17 days at the VA – Day 2

16 Nov
2009

Day 2 was easy.  We had 2 patients, and despite coming in the afternoon, we had no admissions at that point.

After spending 15 minutes getting to know my team – 2 students, 2 interns, and 1 resident (all guys) – we saw the existing patients and then went to the conference room to teach.  Because both patients had left ventricular systolic dysfunction, I focused on the management of that condition.

When I teach about CHF with systolic dysfunction, I tell a history story.

1975 – I am an intern.  We treat CHF with digoxin and furosemide.  We push the digoxin dose to high levels.  Admitted patients have a life expectancy of around 6 months

mid-1980s – the VHeFT trial shows that hydralazine and isosorbide dinitrate can (for the 2/3 of patients who can tolerate the combination) slightly decrease mortality.  Physicians respond with apathy.

1988 – the CONSENSUS trial shows that enalapril (in addition to digoxin and lasix) has a significant positive impact on mortality in Class IV CHF.  Over the next decade we learn that we can decrease morbidity and mortality with high doses of ACE inhibitors (more than low doses).  We also learn that ARBs do just as well, generally with less side effects.  I comment that once ARBs become generic I will probably favor them

1990s – we start to read reports that beta blockers might actually help CHF patients! 

2003 – the COMET study suggests that carvedilol improves survival over metoprolol (although some still debate this finding.

1999 – the RALES trial shows that spironalctone increases survival when added to ACE inhibitors and beta blockers in patients having Class IV CHF within the last 6 months and still in Class III

1997 – the digoxin study shows no mortality benefit, but does show decreased hospitalizations.  Subsequent analyses show that low dose digoxin trumps high dose digoxin.  Women have increased mortality on digoxin.

recently – AICD improves survival in patients with LVEF less than 35%

biventricular pacing improves survival in patients with QRS duration of 0.12 or greater

Obviously, this talk has many more nuances – but that is most of what we discussed yesterday. 

I left out diuretic use because I covered that well last year – On diuretic use for CHF

I also suggest this article from a colleague – A Comprehensive Review of the Loop Diuretics: Should Furosemide Be First Line?

Related posts:

  1. 15 days at the VA – day 4
  2. 15 days at the VA – day 10
  3. On diuretic use for CHF
  4. Which 2 drug regimen for hypertension
  5. 15 days at the VA – day 5

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1 Response to 17 days at the VA – Day 2

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Moises Auron

November 19th, 2009 at 2:10 pm

I agree – it is a very common error when patients with exacerbation of chronic heart failure are admitted – instead of targeting euvolemia, it seems that the limiting point in using diuretics is when creatinine starts bumping up – this is a mistake, as patients with chronic heart failure (either with preserved or low ejection fraction) can develop cardiorenal syndrome even in the setting of volume overload (as are intravascularly volume depleted in addition to poor pump functioning).
I feel a challenge with the heart failure with preserved ejection fraction – as even with a normal EF, they can in fact have a systolic dysfunction – the issue is that we need to use more technology in this patients – use tissue doppler along with the echocardiogram. You can access the presentation here: http://www.scribd.com/doc/20416429/EBM-Diastolic-HF
I made a presentation for my colleagues hospitalists about this setting – it is so difficult as well to get out the name of "diastolic heart failure" and I hope Medicare will take this mistaken name out of its diagnosis list.
Excellent posts, I enjoy very much reading your updates.
Best!
Moises

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