ALURETIC IN CONGESTIVE CARDIAC FAILURE

Summary

The efficacy of the Ayurvedic Aluretic drug was studied in 50 patients of congestive cardiac failure. The response in 96% of the cases was satisfactory. On further analysis the diuresis effect was excellent in 80% (40 cases), good in 10% (5 cases) and fair in 6% (3 cases). The response was excellent in patient with CHF due to ischemic heart disease and hypertensive heart disease, good in anaemia, and fair in valvular heart disease. There was no significant side effects and the biochemical and electrolytes were not altered.

The conclusion is ALURETIC may be considered as a diuretic drug of choice, in the treatment of congestive cardiac failure.

Introduction

Congestive heart failure is a common disorder and has a wide spectrum of clinicopathological states, ranging from the rapid impairment of pumping function to the gradual but progressive impairment of pumping function which may be observed only during stress occurring in a patient whose heart sustains a pressure or volume overload for a prolonged period.

The operation of compensatory mechanisms themselves may cause changes resulting in cardiac dysfunction due to overcompensation. The occurrence of heart failure increases progressively with age from about 1% prevalence in those aged 50 to 59 years to a prevalence of about 10% in persons 80 to 89 years. Even these estimates are probably underestimates.

The case fatality rate for cardiac failure is high, with one in five dying. The current therapies available for heart failure, carefully tailored to the needs of the individual patient can yield noteworthy results.

The studies by Stevenson indicate the potential that exists for symptomatic improvement, with judicious aggressive management even in end stage heart failure.

The general strategy in management should be to utilize relatively simple means, and if not responding, more aggressive measures. The ultimate goal in treatment of heart failure is to improve the quality and quantity i.e., the survival of life.

In a patient with known or suspected formulation of prognosis is the initial step in the management. The course of heart failure is punctuated by series of acute decompensation, depending upon patient's age, occupation, personality, life style, family setting, associated illnesses, infections etc.

The earliest stage in heart failure manifests as appearance of symptoms during exertion, at this stage, restriction of strenuous activity, correction of any risk factors, and salt restriction are the main treatment lines.

If heart failure recurs, or persists, during the next stage an oral diuretic is started. Despite this, if patient enters class III, rest is intensified, more powerful diuretics and vasodilators are substituted.

In functional Class IV, intravenous inotropes and vasodilators are indicated apart from measures like physical removal of fluids, assisted circulation.

Rest

Except for patients in Class III or IV, where rest is mandatory, in order to prevent the well-known hazards of phlebothrombosis and pulmonary emboli, deep breathing exercises, leg exercises, wearing of elastic stockings, usage of anti-coagulants in high risk cases are to be considered.

Diet

The monotony and the unpalatability of low sodium diet, may interfere with adequate nutrition. While restricting sodium to 1.2-2 gms/day, potassium chloride may be substituted.

Diuretics

The net effect of various hemodynamic, hormonal and neural influences on the kidney induced by the failing myocardium, is retention of solute and water, and expansion of extracellular volume.

The diuretics, although may not influence the neural history, can improve the congestive symptoms, and reduce the pre-load.

The other therapy includes usage of cardiac glycosides, potassium supplementation, vasodilators and ACE inhibitors.

An ideal diuretic should be safe, have minimum side effects, a good patient compliance and effective on prolonged use.

High efficacy diuretics, for example frusemide or bumetanide should be administered in the early stages of the treatment of moderate or severe heart failure, but maintenance therapy in chronic heart failure, medium-efficacy diuretics like thiazide is used.

All diuretics apart from potassium-sparing agents or spironolactone may produce hypokalaemia.

There are different drug in the market and none of the drugs fulfills all the criteria of a good diuretic drug, because commonly diuretics reduce the BP (mild to moderate). Causes hypokalaemia, hyponatraemia, postural hypotension, hyperglycemia and hyperuricemia. Sometimes urinary complications are noted.

Aluretic, an ayurvedic drug is taken for trial as a diuretic in cases of congestive cardiac failure as a therapeutic agent in relieving oedema.

Materials & Methods

50 Patients, 30 males, 20 females aged 25-75 years with congestive cardiac failure with different etiology like Ischaemic Heart Disease, hypertensive heart disease, valvular heart disease and congenital heart disease were studied.

