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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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