So confused... BB or Spironolactone to decrease CHF mortality?

[shigella123]

Advertisement - Members don't see this ad

One UW questions says to decrease mortality in CHF, the preferred drug to add is Beta Blocker=Carvedilol and on other question it says to use Spironolactone. Which is it? Isn't spironolactone used to prevent left ventricular remodeling?

 

[periaqueductal]

Without knowing the question specifics, it depends on the patient. In patients with moderate CHF you add a beta blocker to furosemide, ace inhib etc to decrease mortality. In severe CHF (higher NY classes) you add spironolactone to decrease mortality and digoxin for symptom relief. My guess is in the stems it gave you indications of the New York CHF classification to decide which one. Hope that helps.

 

[Charles_Carmichael]

One UW questions says to decrease mortality in CHF, the preferred drug to add is Beta Blocker=Carvedilol and on other question it says to use Spironolactone. Which is it? Isn't spironolactone used to prevent left ventricular remodeling?

Why does it have to be only one drug that improves mortality?

Beta-blockers, ACEIs/ARBs, aldosterone antagonists (ex. spironolactone), and hydralazine + isosorbide dinitrate are the only drugs that have been shown to decrease mortality in CHF. Everything else (ex. furosemide) is for symptomatic control.

Honestly, this type of question (requiring you to know which drugs decrease mortality vs. which decrease only morbidity, what NYHA or ACC/AHA class of CHF you're dealing with, etc) is NOT something you should expect to see on Step 1. These are Step 2 type questions. The type of question you might see on Step 1 would be something like how beta-blockers or ACEIs help in CHF -- by preventing ventricular remodeling.

 

[shigella123]

Yea, I was thinking it would be group of drugs instead of one to lower the mortality, but the question was referring to one drug that should be added.

The question in short was: 65 yo w/ dyspnea with lower extremity edema, hypertension, MI 2 years ago, takes aspirin and hydrochlorothiazide. What will decrease his mortality rate?

Another question was, elderly man gets tired easily when he walks, swollen feet, no help with elevating his legs, takes aspirin and HCTZ. The question was what else can you add?

For both of these the answer was carvedilol, but I clearly remember there was also a question where they said spironolactone should be added to decrease the mortality rate in CHF as it prevents aldosterone effect of ventricular remodeling.

I'm sorry, I don't have the full questions as my subscription ended so that's why I'm asking you guys...

 

[Modeselektor]

Yeah its a group guys.

These lower mortality in CHF:
•Beta blockers, (ONLY misoprolol, carvedilol, bisoprolol)
•ACE#/ARBs
•Spironolactone, (generally only in advanced, but hey, if its the only option pick it)


These are only for symptoms, they DO NOT lower mortality:
•Diuretics
•Digoxin

 

[Phloston]

Yeah its a group guys.
These lower mortality in CHF:
•Beta blockers, (ONLY misoprolol, carvedilol, bisoprolol)
•ACE#/ARBs
•Spironolactone, (generally only in advanced, but hey, if its the only option pick it)


These are only for symptoms, they DO NOT lower mortality:
•Diuretics
•Digoxin

This is 110% spot-on for systolic failure-CHF only, apart from the fact that those three beta-blockers should say metoprolol (specifically metoprolol-XR, carvedilol and bisoprolol). Aspirin should also be added to this list for lowering mortality. Now you have the complete list.

For diastolic failure-CHF, the ACE/ARBs and spironolactone are not proven to lower mortality. Only aspirin and beta-blockers lower mortality in diastolic failure. This is because knocking out the ACE system is important when ejection fraction is low, but in diastolic failure, ejection fraction is normal.

These drugs in their respective categories are exceedingly HY for Step 2CK, as far as knowing which ones decrease mortality vs which ones are merely for Sx.

On the wards, consultants tend to use metoprolol-XR for CHF, whereas classic metoprolol is more for AF. I've actually had a consultant get pedantic on this point.

I also saw a consultant throw a patient on bisoprolol. I asked her specifically why bisoprolol (and not metoprolol or carvedilol) and she said it was because it's the only one that decreases mortality and is once daily; the patient had adherence problems.

Spironolactone is the one that I've seen forgotten in patient's charts quite frequently. It's literally become my commonest question to consultants: would you consider spironolactone in this patient? Going into the wards knowing spironolactone lowers mortality is really important because so many patients could benefit from the drug and aren't on it. And on rounds, the doctors are always refining/updating the drug list. Seriously, be the one to jump in with that point if the interns don't speak up.

And yeah, furosemide (+ other diuretics) and digoxin do not lower mortality.

 

[ChessMaster3000]

This is 110% spot-on for systolic failure-CHF only, apart from the fact that those three beta-blockers should say metoprolol (specifically metoprolol-XR, carvedilol and bisoprolol). Aspirin should also be added to this list for lowering mortality. Now you have the complete list.

For diastolic failure-CHF, the ACE/ARBs and spironolactone are not proven to lower mortality. Only aspirin and beta-blockers lower mortality in diastolic failure. This is because knocking out the ACE system is important when ejection fraction is low, but in diastolic failure, ejection fraction is normal.

These drugs in their respective categories are exceedingly HY for Step 2CK, as far as knowing which ones decrease mortality vs which ones are merely for Sx.

On the wards, consultants tend to use metoprolol-XR for CHF, whereas classic metoprolol is more for AF. I've actually had a consultant get pedantic on this point.

I also saw a consultant throw a patient on bisoprolol. I asked her specifically why bisoprolol (and not metoprolol or carvedilol) and she said it was because it's the only one that decreases mortality and is once daily; the patient had adherence problems.

Spironolactone is the one that I've seen forgotten in patient's charts quite frequently. It's literally become my commonest question to consultants: would you consider spironolactone in this patient? Going into the wards knowing spironolactone lowers mortality is really important because so many patients could benefit from the drug and aren't on it. And on rounds, the doctors are always refining/updating the drug list. Seriously, be the one to jump in with that point if the interns don't speak up.

And yeah, furosemide (+ other diuretics) and digoxin do not lower mortality.

Step 2 CK FTW

 

[Modeselektor]

Oh yeah, metoprolol, not miso haha. And yeah, what I said is for systolic.

•Beta blockers are beneficial in diastolic failure,
•Diuretics (NOT ACE#/ARBS) are used to control symptoms of fluid overload in diastolic failure.

ACE#, ARBS, Spironolactone are uncertain.


Also in systolic failure there's a mortality benefit with hydralazine used WITH nitrates.
• you generally don't use it if you can use an ACE#/ARB, but if its there as an option and nothing else makes sense go for it.

 

[shigella123]

I really appreciate all of your responses... You guys are great teachers along with being students. I'm glad I asked this question as it will prepare me for step 2 too. I will make a note of everything you all said. Thanks a lot again!

 

[Phloston]

Oh yeah, metoprolol, not miso haha. And yeah, what I said is for systolic.

•Beta blockers are beneficial in diastolic failure,
•Diuretics (NOT ACE#/ARBS) are used to control symptoms of fluid overload in diastolic failure.

ACE#, ARBS, Spironolactone are uncertain.


Also in systolic failure there's a mortality benefit with hydralazine used WITH nitrates.
• you generally don't use it if you can use an ACE#/ARB, but if its there as an option and nothing else makes sense go for it.

Actually, that's an awesome point. If hyperkalaemia occurs secondary to ACEi/ARBs, then switching to hydralazine + nitrates (the combo) also provides mortality benefit.

The potential adverse Sx of ACEi alone (i.e., angioedema or cough) is only enough to switch to an ARB, but the high K+ would be the reason for the switch to hydralazine + nitrates.