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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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contributor to the development of a patient’s HF. Revascularization of coronary
lesions causing ischemic heart disease has been shown to improve outcomes in
patients with HF.
Treatment of Acute Heart Failure
In all cases of acute decompensated HF, the initial management imperative is the
stabilization of the cardiopulmonary system. Supplemental oxygen, initially 100%
via nonrebreather face mask, should be administered. If necessary, ventilation
can be assisted with continuous positive airway pressure, bilevel positive airway pressure, or mechanical ventilation. Cardiac and continuous pulse oximetry
monitors should be placed and intravenous access obtained. The goals of managing an acute exacerbation of HF are to stabilize hemodynamics, treat reversible
underlying conditions contributing to HF, and establish an effective regimen for
outpatient therapy.
Treating Volume Overload. Ninety percent of patients admitted to the hospital
with decompensated HF are volume overloaded. When volume overload caused by
HF (which frequently causes acute pulmonary edema) is diagnosed, the next step
in management is the administration of a loop diuretic. Furosemide is generally
the treatment of choice, both for its potent diuretic effect and for its rapid bronchial vasculature vasodilation. Volume overload may also be treated acutely with
vasodilators to reduce filling pressures. Nitrates, particularly nitroglycerin when
given intravenously, reduce myocardial oxygen demand by reducing preload and
afterload. Nitroglycerin also can rapidly reduce BP and is the treatment of choice
in a patient who has HF and whose BP is elevated. It should be used with caution
or avoided in a hypotensive patient.
Intravenous morphine sulfate can be an effective adjunct to therapy. Along with
its analgesic and anxiolytic properties, morphine is a venodilator (primary effect)
and arterial dilator, resulting in a reduction in preload and an increase in cardiac
output. Patients with severely reduced ejection fraction may require short-term use
of inotropic agents such as dobutamine or milrinone to improve cardiac output.
Vasopressors may also be necessary for hypotension, and dopamine is the preferred
agent for HF patients. Hemodialysis for fluid removal may be required in patients
with concomitant end-stage renal disease.
Treatment of Chronic Heart Failure
Lifestyle Modification. Patient care management and education are important
aspects of care for all patients with HF. All patients should be advised about the
importance of dietary sodium and fluid restriction. A normal American diet contains 6 to 10 g of sodium chloride a day, and there is evidence to show that sodium
reduction is beneficial in all classes of HF. Fluid restriction of 1.5 to 2 L/d can
be considered in patients with class D HF. Patients should be warned to avoid
nonsteroidal anti-inflammatory medications, as these can worsen fluid retention
and reduce the efficacy of diuretics and ACEIs. Exercise training such as cardiac
rehabilitation in patients with HF is associated with improved response to pharmacologic vasodilators, reduced hospitalizations, and improvement in well-being
and exercise capacity.
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Managing Risk Factors. The importance of strict management of BP and modification of other cardiac risk factors, especially smoking, should be emphasized
as well. Sleep apnea is common in patients with systolic HF, and treatment with
positive airway pressure therapies has been associated with improved ejection fraction and survival. Daily weights, with medication adjustment based on acute shifts
in weight, are used by care management teams to reduce risk for emergent need
for hospitalization. Interdisciplinary care management should be instituted for
patients deemed at high risk for readmissions.
ACEIs and ARBs. An ACEI or ARB should be considered first-line therapy in
patients with HFrEF. ACEIs and ARBs reduce preload and afterload, improve
cardiac output without increasing heart rate, and inhibit tissue renin-angiotensin
systems, which improves myocardial relaxation and compliance. The result of
this is improvement in symptoms and reduction in mortality and hospitalization. ACEIs or ARBs can also delay the development of symptomatic HF in
asymptomatic patients with a reduced cardiac ejection fraction (AHA stage B
or NYHA class I). Better outcomes are seen at higher doses, so patients should
be maintained at the highest tolerable dose. Consider switching from an ACEI or
ARB to sacubitril (prodrug neprilysin inhibitor with valsartan) in patients with
symptomatic HF, ejection fraction ≤ 35%, and elevated BNP, but be aware of
risk for symptomatic hypotension. ACEIs and ARBs are contraindicated in pregnancy, hypotension, hyperkalemia, and bilateral renal artery stenosis and should
be used with caution in patients with renal insufficiency.
