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[Classic treatment of chronic heart insufficiency. What if new?]
M C Aumont1, D Agnola, J M Juliard
1Service de cardiologie A, hôpital Bichat, Paris.
Insights
Diuretics improve chronic heart failure symptoms by removing excess salt and water. Combining them with angiotensin converting enzyme inhibitors may reduce mortality and prevent left ventricular dysfunction.
Area of Science:
- Cardiology
- Pharmacology
Context:
- Chronic heart failure (CHF) management aims to improve quality of life and reduce mortality.
- Neurohormonal activation, including increased catecholamines and atrial natriuretic peptide, precedes CHF symptoms.
Purpose:
- To evaluate the role of diuretics in CHF treatment.
- To explore the neurohormonal effects of diuretics and their interactions with other therapies.
- To assess the impact of spironolactone on mortality in severe CHF.
Summary:
- Diuretics alleviate CHF symptoms by eliminating salt and water overload, though loop diuretics can disrupt electrolyte balance and activate the renin-angiotensin system.
- Angiotensin converting enzyme inhibitors counteract diuretic-induced neurohumoral activation, allowing for reduced diuretic dosage and potentiating vasodilator effects.
- Spironolactone corrects electrolyte imbalances caused by loop diuretics and may prevent myocardial fibrosis. The RALES study investigates its effect on mortality in advanced CHF.
Impact:
- Diuretic use is crucial for symptom management in CHF.
- Combined therapy with ACE inhibitors and diuretics offers a logical and effective approach to CHF treatment.
- Spironolactone holds promise for improving outcomes in severe CHF patients, potentially reducing mortality.
Abstract:
The aims of treatment of chronic heart failure are to improve the symptoms and the quality of life, reduce mortality and prevent left ventricular dysfunction. Before the first symptom occurs, neurohormonal activation takes place (increased catecholamines and atrial natriuretic peptide levels). Diuretics improve symptoms and are irreplaceable for the elimination of salt and water overload. Loop diuretics are used more often than the thiazides. Their deleterious effects on electrolyte balance are well known. The fact that they activate the renin angiotensin system is a more recent acquisition; the increase in plasma renin activity is a poor prognostic factor. Diuretics potentialize the vasodilator effect of angiotensin converting enzyme inhibitors which inhibit the neurohumoral activation induced by the diuretics. This therapeutic association is very logical, effective and allows reduction in the dosage of the diuretic. To date, there are no large scale controlled studies of the effects of diuretics on mortality. Spironolactone corrects hypokalaemia and hypomagnesaemia induced by loop diuretics. Moreover, it has been shown experimentally in renovascular hypertension and in hyperaldosteronism, that this molecule can prevent myocardial fibrosis, a factor which leads to ventricular dysfunction. The RALES study will analyse the effect of associating spironolactone to diuretic and ACE inhibitor therapy on the mortality of patients in NYHA classes III-IV. The value of digitalis in heart failure patients with sinus rhythm is a classical controversy. Digitalis has a positive inotropic effect (inhibition of NaK-dependent ATPase). More recently, a favourable neurohormonal effect has been reported; digitalis decreases the activation of the sympathetic and renin-angiotensin systems.(ABSTRACT TRUNCATED AT 250 WORDS)