Tips For Healthy

A. Left ventricular systolic dysfunction is defined as an ejection fraction of less than 40 percent. The ejection fraction should be measured to determine whether the symptoms are due to systolic dysfunction or another cause.

1. Heart failure often presents initially as dyspnea with exertion or recumbency. Patients also commonly have dependent edema, rapid fatigue, cough and early satiety. Arrhythmias causing palpitations, dizziness or aborted sudden death may also be initial manifestations.

1. Electrocardiography. Standard 12-lead electrocardiography should be used to determine whether ischemic heart disease or rhythm abnormalities are present.

2. Transthoracic echocardiography confirms systolic dysfunction by measurement of the left ventricular ejection fraction and provides information about ventricular function, chamber size and shape, wall thickness and valvular function.

3. Exercise stress testing is useful for evaluating active and significant concomitant coronary artery disease.

4. Other Studies. Serum levels of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) are elevated in patients with heart failure. ANP and BNP levels may predict prognosis and are used to monitor patients with heart failure.

1. Cessation of smoking and avoidance of more than moderate alcohol ingestion.

2. Salt restriction to 2 to 3 g of sodium per day to minimize fluid accumulation.

3. Water restriction in patients who are also hyponatremic.

4. Weight reduction in obese subjects.

5. Cardiac rehabilitation program for all stable patients.

B. Improvement in symptoms can be achieved by digoxin, diuretics, beta-blockers, ACE inhibitors, and ARBs. Prolongation of survival has been documented with ACE inhibitors, beta-blockers, and, in advanced disease, spironolactone. Initial management with triple therapy (digoxin, ACE inhibitor, and diuretics) is recommended in agreement with the ACC/AHA task force guidelines.

C. ACE inhibitors and other vasodilators.

All patients with asymptomatic or symptomatic left ventricular dysfunction should be started on an ACE inhibitor. Beginning therapy with low doses (eg, 2.5 mg of enalapril BID or 6.25 mg of captopril TID) will reduce the likelihood of hypotension. If initial therapy is tolerated, the dose is then gradually increased to a maintenance dose of 10 mg BID of enalapril, 50 mg TID of captopril, or up to 40 mg/day of lisinopril or quinapril. Angiotensin II receptor blockers appear to be as effective as ACE inhibitors and are primarily given to patients who cannot tolerate ACE inhibitors, generally due to chronic cough or angioedema.

D. Beta-blockers. Beta-blockers, particularly carvedilol, metoprolol, bisoprolol, improve survival in patients with New York Heart Association (NYHA) class II to III HF and probably in class IV HF. Carvedilol, metoprolol, or bisoprolol is recommended for symptomatic HF, unless contraindicated.

a. Heart rate <60 bpm.

b. Systolic arterial pressure <100 mm Hg.

c. Signs of peripheral hypoperfusion.

d. PR interval >0.24 sec.

e. Second- or third-degree atrioventricular block.

f. Severe chronic obstructive pulmonary disease.

g. History of asthma.

h. Severe peripheral vascular disease.

2. In the absence of a contraindication, carvedilol, metoprolol, or bisoprolol should be offered to patients with NYHA class II, III and IV HF due to systolic dysfunction.

3. Initiation of therapy. Therapy should be begun in very low doses and the dose doubled (every two to three weeks) until the target dose is reached or symptoms become limiting.

a. Carvedilol (Coreg), initial dose 3.125 mg BID; target dose 25 to 50 mg BID.

b. Metoprolol (Lopressor), initial dose 6.25 mg BID; target dose 50 to 75 mg BID, and for extended-release metoprolol (Toprol XL), initial dose 12.5 or 25 mg daily, and target dose 200 mg/day.

c. Bisoprolol (Zebeta), initial dose 1.25 mg QD; target dose 5 to 10 mg QD.

E. Digoxin (Lanoxin) is given to patients with HF and systolic dysfunction to control fatigue, dyspnea, and exercise intolerance and, in patients with atrial fibrillation, to control the ventricular rate. Digoxin therapy is associated with a significant reduction in hospitalization but has no effect on survival.

1. Digoxin should be started in patients with left ventricular systolic dysfunction and NYHA functional class II, III and IV heart failure. The usual daily dose is 0.125 to 0.25 mg, based upon renal function. The serum digoxin is maintained between 0.7 to 1.2 ng/mL.

2. Digoxin is not indicated as primary therapy for the stabilization of patients with acutely decompensated HF. Such patients should first receive appropriate treatment for HF, usually with intravenous medications.

1. A loop diuretic should be given to control pulmonary and/or peripheral edema. The usual starting dose in outpatients with HF is 20 to 40 mg of furosemide (Lasix). Subsequent dosing is determined with goal weight reduction of 0.5 to 1.0 kg/day. If a patient does not respond, the dose should be increased. In patients with a relatively normal glomerular filtration rate, the maximum single doses are 40 to 80 mg of furosemide.

G. Spironolactone. A low dose of spironolactone (25 to 50 mg/day) is recommended in patients with symptoms at rest (despite therapy with the above medications), a serum creatinine concentration less than 2.5 mg/dL (221 :mol/L), and a serum potassium less than 5 meq/L

1. Inotropic agents other than digoxin. Patients with decompensated HF are often treated with an intravenous infusion of a positive inotropic agent, such as dobutamine, dopamine, milrinone, or amrinone.

2. Symptomatic improvement has been demonstrated in patients after treatment with a continuous infusion of dobutamine (at a rate of 5 to 7.5 :g/kg per min) for three to five days. The benefit can last for 30 days or more. Use of intravenous dobutamine is limited to the inpatient management of patients with severe decompensated heart failure.

a. Atrial and brain natriuretic peptides regulate cardiovascular homeostasis and fluid volume.

b. Nesiritide (Natrecor) is structurally similar to atrial natriuretic peptide. It has natriuretic, diuretic, vasodilatory, smooth-muscle relaxant properties, and inhibits the renin-angiotensin system. Nesiritide is indicated for the treatment of moderate-to-severe heart failure. The initial dose of is 0.015 mcg/kg/min IV infusion, max 0.03 mcg/kg/min.

4. Pacemakers. Indications for pacemakers in patients with HF include symptomatic bradycardia, chronic AF, or AV nodal ablation. Patients with refractory HF and severe symptoms may benefit from long-term dual-chamber pacing.

5. Hemofiltration. Extracorporeal ultrafiltration via hemofiltration removes intravascular fluid; it is an effective treatment for patients with refractory HF.

6. Mechanical circulatory support. Circulatory assist devices are used for refractory HF. There are three major types of devices:

a. Counterpulsation devices (intraaortic balloon pump and noninvasive counterpulsation).

b. Cardiopulmonary assist devices.

c. Left ventricular assist devices.

a. Repeated hospitalizations for HF.

b. Escalation in the intensity of medical therapy.

c. A reproducible peak oxygen of less than 14 mL/kg per min.

d. Other absolute indications for cardiac transplantation, recommended:

(1) Refractory cardiogenic shock.

(2) Continued dependence on intravenous inotropes.

(3) Severe symptoms of ischemia that limit routine activity and are not amenable to revascularization or recurrent unstable angina not amenable to other intervention.

(4) Recurrent symptomatic ventricular arrhythmias refractory to all therapies.

Education

www.edu.safeurlives.com

INSURANCE

HEALTH INSURANCE