The cardinal manifestations of heart failure are (1) dyspnea and fatigue, which may limit exercise tolerance, and (2) fluid retention, which may lead to pulmonary and peripheral edema. Both abnormalities can impair the functional capacity and quality of life of affected individuals. In addition, by its very nature, heart failure is a progressive disorder.
[...] Outpatient Treatment of Heart Failure The goals of outpatient management of patients with symptoms of heart failure due to systolic dysfunction of the left ventricle are the control of fluid retention, the control of neurohormonal activation (to reduce morbidity and mortality), and the control of symptoms and disability. GENERAL MEASURES Several general measures are advisable for most patients with chronic heart failure. Obese patients should lose weight, smokers should stop using tobacco products, and those concomitant cardiac conditions and risk factors (e.g., hyperlipidemia) should have their conditions actively managed. [...]
[...] DRUGS USED TO RELIEVE SYMPTOMS AND LESSEN DISABILITY Digitalis The digitalis glycosides exert their effects in patients with heart failure by virtue of their ability to inhibit sodium-potassium adenosine triphosphatase , -ATPase). Inhibition of this enzyme in the heart results in an increase in cardiac contractility, and for many decades, the benefits of digitalis in heart failure were ascribed to this positive inotropic action. However, by inhibiting Na+ , -ATPase in vagal afferents, digitalis acts to sensitize cardiac baroreceptors, which, in turn, reduce the outflow of sympathetic impulses from the central nervous system. [...]
[...] Patients with heart failure are predisposed to the proarrhythmic effects of antiarrhythmic drugs and the cardiodepressant effects of calcium channel blockers, and such agents should be avoided. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the effects of diuretics and ACE inhibitors and can worsen both cardiac and renal function. DRUGS FOR THE CONTROL OF FLUID RETENTION The first step in the treatment of patients with chronic heart failure is the control of fluid retention. This step is generally not necessary in patients with asymptomatic left ventricular systolic dysfunction. [...]
[...] Five ACE inhibitors have been approved for the treatment of chronic heart failure by the FDA: captopril, enalapril, lisinopril, quinapril, and fosinopril. Ramipril is approved for the treatment of heart failure after an acute MI. CLINICAL EFFECTS. All ACE inhibitors approved for the treatment of heart failure have been shown in double-blind, placebo-controlled trials to produce hemodynamic and clinical benefits. Treatment with these drugs improves left ventricular ejection fraction and decreases left ventricular chamber size; both actions suggest a favorable effect on the process of cardiac remodeling. [...]
[...] Approach to the Patient with Heart Failure DEFINING THE CAUSE OF HEART FAILURE The primary step in the management of heart failure is to identify and characterize the nature of the underlying cardiac disorder. A careful history may reveal the past occurrence of a myocardial infarction valvular disease, hypertension, myocarditis, thyroid disease, or the ingestion of cardiotoxic substances. Direct inquiry may also identify any associated disorders (e.g., anemia, arrhythmias, ischemia, or renal dysfunction) or concomitant medications (e.g., calcium channel blockers, antiarrhythmic drugs, and nonsteroidal anti-inflammatory drugs) that can exacerbate the syndrome of heart failure or complicate its management. [...]
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