Edema, cardiac

Nephrotic syndrome is characterized by proteinuria and edema due to some form of glomerulonephritis. The resulting fall in plasma protein concentration decreases vascular volume, which leads to diminished renal blood flow. This in turn causes secondary aldosteronism characterized by Na and water retention and K+ depletion. Rigid control of dietary Na is essential. Therapy of the nephrotic syndrome using a thiazide (possibly with a K -sparing diuretic) to control the secondary aldosteronism, is a useful initial approach to treatment Since nephrotic edema is frequently more difficult to control than cardiac edema, it may be necessary to switch to a loop diuretic (and spironolactone) to obtain adequate diuresis. 

Egeberg studied a number of acute states and found that a rise of factor VIII was associated with the induction of nonspecific fever (E6, ElO), intravenous infusion of serum (E7), intramuscular injection of blood (E8) or intravenous infusion of hemolyzed blood (E2), drug-induced diuresis in a patient with cardiac edema (Ell), and surgical operations (El). In the very acute changes, factor VIII alone rose in concentration, but where the process occupied several days there were normally associated increases in fibrinogen and in factor V. Other clotting factors remained at their previous levels. These investigations were all made in persons with normal hemostasis. 

The search was rewarding and opened up new vistas. The first breakthrough in this field was acetazolamide, a potent inhibitor of carbonic anhydrase. This compound induces increased sodium ion excretion and diuresis. It found wide medicinal application in the treatment of cardiac edema, acting presumably by suppression of carbonic anhydrase activity in the renal tubules. Unfortunately, drug tolerance developed in patients, limiting its utility. This deficiency stimulated medicinal chemists to persist in the modification of the sulfanilamide molecule and led to the discovery of chlorothiazide and the thiazide family of drugs. 

Indications 1) Exterior pattern with interior stoppage of water dampness, 2) water dampness stopped internally, and 3) Phlegm rheum. Chronic nephritic edema, acute and chronic nephritis, chronic renal failure, acute gastritis, cardiac edema from congestive heart failure, gastroptosis,... 

Most patients with cardiac edema do not have increased aldosterone levels. 

Adverse reactions to digoxin include anorexia, vomiting, diarrhea, dizziness, headaches, visual disturbances, and cardiac arrhythmias. Allergic reaction such as urticaria, skin emptions, fever, and edema have been reported (87). 

Moreover, digitahs has indirect effects on the circulation, which in normal hearts results in a small increase in arterial pressure, peripheral resistance, and cardiac output (114). The effects of digitahs on the circulation of an individual experiencing congestive heart failure are much more dramatic, however. The increased cardiac output, for example, increases renal blood flow which can reheve in part the edema of CHF associated with salt and water retention (114). 

Untoward effects of both E and NE (usually to a lesser degree) are anxiety, headache, cerebral hemorrhage (from vasopressor effects), cardiac arrhythmias, especially in presence of digitaUs and certain anesthetic agents, and pulmonary edema as a result of pulmonary hypertension. The minimum subcutaneous lethal dose of E is about 4 mg, but recoveries have occurred after accidental overdosage with 16 mg subcutaneously and 30 mg intravenously, followed by immediate supportive treatment. 

While epinephrine is usually well tolerated in young and healthy individuals, there may be problems in elderly patients with cardiac arrhythmia or previous myocardial infarction episodes [31-33]. Pharmacological effects of epinephrine include rapid rise in blood pressure, pallor, anxiety, tachycardia, headache and tremor as well as vertigo. Most commonly these effects occur after intravenous injection or after overdosing epinephrine. Cardiac arrhythmia or pulmonary edema may develop in serious cases [33, 34]. 

Hypoperfusion of skeletal muscles leads to fatigue, weakness, and exercise intolerance. Decreased perfusion of the central nervous system (CNS) is related to confusion, hallucinations, insomnia, and lethargy. Peripheral vasoconstriction due to SNS activity causes pallor, cool extremities, and cyanosis of the digits. Tachycardia is also common in these patients and may reflect increased SNS activity. Patients will often exhibit polyuria and nocturia. Polyuria is a result of increased release of natriuretic peptides caused by volume overload. Nocturia occurs due to increased renal perfusion as a consequence of reduced SNS renal vasoconstrictive effects at night. In chronic severe HF, unintentional weight loss can occur which leads to a syndrome of cardiac cachexia. This results from several factors, including loss of appetite, malabsorption due to gastrointestinal edema, elevated metabolic rate, and elevated levels of proinflammatory cytokines. 

