Seema Nour MD presented information on heart failure including:
- Heart failure is a clinical syndrome resulting from structural or functional issues impairing the heart's ability to pump blood.
- It can be systolic or diastolic dysfunction.
- Incidence is high with 500,000 new US cases annually and many rehospitalizations.
- Causes include coronary artery disease, hypertension, diabetes, toxins and more.
- Diagnosis involves labs, EKG, echo, and assessing for reversible causes.
- Treatments include diuresis, ACE inhibitors, beta blockers, aldosterone antagonists, and device therapies like ICD or CRT depending on criteria. Proper management
Heart Failure (Dr Vosik Presentation) Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Heart Failure (Dr Vosik Presentation) Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
What is Hypertension?
Hypertension is the term used to portray hypertension. Hypertension is more than once raised pulse surpassing 140 north of 90 mmHg. It is ordered as essential or fundamental (roughly 90% of all cases) or auxiliary because of a recognizable, now and again correctable neurotic condition, like renal illness or essential aldosteronism.
The lifetime risk of developing HF is 20% for Americans 40 years of age
HF incidence increases with age, rising from approximately 20 per 1,000 individuals 65 to 69 years of age to >80 per 1,000 individuals among those 85 years of age.
HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. Introduction
Heart failure (HF) is a complex clinical
syndrome that can result from any structural
or functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject
blood
No longer use the term “congestive” because
all heart failure does not result in clinically
apparent volume overload
4. How to define heart failure?
Systolic Versus Diastolic Heart Failure
A. Systolic cardiac (heart) dysfunction (or
systolic heart failure) occurs when the heart
muscle doesn't contract with enough force,
so there is not enough oxygen-rich blood to
be pumped throughout the body.
B. Diastolic cardiac dysfunction (or diastolic
heart failure) occurs when the heart
contracts normally, but the ventricle doesn't
relax properly so less blood can enter the
heart.
5. What is the incidence of heart failure?
Estimated 500,000 new cases per year
Within 5 years, half of those diagnosed will be
dead
Over 1 million hospitalizations per year with
HF as primary diagnosis
Most common reason for hospitalization in
those >65 years old
Heart failure is 4th in a list of quality of care
initiatives in vulnerable older adults
6. Case-Mr Abdallah
45 yr old man with poorly controlled
hypertension, DM presents with 3 weeks of
progressive shortness of breath, LE edema
Exam remarkable for HR 150, BP 80/40, RR 26
Appears lethargic, Elevated JVP, PMI displaced,
irregular, S1, S2, S3 on exam, no murmurs, lungs
with crackles, Extremities cold with edema
10. Back to our patient
So Mr Abdallah has risk factors for CAD
Also has elevated BP-so hypertensive heart
No murmur on exam so valvular heart disease
unlikely
Arrythmias……..afib, tachycardia induced
cardiomyopathy
What about amyloidosis
ALWAYS LOOK FOR REVERSIBLE CAUSES
12. Initial Workup
Basic labs, check for anemia-high output
failure, chem8, TSH, ferritin
EKG-look for acute MI or prior infarcts
CXR- pulmonary edema, heart size
Echocardiogram to assess LV function, assess
for diastolic dysfunction
13. Future workup
Coronary Angiogram
If flash pulmonary edema and severe HTN,
consider renal angiogram
If no clear cause in young patient consider
cardiac biopsy
14. Mr Abdallah tests showed
Normal CBC
Elevated BUN/Creatinine 45/1.8
Elevated LFTS ( AST/ALT)
CXR showed pulmonary edema
Echo showed an EF of 30% with diffuse global
hypokinesis
17. Acute Treatment
Congestion?
Orthopnea, rales, JVD, edema, ascites
Warm and Dry Warm and Wet
Adequate
perfusion
Lethargy,
cool, pulse
pressure
Cold and Dry Cold and Wet
(Mr Abdallah)
Nohria, A. et al. JAMA 2002;287:628-640
18. Cardiogenic Shock
(Cold and Wet)
1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m²/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure >
18mmHg mmHg
19. Choice of Ionotropes
Dopamine
<2 renal vascular dilation
<2-10 +chronotropic/inotropic (beta effects)
>10 vasoconstriction (alpha effects)
Dobutamine – positive inotrope, vasodilates,
arrhythmogenic at higher doses
Norepinephrine (Levophed): vasoconstriction,
inotropic stimulant. Should only be used for
refractory hypotension with dec SVR.
