new strategies in the management of heart failure dr. hassan chamsi pasha md, frcp(lond), frcp(ire),...
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New Strategies in the Management New Strategies in the Management of Heart Failureof Heart Failure
Dr. Hassan Chamsi Pasha MD, FRCP(Lond), FRCP(Ire),
FRCP(Glasg), FACC
Head, Non–Invasive Cardiology
King Fahd Armed Forces Hospital
Heart failureHeart failure
Approximately 4.6 million Americans currently have heart failure.
400,000 new cases occur each year. Prevalence of the disease increases with
age, affecting approximately 1% of persons in their fifth decade and nearly 10% of those aged 80 to 89.
South Med J 2001 ,94(2):166-174
Heart failureHeart failure
Contributes directly or indirectly to approximately 260,000 deaths annually.
Primary diagnosis in 870,000 hospital discharges. Five-year survival after the diagnosis is only 25% in
men and 38% in women. In more severe disease, 1-year mortality approaches
30-50%. For all patients, median survival is 1.7 years in men
and 3.2 years in women. Annual cost exceeding $34 billion.
Pharmacotherapy 20(7):787-804, 2000.
One third of patients who are hospitalized for heart failure either die or require readmission within 60 days of hospital discharge.
One half are readmitted within 90 days.
Mechanisms of Heart FailureMechanisms of Heart Failure
Disease progression is related to structural changes in the heart and blood vessels that lead to ventricular remodeling.
Remodeling process is characterized by alterations in the size and shape of the left ventricle and is triggered by activation of endogenous neurohormonal systems, primarily the renin-angiotensin system (RAS) and the sympathetic nervous system (SNS).
Goals of TreatmentGoals of Treatment
The primary goal of treatment has shifted from symptomatic relief to slowing or arresting disease progression.
Neurohormonal abnormalities, not hemodynamic abnormalities, are responsible for disease progression
Usual Treatment TodayUsual Treatment Today
AIMS OF HEART FAILURE MANAGEMENT
TO IMPROVE SYMPTOMS DIURETICS DIGOXIN ACE INHIBITORS
TO IMPROVE SURVIVAL ACE INHIBITORS BLOCKERS ORAL NITRATES PLUS HYDRALAZINE SPIRONOLACTONE
Davies et al. BMJ 2000;320:428-431
HF: Mortality Remains HighHF: Mortality Remains High
ACEI RISK REDUCTION 35% (MORTALITY AND HOSPITALIZATIONS)1
BLOCKERS RISK REDUCTION 38% (MORTALITY AND HOSPITALIZATIONS)2
ORAL NITRATES AND HYDRALAZINEBENEFIT VS. PLACEBO; INFERIOR TO ENALAPRIL (MORTALITY)
HOWEVER: 4-YEAR MORTALITY REMAINS ~40%
Davies et al. BMJ 2000;320:428-431 (metanalysis: 32 trials, n=7105) 2 Gibbs et al. BMJ 2000;320:495-498 (metanalysis: 18 trials, n=3023)
Nonpharmacologic interventionsNonpharmacologic interventions
smoking cessation. Weight reduction Avoidance of alcohol. Limiting sodium intake (no more than 3 g
daily). Daily weight. Contact physician if body weight increases by
2 lb or more.
Benefits of ACE inhibitor therapy may not become apparent for 1 or 2 months after initiation of treatment.
Approximately 90% of patients with heart failure tolerate long-term ACE inhibitor therapy.
Aspirin-ACE Inhibitor InteractionAspirin-ACE Inhibitor Interaction
Studies are largely contradictory, but do reiterate the possibility of an interaction.
Low dosages (</= 100 mg/day) of aspirin appear to be safer than higher dosages.
Pharmacotherapy 20(6):698-710, 2000
B blockersB blockers
Four randomized, double-blind, placebo-controlled clinical trials:
mortality reduced 65% by carvedilol, 34% by metoprolol, 33% by bisoprolol; trials were ended early. Bucindolol: no significant effect on mortality.
