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Acute Precipitants of Congestive Heart Failure Exacerbations
Ross T. Tsuyuki, BSc(Pharm), PharmD, MSc;
Robert S. McKelvie, MD, PhD;
J. Malcolm O. Arnold, MD;
Álvaro Avezum, Jr, MD;
Antônio C. P. Barretto, MD;
Antonio C. C. Carvalho, MD;
Debra L. Isaac, MD;
Allan D. Kitching, MD, MSc;
Leopoldo S. Piegas, MD, PhD;
Koon K. Teo, MB, PhD;
Salim Yusuf, DPhil, FRCPC
Arch Intern Med. 2001;161:2337-2342.
Background Few studies have prospectively and systematically explored the factors
that acutely precipitate exacerbation of congestive heart failure (CHF) in
patients with left ventricular dysfunction. Knowledge of such factors is important
in designing measures to prevent deterioration of clinical status. The objective
of this study was to prospectively describe the precipitants associated with
exacerbation of CHF status in patients enrolled in the Randomized Evaluation
of Strategies for Left Ventricular Dysfunction Pilot Study.
Methods We conducted a 2-stage, multicenter, randomized trial in 768 patients
with CHF who had an ejection fraction of less than 40%. Patients were randomly
assigned to receive enalapril maleate, candesartan cilexetil, or both for
17 weeks, followed by randomization to receive metoprolol succinate or placebo
for 26 weeks. Investigators systematically documented information on clinical
presentation, management, and factors associated with the exacerbation for
any episode of acute CHF during follow-up.
Results A total of 323 episodes of worsening of CHF occurred in 180 patients
during 43 weeks of follow-up; 143 patients required hospitalization, and 5
died. Factors implicated in worsening of CHF status included noncompliance
with salt restriction (22%); other noncardiac causes (20%), notably pulmonary
infectious processes; study medications (15%); use of antiarrhythmic agents
in the past 48 hours (15%); arrhythmias (13%); calcium channel blockers (13%);
and inappropriate reductions in CHF therapy (10%).
Conclusions A variety of factors, many of which are avoidable, are associated with
exacerbation of CHF. Attention to these factors and patient education are
important in the prevention of CHF deterioration.
From the Division of Cardiology, University of Alberta, Edmonton (Dr
Tsuyuki); the Division of Cardiology, McMaster University, Hamilton, Ontario
(Drs McKelvie, Kitching, Teo, and Yusuf); the Division of Cardiology, University
of Western Ontario, London (Dr Arnold); the Dante Pazzanese Cardiology Institute
(Drs Avezum and Piegas), the Heart Institute, University of São Paulo
Medical School Hospital (Dr Barretto), and the Paulista School of Medicine,
Federal University of São Paulo (Dr Carvalho), São Paulo, Brazil;
and the Division of Cardiology, University of Calgary, Calgary, Alberta (Dr
Isaac).
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