CURRENT APPROACH TO THE TREATMENT OF CONGESTIVE HEART FAILURE

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Meds include Enalapril 10 mg qd, lasix 60 mg bid, Carvedilol 12.5 mg bid Case Study Same patient but the JVP is low and the BP is 80/60 mmHg. What would you do?
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Title: CURRENT APPROACH TO THE TREATMENT OF CONGESTIVE HEART FAILURE 1 CURRENT APPROACH TO THE TREATMENT OF CONGESTIVE HEART FAILURE 2 Treatment of CHF in 1970
  • Digitalis
  • Diuretics
  • Salt restriction
  • 3 Modern Rx of CHF
  • Diuretics
  • Vasodilators
  • Beta-blockers
  • Inotropic agents
  • Digoxin
  • Adrenergic agents
  • Milrinone
  • Aldactone
  • BiV Pacing
  • 4 Diuretics
  • Decrease edema
  • Do not improve cardiac output
  • Improve exercise capacity
  • No known beneficial molecular effects
  • No reversed remodeling
  • Do not slow progression of disease
  • Cause pre-renal failure
  • Increase mortality
  • 5 Digitalis Effect on Hospitalizations 67.1 64.3 Hospitalizations () Digoxin Placebo N Engl J Med 1997336525-533 6 Digitalis Effect on Mortality 40 35.1 34.8 Mortality 0 Digoxin Placebo N Engl J Med 1997336525-533 7 Newer Therapies
  • ACE inhibitors (class effect)
  • Hemodynamic and molecular effects
  • Beta-blockers (may not be class effect)
  • Long-term hemodynamic benefits
  • Probably achieved by molecular effects
  • Aldactone
  • Probably just molecular effects
  • Angiotensin receptor blockers
  • Similar to ACE inhibitors in most ways
  • 8 CLINICAL ASSESSMENT OF CHF
  • BLOOD PRESSURE
  • JVP
  • RALES
  • EDEMA
  • SERUM CREATININE
  • MITRAL REGURGITATION
  • POSTURAL SYMPTOMS
  • BNP
  • 9 WHAT TO EXPECT FROM DIURETICS
  • RAPID RESPONSE
  • DECREASED FILLING PRESSURES
  • EDEMA
  • BUT the tendency is for
  • CARDIAC OUTPUT
  • CREATININE
  • NEUROHUMORAL ACTIVATION
  • 10 VASODILATORS
  • NITRATES
  • VENOUS
  • ARTERIOLAR
  • ARTERIAL DILATORS
  • HYDRALAZINE
  • BALANCED VASODILATORS
  • NITROPRUSSIDE
  • ACE INHIBITORS
  • ANGIOTENSIN RECEPTOR BLOCKERS
  • OMEPATRILAT (combined ACEI and NEP)
  • 11 WHAT TO EXPECT FROM VASODILATORS
  • FILLING PRESSURES
  • CARDIAC OUTPUT
  • EXERCISE TOLERANCE
  • NEUROHUMORAL ACTIVATION
  • REVERSE REMODELING
  • HOSPITALIZATIONS and MORTALITY
  • 12 HOW TO USE ACE INHIBITORS
  • PHYSIOLOGICAL APPROACH
  • DOSES SHOULD BE MAXIMUM TOLERATED
  • IN CHF, TWICE A DAY (CAPTOPRIL 3-4 TIMES/DAY)
  • IDEAL BLOOD PRESSURE OFTEN lt100 mmHg IF NO POSTURAL SYMPTOMS
  • IF CHF WORSE AND HYPOTENSIVE, DONT REDUCE THE DOSE UNLESS CLEARLY NECESSARY
  • KEEP PATIENT ON IT DESPITE MINOR INCREASES IN CREATININE OR POTASSIUM
  • 13 ATLAS (high vs low dose lisinopril) Risk of all cause mortality Risk of death or hospitalization Frequency of HF hospitalizations 8 p0.12 12 p0.002 Decrease 25 p0.002 14 WHAT TO EXPECT OF NITRATES
  • VENODILATATION AT LOW DOSES
  • ARTERIAL DILATATION AT HIGH DOSES
  • CARDIAC OUTPUT
  • MITRAL REGURGITATION
  • BENEFICIAL REMODELING
  • IMPROVED EXERCISE TOLERANCE
  • 15 DRUG COMBINATIONS
  • ACE INHIBITORS AND NITRATES
  • ACE INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS
  • BETA-BLOCKERS
  • ALDACTONE
  • HYDRALAZINE
  • INOTROPES
  • 16 (No Transcript) 17 (No Transcript) 18 (No Transcript) 19 Nitrates and Hydralazine
  • Reduce mortality
  • ACE/ARB-intolerant patients
  • Combination with ACE Inhibitors
  • No adverse effect on renal function
  • ACE Inhibitors more effective in reducing mortality
  • Nitrates and Hydralazine - better hemodynamic responses
  • 20 Beta-Adrenergic Blockade in Congestive Heart Failure
  • Historically contraindicated in CHF
  • Counter-intuitive
  • Early studies not definitive
  • Anecdotes impressive
  • Recent trials definitive
  • Still slow to be adopted
  • 21 US CARVEDILOL TRIAL 22 Carvedilol Causes a Dose-Related Improvement in LV Ejection Fraction 8 plt0.005 vs. placebo plt0.0001 vs. placebo plt0.0001 7 6 5 4 3 2 1 0 6.25 mg 12.5 mg 25 mg bid Placebo Carvedilol Circulation 1996942807-2816 23 Beta-Blockers Patient Selection
  • Stable Class I-IV patients
