JVD, hepatojugular reflux, S 3 gallop, rales, and peripheral edema. An echocardiogram may be indicated to evaluate LV and RV ejection fractions, movement of chamber walls and valves, and chamber sizes. In systolic dysfunction, ejection fraction is decreased. Electrolytes, BUN, creatinine, ABG, CBC count, and serum digoxin level if indicated. In mild heart failure, a thiazide diuretic may be sufficient.
Some patients develop resistance to loop diuretics after chronic usage.
Patients with heart failure who are receiving diuretics should have potassium and magnesium levels monitored. Supplementation should be provided if necessary, since hypokalemia and hypomagnesemia are risk factors for the development of arrhythmias. ACE inhibitors have also been shown to improve hemodynamics and increase exercise tolerance in heart failure patients. Up to now only captopril, enalapril, lisinopril, and ramipril have been shown to be efficacious in large controlled clinical trials. Begin therapy at low doses such as enalapril 2.5 mg PO BID and titrate to 10 mg PO BID gradually.