Heart failure medications

These population changes have important implications for pharmacotherapy. It is now widely accepted that genetic differences between the various ethnic groups are quite small and probably less than individual differences. The recent experience with the newly approved congestive heart failure medication, BiDil, suggests that even minor differences can have significant pharmacological consequences. 

When identifying economic, clinical, and humanistic variables to be measured, it is important to integrate elements from all components of health care. In our example, Cynthia is trying to manage her patients heart failure medications. Because she is a pharmacist, she may identify only medication-related variables to... 

Cynthia s objectives are to reduce hospitalizations and emergency department visits by increasing compliance with heart failure medications and educating patients about their disease state and how to make diet and behavioral modifications, as well as improve patients health-related quality of life and satisfaction with care. 

Serum iron levels significantly decreased by 3.3 [imol/1 (from 15.5 4.9 to 12.2 3.9 [xmol/1) in 11 patients with chronic congestive heart failure medicated with 5 mg ramipril per day for 2 weeks (Verho et al. 1993). 

Artificial Hearts. Congestive heart failure (CHF) is a common cause of disabiHty and death. It is estimated that three to four million Americans suffer from this condition. Medical therapy in the form of inotropic agents, diuretics (qv), and vasofilators is commonly used to treat this disorder (see Cardiovascularagents). Cardiac transplantation has become the treatment of choice for medically intractable CHF. Although the results of heart transplantation are impressive, the number of patients who might benefit far exceeds the number of potential donors. Long-term circulatory support systems may become an alternative to transplantation (5). 

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

Total estimated direct and indirect costs for managing both chronic and acute HF in the United States for 2005 was approximately 27.9 billion. Medications account for approximately 10% of that cost.3 Heart failure is the most common hospital discharge diagnosis for Medicare patients and is the most costly diagnosis in this population. 

Unlike systolic HF, few prospective trials have evaluated the safety and efficacy of various cardiac medications in patients with diastolic HF or preserved ejection fraction. The Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) study demonstrated that angiotensin receptor blockade with candesartan resulted in beneficial effects on HF morbidity in patients with preserved LVEF similar to those seen in depressed LV function.25... 

Heart failure is more prevalent and associated with a worse prognosis in African-Americans compared to the general population.1 Unfortunately, deficiencies in disease prevention, detection, and access to treatment are well documented in minority populations. African-Americans and other races are underrepresented in clinical trials, compromising the extrapolation of results from these studies to ethnic subpopulations. The influence of race on efficacy and safety of medications used in HF treatment has received additional attention with... 

Once BE s symptoms are improved, how would you optimize her oral medication therapy for heart failure ... 

Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA 2002 287 628-640. 

Venous stasis Major medical illness (e.g., congestive heart failure) Major surgery (e.g., general anesthesia for greater than 30 minutes) Paralysis (e.g., due to stroke or spinal cord injury) Polycythemia vera Obesity Varicose veins... 

Upon stabilization, placement of a pulmonary artery (PA) catheter may be indicated based on the need for more extensive cardiovascular monitoring than is available from non-invasive measurements such as vital signs, cardiac rhythm, and urine output.9,10 Key measured parameters that can be obtained from a PA catheter are the pulmonary artery occlusion pressure, which is a measure of preload, and CO. From these values and simultaneous measurement of HR and blood pressure (BP), one can calculate the left ventricular SV and SVR.10 Placement of a PA catheter should be reserved for patients at high risk of death due to the severity of shock or preexisting medical conditions such as heart failure.11 Use of PA catheters in broad populations of critically ill patients is somewhat controversial because clinical trials have not shown consistent benefits with their use.12-14 However, critically ill patients with a high severity of illness may have improved outcomes from PA catheter placement. It is not clear why this was... 

A 57-year-old African-American man presents to the clinic for follow-up management of UC. He has had left-sided disease for 3 years and has been maintained in remission on maximal doses of oral mesalamine and prednisone 35 mg orally once daily. His provider has attempted several times to taper the prednisone dose, but the patient experiences a reappearance of symptoms if the dose is lowered below this level. Medical history is also significant for hypertension and heart failure. He has no known drug allergies. 

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. 

Biologic response modifiers (BRMs) are indicated in patients who have failed an adequate trial of DMARD therapy.1 BRMs may be added to DMARD monotherapy (i.e., methotrexate) or replace ineffective DMARD therapy.22 The decision to select a particular agent generally is based on the prescriber s comfort level with monitoring the safety and efficacy of the medications, the frequency and route of administration, the patient s comfort level or manual dexterity to self-administer subcutaneous injections, the cost, and the availability of insurance coverage.23 In general, BRMs should be avoided in patients with serious infections, demyelinating disorders (e.g., multiple sclerosis or optic neuritis) or heart failure.21... 

Clinicians should play a role in chemotherapy safety, patient education, and monitoring patient response to therapy. For example, cumulative doses of anthracyclines should be monitored along with signs and symptoms of heart failure. Clinicians also should monitor concurrent medications along with chemotherapy for drug interactions. 

Venous stasis is slowed blood flow in the deep veins of the legs resulting from damage to venous valves, vessel obstruction, prolonged periods of immobility, or increased blood viscosity. Conditions associated with venous stasis include major medical illness (e.g., heart failure, myocardial infarction), major surgery, paralysis (e.g., stroke, spinal cord injury), polycythemia vera, obesity, or varicose veins. 

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