This week's article, at the beginning of the week, no less!

[bunrab]

One of the sites I'm registered at is MedScape from WebMD, and specifically I signed up for their pharmacists' newsletter. If one carefully reads the fine print, one does not have to be a medical professional to register for these sites. So, here's a link to the article, for those who would care to register at MedScape and get the news on a current basis. They don't seem to sell their list nor spam their subscribers with stuff, just the newsletter on a regular basis.

For those who can't register, here's the highlights of the article, which was originally published in the journal Pharmacotherapy, V. 27 No. 4:

Current Guidelines for Treatment of Heart Failure: 2006 Update

Abstract

Several pivotal clinical trials have generated new knowledge regarding drug therapy for heart failure. Thus, the Heart Failure Society of America (HFSA) and the American College of Cardiology-American Heart Association (ACC-AHA) guidelines were updated in 2006 and 2005, respectively. We review the evidence from these trials and summarize the changes to the HFSA and ACC-AHA guidelines. Based on data from these studies, the new guidelines include broader, stronger recommendations for β-blocker therapy, and strong recommendations for angiotensin II receptor blockers. The aldosterone antagonists, spironolactone and eplerenone, are also included in the guidelines. Pharmacists should have a basic level of familiarity with the new guidelines on heart failure and the evidence from recent clinical studies. They should be able to relate how this information contributes to the evolving understanding of treatment strategies for heart failure.
***
The article introduces the treatment guidelines issued by the Heart Failure Society of America (HFSA), the European Society of Cardiology (ESC), and the American College of Cardiology-American Heart Association (ACC-AHA). The next section is a description of the changes in understanding the pathophysiology of heart failure, and the current neurohormonal model that guides practices. Section 3 mentions which organizations still use the New York Heart Association system for classifying heart failure, and that the ACC-AHA uses a different system of "stages":
*Stage A: High risk for heart failure with no structural damage or heart failure symptoms
*Stage B: Structural damage without heart failure symptoms
*Stage C: Structural damage with previous or current heart failure symptoms
*Stage D: Refractory heart failure, specialized intervention.

Stage C is roughly equivalent to NYHA classes II and III [NYSA class III is where I fall, currently], and in addition to ACE inhibitors and β-blockers, diuretics are often a routine part of the drug regimen to manage volume overload in these patients. Stage D can be likened to NYHA class IV and includes special interventions, such as mechanical assist devices, transplantation, inotropic infusions, and hospice and palliative therapy, added to already existing standard care.

The highlights of the descriptions of actual drugs recommended include the studies showing that ARBs (the "sartans") are not inferior to ACE inhibitors (the "prils"), and the recommendation that people intolerant of ACE inhibitors (that intractable cough, for example) be switched to ARBs, and that many people can take both ACE inhibitors and ARBs together. [I really don't understand why someone would take both, myself - as best I understand it, the ARBs are actually superior to the ACE inhibitors, though more expensive, so once you would be taking an ARB and spending that much anyway, why bother with the ACEI? This will require some more digging on my part.] About spironolactone, they say:

The neurohormonal activation of the renin-angiotensin-aldosterone system results in increased aldosterone levels, which leads to three main effects: sodium and water retention with subsequent edema, potassium and magnesium excretion increasing the risk for arrhythmias, and left ventricular remodeling and interstitial cardiac fibrosis. Blocking the actions of aldosterone may reverse these detrimental effects, and guidelines recommend the use of spironolactone 25 mg/day or every other day to patients with severe heart failure (recent or current NYHA class IV)... The 1999 Randomized Aldactone Evaluation Study (RALES) demonstrated a dramatic reduction in overall mortality (~30%) with use of spironolactone 25 mg/day in patients with moderate-to-severe (NYHA classes III-IV) heart failure.[15] This reduction in mortality rate was not limited to mortality due to progressive heart failure, but included mortality due to sudden cardiac death as well. Based on the results of RALES, the guidelines recommend the use of low-dose spironolactone 25 mg/day in patients with severe heart failure despite standard therapy.

About beta-blockers, the article mentions the difficulty in running trials, since a lot of people drop out of such trials due to adverse events, and there appears to be a higher rate of problems with tolerance than with other drugs, although the drugs are successfully tolerated by more people than was previously thought. And they say:

Other subgroups of patients have also caused concerns that limit the use of β-blockers in patients with heart failure. Patients with diabetes, chronic obstructive pulmonary disease, asthma, peripheral vascular disease, heart rate below 55 beats/minute, or systolic blood pressure below 80 mm Hg have long been considered a subgroup in whom β-blockers should be avoided. A sound pharmacotherapeutic strategy, involving cautious initiation and upward dosage titration based on strict monitoring parameters, can prevent the exclusion of these patients from deriving the important benefits of β-blocker therapy. The significant reduction in mortality and morbidity should not be ignored in these patients, as these benefits have been clearly demonstrated to outweigh the risk of avoiding therapy.

I know I have several readers who have diabetes as well as heart failure; that last should be of interest to you.