Page 198 - fbkCardioDiabetes_2017

174 Cardio Diabetes Medicine 2017

may be helpful as an alternative to other vasodilator recommendation .
therapy (nitroglycerin or nitroprusside).
For patients with HF with volume overload with per-
Nesiritide is typically given as an initial intravenous sistent severe hyponatremia (ie, serum sodium ≤120
bolus of 2 mcg/kg, followed by a continuous infusion meq/L) despite water restriction and maintenance of
of 0.01 mcg/kg per minute, with subsequent dose guideline-directed medical therapy, short-term use of
adjustment as necessary. Close monitoring of hemo- a vasopressin receptor antagonist (either a V2 recep-
dynamics, urine output, and renal function are nec- tor selective or nonselective vasopressin antagonist)
essary for effective clinical use and safety. Nesiritide is an option to improve serum sodium concentration.
is less potent than nitroprusside, and both the onset Cautions include hepatotoxicity and overly rapid cor-
and offset of action are slower. Because nesiritide rection of hyponatremia, which can lead to irrevers-
has a longer effective half-life than nitroglycerin or ible neurologic injury.
nitroprusside, side effects such as hypotension may Opiates: Data is limited but morphine does reduce
persist longer.
patient anxiety and decreases the work of breathing.
These effects diminish central sympathetic outflow,
Sodium and fluid restriction leading to arteriolar and venous dilatation with a re-
Hyponatremia is common among HF patients and sultant fall in cardiac filling pressures . The largest
the degree of reduction in serum sodium parallels of the studies found that morphine administration
the severity of the HF and is an adverse prognos- for ADHF was associated with increased frequency
tic indicator. Given the available evidence, sodium of mechanical ventilation, admission to an intensive
restriction (eg, <2 g/d) in patients with symptomatic care unit, and in-hospital mortality; hence their use
HF is suggested. The 2013 ACC/AHA guidelines sug- is not recommended
gest some degree (eg, <3 g/d) of sodium restriction
in patients with symptomatic HF, while the 2012 ESC MANAGEMENT OF INADEQUATE
guidelines note that the safety and efficacy of salt RESPONSE TO DIURETIC THERAPY
restriction require further study .
In patients with ADHF who fail to adequately respond
Fluid restriction — Fluid restriction (eg, 1.5 to 2 L/d) to diuretic therapy ,the following measures are sug-
may be helpful in patients with refractory HF and gested:
hyponatremia, as suggested by the 2013 ACC/AHA
guidelines. Stricter fluid restriction is indicated in • Doubling the diuretic dose until diuresis ensues
patients with severe (serum sodium <125 meq/L) or or the maximum recommended dose is reached.
worsening hyponatremia. • Addition of a second diuretic to potentiate the ef-
fects of the loop diuretic. For patients in whom the
Venous thromboembolism prophylaxis diuretic response is inadequate, intravenous chlo-
Prophylaxis against venous thromboembolism (deep rothiazide or oral metolazone or spironolactone are
vein thrombosis and pulmonary embolism) with low- reasonable choices for a second diuretic.
dose unfractionated heparin or low molecular weight Chlorothiazide is the only thiazide diuretic that can
heparin, or fondaparinux, is indicated in patients ad- be given intravenously (500 to 1000 mg/day). An
mitted with ADHF who are not already anticoagulated oral thiazide, such as hydrochlorothiazide (25 to 50
and have no contraindication to anticoagulation. In mg twice daily) or metolazone (which has the ad-
patients admitted with ADHF who have a contraindi- vantage of once daily dosing), is an alternative for
cation to anticoagulation, venous thromboembolism acute therapy and can be given chronically. Although
prophylaxis with a mechanical device (eg, intermit- it has been suggested that metolazone is the thia-
tent pneumatic compression device) is suggested . zide of choice in refractory patients with advanced
renal failure (glomerular filtration rate below 20 mL/
Vasopressin receptor antagonists (VRA) min), there is at present no convincing evidence that
VRA have been investigated as an adjunct to di- metolazone has unique efficacy among the thiazides
uretics and other standard therapies in patients with when comparable doses are given.
ADHF as a means of countering arterial vasocon- Addition of a mineralocorticoid receptor antagonist
striction, hyponatremia, and water retention. Tolvap- (spironolactone or eplerenone) is recommended in
tan is the most studied agent in this setting. The 2012 selected patients with HF with reduced ejection frac-
ESC guidelines suggest consideration of tolvaptan tion to improve survival. In addition, the associated re-
for HF patients with hyponatremia in an ungraded duction in collecting tubule sodium reabsorption and

GCDC 2017