Acute and chronic heart failure : diagnosis and therapy

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Bibliographic Information

Acute and chronic heart failure : diagnosis and therapy

Wulf-Dirk Bussmann ; foreword by Martin Kaltenbach ; translator, Angelika Beisel

Springer, c1986

  • : us
  • : gw

Other Title

Akute und chronische Herzinsuffizienz

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Translation of: Akute and chronische Herzinsuffizienz

Includes bibliographical references and index

Description and Table of Contents

Description

Withering demonstrated 200 years ago in the year 1784 that "drop- sy" could be successfully treated with foxglove extracts. This dis- covery eventually led to the scientifically based treatment of heart failure with chemically defined digitalis glycosides. In Germany, particularly, the usefulness of this development was greatly exagger- ated and often resulted in the indiscrimate use of digitalis for pa- tients with coronary artery disease and its complications. Today, this type of drug intervention is used more sparingly. At the same time, other therapeutic concepts were introduced, particularly that of drug-induced diuresis and the concept of vasodilation. This book is the result of a systematic study of various therapeu- tic approaches for the management of heart failure and includes clinical, experimental and theoretical aspects. For more than a de- cade, various therapeutic modalities have been clinically evaluated in the setting of acute heart failure managed in the intensive care unit as well as chronic heart failure for inpatient and outpatient therapy. Experience has shown that in certain clinical situations, particu- larly the management of acute disease, specific, individual drug in- tervention is required and is based on the underlying etiology for heart failure. However, in chronic heart failure, long-term success can only be achieved by the rational combination of treatment mo- dalities. The present text is aimed at providing the clinically and scientif- ically oriented physician with the pathophysiologic and pharmaco- logic background necessary to place into perspective the therapeutic efforts for the management of heart failure.