Vasopression – vasoconstriction
VASO and LEVO should only be used as a last
resort
20. If patient tachycardic, dopamine and
dobutamine are not great choices
So in Mr Abdallah would attempt to
cardiovert him as he will not sustain pressor
support
TEE to r/o left atrial appendage thrombus
Followed by Cardioversion
21. So Mr Abdallah underwent TEE
Was cardioverted
BP improved
HR stabilized
Still congested but now hemodynamically
stable
NOW WHAT??
23. Furosemide Dosing
If patient is lasix naive start slow and titrate
up per urine output
Lasix dose usually 0.5-1mg/kg twice a day
Usually expect response in first 5-10mins with
IV
Usual start dose 40mg or 80mg IV q8hrs
Always give potassium supplements when
diuresing patient
24. Regular monitoring of electrolytes with IV
diuresis
Switch to PO when more euvolemic,
BUN/creatinine start rising
Remember 80mg PO =40mg IV
If patient already on PO lasix e.g 80mg PO
would start treating with higher IV dose (ie
80mg IV)
If poor response to lasix add thiazide diuretic
25. ACEI and Beta Blockers
Start ACEI in patients as soon
hemodynamically stable
Help reduce preload and afterload
Titrate up per patient, don’t look at BP!!
Beta Blockers-start low dose prior to discharge
Titrate dose as outpatient
26.
27. Back to Mr Abdallah
So Mr Abdallah is doing well, he maintained
sinus rhythm and is being discharged
What medications should he be on long term
for a mortality benefit??
29. Beta Blockers
34% reduction in all mortality with use of
beta-blockers
Decrease Cardiac Sympathetic Activity
Titrate slowly
Contraindications-bradycardia, heart block or
hemodynamic instability
Mild asthma is not a contraindication
Work irrespective of the etiology of the heart
failure
30. Three beta-blockers
Bisoprolol (Zebeta) -Trial CIBIS-II
Metoprolol (Toprol XL) –Trial MERIT-HF
(sustained release)
Carvedilol (Coreg) Trial-COPERNICUS
6 RCT’s with > 9,000 pts already taking ACE-I
showed a significant reduction in total
mortality and sudden death (NNT 24, and 35
over 1-2 years) regardless of severity
31.
32. Carvedilol vs. Metoprolol (COMET
2003)
3029 pts; carvedilol 25mg bid vs.
metoprolol 50 mg bid
Patient with NYHA Classes II-IV
Carvedilol –greater reduction in mortality
(NNT, 18 over 5 years) and cardiovascular
mortality (NNT, 16 over 5 years) than
metoprolol but hypotension was greater in
carvedilol (14 vs 11 percent)
33. Beta Blockers and concomitant
disease
Beta blocker therapy is recommended in the
great majority of patients with HF and
reduced LVEF—even if there is concomitant
diabetes, chronic obstructive lung disease or
peripheral vascular disease.
Use with caution in patients with:
Diabetes with recurrent hypoglycemia
Asthma or resting limb ischemia.
Use with considerable caution in patients with marked
bradycardia (<55 bpm) or marked hypotension (SBP < 80
mmHg).
Not recommended in patients with asthma with active
bronchospasm.
34. HFSA 2010 Practice Guideline ACE
Inhibitors
ACE inhibitors are recommended for
symptomatic and asymptomatic patients
with an LVEF ≤ 40%
ACE inhibitors should be titrated to doses
used in clinical trials (as tolerated during
uptitration of other medications, such as
beta blockers).
