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Thursday, June 17, 2010

How heart failure is treated

Heart failure is what happens when the heart becomes a weaker pump, and thus fluid backs up into the lungs and the rest of the body. Often the ankles become swelled, and breathing becomes difficult.

This can occur as a result of a variety of ailments from a heart attack to lung disease such as severe COPD. The good thing about heart disease is it can be managed, although it may entail some lifestyle changes, and managing some new medicines.

Heart failure may may refer to congested heart failure (CHF), which is when the left heart fails, or it may refer to left heart failure secondary to right heart failure.

Methods of improving heart function include anything that reduces afterload. This is anything that forces the heart to use a more forceful contraction, such as systemic hypertension, or pulmonary hypertension caused by pulmonary disease, or coronary artery disease. Another way to improve heart function are medicines that increase that make the heart a better pump.

Note that any blood used to decrease afterload must be titrated to make sure blood pressure is not decreased too much. Individual response to such medicines vary from person to person.

According to the American Heart Association, Medicines used to treat heart failure are:
1. Ace inhibitors: They are a type of vasodilator, which are medications that cause the blood vessels to expand, lowering blood pressure and reducing the heart's workload (reduce afterload). Medical billing employees in cardiac offices are familiar with these drug names.
Common brand names are: Capoten, Vasotec, Altace, Prinivil, Zestril, Accupril, Monopril, Lotensin, Univasc, Mavik, and Aceon

2. Diruetics:
Diuretics are prescribed for almost all patients who have fluid buildup in the body and swelling in the tissues. A diuretic causes the kidneys to remove more sodium and water from the bloodstream than usual and convert it into urine. This actually reduced preload (the amount of fluid that arrives in the heart that it has to pump to the system), and thus helps to relieve the heart's workload, since there's less fluid to pump throughout the body. It also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Diuretics are usually given in high doses when symptoms are more severe, and tapered off as as the patient gets better. Note here that diuretics make you pee (coffee isalso a diuretic, as you may have noticed you pee more after drinking several cups. Theophylline used to treat asthma and COPD is also a diuretic).

Of course your doctor will need to find a good balance of diuretics, as too much will cause your kidney's too pump out too many electrolytes such as potassium (see below), which isn't good either. Often times, a potassium supplement may me necessary.

Common brand names: Bumex and Lasix. Others include:
Hydrodirul, Diuril, Aldactone, Dyrenium, Zaroxolyn, Lozol, Midamo and Dyazide

3. Vasodilators:
Vasodilators cause the blood vessel walls to widen or relax, allowing blood to flow more easily. These are used for people who can't tolerate ACE inhibitors. Some, such as Nitro, are used in the emergency room to control angina (chest pain) due to cardiac disease or mycardial ischemia (heart attack).

Common brand names:
Isordil, Apresoline, Loniten, Natrecor, nitroglycerin, nitropress (nitroprusside), Nitrogard (Nitroglycerin pills), Nitro-Bid (Nitroglycerin patch), Hydralazine,

4. Inatropic drugs: Increase the force of the heart's contractions, which can be beneficial in heart failure. This relieves heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Most people continue taking the drug even after they feel well, to keep the heart working effectively.

In the hospital setting the nurse will often have to work to find the right dose of the inatropic drug to increase the force of the heart (to increase blood pressure) and the anit-hypertensive agent (like Nitroprusside) to maintain the target blood pressure.
It also slows certain types of irregular heartbeats (arrhythmia), such as atrial fibrillation. This is the rapid, irregular beating of the heart muscle that's present in some people with heart failure. When used by someone who has atrial fibrillation, digoxin prevents the ventricles (the lower, more powerful chambers of the heart) from beating too rapidly.

A patient on Digitalis will need to have his level checked often for dig toxicity, which will result in nausea, insomnia, vomiting, altered color vision, and irregular heart beat such as preventricular contractions (PVC). This shows up on the EKG as large t-waves.

