Special Considerations

Special Considerations is a topic covered in the Washington Manual of Medical Therapeutics.

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  • Fluid and free water restriction (<1.5 L/d) is especially important in the setting of hyponatremia (serum sodium <130 mEq/L) and volume overload.
  • Minimization of medications with deleterious effects in HF should be emphasized.
    • Negative inotropes (e.g., verapamil, diltiazem) should be avoided in patients with impaired ventricular contractility, as should over-the-counter β stimulants (e.g., compounds containing ephedra, pseudoephedrine hydrochloride).
    • NSAIDs, which antagonize the effect of ACE inhibitors and diuretic therapy, should be avoided if possible.
  • Administration of supplemental oxygen may relieve dyspnea, improve oxygen delivery, reduce the work of breathing, and limit pulmonary vasoconstriction in patients with hypoxemia but is not routinely recommended in patients without hypoxemia.
  • Sleep apnea has a prevalence rate as high as 48% in the HF population. Treatment with nocturnal positive airway pressure improves symptoms and EF.1,2 However, treatment of central sleep apnea with adaptive servo-ventilation was associated with increased mortality.3 Treatment of obstructive sleep apnea may be warranted.
  • Dialysis or ultrafiltration may be beneficial in patients with severe HF and renal dysfunction who cannot respond adequately to fluid and sodium restriction and diuretics.4 Ultrafiltration is not superior to a scaled diuretic regimen in patients with acute HF and cardiorenal syndrome and is associated with higher rate of adverse events.5 Other mechanical methods of fluid removal such as therapeutic thoracentesis and paracentesis may provide temporary symptomatic relief of dyspnea. Care must be taken to avoid rapid fluid removal and hypotension.
  • End-of-life considerations may be necessary in patients with advanced HF who are refractory to therapy. Discussions regarding the disease course, treatment options, survival, functional status, and advance directives should be addressed early in the treatment of the patient with HF. For those with end-stage disease (stage D, NYHA class IV) with multiple hospitalizations and severe decline in their functional status and quality of life, hospice and palliative care should be considered.6

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