Step I Chf

[BrooklynDO]

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Hey all, I ran into two different qbanks giving two diff answers for this so can someone pipe in? First line management for CHF is A) Loops (kaplan) or B) ACEi (blackwell) ?
anyone?

 

[Kalel]

Loops during acute exacerbations and to decrease symptoms. ACEi and beta blockers to decrease morbidity and mortality. Loops may actually increase mortality, but we still use them to get rid of the excess fluid.

 

[MedPuck]

ACE-inhibitors, I believe are the 1st line against CHF as I recall reading in Lipincott's Pharm. Diuretics are the next choice.

 

[GiJoe]

correct me if I'm wrong, but from what I understand, its spirnolactone thats the diuretic of choice after ace inhibitors because its the only one shown to decrease mortality.

 

[Stinger86]

I think diuretics are first line for CHF, unless it's complicated by diabetes, in which case ACEIs are first line drugs.

 

[sean wilson]

ACE-I are first-line, esp. for chronic CHF. HCTZ, furosemide are also used, as well as b-blockers--all in chronic.

In acute exac, people use diruretics to lower preload, etc. B-blockers not good here, ACE-I, I believe, are good here, and if CO is compromised, they'll sometimes use an inotrope like dobutamine (probably not the best answer on the Step exams unless specific to low CO-situations).

 

[Idiopathic]

ACE-I is first-line (decreases both pre-load and after-load) in CHF, and never give an ACE and spironolactone together, because they essentially both block the same pathway, and K+ can really get high.

ACE and HCTZ are safe to be used together, of course, and since HCTZ is so cheap, it is really probably used anyway

 

[Kalel]

correct me if I'm wrong, but from what I understand, its spirnolactone thats the diuretic of choice after ace inhibitors because its the only one shown to decrease mortality.

spirnolactone is mainly given in patients who have developed class III-IV heart failure, that's where it's been shown to have the greatest benefit on mortality. It is frequently/usually given to patients who are also taking ACE-i's despite the risk of hyperkalemia. Usually, these patients who have class III-IV are on a loop too, whose side effect of hypokalemia is usually "stronger" then ACE's or spirnolactone. Hctz (thiazide diuretic) was recently shown to decrease the incidence of patients developing heart failure in your asymptomatic, hypertensive patient; beyond the cardioprotective effects of other anti-htn. That's one of the reasons why it's considered first line in many patients. Anyways, I don't think that you need to know most of this stuff for the USMLE step I. This is step II or ward material. Stick with the stuff in first aid and step up.