Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3), with jejunostomy being reserved for cases in which it is not possible to use the gastric route.

Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is [HIDDEN], with jejunostomy being reserved for cases in which it is not possible to use the gastric route.

A 73-year-old patient...swallowing a complete neurological dysphagia secondary to a cardioembolic stroke in the left middle cerebral artery territory. will require long-term nutritional support. Of the following treatment modalities, which do you consider most appropriate for this case?

Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke.

The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group (n = 115); 30-day mortality was similar but more patients recovered the ability to swallow. Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.

[Nutritional support in stroke patients].

Stroke is a public health problem of the first order. In developed countries is one of the leading causes of death, along with cardiovascular disease and cancer. In addition, stroke is the leading cause of permanent disability in adulthood. Many of the patients who survive do so with significant sequelae that limit them in their activities of daily living. Most strokes (80-85%) are due to ischemia, while the rest are hemorrhagic. We have identified many modifiable risk factors, some with an important relationship with dietary factors or comorbidities in wich the diet has a significant impact. The incidence of malnutrition in stroke patients is not well known, but most likely impacts on patient prognosis. Furthermore, the nutritional status of patients admitted for stroke often deteriorates during hospitalization. It is necessary to perform a nutritional assessment of the patient in the early hours of admission, to determine both the nutritional status and the presence of dysphagia. Dysphagia, through alteration of the safety and efficacy of swallowing, is a complication that has an implication for nutritional support, and must be treated to prevent aspiration pneumonia, which is the leading cause of mortality in the stroke patient. Nutritional support should begin in the early hours. In patients with no or mild dysphagia that can be controlled by modifying the texture of the diet, they will start oral diet and oral nutritional supplementation will be used if the patient does not meet their nutritional requirements. There is no evidence to support the use of nutritional supplements routinely. Patients with severe dysphagia, or decreased level of consciousness will require enteral nutrition. Current evidence indicates that early nutrition should be initiated through a nasogastric tube, with any advantages of early feeding gastrostomy. Gastrostomy will be planned when the enteral nutrition support will be expected for long-term (4 weeks). Much evidence points to the importance of glycemic control during hospitalization for stroke. Hyperglycemia at diagnosis and during the first hours of admission impact on patient prognosis. The goal of glycemic control necessary to modify this bad prognosis without adding risk by iatrogenic hypoglycemia is still matter of debate.

Laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy for superior mesenteric artery syndrome with dysphagia: a case report.

Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient's condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy. A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up. Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke?

Dysphagia occurs in up to 50% of patients admitted to hospital with acute strokes with up to 27% remaining by seven days. Up to 8% continue to have swallowing problems six months after their stroke with 1.7% still requiring enteral feeding. Nasogastric tubes (NGT) are the most commonly used method for providing enteral nutrition in early stroke, however they are easily and frequently removed leading to inadequate nutrition, early PEG (Percutaneous Endoscopic Gastrostomy) insertion or abandoning of feeding attempts. Looped nasogastric tube feeding may improve the delivery of nutrition to such patients. Three centre, two arm randomised controlled trial, with 50 participants in each arm comparing loop (the intervention) versus conventional nasogastric tube feeding. The primary outcome measure is proportion of intended feed delivered in the first 2 weeks. The study is designed to show a mean increase of feed delivery of 16% in the intervention group as compared with the control group, with 90% power at a 5% significance level. Secondary outcomes are treatment failures, mean volume of feed received, adverse events, cost-effectiveness, number of chest x-rays, number of nasogastric tubes and tolerability. ISRCTN Number: ISRCTN61174381.

Continuation of Enteral Nutrition and Relief from Vomiting by Administration of a New Formula: a Case Report.

Gastro-esophageal reflux (GER) is a common and serious complication in patients receiving enteral nutrition, making continuation of enteral nutrition difficult. Semi-solid enteral nutrients were developed to prevent feeding-related GER. Semi-solid enteral nutrients have high viscosity and, therefore, are typically administered through a large-diameter percutaneous endoscopic gastrostomy (PEG) tube. Recently, a new formula (Mermed<sup®</sup, Mermed Plus<sup®</sup) was introduced that uses alginate, which behaves like a gelatin in acidic conditions. This formula improved GER during enteral feedings. Our case report shows that this new formula enables the continuation of enteral nutrition via a nasogastric tube (NGT) in patients with difficulty tolerating enteral nutrition secondary to vomiting. An 86-year-old woman with an atherothrombotic cerebral infarction vomited during tube feeding, resulting in aspiration pneumonia. After 1 week, we introduced a viscosity regulator and restarted enteral feeding using a 100 mL liquid diet, but vomiting persisted. Because of the continued difficulty in tolerating enteral nutrition, the patient was transferred to our hospital. From hospital day 4, Mermed Plus<sup®</sup (300 mL/225 kcal, administered for 1 hour, 3 times a day) was started, eventually increasing to 535 mL/400 kcal at hospital day 5. After this, vomiting ceased. Mermed Plus<sup®</sup was easily administered via NGT, and its effects were immediate. This treatment appeared to improve the patient's quality of life while reducing the burden on medical staff.

[Percutaneous endoscopic gastrostomy--a possibility for enteral feeding of patients with severe cerebral dysfunctions].

Patients who are unable to be adequately nourished owing to cerebral dysfunction do not tolerate nasogastric tubes for enteral nutrition well. They are threatened by active or passive dislocation of the tube into the oesophagus with subsequent aspiration. Although these risks are minimized by percutaneous gastrostomy (PEG), aspiration cannot be completely prevented even when this method of feeding is employed. Enteral nutrition was provided by PEG in 33 patients with different cerebral disorders. PEG was indicated when adequate oral intake of food and fluids proved impossible 8 to 12 days after an acute hypoxaemic cerebrovascular event. 3 of 23 patients who had suffered a stroke, 2 of 8 patients with hypoxaemic brain damage and 3 of 5 patients with decompensated cerebral sclerosis regained the ability to eat between the 21st and 50th day of treatment, so that the gastrostomy could be dispensed with. The other patients died of their severe underlying disease. 6 patients aspirated. In 2 cases this complication occurred during acute aggravation of the underlying disease after several weeks of satisfactory enteral tube feeding. 2 patients aspirated after returning to oral nutrition, whereby feeding was certainly implicated in 1 patient and probable in the other patient. PEG enables adequate enteral nutrition of patients with severe neurological impairment. The advantages of PEG over parenteral nutrition are fewer complications, lower costs and, above all, its superiority in meeting physiological requirements.

Long-Term Nasogastric Versus Percutaneous Endoscopic Gastrostomy Tube Feeding in Older Asians With Dysphagia: A Pragmatic Study.

A barrier to gastrostomy feeding exists among Asian clinicians and caregivers due to negative perceptions regarding complications. We compared clinical and nutrition outcomes in older dysphagic Asian patients with nasogastric (NG) or gastrostomy tube feeding using a pragmatic study design. The choice of enteral tube access was determined by managing clinicians and patients/caregivers. Comparisons of tube feeding methods were made during a 4-month period, adjusting statistically for inherent confounders. A total of 102 participants (NG: n = 52, gastrostomy: n = 50) were recruited over 2 years from 2013 to 2015. Subjects on long-term NG tube feeding were older (82.67 ± 7.15 years vs 76.88 ± 7.37 years; P < .001) but both groups had similar clinical indications (stroke: 63.5% NG vs 54% gastrostomy; P = .33). After adjustment for confounders, gastrostomy feeding was associated with fewer tube-related complications (adjusted odds ratio [aOR] = 0.19; 95% confidence interval [CI] = 0.06-0.60) and better complication-free survival rate (aOR = 0.32; 95% CI = 0.12-0.89) at 4-month follow-up. Anthropometric and biochemical nutrition parameters improved significantly in both groups at 4 months, but no significant differences were observed at the end of the study. Gastrostomy feeding is associated with a greater 4-month complication-free survival and lower tube-related complications compared with long-term NG feeding in older Asians with dysphagia. However, no differences in nutrition outcomes were observed between NG and gastrostomy feeding at 4 months.

Indications for tube feedings in elderly patients.

