Congestive heart failure combination therapy

The comorbid conditions that can affect therapy and outcomes in patients with CAP include diabetes mellitus, COPD, congestive heart failure, and renal failure.27,28 If the patient has not received antibiotics in the past 3 months, then clarithromycin or azithromycin is the recommended first-line therapy by the IDSA. If the patient has received antibiotics in the last 3 months, then the IDSA recommends using either a respiratory fluoroquinolone alone or a combination of an oral P-lactam and an advanced macrolide/azalide (e.g., clarithromycin/azithromydn). The ATS recommends combination therapy or monotherapy with a respiratory fluoroquinolone for all patients with comorbidities. The p-lactam agents recommended include high-dose amoxicillin, high-dose amoxicillin-clavulanate, cefpodoxime, cefprozil, and cefuroxime. 

Therapy of congestive heart failure. By lowering peripheral resistance, diuretics aid the heart in ejecting blood (reduction in afterload, pp. 132, 306) cardiac output and exercise tolerance are increased. Due to the increased excretion of fluid, EEV and venous return decrease (reduction in preload, p. 306). Symptoms of venous congestion, such as ankle edema and hepatic enlargement, subside. The drugs principally used are thiazides (possibly combined with K+-sparing diuretics) and loop diuretics. 

Captopril, as well as other ACE inhibitors, is indicated in the treatment of hypertension, congestive heart failure, left ventricular dysfunction after a myocardial infarction, and diabetic nephropathy. In the treatment of essential hypertension, captopril is considered first-choice therapy, either alone or in combination with a thiazide diuretic. Decreases in blood pressure are primarily attributed to decreased total peripheral resistance or afterload. An advantage of combining captopril therapy with a conventional thiazide diuretic is that the thiazide-induced hypokalemia is minimized in the presence of ACE inhibition, since there is a marked decrease in angiotensin Il-induced aldosterone release. 

Elkayam U, AminJ, Mehra A, VasquezJ, Weber L, Rahimtoola SH. A prospective, randomized, double-blind, crossover study to compare the efficacy and safety of chronic nifedipine therapy with that of isosorbide dinitrate and their combination in the treatment of chronic congestive heart failure, Circulation 1990 82 1954-1961. 

Iwata, A., Miura, S., Nishikawa, H., Kawamura, A., Matsuo, Y., Sako, H., Kumagai, K., Matsuo, K., and Saku, K. 2006. Significance of combined angiotensin II receptor blocker and carvedilol therapy in patients with congestive heart failure and arginine variant. J. Cardiol. 47 1-7. 

Like p-blockers, ACE inhibitors are most effective in hypertensive patients who are white and young. However, when used in combination with a diuretic, the effectiveness of ACE inhibitors is similar in white and black hypertensive patients. Unlike p-blockers, ACE inhibitors are effective in the management of patients with chronic congestive heart failure (see p. 156). ACE inhibitors are now a standard in the care of a patient following a myocardial infarction. Therapy is started 24 hours after the end of the infarction. 

Persons at greatest risk for NSAID hemodynamic nephropathy generally have pre-existing renal insufficiency, medical problems associated with high plasma renin activity (hepatic disease with ascites, decompensated congestive heart failure, or intravascular volume depletion), or systemic lupus erythematosus. Additional risk factors include atherosclerotic cardiovascular disease and diuretic therapy. The elderly are also at higher risk due to interaction of prevalent medical problems, multiple drug therapies, and reduced renal hemodynamics. Advanced age, however, has not been shown to be an independent risk factor for toxicity in limited trials in otherwise healthy elderly subjects. Combined NSAID and ACEl or ARB therapy is also a concern and should be avoided. 

The primary efficacy endpoint of FINESSE is the composite of all-cause mortality and post-MI complications within 90 days of randomization. Complications included in the endpoint are resuscitated ventricular fibrillation occurring >48 hours after randomization, rehospitalization or emergency department visit for congestive heart failure, and cardiogenic shock. This composite endpoint was chosen to reflect the physiological hypothesis that combination medical therapy prior to PCI will result in earlier and improved reperfusion, leading to improved myocardial salvage and, hence, decreased infarct size-dependent complications. 

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