Controversy Over An Old Drug
In 1785, Withering published an account of digitalis and some of its medical uses.12 Although digoxin continues to be viewed as beneficial in patients with heart failure and atrial fibrillation, its role in patients with heart failure and sinus rhythm has been increasingly challenged. Mackenzie and Christian, two eminent clinicians and coeditors of Oxford Medicine, debated this issue in 1922. Mackenzie advocated the use of digitalis only in heart failure with associated atrial arrhythmias, whereas Christian argued that digitalis was effective irrespective of an irregular pulse. In 1938, Cattell and Gold first showed a direct inotropic effect of digitalis on cardiac muscle.
For many more years, digitalis continued to be an important part of heart failure management. The detrimental aspects of digoxin therapy were not considered important until excess mortality was reported in survivors of myocardial infarction who received digitalis.13,14 Uncontrolled observations that the withdrawal of digoxin produced no ill effects also raised concerns about the efficacy of the drug.15,16
If You Have Diabetes Or Prediabetes
HOW GLUCOSE AFFECTS YOUR HEART
Elevated blood glucose level can lead to changes in the circulatory system. These changes may cause damage to your heart.
KEEPING YOUR BLOOD GLUCOSE LEVELS HEALTHY
- Take your medications as prescribed
- Learn about managing diabetes by attending a diabetes education program
- Monitor and keep track of your blood glucose
- Target: blood glucose before meals between 4.0 and 7.0 mmol/L
- Target: blood glucose two hours after meals between 5.0 and 10.0 mmol/L
- Aim to make healthier food choices
- Be active every day
- Follow your Physical Activity Plan
- Visit your family doctor or diabetes specialist regularly
- Additional Meal Planning Tips:
- Eat regular meals. Aim to eat every four to six hours. Include a healthy snack if meals are more than four to six hours apart.
- Eat breakfast.
- Limit sugars and sweets such as sugar, regular soft drinks, fruit drinks, desserts, candies, jam, syrup and honey.
- If you are thirsty, drink water or sugar free drinks. Drinking regular soft drinks, sweetened drinks or fruit juices will raise your blood sugar level. Remember to stay within your fluid restriction as prescribed by your doctor.
Doses Of Baseline Medications In Phase Iii Clinical Trials
Due to application of strict inclusion/exclusion criteria, patients in phase III drug trials are more likely to be on background evidence-based therapies than community-based populations. This may be related to the enrolled patient cohort, who tend to be younger, with fewer comorbid conditions, and/or better access to care than the HF population at large. However, even in this setting, some patients in trials are not on all evidence-based therapies at baseline, let alone guideline-directed target doses . In many trials, doses of baseline medications are not reported, or when reported, it is frequently not documented whether higher doses had been attempted but not tolerated. As such, the incremental value of novel drugs over ideal background therapy in every patient is almost never known. Instead, trials inform the incremental efficacy and safety over a regimen of guideline-directed medical therapy over a range of background therapy dosing. While it is expected that not all patients will be able to tolerate maximum doses of standard therapies prior to enrollment, trials generally recommend optimization of HF medications per HF guidelines prior to enrollment at the discretion of the local investigator. However, the optimization of background therapy called for in clinical trials is not standardized and rarely protocolized.
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Biomarker Guided Medication Titration
The natriuretic peptides, B-type natriuretic peptide and N-terminal proB-type natriuretic peptide , have demonstrated both diagnostic and prognostic value in patients with HF. A decrease in natriuretic peptide levels over a period of follow-up has been associated with improved outcomes, including morbidity and mortality. Importantly, HF therapy guided by natriuretic peptides has not been shown to improve outcomes in HF patients Beta-blockers have been shown to substantially decrease natriuretic peptide levels in the long run, as have ACEi/ARBs and MRAs. One recent study demonstrated improved outcomes with patients who attained a significant reduction in NT-proBNP < 1000 importantly, treatment with sacubitril/valsartan was nearly twice as likely as enalapril to achieve reductions in NT-proBNP to this level. More data are needed regarding doses of medications and their interaction with natriuretic peptides, or other biomarkers, and clinical outcomes and importantly if doses should be specifically titrated to achieve specific biomarker levels rather than the current recommendation for maximally tolerated dosing.