Tube feedings are utilized in elderly patients with acute and chronic problems. Inadequate oral intake with malnutrition, comatose state, neurologic disorders with severe dysphagia, extensive burns, massive gastrointestinal resection, and oropharyngeal and upper gastrointestinal malignancies are the commonly encountered conditions requiring tube alimentation. Dysphagia with frequent aspiration is the most common indication for use of tube feedings in the elderly. Nasogastric tube is preferred for short-term feeding, while gastrostomy or jejunostomy is indicated for long-term or permanent nutritional support. Nutritional assessment should be done initially and on a regular basis. Specific formulas are available to calculate height, weight, and caloric needs of bedbound elderly patients. Various enteral feeding formulas are available for a specific clinical condition and are preferably administered by continuous drip using a pump. Parenteral nutrition is also indicated for certain situations in which enteral feeding cannot meet the patient's nutritional requirement, and in particular situations where enteral feeding is contraindicated and not feasible. Optimal patient care is dependent on adequate nutritional support.

Enteral tube feeding for dysphagic stroke patients.

Enteral feeding tubes, a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG), are commonly used to provide nutrition, hydration and essential medications to stroke patients who cannot swallow. Early tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. NGT feeding is the preferred method for short-term feeding in the acute phase of stroke as it has the advantage of being easily placed at the bedside. However, there are often difficulties inserting the NGT and it can be easily dislodged by agitated and confused patients, leading to potentially fatal complications. A PEG tube is considered a more secure method of feeding stroke patients who require longer-term nutritional support, but it is an invasive procedure that can result in complications that are associated with an increased risk of morbidity and mortality after stroke. The aim of this article is to review the complications associated with enteral feeding tubes and discuss their prevention and management for stroke patients.

[Dysphagia in patients with disorders of the nervous system--comparison of a nasogastric tube with percutaneous endoscopic gastrostomy].

Dysphagia is frequently encountered in patients with acute affections of the nervous system (cerebrovascular attacks, craniocerebral injuries) and in chronic nervous diseases (amyotrophic lateral sclerosis, Parkinson s disease, dementia). To these patients enteral nutrition must be administered. If the perspective of dysphagia is short (several days) then nutrition by a nasogastric tube is fully indicated and sufficient. In cases of more prolonged dysphagia and in patients with a long perspective of dysphagia percutaneous endoscopic gastrostomy (PEG) is indicated. Both these methods of enteral nutrition have their advantages and disadvantages which are manifested in different ways in patients with disorders of the nervous system. The authors compared 62 patients hospitalized in the course of 4.5 years at the neurological department who had PEG with 72 patients who had nasogastric tubes and were hospitalized at the neurological intensive care unit in the course of one year. The authors evaluated the different indications for application, the incidence of complications and the advantages and disadvantages of the two methods.

A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke.

To compare percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. Randomised prospective study of inpatients with acute stroke requiring enteral nutrition. One university hospital (Nottingham) and one district general hospital (Derby). 30 patients with persisting dysphagia at 14 days after acute stroke: 16 patients were randomised to gastrostomy tube feeding and 14 to nasogastric tube feeding. Six week mortality; amount of feed administered; change in nutritional state; treatment failure; and length of hospital stay. Mortality at 6 weeks was significantly lower in the gastrostomy group with two deaths (12%) compared with eight deaths (57%) in the nasogastric group (P < 0.05). All gastrostomy fed patients (16) received the total prescribed feed whereas 10/14 (71%) of nasogastric patients lost at least one day's feed. Nasogastric patients received a significantly (P < 0.001) smaller proportion of their prescribed feed (78%; 95% confidence interval 63% to 94%) compared with the gastrostomy group (100%). Patients fed via a gastrostomy tube showed greater improvement in nutritional state, according to several different criteria at six weeks compared with the nasogastric group. In the gastrostomy group the mean albumin concentration increased from 27.1 g/l (24.5 g/l to 29.7 g/l) to 30.1 g/l (28.3 g/l to 31.9 g/l). In contrast, among the nasogastric group there was a reduction from 31.4 g/l (28.6 g/l to 34.2 g/l) to 22.3 g/l (20.7 g/l to 23.9 g/l) (P < 0.003). In addition, there were fewer treatment failures in the gastrostomy group (0/16 versus 3/14). Six patients from the gastrostomy group were discharged from hospital within six weeks of the procedure compared with none from the nasogastric group (P < 0.05). This study indicates that early gastrostomy tube feeding is greatly superior to nasogastric tube feeding and should be the nutritional treatment of choice for patients with acute dysphagic stroke.

[Home enteral nutrition: analysis of efficiency in a Health District].

Studies on the analysis of direct costs generated by household enteral nutrition (HEN) have been scant. The objective of our study was to carry out a direct costs analysis of household enteral nutrition using both the biochemical and nutritional monitoring values of the nutritional state as a point of reference. Since January 1999 until December 2001, we studied a total sample of 102 consecutive patients with indication of household nutritional support. The following epidemiological data were obtained in all patients: age, sex, and primary condition for which enteral nutrition was prescribed; we carried out an anthropometric assessment and a biochemical nutritional assessment quarterly. We recorded also the number of episodes of diarrhea, vomiting, aspiration pneumonia, and death during the treatment. Average age of the patients was 58.7 13.3 years. The number and proportion of patients according to primary conditions were the following: 71 (69.3%) with head and neck cancer, 14 (13.9%) with a neurological condition with swallowing disturbance (stroke and/or dementia), 6 (5.9%) with tumors in other locations, and 11 (10.9%) with a group of diseases associated with dysphagia or anorexia. HEN was administered by oral route in 81 patients (79.4%), by nasogastric tube (NGT) in 15 patients (14.7%), by PEG in 5 patients (4.9%) and by yeyunostomy in 1 patient (1%). Average duration of HEN was 101 46.9 days. We showed a significant improvement of biochemical and anthropometric parameters in patients with HEN. The economic analysis of direct costs generated by enteral nutrition showed that the total average cost of nutritional formulas and expendable equipment utilized (holders, probes and nutritional tubes) was 300,033 599,203 pesetas/full treatment/patient (1,803 3,601 euros), or a daily average cost of 2,970 5,932 pesetas/day/patient (17.8 35.6 euros). In the analysis of costs acording to different items, the expendable equipment (nutritional tubes, nasogastric tubes and nutritional formula holders) were an average of 1,284 4,571 pesetas/full treatment/patient (7.7 27.4 euros) (5% in total), and the nutritional preparations were an average of 231,313 399,756 pesetas/full treatment/patient (1,390.2 2,402 euros) (95%). The patients with greater resources expenditure were those with tumors of head and neck. In order to analyze the efficiency of this treatment an analysis of costs was carried out for each objective parameter indicating nutritional status improvement; that way, the increase of 1 g/dl of albumin was an average cost of 103,817 2,897 pesetas (623.9 17.4 euros), while the increase of 1 kg of weight was an average cost of 857,237 25,097 pesetas (5,152.1 150.8 euros). CONCLUSIONS. In summary, nutrition enteral household was an effective therapy for nutritional status improvement in different groups of ambulatory patients. The cost of the nutritional support was superior in the group of patients with tumors of the upper aereodigestive system because of the greater duration of the treatment and the complex access route.

Ischemic Stroke -- Treatment / Management -- Nutrition

Early enteric feeding should be encouraged. For patients with dysphagia, use a nasogastric tube to promote enteric feeding. If there is concern that the patient may have swallowing difficulties for a prolonged period (more than 2 to 3 weeks), placing a percutaneous gastrostomy tube is recommended. Early feeding has been demonstrated to have an absolute reduction in the risk of death [24] .

The Use of Enteral Nutrition in the Management of Stroke.

This article discusses the use of enteral nutrition in the management of stroke. Stroke is a major source of disability, including dysphagia. The clinical manifestation of swallowing difficulties in stroke patients may lead to malnutrition which has implications for health status and clinical outcomes including morbidity, mortality and cost to the health service. The prevalence of malnutrition following an acute stroke could range from 8% to 34%. Therefore, the need to develop and implement the use of enteral nutrition support in stroke patients becomes pertinent. A range of enteral feeding tubes and feeding methods may be used to support stroke patients who are unable to meet their nutritional requirements through oral intake alone, although each of these approaches has its merits and limitations. Based on this review, there is evidence that enteral nutrition support is a useful method of providing nutrition for patients with dysphagia following a stroke in order to enhance their nutritional status and promote their health. However, there are challenges in the use of enteral tube feeding in these patients.

Percutaneous endoscopic gastrostomy

PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus. Indications Gastrostomy may be indicated in numerous situations, usually those in which normal (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).