Table of Contents

Acute Heart Failure.- A. Overview.- I. Recent Developments.- II. Systematic Use of Vasodilating Agents.- 1. Milestones.- 2. Present State of the Art.- Literature.- B. Pathophysiology of Heart Failure With Respect to Vasodilation.- I. Definition of Heart Failure.- 1. Acute and Chronic Heart Failure.- 2. Clinical Presentations.- a) Acute Heart Failure.- b) Chronic Heart Failure.- c) New York Heart Association Functional Classification.- II. Hemodynamics in Heart Failure.- 1. Intracardiac Pressures in Heart Failure.- 2. Technique of Measurement.- a) Swan-Ganz Catheter.- b) Left Ventricular Filling Pressure.- c) Right Atrial Pressure.- d) Cardiac Output.- e) Arterial Blood Pressure.- f) Systemic Vascular Resistance.- III. Pathophysiology.- 1. Pumping Performance as a Function of Ejection Impedance.- 2. Sympathetic Adrenergic Mechanisms of Regulation.- 3. Influence of the Renin-Angiotensin-Aldosterone System.- 4. Venoconstriction.- 5. Preload and Afterload.- a) Preload.- b) Afterload.- IV. Therapeutic Concepts in Heart Failure.- 1. Increase of Myocardial Contractility.- a) Digitalis.- b) Catecholamines.- 2. Vasodilating Agents.- a) Unloading Mechanism.- b) Spectrum of Activity.- 3. Regulation of Venous Vasculature in Heart Failure.- a) Significance of the Venous System.- b) Intrinsic Venous Pooling Capacity.- 4. Hemodynamic Effects of Venodilation.- a) Venous Return.- b) Reduction of Filling Pressure.- c) Subendocardial Perfusion.- d) Diastolic Wall Tension.- e) Intrinsic Counterregulation.- 5. Arterial Vasodilation.- 6. Agents with Activity on the Venous and Arterial Side.- 7. Attenuation of Action with Long-Term Treatment.- a) Non-Responders.- b) Intrinsic Counterregulation.- c) Genuine Tolerance.- d) Differences in Response.- Literature.- C. Acute Left Sided Heart Failure.- I. Conventional Therapy.- 1. Is there still an Indication for Digitalis in Acute Heart Failure?.- 2. Diuretics in Acute Heart Failure.- Literature.- D. Therapy of Acute Pulmonary Edema.- I. Etiology of Pulmonary Edema.- II. Hemodynamics in Pulmonary Edema.- III. Clinical Classification of Pulmonary Edema.- IV. Treatment of Pulmonary Edema.- 1. Action of Nitroglycerin.- a) Hemodynamics.- b) Clinical Presentation.- c) Clinical and Practical Experiences.- d) Ease of Administration.- e) Dosage of Nitroglycerin.- f) Non-Responders in Cardiogenic Shock.- g) Influence on Peripheral Edema.- h) Intravenous Administration of Nitroglycerin in Pulmonary Edema.- i) Sequence of Therapeutic Interventions in the Management of Pulmonary Edema.- 2. Role of Diuretics in the Treatment of Pulmonary Edema.- 3. Digitalis in Pulmonary Edema?.- 4. Morphine.- 5. Drug of Choice.- 6. Other Vasodilators for the Treatment of Pulmonary Edema.- a) Sodium Nitroprusside.- b) Phentolamine.- c) Nifedipine.- 7. Positive Pressure Ventilation.- Literature.- E. Left-Sided Heart Failure in Acute Myocardial Infarction.- I. Clinical Presentation.- 1. Physical Findings.- 2. Radiologic Signs.- 3. Hemodynamics.- II. Treatment with Nitroglycerin and Nitrates.- 1. Reasons for Contraindications in the Past.- 2. Origins of Nitroglycerin Therapy in Acute Myocardial Infarction.- 3. Hemodynamic Effects of Nitroglycerin.- a) Sublingual Nitroglycerin.- b) Continuous Intravenous Infusion of Nitroglycerin.- 4. Oral and Intravenous Administration of Isosorbide Dinitrate.- 5. Clinical Effects of Nitrates.- a) Influence on Pain.- b) Reduction of Dyspnea.- 6. Influence on Myocardial Ischemia.- 7. Reduction of Infarct Size.- a) CK and CK-MB Infarct Size.- b) Electrocardiographic Signs of Necrosis.- 8. Indications for Potential Influence on Prognosis.- 9. Influence of Nitrates on Ventricular Ectopy.- 10. Decrease in Bradyarrhythmias.- 11. Dilation of Functionally Narrowed Coronary Artery Stenosis.- 12. Long-Term Follow-Up: Increased Incidence of Angina Pectoris.- 13. Side Effects.- 14. Summary.- III. Therapeutic Intervention in Acute Myocardial Infarction with Left Ventricular Failure Outside the Hospital.- IV. Mechanism of Action of Sodium Nitroprusside.- 1. History.- 2. Pharmacology and Hemodynamics.- 3. Release of Cyanide.- 4. Effects on Acute Myocardial Infarction.- a) Profile of Action in Specific Subgroups.- b) Recommendations for Use.- c) Potential Side Effects.- 5. Role of Sodium Nitroprusside Therapy Today.- a) Side Effects.- b) Microcirculation: Nonhomongenous Perfusion.- V. Isosorbide Dinitrate in Patients with Acute Myocardial Infarction and Left-Sided Heart Failure.- 1. Comparison with Nitroglycerin.- 2. Sustained Action after Oral Administration.- 3. Prognostic Aspects.- VI. Isosorbide-5-Mononitrate Efficacy Compared to Isosorbide Dinitrate.- 1. Pharmacokinetics.