What Are The Symptoms Of Heart Failure
You may not have any symptoms of heart failure, or the symptoms may be mild to severe. Symptoms can be constant or can come and go. The symptoms can include:
- Congested lungs. Fluid backup in the lungs can cause shortness of breath with exercise or difficulty breathing at rest or when lying flat in bed. Lung congestion can also cause a dry, hacking cough or wheezing.
- Fluid and water retention. Less blood to your kidneys causes fluid and water retention, resulting in swollen ankles, legs, abdomen , and weight gain. Symptoms may cause an increased need to urinate during the night. Bloating in your stomach may cause a loss of appetite or nausea.
- Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion.
- Rapid or irregular heartbeats. The heart beats faster to pump enough blood to the body. This can cause a rapid or irregular heartbeat.
If you have heart failure, you may have one or all of these symptoms or you may have none of them. They may or may not indicate a weakened heart.
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More Information About Diabetes Or Prediabetes
Its natural to have questions about what food to eat. A registered dietitian can help you make healthier food choices. If you have diabetes and are taking insulin, speak with your family doctor. You may need to see an endocrinologist .
COMMUNITY DIABETES EDUCATION PROGRAM OF OTTAWA
- For adults with type 2 diabetes who are controlled with diet, pills or just starting insulin
- Teaching is also available for people with prediabetes
- Group and individual sessions on healthy eating, getting active, testing blood glucose, stress and emotions, delaying or preventing complications and foot care
- In English, French and other languages
- To register, call 613-238-3722
DIABETES EDUCATION PROGRAMS
- To locate a diabetes education program near you, contact Diabetes Canada at 1-800-BANTING or at .
BOOKS
- The Essential Diabetes Book, Mayo Clinic
WEBSITES
- Diabetes Canada: 1-800-BANTING
What Makes Yale Medicines Approach To Treating Congestive Heart Failure Unique
Yale Medicines multidisciplinary team comprises heart failure cardiologists and cardiac surgeons, dedicated advanced-practice, registered nurses and nurse coordinators, dietitians, exercise physiologists, financial counselors, immunologists specializing in transplants, psychologists, and specialists in palliative care.
With a multidisciplinary approach, Yale Medicine physicians include the patients desires as well as input from the family to develop a comprehensive treatment plan that’s right for them.
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Congestive Heart Failure In Dogs
Simon Swift
MA, VetMB, CertSAC, DECVIM-CA , MRCVS
After qualifying from Cambridge University, Dr. Swift spent 2 years in mixed practice before moving to a specialist small animal practice in the Northwest of England. He developed an interest in cardiology, taking the RCVS cardiology certificate in 1990. He became a partner in a large emergency and referral hospital building up the cardiology referral service until he left in 2005 to follow an alternative residency program at Liverpool University. Since becoming a European Diplomate in cardiology, he worked in a private referral hospital before moving to Florida to join the College of Veterinary Medicine as Clinical Associate Professor. He is service chief for cardiology and has recently been appointed medical director. He has been involved in breeding programs and the treatment of degenerative valvular disease especially in the cavalier King Charles spaniel having been adviser to the UK CKCS club for 20 years and more recently has helped develop advanced interventional techniques at the University of Florida.
STAGE
A: A dog at risk of heart disease
B1: Signs of heart disease . The dog is asymptomatic.
B2: Signs of heart disease . The dog is asymptomatic.
C: Congestive heart failure is present or has been present and the dog is receiving treatment.
D: Congestive heart failure is present and refractory to standard therapies. The patient requires hospitalization.
Things You Should Do To Manage Chf Symptoms
There are many dogs that live long lives with CHF and another congenital heart disease.
Successful living with heart disease is much like it is with humans, it takes care, medications, quality nutrition, and exercise.