[Am J Health-Syst Pharm 58(02):140-145, 2001.
MERIT-HF studyMERIT-HF study
3991 patients with heart failure from 313 centers in 14 countries randomly assigned to metoprolol CR/XL or placebo, in addition to their standard heart failure regimens.
Metoprolol CR/XL reduced the risk:
By 19%, for all-cause mortality or all-cause hospitalizations
By 31%, for total mortality or hospitalizations due to worsening heart failure
By 32%, for death or heart transplant by
By 39%, for cardiac death or nonfatal MI
By 32%, for mortality and hospitalization or emergency department visit due to worsening heart failure
Hjalmarson et al.J AMA 2000; 283: 1295-1302
MERIT-HF trial
JAMA 2000; 283: 1295-1302
CarvedilolCarvedilol
Four US studies: 1,094 patients with mild, moderate, or severe
heart failure receiving standard therapy with a diuretic, an ACE inhibitor, and digoxin.
Overall mortality in carvedilol group was 3.2% vs 7.8%, a reduction of 65%.
27% reduction in hospitalization 38% reduction in the combined risk of
hospitalization or death.
COPERNICUS trialCOPERNICUS trial
Enrolled 2289 patients with severe HF (LVEF <25%), randomized to carvedilol in a target dose of 25 mg bid for up to 29 months.
Trial was stopped early for efficacy.
COPERNI CUS: Effect of carvedilol on the combined risk of morbidity and mortality
Death or hospitalization for HF
0.000004
p valueEndpoint
COPERNICUS and CAPRICORN
0.00004
31%
Death or hospitalization for a CV reason
0.76Death or hospitalization for any reason
Relative risk reduction
24%
0.00002
Odds ratio
27% 0.73
0.69
COPERNI CUS: Hospitalizations
Days per hospitalization
0.015
p valueEndpoint
COPERNICUS and CAPRICORN
0.0005
31%
Number of hospitalizations
Total days in hospital
Reduction with carvedilol
24%
0.001727%
CAPRICORN trialCAPRICORN trial
Examined the effect of carvedilol in patients with left ventricular dysfunction (LVEF < 40%) after an MI, with or without HF.
CAPRI CORN: Primary endpoints
p valueEndpoint
COPERNICUS and CAPRICORN
0.031
367 (37%)All-cause mortality or CV hospitalization
0.77 (0.60-0.98)All-cause mortality
Relative risk reduction
151 (15%)
0.296
Odds ratio
0.92 (0.80–1.07)
CAPRI CORN
All-cause mortality and nonfatal MI
0.002
p valueEndpoint
COPERNICUS and CAPRICORN
0.098
HF hospitalization
0.74Sudden death
0.014
Hazard ratio
0.59
0.71
Nonfatal MI
0.2150.86
Packer :
“Instead of prescribing carvedilol to such patients in the midst of their acute illness, it would be prudent first to take measures to stabilize their clinical condition"
N Engl J Med 2001; 344(22):1651-8.
3
Packer The use of carvedilol for severe HF would prevent
approximately 70 deaths per 1000 patients treated for 1 year
This compares with 20-40 deaths prevented with ACE inhibitors or beta blockers in mild to moderate HF, and with about 50 deaths prevented with an aldosterone antagonist in severe HF.
N Engl J Med 2001; 344(22):1651-8.
CIBIS-IICIBIS-II
Cardiac Insufficiency Bisoprolol Study II (CIBIS-II) compared a ß-blocker-containing regimen with standard therapy alone (diuretic plus ACE inhibitor) in 2,647 patients with NYHA class III or IV heart failure
Bisoprolol:
34% reduction in mortality
32% reduction in hospitalization. Lancet 1999; 353:9-13
BEST trialBEST trial
The Beta-blocker Evaluation of Survival Trial. Randomized 2708 patients with NYHA Class
III (92%) or IV (8%) HF and an ejection fraction of 35% or lower to bucindolol or placebo.