Nasogastric Tube -- Indications

Less commonly, nasogastric tubes can be placed to administer medications or nutrition in patients who have a functional gastrointestinal tract but are unable to tolerate oral intake. This is most common in patients who have suffered a stroke or other malady, which has left them unable to swallow effectively. [3] Nasogastric tubes may be placed for nutritional support while waiting to see how much function the patient will recover, and if the patient does not recover their swallowing ability or will otherwise require long term nutritional support, then a more permanent feeding tube should be placed such as gastrostomy or jejunostomy feeding tube.

Dysphagia

Oral vs. nonoral feeding Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy.

Nutrition in the stroke patient.

Malnutrition is common both before and after stroke, with dysphagia adding to nutrition risk. Many patients require specialized nutrition support in the acute phase and beyond when swallowing function does not improve or return to allow for nutrition autonomy. When neurologic deficits improve, assessment of the swallowing function, introduction of dysphagia diets, and specialized swallowing techniques are used to transition away from enteral feeding tubes to oral diets. This article reviews the evaluation and treatment of dysphagia, use of specialized nutrition support, strategies for weaning enteral tube feedings, and the impact of nutrition on quality of life in the stroke patient population.

[The use of percutaneous endoscopic gastrostomy for provision of the long-term enteral nutrition].

Percutaneous endoscopic gastrostomy for provision of the long-term enteral nutrition is well established in clinical practice because unlike from traditional gastrostomy and jejunostomy allowed to avoid many complications. The technique is used for enteral tube feeding in the absence of real positive predictive recovery of consciousness and swallowing function. During presented study from 387 patients with a gastrostomy imposed by percutaneous endoscopic technique, observed only 1,8% of suppurative complications and in 1% of cases - uncontrolled removal of the tube by the patient. Our experience allows us to recommend this technique for wide implementation in practice of medical institutions in case when it is necessity in enteral feeding more than 3 weeks of patients with impaired

[Percutaneous endoscopic gastrostomy: prospective experience at a national private center].

Percutaneous endoscopic gastrostomy tube feeding is a safe and effective method of providing long-term enteral nutrition in patients who are unable to swallow and offers important advantages over nasogastric tub feeding. The indications of this procedure have been received and over 7 years of practice on 103 patients and 128 procedures have been experienced with Ponsky pull techniques. All patients were given vitamin K and a prophylactic antibiotic (chephalotine) prior to testing. 1.56% of major deadly complications have been reports both for reflux and aspiration at 48 and 72 hours post treatment. The most common minor complication was wound infection in 8.9% of patients. There was no further mortality during testing or while undergoing treatment in the following 30 days. All patients were suffering from post heart attack dementia and stroke (CVA) at a rate of 23.3% and 21.4%, respectively. Percutaneous endoscopic gastrostomy has become the method of choice to sustain long-term enteral nutrition.

Feeding tube

Product types Medical nutrition companies make flavored products for drinking and unflavored for tube feeding. These are regulated as medical foods, which are defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) as "a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation." Types The most common types of tubes include those placed through the nose, including nasogastric, nasoduodenal, and nasojejunal tubes, and those placed directly into the abdomen, such as a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube. Nasogastric feeding tube

Clinical outcomes and complications of enteral nutrition among older adults.

Several reviews or clinical trials published in the last years have not demonstrated that tube feeding can improve outcomes, including inhalation pneumonia, survival, pressure sores. Further, high rate of risks are recognized. Therefore, this practice should be discouraged for severely demented patients. The aim of this study was to assess the validity of these findings in a sanitary district in the Venetian Region, Italy, characterized by a fully integrated program of territorial-hospital care and where enteral nutrition (EN) is supervised by a specialized nutritional team (NT). A distinctive aspect of this study concerns the fact that all patients with tube feeding were followed at home, in hospital, in nursing home by the same NT. The team controls the selection of patients and supports the follow-up, according to the guidelines of the Italian Society of Parenteral and Enteral nutrition. The study provides a prospective evaluation including 108 patients, mean age 78.2 years, followed for 12 months. Each patient underwent multidimensional tests, including activities of daily living, instrumental activities of daily living, Norton, Pfeiffer and Karnofsky scales, and anthropometric and biochemical indicators of nutritional status. The main diagnoses were dementia (72 patients), stroke (23 patients), malignancy (5 patients), amyotrophic lateral sclerosis (3 patients) and miscellaneous disease (5 patients). EN was delivered by PEG (62 patient), NGT (45 patient), jejunostomy in one patient. The main complications of nasogastric tube versus PEG have been inhalation 15.5% and 7.9%, respectively, tube displacement 62.2%, and 4.7%, tube clogging 11.1% and 7.9 %. The first month mortality rate was 7.4% and 23.1% at one year. The mean survival was 674 days. Almost all complications have been mild and could be managed throughout adequately. Their prevalence is low, with reference to the long period of follow-up, for a whole of 39420 days. Tube displacement is frequent with NGT but not with PEG and may be a cause of physical restraint, compromising in this way patient's quality of life. In this study, survival was nearly three times higher than reported in literature. These positive outcomes may be the result of two factors. First, the selection and follow-up program was supervised by the same nutritional team. Second, the network of integrated services of continuing care, including nursing homes, hospital and home care.

A Descriptive Study of enteral tube feeding among adults in an acute care tertiary hospital-patient selection, characteristics and complications.

It is vital to develop a better understanding of the use of different modalities for enteral feeding and its associated complications, given differences in funding support, community resources and infrastructure available to support home enteral feeding in an acute care tertiary hospital. To provide a description of the clinical characteristics of patients on long-term enteral feeding and incidence of associated complications. A retrospective case records review study design was adopted. Medical records of patients discharged from a tertiary hospital with long-term nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) feeding for the first time during the period of January 2010 to June 2017 were reviewed. Data collected include patient's demographics, reason for enteral feeding, morbidity and nutritional status upon initiation of NGT and PEG feeding, readmission episodes and documented complications (associated with enteral feeding) within one-year post discharge. Records of 120 NGT and 118 PEG patients were analysed. Significant age and gender differences were found with older patients being more likely to be placed on NGT [NGT (Mean 79.1, SD 11.3) vs. PEG (Mean 67.1, SD 12.6)] and higher number of females in the NGT group as compared to the PEG group (NGT 59.2% vs. PEG 31.4%). Majority of patients were fed by caregivers in the NGT (99.2%) as compared to the PEG (51.7%) group. Patients with cancer were more likely to be on PEG feeding (NGT 5%, PEG 70.3%), whereas patients with stroke-related diagnoses were more likely to be on NGT feeding (NGT 48% vs. PEG 8.5%). The total Charlson Comorbidity score was also significantly different between the NGT (mean = 5.7; SD = 1.5) and PEG (mean = 4.5; SD = 2.0) groups. A higher number of patients with PEG feeding had no complications (47.5%) as compared to the NGT group (8.3%). Patients who received NGT feeding were more likely experience tube blockage [OR 0.03, 95% CI (0.001-0.72), p = 0.03], secondary displacement of tube [OR 0.04, 95% CI (0.002-0.72), p = 0.03] and accidental tube removal [OR 0.03, 95% CI (0.004-0.21), p < 0.001]. Overall, patients who received NGT feeding experienced more complications than those who had PEG feeding. The choice for NGT or PEG feeding may be influenced by patient related factors as well as the presence of caregivers, which need to be considered in the improvement of enteral nutrition services in the local context.

Medical decision making about long-term artificial nutrition after severe stroke: a case report.

Choosing to use a percutaneous endoscopic gastrostomy (PEG tube) for long term artificial nutrition in the setting of inadequate oral intake after stroke is complex because the decision must be made in a relatively short amount of time and prognosis is often uncertain. This case study utilized interviews with attending and resident neurologists, and surrogate medical decision makers in order to examine how neurologists and surrogate medical decision makers approached the decision to either receive a PEG tube or pursue comfort measures after severe stroke in two patients. Although these two patients presented with similar clinical characteristics and faced similar medical decisions, different decisions regarding PEG tube placement were made. Major challenges included physicians who did not agree on prognosis and surrogates who did not agree on whether to place a PEG tube. These cases demonstrate the importance of the role of the surrogate medical decision maker and the necessity of physicians and surrogate medical decision makers approaching the complex decision of PEG tube placement after stroke together. Additionally, these cases highlight the differing views on what defines a good quality of life and show the vital importance of high-quality goals of care conversations about prognosis and quality of life when deciding whether to place a PEG tube after severe stroke.

Physician Orders for Life-Sustaining Treatment

Artificially Administered Nutrition This section comes with options of “no artificial nutrition by tube”, “defined trial period of artificial nutrition by tube” and “long-term artificial nutrition by tube”. If the person is able to chew and swallow, the food will be taken by mouth. Studies have found that orders to withhold artificial nutrition such as feeding tubes are usually executed by the providers.

