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A diuretic is initially indicated in the presence
of symptomatic volume overload. Subsequent use of diuretics must
be adjusted to avoid intravascular volume contraction and a detrimental
increase in the levels of renin and angiotensin II levels. Diuretics
may also induce electrolyte imbalance and provoke arrhythmias.
An ACE inhibitor may be subsequently added in order
to slow progression to slow further progression of heart failure
and reduce mortality (as demonstrated by the SOLVD Prevention trial
of enalapril which showed a 29% reduction in death or overt progression
of symptomatic heart failure over 3 years). Similar beneficial effects
have also been reported with the use of other Angiotensin converting
enzyme inhibitors (ACE-I). The beneficial effect of ACE-I appears
to be independent of the etiology of heart failure.
Digitalis improves symptoms in CHF but does not
offer any survival benefits (Digitalis Investigator Group).
Amiodarone is not indicated for the suppression
of asymptomatic PVC's.
A beta-blockers may be subsequently added in low
doses and titrated, as tolerated. In most cases, significant homodynamic
improvement may not be noted for at least 2-3 months. Potential
benefits in cardiac patients include antihypertensive and anti-ischemic
effects and reduced probability of sudden death.It also has beneficial
ant-arrhythmic effects.
Remember that beta-blockers must be reserved
for patients with at least Class II symptoms. It is not found
to be clearly beneficial in minimally symptomatic patients with
dilated CMP.
With the exception of ICD, beta-blockers are
the most effective agents for reducing sudden death in high
risk patients.
Work-up for ischemic heart disease may be in order for
patients with otherwise unexplained CHF.
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