The case described is typical of coronary artery disease in a patient with hyperlipidemia. Her hyperlipidemia should be treated vigorously to slow progression of, and if pos-sible reverse, the coronary lesions that are present (see Chapter 35). Coronary angiography is not indicated unless symptoms become much more frequent and severe; revas-cularization may then be considered. Medical treatment of her acute episodes of angina should include sublingual tab-lets or sublingual nitroglycerin spray 0.4–0.6 mg. Relief of discomfort within 2–4 minutes can be expected. To prevent episodes of angina, a βblocker such as metoprolol should be tried first. If contraindications to the use of a β blocker are present, a mediumto long-acting calcium channel blocker such as verapamil, diltiazem, or amlodipine is likely to be effective. Because of this patient’s family history, an antiplatelet drug such as low-dose aspirin is indicated. Care-ful follow-up is mandatory with repeat lipid panels, repeat dietary counseling, and lipid-lowering therapy; coronary angiography should also be considered if her condition worsens.
Sildenafil Viagra, Revatio
Tadalafil Cialis, Adcirca
Cilostazol Generic, Pletal
Pentoxifylline Generic, Trental
Bertram G. Katzung, MD, PhD*
A 55-year-old man noticed shortness of breath with exer-tion while on a camping vacation in a national park. He has a 15-year history of poorly controlled hypertension. The shortness of breath was accompanied by onset of swelling of the feet and ankles and increasing fatigue. On physical examination in the clinic, he is found to be mildly short of breath lying down but feels better sitting upright. Pulse is 100 bpm and regular, and blood pressure is 165/100 mm Hg. Crackles are noted at both lung bases, and his jugular venous pressure is elevated. The liver is enlarged, and there is 3+ edema of the ankles and feet. An echocardiogram shows an enlarged, poorly contracting heart with a left ven-tricular ejection fraction of about 30% (normal: 60%). The presumptive diagnosis is stage C, class III heart failure with reduced ejection fraction. What treatment is indicated?
Heart failure occurs when cardiac output is inadequate to provide the oxygen needed by the body. It is a highly lethal condition, with a 5-year mortality rate conventionally said to be about 50%. The most common cause of heart failure in the USA is coronary artery disease, with hypertension also an important factor. Two major types of failure may be distinguished. Approximately 50% of younger patients have systolic failure, with reduced mechanical pumping action (contractility) and reduced ejection fraction (HFrEF). The remaining group has diastolic failure, with stiffening and loss of adequate relaxation playing a major role in reducing filling and cardiac output. Ejection fraction may be normal (preserved, HFpEF) in diastolic failure even though stroke volume is significantly reduced. The proportion of patients with diastolic failure increases with age. Because other cardiovascular conditions (especially myocardial infarction) are now being treated more effectively, more patients are surviving long enough for heart failure to develop, making heart failure one of the cardiovascular conditions that is actually increasing in prevalence in some countries.
* The author thanks Dr. William W. Parmley, MD, coauthor of this chapter in prior editions.
Heart failure is a progressive disease that is characterized by a gradual reduction in cardiac performance, punctuated in many patients by episodes of acute decompensation, often requiring hospitalization. Treatment is therefore directed at two somewhat different goals: (1) reducing symptoms and slowing progression as much as possible during relatively stable periods and (2) managing acute episodes of decompensated failure. These factors are discussed in Clinical Pharmacology of Drugs Used in Heart Failure.