Beta-Blockers. The administration of beta-blockers, especially in high doses, in the
setting of acute HF can worsen symptoms; consequently, they should preferentially
be started when patients have minimal evidence of fluid retention and few symptoms, and initial doses should be low and titrated up over several weeks. Betablockers reduce sympathetic tone and the cardiac muscle remodeling associated
with chronic HF. In combination with ACEIs, beta-blockers improve mortality.
Contraindications to beta-blocker use include symptomatic bradycardia, atrioventricular block in the absence of a pacemaker, hypotension, severe peripheral vascular disease, and severe bronchospasm.
Diuretics. Diuretics should be used to reduce volume overload in both the
acute and chronic settings. They are most helpful in symptom management and
should be used with ACEIs/ARBs and beta-blockers for long-term reduction
in HF exacerbations. Loop diuretics (furosemide, bumetanide, torsemide) can
be used in all stages of HF and are useful for pulmonary edema and refractory
HF. These are preferred because they can increase sodium excretion by 20% to
25% and increase free water excretion. Thiazide diuretics (hydrochlorothiazide,
chlorthalidone, others) only increase sodium excretion by 5% to 10%, and this
effect is reduced in renal insufficiency. Their primary role in management of HF
is in treatment of hypertension. Diuretic doses can be adjusted based on daily
weight measurements by the patient, and patients should be monitored closely
for overdiuresis.
Aldosterone Antagonists. The aldosterone antagonists, spironolactone and
eplerenone improve symptoms, reduce hospitalizations, and reduce mortality in
advanced HF. Elevated aldosterone levels contribute to sodium and water retention,
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potassium and magnesium loss, myocardial hypertrophy and fibrosis, and endothelial dysfunction. Aldosterone blockade promotes reversal of these effects. It also
functions as a potassium-sparing diuretic and should be considered in NYHA
class III and IV HF. Patients on this medication must be closely monitored for the
development of hyperkalemia, which can become profound and lead to arrhythmia.
It should be avoided in patients with renal failure.
Nondihydropyridine Calcium Channel Blockers. Nondihydropyridine calcium
channel blockers (diltiazem, verapamil) increase mortality in HFrEF and should
be avoided. The dihydropyridine calcium channel blocker amlodipine does not
increase or decrease mortality, and it can be very effective in treating hypertension.
Nondihydropyridine calcium channel blockers may be useful in HFpEF, as they
promote increased cardiac output by lowering heart rate, which allows for more
ventricular filling time.
Digoxin. Digoxin is only indicated to reduce hospital stays in patients with
uncontrolled HF on appropriate medical therapy or for ventricular rate control in
patients with known arrhythmias, such as atrial fibrillation. It can improve symptoms and exercise tolerance, and it can slightly improve ejection fraction and cardiac output; however, it has no mortality benefit and has a very narrow therapeutic
window with significant adverse effects in overdose. Symptoms of digoxin toxicity
include nausea, vomiting, headache, somnolence, altered color vision, and arrhythmias. Benefits of digoxin therapy are greatest in patients with NYHA class IV disease, cardiomegaly, and ejection fraction less than 25%.
Other Medications. The combination of hydralazine with nitrates has been
shown to provide increased survival and decreased hospitalizations when used
in combination with ACEIs, beta-blockers, and spironolactone in patients with
HFrEF who self-identified as African American. Anticoagulation is recommended
for HF patients with atrial fibrillation and/or history of cardiac thrombus or history of thromboembolic events.
Cardiac Resynchronization Therapy. Approximately one-third of patients with
NYHA class III or IV HF and reduced ejection fraction have ECG evidence of
abnormal ventricular conduction (ie, prolonged QRS duration), which causes
ventricular dyssynchrony. This results in reductions in ventricular filling, left ventricular contractility, paradoxical septal wall motion, and worsening of mitral regurgitation. These patients can be helped by promoting synchronous contraction of
both the right and left ventricles using a biventricular pacemaker. This process, also
known as cardiac resynchronization therapy, has been shown to reduce mortality
and hospitalization in patients with symptomatic HF in spite of maximal medical
therapy, as well as improve quality of life, exercise capacity, and left ventricular ejection fraction.
