What are the pertinent negatives for Congestive Heart Failure (CHF)?

From the Guidelines

The most critical negatives for Congestive Heart Failure (CHF) include the avoidance of certain medications that can exacerbate the condition, such as diltiazem or verapamil, which increase the risk of HF worsening and hospitalization 1. When managing patients with symptomatic heart failure with reduced ejection fraction, it is essential to be aware of treatments that may cause harm. Key negatives to consider include:

• The use of diltiazem or verapamil, which are not recommended due to their potential to increase the risk of HF worsening and hospitalization 1
• The addition of an angiotensin receptor blocker (ARB) or a renin inhibitor to a combination of an angiotensin-converting enzyme inhibitor (ACE-I) and a mineralocorticoid receptor antagonist (MRA), as this can lead to an increased risk of renal dysfunction and hyperkalemia 1 These considerations are crucial in the management of CHF, as they can significantly impact patient outcomes, including morbidity, mortality, and quality of life. By avoiding these harmful treatments, clinicians can optimize care for patients with CHF and reduce the risk of adverse events. It is also important to note that these recommendations are based on the most recent and highest-quality evidence available, specifically the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.

From the FDA Drug Label

In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention Patients with acute myocardial infarction, treated with lisinopril, had a higher (9.0% versus 3.7%) incidence of persistent hypotension (systolic blood pressure < 90 mmHg for more than 1 hour) and renal dysfunction (2.4% versus 1. 1%) in-hospital and at six weeks (increasing creatinine concentration to over 3 mg per dL or a doubling or more of the baseline serum creatinine concentration)

The pertinent negatives for Congestive Heart Failure (CHF) when using lisinopril include:

• Persistent hypotension: 9.0% incidence in patients with acute myocardial infarction
• Renal dysfunction: 2.4% incidence in patients with acute myocardial infarction These negatives are associated with the use of lisinopril in patients with CHF, particularly in those with acute myocardial infarction 2.

From the Research

Pertinent Negatives for Congestive Heart Failure (CHF)

The following are some of the pertinent negatives associated with Congestive Heart Failure (CHF):

• Increased risk of rehospitalization for HF, with the presence of pulmonary rales and S3 associated with worse readmission rates 3
• Elevated troponin T (TnT) levels at the time of discharge, which may indicate ongoing myocardial injury 3
• Limited ability to manage the condition, particularly among older patients with depression and anxiety 4
• Salt avidity, which can contribute to an inability to adequately excrete dietary sodium, leading to clinical decompensation and the appearance of CHF 5
• Difficulty in assembling HF-free cohorts for prospective population studies due to the limitations of symptoms such as orthopnea and paroxysmal nocturnal dyspnea in diagnosing prevalent HF 6
• Limited effectiveness of certain treatments, such as ramipril, in improving exercise capacity in patients with moderate CHF 7

Clinical Implications

These negatives have significant clinical implications, including:

• The need for close monitoring and management of patients with CHF to prevent rehospitalization and reduce the risk of ongoing myocardial injury 3
• The importance of addressing psychological and social factors, such as depression and anxiety, in the management of CHF 4
• The need for careful management of dietary sodium and fluid balance to prevent clinical decompensation 5
• The development of more effective diagnostic tools and strategies for assembling HF-free cohorts for prospective population studies 6
• The need for further research into the effectiveness of different treatments for CHF, including the use of angiotensin converting enzyme inhibitors such as ramipril 7