Heart failure symptoms

STE ACS, class I recommendation for patients with Ml and EF less than 40% and either diabetes mellitus or heart failure symptoms who are already receiving an ACE inhibitor. 

Although P-blockers should be avoided in patients with decompensated heart failure from left ventricular systolic dysfunction complicating an MI, clinical trial data suggest that it is safe to initiate P-blockers prior to hospital discharge in these patients once heart failure symptoms have resolved.64 These patients may actually benefit more than those without left ventricular dysfunction.65 In patients who cannot tolerate or have a contraindication to a P-blocker, a calcium channel blocker can be used to prevent anginal symptoms, but should not be used routinely in the absence of such symptoms.2,3,62... 

To reduce mortality, administration of an aldosterone antagonist, either eplerenone or spironolactone, should be considered within the first 2 weeks following MI in all patients who are already receiving an ACE inhibitor (or ARB) and have an EF of equal to or less than 40% and either heart failure symptoms or diagnosis of diabetes mellitus.3 Aldosterone plays an important role in heart failure and in MI because it promotes vascular and myocardial fibrosis, endothelial dysfunction, hypertension, left ventricular hypertrophy, sodium retention, potassium and magnesium loss, and arrhythmias. Aldosterone antagonists have been shown in experimental and human studies to attenuate these adverse effects.70 Spironolactone decreases all-cause mortality in patients with stable, severe heart failure.71... 

Either eplerenone or spironolactone should be considered within the first 2 weeks after MI to reduce mortality in all patients already receiving an ACE inhibitor who have LVEF <40% and either heart failure symptoms or a diagnosis of diabetes mellitus. The drugs are continued indefinitely. Example oral doses include the following ... 

A chest radiograph should be done if the patient has heart failure symptoms. 

Treat fluid retention (with or without transient worsening heart failure symptoms) with an increase in the dose of diuretics. 

Di Carh MF, Asgarzadie F, Schelbert HR, Brunken RC, Laks H, Phelps ME et al. Quantitative relation between myocardial viabihty and improvement in heart failure symptoms after revascularization in patients with ischemic cardiomyopathy. Circulation 1995 92 3436-3444... 

Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E et al. Relationship between preoperative viability and postoperative improvement in LVEF and heart failure symptoms. J Nucl Med 2001 42 79-86... 

Linde C, Abraham WT, Gold MR, St John Sutton M, Ghio S, Daubert C. Randomized trial of cardiac resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms. J. Am. Coll. Cardiol. 2008 52 1834-A3. 

Tse et al. [130] have reported that transendocar-dial injection of autologous BMMNCs in eight patients with severe ischemic heart disease led to preserved left ventricular function. At 3-month follow-up, heart failure symptoms and myocardial perfusion had improved, especially in the ischemic region as shown by cardiac MRI. 

Administration of one of the jS-blockers and an ACE-I is mandatory for all patients with a recent MI, regardless of the ejection fraction (EE). If the LVEE is reduced in patients without a history of MI, yS-blockers and/or ACE-I should be administrated as long as the patients do not have heart failure symptoms. If an ACE-I is contraindicated, it has to be substituted by an ARB, if the patient is post-MI with low EE, but no manifest HF. This may also be true without a history of MI. ACE-I and ARB are beneficiary for those with hypertension and left ventricular hypertrophy (LVH), without HF symptoms. 

Closely monitor serum electrolytes, calcium, BUN, creatinine, hemoglobin, and hematocrit. For victims of arsine poisoning, avoid high levels of fluid replacement to avoid the onset of congestive heart failure symptoms. 

Marangelli et al.270 VAMI Verapamil infusion in patients with 1st anterior AMI before thrombolysis 88 Left ventricular remodeling, NYHA class A trend towards smaller left ventricular volunes and significant reduction in heart failure symptoms after 3 months... 

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. 

The most common cause of heart failure is ischemic heart disease, where MI results in loss of myocytes, followed by ventricular dilatation and remodeling. Captopril, ramipril, and trandolapril all have been shown to benefit post-MI patients whether they are initiated early (within 36 hours) and continued for 4 to 6 weeks or started later and administered for several years. Collectively, these studies indicate that ACE inhibitors after MI improve overall survival, decrease the development of severe heart failure, and reduce reinfarction and heart failure hospitalization rates. The benefit occurs within the first few days of therapy and persists during long-term treatment. The effects are most pronounced in higher-risk patients, such as those with symptomatic heart failure or reduced EFs, with 20% to 30% reductions in mortality reported in these patients. Post-MI patients without heart failure symptoms or decreases in EF also benefit from ACE inhibitors, but the magnitude of this effect is less pronounced, with all-cause mortality reduced by 7% to 11%. ... 

Heart failure is often accompanied by other disorders whose natural history or therapy may affect morbidity and mortality. In selected patients, optimal management of these concomitant disorders may have a profound impact on heart failure symptoms and outcomes. 

Although -blockers and calcium chaimel blockers have taken a more prominent role in acutely controlling rate in patients with rapid atrial fibrillation or flutter, a cautionary note must be made. That is, most patients with these tachycardias also have concomitant symptoms of heart failure, and these two forms of drug therapy may worsen the situation initially. Usually, a prompt decline in rate and increase in stroke volume balances the decrease in contractility seen with p blockers or calcium chaimel blockers such that heart failure symptoms remain unchanged. However, occasionally, severe reactions and hypotension may occur one study implies that diltiazem may be safer than verapamil. ... 

Like MIRACLE, COMPANION showed that CRT improved heart failure symptoms based on exercise tolerance testing and quality of life surveys. 

Tops et al. recently reported on the development of left ventricular dyssyn-chrony and heart failure symptoms during long term right ventricular pacing following AV junction ablation in 55 patients with preserved systolic function at the time of ablation (59). Patients were followed for 3.8 1.7 years. During follow-up, 27 patients (49%) developed left ventricular dyssynchrony and worsened heart failure symptoms. The New York Heart Association functional class increased from 1.8 0.6 to 2.2 0.7, p < 0.05. The left ventricular ejection... 

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