Left ventricular systolic 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... 

Until recently, the cardiotonics and a diuretic were the treatment of choice for HE However, other dragp such as the angiotensin-converting enzyme (ACE) inhibitors, and beta blockers have become the treatment of choice during the last several years. See Figure 39-1 for an example of a method of determining treatment for left ventricular systolic dysfunction. See Chapters 23, 42, and 46 for more information on the beta blockers, ACE inhibitors, and diuretics, respectively. 

Managing Heart Failure in Patients with Left Ventricular Systolic Dysfunction ... 

FIGURE 39-1. Management of left ventricular systolic dysfunction. (Adapted from Ammon, S [2001], Managing patients with heart failure, AJN 101 [12] 35.)... 

Which of tire following is commonly associated with left ventricular systolic dysfunction ... 

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... 

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... 

Left ventricular systolic dysfunction and symptoms such as dyspnea, fatigue, and reduced exercise tolerance... 

Heart failure Some ACEIs are effective in the management of CHF, usually as adjunctive therapy and in patients who demonstrate clinical signs of CHF or have evidence of left ventricular systolic dysfunction within the first few days after an acute myocardial infarction (Ml). 

Heart failure post-Mi/ieft-ventricuiar dysfunction post-MI (trandolapril, ramipril) For stable patients who have evidence of left-ventricular systolic dysfunction (identified... 

Congestive heart failure (CHF) post-myocardial infarction (Ml) To improve survival of stable patients with left ventricular systolic dysfunction (ejection fraction 40% or less) and clinical evidence of CHF after an acute Ml. 

The pharmacokinetic properties of these drugs are set forth in Table 12-5. The choice of a particular calcium channel-blocking agent should be made with knowledge of its specific potential adverse effects as well as its pharmacologic properties. Nifedipine does not decrease atrioventricular conduction and therefore can be used more safely than verapamil or diltiazem in the presence of atrioventricular conduction abnormalities. A combination of verapamil or diltiazem with 3 blockers may produce atrioventricular block and depression of ventricular function. In the presence of overt heart failure, all calcium channel blockers can cause further worsening of heart failure as a result of their negative inotropic effect. Amlodipine, however, does not increase the mortality of patients with heart failure due to nonischemic left ventricular systolic dysfunction and can be used safely in these patients. 

Shekelle PG et al Efficacy of angiotensin-converting enzyme inhibitors and beta blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status A meta-analysis of major clinical trials. J Am Coll Cardiol 2003 41 1529. [PMID 12742294]... 

Patients with left ventricular systolic dysfunction... 

All patients with heart failure due to left ventricular systolic dysfunction must be initiated on an ACE inhibitor. This should be initiated as soon as the patient s acute symptoms have been controlled at the appropriate dose and then titrated up at short intervals to the target dose or maximum tolerated dose. A suitable agent would be ramipril 2.5 mg once daily, which then could be slowly titrated (e.g. approximately every two weeks) to the target of 10 mg once daily or 5 mg twice daily. Parameters that require regular monitoring are blood pressure, urea and electrolytes (particularly serum potassium) at drug initiation then every week and after each dose increase until stable. 

NICE guidelines state that beta-blockers should be used in patients with heart failure due to left ventricular systolic dysfunction after a diuretic and ACE inhibitor regardless of whether symptoms persist or not. 

ACE inhibitors reduce morbidity and mortality post myocardial infarction in patients with left ventricular systolic dysfunction (LVSD). This is thought to be mediated via their action on the renin-angiotensin system. More recent evidence from the HOPE study (2000) has established that ACE inhibitors given to high risk CVD patients who had not got low ejection fraction or heart failure resulted in benefits in terms of reduced morbidity and mortality. 

Udelson JE, DeAbate CA, Berk M, Neuberg G, Packer M, Vijay NK, Gorwitt J, Smith WB, Kukin ML, LeJemtel T, Levine TB, Konstam MA. Effects of amlodipine on exercise tolerance, quality of life, and left ventricular function in patients with heart failure from left ventricular systolic dysfunction. Am Heart J 2000 139(3) 503-10. 

The angiotensin II receptor antagonists are being considered for the treatment of diseases other than hypertension (heart failure with or without left ventricular systolic dysfunction, during and after acute myocardial infarction, diabetic nephropathy, other forms of glomerulopathy, restenosis after coronary angioplasty, and atherosclerosis). 

