Heart failure, chronic treatment

Many elderly persons, whether demented or cognitively intact, have medical conditions that disrupt sleep. Untreated insomnia and daytime sleepiness have been associated with nursing home placement and mortality. Medically ill older adults admitted to acute care hospitals are particularly vulnerable to sleep disruptions, which appear to be created as much by the various treatments and procedures, unfamiliar routines, and environmental conditions, as by the pain, anxiety, and discomfort associated with their underlying medical condition. Medical conditions especially likely to disrupt sleep are congestive heart failure, chronic obstructive pulmonary disease, Parkinson s disease, gastroesophageal reflux disease, arthritis, and nocturia. 

Winkel E, Costanzo MR Chronic heart failure. Current Treatment Options in Cardiovascular Medicine... 

As endothelins mediate potent vasoconstrictor effects, ECE inhibitors and endothelin receptor antagonists were developed for the treatment of cardiovascular diseases, such as acute and chronic heart failure, pulmonary hypertension and subarachnoid haemorrhage. As ETa recqrtors have potent mitogenic responses and may promote progression of ovarian and prostate cancer and bone metastases ETA receptors are also considered as a potential targets for anti-tumour activity. 

Develop a specific evidence-based pharmacologic treatment plan for a patient with acute or chronic heart failure based on disease severity and symptoms. 

FIGURE 3-1. Treatment algorithm for chronic heart failure. ACE, angiotensin-converting enzyme ARB, angiotensin receptor blocker EF, ejection fraction HF, heart failure LV, left ventricular Ml, myocardial infarction SOB shortness of breath. Table 3-5 describes staging of heart failure. 

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. 

Ellis et al. [72] recently studied the effects of short- and long-term vitamin C therapy in the patients with chronic heart failure (CHF). It was found that oxygen radical production and TBAR product formation were higher in patients with CHF than in control subjects. Both short-term (intravenous) and long-term (oral) vitamin C therapy exhibited favorable effects on the parameters of oxidative stress in patients the treatments decreased oxygen radical formation and the level of lipid peroxidation and improved flow-mediated dilation in brachial artery. However, there was no correlation between changes in endothelial function and oxidative stress. 

The most serious side effects early in ACS are hypotension, bradycardia, and heart block. Initial acute administration of //-blockers is not appropriate for patients presenting with decompensated heart failure. However, therapy may be attempted in most patients before hospital discharge after treatment of acute heart failure. Diabetes mellitus is not a contraindication to //-blocker use. If possible intolerance to //-blockers is a concern (e.g., due to chronic obstructive pulmonary disease), a short-acting drug such as metoprolol or esmolol should be administered IV initially. 

Atrial fibrillation Peak digoxin body stores larger than the 8 to 12 mcg/kg required for most patients with heart failure and normal sinus rhythm have been used for control of ventricular rate in patients with atrial fibrillation. Titrate doses of digoxin used for the treatment of chronic atrial fibrillation to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects. Data are not available to establish the appropriate resting or exercise target rates that should be achieved. 

IR concentrated oral solution and tablets/suppositories - Respiratory insufficiency or depression severe CNS depression attack of bronchial asthma heart failure secondary to chronic lung disease cardiac arrhythmias increased intracranial or CSF pressure head injuries brain tumor acute alcoholism delirium tremens convulsive disorders after biliary tract surgery suspected surgical abdomen surgical anastomosis concomitantly with MAOIs or within 14 days of such treatment paralytic ileus. 

Cohn IN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure, [see comment]. N. Engl. J. Med. 1991 325 303-10. 

Willenheimer R, van Veldhuisen DJ, Silke B, et al. Effect on survival and hospitalization of initiating treatment for chronic heart failure with bisoprolol followed by enalapril, as compared with the opposite sequence results of the randomized Cardiac Insufficiency Bisoprolol Study (CIBIS) III. Circulation. Oct 18 2005 112(16) 2426-2435. 

A toxicity that is unique to cyclophosphamide and ifosfamide is cystitis. Dysuria and decreased urinary frequency are the most common symptoms. Rarely, fibrosis and a permanently decreased bladder capacity may ensue. The risk of development of carcinoma of the bladder also is increased. Large intravenous doses have resulted in impairment of renal water excretion, hyponatremia, and increased urine osmolarity and have been associated with hemorrhagic subendocardial necrosis, arrhythmias, and congestive heart failure. Interstitial pulmonary fibrosis may also result from chronic treatment. Other effects of chronic drug treatment include infertility, amenorrhea, and possible mutagenesis and carcinogenesis. 

ACE inhibitors have a particularly useful role in treating patients with chronic kidney disease because they diminish proteinuria and stabilize renal function (even in the absence of lowering of blood pressure). This effect is particularly valuable in diabetes, and these drugs are now recommended in diabetes even in the absence of hypertension. These benefits probably result from improved intrarenal hemodynamics, with decreased glomerular efferent arteriolar resistance and a resulting reduction of intraglomerular capillary pressure. ACE inhibitors have also proved to be extremely useful in the treatment of heart failure, and after myocardial infarction, and there is recent evidence that ACE inhibitors reduce the incidence of diabetes in patients with high cardiovascular risk (see Chapter 13). 

The major steps in the management of patients with chronic heart failure are outlined in Table 13-3. The ACC/AHA 2005 guidelines suggest that treatment of patients at high risk (stages A and B) should be focused on control of hypertension, hyperlipidemia, and diabetes, if present. Once symptoms and signs of failure are present, stage C has been entered, and active treatment of failure must be initiated. 

Table 13-3 Steps in the Prevention and Treatment of Chronic Heart Failure. ...

Swedberg et al Guidelines for the diagnosis and treatment of chronic heart failure. Task Force for the Diagnosis and Treatment of Chronic Heart Failure. Eur Heart J 2005 26 1115. [PMID 15901669]... 

---