Stage A heart failure is the stage of increased risk of heart failure. This stage is associated with diabetes, high blood pressure, metabolic syndrome, coronary heart diseases, and a history of cardiomyopathy, cardiotoxic drug therapy, alcohol abuse, or rheumatic fever (Burchum & Rosenthal, 2020). During this stage, the first-line treatments include lifestyle changes. Patients are encouraged to undertake physical exercises and quit alcohol and tobacco. Patients in this stage who present with hypertension and metabolic syndrome such as diabetes are treated using both pharmacotherapy and life changes strategies. There is a positive link between the Renin-angiotensin-aldosterone -system and the progression of cardiovascular diseases such as heart failure, hence angiotensin-converting enzyme inhibitors used to treat diabetic hypertensive patients significantly reduce their risk of developing heart failure (Zhang et al., 2020). Treating patients with heart failure stage on with angiotensin-converting enzymes greatly benefits them as these drugs reduce their progression to the other stages of heart failure. The author also noted that patients with diabetic kidney diseases greatly benefit from AECI as the drugs delay progression to end-stage kidney diseases and reduce the risk of cardiovascular diseases such as heart failure.
Addition of diuretics in heart failure treatment therapy
physicians add diuretics drugs to the treatment therapy of heart failure in stage C. This stage presents with a complex clinical illness that develops due to structural modifications and cardiac dysfunctions that affect ventricular filling, blood ejection into the systemic circulation, and inadequate systemic circulation (Malik et al., 2022). The level of left ventricular ejection fraction differentiates different types of heart failure. Heart failure with reduced ejection fraction (HFrEF) presents with an ejection fraction of less than 40%, while preserved ejection heart failure has an ejection fraction of 50% and above. In comparison, heart failure with mid-range ejection fraction (HFmrEF) has between 40-50% ejection fraction and is associated with systolic and diastolic heart failure.
At this stage, cardiac physiology adaptive mechanisms to help maintain average contractile performance, but in the long run, the mechanisms become maladaptive. These mechanisms include the Frank-Starling, myocardial hypercontractility, myocardial hypertrophy, and myocyte renewal modifications. Increased wall stress results in remodeling of the myocardium, which worsens the existing loading conditions- Further decreases in cardiac output stimulate the neuroendocrine system, which releases epinephrine, vasopressin hormone, and norepinephrine in the system, thus increasing vasoconstriction afterload. Myocytes’ cytosolic calcium increases further, increasing myocardial contractibility and low relaxation. Increased myocardial contraction increases myocardial oxygen demand, pushing for more cardiac output to meet the demand. These mechanisms eventually become unsustainable, resulting in cardiac cell apoptosis and gradual low cardiac output. Decreased cardiac output eventually activates the renin-angiotensin-aldosterone system (Burchum & Rosenthal, 2020). The RAAS increases vasoconstriction causing peripheral and central edema, thus necessitating diuretics to manage fluid retention. According to Malik et al. (2022), a loop diuretic is the primary diuretics drug used to treat congestion in patients with heart failure—the drugs work by blocking the sodium-potassium-chloride co-transporter in the loop of henle, thus reducing peripheral water retention.
Patients’ candidates for diuretics at stage A
Stage, A of heart failure is often marked with hypertension. Diuretic drugs such as thiazide diuretics drugs are used as the first-line ant-hypertensive for black and Caribbean-origin patients. The populations have poor blood pressure control compared to patients of white origin when treated with ACEI and angiotensin receptor blockers (Sinnott et al., 2020). Among these populations, hypertension has also been found to occur early and is associated with adverse cardiovascular diseases such as heart failure and heart attack. A joint guideline of the international society of hypertension and the American society of hypertension for the management of hypertension recommends thiazide, a diuretic drug, as a first-line treatment drug for hypertensive patients of the black origin or Caribbean. This therapy can be used as monotherapy or combined with calcium channel blockers. However, all the other populations are recommended to use ACEI and angiotensin receptor inhibitors as first-line drug therapy. Therefore heart failure patients of black and Caribbean origin may use diuretics at stage A of heart failure progression.
References
Burchum, J. & Rosenthal, L. D. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier. ISBN: 9780323554954. https://myclasses.southuniversity.edu/d2l/common/dialogs/quickLink/quickLink.d2l?ou=98040&type=lti&rcode=southu-1435540&srcou=92411
Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022). Congestive heart failure. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Sinnott, S. J., Douglas, I. J., Smeeth, L., Williamson, E., & Tomlinson, L. A. (2020). First line drug treatment for hypertension and reductions in blood pressure according to age and ethnicity: cohort study in UK primary care. BMJ (Clinical research ed.), p. 371, m4080. https://doi.org/10.1136/bmj.m4080
Zhang, Y., Ding, X., Hua, B., Liu, Q., Chen, H., Zhao, X. Q., … & Li, H. (2020). Real-world use of ACEI/ARB in diabetic hypertensive patients before the initial diagnosis of obstructive coronary artery disease: patient characteristics and long-term follow-up outcome. Journal of Translational Medicine, 18, 1-13. https://link.springer.com/article/10.1186/s12967-020-02314-y
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