Chest x-ray Useful for detection of cardiac enlargement, pulmonary edema, and pleural effusions. 

TO, a 77-year-old male nursing home resident is admitted to the hospital with a 3-day history of altered mental status. The patient was unable to give a history or review of systems. On physical examination the vital signs revealed a blood pressure of 100/60 mm Hg, pulse 110 beats per minute, respirations 14/minutes, and a temperature of 101°F (38.3°C). Rales and dullness to percussion were noted at the posterior right base. The cardiac exam was significant for tachycardia. No edema was present. Laboratory studies included sodium 160 mEq/L (160 mmol/L), potassium 4.6 mEq/L (4.6 mmol/L), chloride 120 mEq/L (120 mmol/L), bicarbonate 30 mEq/L (30 mmol/L), glucose 104 mg/dL (5.77 mmol/L), BUN 34 mg/dL (12.14 mmol/L), and creatinine 2.2 mg/dL (194.5 pmol/L). The CBC was within normal limits. Chest x-ray indicated a right lower lobe pneumonia. 

Severe, acute respiratory acidosis produces a variety of neurologic abnormalities. Initially these include headache, blurred vision, restlessness, and anxiety. These may progress to tremors, asterixis, somnolence, and/or delirium. If untreated, terminal manifestations include peripheral vasodilation leading to hypotension and cardiac arrhythmias. Chronic respiratory acidosis is typically associated with cor pulmonale and peripheral edema. 

Terbutaline has been shown to prolong pregnancy but has not been associated with decreased neonatal morbidity.36 It is contraindicated for use in women with preexisting cardiac arrhythmia. Potentially serious adverse effects include pulmonary edema, cardiac arrhythmia, or myocardial ischemia in the mother. Reported fetal and neonatal adverse effects include tachycardia, hyperglycemia, and hyperinsulinemia.41... 

Side effects may be as mild and rare as headache, nausea, and stomach upset for saw palmetto [23,24], However, some supplements may have serious side effects. Hypertension, euphoria, restlessness, nervousness, insomnia, skin eruptions, edema, and diarrhea were reported in 22 patients following long-term ginseng use at an average dose of 3 g of ginseng root daily [38]. Side effects reported with valerian use include headaches, hangover, excitability, insomnia, uneasiness, and cardiac disturbances. Valerian toxicity including ataxia, decreased sensibility, hypothermia, hallucinations, and increased muscle relaxation have been reported [39]. 

Claims for acute hydrogen sulfide exposure that occurred over a 5-year period (1969-1973) in Alberta, Canada, primarily among petrochemical workers, were reviewed by Burnett et al. (1977). Acute effects noted included coma, disequilibrium, and respiratory insufficiency with pulmonary edema. Of 221 cases, there were 14 deaths. A follow-up study of 250 workers claims for hydrogen sulfide exposure from 1979 to 1983 in Alberta, Canada, found 7 fatalities that usually involved the central nervous and respiratory systems hepatic congestion and cardiac petechiae were also noted (Arnold et al. 1985). The difference in fatality rate (6% down to 2.8%) was attributed to improved first aid training and an increased awareness of the dangers of hydrogen sulfide. 

Severe Abrupt tremor, generalized convulsions, psychic disturbance, intensive cyanosis, lung edema, coma Respiratory or cardiac failure, death... 

It is this reduction in preload that, in some cases, is beneficial to patients experiencing heart failure or hypertension. Unlike a healthy heart, a failing heart is unable to pump all of the blood returned to it. Instead, the blood dams up and overfills the chambers of the heart. This results in congestion and increased pressures in the heart and venous system and the formation of peripheral edema. Because the failing heart is operating on the flat portion of a depressed cardiac function curve (see Figure 14.2), treatment with diuretics will relieve the congestion and edema, but have little effect on stroke volume and cardiac output. 

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