Enteral nutrition delivery technique.

Ingestion and absorption of a nutritionally adequate diet is necessary to maintain normal body composition and organ function. Patients with all kinds of diseases are at increased risk of developing nutritional abnormalities from anorexia, dietary restriction, malabsorption, increased intestinal losses or altered nutrient requirements. Therefore, it is important for doctors to understand the general principles of clinical nutrition for optimal management of patients with various disorders. The purpose of this review is to highlight an important aspect of nutrition: methods for enteral nutrient delivery. Enteral feeding is the preferred method to provide nutritional support in patients who cannot or will not eat but who have a functional gastrointestinal tract. The placement of a small-diameter nasogastric or nasoduodenal tube is the simplest technique for feeding patients who are unlikely to require tube feeding for more than 6 weeks. Gastrostomy, gastrojejunostomy and jejunostomy tubes placed by using endoscopic, radiologic, or surgical techniques should be considered in patients who require long-term feeding. With newer endoscopic feeding techniques replacing more conventional surgical techniques, this review proposes to discuss the newer developments in techniques of enteral feeding. This review will briefly discuss the principles governing nasoenteral feeding and will describe in detail the endoscopic assisted methods for placing enteral feeding tubes. These include percutaneous endoscopic gastrostomy, jejunal extension through a percutaneous endoscopic gastrostomy or direct endoscopic jejunostomy. It will also discuss the procedural complications and long term results of these methods of enteral feeding. Lastly the latest innovation in enteral feed - the one step button - is also discussed. Percutaneous endoscopic gastrostomy placement is an appropriate method for providing nutrition in ill patients if no contraindication to enteral feeding exists. In certain situations, percutaneous endoscopic gastrostomy placement may even be used to make the life of a terminally ill patient comfortable.

Percutaneous endoscopic gastrostomy tube placement in left versus right middle cerebral artery stroke: effects of laterality.

Prolonged dysphagia after middle cerebral artery (MCA) territory strokes may require percutaneous endoscopic gastrostomy (PEG) tube feeding. We examined the predictors of PEG placement among patients with MCA stroke. It was hypothesized that stroke laterality was a predictor. A retrospective cohort study of existing data from Hartford Hospital Stroke Database was done. A total of 157 patients with acute ischemic MCA stroke were included. Patients were divided into the "PEG" group (n = 24) and "no PEG" group (n = 133). Existing demographic, clinical and swallowing data were compared between the 2 groups. Demographic data were similar between the groups. The "PEG" group had a higher admission National Institute of Health Stroke Scale (NIHSS) score, higher proportion of patients who had thrombolytic administration, in- hospital aspiration pneumonia and inability to be assessed on first swallow evaluation. Multivariate analysis revealed that all, except thrombolytic administration may predict PEG placement. Admission NIHSS score, in-hospital aspiration pneumonia and inability to undergo first swallow evaluation may predict PEG placement in patients with acute MCA stroke. Stroke laterality was not associated. This knowledge facilitates early identification of patients that may require PEG tube placement for early nutrition provision and discharge to rehabilitation.

Predicting the chance of weaning dysphagic stroke patients from enteral nutrition: a multivariate logistic modelling study.

The aim of this article was to develop a simple predictive model of dysphagia outcome for stroke patients. The study enrolled patients recovering from first-ever stroke (supratentorial lesions) staying in a long-term rehabilitation hospital. On admission, all patients were being fed via nasogastric or percutaneous endoscopic gastrostomy (PEG) tube. Functional Independence Measure (FIMTM) scores were assessed on admission. FIM-motor and cognition score, age, days after onset on admission were set as explanatory variables. Target criteria were defined as dichotomous categories; completely oral feeding or any need for nutrition via tube feeding. Multivariate logistic analysis was performed on these data. Thirty patients were enrolled: age range was 50-94 (median 75) years; FIM-motor scores spanned 13 to 17 (median 13), FIM-cognition scores spanned 5 to 19 (median 9); and days from stroke onset to transfer to long-term rehabilitation care ranged from 15 to 64 (median 43.5) days. Of these patients, 12 were weaned back to oral feeding and 18 were not. Multivariate logistic regression modelling was successful on these data (P=0.0003, R2=0.518; Logit=0.770xFIM-motor+0.089xFIM-cognition 0.070xdays after onset 0.255xage+10.222). Estimated probability for return to oral feeding is nearly 10% when logit equals -2, 50% when logit equals 0, nearly 90% when logit equals 2. A logit formula factoring in age, FIM scores, and days after stroke onset can readily predict oral feeding outcome. Further studies are needed to assess external validation to establish wide clinical applicability of this prediction model.

Malabsorption

Management Treatment is directed largely towards management of underlying cause: Replacement of nutrients, electrolytes and fluid may be necessary. In severe deficiency, hospital admission may be required for nutritional support and detailed advice from dietitians. Use of enteral nutrition by naso-gastric or other feeding tubes may be able to provide sufficient nutritional supplementation. Tube placement may also be done by percutaneous endoscopic gastrostomy, or surgical jejunostomy. In patients whose intestinal absorptive surface is severely limited from disease or surgery, long term total parenteral nutrition may be needed. Pancreatic enzymes are supplemented orally in pancreatic insufficiency. Dietary modification is important in some conditions: Gluten-free diet in coeliac disease. Lactose avoidance in lactose intolerance. Antibiotic therapy to treat Small Bowel Bacterial overgrowth.

[Endoscopic gastrostomy in patients with complicated heart diseases].

Complicated cardiologic patients with brain ischemia and heart failure need long term enteral nutrition. Long term nasoenteral tube feeding may cause complications that could be avoided with percutaneous endoscopic gastrostomy. The aim of this study was to evaluate the indications for percutaneous endoscopic gastrostomy and its main complications. Twelve patients were submitted to percutaneous endoscopic gastrostomy (eight male) with main age of 62.42 +/- 22.10 years old. Brain ischemia was the main indication of percutaneous endoscopic gastrostomy and occurred after 35.58 +/- 26.79 days, after initiated enteral nutrition. There were no complications during procedure. On late post operatory period there were local infection in one cases, treated with local care. In conclusion, percutaneous endoscopic gastrostomy is a secure technique with low incidence of complications and its indication should be earlier.

Percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation). This provides enteral nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition (which is only used when the GI tract must be avoided). The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the jejunum via the pylorus.

Safe and effective tube feeding of bedridden elderly.

An increasing number of patients with swallowing disorders due to stroke, head trauma, degenerative neurologic diseases, and other causes are surviving for prolonged periods with tube feeding of commercial formulas as their sole source of nutritional support. Reviewed in this article are the indications, methods, strategies for formula selection, complications, and outcomes of tube feeding in the long-term care patient.


These are typical adverse effects of ACEIs, in the case of cough it is usually dry and irritative and appears in up to 3% of patients. Hyperkalemia may also appear in 1%.

A 70-year-old woman with a history of hypertension and moderate heart failure presents with a persistent, dry cough that begins as an itchy sensation in the throat. What is the drug suspected of causing the patient's clinical and laboratory alteration?

Hypersensitivity myocarditis associated with ephedra use.

Ephedrine has previously been described as a causative factor of vasculitis but myocarditis has not yet been associated with either ephedrine or its plant derivative ephedra. A 39-year-old African American male with hypertension presented to Rush Presbyterian St. Luke's Medical Center with a 1-month history of progressive dyspnea on exertion, orthopnea, and dependent edema. He was taking Ma Huang (Herbalife) 1-3 tablets twice daily for 3 months along with other vitamin supplements, pravastatin, and furosemide. Physical examination revealed a male in mild respiratory distress. The lung fields had rales at both bases without audible wheezes. Internal jugular venous pulsations were 5 cm above the sternal notch. Medical therapy with intravenous furosemide and oral enalapril was initiated upon admission. Cardiac catheterization with coronary angiography revealed normal coronary arteries, a dilated left ventricle, moderate pulmonary hypertension, and a pulmonary capillary wedge pressure of 34 mm Hg. The patient had right ventricular biopsy performed demonstrating mild myocyte hypertrophy and an infiltrate consisting predominantly of lymphocytes with eosinophils present in significantly increased numbers. Treatment for myocarditis was initiated with azothioprine 200 mg daily and prednisone 60 mg per day with a tapering course over 6 months. Anticoagulation with warfarin and diuretics was initiated and angiotensin-converting enzyme inhibition was continued. Hydralazine was added later. One month into therapy, an echocardiogram demonstrated improved left ventricular function with only mild global hypokinesis. A repeat right ventricular biopsy 2 months after the first admission showed no evidence of myocarditis. At 6 months, left ventricular ejection fraction was normal (EFN 50%) and the patient asymptomatic. Ephedra (Ma Huang) is the suspected cause of hypersensitivity myocarditis in this patient due to the temporal course of disease and its propensity to induce vasculitis.

