Mortality heart failure, reducing

P-Blockers and ACE inhibitors are also indicated for post-myocardial infarction for the reduction of cardiovascular morbidity and mortality, as are aldosterone antagonists, in post-myocardial infarction patients with reduced left ventricular systolic function and diabetes or signs and symptoms of heart failure.2,48... 

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... 

The ACC/AHA recommends that P-blockers be initiated in all patients with NYHA FC I to IV or ACC/AHA stages B through D heart failure if clinically stable.1 To date, only three p-blockers have been shown to reduce mortality in systolic HF, including the selective prantagonists bisoprolol and metoprolol succinate, and the non-selective pr, p2-, and arantagonist carvedilol.29 33 The positive findings should not be extrapolated to be indicative of a class effect, as bucindolol did not exhibit a beneficial effect on mortality when studied for HF, and there is limited information with propranolol and atenolol. 

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... 

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. 

ACE inhibitors should be initiated in all patients after MI to reduce mortality, decrease reinfarction, and prevent the development of heart failure. Data suggest that most patients with CAD (not just those with ACS or heart failure) benefit from an ACE inhibitor. 

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 ... 

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). 

The SLOVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992 327 685-91. 

Ramipril in patients with mild to moderate hypertension results in a reduction of both supine and standing blood pressure. In patients of acute myocardial infarction with CHE, ramipril reduced total mortality, progression of heart failure and CHF-related hospitalizations. 

Propranolol was the first blocker shown to be effective in hypertension and ischemic heart disease. Propranolol has now been largely replaced by cardioselective blockers such as metoprolol and atenolol. All B-adrenoceptor-blocking agents are useful for lowering blood pressure in mild to moderate hypertension. In severe hypertension, blockers are especially useful in preventing the reflex tachycardia that often results from treatment with direct vasodilators. Beta blockers have been shown to reduce mortality after a myocardial infarction and some also reduce mortality in patients with heart failure they are particularly advantageous for treating hypertension in patients with these conditions (see Chapter 13). 

Carvedilol, like labetalol, is administered as a racemic mixture. The S(-) isomer is a nonselective B-adrenoceptor blocker, but both S(-) and R(+) isomers have approximately equal E-blocking potency. The isomers are stereoselectively metabolized in the liver, which means that their elimination half-lives may differ. The average half-life is 7-10 hours. The usual starting dosage of carvedilol for ordinary hypertension is 6.25 mg twice daily. Carvedilol reduces mortality in patients with heart failure and is therefore particularly... 

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