Congestive heart failure Pharmacological treatments for patients with heart failure with reduced ejection fraction: Difference between revisions
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==For selected patients: To reduce mortality/HF hospitalization== | ==For selected patients: To reduce mortality/HF hospitalization== | ||
===Diuretics=== | ===Diuretics=== | ||
Diuretics can reduce volume overload and reduce [[shortness of breath]] and [[edema]], and are recommended in patients with signs or symptoms of volume overload. There are three major types of diuretics, [[loop diuretics]], [[thiazides]] and [[potassium-sparing diuretics]]. [[Diuretics]] rapidly improve the symptoms of [[heart failure]] (within hours to days). [[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 be a better choice due to its 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. Given the risk of [[hypokalemia]] or [[hyperkalemia]], the blood level of electrolyes should be checked regularly. | *Diuretics reduce HF symptoms and HF hospitalization and improve exercise capacity. However, their effects on mortality are remained to be elucidated. | ||
*Loop diuretics can reduce volume overload and reduce [[shortness of breath]] and [[edema]], and thus are recommended in patients with signs or symptoms of volume overload. | |||
*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. | |||
* | |||
There are three major types of diuretics, [[loop diuretics]], [[thiazides]] and [[potassium-sparing diuretics]]. [[Diuretics]] rapidly improve the symptoms of [[heart failure]] (within hours to days). [[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 be a better choice due to its 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. Given the risk of [[hypokalemia]] or [[hyperkalemia]], the blood level of electrolyes should be checked regularly. | |||
:*'''Simultaneous With Initiating Diuresis''' | :*'''Simultaneous With Initiating Diuresis''' | ||
::*[[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]]. |
Revision as of 13:06, 19 September 2021
Congestive Heart Failure Microchapters |
Pathophysiology |
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Differentiating Congestive heart failure from other Diseases |
Diagnosis |
Treatment |
Medical Therapy: |
Surgical Therapy: |
ACC/AHA Guideline Recommendations
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Specific Groups: |
Congestive heart failure Pharmacological treatments for patients with heart failure with reduced ejection fraction On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]
Overview
The major goals of pharmacologic treatment for patients with HFrEF are reducing mortality, reducing the risk of repeated hospitalizations due to worsening HF, and improving clinical status, functional capacity, and quality of life. The mainstay of treatment for HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system.
Therapuetic approach
- The major goals of pharmacologic treatment for patients with HFrEF are:
- 1) Reducing mortality (either all-cause or cardiovascular)
- 2) Reducing the risk of repeated hospitalizations due to worsening HF
- 3) Improving clinical status, functional capacity, and quality of life
- The cornerstone of pharmacologic management of HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system (i.e., neurohormonal blockade).
For all patients: To reduce mortality
- Angiotensin-converting enzyme inhibitors (ACE-I) or an angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) reduce mortality, reduce the risk of repeated HF hospitalizations, and improve symptoms in patients with HFrEF.
- Thus, a combination of an ACE-I/ARNI, a beta-blocker, and an MRA is recommended as class I therapies for all HFrEF patients unless they are contraindicated or not tolerated. These drugs should be uptitrated to the doses used in the clinical trials or to maximally tolerated doses.
- Unless contraindicated or not tolerated, the sodium-glucose co-transporter 2 (SGLT2) inhibitors (dapagliflozin and empagliflozin) are also recommended for all HFrEF patients and should be added to pharmacotherapy of HFrEF patients that are already taking an ACE-I/ARNI, a beta-blocker, and an MRA, regardless of diabetes status.
For all patients with HFrEF (LVEF<40%) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ACE-I/ARNI | BB | MRA | SGLT2i | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Captopril | Sacubitrl/valsartan | Bisoprolol
| Eplerenone
| Dapagliflozin
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
For selected patients: To reduce mortality/HF hospitalization
Diuretics
- Diuretics reduce HF symptoms and HF hospitalization and improve exercise capacity. However, their effects on mortality are remained to be elucidated.
- Loop diuretics can reduce volume overload and reduce shortness of breath and edema, and thus are recommended in patients with signs or symptoms of volume overload.
- 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.
There are three major types of diuretics, loop diuretics, thiazides and potassium-sparing diuretics. Diuretics rapidly improve the symptoms of heart failure (within hours to days). 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 be a better choice due to its 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. Given the risk of hypokalemia or hyperkalemia, the blood level of electrolyes should be checked regularly.
- Simultaneous With Initiating Diuresis
- 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][5]
- ↑ 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
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