Chronic Heart Failure

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Information about Chronic Heart Failure

Published on September 26, 2008

Author: pattersonby


Congestive (chronic) Heart Failure: Brooke Y. Patterson, PharmD, BCPS Congestive (chronic) Heart Failure Introduction: Introduction 5 million Americans have heart failure 550,000 new cases per year Affects nearly 10% of individuals over the age of 75 Most common hospital discharge for patients over 65 years old Overview: Overview CHF is used to describe a condition in which the heart is incapable of maintaining adequate CO LV systolic dysfunction Acute vs. chronic Mainstay of therapy Alter RAAS, SNS, natriuretic peptide system, vasopressin, endothelin, and cytokines Pathophysiology: Pathophysiology Impaired ability of the heart to contract or relax Compensatory mechanisms Tachycardia and increased contractility Increased preload Vasoconstriction Ventricular hypertrophy and remodeling Etiology: Etiology MI Cardiomyopathies Ventricular hypertrophy Uncontrolled HTN Volume overload Stages of Heart Failure: Stages of Heart Failure NYHA Functional Classification of CHF: NYHA Functional Classification of CHF General Principles: General Principles Correct underlying cause Systemic factors (thyroid, infection, etc.) Lifestyle modifications Review of medication regimen Discontinue drugs that may contribute to HF Pharmacologic therapy Goals of Therapy: Goals of Therapy Prolong survival Prevent disease progression Reduce hospitalizations Reduce symptoms Improve quality of life Pharmacology: Pharmacology Diuretics: Diuretics Loop diuretics Symptomatic treatment ONLY Impact on long-term outcomes not established Negative effects of long-term use Neurohormonal activation Diuretic tolerance Electrolyte imbalance Hypotension Renal dysfunction Ace Inhibitors: Ace Inhibitors Mainstay of treatment Prevention of HF in high-risk patients All patients with HF and reduced EF should receive ACE inhibitors unless contraindicated No preferred ACE inhibitor ACE Inhibitors: ACE Inhibitors Benefits Decreased mortality Decreased symptoms Decreased hospitalizations Dosing considerations Start low and increase dose every 1-4 weeks to goal Avoid abrupt discontinuation Target dose is middle dose in dosing range Angiotensin-Receptor Blockers: Angiotensin-Receptor Blockers Reasonable alternative for patients who cannot take ACE inhibitors Consider adding ARB to patients who are symptomatic with reduced LVEF and currently on an ACE inhibitor Controversial Beta-Blocking Agents: Beta-Blocking Agents Not all beta-blockers were created equal! Carvedilol Metoprolol XL Recommended for stable patients with HF and reduced LVEF Initiate at low dose Beta-Blockers: Beta-Blockers Benefits (when added to ACEI) Decreased mortality Decreased hospitalizations Symptom improvement Dosing considerations Added to existing ACEI therapy (low-dose) when symptoms are stable Start low, double dose every 2-4 weeks to goal Avoid abrupt discontinuation Aldosterone Antagonists: Aldosterone Antagonists Spironolactone vs. eplerenone Generic available Affinity for aldosterone receptor Initiate in patients with severe HF despite standard therapy Do not use with ACE and ARB combined Aldosterone Antagonists: Aldosterone Antagonists Benefits Decreased mortality Decreased hospitalizations For patients with Class III and IV heart failure Do NOT use with ACE inhibitor and ARB Dosing considerations Spironolactone 12.5-25mg QD Digoxin: Digoxin Benefits Improved symptoms No effect on mortality Used in symptomatic patients despite optimal ACE inhibitor, BB, spironolactone, and/or diuretic therapy Dosing considerations Serum digoxin levels of 0.5-1.0 ng/dL High risk of toxicity in elderly For most patients, 0.125mg PO QD is adequate Isosorbide & Hydralazine: Isosorbide and Hydralazine Mortality data specific for African-Americans with NYHA Class III-IV HF Currently receiving SOC Cannot tolerate ACE or ARBs HA and dizziness are common and dose-limiting Adjunctive Therapy: Adjunctive Therapy Anticoagulation NO routine use of warfarin Patients with HF who have previous thromboembolic event Antiarrhythmic Drugs Several drugs have increased mortality Amiodarone and dofetilide proven safe Lifestyle Modifications: Lifestyle Modifications Self-monitoring of weight (daily) Drug adherence Low-sodium/DASH diet Exercise Smoking cessation EtOH abstinence Immunizations Influenza Penumovax Case: Case SD is a 71 yo AAF with a PMH signification for s/p MI (1999), HTN, and CKD. Her most recent calc CrCl is 45 mL/min. Her current meds include metoprolol 50mg BID, ASA 81 mg QD, and lisinopril 2.5mg QD. Her BP is 135/88 mmHG. She has some dyspnea on exertion. PE is unremarkable. LVEF 33%.

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