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CLINICAL EVALUATION OF HYPERTENSIVE PATIENTS WITH HEART FAILURE TREATED BY IECA

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CLINICAL EVALUATION OF HYPERTENSIVE PATIENTS WITH HEART FAILURE TREATED BY IECA

SUMMARY



Considering the present conception on the pathogenical mechanismes in the heart failure, IECA(angiotensin converting enzyme inhibitors) introduction in the treatment of heart failure at the hipertensive patients is trully justified. The eficacity of the treatment with IECA has been analyzed on 159 hipertensive patients with different grades of heart failure found in the health care of the general practioners. The patients were divided in two groups:

group A – was treated with IECA + diuretics +/- digoxin +/- nitrate;

group B – was treated with diuretics + calcium blockers +/- digoxin +/- nitrate.

Analysing the result data at the end of the fourteen months of following, in group A it is noticed an obvious improvement of the clinical condition, reducing the days of hospitalization and of the rate of rehospitalization, a reducing of the rate of major cardiovascular events and a rising of the quality life.

RESUME

Conformnement avec l’actuelle conception sur les mecanismes patogenetique dans l’insuficiences cardiaque, l’introduction IECA dans le traitement IC des patientes hypertensives est totalment justifie.

L’eficacite du traitement avec IECA a ete analyse sur 159 patients hypertensives avec les degres differents d’insuficience cardiaque trouves sur le listes de capilation de cabinet de medecen de famille.

Les patients ont ete partages dans deux lots:

le lot A a recu une traitement avec IECA + diuretique +/- digitale +/- nitrats

le lot B a recu une traitement avec diuretique + des blocants de calcium +/- digitale +/- nitrats

En etudiant les datte resultes on observe une evident amelioration entre ces deux lots de malade. Sur les patients du lot A traites avec IECA on observe une evidente amelioration de symptomatologie, une diminution de periode d’hospitalisation, et une reduction, de numbres des evenements cardiovasculaires majore et aussi une augmentation de qualite de la vie.

BACKGROUND

Numerous clinical trials have shown that IECA confer considerable sustained survival benefits in patients with cardiac heart failure (CHF) and are asociated with reductions in all cause mortality, disease progresion and hospitalizations in most CHF patient populations.

This study is following the IECA efficiency at hypertensive patients with CHF.

MATERIALS AND METHOD

We included in the study 159 hypertensive patients with different grades of heart failure found in the health care of the general practioniers. The patients were: 57(36%) men and 102(64%) women.

Fig.

The distribution on ages of patients was the following:

30-39 years –1 patient (< 1%)

40-49 years – 18patients (11%)

50-59 years – 39 patiens (25%)

60-69 years – 47 patiens (29%)

70-79 years – 48 patiens (30%)

80 and > 80 years – 6 patients (4%)

Fig.

The patients were divided in two groups:

Group A – was treated with IECA + diuretics +/ - digoxin +/- nitrate;

Groups B – was treated with diuretics + calcium blockors +/- digoxin +/- nitrate;

In group A there have been administered the following IECA:

LISINOPRIL – 15 patients (18%) usual daily dose 10- 20 mg;

CAPTOPRIL – 14 patients (17%) usual daily dose 12,5- 75 mg;

BENAZEPRIL – 9 patients (11%) usual daily dose 5- 20 mg;

PERINDOPRIL – 3 patients (4%) usual daily dose 2- 4 mg;

FOSINOPRIL – 2 patiens (2 %) usual daily dose 10 mg;

QUINALAPRIL –2 patients (2%) usual daily dose 5-10 mg.

Fig.

Both groups have been followed for 8 months.

In this period of time in both groups was followed the next parameters:

dyspnea ,cardiac pain , palpitations , another symptoms;

heart rate , blood pressure , arrhythmias , hepatomegaly , edema , weight;

cardio-thoracic index;

EKG , biological probes;

the number of their own presentations at the practionier due to subjective simptoms;

the number of rehospitalisation in Cardiologic Clinic and number of hospitalisation days during observation.

Also, we followed the way which was respected non farmacological and farmacological therapy.

RESULTS



After eight months from the begining of the treatment, the results between group A and group B were different. The number and percent of patients NYHA-classes was as followed:

Group A – initially had a number of:

- 52 patients (63,1%) in NYHA class II;

- 28 patients (33,3%) in NYHA class III;

- 3 patients (3,6%) in NYHA class IV.

Fig.

At the end of the eight months, the distribution on NYHA classes was:

36 patients (43%) in NYHA class I;

29 patients (34,4%) in NYHA class II;

18 patients (21,4%) in NYHA class III;

1 patient (1,2%) in NYHA class IV.

Fig.

Group B – initially had a number of:

49 patients (65,1%) in NYHA class II;

24 patients (32,3%) in NYHA class III;

2 patients (2,6%) in NYHA class IV.

Fig.

After the treatment, the distribution of NYHA classes has been the next:

- 23 patients (30,8%) in NYHA class I;

- 28 patients (37,3%) in NYHA class II;

- 22 patients (29,3%) in NYHA class III;

- 2 patients (2,6%) in NYHA class IV.

Fig.

The number of presentations of their own initiative at the general practioner, due of the appearance of an obvious symptomatology was of 26 (30,9%) in group A and of 41(54,6%) in group B.