Implantable Cardioverter-Defibrillator. Patients with an ejection fraction less than
35%, NYHA class II or III HF, and a reasonable life expectancy of at least 1 year
are recommended to have an implantable cardioverter-defibrillator (ICD) placed
for secondary prevention of sudden cardiac death due to ventricular arrhythmias,
especially if the patient has a history of cardiac arrest, ventricular fibrillation, or
unstable ventricular tachycardia.
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CASE CORRELATION
See also Case 2 (Dyspnea [Chronic Obstructive Pulmonary Disease]) and
Case 20 (Chest Pain).
COMPREHENSION QUESTIONS
27.1 A 57-year-old man who has known NYHA class II HF presents to the clinic
after becoming dyspneic with significant exertion. On physical examination, his BP is 140/86 mm Hg, pulse is 86 beats/min, and respiratory rate is
20breaths/min. A 2/6 pansystolic murmur is best heard at the right sternal
border. There is no JVD, but 1+ pretibial and pedal edema are noted. He
currently takes an ACEI and aspirin. Which one of the following additional
medications has been shown to improve longevity in this situation?
A. Warfarin (Coumadin)
B. Digoxin
C. Beta-blocker
D. Nondihydropyridine calcium channel blocker
E. Amiodarone (Cordarone)
27.2 A 52-year-old man with a 25-year history of hypertension presents with
gradually increasing shortness of breath and reduced exercise tolerance with
pain in his calves that causes him to stop walking after one block. His records
indicate that his BPs have fluctuated over the years in the range of 140/90
to 160/105 mm Hg. His medications include enalapril and metoprolol. The
physical examination reveals a BP of 140/90 mm Hg, a respiratory rate of
22 breaths/min, and a heart rate of 88 beats/min. The heart examination
reveals a normal S1 and S2 and no murmurs. Lung examination shows bibasilar rales. There is trace pitting edema bilaterally. Posterior tibial and dorsalis
pedis pulses are 1+. Which of the following diagnostic tests is most likely to
confirm the diagnosis in this patient?
A. Cardiac magnetic resonance imaging (MRI)
B. 24-hour Holter monitoring
C. Spiral computed tomography (CT) of the chest
D. Two-dimensional echocardiography with Doppler
E. Posteroanterior and lateral chest radiographs
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27.3 A 64-year-old man is noted to have HF because of CAD. Over the past 2days,
he has developed progressive dyspnea and orthopnea. On examination, he is
found to be in moderate respiratory distress and have JVD, and he has rales
on pulmonary examination. He is diagnosed with pulmonary edema. Which
of the following agents is most appropriate at this time?
A. Hydrochlorothiazide
B. Furosemide
C. Carvedilol
D. Spironolactone
E. Digitalis
27.4 A 70-year-old African American man with a history of HF sees you in the
office for follow-up. He has shortness of breath with minimal exertion such
as walking 20 feet on level ground. The patient states he is adherent to his
medication regimen, which consists of lisinopril 40 mg twice daily, carvedilol
25mg twice daily, furosemide 80 mg daily, and spironolactone 25 mg daily. His
BP is 100/60 mm Hg, and his pulse rate is 70 beats/min and regular. Lung
examination findings reveal a few scattered bibasilar rales. Cardiac examination shows a normal S1 and S2 and an S3 gallop. There is no peripheral edema.
An ECG reveals a left bundle branch block, and echocardiography reveals an
ejection fraction of 25%. Which of the following is the best next step in the
management of this patient?
A. Increase the furosemide dosage to 80 mg twice daily.
B. Refer for coronary angiography.
C. Increase the lisinopril dosage to 80 mg twice daily.
D. Increase the carvedilol dosage to 50 mg twice daily.
E. Refer for cardiac resynchronization therapy.
ANSWERS
27.1 C. Beta-blockers are recommended to reduce mortality in symptomatic
patients with HF. Digoxin (answer B) is only recommended in patients
who are already on maximal medical therapy. Nondihydropyridine calcium
channel blockers (answer D) should be used with caution in patients with
HF because they can cause peripheral vasodilation, decreased heart rate,
decreased cardiac contractility, and decreased cardiac conduction. Anticoagulation with warfarin (answer A) is not indicated, and amiodarone (answer E)
is used for treatment of arrhythmias.
