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Extra resources for ABC of Heart failure
In general, amiodarone should probably be reserved for patients with chronic heart failure who also have symptomatic ventricular arrhythmias. Interest has also developed in implantable cardioverter defibrillators, which reduce the risk of sudden death in high risk patients with ventricular arrhythmias (MADIT and AVID studies), although the role of these devices in patients with chronic heart failure still remains to be established. 4 0 90 180 270 360 450 540 630 720 Days from randomisation Survival curves from GESICA trial (see key references box), showing difference between patients taking amiodarone and controls Summary of drug management in chronic heart failure Drug class Potential therapeutic role Diuretics Symptomatic improvement of congestion.
Short term bed rest is valuable until signs and symptoms improve: rest reduces the metabolic demand and increases renal perfusion, thus improving diuresis. Although bed rest potentiates the action of diuretics, it increases the risk of venous thromboembolism, and prophylactic subcutaneous heparin should be considered in immobile inpatients. Full anticoagulation is not advocated routinely unless concurrent atrial fibrillation is present, although it may be considered in patients with very severe impairment of left ventricular systolic function, associated with significant ventricular dilatation.
Nevertheless, there is conflicting evidence of benefit from routine treatment of patients with heart failure who are in sinus rhythm with antithrombotic treatment, although anticoagulation should be considered in the presence of mobile ventricular thrombus, atrial fibrillation, and severe cardiac impairment. Large scale, prospective randomised controlled trials of antithrombotic treatment in heart failure are in progress, such as the WATCH study (a trial of warfarin and antiplatelet therapy); the full results are awaited with interest.