WHO Model List of Essential Medicines

Antianginal medicines Bisoprolol Glyceryl trinitrate Isosorbide dinitrate Verapamil Antiarrhythmic medicines Bisoprolol Digoxin Epinephrine (adrenaline) Lidocaine Verapamil Amiodaroneα Antihypertensive medicines Amlodipine Bisoprolol Enalapril Hydralazine Hydrochlorothiazide Lisinopril/amlodipine (lisinopril + amlodipine) Lisinopril/hydrochlorothiazide (lisinopril + hydrochlorothiazide) Losartan Methyldopa Telmisartan/amlodipine (telmisartan + amlodipine) Telmisartan/hydrochlorothiazide (telmisartan + hydrochlorothiazide) Sodium nitroprussideα Medicines used in heart failure Bisoprolol Digoxin Enalapril Furosemide Hydrochlorothiazide Losartan Spironolactone Dopamineα Antithrombotic medicines Anti-platelet medicines Acetylsalicylic acid (aspirin) Clopidogrel Thrombolytic medicines Alteplaseα Streptokinaseα Lipid-lowering agents Simvastatin Dermatological medicines (topical)

Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure in elderly patients.

American College of Cardiology/American Heart Association class I recommendations for treating patients with heart failure (HF) and abnormal left ventricular ejection fraction are diuretics in patients with fluid retention, an angiotensin-converting enzyme (ACE) inhibitor unless contraindicated, a beta-blocker unless contraindicated, digoxin for the treatment of symptoms of HF, and withdrawal of drugs known to precipitate or aggravate HF such as nonsteroidal anti-inflammatory drugs, calcium channel blockers, and most antiarrhythmic drugs. Class II(a) recommendations for treating HF with abnormal left ventricular ejection fraction are spironolactone in patients with class IV symptoms, preserved renal function, and normal serum potassium; exercise training as an adjunctive approach to improve clinical status in ambulatory patients; an angiotensin receptor blocker in patients who cannot be given an ACE inhibitor because of cough, rash, altered taste sensation, or angioedema; and hydralazine plus nitrates in patients being treated with diuretics, a beta-blocker, and digoxin who cannot be given an ACE inhibitor or an angiotensin receptor blocker because of hypotension or renal insufficiency. Patients with diastolic HF should be treated with cautious use of diuretics and with a beta-blocker. An ACE inhibitor should be added if HF persists or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioedema, rash, or altered taste sensation. Isosorbide dinitrate plus hydralazine should be added if HF persists. A calcium channel blocker should be added if HF persists. Digoxin should be avoided in diastolic HF if sinus rhythm is present.

Pharmacology_Katzung

During a routine check and on two follow-up visits, a 45-year-old man was found to have high blood pressure (160–165/95–100 mm Hg). His physician initially prescribed hydrochlorothiazide, a diuretic commonly used to treat hyper-tension. His blood pressure was reduced by hydrochloro-thiazide but remained at a hypertensive level (145/95 mm Hg), and he was referred to the university hypertension clinic. Because the patient had elevated plasma renin activity and aldosterone concentration, hydrochlorothiazide was replaced with enalapril, an angiotensin-converting enzyme inhibitor. Enalapril lowered his blood pressure to almost normotensive levels. However, after several weeks on enalapril, the patient returned complaining of a persistent cough. In addition, some signs of angioedema were detected. How does enalapril lower blood pressure? Why does it occasionally cause coughing and angioedema? What other drugs could be used to inhibit the renin-angiotensin system and decrease blood pressure,

Treatment of heart failure with normal left ventricular ejection fraction.

Underlying causes and precipitating causes of heart failure (HF) should be treated when possible. Persons with HF and normal left ventricular ejection fraction (LVEF) should have maintenance of sinus rhythm, treatment of hypertension, myocardial ischemia, dyslipidemia, and anemia, slowing of the ventricular rate below 90 bpm, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers and angiotensin-converting enzyme (ACE) inhibitors. If persons are unable to tolerate ACE inhibitors because of cough, angioneurotic edema, rash, or altered taste sensation, angiotensin II type I receptor antagonists (ARBs) should be given. If HF persists despite diuretics, beta blockers, and ACE inhibitors or ARBs, isosorbide dinitrate plus hydralazine should be administered. Beta blockers, verapamil, diltiazem, and digoxin may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with HF in sinus rhythm with normal LVEF. Exercise training should be encouraged in persons with mild to moderate HF to improve functional status and to decrease symptoms.

Angiotensin-converting enzyme inhibitor-induced cough.

A 65-year-old woman started taking enalapril 2.5 mg daily for hypertension. Twelve days later she complained of a persistent, dry cough. Due to the coughing and a preexisting cystocele, she developed stress incontinence and a marked decline in her functional status. The coughing and incontinence resolved with the discontinuation of enalapril. During a subsequent hospitalization the patient received captopril 6.25 mg twice daily for congestive heart failure. Within 24 hours the dry cough recurred. It resolved with the discontinuation of the drug. Cough is a symptom that is generally not recognized as a drug side effect. However, increasing numbers of case reports document angiotensin-converting enzyme inhibitor-induced cough. Although the actual frequency and mechanism are currently unknown, the dry cough typically begins early in the course of therapy. It may be specific to this pharmacologic class rather than to one individual agent. Age and sex may be contributing factors. While cough has been considered a minor side effect, unnecessary hospitalizations and inappropriate treatments may easily result. Even minor adverse reactions may have an impact on a patient's quality of life.

Left ventricular diastolic heart failure with normal left ventricular systolic function in older persons.

Underlying causes and precipitating causes of congestive heart failure (CHF) should be treated when possible. Older persons with CHF and normal left ventricular (LV) ejection fraction should have maintenance of sinus rhythm, treatment of hypertension and myocardial ischemia, slowing of the ventricular rate below 90 beats/minute, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers as tolerated. Angiotensin-converting enzyme (ACE) inhibitors should be administered if CHF persists despite diuretics and beta blockers. If persons are unable to tolerate ACE inhibitors because of cough, rash, or altered taste sensation, angiotensin II type 1 receptor antagonists should be given. If CHF persists despite diuretics, beta blockers, and ACE inhibitors or the person is unable to tolerate beta blockers, ACE inhibitors, and angiotensin II type 1 receptor antagonists, isosorbide dinitrate plus hydralazine should be administered. Calcium channel blockers should be used if CHF persists despite administration of diuretics and the person is unable to tolerate beta blockers, ACE inhibitors, angiotensin II type 1 receptor antagonists, and isosorbide dinitrate plus hydralazine. Digoxin, beta blockers, verapamil, and diltiazem may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with CHF in sinus rhythm with normal LV ejection fraction.

When a Diuretic Causes Pulmonary Oedema.

Hydrochlorothiazide (HCTZ) is one of the most popular drugs for the treatment of hypertension and heart failure. Most of its side effects are harmless and predictable, but some studies report a few life-threatening reactions to this drug, one of the most dangerous being acute pulmonary oedema. A 73-year-old woman was admitted to the Emergency Department with acute respiratory failure due to pulmonary oedema. Her past medical history included long-lasting hypertension with permanent atrial fibrillation and mitral stenosis. Her blood pressure control had been suboptimal, so her cardiologist had changed amlodipine to combination therapy with ramipril and HCTZ. However, 20 min after taking the new drug, the patient experienced fever, vomiting and diarrhoea immediately followed by acute onset of dyspnoea. Since HCTZ is one of the most popular drugs for hypertension treatment and millions of patients take it every day, it is important to keep in mind both the common adverse reactions as well as the dangerous, although rare, ones. Pulmonary oedema is a very unusual adverse reaction to hydrochlorothiazide, and a rare presentation of a common condition.Pulmonary oedema is not always due to heart problems.It is important to keep in mind that hypersensitivity reactions may have many different presentations.

