Congestive heart failure ACE inhibitors

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Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
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Ca Channel Blockers
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Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
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Left Ventricular Assist Devices (LVADs)
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

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Congestive heart failure end-of-life considerations

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Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [1] and C. Michael Gibson, M.S., M.D. [2], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School

Overview

Indications For ACE Inhibitor or ARB

1. The left ventricular ejection fraction (LVEF) is ≤ 40%

or

2. There is a prior history of myocardiial infarction (MI)

Background

  • ACE Inhibitors (ACEI) should be considered as first-line therapy for the treatment of patients with clinical heart failure due to reduced left ventricular systolic dysfunction (LVSD), patients with asymptomatic LV dysfunction, and for patients who are at high risk for the development of heart failure due to the presence of coronary, cerebrovascular, or peripheral vascular disease.
  • Treatment should not be deferred in patients with few or no symptoms because of the significant mortality benefit derived from ACEI therapy.
  • Initial therapy usually consist of 12.5 mg tid of captopril, 2.5 mg bid of enalapril, or 2.5 mg daily lisinopril. The optimal dose is usually established by optimizing the dose every 4 to 6 weeks.
  • ACE inhibitors are rarely adequate for the treatment of congestion without the use of diuretics.
  • 5-10 % patients cannot tolerate ACE inhibitors because of cough. Cough can be a sign of elevated left-sided filling pressures. Sometimes cough will diminish with the treatment of heart failure. A
  • Renal artery stenosis should be considered if there's a decline in renal function with the initiation of ACE inhibitors.

Angiotensin receptor blockers (ARB)

  • In the CHARM study candesartan reduced both hospitalization and mortality.

Aldosterone Antagonists

References


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