- 2. Hemodynamic Effects.- 3. Absence of Sublingual Efficacy.- VII. Molsidomine in Left Ventricular Failure.- 1. Pharmacology and Mechanism of Action.- 2. Hemodynamics.- 3. Myocardial Ischemia and Necrosis.- VIII. Xanthine Derivatives.- IX. Calcium Antagonists for the Treatment of Patients with Myocardial Infarction and Left-Sided Heart Failure.- 1. Nifedipine.- a) Hemodynamic Effects.- b) Effects on Pulmonary Edema.- c) Myocardial Ischemia.- d) Side Effects.- e) Therapeutic Role of Nifedipine.- 2. Verapamil for the Treatment of Acute Myocardial Infarction.- a) Negative Inotropic Effect.- b) Anti-Ischemic Mechanism of Action.- c) Hemodynamic Effects of Verapamil in Patients with Myocardial Infarction.- d) Reduction of Infarct Size.- e) Antiarrhythmic Effects.- f) Side Effects.- g) Pharmacokinetics of Verapamil.- Literature.- F. Left-Sided Heart Failure and Papillary Muscle Dysfunction.- I. Etiology and Clinical Signs of Mitral Regurgitation.- 1. Case Report 1.- 2. Case Report 2.- II. Hemodynamics.- III. Therapy.- 1. Sodium Nitroprusside.- 2. Nitroglycerin.- IV. Papillary Muscle Dysfunction with Cardiogenic Shock.- Literature.- G. Heart Failure Following Rupture of the Ventricular Septum.- I. Incidence.- II. Clinical Manifestations.- 1. Verification of Diagnosis.- 2. Clinical Course.- III. Treatment.- a) Drugs.- b) Surgery.- Literature.- H. Cardiogenic Shock.- I. Definition.- 1. Etiology of Cardiogenic Shock.- 2. Clinical Presentation.- 3. Hemodynamics.- 4. Mortality.- II. Treatment of Cardiogenic Shock.- 1. Goals of Treatment.- a) Mild Increase in Blood Pressure.- b) Mild Reduction of Filling Pressure.- 2. Dopamine.- 3. Dobutamine.- 4. Comparison between Dopamine and Dobutamine.- 5. Epinephrine.- 6. Norepinephrine.- 7. Combination Therapy with Dobutamine and Nitroglycerin.- a) Patients with Valvular Defects.- b) Patients with Myocardial Lesions.- 8. Combination Therapy with Dobutamine and Sodium Nitroprusside.- 9. Volume Replacement?.- 10. Cardiogenic Shock without Increased Filling Pressures.- III. Mechanical Therapeutic Modalities: Intra-Aortic Balloon Counterpulsation.- 1. Technique.- 2. Mechanism.- 3. Influence on Mortality.- 4. Therapeutic Guidelines.- Literature.- I. Left-Sided Heart Failure Associated with Rheumatic Valvular Defects or Cardiomyopathies.- I. Effects of Nitroglycerin on Acute Decompensation with Left Ventricular Failure and Pulmonary Congestion.- II. Vasodilating Agents in Aortic Stenosis.- Literature.- J. Left-Sided Heart Failure in Hypertensive Crisis.- I. Etiology.- II. Treatment.- 1. Recommendations of the League.- 2. Sodium Nitroprusside.- 3. Nitroglycerin.- 4. Nifedipine.- 5. Urapidil.- III. Treatment of Postoperative Hypertension.- Comparison between Nitroglycerin and Sodium Nitroprusside.- Literature.- K. Acute Right-Sided Heart Failure.- I. Pulmonary Thromboembolism.- 1. Etiology.- 2. Clinical Presentation.- 3. Diagnostic Procedures.- a) Shock Symptoms.- b) Less Severe Pulmonary Embolism.- c) Hemodynamics.- d) Pulmonary Scintigraphy.- e) Digital Subtraction Angiography.- f) Echocardiography.- 4. Treatment.- a) Embolectomy.- b) Fibrinolysis.- c) Other Therapeutic Agents.- II. Right Ventricular Infarction.- 1. Incidence of Right Ventricular Infarction.- 2. Hemodynamics.- 3. Treatment.- III. Right Heart Failure in Chronic Obstructive Lung Disease.- Literature.- L. Pharmacokinetics of Vasodilating Agents.- I. Nitroglycerin.- 1. Sublingual Nitroglycerin.- 2. Intravenous Administration of Nitroglycerin.- a) Accumulation in the Vascular Wall.- b) Dose-Response Curve in the Venous and Arterial Beds.- c) Loss of Active Substance through Plastic Material.- 3. Oral Nitroglycerin.- 4. Transdermal Nitroglycerin.- II. Isosorbide Dinitrate.- 1. Sublingual and Oral Administration.- 2. Pharmacokinetics During Acute and Chronic Administration.- III. Sodium Nitroprusside.- Literature.- Chronic Heart Failure.- A. Pathophysiologic Mechanisms of Chronic Heart Failure.- I. Frank-Starling Mechanism.- II. Sympathetic Adrenergic Stimulation.- 1. Reduction of Beta-Adrenergic Receptor Density.- 2. Decrease of Myocardial Norepinephrine Stores.- III. Stimulation of the Renin-Angiotensin-Aldosterone System.- IV. Reactivity of Vessel Walls in Chronic Heart Failure.- V. Renal Vasoconstriction.- Literature.- B. New Aspects in the Treatment of Chronic Heart Failure.- I. Digitalis and Diuretics.- II. Vasodilators.- 1. Critical Evaluation of the Therapeutic Concept.- 2. The Classic Therapeutic Concept.- 3. Restrictions on Therapy for Patients with Severe Heart Failure.- Literature.- C. Role of Digitalis.- I. Mechanism of Action of Digitalis Glycosides.- 1. Molecular Mechanism.- 2. Hemodynamic Effects.