[CRT-FORUM] 25E Management for heart failure. Dr. Balkin

[CRT-INFO]

I would like to add that Metolazone may also be a useful diuretic when 
added to Furosemide in cases of severe CHF non responsive to increasing 
doses of furosemide and spironolactone. the combination is often 
effective- but should be used with care 2.5mg X1-2/week- with careful 
attention to sodium levels.

Jonathan Balkin <drbalkin at netvision.net.il>

> Dear Colleague Antonio Triana from Cuba:
> In HF treatment we have several approaches: Diet and lifestyle measures,
> pharmacologica approach, devises, and surgeries.
>
> I) DIET AND LIFESTYLE MEASURES
> 1) Physical activity, Moderate when symptoms are mild or moderate; or
> bed rest when symptoms are severe.
> 2) If sleep apnea is identified, treat with CPAP, BiPAP, dental
> appliances or surgery. Sleep apnea is an under recognized risk factor 
> for HF
> 3) Weight reduction – through physical activity and dietary
> modification, as obesity is a risk factor for HF and LVH.
> 4) Monitor weight - this is a parameter that can easily be measured at
> home. Rapid weight increase is generally due to fluid retention.
> 5) Sodium restriction – excessive sodium intake may precipitate or
> exacerbate HF, thus a "no added salt" diet (60–100 mmol total daily 
> intake)
> is recommended for patients with CHF. More severe restrictions may be
> required in severe CHF.
> 6) Fluid restriction – patients with CHF have a diminished ability to
> excrete free water load. Hyponatremia frequently develops in 
> decompensated
> heart failure due to the effects of excess circulating neuroendocrine
> hormones. While the activation of the renin-angiotensin-aldosterone 
> axis due
> to decreased renal perfusion promotes both sodium and water retention, 
> the
> activation of atrial natriuretic peptide due to atrial stretch favors 
> sodium
> excretion, and the activation of antidiuretic hormone due to peripheral
> baroreceptors that sense hypotension as well as due to the activation 
> of the
> sympathetic nervous system favors water retention alone, leading to
> disproportionately more water retention than sodium retention. The 
> severity
> of the hyponatremia during an episode of decompensated heart failure 
> can be
> predictive of mortality. Generally water intake should be limited to 
> 1.5 L
> daily or less in patients with hyponatremia, though fluid restriction 
> may be
> beneficial regardless in symptomatic reduction.
>
> II) PHARMACOLOGICA APPROACH. They include:
> 1) Angiotensin-converting enzyme (ACE) inhibitors
> 2) Angiotensin II (A-II) receptor blockers (ARBs).
> 3) Beta blockers: mainily carvedilol
> 4) Positive inotropes: Digoxin, phosphodiesterase inhibitors,
> dobutamine.
> 5) Loop Diuretics: furosemide, bumetanide.
> 6) Aldosterone antagonists. spironolactone (Aldactone) and eplerenone
> (Inspra).
> 7) Thiazide diuretics (e.g. hydrochlorothiazide, chlorthalidone,
> chlorthiazide) – may be useful for mild CHF, but typically used in severe
> CHF in combination with loop diuretics, resulting in a synergistic 
> effect.
> 8) BiDil medication: is a single pill that combines hydralazine and
> isosorbide dinitrate — both of which dilate and relax the blood vessels.
> BiDil increases survival when added to standard therapy in black 
> people with
> advanced heart failure. This is the first drug studied and approved for a
> specific racial group.
> 9) Recombinant neuroendocrine hormones Nesiritide, a recombinant form
> of B-natriuretic peptide, is indicated for use in patients with acute
> decompensated HF who have dyspnea at rest. Nesiritide promotes 
> diuresis and
> natriuresis, thereby ameliorating volume overload. It is thought that, 
> while
> BNP is elevated in HF, the peptide that is produced is actually
> dysfunctional or non-functional and thereby ineffective. Extreme 
> caution is
> required when using nesiritide in patients with both HF and concurrent
> morbidities such as renal dysfunction.
