Heart failure, chronic evaluation

Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001 38 2101-2113. 

Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Cahff RM, Schuhnan KA. Multinational economic evaluation of valsartan in patients with chronic heart failure results from the Valsartan Heart Failure Trial (Val-HeFT). Am Heart J 2004 148 122-8. 

To evaluate aspects of HRQL that are specific to a particular disease or condition, specific measures also may be used. Specific measures include only important aspects of HRQL that are relevant to the patients being studied, such as the loss of function patients experience from asthma or the amount of pain they have from arthritis. Disadvantages of using specific measures are that they are not comprehensive and cannot be used to compare across conditions. They also cannot measure unforeseen side effects or conditions. Examples of specific instruments for heart failure are the Minnesota Living with Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire (Guyatt et al., 1989 Rector, Kubo, and Cohn, 1987). 

The-Beta-Blocker-Evaluation-of-Survival-Trial-Investigators, A Trial of the beta-blocker bucindolol in patients with advanced chronic heart failure, N Engl J Med 2001 344 1659-1667. 

Packer M, O Connor CM, Ghali JK, et al. Effect of amlodipine on morbidity and mortality in severe chronic heart failure, Prospective Randomized Amlodipine Survival Evaluation Study Group. N Engl J Med 1996 335 1 107-1 I 14. 

ACC/AHA Task Force Report. Guidelines for the evaluation and management of chronic heart failure in the adult. Circulation 2001 104 2996-3007. 

Simonton CA, Chatterjee K, Cody RJ, Kubo SH, Leonard D, Daly P, Rutman H. Milrinone in congestive heart failure acute and chronic hemodynamic and clinical evaluation. J Am Coll Cardiol 1985 6(2) 453-9. 

Elkayam U, Johnson JV, Shotan A, Bokhari S, Solodky A, Canetti M, Wani OR, Karaalp IS. Double-blind, placebo-controlled study to evaluate the effect of organic nitrates in patients with chronic heart failure treated with angiotensin-converting enzyme inhibition. Circulation 1999 99(20) 2652-7. 

Nony P, Boissel JP, Lievre M, Leizorovicz A, Haugh MC, Fareh S, de Breyne B. Evaluation of the effect of phosphodiesterase inhibitors on mortality in chronic heart failure patients. A meta-analysis. Eur J Clin Pharmacol 1994 46(3) 191-6. 

The safety of perflenapent has been evaluated in multicenter phase II studies in 146 patients with congestive heart failure (NYHA class III or IV, mean age 68 years), of whom 99 received perflenapent and 47 received isotonic saline, and in 134 patients with severe chronic obstructive pulmonary disease (FEVi no more than 60% of predicted, mean age 65 years), of whom 91 received perflenapent and 43 received isotonic saline (13). Blood pressure, heart rate, respiratory rate, oxygen saturation, the electrocardiogram, FEVi, complete serum biochemistry, hematology, and mental state were assessed. Adverse events were mild and required no treatment. There was no significant difference in the incidence of adverse reactions between those given perflenapent (15%) and those given placebo (11%). The most frequent adverse events with perflenapent were vasodilatation (n = 8), taste disturbance (n = 6), nausea (n = 5), and headache (n = 3). 

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. 

In addition to their benefits in patients with established heart failure, ACE inhibitors also are effective for prevention of heart failure. The SOLVD prevention trial showed that enalapril decreased the risk of hospitalization for worsening heart failure and reduced the composite end point of death and heart failure hospitalization in patients with asymptomatic left ventricular dysfunction. The development of diabetes mellitus, an important risk factor for cardiovascular disease that also increases morbidity and mortality in heart failure patients, is reduced by enalapril in patients with chronic heart failure. In a post-hoc analysis of the Heart Outcomes Prevention Evaluation (HOPE) trial, ramipril reduced the development of new-onset heart failure by nearly 25% in patients with normal EFs and no symptoms of heart failure. ... 

More recent data suggest that all patients with CAD, not just ACS or heart failure patients, benefit from an ACE inhibitor. In the Heart Outcome Prevention Evaluation (HOPE) trial, ramipril significantly reduced the risk of death, MI, or stroke in high-risk patients aged 55 years or older with chronic CAD or with diabetes and one cardiovascular risk factor. The more recent European trial On Reduction Of Cardiac Events With Perindopril In Stable Coronary Artery Disease (EUROPA) extended the benefit of chronic therapy with ACE inhibitors to patients with stable CAD at lower risk of cardiovascular events compared with patients from the HOPE trial. In the EUROPA trial, patients randomized to perindopril experienced a lower risk of the combined end point of cardiovascular death, MI, or cardiac arrest compared with patients randomized to placebo. Therefore, based on the extensive benefit of ACE inhibitors in patients with CAD, their routine use should be considered in all patients following an ACS in the absence of a contraindication. 

Clinicians rely mainly on blood urea nitrogen (BUN) and serum creatinine measurements to evaluate patients with renal failure. Yet the correlation between symptoms and blood levels is at best approximate. In acute renal failure the underlying disease and its associated complications often dominate the clinical picture and determine the prognosis, and it is unclear at what level of nitrogen retention symptoms may be attributed to uremia. Clinicians generally institute dialysis when the BUN exceeds 100 mg/dl or the serum creatinine exceeds 10 mg/dl, but sometimes earlier or later, and early dialysis has not been shown to confer distinct benefits. In chronic renal failure, patients may be quite asymptomatic despite very high BUN and serum creatinine levels. Many so called uremic symptoms may be more properly attributed to anemia, heart failure, nephrotic edema and hypoproteinemia, hypertension, malnutrition, or uncontrolled diabetes or its complications, such as gastroparesis, diarrhea, and neuropathy. 

Apart from the valuable benefit of aldosterone antagonism in hypertension, MR blockade has been shown to substantially reduce both morbidity and mortality among patients with severe chronic heart failure (CHF) and post-myocardial infarction (MI) in clinical trials [17, 18]. The Randomized Aldactone Evaluation Study (RALES) has shown that 26 mg spironolactone on average per day on top of existing standard therapy [i.e. an angiotensin-converting enzyme (ACE) inhibitor, aspirin and a loop diuretic] given to patients with severe heart failure (New York Heart Association class III or IV, left ventricular ejection fraction <35%) results in 30%... 

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