Drugs for Treatment of Heart Failure

I type the number of drugs in each class rather than the name of the drugs, just as a reminder to how many drugs are in each class. I hope that helps with name memorization later on.

A progressive disorder where the heart can’t sufficiently pump blood to meet the needs of the body.

A progressive disorder where the heart can’t sufficiently pump blood to meet the needs of the body.

What is Heart Failure?

Dyspnea, fatigue, fluid retention

Abnormal increase in blood volume or interstitial fluid

Symptoms of Heart Failure?

Typically damage to heart tissue

What causes heart failure?

Chronic sympathetic nervous system and RAAS activation. Cardiac tissue remodels, myocytes die, heart size increases, and missing tissue is replaced with fibrin.

How does the body compensate for HF?

Reduce heart workload, decrease blood volume, improve heart function, and stop cardiac remodeling.

What are we trying to do to treat HF?

There are 7; angiotensin receptor blockers, ACE inhibitors, aldosterone antagonists, beta blockers, diuretics, vaso- and venodilators, and ionotropic agents.

What drug classes prove effective?

The concentration of free cytosolic calcium

Contractility of the heart is based on:

Increases heart rate and contractility, and increase vasoconstriction to increase cardiac output

What does the SNS do during heart failure?

Renin is released, increases angiotensin II and aldosterone. Peripheral resistance increases, sodium and water is retained, and blood volume increases. Also enhances cardiac remodeling.

What does RAAS do during heart failure?

The thickness of the ventricles increases to compensate excessive stretching and reduced ejection fraction. Their volume decreases, and the heart actually gets worse at pumping blood.

What’s myocardial hypertrophy?

Adaptive mechanisms are able to restore cardiac output.

What is compensated HF?

Decompensated HF, adaptive mechanisms can’t keep up with the failing heart. Symptoms will worsen, typically dyspnea is the most troublesome.

What is acute HF?

Fluid limitations, low sodium intake, and treatment of any conditions that may make it worse, like obesity. Drug use IS included

What lifestyle changes manage HF?

The inpatient setting

Where do we usually use ionotropic agents?

NSAID’s (water loss), alcohol, any calcium blockers, and antiarrhythmic drugs

What drugs make HF worse?

Angiotensin II is reduced, bradykinin is increased (vasodilation) and aldosterone is decreased (salt and water loss increases). There are 6 ACE inhibitors

What are the effects of ACE inhibitors?

Decrease vascular resistance, improving cardiac output. by reducing preload Decrease sympathetic response, and improve survival and symptoms of HF patients.

How do ACE inhibitors help HF?

Taken orally, hepatically activated. Captopril and lisinopril aren’t hepatically activated, though. Usually eliminated renally, but Fosinopril can be used in renal impairment.

What is the ACE inhibitor profile?

Dry cough and angioedema, hyperkalemia, postural hypotension. Teratogenic; not to be used in pregnancy.

ACE inhibitor symptoms?

Completely block angiotensin II only, do not affect bradykinin. That means this is a potent vasodilator.

How do Angiotensin receptor blockers (ARBs) help HF?

Dry cough and angioedema, postural hypotension, hyperkalemia, and teratogenic.

Symptoms of ARBs?

Block Na/K system intracellularly, leading to secretion of sodium and water. Reduces cardiac remodeling MAINLY, as well as a diuretic. There are 2 of these.

How do aldosterone receptor antagonists help HF?

Hyperkalmeia and gynecomastia.

Symptoms of ARA’s?

They block sympathetic activity on the heart, decreasing heart rate, renin release, remodeling, hypertrophy, heart workload, and cell death. Recommended for chronic, but stable, HF. There are 3 of these.

How do beta blockers help with HF (concomitant with hypertension)?

Reducing cardiac workload and oxygen demand by decreasing blood volume. Do not increase survival rates; only manage signs and symptoms. There are 4 of these.

How do diuretics help with HF?

Loop Diuretics

What type of diuretics do we use in HF?

Decreasing cardiac preload for patients with chronic HF gives the heart more rest/a break. There are 2 of these.

How do vasodilators help with HF?

Enhancing cardiac contractility by increasing cytoplasmic calcium. Typically reduced survival, and used in acute and emergency settings. Digoxin is fine for daily use though.

How do ionotropic agents help HF?

Blocking the Na/K ATPase makes the heart kick a small amount of sodium out in exchange for some calcium. Vagal tone enhances to reduce heart workload, and AV conduction is reduced.

Why can digoxin be used daily, and not other ionotropic agents?

As a last resort, after all other drug and lifestyle avenues have been used.

When do we use digoxin?

It’s dangerous; it has a narrow therapeutic index, but a high volume of distribution and a long half life. It interacts with a lot of drugs, creases many awful side effects like arrythmias, and becomes toxic very easily.

Why don’t we like using digoxin?

Has positive inotropic and chronotropic effects. Treats hypotension and severe heart failure, used ACUTELY because sympathetic effects can cause worsened damage.

How do beta agonists help HF?

Increases intracellular cAMP, which cascades to increased calcium and better muscle contraction. Used ACUTELY, will harm a patient otherwise.

How does milrinone (phosphodiesterase inhibitor) help HF?

Diuretics first, then ACE inhibitor or ARB. Then beta blockers, slowly. Go for hydralazine and it’s partner next, before finally putting digoxin to use.

Heart failure: order of therapy?