Common brand names: Lanoxin (Digoxin), Dobutamine, amrinome

5. Beta blockers:
The failing heart tries to compensate for its weakened pumping action by beating faster, which puts more strain on it. Beta blockers reduce the heart's tendency to beat faster. The drugs block specific receptors ("beta receptors") on the cells that make up the heart, reducing the effects of chemical messengers that increase heart rate. This allows the heart to maintain a slower rate and lowers blood pressure. Beta blockers are used for mild to moderate heart failure and often with other drugs such as diuretics, ACE inhibitors and digoxin.

Note: Beta blockers block the effects of beta adrenergic medicines such as Albuterol and Xopenex. They also can cause bronchodilation. So they should be used with caution in patients with COPD and asthma.

Common generic and brand names: carvedilol (Coreg), metoprolol (Lopressor & Toprol XL), atenolol (Tenormin), bisoprolol (Zebeta), labatelol, propranolol (Inderal), sotalol (Betapace), pindolol, penbutolol, acebutolol (Sectral), timolol (Blocadren), nadolol (Corgard), betaxolol (Kerlone).

6. Blood thinners: People with heart failure are at risk of developing blood clots, usually in the blood vessels of the legs, lungs and heart. The last type can occur in cases of a condition called atrial fibrillation, which happens when the heart's upper chambers (atria) contract rapidly and without coordination. This causes the blood to pool in the atria, where it can form clots. These clots can be carried into the blood vessels that supply the brain. If one gets stuck in a vessel, blood flow to the brain is cut off and a stroke results. Doctors prevent strokes by prescribing blood thinners for patients who have a history of clots in the lungs or legs, atrial fibrillation or stroke.

Common blood thinners: 1) heparin. It can only be taken by injection, and usually in the hospital 2) warfarin (Coumadin) It can be taken long term at home.

6. Angiotensin II Receptor Blockers (ARBs): ACE inhibitors, the cornerstone of heart failure drug therapy, prevent the formation of a chemical called angiotensin II. This chemical causes the small blood vessels to constrict, which raises blood pressure and places more stress on the heart. However, even when a patient is using an ACE inhibitor, some angiotensin II may still be formed. Rather than lowering levels of angiotensin II (as ACE inhibitors do), angiotensin II receptor blockers (ARBs) prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising.

Common meds available: Losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro), candesartan (Atacand), telmisartan (Micardis), leprosaria (Teveten), olmesartan.

Calcium Channel Blockers: Muscles of the heart and blood vessels need calcium to contract. Calcium channel blockers may be used to treat the high blood pressure often associated with heart failure. These drugs interfere with calcium's role in the contraction of these muscles, which causes the muscles to relax. This lowers blood pressure and can improve the blood circulation in the heart.

Common meds available:
Amlodipine (Norvasc), Verapamil

Potassium: Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles. It's important to have just the right amount of potassium in the body, especially for the heart. The kidneys control the amount of potassium in the bloodstream and eliminate any excess through the urine.

Since most diuretics remove potassium from the body, heart failure patients who use them are at risk of losing too much potassium. Some patients need to take potassium supplements or pills to compensate for the amount they're losing. Sometimes all they need to do is eat foods high in potassium, such as bananas. However, ACE inhibitors can cause the body to retain potassium, so this needs to be taken into account too.

The doctor will do blood tests to check on potassium level and kidney function. Kidney function can change over time in people with heart failure, which can result in potassium level changes. Patients should check with their doctors to determine their potassium needs.

8. Sedatives: These are used sometimes to reduce anxiety and agitation, and reduce autonomic (neurological) stimulation on the heart (prevent rapid heart rate and increased force and contractility of the heart due to outside stimulants, such as stress and anxiety).

Examples of this include morphine and Versed.

Word of the day: Cognizant: To be aware, fully informed, or conscious
It's good to be cognizant of the latest wisdom.


Glenna said...

What? I thought we treated CHF with albuterol and albuterol only.??? Hehehehehehe

Rick Frea said...

It sure seems that way sometimes.

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