27.2 D. The most useful diagnostic tool for evaluating patients with HF is twodimensional echocardiography with Doppler to assess left ventricular ejection fraction, left ventricular size, ventricular compliance, wall thickness, and
valve function. It should be performed during the initial evaluation. Chest
radiography (answer E) and 12-lead ECG should be performed in all patients
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presenting with HF but should not be used as the primary basis for determining which abnormalities are responsible for the HF. Answer A (cardiac
MRI) is much more costly and not considered the first-line measure for the
evaluation of HF. Answer B (24-hour Holter monitoring) is appropriate for
symptoms of arrhythmias or palpitations. Answer C (spiral CT of the chest)
is useful for assessing for possible pulmonary embolism.
27.3 B. Furosemide, a loop diuretic, is a first-line agent in HF exacerbation with
pulmonary edema. The other medications listed (answer A, hydrochlorothiazide; answer C, carvedilol; answer D, spironolactone; and answer E, digitalis)
may be used in the management of HF but are not indicated in an acute
exacerbation.
27.4 E. This patient is already receiving maximal medical therapy; therefore, the
answer choices A (increase furosemide), C (increase lisinopril), and D
(increase carvedilol) are incorrect. Cardiac resynchronization therapy (which
utilizes a pacemaker to produce a more efficient cardiac output) is recommended for patients in sinus rhythm, particularly efficacious with left bundle
branch block with an EF < 35%, QRS >120 ms, and those who remain symptomatic (NYHA III–IV) despite optimal medical therapy.
CLINICAL PEARLS
» Compliance with diet and medications is a fundamental part of the treat-
ment plan of HF patients.
» Angiotensin-converting enzyme inhibitors and aldosterone inhibitors
have been shown to improve survival in HF patients by decreasing cardiac remodeling, whereas other agents, such as digoxin and loop diuretics, may help with symptoms but not survival.
» Beta-blockers can also help in slowing HF disease progression and
improve survival but should be used cautiously in those with significantly
reduced EF.
» The initial hour in the management of a patient with either new-onset HF
or an acute exacerbation is crucial to the patient’s outcome.
» The most common cause of HF is coronary heart disease.
» Simple measures, such as decreasing cardiac preload by sitting the
patient up with their legs on the ground and their arms by their side,
maintaining an airway and giving oxygen, and giving sublingual nitroglycerin, can alleviate HF immediately.
» Interdisciplinary care management helps in the care of HF patients and
leads to improved outcomes and better survival.
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REFERENCES
Inamdar AA, Inamdar AC. Heart failure: diagnosis, management and utilization. J Clin Med.
2016;5(7):62.
King M, Perez O. Heart failure. In: South-Paul JE, Matheny SC, Lewis EL, eds. CURRENT Diagnosis
& Treatment: Family Medicine. 4th ed. New York, NY: McGraw Hill; 2015. https://accessmedicine-
mhmedical-com.evms.idm.oclc.org/content.aspx?bookid=1415§ionid=77056309
Mann DL, Chakinala M. Heart failure: pathophysiology and diagnosis. In: Kasper D, Fauci A, Hauser S,
Longo D, Jameson J, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20th ed. New York,
NY: McGraw Hill; 2018: Chap. 279. http://accessmedicine.mhmedical.com/content.aspx?bookid=
1130&Sectionid=79742466
Mehra MR. Heart failure: management. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J,
eds. Harrison’s Principles of Internal Medicine. 20 ed. New York, NY: McGraw Hill; 2018: Chap. 280.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid=79742558
Metra M, JR Teerlink. Heart failure. Seminar. 2017;390(10106):1981-1995.
Quesada O, Klein L. Heart failure with reduced ejection fraction. In: Crawford MH, ed. Current Diag-
nosis & Treatment: Cardiology. 5th ed. New York, NY: McGraw Hill; 2017: Chap. 27. http://access-
medicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=715&Sectionid=48214560
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart fail-
ure: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines. Circulation. 2013;128(16):e240.
CASE 28
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A 30-year-old woman who is a para 3 (P3), divorced executive presents to your
clinic for contraceptive advice. She has been in a monogamous relationship with
her boyfriend for several months. She denies any drug allergies. She occasionally
drinks alcohol and does not smoke. She mentions that she used to take birth
control pills without any problems. All three of her children were born via vaginal
delivery without complication. She and her partner are free of sexually transmitted
infections (STIs) based on their recent checkups. She said that her life is very busy
because of work, so she would like something that “she doesn’t have to think
about” using. She fears any form of surgery and has not excluded having another
child. Her only significant medical history is an occasional migraine headache with
aura. Her laboratory workup is normal. Her physical examination is normal. She is
looking for the “best contraceptive method” for her situation.