Patients with history of recent Myocardial infarction, Acute L.V.F., renal or hepatic impairment, pregnancy were excluded from this trial.

All other drugs were stopped who were on Digoxin. Treatment with Aluretic two tablets 3 times daily and adjusted depending upon the diuresis effect was given for a period of 4-6 week.

Care was taken not to give the evening dose, late in the evening to avoid nocturnal diuresis.

Before starting diuretic therapy, the blood was drawn for biochemical, haematological analysis.

The response was graded as excellent (reduction of oedema feet, weight reduction to a maximum of 4 kgs), Good (weight reduction 2 to 3 kgs), Fair (one kg), None (no change in the oedema feet and no reduction in the weight).

Monitoring

The side effects were noted by asking patients how they felt and checking against list of any side effects attributed to a diuretic.

At the beginning and end of each treatment period, every week Biochemical, haematological profile, urine analysis, Haemoglobin, RBC, WBC counts BUN creatinine, transaminases, and cholesterol were estimated.

Results

The weight reduction in patients were significant excellent in 40(80%) out of 50 patients, good in 5(10%) patients out of 50. Fair in 3 patients(6%), none in 2 (4%) patients.

The reduction in weight, and general well-being and clinical improvement were noted.

The adverse-effects observed in 2 patients as itching, sweating and skin rash, weakness were observed in 5 patients.

The itching in 2 patients were thought to be due to hypersensitive reaction and hence stopped from the trial.

The other adverse effect (weakness) was transient and did not require the discontinuation of the drug.

There was no evidence of any biochemical, electrolyte, haematological or renal abnormality.

Discussion

The efficacy of the Aluretic drug as a diuretic in relieving oedema in congestive cardiac patients was studied in 50 patients.

Out of 50 patients, 40 (80%) excellent result, 23 (57.5%) were males and 17 (42.5%) were females. The minimum age was 25 years and the maximum was 75 years.

The response was good in 5 (10%) were all females. Out of 50 cases 3 showed fair response and all the 3 (6%) were males. The two cases (4%) who developed itching sensation did not continue the trial.

The response was excellent in patient with congestive cardiac failure due to Ischaemic Heart Disease. All 24 (48%) patients with oedematous states due to Ischaemic Heart Disease showed excellent response to Aluretic therapy.

The response was excellent in 16 (32%) patients where the oedematous state due to Hypertensive heart disease.

5 (10%) showed good response were CHF due to anaemia. The 3 patients (6%) showed fair result were CHF due to valvular heart disease.

The good diuretic response was seen after 2-3 days and the maximum effect of diuresis was observed after one week of continuous therapy.

There was no incidence of any incontinence or retention of urine in this diuretic therapy.

Conclusion

I conclude diuresis effect in congestive cardiac failure on Aluretic therapy as very encouraging, and it may be considered as a drug of choice in diuretic treatment of congestive cardiac failure as there was no adverse side effects, no haematological, Biochemical or electrolyte changes observed in this study.

Acknowledgement

I thank "ALARSIN PHARMACEUTICALS", BOMBAY, for their help and co-operation in conducting this trial.

References

1. Opie LH. Compensation and overcompensation in congestive heart failure. Am Heart J 1990; 120 (6 pt 2): 1552-7.
2. Ross J Jr. Cardiac Function and Circulatory control. In: Wyngaarden JB, Smith LH Jr., Bennet JC, editors. Cecil Text Book of Medicine, Philadelphia: Saunders, 1992: 155-62.
3. Stevenson, C.W., Dracup, K.A., and Tillisch, J.H. Congestive Heart Failure. Efficacy of medical therapy for severe heart failure in patients transferred for urgent cardiac transplantation. Am J. Cardiol, 1989, 63:481.
4. Cohn, J.N. Current therapy of failing heart. Circulation, 1988, 78:1099.
5. Jaeschke, R. and Guyatt, G.H. Medical therapy for chronic congestive heart failure. Ann Intern Med. 1989, 110:758.
6. Packer, M. Therapeutic options in the management of chronic heart failure. Is there a drug of first choice? Circulation 1989, 79:189.