Cardiac medications
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Cardiac Medications: Efficacy, Risks, and Management
Traditional Chinese Medication for Cardiovascular Disease
Efficacy and Challenges
Traditional Chinese medication (TCM) is increasingly utilized for treating cardiovascular disease (CVD) in China and other Asian countries. Despite its popularity, the therapeutic efficacy and adverse effects of TCM are difficult to evaluate due to the lack of large-scale, randomized controlled trials (RCTs). A review of 68 RCTs involving 16,171 patients indicated that TCM significantly improved surrogate endpoints for hypertension, coronary heart disease, cardiac arrhythmias, and heart failure. However, the methodological quality of these trials was generally low, and only three reports specifically described adverse cardiovascular events.
Safety Profile
The risk of adverse effects with TCM was not higher compared to no intervention, placebo, or Western medications. However, the effectiveness of TCM in reducing all-cause or cardiovascular mortality remains unproven and requires further large-scale RCTs.
Antiarrhythmic Drug Therapy and Cardiac Mortality
Increased Mortality Risk
Antiarrhythmic drugs are commonly used to manage atrial fibrillation, but their impact on cardiac mortality is concerning. In a study involving 1,330 patients, those receiving antiarrhythmic drugs had a 2.5-fold increase in cardiac mortality and a 2.6-fold increase in arrhythmic death compared to those not receiving these drugs. The risk was particularly high in patients with a history of congestive heart failure, where the relative risk of cardiac death was 4.7 and arrhythmic death was 3.7.
Clinical Implications
These findings suggest that the risks of antiarrhythmic drug therapy may outweigh the benefits in patients with atrial fibrillation and a history of heart failure, highlighting the need for careful patient selection and monitoring.
Use of Antiarrhythmic Drugs During Cardiac Arrest
Guideline Updates
The 2018 American Heart Association guidelines recommend considering either amiodarone or lidocaine for treating shock-refractory ventricular fibrillation/pulseless ventricular tachycardia during cardiac arrest. However, evidence supporting the use of these medications to improve patient outcomes remains limited.
Systematic Review Findings
A comprehensive review of 25 studies found that amiodarone improved survival to hospital admission but not to hospital discharge when compared to lidocaine in patients with ventricular tachycardia/ventricular fibrillation. This suggests that while amiodarone may be beneficial in the acute setting, its long-term benefits are unclear.
Medication Management of Cardiac Allograft Vasculopathy
Preventive Strategies
Cardiac allograft vasculopathy (CAV) is a common complication post-heart transplantation. Immunosuppressive medications like mycophenolate, tacrolimus, sirolimus, and everolimus have been effective in preventing CAV. Additionally, cardiovascular medications such as statins, gemfibrozil, calcium channel blockers, and ACE inhibitors have shown efficacy in preventing CAV.
Disease Management
For patients who develop CAV, sirolimus is the only medication shown to arrest disease progression, emphasizing the importance of early and effective medication management.
Drug-Induced Heart Failure and Arrhythmias
Non-Cardiac Drugs
Heart failure can be induced by non-cardiac drugs, including anticancer agents, immunomodulating drugs, antidiabetic medications, and NSAIDs. These drugs can adversely affect hemodynamic mechanisms, particularly in patients with pre-existing heart conditions.
Arrhythmias
Many medications, including antiarrhythmic agents, antimicrobials, and psychotropic drugs, can cause or exacerbate arrhythmias. These can range from bradyarrhythmias to life-threatening conditions like torsades de pointes and ventricular tachycardia. Management involves discontinuing the offending drug and following specific treatment guidelines for the arrhythmia.
Cardiovascular Drug Therapy in Elderly Patients
Age-Related Considerations
Elderly patients often receive cardiovascular drugs for both acute and chronic conditions. However, age-related changes in pharmacokinetics and pharmacodynamics necessitate careful consideration of drug therapy in this population. There is limited evidence on the effects of these drugs in patients over 80 years, raising concerns about their appropriate use.
Enhancing Medication Adherence
Interventions
Adherence to cardiac medications is crucial for managing heart disease, yet remains suboptimal. Interventions such as motivational interviewing, education, and phone or text messaging have shown promise in improving adherence. Future research should focus on multifaceted interventions targeting individual behavior change to enhance adherence to cardiovascular medications.
Conclusion
Cardiac medications play a vital role in managing various cardiovascular conditions, but their use comes with significant risks and challenges. Traditional Chinese medications show promise but require more rigorous evaluation. Antiarrhythmic drugs, while essential in certain scenarios, can increase mortality risk, particularly in patients with heart failure. Effective management of cardiac allograft vasculopathy and drug-induced heart conditions necessitates careful selection and monitoring of medications. Enhancing adherence to cardiovascular drugs through targeted interventions can significantly improve patient outcomes.
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