Drug Topics - June 16, 2008 - (Page 46)

46 DRUG TOPICS JUNE 16, 2008 www.drugtopics.com CONTINUING EDUCATION tients are staged using the letters A-D to help categorize them in a more progressive fashion. Patients may begin with only risk factors for HF (Stage A) and progress to severe end-stage disease (Stage D) (Table 2). As clinicians and researchers continue to unravel new findings in HF, staying current is imperative. For this reason, the major guidelines continue to create updates as the need arises. Two different guidelines serve as the foundation for assessment and treatment for HF patients in the United States. The American College of Cardiology/American Heart Association (ACC/ AHA) updated their guidelines in 2005 and the Heart Failure Society of America published additional revised guidelines in 2006. Recommendations are similar between the two guidelines, but this article uses primarily the ACC/AHA guidelines for most commonly accepted recommendations. ACE inhibitors Persistent activation of the renin-angiotensin-aldosterone-system (RAAS) progresses into a detrimental compensation mechanism of HF. For this reason, angiotensin-converting enzyme (ACE) inhibitors have become a mainstay of HF treatment. This extensively studied drug class has consistently shown a benefit in HF patients. More than 30 trials have demonstrated positive endpoints such as decreased hospitalizations, improved symptoms, and delayed disease progression. Unless contraindicated, the ACC/AHA guidelines recommend the use of an ACE inhibitor for nearly all patients with HF. As this drug class was the first to show mortality benefit in HF, they now serve as the standard for which other drug classes are compared. As a class, ACE inhibitors are typically seen as comparable. No evidence currently exists that one agent is preferred to another. Although the guidelines give preference for ACE inhibitors that have shown actual benefit in trials, selection based on formulary availability is more likely. Importance is given more for reaching target doses of the selected ACE inhibitor rather than the particular medication. A comparison of ACE inhibitors is available in Table 3. Concerns exist for adverse effects and contraindications for ACE inhibitors, which likely contributes to underutilization of this drug class despite the proven benefits. Cough, a common adverse effect within the drug class, may also be due to underlying congestion and needs to be further assessed before discon- Chronic primary treatment Overall goals for the treatment of HF include decreasing rate of hospitalizations, preventing disease progression, decreasing patient symptoms, improving quality of life, and increasing survival. Standard HF therapy primarily targets alteration of neurohormonal processes responsible for the injurious cycle of the disease as discussed above. Table 2 Stages of HF and recommended therapy by stage Stage A Definition High risk for HF but without structural disease or symptoms Hypertension Atherosclerotic disease Diabetes Obesity Metabolic syndrome Target risk factors Encourage exercise Encourage smoking cessation ACE inhibitors or ARBs in appropriate patients Stage B At risk for heart failure (HF) Structural disease without symptoms Stage C Stage D Heart failure Structural disease with prior or Refractory HF current symptoms Marked symptoms at rest despite optimal therapy Examples Prior MI Symptoms of dyspnea, LV remodeling (including fatigue, and decreased hypertrophy and low EF) exercise tolerance Asymptomatic valvular disease Same Same plus sodium restriction Non Rx therapy Medication therapy Same plus decision regarding compassionate care Maximal medication therapy Other options chronic inotropes experimental medications ACE inhibitors or ARBs in appropriate patients -blockers in appropriate patients ACE inhibitors -blockers Diuretics for fluid retention Select patients Aldosterone receptor antagonists ARBs Digoxin Hydralazine/nitrates Adapted from ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. http://www.drugtopics.com

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Drug Topics - June 16, 2008 Contents Latebreakers Letters Latebreakers in Depth Pharmacists Lose in Final ESRD Rule New Drug Helps Palliative Patients on Opioids Take Care of Business Oral Treatment Reduces Multiple Sclerosis Flare-ups Beware of Inflammatory Masses From Implantable Infusion Systems Safer Therapeutic Options Emerging for Atrial Fibrillation Congressional Committee Chair Calls for Action Against Hospital Infections This Software System Helps Hospitals Manage Anticoagulation Therapy Rx Care Community Practice JP at Large Self-Care Cover Story Long-Term Care Chains and Business Technology Technology Update Continuing Education New Products Advertisers Index Classified Viewpoint

Drug Topics - June 16, 2008

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