Mortality was not significantly different between the two groups .
May 31, 2001 issue of the New England Journal of Medicine.
BEST results
35%
p valueEndpoint
Bucinodol and carvedilol in HF
0.0429%
Death or heart transplant
0.90
CV death
Placebo
42% <0.001
Hazard ratioBucindolol
BEST investigators. N Engl J Med 2001; 344(22):1659-67.
Hospitalized due to CHF
Death 33%
Heart transplant 3%
30%
25%
35%
2%
32%
0.86
0.78
0.69
0.87
0.10
0.12
0.04
COMET TRIALCOMET TRIAL
The ongoing Carvedilol and Metoprolol European Trial, which involves 3,000 patients with NYHA class II to class IV heart failure, is testing the hypothesis that multiple-receptor blockade with carvedilol offers a therapeutic advantage over selective adrenergic blockage with metoprolol.
ß-blocker therapyß-blocker therapy
Although ejection fraction continues to improve at the highest dosage of Carvedilol (25 mg twice daily or 50 mg twice daily in heavier patients), significant treatment effect (two thirds or more of maximum mortality benefit) is seen at 6.25 mg twice daily.
Continue at a minimum dosage of 6.25 mg twice daily and do not abandon therapy if higher doses are not tolerated.
beta-Blocker withdrawal: beta-Blocker withdrawal: The song of OrpheusThe song of Orpheus
Morimoto : 13 patients with dilated cardiomyopathy who were
receiving long-term beta-blockade; Investigators withdrew the therapy to see if the patients
would continue to do well. Seven of the 13 patients deteriorated, including 4 who
died either suddenly or of progressive pump dysfunction.
Am Heart J 1999;138:387-9.
ATLAS study ATLAS study
Increasing ACE inhibitor doses from low to high confers relatively modest absolute reductions in mortality (8%).
Eur Heart J 1998; 19(suppl):142
Adding ß-blockade to intermediate doses of ACEI reduces mortality by 30% or more.
Lancet 1999; 353:9-13
Lancet 1999; 353:2001-2007
To optimally slow disease progression, it may, therefore, be preferable to add ß-blockade to moderate doses of ACE inhibitors, then increase the ACE inhibitor dose later, titrating upward as each successive dose is tolerated.
ß-blocker therapyß-blocker therapy
Taking the ACE inhibitor 2 hours after the carvedilol or taking carvedilol with food may reduce this hypotensive effect.
A temporary reduction in the dose of the ACE inhibitor may also be required.
Am J Cardiol 1999; 83(suppl 2A):1A-38A
-Blockers underutilized in heartfailure: major side effects
N/A 5%Impotence
N/A 8%Depression
12% 9%Diarrhea
9% 17%Bradycardia
13% 22%Hyperglycemia
9% 22%Hypertension
22% 27%Dyspnea
33% 35%Dizziness
25% 61%Fatigue
10% 64%Weight gain
US carvedilol studyStudy populationSide effect
Dr Ghazanfar Khadin et al, 49th AnnualScientific Session of the ACC
ELITEELITE Study Study
Evaluation of Losartan in the Elderly (ELITE) study:
722 patients to compare effects of losartan and captopril on renal function.
losartan associated with a 46% lower risk of mortality than captopril.
Lancet 1996; 2:47-54
ELITE StudyELITE Study
The study was not powered to investigate mortality, and after adjustment for the multiplicity of end points, no difference was seen in frequency of hospitalization or combined morbidity and mortality risk
Pharmacotherapy 20(7):787-804, 2000
RESOLVD studyRESOLVD study
Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) study involved 768 patients.
No significant differences in the rate of cardiac events among patients treated with candesartan, enalapril, or the combination.
