Exacerbation of heart failure

Blocker therapy is appropriate to further modify disease in systolic heart failure. In patients on a standard regimen of a diuretic and ACE inhibitor, /3-blockers have been shown to reduce morbidity and mortality.It is of paramount importance that /3-bIockers be dosed appropriately because of the risk of inducing an acute exacerbation of heart failure. They must be started in very low doses, doses much lower than those used to treat hypertension, and titrated slowly to high doses based on tolerability. 

D in the ACC/AHA classification scheme)."" " The terms decompensated heart failure and exacerbation of heart failure refer to patients with acute worsening of their baseline symptoms that is usually caused by volume overload and/or hypoperfusion. Irrespective of the term used, these forms of severe heart failure may be caused by progression of the underlying disorder or by other intercurrent events that result in worsening of the patient s symptoms. Early identification and aggressive management of patients with advanced heart failure hopefully will reduce morbidity, mortality, and cost of care. 

Although bradycardia, transient asystole, and exacerbation of heart failure have been reported with verapamil, these responses usually have occurred after intravenous administration in patients with disease of the S A node or AV nodal conduction disturbances or in the presence of f) adrenergic receptor blockade. The use of intravenous verapamil with a f) adrenergic receptor antagonist is contraindicated because of the increased propensity for AV block and/or severe depression of... 

Digoxin is used to control the ventricular response rate in tachyarrhythmias such as atrial fibrillation and atrial flutter. In the setting of systolic heart failure and normal sinus rhythm, digoxin improves morbidity and decreases the frequency of hospitalizations for exacerbation of heart failure. The therapeutic range for digoxin is 0.8 to 2 ng/ml. ... 

Decreases frequency of hospitalization for exacerbation of heart failure... 

The clinician must identify potential reversible causes of heart failure exacerbations including prescription and nonprescription drug therapies, dietary indiscretions, and medication non-adherence. 

Edema Use pioglitazone and rosiglitazone with caution in patients with edema. Because thiazolidinediones can cause fluid retention, which can exacerbate or lead to CHF, use with caution in patients at risk for heart failure and monitor patients at risk for heart failure for signs and symptoms of heart failure. 

However, no specific method of reducing heart failure is addressed, and heart failure itself has many potential outcomes. On the other hand, if the problem is addressed more narrowly, a more narrowly defined objective could be studied. For example, one may look to reduce the number of heart failure exacerbations related to noncompliance with medications. Additionally, other specific objectives may be included, such as increasing the quality of life of patients with heart failure, reducing the number of medications used by patients with heart failure, or making patients more aware of behavioral and dietary modifications related to heart failure. 

The nonsalicylate NSAIDs can also affect renal function. Risk factors fc>r NSAID-induced acute renal failure include congestive heart feilure, glomerulonephritis, chronic renal insufficiency, cirrhosis, systemic lupus erythematosus, diabetes mellitus, significant atherosclerotic disease in the elderly and use of diuretics. NSAIDs can adversely affect cardiovascular homeostasis and can be a risk factor for the onset or exacerbation of heart feilure. 

Sodium bicarbonate is metabolized to the sodium cation, which is eliminated from the body by renal excretion, and the bicarbonate anion, which becomes part of the body s bicarbonate store. Any carbon dioxide formed is eliminated via the lungs. Administration of excessive amounts of sodium bicarbonate may thus disturb the body s electrolyte balance, leading to metabolic alkalosis or possibly sodium overload with potentially serious consequences. The amount of sodium present in antacids and effervescent formulations has been sufficient to exacerbate chronic heart failure, especially in elderly patients. ... 

Eactors involved in precipitating decompensation have been evaluated prospectively in patients admitted to the hospital with heart faUure. ° These studies consistently show that noncompliance with drugs or diet is a common cause of heart failure exacerbation. Eor example, 43% of patients admitted with an acute decompensation of chronic heart failure were assessed as having dietary sodium excess, 34% had excess fluid intake (defined as >2.5 L/day), and about 24% had drug noncompliance that may have contributed to their decompensation (although not necessarily defined as the primary cause of decompensation). Use of inappropriate medications such as antiar-rhythmic agents or calcium channel blockers also was an important precipitant of exacerbations. 

Cardiac events also may precipitate heart failure exacerbations. Myocardial ischemia and infarction are potentially reversible causes that must be considered carefully because nearly 70% of heart failure patients have coronary artery disease. It should be noted that myocardial ischemia can be either a cause or a consequence of heart failure decompensation. Revascularization should be considered in appropriate patients. Atrial flbrillation occurs in up to 10% to 30% of patients with heart failure and is associated with increased morbidity and mortality. Atrial flbrillation can exacerbate heart failure through rapid ventricular response and loss of atrial contribution to ventricular Ailing. Conversely, decompensated heart failure can precipitate atrial flbrillation by atrial distension resulting from ventricular volume overload. Control of ventricular response, maintenance of sinus rhythm in appropriate patients, and prevention of thromboembolism... 

As discussed previously, the number of patients with heart failure is substantial and continues to increase. Although mortality from heart failure has improved, the growing number of patients with the disorder and the progressive nature of the syndrome have led to substantial increases in hospitalizations for heart failure. Recent data indicate that nearly 1 million patients are hospitalized annually for heart failure, resulting in significant morbidity, reduced quality of life, and consumption of large quantities of health care resources. In fact, the majority of costs for the treatment of heart failure are attributed to patients admitted to the hospital. Inpatient admission for heart failure exacerbations is associated with an increased risk of subsequent hospitalization and decreased long-term survival."" ... 

There is evidence that most NSAIDs can increase blood pressure in patients taking antihypertensives, including diuretics, although some studies have not found the increase to be clinically relevant. The concurrent use of NSAIDs with thiazide diuretics may exacerbate congestive heart failure and increase the risk of hospitalisation. 

The corticosteroids are administered with caution in older adults because they are more likely to have preexisting conditions such as congestive heart failure, hypertension, osteo-poros s and arthritis which may be worsened by the use of such agents The nurse monitors older adults for exacerbation of existing conditionsduring corticosteroid therapy. In addition, lower dosages may be needed because of the effects of aging, such as decreased muscle mass renal function, and plasma volume. 

Labetalol 3-6 hour 5-10 minute 10-120 mg/hour Conduction block, heart failure, bradycardia, bronchospasm, exacerbate underlying pulmonary disease Rapid onset of action... 

Medications can increase the risk of hyperkalemia in patients with CKD, including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, used for the treatment of proteinuria and hypertension. Potassium-sparing diuretics, used for the treatment of edema and chronic heart failure, can also exacerbate the development of hyperkalemia, and should be used with caution in patients with stage 3 CKD or higher. 

Sodium bicarbonate tablets are administered in increments of 325 and 650 mg tablets. A 650 mg tablet of sodium bicarbonate contains 7.7 mEq (7.7 mmol) each of sodium and bicarbonate. Sodium retention associated with sodium bicarbonate can cause volume overload, which can exacerbate hypertension and chronic heart failure. Patient tolerability of sodium bicarbonate is low because of carbon dioxide production in the GI tract that occurs during dissolution. 

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