P4 - CHF DUGS

HEART FAILURE

cardiac disorder that impairs the ability of the ventricle to deliver adequate quantities of blood to the metabolizing tissues during normal activity or at rest

• CLASS I

CLASSES OF HEART FAILURE

• degree of effort necessary to elicit HF symptoms equals to those that would limit normal individuals

• CLASS II

CLASSES OF HEART FAILURE

• symptoms occurs with ordinary exertion

CLASS III

CLASSES OF HEART FAILURE

• symptoms occurs with less- than-ordinary exertion.

CLASS IV

CLASSES OF HEART FAILURE

• Symptoms occurs while at rest

LOW OUTPUT

Metabolic demands are NORMAL but heart is unable to meet them

HIGH OUTPUT

Metabolic demands are INCREASED (hyperthyroidism anemia)and the heart is unable to meet them

DIASTOLIC DYSFUNCTION

• Result of hypertrophy and stiffening of myocardium, reduced filling

• Reduced CO, normal ejection fraction

• Does not respond to inotropic drugs

SYSTOLIC DYSFUNCTION

• Reduced mechanical pumping action

• Reduced CO and reduced ejection fraction (< 45%)

• Results from MI

• respond to inotropic drugs

PERIPHERAL EDEMA

RIGHT-SIDED FAILURE =

PULMONARY EDEMA

LEFT-SIDED FAILURE =

• Tachycardia

• Decreased exercise tolerance

• Shortness of breath

• Cardiomegaly

Signs and symptoms of all types of HF

CONCENTRIC CARDIAC HYPERTROPHY

do to protect heart it CHANGE THE SIZE AND SHAPE

FRANK-STARLING MECHANISM

– increased fiber dilation heightens the contractile force, which then increases the energy released.

• IT LOOSEN

AFTERLOAD

– tension in ventricular muscles during contraction.

In the left ventricle,

• this tension is determined by the amount of force needed to overcome pressure in the pulmonary artery.

PRELOAD

– force exerted on the ventricular muscle at the end of diastole that determines the degree of muscle fiber stretch.

• Also known as ventricular end diastolic pressure; also a key factor in contractility

• Antibiotics

Digoxin

• can affect the concentration of digoxin

• KIDNEY

• BILE

• Digoxin

• Digitoxin

  • EXERTED

Cardiac glycosides (DIGOXIN, DIGITOXIN)

• sodium pump.

MECHANISM OF ACTION

• inhibit Na+/K+ ATPase, the membrane-bound transporter often called the

• disorientation

• hallucinations

Central nervous system effects

• IN ERDERLY

Gynecomastia

is a rare effect

• it is not certain whether this effect represents a peripheral estrogenic action of these steroid drugs or a manifestation of hypothalamic stimulation.

POSITIVE INOTROPIC EFFECTS

DEACTIVATION OF renin-angiotensin-aldosterone compensation

THERAPEUTIC EFFECTS of DIGOXIN

DIGOXIN

With narrow therapeutic index

• available in tablet, injection, elixir and capsule forms.

0.5–1.5 ng/mL

DOSAGE AND ADMINISTRATION of Digoxin

• Therapeutic plasma concentration

> 2 ng/mL

DOSAGE AND ADMINISTRATION of Digoxin

• Toxic plasma concentration

0.25 (0.125–0.5) mg

DOSAGE AND ADMINISTRATION of Digoxin

• Daily dose (slow loading or maintenance)

0.5–0.75 mg every 8 hours for three doses

DOSAGE AND ADMINISTRATION of Digoxin

• Rapid digitalizing dose (rarely used)

QUINIDINE

RISK OF TOXICITY •increases with coadminstration of

• DECREASE RENAL CLEARANCE OF DIGOXIN

• potassium supplements

C. TREATMENT OF TOXICITY

• If the patient is hypokalemic: Administer

• lidocaine or phenytoin

C. TREATMENT OF TOXICITY

• Arrhythmias

• Cholestyramine

C. TREATMENT OF TOXICITY

• binds to digitalis glycosides to prevent absorption of digitalis in the bile

• purified digoxin Fab fragment antibodies.

