[CRT-FORUM] 27E Management for heart failure. Dr. Perez Riera

[CRT-INFO]

Excellent observation dear Dr. Jonathan Balkin: Metolazone was developed in
the 1970s. Its creator, Indian physician Dr. B. Vithal Shetty, has been
active in helping the U.S. FDA review drug applications, and in the
development of new medicines. Metolazone quickly gained popularity due to
its lower renal toxicity compared to other diuretics (especially thiazides)
in patients with renal insufficiency. Metolazone is a thiazide diuretic (or,
rather, a thiazide-like diuretic because it acts similarly to the thiazides
but does not contain the benzothiadiazine molecular structure) This lowers
blood pressure and prevents excess fluid accumulation in HF. Metolazone is
sometimes used together with loop diuretics, but these highly effective
combinations can lead to dehydration and electrolyte abnormalities.
Recently, Kumar et al(1) investigated in 51 consecutive outpatients with
symptomatic CHF caused by abnormal LVEF  treated with furosemide or
torsemide (10% also with metolazone), beta blockers, and ACEI or ARBs, 55%
with spironolactone, and 18% with digoxin, the effects of doubling the dose
of furosemide, torsemide, and metolazone on:
1)    Symptoms
2)    Weight, 6-minute walk distance
3)     Echocardiographic measurements of LV systolic and diastolic
function at 24 +/- 6 days follow-up.
Doubling the dose of diuretics in outpatients with symptomatic CHF caused a
significant loss of weight and a significant improvement in symptoms and
6-minute walk distance but did not change LV systolic and diastolic function
(1).
SIDE EFFECTS: Dizziness, lightheadedness, headache, blurred vision, loss of
appetite, stomach upset, diarrhea, or constipation may occur as your body
adjusts to the medication.. This medication may lead to excessive loss of
body water and minerals (including potassium).Serious symptoms secondary to
dehydration or mineral loss are muscle cramps or weakness, confusion, severe
dizziness, unusual dry mouth or thirst, nausea or vomiting, fast/irregular
heartbeat, unusual decrease in the amount of urine, fainting, seizures,
numbness/tingling of the arms/legs, decreased sexual ability, chest pain,
persistent sore throat or fever, easy bleeding or bruising,
stomach/abdominal pain, persistent nausea/vomiting, yellowing of eyes/skin.
A serious allergic reaction to this drug is unlikely, but seek immediate
medical attention if it occurs. Symptoms of a serious allergic reaction
include: rash, itching, swelling, severe dizziness, trouble breathing.
PRECAUTIONS: allergies,  kidney disease, liver disease, untreated mineral
imbalance (e.g., sodium, potassium), gout, lupus. If the patien have
diabetes, metolazone may worsen control of blood glucose levels. This drug
may reduce the potassium levels. A. This medication may make the patient
more sensitive to the sun. Avoid prolonged sun exposure, tanning booths or
sunlamps. Use a sunscreen and wear protective clothing when outdoors. This
drug may make you dizzy or cause blurred vision; use caution engaging in
activities requiring alertness such as driving or using machinery. Limit
alcoholic beverages. To minimize dizziness and lightheadedness, get up
slowly when rising from a seated or lying position. Caution is advised when
using this drug in the elderly because they may be more sensitive to its
effects, especially dizziness. Metolazone should be used only when clearly
needed during pregnancy. This drug passes into breast milk.

Reference.
1)    Kumar A, Aronow WS, Vadnerkar A, Sivan K, Mittal S.Effects of
Increased Dose of Diuretics on Symptoms, Weight, 6-Minute Walk Distance, and
Echocardiographic Measurements of Left Ventricular Systolic and Diastolic
Function in 51 Patients With Symptomatic Heart Failure Caused by Reduced
Left Ventricular Ejection Fraction Treated With Beta Blockers and
Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers.
Am J Ther. 2009 Jan 8. [Epub ahead of print]
All the best for all
Andrés Ricardo Pérez Riera.MD
Chief of electrovectorcardiographic sector. ABC’s Medical School, ABC
Foundation, Santo André, São Paulo, Brazil Riera at uol.com.br
> 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