Diastolic Dysfunction Drug Rx

Diastolic dysfunction: Drug  Rx

 

Pretest

 

Question 1

 

Drugs used in heart failure may include:

 

1. angiotensin converting enzyme

inhibitor

 

2. a beta blocker such as carvedilol, bisoprolol, or metoprolol

 

3. angiotensin II receptor blocker valsartan

 

4. Digoxin has an important role in the symptomatic treatment of patients with heart failure and atrial fibrillation.

 

Keyword

 

·                 Diuretics are the most effective means of removing fluid retention, and their introduction often produces rapid symptomatic relief.

 

·                 Most patients with heart failure need at least a small dose of regular diuretic.

 

·                 On its own such treatment exacerbates neurohormonal activation, and modern treatment of heart failure due to systolic dysfunction of the left ventricle thus demands the use of two other types of drug: an angiotensin converting enzyme inhibitor and a beta blocker.

 

·                 The angiotensin converting enzyme inhibitor should be introduced at a low dose and titrated upwards over several weeks to the doses shown to be effective in clinical trials, while symptoms, blood pressure, and renal function are monitored.

 

·                 This can be safely accomplished in primary care, provided the patient is not hypotensive or on high dose diuretic treatment.

 

·                 Once the patient is stable on this treatment a beta blocker such as carvedilol, bisoprolol, or metoprolol can be added again starting at a low dose and titrating upwards gradually over several weeks, with close supervision of the control of the heart failure syndrome.

 

·                 Until recently, beta blockers were considered to be contraindicated in heart failure, but recent trials have shown that they can markedly improve survival and are safe to introduce,w1-w3 provided a "start low, go slow" policy is used.

 

·                 This can be very labour intensive and may be best managed by a nurse specialist.

 

·                 The valsartan heart failure trial found that patients did not live longer if the angiotensin II receptor blocker valsartan was added to conventional treatment with an angiotensin converting enzyme inhibitor.

 

·                 However, this study did show a reduction in the risk of admission to hospital for worsening heart failure.

 

·                 Ongoing trials will help to clarify the role of this class of drugs, but current evidence indicates that they are no more effective than angiotensin converting enzyme inhibitors in reducing mortality in patients with heart failure due to left ventricular systolic dysfunction.

 

·                 Most doctors would, however, now consider using angiotensin II receptor blockers for patients who develop an intractable cough on angiotensin converting enzyme inhibitors, rather than the previously favoured combination of oral hydralazine and nitrate.

 

·                 Spironolactone at a dose of 25-50 mg once daily reduces mortality in patients with moderate or severe symptoms due to systolic heart failure. Its benefit in other patient groups is unclear.

 

·                 Digoxin has an important role in the symptomatic treatment of patients with heart failure and atrial fibrillation. There is no evidence, however, that digoxin improves survival in patients in sinus rhythm.

 

·                 It may reduce the risk of admission to hospital, but its toxicity has to be considered, especially in elderly patients.

 

·                 Patients with atrial fibrillation are particularly complicated and usually benefit from specialist assessment.

 

·                 Formal anticoagulation with warfarin should be considered in order to reduce the risk of thromboembolism.

 

·                 Drugs that interact with anti-failure drugs or increase fluid retention such as non-steroidal anti-inflammatory agents; diltiazem, verapamil, or short acting dihydropyridine calcium antagonists; lithium; and parenteral corticosteroids should be avoided.

 

·                 Tricyclic antidepressants may increase the risk of arrhythmia. It is essential to educate patients about their drug treatment and which over the counter medicines they should avoid.

 

Post test

 

Question 1

 

Drugs used in heart failure may include:

 

1. angiotensin converting enzyme inhibitor

 

2. a beta blocker such as carvedilol, bisoprolol, or metoprolol

 

3. angiotensin II receptor blocker valsartan

 

4. Digoxin has an important role in the symptomatic treatment of patients with heart failure and atrial fibrillation.

 

Answer:

 

TTTT

 

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