Congestive heart failure vasodilators

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Summary
Acute Pharmacotherapy
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Chronic Pharmacotherapy in HFrEF
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Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
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Congestive heart failure end-of-life considerations

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Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Nitrates reduce both preload and afterload in the setting of congestive heart failure and thereby relieve symptoms.

Vasodialators

Background

  • A nitrate may be added to ACE inhibitors to relieve symptoms of pulmonary edema
  • The addition of a nitrate to an ACE inhibitor may improve exercised tolerance.
  • The combination of hydralazine and nitrates is useful in patients with advanced heart failure[1] and in particularly, when ACE inhibitors are not well tolerated.
  • Hydralazine by itself is only an arterial vasodilator and does not reduce left ventricular filling pressures to the same extent as nitrates and ACE inhibitors do. In fact when used alone it can stimulate sympathetic tone reflexively. The combination of hydralazine and nitrates has been shown to decrease mortality as well as improve the left ventricular ejection fraction and exercise capacity in patients with heart failure. However the combination of hydralazine and nitrates has been found to be less effective than ACE inhibitors.
  • The major of use of this combination is in those patients who are intolerant of ACE inhibitors.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Class III (No Benefit)

1. Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective. (Class III, Level of Evidence: B-R)

Vote on and Suggest Revisions to the Current Guidelines

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References

  1. Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN (2004). "Combination of isosorbide dinitrate and hydralazine in blacks with heart failure". The New England Journal of Medicine. 351 (20): 2049–57. doi:10.1056/NEJMoa042934. PMID 15533851. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  2. 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, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  3. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA 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):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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