Eur Heart J 1998; 19(suppl):
VALVALSARTAN SARTAN HeHeart art FFailure ailure TTrialrial
LONG-TERM CARDIAC MORBIDITY & MORTALITY TRIAL
CHRONIC STABLE HEART FAILURE PATIENTS
VALSARTAN ADDED TO USUAL HEART FAILURE THERAPY (ACEIS; DIURETICS; DIGOXIN; BLOCKERS)
• 5,010 PATIENTS • 300 CENTERS IN 16 COUNTRIES
HF PATIENTS>18 YR; EF <40%;
NYHA II-IV
906 DEATHS (EVENTS RECORDED)
VALSARTAN40 MG BID
TITRATED TO160 MG BID
RANDOMIZED TO
RECEIVING USUAL THERAPY INCLUDING ACEI, DIURETICS, DIGOXIN, BLOCKERS (STRATIFIED RANDOMIZATION)
Val-HeFT DESIGNVal-HeFT DESIGN
Placebo
Cohn et al. J Card Fail 1999;5:155-160
All Cause MortalityAll Cause Mortality
1.0
0.9
0.8
0.7
VALSARTAN PLACEBO
TIME SINCE RANDOMIZATION (MONTHS)
P = 0.8
SU
RV
IVA
L P
RO
BA
BIL
ITY
0 3 6 9 12 211815 24 27
1.0
0.9
0.8
0.6
13.3%RISK REDUCTION
P= 0.009
COMBINED ALL CAUSE MORTALITY AND MORBIDITY
0
EVEN
T-F
REE P
RO
BA
BIL
ITY
VALSARTAN PLACEBO
3 6 9 12 211815 24 27TIME SINCE RANDOMIZATION (MONTHS)
0.7
TIME SINCE RANDOMIZATION (MONTHS)
1.0
0.9
0.8
0.7
27.5%RISK
REDUCTIONP =0.00001
HF HOSPITALIZATION
VALSARTAN PLACEBO
EVEN
T-F
REE P
RO
BA
BIL
ITY
3 6 9 12 211815 24 27TIME SINCE RANDOMIZATION (MONTHS)
0TIME SINCE RANDOMIZATION (MONTHS)
SECONDARY VARIABLES CHANGE FROM BASELINE
012345
QUALITY OF LIFE(MLWHF* SCORE)†
EF (%)†
PLACEBO VALSARTAN
p= 0.001WORS
E
BETTER
p = 0.005
N=1557 N=1544 N=2509 N=2499
† ENDPOINT ANALYSIS
0
1
2
3
* MINNESOTA LIVING WITH HEART FAILURE
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4
% PatientsAll Patients 100
6547 < 6553
Male 80Female 20EF < 27 50EF 27 50
ACEI (Yes) 93ACEI (No) 7BB (Yes) 35BB (No) 65IHD (Yes) 57IHD (No) 43
FAVORS VALSARTAN FAVORS PLACEBO
COMBINED MORBIDITY/MORTALITYCOMBINED MORBIDITY/MORTALITYIN SUBGROUPSIN SUBGROUPS
ARBs offer an alternative to ACE inhibitors in the management of hypertension, especially for ACE-inhibitor-intolerant patients. ACE inhibitors remain the drugs of choice for patients with heart failure, left ventricular dysfunction after MI, and diabetic nephropathy; ARBs offer these patients an alternative when ACE inhibitor therapy is not tolerated.
Am J Health-Syst Pharm 2001: 58(8):671-683
Combination therapyCombination therapy
The addition of an ARB offers more complete angiotensin II receptor blockade of the RAS than can be obtained by ACE inhibitors alone.
Combination therapy preserves the benefits of bradykinin potentiation offered by ACE inhibitors while providing potential antitrophic influences of AT2 receptor stimulation
May play an increased role in the treatment of chronic HF in the future.
Am Heart J 2000 : 140(3):361-366
Aldosterone AntagonistsAldosterone Antagonists
Randomized Aldactone Evaluation Study involved 1,663 patients with severe heart failure (NYHA class III or IV) of ischemic or nonischemic origin.
