Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.
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 ; A randomized trial of beta-blockade in heart failure. CIBIS investigators and committees.
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Circulation ; Effect of carvedilol on survival in severe chronic heart failure. J Cardiovasc Pharmacol Ther ; The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized aldactone evaluation study investigators. Eplerenone in patients with systolic heart failure and mild symptoms.
Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. Continuous versus bolus dosing of furosemide for patients hospitalized for heart failure. Am J Cardiol ; Digitalis Investigation Group. Hospitalisations for heart failure and for any cause were also reduced with eplerenone. Both MRAs can provoke hyperkalaemia and worsen renal function, while spironolactone, but not eplerenone, can induce gynaecomastia as a side effect. AT 1 -Receptor Antagonists A common side effect of ACE-inhibitors is to provoke dry cough due to inhibition of bradykinin breakdown by chymase.
The Pharmacologic Management of Heart Failure | Thoracic Key
Accordingly, ivabradine reduces HR only in patients with sinus rhythm SR , while in patients with AF, it has no effect. The prevailing pathophysiological view has long been that HR reduction is beneficial for the heart primarily due to lowering oxygen consumption. However, more recent experimental and clinical evidence also indicates that HR reduction improves vascular function and through this, unloads the heart. In animal models of atherosclerosis, HR reduction prevented vascular oxidative stress and endothelial dysfunction, reduced atherosclerotic plaque formation and stimulated collateral artery growth through improving the bioavailability of nitric oxide and reducing inflammation.
Accordingly, the primary endpoint a composite of cardiovascular death, admission to hospital for acute myocardial infarction and admission to hospital for new onset or worsening heart was completely unaffected by ivabradine hazard ratio 1. As a second effect, digitalis glycosides prolong the refractoriness of the atrioventricular AV -node, which accounts for negative chronotropic effects in patients with AF, but less in SR contrary to ivabradine. Combination of Hydralazine and Isosorbite Dinitrate A characteristic hallmark in patients with HF is that through neuroendocrine activation, SVR is elevated, imposing an increased afterload to the failing heart.
Thus, a therapeutic approach that proved beneficial with ACE-inhibitors is to lower SVR by applying vasodilating agents. Drugs Not Recommended Despite its accepted benefit in patients with coronary artery disease, statins have not improved outcome in patients with HF. In Figure 2 , a simplified scheme adapted from the current guidelines on the treatment of patients with chronic systolic HF is illustrated that helps to choose the right drugs at the right time in the treatment of these patients.
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Diastolic Dysfunction 3. Whether the problem is primarily increased venous back pressure behind the heart, or failure to supply adequate arterial perfusion in front of the heart backward vs. Whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance low-output heart failure vs.
The degree of functional impairment conferred by the abnormality as in the NYHA functional classification There are many different ways to categorize heart failure, including: 5. Myocardial Infarction: A myocardial infarction, reducing left ventricular function, may precipitate HF in a previously hemodynamically compensated patient 3.
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Systemic Hypertension: Rapid increases in arterial blood pressure with associated increases in peripheral resistance can increase afterload to an extent sufficient to produce heart failure. Congestive Heart Failure: Causes cont. In an era where morbidity and mortality from other cardiovascular diseases are decreasing, deaths from HF are increasing Framingham Criteria for Congestive Heart Failure 17 Diagnosis of HF requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria. III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.
Comfortable only at rest. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. Chronic thiazide diuretic Tx also results in relaxation of resistance vessels Beta blockers not acute HF, but decrease mortality in chronic HF 4.
The Pharmacologic Management of Heart Failure
Diuretics Cornerstone drugs in the treatment of heart failure. Noteworthy are loop diuretics and aldosterone receptor antagonists. In addition to effects on circulatory system, some of these agents also block the cellular responses that lead to cardiac remodeling and hypertrophy ACE inhibitors, 5. It is also thought that catecholamines and other sympathomimetics have an effect on cardiac remodeling, and blocking their activity can slow the deterioration of cardiac function See: The Importance of Beta Blockers in the Treatment of Heart Failure American Academy of Family Physicians Cardiac glycosides not first line Tx for HF due to risk of toxicities Increases SA nodal refractory period 2.
Increases AV nodal refractory period 2.
N Engl J Med. Taylor AL, etal;