>
> III) DEVISES
> Implantable cardioverter-defibrillators (ICDs).
> Cardiac resynchronization therapy (CRT) or biventricular pacing.
> CRT combined with an ICD to shock a person out of life-threatening
> arrhythmias, such as VT /VF. The worse the left ventricle, the higher the
> risk for sudden death secondary to these arrhythmias.
> Left ventricular assist devices (LVADs).Another current treatment 
> involves
> the use of LVADs are battery-operated mechanical pump-type devices 
> that are
> surgically implanted on the upper part of the abdomen. They take blood 
> from
> the LV and pump it through the aorta. LVADs are becoming more common 
> and are
> often used by patients who have to wait for heart transplants.
> Enhanced external counterpulsation (EECP). This noninvasive technique has
> been used as a treatment for heart-related chest pain, and researchers 
> are
> studying this treatment to see if it's beneficial for people with heart
> failure. Inflatable pressure cuffs are placed on the calves, thighs and
> buttocks. These cuffs are inflated and deflated in sync with your 
> heartbeat.
> The theory is that EECP increases blood flow back to the heart
> The Acorn CorCap Mesh-like constraint devices such as aim to improve
> contraction efficacy and prevent further remodeling. Clinical trials are
> underway.
> Myosplint device Another technique which aims to divide the spherical
> ventricle into two elliptical halves
>
> IV) SURGERIES
> 1) LV remodeling: The aim of the procedures is to reduce the LV diameter
> (targeting Laplace's law and the disease mechanism of HF), improve its 
> shape
> and/or remove non-viable tissue. These procedures can be performed 
> together
> with:
> 2) Mitral Valve repair
>
> 3) Valve replacement
>
> 4) Coronary artery bypass
>
> 5) Partial left ventriculectomy or Batista procedure.
>
> 6)Two-directional cavopulmonal anastomosis (TDCPA) for the surgical
> treatment of congenital heart failure (CHF) in certain complex forms 
> of CHF
> and in patients at risk of poor outcome of Fontan surgery may be used 
> as the
> final stage of hemodynamic correction.
>
> 7) Orthoptic heart transplantation: PROGNOSIS: the prognosis for heart
> transplant patients following the orthotopic procedure has greatly 
> increased
> over the past 20 years, and as of May 30, 2008, the survival rates 
> were as
> follows
> 1 year: 87.5% (males), 85.5% (females)
> 3 years: 78.8% (males), 76.0% (females)
> 5 years: 72.3% (males), 67.4% (females)
>
> 8 Heterotopic procedure: the patient's own heart is not removed before
> implanting the donor heart. The new heart is positioned so that the 
> chambers
> and blood vessels of both hearts can be connected to form what is
> effectively a 'double heart'. The procedure can give the patients 
> original
> heart a chance to recover, and if the donor's heart happens to fail (eg.
> through rejection), it may be removed, allowing the patients original 
> heart
> to start working again. Heterotopic procedures are only used in cases 
> where
> the donor heart is not strong enough to function by itself (due to either
> the patients body being considerably larger than the donor's, the donor
> having a weak heart, or the patient suffering from pulmonary 
> hypertension).
>
> 9) Cardiomyoplasty is a surgical procedure in which healthy muscle from
> another part of the body is wrapped around the heart to provide 
> support for
> the failing heart. Most often the latissimus dorsi muscle is used for 
> this
> purpose. A special pacemaker is implanted to make the skeletal muscle
> contract.
>
> All the best
> Andrés Ricardo Pérez Riera MD chief of electrovectorcardiology sector ABC
> Faculty of Medicine (FMABC), Discipline of Cardiology, Foundation of ABC
> (FUABC), Santo André, São Paulo, Brazil.
>> What is the current management for heart failure?
>>
>> "antonio triana" <atriana at infomed.sld.cu>
>> Cuba
>>
>
>


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee