0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Chronic Heart Failure 325➣Absolute Contraindications: Anuria, hyperkalemia, acute renal
insufficiency
➣Relative Contraindications: Hepatic insufficiency
■Isosorbide dinitrate and hydralazine: combination of vasodilators,
though biochemical effects may be more important. FDA approved
for treatment of symptomatic heart failure in addition to standard
therapy (ACE inhibitors, beta blockers, etc.).
➣Indication: Consider if truly intolerant to ACE inhibitors and
angiotensin II receptor blockers; addition to ACE inhibitor,
diuretic, beta blocker, ARB, digoxin, if still symptomatic
➣Side Effects and Complications: hemolytic anemia, methe-
moglobinemia, headache, dizziness, hypotension, syncope,
angina, reflex tachycardia, nausea/vomiting, edema, rash, GI dis-
tress, rash; agranulocytosis, SLE-like syndrome (hydralazine)
➣Absolute Contraindications: Increased intracerebral pressure,
cerebral hemorrhage, symptomatic hypotension, angle-closure
glaucoma, stenotic valvular disease
➣Relative Contraindications: stroke, hypotension, severe anemia,
impaired renal function, acute MI (hydralazine)
■Unapproved drugs used in treatment of patients with heart failure
■Calcium channel blockers: Generally contraindicated in heart fail-
ure. May consider Amlodipine, which has demonstrated no adverse
effect on survival (also perhaps felodipine).
➣Indication: Angina, hypertension
➣Side Effects and Complications: Hypotension, headache, flush-
ing, congestive heart failure, peripheral edema, bradycardia with
sinus/AV node depression (especially verapamil and diltiazem),
palpitations/reflex tachycardia, constipation (especially vera-
pamil in elderly), GI distress, exacerbate heart failure in patients
with systolic dysfunction, possible increase in myocardial infarc-
tion in diabetics with renal disease (nisoldipine, amlodipine)
➣Absolute Contraindications: 2nd/3rd-degree AV block, sick sinus
syndrome, systolic dysfunction (perhaps except amlodipine),
post-myocardial infarction, hypotension, pulmonary congestion
➣Relative Contraindications: Impaired liver or renal function
■Anti-arrhythmic therapy: Drugs generally contraindicated in heart
failure. Treatment for asymptomatic or nonsustained ventricular
arrhythmias not indicated. Beta-blockers reduce sudden death in
CHF. Class I agents (quinidine, procainamide, flecainide, encainide)
increase risk of death. May consider amiodarone for atrial arrhyth-
mias, but not for general use to prevent death/sudden death.