0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Chronic Heart Failure 323■ACE inhibitors: Improve morbidity and mortality. Captopril, enal-
april, lisinopril, quinapril, fosinopril (ramipril for heart failure after
acute MI) FDA approved; full symptomatic improvement may take
weeks to months
➣Indication: Left ventricular dysfunction (asymptomatic or symp-
tomatic), heart failure
➣Side effects: Hyperkalemia (especially with Type IV RTA), hypo-
tension, chronic dry cough (causes∼5% to discontinue in
blinded trials; should rechallenge later to establish diagnosis),
angioedema, dizziness, skin rash, dysgusia (captopril; often re-
solves spontaneously)
➣Absolute Contraindications: Any prior angioedema, pregnancy,
hyperkalemia, renovascular disease
➣Relative Contraindications: Renal failure (although ACE
inhibitors may improve renal dysfunction), volume depletion
■Beta-blockers: improve morbidity and mortality, may improve dis-
ease progression independent of symptoms; agents with beneficial
results in large clinical trials include carvedilol, metoprolol succi-
nate, bisoprolol. “Start low, go slow” titration. Advise patients of pos-
sible early side effects which do not generally prevent long-time use.
Symptomatic improvement may take months.
➣Indication: Heart failure due to systolic dysfunction (stable NYHA
class II–IV)
➣Side effects: hypotension, fluid retention and worsening of
heart failure, bradycardia and heart block, worsens bron-
chospasm, CNS symptoms (depression, nightmares, excitement,
confusion), fatigue, lethargy, impotence, increase triglycerides
(depression of HDL).
➣Absolute Contraindications: Severe peripheral vascular disease,
severe bronchospastic disease, sick sinus syndrome or advanced
heart block (unless treated with pacemaker), unstable NYHA IV
CHF.
➣Relative Contraindications: Types I and II diabetes, depression,
dyslipidemia, peripheral vascular disease.
■Digoxin: improves symptoms, minimal effect on survival; use in
conjunction with diuretics, ACE inhibitor, and beta blockers; dose-
adjustment required for many medications; serum levels not useful
in guiding therapy. Side effects may occur at any level, though more
frequent >2 ng/mL and in elderly.
➣Indication: Heart failure due to systolic dysfunction (NYHA class
II–IV) for symptom improvement