Heart disease precipitating factors

Heart failure There have been postmarketing reports of worsening of CHF, with and without identifiable precipitating factors, in patients taking etanercept. There also have been rare reports of new onset CHF, including CHF in patients without known preexisting cardiovascular disease. Some of these patients have been younger than 50 years of age. 

Sudden death has occurred in patients with preexisting heart disease on antidepressant therapy. It may be difficult, however, to separate a causally related drug effect from a cardiovascular incident precipitated by other factors and only by chance coincident with drug therapy. Furthermore, Roose ( 418), who has summarized the literature, noted that major depressive disorder occurs frequently after a myocardial infarct and may adversely affect the recovery process. 

The complexity of the heart failure syndrome necessitates a comprehensive approach to management that includes accurate diagnosis, identification and treatment of risk factors (e.g., diabetes, hypertension, and coronary artery disease), elimination or minimization of precipitating factors such as NSAlDs, and appropriate pharmacologic and nonpharmacologic therapy. 

The first step in the management of chronic heart failure is to determine the etiology (see Table 14—1) and/or any precipitating factors. Treatment of underlying disorders such as anemia or hyperthyroidism may obviate the need for treatment of heart failure. Patients with valvular diseases may derive significant benefit from valve replacement or repair. Revascularization or anti-ischemic therapy in patients with coronary disease may reduce heart failure symptoms. Drugs that aggravate heart failure (see Table 14—3) should be discontinued, if possible. 

Cardiac failure can result if the myocardium is damaged by ischaemia, if the heart is inefficient due to valve disease or because of excessive peripheral vascular resistance and hypertension. Depending on the precipitating factors, cardiac failure can affect either side of the heart or both. 

The most severe form (f hyperthyroidism is thyroid storm, a rare but life-threatening disease that usually is precipitated by an intercurrent medical problem. Precipitating factors include infections, stress, trauma, thyroidal or nonthyroidal surgery, diabetic ketoacidosis, labor, heart disease, and rarely, radioactive iodine ablation. Clinical features are similar to those of thyrotoxicosis, but are more severe. Cardinal features include fever and tachycardia out of proportion to the fever. Nausea, vomiting, diarrhea, agitation, and confusion are frequent presentations. The abnormalities in TFTs are not necessarily worse than those in uncomplicated thyrotoxicosis and thyroid storm is a clinical diagnosis. 

To our surprise, hyperapobetalipoproteinemia is found more commonly in people who do not have coronary heart disease. With our technique (solubilization of LDL precipitated with heparin at pH 5.12, determination of cholesterol, and immunoassay of Apo-B by kinetic nephelometry) we find hyperapobetahpoproteinemia not to be a risk factor. 

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