heart failure question

[jok200]

I know the drugs that decrease mortality in heart failure (systolic), but are we supposed to put patients on all of them? If the b-blocker is controlling their BP well and they are not complaining of symptoms like swelling and SOB, should I still add on the ACE and spironolactone at low doses because they decrease mortality as well? I have been told yes and no so I'm confused????


huh, thanks-

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[Bostonredsox]

I know the drugs that decrease mortality in heart failure (systolic), but are we supposed to put patients on all of them? If the b-blocker is controlling their BP well and they are not complaining of symptoms like swelling and SOB, should I still add on the ACE and spironolactone at low doses because they decrease mortality as well? I have been told yes and no so I'm confused????


huh, thanks-

aldactone does not decrease mortality in all comers with HF. there specific subsets of HF patients who have shown benefit, No I am not going to tell you which, read the AHA guidelines and it will tell you.

And ARB/ACEI have mortality benefit in CHF independent of blood pressure lowering so yes, unless there is a contraindication, they should all be one one.

 

[jok200]

thanks... ace/arbs indicated in heart failure NYHA II or more spironolactone does decrease mortality in HF NYHA 3,4 I think.... B-blockers sure. All can actually do it, but the trick in management is knowing which to use, I wouldn't put a patient on all these meds at once simply because they all have mortality benefit. Comorbids would help to guide my therapy. Either way thanks again.

 

[Bostonredsox]

thanks... ace/arbs indicated in heart failure NYHA II or more spironolactone does decrease mortality in HF NYHA 3,4 I think.... B-blockers sure. All can actually do it, but the trick in management is knowing which to use, I wouldn't put a patient on all these meds at once simply because they all have mortality benefit. Comorbids would help to guide my therapy. Either way thanks again.

simple algorithm really. THey all get ASA and a BB, with diminished LV function carvedilol has been shown to be superior. Class 2-4, which is nearly everyone, add ACEI/ARB. Class 3-4, add aldactone. Digoxin improves symptoms and is a good adjunct especially if AFib is also present, but it does not affect mortality. Obviously all of these meds have relative and absolute condtraindications based on the patients profile.

 

[turkeyjerky]

I'm an EM guy so obviously outside my area of expertise. But has the emphasis trial changed practice at all w/ regard to mineralacorticoid antagonists? Results seemed pretty impressive but I really don't see many patients on these drugs.

 

[deleted87716]

I'm an EM guy so obviously outside my area of expertise. But has the emphasis trial changed practice at all w/ regard to mineralacorticoid antagonists? Results seemed pretty impressive but I really don't see many patients on these drugs.

Cost.

Spironolactone is cheap. Inspra is expensive.

Most people with CHF aren't on monotherapy.

 

[Bostonredsox]

Cost.

Spironolactone is cheap. Inspra is expensive.

Most people with CHF aren't on monotherapy.

/nod. Eplerenone is expensive, aldactone is cheap and has mortality data to back it.

Typical stage 4 chf pt.....ASA $1/month, carvedilol $4/month, lisinopril $4/month, aldactone $4/ month. Most are also on a $4/month simvastatin though it is not a chf core measure unto itself. Most tend to use what's cheap and has documented benefit.

 

[turkeyjerky]

Seems like you guys didn't get my question. I wasn't asking about spironolactone vs eplerenone; EMPHASIS seems like it should've expanded the indication for mineralocorticoid antagonists to NYHA Class II patients(most experts believe this is a class effect, although the role of the androgen-sparing effect of eplerenone is kinda interesting). So, I'll ask it again: have you guys changed your practice, or are you still using (spiranolac/epleren)one according to the inclusion criteria for RALES (a study published 14 years ago).