Hydralazine

Medical use Hydralazine is not used as a primary drug for treating hypertension because it elicits a reflex sympathetic stimulation of the heart (the baroreceptor reflex). The sympathetic stimulation may increase heart rate and cardiac output, and in people with coronary artery disease may cause angina pectoris or myocardial infarction. Hydralazine may also increase plasma renin concentration, resulting in fluid retention. To prevent these undesirable side effects, hydralazine is usually prescribed in combination with a beta blocker (e.g., propranolol) and a diuretic. Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol. Hydralazine is used to treat severe hypertension, but is not a first-line therapy for essential hypertension. Hydralazine is often used to treat hypertension in pregnancy, though, with either labetalol and/or methyldopa.

Treatment of systolic and diastolic heart failure in the elderly.

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF should be stopped. Patients with HF and an abnormal left ventricular ejection fraction (LVEF) (systolic heart failure) or normal LVEF (diastolic HF) should be treated with diuretics if fluid retention is present; with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation; and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL. A multidisciplinary approach should be used with nurse monitoring of the condition. In a home-bound patient, a homemaker should be hired.

Captopril. An update of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in hypertension and congestive heart failure.

Captopril is an orally active inhibitor of angiotensin-converting enzyme (ACE) and has been widely studied in the treatment of patients with mild to moderate essential hypertension, severe hypertension not responsive to conventional diuretic/beta-adrenoceptor blocker/vasodilator regimens, and patients with chronic congestive heart failure refractory to treatment with a diuretic and digitalis. In patients with mild or moderate essential hypertension, titrated low doses of captopril used alone or in conjunction with a diuretic are similar in efficacy to usual doses of hydrochlorothiazide, chlorthalidone, or beta-adrenoceptor blocking drugs, as well as to the other ACE inhibitors. In addition, captopril improved well-being to a greater extent than methyldopa or propranolol in a study designed specifically to determine the effect of treatment on the quality of life of patients with mild or moderate essential hypertension. The earlier demonstrated efficacy of captopril, used with a diuretic and often also with a beta-adrenoceptor blocking drug, in the treatment of severe hypertension refractory to conventional 'triple therapy' has been confirmed in more recent trials which illustrate the generally marked antihypertensive effect of captopril-containing regimens in such patients. Results of initial trials in patients with scleroderma are promising, with control of hypertension and stabilization of renal function in these patients when treated at an early stage of the disease. Several comparative and long term trials of captopril in patients with chronic congestive heart failure refractory to treatment with a diuretic/digitalis regimen clearly demonstrate that initial haemodynamic improvement is maintained and correlates with clinical benefit. A tendency for overall clinical response to captopril to be better than the response to prazosin, hydralazine, nisoldipine or enalapril has been reported. Results of a multicentre comparison with digoxin and placebo indicate that captopril is a suitable alternative to digoxin in patients with mild to moderate heart failure who are receiving maintenance diuretic therapy. The tolerability of captopril has now been studied in many thousands of patients involved in formalized trials and the early impression of poor tolerability can no longer be justified. The use of generally lower dosages of captopril in patients with normal or slightly impaired renal function has resulted in a generally low incidence of rash (0.5 to 4%), dysgeusia (0.1 to 3%), proteinuria (0.5%), neutropenia (0.3% during first 3 months) and symptomatic hypotension (0.1 to 3%). Cough is an infrequent but troublesome effect resulting from ACE inhibition.(ABSTRACT TRUNCATED AT 400 WORDS)

Drug treatment of systolic and of diastolic heart failure in elderly persons.

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Patients with HF and an abnormal left ventricular ejection fraction (systolic HF) or normal left ventricular ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/ml. Cardiac synchronized pacing should be considered in patients with severe systolic HF despite optimal medical therapy, with sinus rhythm, and with ventricular dyssynchrony.

Therapeutic challenges and management of heart failure during pregnancy (part I).

Therapeutic management in pregnant patients with heart failure still remains a challenge, even though in most pregnant women with cardiac diseases an outcome is good. A 32-year-old woman, 17 weeks pregnant, was admitted to hospital with heart failure (HF) NYHA class III/IV. Echocardiography revealed enlarged LV, LVEF 13%, significant mitral insufficiency and pulmonary hypertension. The patient wished to continue the pregnancy. In a life-threatening condition, metoprolol, enalapril, spironolactone (for 5 days), furosemide, and digitalis were administered. Enalapril was continued for 42 days. Then the patient was switched to a dihydralazine and isosorbide mononitrate regimen. The fetus was controlled ultrasonographically. In the 19th week of pregnancy, the patient's condition improved (NYHA class II, LVEF 23%). The patient experienced 2 more episodes of HF exacerbation. In the 26th week of pregnancy, in a primary prevention of sudden cardiac death and because of 2nd-degree AV block, an ICD was implanted. In the 32nd week of pregnancy a cesarean section was performed. A male infant was delivered. The patient made a good recovery and was discharged on the 7th postoperative day. The newborn was discharged after 4 weeks, in good general condition. At 1-year follow-up the patient presented NYHA class II.<br />

Enalapril/hydrochlorothiazide

Enalapril/hydrochlorothiazide, sold under the brand name Vaseretic among others, is a fixed-dose combination medication used for the treatment of hypertension (high blood pressure). It contains enalapril, an angiotensin converting enzyme inhibitor, and hydrochlorothiazide a diuretic. It is taken by mouth. The most frequent side effects include dizziness, headache, fatigue, and cough. History Enalapril/hydrochlorothiazide was approved for medical use in the United States in October 1986. References Further reading External links ACE inhibitors Antihypertensive agents Diuretics Prodrugs

Enalapril-induced cough.

A retrospective analysis of records from an outpatient medical practice was undertaken to determine the incidence and features of cough resulting from the use of enalapril maleate. Of 209 patients taking enalapril, 22 (10.5%) required discontinuation of therapy because of an intractable, dry cough. Cough was more than twice as common in women; 16 (14.6%) of 109 women and 6 (6%) of 100 men stopped taking enalapril because of cough. The cough resolved in 21 of 22 patients within 2 weeks of discontinuation of enalapril therapy. When the patients with cough were compared with the others, there was no significant difference in age, smoking status, creatinine levels, enalapril dosage, associated cardiopulmonary disease, or concomitant administration of medications. Among the 187 study patients who did not discontinue taking enalapril because of cough, many developed a persistent, dry cough that to date has not been severe enough to require discontinuation of therapy, after a mean follow-up period of 16 months. The enalapril-induced cough is insidious, dry, persistent, benign, and reversible on discontinuation of therapy. It is important to distinguish enalapril-induced cough from cough resulting from acute illness, reactive airway disease, and congestive heart failure. Optimal clinical application of enalapril in the treatment of hypertension and congestive heart failure will require increased awareness of this incessant cough, which requires discontinuation of the therapy in about 10% of patients.

Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure.

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.

Quinapril in patients with congestive heart failure: controlled trial versus captopril.

After two weeks of a wash-out run-in period with placebo, 131 patients with congestive heart failure (New York Heart Association [NYHA] class II to III) and left ventricular ejection fraction </=40% were randomly assigned to a treatment period of 4 weeks with 10 mg quinapril once daily or 12.5 mg captopril twice daily. At the end of this period, doses were titrated to 20 mg quinapril once daily or 25 mg captopril twice daily on the basis of physician judgment if there were no major adverse reactions and if blood pressure was not below 110/70 mm Hg. Clinical symptoms of heart failure were significantly relieved by both drugs at the end of a 12-week treatment period. At the beginning of the study, 23 (35%) of the 65 patients taking quinapril and 27 (41%) of the 66 patients taking captopril were in NYHA functional class III, whereas, at the end of the trial, only 4 (6%) of the patients in the quinapril group and 14 (22%; p < 0.05 versus quinapril) patients in the captopril group were classified as NYHA class III. Both drugs had a positive effect on echocardiographic parameters. There was a statistically significant increase in exercise duration in both treatment groups (quinapril, 6.2 +/- 1.8 versus 7.8 +/- 1.9 minutes, p < 0.001; captopril, 5.9 +/- 1.9 versus 7.1 +/- 2.3 minutes, p < 0.001). One patient in the quinapril group died suddenly during the study and two patients in the captopril group dropped out of the study due to persistent dry cough. No patient in the quinapril group reported side effects. Three patients in the captopril group suffered from moderate dry cough, one from taste-blindness, and another from unstable angina. The safety of the tested drugs was confirmed by laboratory tests. Quinapril was as effective as captopril in reducing signs and symptoms of heart failure and in improving the left ventricular function and the exercise capacity with few side effects.

