Questions from the mailbag

We love getting questions so please keep them coming. A question was received to the effect of:

1. Is there any upper limit of creatinine which you would NOT give ARB/ACE-I?
2. Are there any special precautions to prevent contrast-induced nephropathy? At which level of creatinine would you consider such measures?
3. For a patient who was admitted for decompensated cardiac failure, when would you initiate betablockers? as soon as he is out of acute failure, or wait a few weeks?

1. I would not use ACE-I / ARB if serum creatinine is > 2x normal for your lab. Obviously, for patients in the borderline zone, close monitoring is required. A significant increase in the serum creatinine, will make stopping the ACE-I / ARB mandatory.
2. Contrast induced nephropathy - Always recognise the high risk group for contrast nephropathy. We need to be pro-active. All patients with significantly raise creatinine, gets this regime. In those not medically contraindicated, overnite IV drip to volume expand, helps. I use acetyl cystiene rountinely, for one day, or even two doses. before the angiogram / angioplasty. I keep them a day longer, to observe for rise in creatinine, or symptoms.
3. I would start beta-blockers, and I mean either carvidelol, or metoprolol XL, as soon as the acute CCF is under control, the patient is ambulating and the observations are stable. Always begin the beta-blockers in hospital, for this group of patients.