Most patients received dosages of 25 mg daily in addition to the conventional background therapy
N Engl J Med 1999; 341:709-717
Aldosterone Inhibition and Heart Aldosterone Inhibition and Heart Failure: Too Good to Be True?Failure: Too Good to Be True?
The Randomized Aldactone Evaluation Study (RALES) h stunningly positive results.
Spironolactone, available for more than 40 years
Reduce the mortality rate by 30% in patients with advanced heart failure.
Hospitalization rate for worsening heart failure was reduced by 35%.
American Heart Journal 2001,1:141
DIG trialDIG trial
Digitalis Investigation Group (DIG), the National Institutes of Health .
To study to digoxin's effect on survival and morbidity in 7788 patients who remained symptomatic while taking diuretics and ACE inhibitors
No significant difference when deaths from all cardiovascular causes (29.9% digoxin vs 29.5% placebo, RR=1.10, p=0.78)
DIG trialDIG trial
Digoxin significantly reduced the rate of hospitalizations (26.8%) compared with placebo (34.7%, RR=0.72, p<0.001).
Admissions were fewer when all cardiovascular reasons were combined, including myocardial infarction and supraventricular arrhythmias (49.9% vs 54.4, RR=0.87, p<0.001).
Intermittent inotropic infusion therapy reported excess mortality with dobutamine. Dobutamine infusions were titrated to produce an optimal hemodynamic profile; mean dosages were 8.1 µg/kg/minute (maximum 15 µg/kg/min).
Death occurred in 32% (10/31) of dobutamine-treated patients compared with 14% (4/29) of placebo-treated patients over 24 weeks.
Causes of death assumed to result from arrhythmias (sudden cardiac death).
Lower dosages of inotropes may be associated with improvements in quality of life with lower risk of mortality.
Long-term therapy with phosphodiesterase inhibitors (e.g., milrinone, venarinone) :excess mortality
Intermittent intravenous inotropic agent may be of value in improving the quality of life or as a bridge to cardiac transplantation.
Catecholamine infusions have been associated with excess mortality.
Cardiac transplantation, left ventricular assist devices, and total artificial hearts are limited by technical, logistic, and cost issues
Pharmacotherapy 20(7):787-804, 2000.
Hydralazine-isosorbide dinitrate should be considered in patients with contraindications to ACE inhibitors. The major limitation with the combination is the frequency of adverse effects at dosages recommended for heart failure.
Calcium Channel AntagonistsCalcium Channel Antagonists
May worsen heart failure Trials of verapamil, diltiazem, and nifedipine
showed detrimental effects in heart failure. Vasoselective dihydropyridines, such as
amlodipine and felodipine :no negative effects.
PRAISE trialPRAISE trial
Amlodipine 10 mg/day or placebo to 1153 patients with class III-IV disease. All patients also received digoxin, a diuretic, and an ACE Inhibitor.
No difference was observed in all-cause mortality or combined end points of death and adverse clinical events in the two groups (p=0.07).
Amlodipine and felodipine have few or no beneficial effects..
DDD pacingDDD pacing
Intraventricular conduction delay may hamper the ability of the heart to contract in an organized manner, with contraction of different segments occurring at less than optimal times
DDD pacing of the right sided chambers may be beneficial in selected dilated cardiomyopathy patients
Change in outcome measures with active pacing in MUSTI C
Hospitalizations <0.05
p valueOutcome measure
Cazeau et al. N Engl J Med 2001; 344: 873-80.
MUSTIC
<0.001
Quality of life score
+32%
Mean (+SD) distance walked
Peak oxygen uptake
% change
+23%
+8%
-66%
<0.001
<0.03
Diastolic Heart FailureDiastolic Heart Failure
Half of heart failure subjects in the community have normal LV systolic function.
