Aldosterone antagonists, consider

Patients with asymptomatic left ventricular systolic dysfunction and hypertension should be treated with P-blockers and ACE inhibitors. Those with heart failure secondary to left ventricular dysfunction and hypertension should be treated with drugs proven to also reduce the morbidity and mortality of heart failure, including P-blockers, ACE inhibitors, ARBs, aldosterone antagonists, and diuretics for symptom control as well as antihypertensive effect. In African-Americans with heart failure and left ventricular systolic dysfunction, combination therapy with nitrates and hydralazine not only affords a morbidity and mortality benefit, but may also be useful as antihypertensive therapy if needed.66 The dihydropyridine calcium channel blockers amlodipine or felodipine may also be used in patients with heart failure and left ventricular systolic dysfunction for uncontrolled blood pressure, although they have no effect on heart failure morbidity and mortality in these patients.49 For patients with heart failure and preserved ejection fraction, antihypertensive therapies that should be considered include P-blockers, ACE inhibitors, ARBs, calcium channel blockers (including nondihydropyridine agents), diuretics, and others as needed to control blood pressure.2,49... 

To reduce mortality, administration of an aldosterone antagonist, either eplerenone or spironolactone, should be considered within the first 2 weeks following MI in all patients who are already receiving an ACE inhibitor (or ARB) and have an EF of equal to or less than 40% and either heart failure symptoms or diagnosis of diabetes mellitus.3 Aldosterone plays an important role in heart failure and in MI because it promotes vascular and myocardial fibrosis, endothelial dysfunction, hypertension, left ventricular hypertrophy, sodium retention, potassium and magnesium loss, and arrhythmias. Aldosterone antagonists have been shown in experimental and human studies to attenuate these adverse effects.70 Spironolactone decreases all-cause mortality in patients with stable, severe heart failure.71... 

An aldosterone antagonist may be considered in addition to a diuretic, ACE inhibitor or ARB, and /1-blocker. Regimens employing both an aldosterone antagonist and ARB are not recommended because of the potential risk of severe hyperkalemia. 

Intravenous application of sodium-free albumin and/or 10% mannitol can be successful, possibly with the additional administration of low-dose diuretics (such as xipamide, torasemide), whereby due attention should be paid to renal function. Diuretics or aldosterone antagonists may only be used if the indication is precise and all risks have been considered. 

The addition of aldosterone antagonists can rednce morbidity and mortality in systolic heart failure. Spironolactone has been studied in severe heart failure and has shown benefit in addition to diuretic and ACE inhibitor therapy. Eplerenone, the newest aldosterone antagonist, has been smdied in patients with symptomatic systolic heart failure within 3 to 14 days after an acute myocardial infarction in addition to a standard three-drug regimen. Collectively, both these agents should be considered in the specific heart failure population smdied but only in addition to diuretics, ACE/ARBs, and /8-blockers. 

Thiazides are the preferred type of diuretic for treating hypertension. In patients with adequate kidney function (estimated GER > 30 mL/min), thiazides are the most effective diuretics for lowering BR As kidney fnnction declines, a more potent diuretic is needed to counteract the associated increase in sodinm and water retention. In this case, a loop dinretic (e.g., furosemide dosed twice daily) should be considered. Dinretics ideally should be dosed in the morning if given once daily and in the morning and afternoon if dosed twice daily to minimize the risk of nocturnal diuresis. However, with chronic use, thiazides, potassium-sparing diuretics, and aldosterone antagonists rarely cause a pronounced diuresis. 

Aldosterone antagonism with low-dose spironolactone has been shown to reduce mortality in patients with New York Heart Association (NYHA) class III and IV heartfailure and thus should be strongly considered in these patients. Given its low cost and safety profile at the doses studied, it may be reasonable to consider in other patients with symptomatic heart failure, especially those taking potassium supplementation, in whom the aldosterone antagonist might allow dose reduction or discontinuation of the potassium supplement, and should be considered strongly in patients with severe heart failure. 

I Aldosterone antagonist, nesirltide I Consider multidisciplinary team I Revascularization, mitral-valve surgery I Cardiac resynchronization if bundle-branch block preseht Dietary Na restriction, diuretics, and dlgoxln I ACE Inhibitors and p blockers in all patients I ACE Inhibitors or AT blockers In all patients J3 blockers In selected patients Treat hypertension, diabetes, dyslipidemla ACE inhibitors or ATr blockers In some patients Risk-factor reduction, patient and family education... 

In addition to CKD as a risk factor, other contributing factors should also be considered. This includes exposure to potassium-sparing diuretics -blockers, which work predominantly via 82-antagonistic effects to interfere with the extrarenal translocation of potassium into cells and ACEls, which may cause hyperkalemia by reducing aldosterone production. Polycitra, used for the treatment of metabolic acidosis, contains potassium citrate and should not be prescribed for patients with severe CKD. If hyperkalemia develops, management options are based on the degree to which potassium is elevated (see Chap. 50). 

---