Heart failure treatment monitoring

Expert opinion is a source, frequently elicited by survey, that is used to obtain information where no or few data are available. For example, in our experience with a multicountry evaluation of health care resource utilization in atrial fibrillation, very few country-specific published data were available on this subject. Thus the decision-analytic model was supplemented with data from a physician expert panel survey to determine initial management approach (rate control vs. cardioversion) first-, second-, and third-line agents doses and durations of therapy type and frequency of studies that would be performed to initiate and monitor therapy type and frequency of adverse events, by body system and the resources used to manage them place of treatment and adverse consequences of lack of atrial fibrillation control and cost of these consequences, for example, stroke, congestive heart failure. This method may also be used in testing the robustness of the analysis [30]. 

Formulate a monitoring plan for the nonpharmacologic and pharmacologic treatment of a patient with heart failure. 

The mainstay of treatment for vaso-occlusive crisis includes hydration and analgesia (see Table 65-7). Pain may involve the extremities, back, chest, and abdomen. Patients with mild pain crises may be treated as outpatients with rest, warm compresses to the affected (painful) area, increased fluid intake, and oral analgesia. Patients with moderate to severe crises should be hospitalized. Infection should be ruled out because it may trigger a pain crisis, and any patient presenting with fever or critical illness should be started on empirical broad-spectrum antibiotics. Patients who are anemic should be transfused to their baseline. Intravenous or oral fluids at 1.5 times maintenance is recommended. Close monitoring of the patient s fluid status is important to avoid overhydration, which can lead to ACS, volume overload, or heart failure.6,27... 

World-wide, about 130 million people are believed to suffer from diabetes, a disease which occurs when the body does not adequately produce the insulin needed to maintain a normal circulating blood glucose (80-120 mg/dl). It is estimated that the disease is in rapid expansion (300 million in 2025). Frequent monitoring of blood glucose is crucial for effective treatment and to reduce the morbidity and mortality of diabetes. Blindness, kidney and heart failure, peripheral neuropathy, pure circulation, gangrene are the severe complications which, over time, are related to diabetes. 

Invasive hemodynamic monitoring should be considered in patients who are refractory to initial therapy, whose volume status is unclear, or who have clinically significant hypotension such as systolic BP <80 mm Hg. Such monitoring helps guide treatment and classify patients into four specific hemodynamic subsets based on cardiac index and pulmonary artery occlusion pressure (PAOP). Refer to textbook Chap. 16 (Heart Failure) for more information. 

QT prolongation, recent acute Ml, uncompensated heart failure, cardiac arrhythmia). Discontinue treatment if the QT interval is over 500 msec. Patients who experience symptoms that may be associated with the occurrence of torsade de pointes (eg, dizziness, palpitations, syncope) may warrant further cardiac evaluation in particular, consider Holter monitoring. 

Heart failure Do not administer doses greater than 5 mg/kg to patients with moderate to severe heart failure. Infliximab has been associated with adverse outcomes in patients with heart failure use in patients with heart failure only after considering other treatment options. Monitor patients closely infliximab must not be continued in patients who develop new or worsening symptoms of heart failure. 

Myocardial toxicity, manifested in its most severe form by potentially fatal CHF, may occur either during therapy with mitoxantrone or months to years after termination of therapy. Mitoxantrone use has been associated with cardiotoxicity this risk increases with cumulative dose. In cancer patients, the risk of symptomatic CHF was estimated to be 2.6% for patients receiving up to a cumulative dose of 140 mg/m. For this reason, monitor patients for evidence of cardiac toxicity and question them about symptoms of heart failure prior to initiation of treatment. Monitor patients with multiple sclerosis (MS) who reach a cumulative dose of 100 mg/m for evidence of cardiac toxicity prior to each subsequent dose. Ordinarily, patients with MS should not receive a cumulative dose greater than 140 mg/m. Active or dormant cardiovascular disease, prior or concomitant radiotherapy to the mediastinal/pericardial area, previous therapy with other anthracyclines or anthracenediones, or concomitant use of other cardiotoxic drugs may increase the risk of cardiac toxicity. Cardiac toxicity with mitoxantrone may occur at lower cumulative doses whether or not cardiac risk factors are present (see Warnings and Administration.and.Dosage). 

The most common side effects are Raynaud s phenomenon with cold or even cyanotic distal extremities and digits, tiredness or weakness, bradycardia, and sexual impotence. Less common side effects are depression and dysphoria, bronchoconstriction, congestive heart failure, hallucinations, hypotension, vomiting or nausea, diarrhea, insomnia and nightmares, dizziness, and hypoglycemia. When due attention is paid to contraindications and the treatment is carefully monitored, the side effects of beta-blocker treatment are generally mild. 

Heart failure is a progressive syndrome, and optimal pharmacologic management is based on a detailed diagnosis, determination of the etiology, characterization of the clinical syndrome (systolic vs. diastolic) and careful monitoring of the response to pharmacologic therapy. There is a need to modify treatment in accordance with the patient s response to therapy. 

Adverse effects Thiazide diuretics induce hypokalemia and hyperuricemia in 70% of patients, and hyperglycemia in 10% of patients. Serum potassium levels should be monitored closely in patients who are predisposed to cardiac arrhythmias (particularly individuals with left ventricular hypertrophy, ischemic heart disease, or chronic congestive heart failure) and who are concurrently being treated with both thiazide diuretics and digitalis glycosides (see p. 160). Diuretics should be avoided in the treatment of hypertensive diabetics or patients with hyperlipidemia. 

PROCAINAMIDE ANTI HYPERTENSIVES AND HEART FAILURE DRUGS-ACE INHIBITORS Possible T risk of leukopenia Uncertain at present Monitor FBC before starting treatment, 2-weekly for 3 months after initiation of therapy, then periodically thereafter... 

ANTIHYPERTENSIVES AND HEART FAILURE DRUGS ANTIPSYCHOTICS t hypotensive effect Dose-related 1 BP (due to vasodilatation) is a side-effect of most antipsychotics, particularly phenothiazines Monitor BP closely, especially during initiation of treatment. Warn patients to report symptoms of hypotension (light-headedness, dizziness on standing, etc.)... 

Renal insufficiency can occur in patients with heart failure treated with carvedilol, usually when pre-existing renal insufficiency, low blood pressure, or diffuse vascular disease are present (2). Patients at high risk of renal dysfunction should be carefully monitored, particularly at the beginning of treatment, and the drug should be withdrawn in case renal function worsens. 

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