Optimizing therapy for complex or refractory heart failure: A management algorithm,☆☆,,★★

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Abstract

Am Heart J 1998:135:S293-S309.

Section snippets

Optimizing Standard Therapy

Major advances in our understanding and therapy of heart failure have occurred during the last 2 decades. Well-designed large clinical trials have established the benefits of ACE inhibitors, the combination of nitrates and hydralazine, and digoxin. At the same time the potential hazards of agents such as antiarrhythmic drugs and nonsteroidal antiinflammatory agents have been recognized. This experience and evidence have been incorporated into practice guidelines, which provide sufficient

The Management Algorithm for Patients with Complex or Refractory Heart Failure

This discussion of the optimization of further therapy focuses on those patients who have persistent or recurrent limitation of routine daily activity by heart failure symptoms (New York Heart Association class III-IV) despite the initiation of standard therapies with ACE inhibitors, diuretics, and digoxin, according to the Heart Failure Clinical Practice guidelines reviewed previously.7, 21, 22 Many of those patients will have been hospitalized one or more times on these medications. It is

Patient education

Patient education should begin with a simple version of the cause, features, and prognosis of heart failure19, 20 (Table IV). Specific instructions should emphasize the positive aspects of what the patient can do including self-monitoring, employment, exercise, and sexual activity (Table V). Patients who have had major fluid retention should in general follow a 2 gm sodium diet, although negotiation may be required for patients with cultural reliance on a higher salt diet. The emphasis on fluid

Outlook for Chronic Heart Failure

The classic image of the patient with heart failure languishing with intractable dyspnea is becoming increasingly rare as comprehensive care evolves and becomes more widely available. Although the survival rates are comparable to those for severe cancer, the analogy subsequently weakens, because comfort is easier to maintain with heart failure. Most patients can live comfortable lives until death intervenes suddenly or at least rapidly. Most patients without complicating noncardiac illness can

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  • Cited by (93)

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    From the aCardiomyopathy and Heart Failure Program, Cardiovascular Divison, Department of Medicine, Brigham and Women's Hospital; the bDepartment of Medicine and Cardiovascular Research Institute of the University of California, San Francisco and the Cardiology Section of the San Francisco Department of Veterans Affairs Medical Center; and cthe Cardiovascular Division, University of Minnesota Hospital.

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    Supported in part by the FE Rippel Foundation and the Department of Veterans Affairs Research Service.

    Reprint requests: Lynne W. Stevenson, MD, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.

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