35. ACEI
CONSENSUS-Enalapril 2.5-40mg (188 days) vs placebo
Pts were already taking digoxin and diuretics
253 Patient with NYHA Class IV
Dec mortality at:
6 months -40%
1 Year – 27%
SOLVD-Enalapril 20mg/day (41 mo)
2569 Patients with and EF <35%
Earlier stages of HF even asymptomatic
NYHA Class II-III
All cause mortality dec by 16%
Morality rate from HF dec by 16%
36.
37. HFSA 2010 Practice Guideline
Angiotensin Receptor Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an LVEF ≤ 40%
who are intolerant to ACE inhibitors for
reasons other than hyperkalemia or renal
insufficiency.
38. ACEI+ARB
CHARM-Added (Lancet 2003)
2548 NYHA II-IV; LVEF < 40%
CV death, hospital admission
NNT=25
Second study found no benefit
But 23% discontinued due to side effects
(increased cr, hypotension, hyperkalemia)
Currently Ace + Arb is not recommended
39. Nitrates/hydralazine
A combination of hydralazine and isosorbide
dinitrate is recommended as part of standard
therapy, in addition to beta-blockers and ACE-
inhibitors, for African Americans with HF and
reduced LVEF:
NYHA III or IV HF
NYHA II HF
40.
41. Pharmacologic Therapy:
Aldosterone Antagonists
An aldosterone antagonist is recommended
for patients on standard therapy, including
diuretics, who have:
NYHA class IV HF (or class III, previously
class IV) HF from reduced LVEF (≤ 35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF <
40% who are on standard therapy, including
an ACE inhibitor (or ARB) and a beta blocker.
42. Aldosterone receptor antagonsists
Spironolactone (Aldactone; RALES 1999)
Pts 1,663 Class III/IV, ACE, Loop,Dig, EF < 35%
Decreased all cause mortality of 30%, NNT=10
Hyperkalemia, gynecomastia
Eplerenone (Inspra; EPHESUS 2003)
Pts 6,642 asym LV dysfunction, DM, or after MI
Dec CV mortality of 13%, NNT=43
Newer more selective inhibitor; fewer side effects
More pts on beta-blockers
43. Aldosterone Antagonists and Renal
Function
Aldosterone antagonists are not recommended when:
Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing
diuretics
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L Strength
44. Digoxin
Digoxin, given in combination with a diuretic
and an ACE inhibitor to people with heart failure
(NYHA grades II-IV) in normal sinus rhythm, has
been found to reduce hospitalization and clinical
deterioration, but not mortality
Consider digoxin if the person continues to be
symptomatic despite adequate doses of diuretic
and ACE inhibitor
Give digoxin to all people with heart failure
and atrial fibrillation who need control of the
ventricular rate.
45. So Mr Abdallah is going home
Which of the following medications has not been
shown to improve mortality in patients with
systolic heart failure?
1. Beta Blocker
2. ACEI
3. Aldosterone antagonist
4. Digoxin
5. ARB
46. What discharge instructions do we
give MR Abdallah
Low salt diet <2gm/day
No Faseekh or maloo7a
Take medications
Weigh yourself everyday
If weight increases over 3-5lb take extra lasix
dose and contact doctor
47. Mr Abdallah wishes to know if
there are any drugs he needs to
avoid
NSAIDs
Most antiarrhythmics
Most calcium channel blockers
Thiazolidinediones e.g Actos, Avandia
48. Further testing??
Remember presumed LV systolic dysfunction
from tachycardia and HTN
But has risk factors for CAD
So will need a coronary angiogram
49. Mr Abdallah underwent coronary angiogram
and showed no significant CAD,
Now what…………..
A. Continue with medical therapy only
B. Repeat echo in 1 year
C. Repeat echo in 3 months
D. Refer for Biv/ICD immediately
50. Device Therapy:
Prophylactic ICD Placement
Prophylactic ICD placement should be
considered in patients with an LVEF ≤35%
and mild to moderate HF symptoms:
Ischemic etiology
Non-ischemic etiology
Today I will mostly focus on systolic heart failure
Initiation of a beta blocker prior to hospital discharge is safe and well tolerated in the majority of patients and dramatically improves utilization of this evidence-based therapy following discharge.