Below is a list of 10 things you should do to manage symptoms of congestive heart failure in dogs to ensure your pet lives a quality life.
1. Coughing
If coughing becomes severe, contact your veterinarian. If already diagnosed with CHF and on furosemide, your vet may recommend an additional dose to alleviate any extra accumulation of fluids.
Watch your dog carefully, time coughing, and take notes for the next visit.
2. Difficulty Breathing
With CHF, difficulty breathing indicates fluid build-up in the lungs. Your vet may prescribe additional diuretics like furosemide.
If the difficulty breathing worsens call your veterinarian immediately.
3. Difficulty Sleeping
Dogs may try to sleep on their chest instead of their sides. You may observe your dog trying to sleep quietly sitting up.
This is due to the fluid build-up in the lungs when your dog lies on its side making it uncomfortable. Its a sign to get a check-up.
4. Exercise
Dogs with CHF should be allowed the amount of exercise they want to enjoy life. If they become tired or weak, it’s best to take a break.
Pushing your dog beyond its limits can cause irregular heartbeats .
5. Expensive Medications
There may also be a less expensive alternative treatment that your vet may be aware of. Call your vet first.
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What Foods Should Be Avoided With Congestive Heart Failure
Dietary changes are a major part of heart failure treatment, and they will require certain foods to be reduced or eliminated in the diet:
- Salt: Above all else, avoid salty foods. Sodium contributes to the swelling and fluid retention that damages the heart, lungs, and other organs in patients with heart failure.
- Alcohol: Alcohol damages the heart muscle and will worsen heart failure.
- Fats: Saturated fats and trans-unsaturated fatty acids are associated with coronary heart disease, so your cardiologist or nutritionist will reduce your intake of saturated and trans fats.
- Carbohydrate snacks: Crackers, chips, cookies, popcorn all put on the pounds without adding much nutrition to the diet. Life expectancy is significantly reduced in heart failure patients who carry excess weight.
- Water: Fluid retention is common to heart failure and damages the heart and other organs, so only drink as much water and other liquids as advised by your cardiologist or nutritionist.
Manage Your Medications Safely
Knowledge Is the Best Medicine
1. When you receive a prescription from the doctor, make sure you ask:
- What is the brand name and chemical name of the medication?
- Why is it being prescribed?
- When and how should it be taken?
- How long will you need to take it?
- What side effects should you expect to have?
- What should you do about the side effects?
2. When you pick up your medication, ask your pharmacist to:
- Explain the best way to take the medication
- Describe what is written on the label
- Provide written information about the medication
3. Try to use the same pharmacy for all of your prescriptions. It is important for your pharmacist to have a complete list of your medications. Your pharmacist can then evaluate whether your medications can be safely taken together.
4. Carry your medication list with you. Make sure the list includes:
- All of your medications, as well as any vitamins, supplements and herbals
- Your allergies, immunizations and pharmacy phone number
Bring the pill bottles or a list of your current medications to all visits with your doctors.
5. Always ask your doctor or pharmacist before taking any medications or herbal products you can buy without a prescription. Medications you can buy over the counter at the drug store include pain medication, antacids, laxatives and cough medicines.
Non-steroidal anti-inflammatory drugs , such as ibuprofen and naproxen , may worsen your symptoms and/or make your prescription medication less effective.
- Phone: 1-800-575-5386
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About Congestive Heart Failure
Heart failure, sometimes called congestive cardiac failure , is a condition in which the heart muscle is weakened and cant pump as well as it usually does. The main pumping chambers of the heart can change size and thickness, and either cant contract or cant relax as well as they should. This triggers fluid retention, particularly in the lungs, legs and abdomen.
The major causes of heart failure include coronary heart disease and heart attack, high blood pressure, damage to the heart muscle , heart valve problems and abnormal heart rhythms. Of these, coronary heart disease and heart attack are the most common causes.
The major factors that contribute to coronary heart disease include:
- reduced emotional and social wellbeing
- physical inactivity.
