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Therapeutic Approaches in Acute Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Getu Teressa, Rachel A. Bright, Andreas P. Kalogeropoulos
If the clinical trajectory of decongestion goal is slow, stalled, or worsening, diuretic therapy can be intensified while assessing other parameters such as blood pressure, electrolytes, and renal function. To achieve the goal of net negative fluid balance, fluid restriction (1.5–2 L/day) can be considered in patients with stage D heart failure, particularly in patients with hyponatremia (ACCF/AHA class IIa, Level C).82 However, aggressive sodium and fluid restriction was shown not to affect weight loss or clinical stability at three days compared with a standard hospital diet in patients with acute decompensated heart failure.88
The heart
Published in Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella, Essentials of Human Physiology and Pathophysiology for Pharmacy and Allied Health, 2019
Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella
The signs and symptoms of heart failure may not appear in the early stages due to a number of compensatory mechanisms that combine to maintain CO. This early stage of heart failure is termed compensated heart failure. The compensatory responses are only effective in the short term and will eventually be unable to maintain CO for a long period of time. Decompensated heart failure occurs when CO is no longer adequately maintained and overt symptoms of heart failure appear (see Figure 7.14).
Preoperative Care Including the High-Risk Surgical Patient
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Left ventricular failure is the end result of several conditions including IHD, hypertension, cardiomyopathies and valve dysfunction. Decompensated heart failure puts the patient at risk of multiorgan failure. Those with ejection fractions of less than 35%, and in whom the failure is undiagnosed or its severity underestimated, are at the highest risk. The patient’s functional capacity needs to be assessed and surgery may have to be delayed for investigations such as an echocardiogram and/or for optimisation of medical therapy. Drugs used in chronic heart failure have significant implications for perioperative care, and P-blockers and probably ACE inhibitors (unless renal perfusion is to be significantly affected) should be continued. Anaesthesia should ensure minimal myocardial depression and change in afterload during surgery. Arrhythmias must be rapidly brought under control, particularly AF, and correcting any electrolyte imbalance is crucial in this respect. Invasive monitoring of trends in central venous and arterial pressure monitoring may help management, particularly when large fluid shifts are expected to occur.
A new role for an old drug: acetazolamide in decompensated heart failure
Published in Expert Opinion on Pharmacotherapy, 2023
The most usual treatment for decompensated heart failure with volume overload is a loop diuretic (furosemide, bumetanide, or torsemide), as they are potent diuretics. However, despite their use, subjects often leave hospital with residual congestion. For instance, in the Diuretic Optimization Strategies Evaluation (DOSE) in subjects with acute decompensated heart failure, this occurred with two doses (low and high) of both oral and intravenous furosemide [3]. There were no differences between doses on the primary outcome of subject’s assessment of symptoms at 72 hours [3]. But importantly, overall, there was treatment failure in 38% of subjects, with another 25% of them having worsening or persistent heart failure, and only 15% of them being free from congestion at 72 hours [3]. In the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF), with loop diuretic treatment, 18% had worsening condition at seven days and only 9% had clinical decongestion at 96 hours [4].
The pathophysiology and management of diuretic resistance in patients with heart failure
Published in Hospital Practice, 2022
Steven G. Chrysant, George S. Chrysant
Diuretic resistance to the treatment of patients with CHF is common ranging between 20% and 50% of patients with advanced CHF, especially in the presence of renal functional impairment. Among the diuretics used, loop diuretics are the line of therapy with furosemide being the most commonly employed, although other loop diuretics like bumetanide and torsemide are more potent and longer acting, like torsemide. If resistance to loop diuretics persists after the use of maximal doses ranging from 200 to 300 mg/day, the resistance can be overcome with the addition of other diuretics like thiazide and thiazide-like, mineralocorticoid receptor antagonists (MRAs), as well as the sodium-glucose co-transporter 2 (SGLT2) inhibitors acting at different segments of the renal tubule and have complementary effects. Other drugs used in acute decompensated heart failure include dopamine, nesiritide, and the vasopressin-2 inhibitor tolvaptan. This latter drug is particularly useful in patients with CHF and diuretic-induced hyponatremia, because they increase the free water clearance and improve the hyponatremia.
A giant left atrial myxoma causing mitral valve pseudostenosis – a mimicker
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Basel Abdelazeem, Hafiz Khan, Hameem Changezi, Ahmad Munir
CM is a rare condition with an incidence of 0.5 per one million annually [1]. Although it is a benign tumor, it can result in potentially life-threatening conditions. A detailed history and physical examination are crucial for early diagnosis. Cardiovascular symptoms, including chest pain, syncope, dyspnea, and angina, are the most common features in around 67% of the patients, out of which 28% can present with acute decompensated heart failure (ADHF) [4]. Constitutional symptoms, including fever, malaise, arthralgia, and myalgia, are the second most common presentation in around 34%, while the embolic symptoms constitute up to 29% of the patients. Left-sided CM embolizes systemically to cerebral circulation (most common site, up to 30–40% of the patients), kidneys, and lower extremities, while the right-sided CM embolization occurs to pulmonary circulation [5,6]. In an asymptomatic patient, CM can be an incidental finding on imaging.