Major contributor to hospital admissions, but is often overlooked in studies that focus only on patients with impaired systolic function
Hypertension, coronary artery disease, the normal aging process, obesity, and diabetes mellitus are associated with diastolic dysfunction
Cardiology Clinics 2000 :18 ,3
Diastolic heart failureDiastolic heart failure
Currently, there are no therapies that specifically affect the rate of calcium sequestration or protein phosphorylation, which would produce specific therapy for diastolic failure.
Therapy currently is based on the underlying cardiovascular disorder and the use of pharmacologic agents that appear to specifically influence known pathophysiologic abnormalities
Optimal treatment of diastolic heart failure has not yet been defined.
Goals of Therapy for Diastolic Heart Goals of Therapy for Diastolic Heart FailureFailure
Treat underlying cardiovascular disease:Coronary artery diseaseHypertensionDiabetesAtrial fibrillation
Avoid volume depletion ( may predispose to:
Orthostatic symptomsTachycardiaStimulation of vasodepressor syncope
Facilitate diastolic filling time
Slow heart rate. beta Blockade
Avoid chronotropic/inotropic stimulation. with agents, such as:
DigoxinTheophylline
Ephedrine and decongestantsCaffeine
Reverse or minimize ventricular hypertrophy:
Afterload reductionAngiotensin II blockade
Cardiology ClinicsVolume 18 • Number 3 • August 2000
باشا شمسي حسان الدكتور باشا موقع شمسي حسان الدكتور موقعاإلنترنت اإلنترنت على على
www.khayma.com/chamsipashawww.khayma.com/chamsipasha
Heart Failure Society Guidelines: A Heart Failure Society Guidelines: A Model of Consensus and ExcellenceModel of Consensus and Excellence
Committee Members: Kirkwood F. Adams, Jr., MD, Chair, Kenneth L. Baughman, MD Marvin A. Konstam, MD, William G. Dec, MD Peter Liu, MD, Uri Elkayam, MD Barry M. Massie, MD, Alan D. Forker, MD J. Herbert Patterson, PharmD, Mihai Gheorghiade, MD Marc A. Silver, MD, Denise Hermann, MD Lynne Warner Stevenson, MDExecutive Council: Arthur M. Feldman, MD, PhD, President, Jay N. Cohn, MD Bertram Pitt, MD, Gary S. Francis, MD Marc A. Silver, MD, Barry Greenberg, MD Edmund Sonnenblick, MD, Marvin A. Konstam, MD John Strobeck, MD, PhD, Carl Leier, MD Richard Walsh, MD, Beverly H. Lorell, MD Salim Yusuf, MBBS, PhD, Milton Packer, MD
Phamacotherapy : 2000, 20(5):495-522
Emphasis is placed on: the results of well-designed and adequately
controlled clinical trials (Strength of Evidence = A)
other useful investigations, including cohort studies (Strength of Evidence = B).
Expert opinion is the basis for a recommendation (Strength of Evidence = C).
Phamacotherapy : 2000, 20(5):495-522
ß-blocker therapyß-blocker therapy
Recommendation : ß-blocker therapy should be routinely
administered to clinically stable patients with left ventricular systolic dysfunction (left ventricular ejection fraction less than or equal to 40%) and mild to moderate heart failure symptoms (ie, NYHA class II-III, Appendix A) who are on standard therapy, which typically includes ACE inhibitors, diuretics as needed to control fluid retention, and digoxin (Strength of Evidence = A).
Phamacotherapy : 2000, 20(5):495-522
ß-blocker therapyß-blocker therapy
Recommendation : There is insufficient evidence to recommend
the use of ß-blocker therapy for inpatients or outpatients with symptoms of heart failure at rest (ie, NYHA class IV) (Strength of Evidence = C).
Phamacotherapy : 2000, 20(5):495-522
ß-blocker therapyß-blocker therapy
Recommendation : ß-blocker should be initiated at low doses and
uptitrated slowly, no sooner than at 2-week intervals.