Fig.

Within group A have hospitalised in Cardiologic Clinic a number of 9 patients while within group B have hospitalised a number of 17 patients.

Fig.

The average number of hospitalisation days in group A has been 7 days, and in group B has been 11 days.

Fig.

A total number of hospitalization days in group A has been 63 days while in group B has been 187 days.

Fig.

In group A have been registered majore cardiovascular events (acute myocardial infarction, unstable pectoris angina, stroke) at 3 pacients while in group B at 4 pacients.

Fig.

DISCUSSIONS

Analysing the result datas at the end of the eight months of following, it is noticed an obvious difference between the two groups of patients. In GROUP A it is noticed a reducing of the number of patients within NYHA class IV from 3 to 1, 2 patients passing in NYHA class III. From the 28 patients NYHA class III, at the end of following period in NYHA class III there have been only 18 (21,4%). From the 53 patients in NYHA class II (63,1%), 36 (43%) have passed in NYHA class I.

In GROUP B between the 24 patients in NYHA class III (32,3%) only 2 have passed in NYHA class II and from the 49 patients in NYHA class II (65,1%) at the end of the following period 23 patients have passed in NYHA class I (30,8%), in NYHA class II remaining 28 patients (37,3%).

It is noticed a significant improvement of NYHA class in group A which received IECA as treatment compared with group B. This improvement has an obvious correspondent in patients symptomatology, near the dyspnea reducing the others subjective accusations (chest pain, palpitations, physical astenia, fatique).

Tensional values have reduced moderately during the evolution without appearence simptomatic hipotencion. This is due to the applicatated therapeutical strategy too initially administrating reduced doses of IECA that we progressively rised.




Number of presentation of their own at the practionier because of manifest simptomatology was of 26 (30,9%) in group A compared with group B of 41 (54,6%).

Analysing the total and average number of hospitalisation days, the patients in group A needed an average number of 7 days and a total of 63 days compared to 11 respectively 187 days registered in group B.This aspect is very important considering the high cost of hospitalisation day and the necessity of the efficienty of the medical services.

The percent of the major cardiovascular events registered in group A was of 3,58% compared of 5,34% in group B. IECA reduce efficiently the blood pressure, have a very good effect upon the parameters of atheroscleroses.

It hasn’t been noticed the development of tolerance at the treatment with IECA after 8 months, at none of the patients in group A. Among the adverse effects of the treatment with IECA most frequently seen was dry cough, phenomen due to the excess of bradichinine – produced by these. The dry cough has been seen at 7 patients – 8,34% (4 women and 3 men), hasn’t needed interruption of the treatment but only the doses modify or the change of the administrated IECA type.

Analysing the obtained datas with the ones in the literature, it can be said that considering the investigated parametres, they are similar or superior to the reported datas in other studies. The interpretation must be done obviously considering the reduce relative number of studied cases compared with the investigated cases in great trials that proved the efficacity IECA in the treatment of the hypertensive patients and of those with heart failure.

CONCLUSIONS

The administration of IECA at the hypertensive patients with cardiac failure has a benefic effect determed:

the improvement of NYHA class ;

the reducing of the hospitalisation period and of the rehospitalisation rate;

the reducing with time of the dose and the frequency of the diuretics administration ;

the reducing of the major cardiovascular rate events;

incipient stages of cardiac failure, the early treatment with IECA reduce its progretion;

the improvement of the symptomatology and the quality of the life.

In the ambulatory following of the patients the most important role has the general practitioner. A constant care of the general practitioner will be represented by the sanitary education of the patient, the accurate information regarding his disease, the risk factors and the recovering methods, trying this way to gain their trust in the proposed therapeutical programme. The accurate supervising of the patient in ambulatory is one of the main methods of remove of the cardiovascular complications of HTA, so to reduce the mortality at this group of patients.

REFERENCES

  1. Bouvy ML, Heerdink ER, Leufkens HGM. Predicting mortality in patients with heart failure: a pragmatic approach. Heart 2003;89:605-9
  2. European Society of Hypertension-European Society of Cardiology Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hyperension. J Hypertens 2003; 21:1011-1053.
  3. Fuat A. Hungin A. Murphy J. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 2003; 326:196-201.
  4. Garg R, Yusuf S Overview of randomized trials of angiotensin – converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Jama 1995; 273:1450-1456.
  5. Guidelines Committee 2003. European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J. Hypertens 2003;21:1011-1053. GL
  6. Gherasim L., Dorobantu M – Tratamentul hipertensiunii arteriale – Principii si Practica – edit. Infomedica Bucuresti 2004
  7. Komajda M., Follath F., Swedberg K et al. The Euroheart Failure Survey programme – a survey on the quality of care among patients with heart failure in Europe. Part 2: Treatment Eur. Heart J. 2003;24:464-474.
  8. Popescu M Angiotensine-Converting Enzyme Inhibitors,edit. Univ. Oradea 2001 o enalapril or placebo. A, J Cardiol 1993;71(12):
  9. Rector TS, Kubo SH, Cohn JN. Validity of Minnesota Living with Heart Failure questionnaire as a measure of therapeutic response to enalapril or placebo. A, J Cardiol 1993;71(12):1106-7.


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