Heart Failure - Management of Congestion: Use of Ace-inhibitors, Diuretics, and Salt Restriction a

The most important signs of heart failure, such as dyspnea (due to pulmonary edema or pleural effusion) and ascites, are directly attributable to sodium and fluid retention resulting from activation of the renin-angiotensin-aldosterone system (RAAS). Management of the signs of congestive heart failure (CHF) has relied upon the use of natiuretic diuretics (furosemide), restriction of dietary sodium, and more recently angiotensin converting-enzyme inhibitors (ACEI) which, by blocking aldosterone production, combat sodium retention and congestion. In addition, as vasodilators, ACE-I unload the heart, improving cardiac output and exercise, normalize electrolyte abberations, and blunt the pathological cardiovascular remodeling produced by angiotensin II and aldosterone.

While off-loading therapy with the aforementioned drug groups can be life-saving, their use can be associated with adverse side-effects. Most notable of these are hypotension, azotemia, renal failure, and arrhythmias. Certain complications are more apt to occur when combinations of drugs are used. Because of the potential for such side effects, these drugs are best employed in specific sequence and combinations. The following discussion relates to their use in the management of chronic heart failure.

ANGIOTENSIN CONVERTING-ENZYME INHIBITORS

In landmark veterinary studies of enalapril in NYHA phase III and IV heart disease (moderate to severe heart failure), due to mitral regurgitation (MR) and dilated cardiomyopathy (DCM), enalapril improved survival by >100% as well as reducing pulmonary edema and, improving quality of life scores. 1-3 Exercise capacity is also improved in dogs with experimental mitral insufficiency. 4 Benazepril has likewise been shown to improve survival. […]