Eplerenone in patients with systolic heart failure and mild symptoms". The New England Journal of Medicine. 364 (1): 11–21. doi:10.1056/NEJMoa1009492. PMID 21073363. Retrieved 2013-04-29. Unknown parameter
|month=
ignored (help) - ↑ Brophy JM, Joseph L, Rouleau JL (2001). "Beta-blockers in congestive heart failure. A Bayesian meta-analysis". Annals of Internal Medicine. 134 (7): 550–60. PMID 11281737. Retrieved 2013-04-28. Unknown parameter
|month=
ignored (help)