  • LVEF lt 35 - 40
  • Ischemic or non-ischemic
  • On ACE inhibitor, diuretics, with or without digoxin
  • Heart Rate gt 60 bpm, no high degree a-v block
  • Systolic BP gt 85 - 90 mmHg
  • No contraindications to beta-blockade
  • 24 Initiation of Beta-Blockers in Heart Failure
  • Optimize control of failure first
  • Start at the lowest dose
  • Increase the dose gradually as tolerated
  • (No sooner than every 2 weeks)
  • Monitor vital signs, weight, and clinical status
  • Adjust concomitant medications as needed
  • 25 Time course of effects Beta-Blockade Therapy Clinical Benefit Clinical Deterioration 0 1 - 2 3 - 4 5 - 6 11 - 12 Months Am J Cardiol 199779794-798 26 (No Transcript) 27 Recommended Monitoring During Titration of Beta-Blocker Therapy
  • Symptoms
  • Weight
  • Heart rate (rhythm)
  • Blood pressure
  • Jugular venous pressure
  • Lung auscultation
  • 28 Management of Adverse Effects
  • Control chf before initiation or up-titration
  • Persist if possible (symptoms usually improve)
  • May need to consider pacing
  • If hypotension symptomatic, consider reducing vasodilator or diuretic dose
  • Deterioration on maintenance Rx, dose reduction or stopping drug usually unnecessary
  • 29 General Approach to Rx
  • Look for precipitating cause
  • B.P, JVP and Creatinine central to assessment and monitoring
  • A quick fix probably wont work as well as re-optimizing Rx
  • Follow up is usually essential
  • 30 Blood pressure
  • BP 90-100 well-tolerated. Some tolerate 70.
  • If asymptomatic, dont decrease vasodilators.
  • If symptomatic and JVP low, consider reducing diuretic.
  • If JVP increased and BP is low, can either diurese or add nitrate).
  • Nitrates have greater potential benefit.
  • Can add ARB when ACE dose is maximum tolerated.
  • 31 JVP Elevated If BP low, consider adding a nitrate (diuretic often but not always necessary). If blood pressure ok, increase ACE/add nitrate. Fine tune with diuretic when necessary. 32 Creatinine Increasing
  • Most often, this means cardiac output is decreasing, not renal artery stenosis.
  • Need to increase output. Dont decrease vasodilators unless it clearly is required.
  • Vasodilators often improve status, diuretics are a throwback to the 70s and signal defeat.
  • 33
  • If a patient deteriorates on vasodilators
  • and beta-blockers
  • dont decrease the vasodilators
  • the beta-blocker should probably also be
  • continued (perhaps after the first few
  • hours which are needed to stabilize the
  • patient).
  • consider tailored therapy if vasodilators
  • appear to be at maximum-tolerated dose.
  • 34 Case Study
  • 49 year old man chf due to cardiomyopathy.
  • BP 135/90, pulse was 90
  • Jugular venous pressure 12 cm. asa.
  • On lasix (40 mg b.i.d.),enalapril (5 mg qd) and digoxin (.25 mg qd).
  • 35 One approach is to diurese aggressively until dry. If you do that, you can expect decreased edema. The patient will feel better and the response is easy to measure (decreased weight, JVP, edema) and the blood pressure will probably change little. 36
  • Another approach is to view this as an
  • opportunity to improve his therapy by
  • Increasing vasodilators
  • ?Reduce diuretics
  • ?Combine vasodilators
  • Add beta-blocker
  • Add aldosterone antagonist
  • 37 Case Study
  • An 83 year old woman with chf presents with not feeling well.
  • B.P. is 90/60, JVP is 12 cm ASA, Creatinine is 250.
  • Meds include Enalapril 10 mg qd, lasix 60 mg bid, Carvedilol 12.5 mg bid
  • 38 You could just give more diuretic. What will happen? or You could manipulate the vasodilators And possibly reduce the diuretics. 39 Case Study
  • Same patient but the JVP is low and the BP is 80/60 mmHg.
  • What would you do?
  • 40 Short and Long-term Goals
  • Short-term goals
  • Improve hemodynamic status
  • decrease filling pressures
  • increase output
  • Improve exercise capacity
  • Long-term goals
  • Reverse remodeling/slow progression
  • Improve cardiac function
  • Maintain improved hemodynamic status
  • Recommended
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