From a post-hoc analysis of the SOLVD trial, it appears that in patients with left ventricular systolic dysfunction, the use of aspirin was associated with improved survival and reduced morbidity. In aspirin users, benefit from enalapril was retained but reduced (106). 

Echemann M, Zannad F, Briancon S, JuUhere Y, Mertes PM, Virion JM, Villemot JP. Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction the EPICAL study. Am Heart J 2000 139(4) 624-31. 

Of 603 adults aged 79 years, of whom 59% were women and 18% African-American, 376 patients (62%) were discharged taking digoxin, and 223 (37%) had no indication for its use, based on the absence of left ventricular systolic dysfunction or atrial fibrillation (20). After adjustment for various factors, prior digoxin use (OR =11 95% Cl = 5.7, 23) and pulse over 100/minute (OR = 2.33 95% Cl = 1.1, 4.9) were associated with inappropriate digoxin use. Unfortunately, the authors did not report the frequency of adverse effects, and it is not therefore clear whether patients in whom digoxin is used inappropriately are more or less likely to suffer adverse reactions. 

These data suggest that diuretic-induced potassium disturbances can cause fatal dysrhythmias in patients with left ventricular systolic dysfunction. SOLVD were not randomized trials of the risk of dysrhythmic death caused by diuretics. On average, patients retaking diuretics not only had lower serum potassium concentrations, but were also older, had more severe heart failure and were more likely to be taking antidysrhythmic drugs at baseline, although they had fewer indicators of ischemic... 

Keating GM, Plosker GL. Epierenone a review of its use in left ventricular systolic dysfunction and heart failure after acute myocardial infarction. Drugs 2004 64(23) 2689-707. 

Nielsen OW, McDonagh TA, Robb SD, Dargie HJ.Ret-rospective analysis of the cost-effectiveness of using plasma brain natriuretic peptide in screening for left ventricular systolic dysfunction in the general population. J Am Coll Cardiol 2003 41 113-20. 

Predictors for LVH and cardiac failure include age, hypertension, and hemoglobin concentration. In ESRD a Ig/dL fall in hemoglobin increases the relative risk of left ventricular dilation by 1.49, left ventricular systolic dysfunction by 1.55, and death by 1.25. " In patients on dialysis, large observational studies have clearly shown that anemia is associated with increased mortality rates and increased hospitaliza-tion. " In hemodialysis (HD) patients hematocrit levels of 33% to 36% (corresponding to hemoglobin concentration of 11 to 12g/dL) were associated with the lowest risk for all-cause and cardiac mortality,and these patients also had the lowest risk of hospitalization. " " A large randomized controlled trial has tested the hypothesis that normalization of anemia would have benefits in terms of... 

Heart Failure Society of America (1999) Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction-pharmacological approaches. J Card Fail 5 357-382... 

Sandhu R, Bahler RC. Prevalence of QRS prolongation in a community hospital cohort of patients with heart failure and its relation to left ventricular systolic dysfunction. Am J Cardiol 2004 93(2) 244-6. 

MUSTIC, PATH-CHF, MIRACLE, CONTAK CD, MIRACLE ICD, and PATH-CHF II enrolled patients with (a) moderate to severely symptomatic (NYHA class III—IV) CHF despite optimal medical therapy (b) severe left ventricular systolic dysfunction (LVEF <35%) (c) a wide QRS complex (generally defined as a QRS >120-130 msec) and (d) sinus rhythm. As a result, these inclusion criteria have become the standard indications for CRT. The effects in these conventional indication trials are robust—indeed, far more robust than the effects observed with conventional pharmacologic therapy of heart failure (Figure 5.1). For instance, improvement in 6-minute hall walk distance was observed in only 2 of 6 trials of ACE-inhibitors, 3 of 17 trials of beta blockers, and 1 of 4 trials of digoxin (13). Trials of both beta-blockers and ACE inhibitors have likewise shown inconsistent results with respect to V02max (14,15) and quality of life (16,17). 

CRT reduces symptoms of CHF and improves cardiac performance in patients with moderate-to-severely symptomatic heart failure, severe left ventricular systolic dysfunction, normal sinus rhythm and a wide QRS complex. Resynchronization therapy significantly reduces hospitalizations in these patients and is highly cost-effective. Perhaps most important, resynchronization therapy for heart failure improves survival for these patients, particularly when employed in conjunction with an implantable defibrillator. However, randomized clinical trials show that a substantial minority of patients are clinical nonresponders. Therefore, critical questions remain with respect to identifying appropriate candidates for CRT, optimal device programming, and left ventricular lead placement. 

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