Acute coronary syndrome

Heart failure Heart failure (HF) is defined as the incapacity of the heart to function properly, pumping insufficient blood towards the tissues and leading to fluid accumulation within the lungs, liver and peripheral tissues. Oral manifestations Most if not all patients with heart failure will be undergoing drug treatments for their condition and these drugs can produce a series of oral manifestation. In this context, angiotensin-converting enzyme (ACE) inhibitors such as captopril and enalapril can produce burning mouth sensation lichenoid reactions and a loss of taste sensation, while diuretics like furosemide can produce xerostomia.

[Severe and rare adverse reaction to hydrochlorothiazide].

The immune mechanism involved in the reaction to hydrochlorothiazide, which is widely used to control hypertension, is unknown. The short latency period between the take of the drug and the onset of symptoms suggests immediate hypersensitivity. 63-year-old woman with arterial hypertension who, on three occasions, experienced nausea, vomiting, general malaise, shivering, arthralgias, dysthermic sensation, back pain of mechanical characteristics and mild non-productive cough, as well as fever and chest tightness with increased dyspnea and desaturation of up to 88 %, after taking hydrochlorothiazide. Clinical presentation in the patient was similar to a septic shock, which is a rare allergic reaction. The diagnosis has to be clinical. This type of reaction might be due to type III hypersensitivity owing to the formation of immune complexes. Avoiding of the culprit drug is key to a good evolution.

A One-Two Punch: Hydralazine-Induced Liver Injury in a Recovering Ischemic Hepatitis.

A 77-year-old woman presented to the emergency department with a 2-day history of nausea and vomiting. Her medical history included diabetes mellitus, hypertension, atrial fibrillation, dilated cardiomyopathy, and coronary artery disease. Her home medications included aspirin, clopidogrel, warfarin, digoxin, metoprolol, losartan, simvastatin, isosorbide dinitrate, furosemide, and spironolactone. Initial physical examination showed blood pressure of 170/80 mm Hg with a heart rate of 69 beats per minute, otherwise unremarkable. Initial laboratory workup was significant for INR of 3.6, with slightly elevated troponin I and creatinine of 0.06 ng/mL and 1.4 mg/dL, respectively. The patient was admitted to the medicine floor. However, a few hours later, her atrial fibrillation went into rapid ventricular response, associated with hypotension. Cardiac enzymes began to trend up along with worsening of her renal function tests and hepatic enzymes. Her INR remained supratherapeutic despite holding coumadin and giving vitamin K. The patient was transferred to the medical intensive care unit for closer monitoring. During day 1 of the medical intensive care unit stay, losartan, simvastatin, and diuretics were held, whereas aspirin, clopidogrel, and isosorbide dinitrate were continued. In the following 2 days, there was worsening of tissue perfusion, and laboratory workup showed AST 514 IU/L, ALT 391 IU/L, INR >9, creatinine 3.8 mg/dL, and troponin I 0.19 ng/mL; therefore, digoxin was also held. Once the patient achieved hemodynamic stability, she was started on hydralazine. On day 4, renal function, cardiac, and hepatic enzymes improved significantly. However, 24 hours later, transaminases began to trend up again reaching a maximum of AST and ALT of 359 and 525 IU/L, respectively. Other possible causes were ruled out because her viral hepatitis markers, antihistone antibody, antinuclear antibody, and anti-double-stranded DNA were all negative. After thorough review of all medications, hydralazine was held with subsequent improvement in transaminases. The patient was seen a month later after her discharge, and all her laboratory workup improved to baseline.

Overall tolerance and safety of enalapril.

To date, more than 5000 patients have had experience with enalapril. Over 1000 subjects have been exposed to the drug for more than one year and approximately 600 for over two years. In controlled trials, 2249 subjects, who included normal volunteers and patients with hypertension and congestive heart failure, have received enalapril alone or concomitantly with hydrochlorothiazide or other antihypertensive agents. There have been no deaths attributed to enalapril. The incidence of serious adverse experiences in controlled trials was similar to placebo, and was not higher in the elderly. The incidence of adverse experiences was not dose-related. Drug discontinuation due to adverse experiences was 3.5%, similar to placebo, and approximately half that of control drugs. Serious laboratory adverse experiences were rare. Enalapril attenuated the adverse metabolic effects of hydrochlorothiazide, particularly hypokalaemia. Skin rash occurred in approximately 1.0% of patients. One case of transient taste loss occurred on enalapril, and one on enalapril in combination with hydrochlorothiazide. Neutropenia and agranulocytosis were not encountered. Mean white blood cell counts did not change overall. Most patients (approximately equal to 80%) show no change or an improvement in renal function on enalapril. Discontinuation of concomitant hydrochlorothiazide usually normalized renal function. Enalapril is well tolerated in renal insufficiency. Azotaemia may occur in bilateral renovascular hypertension. Proteinuria was rarely seen and often improved on enalapril. Compassionate use protocols have been available to patients either resistant or intolerant to captopril. Of 68 patients admitted for captopril-related skin rashes, only five recurred on enalapril.(ABSTRACT TRUNCATED AT 250 WORDS)

Antihypertensive drug

ARBs happens to be the favorable alternative to ACE inhibitors if the hypertensive patients with the heart failure type of reduced ejection fraction treated with ACEis was intolerant of cough, angioedema other than hyperkalemia or chronic kidney disease. Adrenergic receptor antagonists Beta blockers acebutolol atenolol bisoprolol betaxolol carteolol carvedilol labetalol metoprolol nadolol nebivolol oxprenolol penbutolol pindolol propranolol timolol Alpha blockers: doxazosin phentolamine indoramin phenoxybenzamine prazosin terazosin tolazoline urapidil Mixed Alpha + Beta blockers: bucindolol carvedilol labetalol

InternalMed_Harrison

Diuretics Thiazides Hydrochlorothiazide 6.25–50 mg (1–2) Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia Chlorthalidone 25–50 mg (1) Loop diuretics Furosemide 40–80 mg (2–3) CHF due to systolic dysfunc-Diabetes, dyslipidemia, hypertion, renal failure uricemia, gout, hypokalemia Aldosterone antagonists Spironolactone 25–100 mg (1–2) CHF due to systolic dysfunc-Renal failure, hyperkalemia tion, primary aldosteronism Renal failure, hyperkalemia Triamterene 50–100 mg (1–2) Beta blockers Asthma, COPD, 2ndor 3rd-degree heart block, sick- Cardioselective Atenolol 25–100 mg (1) Angina, CHF due to systolic sinus syndrome dysfunction, post-MI, sinus tachycardia, ventricular tachyarrhythmias Metoprolol 25–100 mg (1–2) Nonselective Propranolol 40–160 mg (2) Propranolol LA 60–180 (1) Combined alpha/beta Labetalol 200–800 mg (2) ?Post-MI, CHF Carvedilol 12.5–50 mg (2) Alpha antagonists

Cough induced by losartan with resolution after substitution with enalapril.

Cough is an adverse event associated with the angiotensin-converting enzyme (AA inhibitor drugs. ACE inhibitor-induced cough is believed to be related to the accumulation of bradykinin,substance P,and prostaglandins resulting from the inhibition of ACE.Angiotensin-receptor blockers (AARBs) do not have any effect on ACE and theoretically might not cause cough. Therefore, a proposed option in patients suffering with ACE inhibitor-induced cough is to try an ARB. However,this report describes the reverse: a case of losartan-induced cough th hat co om completely resolved after it was substituted with an ACE inhibitor, enalapril. A 23-year-old, nonsmoking white woman, weighing 73.55 kg, ACE inhibitor naive (before admission), presented to the emergency department at Imam Referral Hospital, Tehran, Iran,with hypertension,proteinuria, and hyperlipidemia. The patient was admitted to the nephrology ward. She was prescribed hydrochlorothiazide 12.55 mg/d, furosemide 20 mg BID, and simvastatin 20 mg/d. The patient had no respiratory illnesses. The patient experienced cough 3 days following the initiation of losartan treatment. The cough continued in this patient for the 2-week duration of losartan treatment; however, 1 week after substitution of losartan with enalapril (22.5 mg/d),the cough resolved completely. This report describes a young woman who developed cough while receiving losartan treatment,which resolved after substitution with the ACE inhibitor enalapril.

Lump in the throat - a case study.