Heart failure is more common in elderly people. The survival rate for people with this disorder depends on the severity of their condition.
Most common treatments for heart failure are medications and self-managed lifestyle changes. Some less-common treatments may require insertion of implantable cardiac devices or valve replacement.
Can You Reverse Congestive Heart Failure
Early-stage congestive heart failure due to conditions such as high blood pressure, diabetes, or other treatable condition can be reversed by controlling the underlying cause, making significant lifestyle changes, and taking heart failure medications. In particular, exercise can help remodel the heart if the proper medications and lifestyle changes are adopted.
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What Is Congestive Heart Failure
Congestive heart failure is a complex, progressive condition in which the heart does not pump enough blood to the rest of the body.
The heart chambers that pump blood out are called the ventricles. The right ventricle pushes blood into the lungs where it picks up oxygen. The left ventricle pushes oxygenated blood out to the rest of the body to supply cells and tissues with needed oxygen. Congestive heart failure is largely a condition of the left ventricle, but the right ventricle might also be affectedusually as a result of left ventricular dysfunction.
Left-sided heart failure is further classified into one of two categories. Heart failure with reduced ejection fraction, or systolic heart failure, means the ventricle is failing to contract sufficiently to pump enough blood out. Left-sided heart failure with preserved ejection fraction, or diastolic heart failure, describes conditions in which the ventricle is too stiff to sufficiently relax when they fill with blood, resulting in too little blood in the ventricle to pump out.
Congestive heart failure develops as blood flow out of the heart slows, resulting in blood flow back to the heart to become backed up. It can be caused by any number of conditions affecting the heart muscle, heart valves, blood vessels, or metabolism, including
- Heart attack
- Heart valve disease
- High triglycerides
Aside from the progressive worsening of heart function, congestive heart failure can produce many life-threatening complications such as
Pharmacological Management Of Heart Failure
Drugs used in heart failure include those used to initially manage mild to moderate failure and those used more commonly in severe to very severe conditions.
First Agents Used:
Selection of agents and their combinations depend on initial clinical state and on patient responsiveness to initial therapy
Additional Agents:
Selection of agents and their combinations depend on initial clinical state and on patient responsiveness to initial therapy.
An implantable cardioverter-defibrillator is indicated for primary prevention of sudden cardiac death in patients with HF who have an LVEF of less than or equal to 35%.
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How Is Heart Failure Diagnosed
Your doctor will ask you many questions about your symptoms and medical history. Youâll be asked about any conditions you have that may cause heart failure . Youâll be asked if you smoke, take drugs, drink alcohol , and about what drugs you take.
Youâll also get a complete physical exam. Your doctor will listen to your heart and look for signs of heart failure as well as other illnesses that may have caused your heart muscle to weaken or stiffen.
Your doctor may also order other tests to determine the cause and severity of your heart failure. These include:
Other tests may be ordered, depending on your condition.
Approach To Patients With Diastolic Dysfunction
In patients with diastolic dysfunction, appropriate measures include the diagnosis and treatment of myocardial ischemia and the aggressive treatment of hypertension . Digitalis therapy has been considered inappropriate in these patients. In some patients, treatment with diuretics and nitrates could reduce pulmonary congestion.
In the DIG trial,17 a subgroup of nearly 1,000 patients with a left ventricular ejection fraction of 45 percent or greater experienced a reduction in congestive heart failure end points similar to patients with a left ventricular ejection fraction of 25 to 45 percent. One group of investigators27 suggested that this effect may be the result of digoxin’s ability to reduce neurohormonal activities. However, they concluded that information about the effect of digoxin in patients with congestive heart failure and preserved left ventricular systolic function is limited and does not warrant routine use of the drug in this setting until the results of more studies are available.
At present, the consensus is that digoxin therapy is probably inappropriate in patients with preserved left ventricular systolic function. In addition, digoxin therapy may not be useful in patients with congestive heart failure and a high cardiac output syndrome such as anemia or thyrotoxicosis.
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