Left ventricular dysfunction

Left ventricular dysfunction, also called left ventricular systolic dysfunction, is the most common fonn of heart failure and results in decreased cardiac output and decreased ejection fraction (the amount of blood that the ventricle ejects per beat in relationship to the amount of blood available to eject). Typically, the ejection fraction should be greater than 60%. With, left... 

Enalaprilat 4-6 hour Up to 30 minute 1.25-40 mg q6 hour Hyperkalemia, renal failure, cough, anaphylaxis Useful in left ventricular dysfunction, variable response, should not be given in pregnancy... 

Use cautiously in patients with left ventricular dysfunction... 

Bradycardia (heart rate <60 bpm), systolic blood pressure <100 mmHg, severe left ventricular dysfunction with pulmonary edema, second- or third-degree heart block, PR interval >0.24 s, evidence of hypoperfusion, active asthma... 

Use for 4—6 wk in patients without left ventricular dysfunction unless another indication exists... 

Patients with asymptomatic left ventricular systolic dysfunction and hypertension should be treated with P-blockers and ACE inhibitors. Those with heart failure secondary to left ventricular dysfunction and hypertension should be treated with drugs proven to also reduce the morbidity and mortality of heart failure, including P-blockers, ACE inhibitors, ARBs, aldosterone antagonists, and diuretics for symptom control as well as antihypertensive effect. In African-Americans with heart failure and left ventricular systolic dysfunction, combination therapy with nitrates and hydralazine not only affords a morbidity and mortality benefit, but may also be useful as antihypertensive therapy if needed.66 The dihydropyridine calcium channel blockers amlodipine or felodipine may also be used in patients with heart failure and left ventricular systolic dysfunction for uncontrolled blood pressure, although they have no effect on heart failure morbidity and mortality in these patients.49 For patients with heart failure and preserved ejection fraction, antihypertensive therapies that should be considered include P-blockers, ACE inhibitors, ARBs, calcium channel blockers (including nondihydropyridine agents), diuretics, and others as needed to control blood pressure.2,49... 

Chymostatin-sensitive Il-generating enzyme Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction Trial Collaborative Study Captopril Trial ( The Effect of Angiotensin-Converting Enzyme Inhibition on Diabetic Nephropathy ) calcium channel blocking agents Candesartan in Heart Failure Assessment of Reduction in Morbidity and Mortality Trial congestive heart failure, but the latest recommendations use HF for heart failure chronic kidney disease cardiac output... 

To control risk factors and prevent major adverse cardiac events, statin therapy should be considered in all patients with ischemic heart disease, particularly in those with elevated low-density lipoprotein cholesterol. In the absence of contraindications, angiotensin-converting enzyme inhibitors should be considered in ischemic heart disease patients who also have diabetes melli-tus, left ventricular dysfunction, history of myocardial infarction, or any combination of these. Angiotensin receptor blockers... 

As described in the previous section, calcium channel blockers should not be administered to most patients with ACS. Their role is a second-line treatment for patients with certain contraindications to P-blockers and those with continued ischemia despite P-blocker and nitrate therapy. Administration of either amlodipine, diltiazem, or verapamil is preferred.2 Agent selection is based on heart rate and left ventricular dysfunction (diltiazem and verapamil are contraindicated in patients with bradycardia, heart block, or systolic heart failure). Dosing and contraindications are described in Table 5-2. 

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... 

Symptoms of bradyarrhythmias include dizziness, fatigue, lightheadedness, syncope, chest pain (in patients with underlying myocardial ischemia), and shortness of breath and other symptoms of heart failure (in patients with underlying left ventricular dysfunction). 

NSAIDs can cause renal insufficiency when administered to patients whose renal function depends on prostaglandins. Patients with chronic renal insufficiency or left ventricular dysfunction, the elderly, and those receiving diuretics or drugs that interfere with the renin-angiotensin system are particularly susceptible. Decreased glomerular filtration also may cause hyperkalemia. NSAIDs rarely cause tubulointerstitial nephropathy and renal papillary necrosis. 

Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angioten-sion-converting enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl... 

Left Ventricular Dysfunction (Systolic Heart Failure)... 

Exner, C.V., et al., "Lesser Response to Angiotensin-Converting-Enzyme Inhibitor Therapy in Black as Compared with White Patients with Left Ventricular Dysfunction," N. Engl. J. Med., 344, 1351-1357 (2001). 

Masson, S., Masseroh, M., Fiordaliso, F., et al. (1999) Effects of a DA(2)/alpha(2) agonist and a beta(l)-blocker in combination with an ACE inhibitor on adrenergic activity and left ventricular remodeling in an experimental model of left ventricular dysfunction after coronary artery occlusion. J. Cardiovasc. Pharmacol. 34, 321-326. 

Concomitant therapy Concomitant therapy with -blockers or digitalis is usually well tolerated, but the effects of coadministration cannot be predicted, especially in patients with left ventricular dysfunction or cardiac conduction abnormalities. 

VERAPAMIL HYDROCHLORIDE Avo d verapamil in patients with severe left ventricular dysfunction (eg, ejection fractions less than 30%) or moderate to severe symptoms of cardiac failure and in patients with any degree of ventricular dysfunction if they are receiving a beta-adrenergic blocker. 

Verapamil Severe left ventricular dysfunction cardiogenic shock and severe CHF, unless secondary to a supraventricular tachycardia amenable to verapamil therapy and in patients with atrial flutter or atrial fibrillation and an accessory bypass tract. 

Edema Edema, mild to moderate, typically associated with arterial vasodilation and not due to left ventricular dysfunction, occurs in 10% to 30% of patients receiving nifedipine. It occurs primarily in the lower extremities and usually responds to diuretics. In patients with CHF, differentiate this peripheral edema from the effects of decreasing left ventricular function. 

Concomitant use of calcium channel blockers (atenolol) Bradycardia and heart block can occur and the left ventricular end diastolic pressure can rise when beta-blockers are administered with verapamil or diltiazem. Patients with preexisting conduction abnormalities or left ventricular dysfunction are particularly susceptible. Recent acute Ml (sotalol) Sotalol can be used safely and effectively in the long-term treatment of life-threatening ventricular arrhythmias following an Ml. However, experience in the use of sotalol to treat cardiac arrhythmias in the early phase of recovery from acute Ml is limited and at least at high initial doses is not reassuring. 

Left ventricular dysfunction (LVD) following Ml To reduce cardiovascular mortality in clinically stable patients who have survived the acute phase of a Ml and have a left ventricular ejection fraction of 40% or less (with or without symptomatic heart failure). 

Left ventricular dysfunction (LVD) Various ACEIs have demonstrated improved survival and decreased rates of development of overt heart failure in patients with varying degrees of LVD (from modest, asymptomatic to severe with CHF). 

Asymptomatic left ventricular dysfunction 2.5 mg twice daily, titrated as tolerated to the targeted daily dose of 20 mg in divided doses. 

OXYMORPHONE HYDROCHLORIDE Relief of moderate to severe pain. Parenterally for preoperative medication, support of anesthesia, obstetrical analgesia, and for relief of anxiety in patients with dyspnea associated with pulmonary edema secondary to acute left ventricular dysfunction. 

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