- II. Contraindications.- III. Dosage of Digoxin and Digitoxin.- 1. Blood Levels.- 2. Interactions.- IV. Long-Term Effects.- 1. Excessive Prescribing of Digitalis by Physicians in West Germany.- 2. Rate of Intoxication, 3 Percent.- 3. Significance of Discontinuation Trials.- Literature.- D. Role of Diuretic Therapy.- I. Renal Function in Heart Failure.- II. Sites of Action for Various Diuretics.- III. Hemodynamic Changes after Diuretic Therapy in Acute Left Ventricular Failure.- IV. Activity of Furosemide in the Venous System.- V. Long-Term Effects of Diuretics.- VI. Side Effects of Diuretics.- Literature.- E. Clinical Role of Vasodilator Therapy.- I. The Ideal Vasodilating Agent.- II. Spectrum of Side Effects.- III. Effect on Acute Decompensation.- IV. Goals of Chronic Treatment.- V. Therapeutic Agents.- F. The Use of Nitrates in Chronic Heart Failure.- I. Acute Effects in Chronic Heart Failure.- 1. At Rest.- a) Sustained Action.- b) Increase in Cardiac Output.- 2. During Physical Exercise.- II. Chronic Action of Nitrates.- 1. Nitrate Tolerance.- 2. Side Effects.- 3. Combination with Hydralazine.- 4. Pharmacokinetics of Isosorbide Dinitrate in Chronic Heart Failure.- Literature.- G. Hydralazine for Chronic Heart Failure.- I. Pharmacokinetics of Hydralazine.- II. Mechanism of Action of Hydralazine.- 1. Hemodynamic Effects.- a) Renal Blood Flow.- b) Coronary Blood Flow.- c) Increased Blood Flow in Other Vascular Beds.- III. Acute and Chronic Effects of Hydralazine.- 1. Improved Function at Rest.- a) Long-Term Effects.- b) Attenuation of Effects.- c) Clinical Improvement.- 2. Hydralazine Effects During Exercise.- a) Acute and Chronic Effects.- b) Absence of Increase in Oxygen Extraction.- 3. Hydralazine in the Treatment of Mitral and Aortic Regurgitation.- a) Mitral Regurgitation.- b) Aortic Insufficiency.- 4. Hydralazine: Influence on Prognosis.- 5. Side Effects of Hydralazine.- a) Lupus Erythematosus Syndrome.- b) Neuropathy.- c) Febrile Condition.- d) Reflex Tachycardia.- e) Fluid Retention.- f) Flushing.- 6. Hydralazine in Combination with Nitrates.- a) Long-Term Effects.- b) Side Effects.- Literature.- H. Prazosin in Chronic Heart Failure.- I. Mechanism of Action of Prazosin.- 1. Alpha-Adrenergic Blocking Agents.- 2. Plasma Renin Activity with Prazosin.- 3. Myocardial Oxygen Consumption.- II. Pharmacokinetics of Prazosin.- 1. Kinetics in Patients with Hypertension.- 2. Kinetics in Patients with Heart Failure.- 3. Elimination.- 4. Prazosin in Renal Failure.- 5. Dosage.- III. Acute and Chronic Effects of Prazosin in Heart Failure.- 1. Acute Effects of Prazosin.- a) Regional Blood Flow.- 2. Chronic Effect of Prazosin.- a) Follow-Up Studies.- b) Placebo-Controlled Trials.- c) Prazosin Influence on Exercise Tolerance.- IV. Attenuation of Prazosin Effects with Chronic Therapy.- 1. Repetitive Single Dosing.- 2. Temporary Withdrawal of Prazosin.- V. Role of Prazosin in the Treatment of Chronic Heart Failure.- VI. Side Effects of Prazosin.- 1. 'First-Dose Phenomenon'.- 2. Weight Gain.- 3. Other Side Effects.- Literature.- I. Converting Enzyme Inhibition: Therapy for Chronic Heart Failure.- I. Mechanism of Action.- 1. Renin-Angiotensin-Aldosterone System.- 2. Special Mechanism of Action of Converting Enzyme Inhibitors.- a) Influence of Converting Enzyme Inhibitors on the Renin-Angiotensin-Aldosterone System.- b) Local Inhibition of the Renin-Angiotensin-System in the Vascular Wall.- c) Inhibition of Sympathetic Regulation in Resistance Vessels.- d) Inhibition of Bradykinin Metabolism.- e) Influence of Vasoactive Prostaglandins.- f) Hormonal Factors.- g) Conclusion: Mechanism of Action.- II. Pharmacokinetics of Captopril.- 1. Absorption.- 2. Elimination.- III. Other Agents.- 1. Specific Angiotensin II Inhibitor: Saralasin.- 2. Converting Enzyme Inhibitor: Teprotide.- IV. Clinical Use of Captopril in Hypertension.- V. Captopril in Heart Failure.- 1. Acute Effects of Captopril.- 2. Long-Term Effects of Captopril.- a) Repetitive Single Dosing.- b) Sustained Action.- 3. Regional Flow Changes During Captopril Therapy.- a) Renal Blood Flow.- b) Coronary Blood Flow.- c) Splanchnic and Extremity Blood Flow.- 4. Effects of Captopril During Exercise.- 5. Influence on Prognosis.- 6. Captopril for Acute Myocardial Infarction.- 7. Captopril for Acute Left Ventricular Failure.- 8. Captopril Dosage.- VI. Side Effects of Captopril.- 1. Hematologic Side Effects.- 2. Renal Side Effects.- 3. Cutaneous Side Effects.- 4. Alterations in Taste Sensation.- 5. Drug Interactions.- 6. Side Effects in Patients with Heart Failure.- 7. Summary of Side Effects.- Literature.

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