Congestive heart failure treatment of special populations
Revision as of 14:18, 21 June 2022 by Edzelco(talk | contribs)(/* 2022 AHA/ACC/HFSA Heart Failure Guideline/2009 and 2005 ACC/AHA Focused Update Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) {{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A R...)
There is unfortunately insufficient data in subgroups of patients to mandate a change to guidelines recommendations regarding the management of heart failure. Dosages should be altered as needed in the elderly or in those with altered metabolism. African american patients may respond to the addition of hydralazine and nitrates to the standard of care in the treatment of heart failure.
Women
Women may not drive the same benefit from angiotensin-converting enzyme inhibitors in meta-analysis (mortality HR = 0.80 (95% CI 0.68-0.93) for men but HR = 0.90 (95% CI 0.78-1.05) for women) [1], but women do appear to drive the same benefit from beta blockers as men (HRs for mortality 063 & 0.66 respectively).[1]
Race
ACE Inhibition
Blacks tend to have a poorer response to ACE inhibition, specifically in response to equivalent doses of enalapril (44% reduction in heart failure hospitalization among whites versus no benefit among black patients in SOLVD).[2] Similar results have been observed with respect blood pressure management. In the SOLVD study quoted above, there was a 5 mm Hg reduction in systolic blood pressure among white patients but no reduction in systolic blood pressure among black patients. Despite the lack of improvement in hospitalization or systolic blood pressure, blacks did experience a reduction in mortality that was similar to that of white patients. Thus, ACE inhibitors should continue to be used in black patients.
Beta Blockers
Randomized trials have shown mixed benefits for blacks with beta blockers. In the BEST trial, bucindolol (they beta blocker with partial beta agonist activity) was not associated with the benefit in blacks[3], however in the carvedilol trials blacks did sustain a benefit[4]. It has been speculated that there may be differences in the beta adrenergic system between blacks and whites that account for these differences.
Hydralazine Plus Nitrates
Black patients appeared to derive particular benefit from the combination of hydralazine plus nitrates.[5]
2022 AHA/ACC/HFSA Heart Failure Guideline/2009 and 2005 ACC/AHA Focused Update Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [6][7][8][9]
Disparities and Vulnerable Populations (DO NOT EDIT) [6]
"1. In vulnerable patient populations at risk for health disparities, HF risk assessments and multidisciplinary management strategies should target both known risks for CVD and social determinants of health, as a means toward elimination of disparate HF outcomes. [10][11][12][13][14][15](Level of Evidence: C-LD)"
"2. Groups of patients including (a) high-risk ethnic minority groups (e.g., blacks), (b) groups underrepresented in clinical trials, and (c) any groups believed to be underserved should, in the absence of specific evidence to direct otherwise, have clinical screening and therapy in a manner identical to that applied to the broader population. (Level of Evidence: B) "
" 5.ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with LV dysfunction due to prior MI who are at least 40 d post-MI, have an LVEF less than or equal to 30% to 40%, are NYHA functional class II or III, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: A)"
" 1. Implantation of an ICD is reasonable in patients with LV dysfunction due to prior MI who are at least 40 d post-MI, have an LVEF of less than or equal to 30% to 35%, are NYHA functional class I on chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: B) "