  • DIGIbind

C. TREATMENT OF TOXICITY

• Patients with very high serum digoxin levels

Diuretics

MOA: to reduce venous pressure and ventricular preload

GOAL: to reduce and eventually eliminate signs and

THIAZIDE diuretics

lose their effectiveness in HF patients with moderately impaired renal function

LOOP diuretics

increase sodium excretion to 20-25% of the filtered load

• reverse pulmonary edema

POTASSIUM SPARING

Given to patients already on Digoxin or ACE inhibitors

Vasodilators

reduce pulmonary congestion effective in acute heart failure because they provide a reduction in preload (through venodilation), or reduction in afterload (through arteriolar dilation), or both

NITRO PRUSSIDE

Vasodilators
- provide potent dilation of both arteries and veins

HYDRA LAZNE

Vasodilators

• decreases afterload and increases cardiac output.

PRA ZOSIN

Vasodilators

• arteriovenous dilator

NITRATES

Vasodilators

— decreases preload

HYDRALAZINE + nitrosovasodilators

Combination of Vasodilators: reduce damaging remodeling of the heart

• Reduce both preload and afterload

with ISOSORBIDE DINITRATE

Combination of Vasodilators: reduce damaging remodeling of the heart

• reduce afterload

with NITROGLYCERIN

Combination of Vasodilators: reduce damaging remodeling of the heart

• reduce preload

ACE INHIBITORS

first line agents in the treatment of HF beneficial effect on cardiac remodeling.

↓PVR ↓afterload ↓salt and water retention ↓ preload

• added to a diuretic

• Also indicated for patients with left ventricular dysfunction without symptoms of HF. for long-term management of chronic HF

• Combine with a β-blocker, diuretic & digoxin Dose must be carefully titrated to the maximum allowable or tolerable dose

Oma patrilat

inhibits both ACE and neutral endopeptidase increase exercise tolerance

β-adrenergic blockers (bisoprolol, carvedilol, and metoprolol)

Used in stable severe heart failure used in conjunction with diuretics, ACE inhibitors and usually digoxin

• should not be taken without diuretics in patients with a current or recent history of fluid retention

• MONITOR bradycardia and the potential for heart block

INOTROPIC AGENTS

used in the emergency treatment of patients with HF and in patients refractory to or unable to take digitalis

. DOPAMINE (IV)

used in acute heart failure , ↑ TPR

DOBUTAMINE (IV)

↑ CO , ↓ in ventricular filling pressure

BIPYRIDINES

MOA: Inhibits phosphodiesterases , ↑ cAMP

INAMRINONE (IV)

INOTROPIC AGENTS
- Unstable in dextrose sol’n has both a positive inotropic effect and a vasodilating effect

MILRINONE (IV)

INOTROPIC AGENTS

• ADR: hypotension, thrombocytopenia

NESIRITIDE (Natrecor®)

A synthetic brain natriuretic peptide (BNP) •approved for the IV treatment of patients with acutely decompensated HF associated with shortness of breath at rest or with minimal activity.

• MOA: it binds to natriuretic peptide receptors in blood vessels, resulting in increased production in guanosine 3’5’ cGMP in target tissues, which mediates vasodilation

Natrecor®

NESIRITIDE

• BN

ADR: Excessive hypotension

NESIRITIDE (Natrecor®)

• ADR

Bosentan

competitive inhibition of endothelin

• use in pulmonary HPN .

• teratogenic and hepatotoxic

Levosimendan

sensitizes the troponin system to calcium inhibit PDE

Alis kiren

renin inhibition

• Carperitide

• ularitide

NATRIURETIC PEPTIDES

• atrial natriuretic peptide (ANP)

• urodilatin