Patients who develop worsening heart failure or other side effects require adjustment of concomitant medications. May also require a reduction in ß-blocker dose or a temporary or permanent withdrawal of this therapy (Strength of Evidence = B).
Phamacotherapy : 2000, 20(5):495-522
DigoxinDigoxin
Recommendation : Digoxin should be considered for patients
who have symptoms of heart failure (NYHA class II-III, Strength of Evidence = A and NYHA class IV, Strength of Evidence = C) while receiving standard therapy.
Phamacotherapy : 2000, 20(5):495-522
DigoxinDigoxin
Recommendation : In the majority of patients, the dosage of
digoxin should be .125 mg to .25 mg daily (Strength of Evidence = C).
Target dose of digoxin should be lower than traditionally assumed.
Phamacotherapy : 2000, 20(5):495-522
DigoxinDigoxin
Recommendation : In patients with heart failure and atrial fibrillation
with a rapid ventricular response, the administration of high doses of digoxin (greater than .25 mg) for rate control is not recommended.
When necessary, additional rate control should be achieved by the addition of ß-blocker therapy or amiodarone (Strength of Evidence = C).
Phamacotherapy : 2000, 20(5):495-522
AnticoagulationAnticoagulation
Recommendation : All patients with heart failure and atrial
fibrillation should be treated with warfarin (goal INR : 2.0 to 3.0) unless contraindicated
(Strength of Evidence = A).
Phamacotherapy : 2000, 20(5):495-522
AnticoagulationAnticoagulation
Recommendation : Warfarin anticoagulation merits consideration
for patients with left ventricular ejection fraction of 35% or less. Careful assessment of the risks and benefits of anticoagulation should be undertaken in individual patients (Strength of Evidence = B).
Phamacotherapy : 2000, 20(5):495-522
AntiplateletsAntiplatelets
Recommendation : Currently, there is insufficient evidence
concerning the potential negative therapeutic interaction between ASA and ACE inhibitors to warrant withholding either of these medications in which an indication exists (Strength of Evidence = C).
Phamacotherapy : 2000, 20(5):495-522
ACE inhibitorsACE inhibitors
Recommendation ACE inhibitors rather than ARBs continue to
be the agents of choice for blockade of the renin angiotensin system in heart failure, and they remain the cornerstone of standard therapy for patients with left ventricular systolic dysfunction with or without symptomatic heart failure (Strength of Evidence = A).
Phamacotherapy : 2000, 20(5):495-522
Antiarrhythmic TherapyAntiarrhythmic Therapy
Recommendation : Amiodarone is not recommended for the
primary prevention of death in patients with chronic heart failure (Strength of Evidence = A).
Phamacotherapy : 2000, 20(5):495-522
ICDICD
Recommendation : patients with heart failure resuscitated from
primary ventricular fibrillation or who have experienced hemodynamically destabilizing sustained ventricular tachycardia be treated with ICDs (Strength of Evidence = B).
Phamacotherapy : 2000, 20(5):495-522
Antiarrhythmic therapyAntiarrhythmic therapy
Recommendation : Amiodarone is the preferred drug when
antiarrhythmic therapy is indicated in patients with heart failure for supraventricular tachycardia not controlled by digoxin or ß-blocker or for patients with life-threatening ventricular arrhythmia who are not candidates for ICD placement (Strength of Evidence = B).
Phamacotherapy : 2000, 20(5):495-522
Aldosterone AntagonistsAldosterone Antagonists
Recommendation : Spironolactone at low dose (ie, 12.5 mg to 25 mg
once daily) should be considered for patients receiving standard therapy who have severe heart failure (with recent or current NYHA class IV).
Potassium level (less than 5.0 mmol/L) and adequate renal function (creatinine less than 2.5 mg/dL) (Strength of Evidence = A).
Serum potassium should be monitored after the first week and at regular intervals (Strength of Evidence = A).
phamacotherapy : 2000, 20(5):495-522