Jack, aged 66 years, presented to his general practitioner with a foreign body sensation in his throat and altered voice, which developed over 30 minutes. He was otherwise well, having no other new symptoms or recent alterations to medication. He had not eaten anything unusual. He had hypertension, type 2 diabetes, stable ischaemic heart disease, urolithiasis and benign prostatic hypertrophy. His regular medication was metformin, rosuvastatin, carvedilol, candesartan (last 5 years) and saxagliptin (last 6 months). He had no allergies but was intolerant of ramipril due to cough. There was no family history of note. On examination he had no itch or rash, or swelling of the tongue, lips, cheek or neck. However, there was oedema of the soft palate and uvula. He was maintaining his airway, saturating at 98%, and his chest was clear. He was afebrile and systemically well.

Enalapril

Enalapril, sold under the brand name Vasotec among others, is an ACE inhibitor medication used to treat high blood pressure, diabetic kidney disease, and heart failure. For heart failure, it is generally used with a diuretic, such as furosemide. It is given by mouth or by injection into a vein. Onset of effects are typically within an hour when taken by mouth and last for up to a day. Common side effects include headache, tiredness, feeling lightheaded with standing, and cough. Serious side effects include angioedema and low blood pressure. Use during pregnancy is believed to result in harm to the baby. It is in the angiotensin-converting-enzyme (ACE) inhibitor family of medications.

ACE inhibitor and thiazide combination

An ACE inhibitor and thiazide combination is a drug combination used to treat hypertension (high blood pressure). They are given by mouth. ACE inhibitors reduce the activity of angiotensin-converting enzyme (ACE) which produces angiotensin II, a hormone that constricts blood vessels. Thiazides are a class of diuretics that inhibit the thiazide receptor, thereby increasing urine production and reducing excess water and salt in the body. Several organizations recommend combination therapy for hypertension in cases of failure of a single drug to achieve target blood pressure, or even as a first line treatment for some patients. Examples Enalapril/hydrochlorothiazide (trade name Enalapril comp), wherein enalapril is the ACE inhibitor and hydrochlorothiazide is the thiazide. Quinapril/hydrochlorothiazide (trade name Accuretic) Lisinopril/hydrochlorothiazide is marketed as Prinzide, Zestoretic, and many others. Fosinopril/hydrochlorothiazide

A 49-Year-Old Man With Postcoital Hemoptysis.

A 49-year-old man was seen in the pulmonary clinic for evaluation of postcoital hemoptysis. His medical history was significant for nonischemic cardiomyopathy and hypertension. He had red-yellow sputum with streaks of blood associated with dyspnea and wheezing for 5 years. He noted his symptoms occurred only with sexual intercourse while horizontal, but not while upright. He did not have any symptoms with other exertional activities, including heavy weight lifting. He did not have other symptoms. He had a remote history of less than 10 pack years of smoking. He had no personal or family history of pulmonary disease. He worked as a construction worker in the past, and currently as a driver. He had been incarcerated in the past but denied direct contact with TB. He was born in the United States, had always lived in the Northeastern region, and denied international travel. He had no constitutional symptoms or symptoms concerning for malignancy or autoimmune disease, including joint or skin complaints. His medications included aspirin, atorvastatin, carvedilol, furosemide, lisinopril, and spironolactone, and he endorsed adherence. He denied herbal or over-the-counter drugs use and denied illicit drug use.

Effects of long-term treatment with enalapril or hydralazine on the renin-angiotensin-aldosterone system and fluid balance in dogs with naturally acquired mitral valve regurgitation.

To study long-term effects of enalapril, an angiotensin-converting enzyme inhibitor, and hydralazine, an arteriodilator, on renin-angiotensin-aldosterone system and fluid balance before and after administration of furosemide. 22 dogs with clinical signs of congestive heart failure (CHF) attributable to mitral regurgitation. After initial examination, 12 dogs received enalapril and 10 received hydralazine. Dogs were re-examined 3 weeks and 6 months after initial examination. Furosemide was added after the 3-week examination, and at 6 months, dogs had received furosemide for at least 4 months. Angiotensin II and aldosterone plasma concentrations were low before treatment, and only aldosterone became significantly decreased after enalapril monotherapy. Concentrations of both hormones and heart rate increased in dogs receiving hydralazine monotherapy, and fluid retention was evident. After long-term treatment with either of the 2 drugs together with furosemide, angiotensin II and aldosterone values increased in both groups. Natriuresis and kaliuresis developed in all dogs, with greatest effect in those receiving enalapril and furosemide. These dogs had decreased plasma sodium concentration, whereas potassium concentration was equally decreased in both groups. After 6 months, the enalapril group, but not the hydralazine group, had increased cardiac size. All dogs had moderate reduction of weight and were azotemic, although changes were more pronounced in those of the hydralazine group. The 2 drugs have different effects on the renin-angiotensin-aldosterone system and fluid balance in dogs with CHF.

[Dry cough in the elderly patients treated with angiotensin converting enzyme inhibitor].

Since dry cough has recently been recognized as a side effect of angiotensin converting enzyme (ACE) inhibitors employed in the treatment of hypertension or congestive heart failure, the incidence of dry cough in elderly patients receiving ACE inhibitors was investigated. There were 237 out-patients on either captopril, enalapril, or delapril, in August and November 1989. Questionnaires concerning dry cough and smoking were completed by 184 patients. Patients either less than 50 years of age, or with chronic pulmonary disease were excluded. The remaining 168 patients, 63 males, 105 females, with a mean age of 73 years were analyzed for the incidence of a dry cough in relation to age, sex, smoking, and type of drugs. The overall incidence of a dry cough was 21/168 (12.5%), 7/63 (11.1%) for males and 14/105 (13.3%) for females, and was less frequent with advancing age; in the 51-60 age group 4/11 (36.4%), in the 61-70 age group 5/39 (12.8%), in the 71-80 age group 9/75 (12.0%), in the 81-90 age group 3/40 (7.5%), in the 91- age group 0/3 (0%). Enalapril showed significantly higher incidence of dry cough than captopril (16/93, 17.2% vs 7/88, 8.0%, p less than 0.05). Delapril showed an incidence 4/11, 36.4%, however, 9 out of the 11 patients who were given delapril had had a history of a dry cough with captopril or enalapril, and in 4 out of these 9 patients the dry cough disappeared by replacement of captopril or enalapril by delapril.(ABSTRACT TRUNCATED AT 250 WORDS)

Ranolazine Induced Bradycardia, Renal Failure, and Hyperkalemia: A BRASH Syndrome Variant.

Ranolazine is a well-known antianginal drug, that was first licensed for use in the United States in 2006. It was objectively shown to improve exercise capacity and to lengthen the time to symptom onset in patients with coronary artery disease. The most commonly reported side effects of ranolazine include dizziness, headache, constipation, and nausea. Here, we describe a case of bradycardia, hyperkalemia, and acute renal injury in the setting of ranolazine use. Our patient is an 88-year-old female who presented with abdominal pain, nausea, and vomiting. Her medical comorbidities included hypertension, diabetes, CAD, heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, hypothyroidism, and a history of cerebrovascular accident without any residual deficits. Her prescription regimen included amlodipine, furosemide, isosorbide mononitrate, levothyroxine, metformin, omeprazole, and ranolazine. Physical examination was remarkable for bradycardia and decreased breath sounds in the left lower lung field. Laboratory studies were significant for a serum potassium level of 6.8 mEq/L and a serum creatinine level of 1.6 mg/dL. She was given insulin with dextrose, sodium polystyrene, and calcium gluconate in addition to fluids. Her bradycardia and renal function worsened over the next 24 hours. Ranolazine was discontinued. Metabolic derangements were treated appropriately. After 48 hours from presentation, potassium and renal function returned to baseline and her heart rate improved to a range of 60-100 bpm. She was discharged with an outpatient cardiology follow-up. Ranolazine treatment was not continued upon discharge. In summary, our case illustrates an association between ranolazine and renal failure induced hyperkalemia, leading to conduction delays in the myocardium. Though further studies are warranted, we suspect that this is a variant of the recently described BRASH syndrome. We propose that in cases such as ours, along with treatment of the hyperkalemia, medication review and removal of any offending agent should be considered.

Chronic Cough in a 70-Year-Old Woman.

A 70-year-old lifelong nonsmoking woman with a past medical history of hypertension was referred to the respiratory clinic for evaluation of chronic cough. She presented with a 5-month history of dry cough, night sweats, fatigue, and a 4.5-kg weight loss. Her cough tended to be worse while lying flat. She denied having shortness of breath, chest pain, wheeze, or hemoptysis. She was taking amlodipine for her blood pressure as well as omeprazole for indigestion. She denied having any reflux symptoms or heartburn. She worked as a receptionist for an optician. She did not have any pets at home and had no family history of asthma or allergic conditions. She had not been abroad recently.