▶ What contraceptive options are available to this woman?
▶ What option would be contraindicated because of the history of migraines
with aura?
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ANSWERS TO CASE 28:
Family Planning—Contraceptives
Summary: A 30-year-old woman presents with
Parity 3 history
A current monogamous relationship
No history of STIs in herself or in her partner
History of taking birth control pills
Questions about her contraceptive options
Dissatisfaction with barrier options
Statement that she is not ready for permanent sterilization
Migraine with aura
Available contraceptive options: This patient has a contraindication to estrogen due
to migraine with aura, and she prefers something she doesn’t have to think about
to fit her busy lifestyle. This makes her a good candidate for a long-acting reversible
contraception (LARC), such as a progestin implant or intrauterine device (IUD),
which have the highest contraceptive success.
Contraindicated contraceptive options for someone with migraine with aura: Combined estrogen/progesterone contraceptives, which can be found as pills, patches,
or vaginal rings, are relatively contraindicated in those with migraine headaches
due to the increased risk of ischemic stroke. This especially applies to those with
migraine headaches with aura (neurological deficits). These are also contraindicated for women with a history of blood clots or uncontrolled hypertension or who
are over age 35 and smoke.
ANALYSIS
Objectives
1. Be able to talk about the available methods of contraception. (EPA 4, 12)
2. Be able to discuss contraindications for and side effects of contraceptives.
(EPA 4)
Considerations
Choosing a method of contraception is a personal decision based on individual
preferences, medical history, and lifestyle. In the United States, approximately 50%
of pregnancies are unintended, and approximately 25% of women will have had an
abortion by age 45. Eighty percent of women having unprotected sex will become
pregnant within a year. All methods of contraception have a number of risks and
benefits of which the patient should be aware. The methods also all have a failure
rate, defined as inability to prevent pregnancy over a 1-year period. Sometimes,
the failure rate is a result of the method or drug interactions, and sometimes it
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is a result of human error. Each method has possible side effects. Some methods
require lifestyle modifications. Patients with certain medical conditions cannot use
certain types of contraceptives.
There are numerous contraceptive options available, and recommendations
regarding contraceptive use must be individualized. In the case given, there are
several important factors that must be considered. Given the patient’s fear of
surgery and because she is not certain whether she wants to have more children
in the future, surgical sterilization via bilateral tubal ligation or hysteroscopic
tubal occlusion or division is not a choice. A vasectomy for the partner, although
potentially reversible, should be considered permanent sterilization and is not
ideal for this patient. Barrier methods could be a viable option, but the patient
may feel that these are an inconvenience to her busy lifestyle. Given that both the
patient and her boyfriend have no history of STIs and are in a long-term relationship, appropriate methods of contraception for them include LARCs, such
as IUDs or progestin implants. IUDs can last 3, 5, or 10 years before replacement, depending on the type used, and implants can last 3 years. LARCs have a
very low failure rate and, after insertion, do not require active patient effort for
contraceptive success.
APPROACH TO:
Family Planning—Contraceptives
DEFINITIONS
BARRIER CONTRACEPTIVE: Contraceptive method that prevents sperm from
entering the upper female reproductive tract.
HORMONAL CONTRACEPTION: Estrogen plus progestin or progestin alone
to provide contraception in various methods, including pills, patches, vaginal rings,
injections, and implants.
INTRAUTERINE CONTRACEPTIVE DEVICE: Small, T-shaped device placed
in the endometrial cavity as a method of long-term contraception.
PERFECT USE EFFECTIVENESS: Efficacy of a method in perfect conditions,
when consistent and reliable use occurs.
TYPICAL USE EFFECTIVENESS: Efficacy of a method as it is actually used,
when forgetfulness and improper use can occur.
CLINICAL APPROACH
Choosing which contraception agent is best for a patient can be complex. Review
of the patient’s individual situation, medical problems, and ability to remember to
take medication each day are important factors to consider. Table 28–1 summarizes some of the characteristics of various contraceptive agents.
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