Heart Failure

Congestive heart failure

is a complex progressive disorder in which the heart is
unable to pump sufficient blood to meet the metabolic needs
of the body
common causes:
myocardial ischemia and infarction
hypertension and cardiomegaly
valvular stenosis and regurgitation
drug (doxorubicin causes cardiotoxicity)
cardinal symptoms:
dyspnea
fatigue
fluid retention
 Pathophysiology
HF is associated with high morbidity and high
mortality
Pathologic process that may cause HF occur either in
the heart itself or systematically
Cardiac output decreases when the left ventricle is
unable to eject its normal volume of blood during
systole
The heart muscles enlarges to provide more
contractile force
 Compensatory mechanism
SNS releases Epi and NE producing tachycardia
and increase contractility
RAAS stimulates renal sodium and water
retention in an effort to increase circulating
blood volume
Increased production of vasopressin
(antidiuretic hormone)
Types of heart failure
 Drug therapy for heart failure:
Goals:
alleviate symptoms
slow disease progression
improve survival
Benefits:
reduced myocardial workload
decreased extracellular volume
improve cardiac contractility
reduced rate of cardiac remodelling (hypertrophy and
fibrosis)
1. Angiotensin - Converting Enzyme Inhibitors
Pril
decrease vascular resistance
decrease preload ACE INHIBITORS
increase afterload Captopril CAPOTEN
increase cardiac output Enalapril VASOTEC
Fosinopril MONOPRIL
blunt aldosterone release Lisinopril PRINIVIL, ZESTRIL
Quinapril ACCUPRIL
Adverse effects: postural Ramipril ALTACE
hypotension, renal insufficiency,
hyperkalemia, a persistent dry
cough, and angioedema (rare).
 2. Angiotensin Receptor blockers Tan
ARBs have a different mechanism of action than ACE
inhibitors, their actions on preload and afterload are
similar. Their use in HF is mainly as a substitute for ACE
inhibitors in those patients with severe cough or
angioedema, which are thought to be mediated by
elevated bradykinin levels.

Adverse effects: a lower incidence of ARBs

cough and angioedema. Like ACE Candesartan ATACAND
inhibitors, ARBs are contraindicated Losartan COZAAR
in pregnancy. Telmisartan MICARDIS
Valsartan DIOVAN
 3. Aldosterone antagonists
preventing salt retention, myocardial hypertrophy,
and hypokalemia
indicated in patients with more severe stages of
HFrEF or HFrEF and recent myocardial infarction

Adverse effects: lower incidence ALDOSTERONE ANTAGONISTS

of endocrine-related Eplerone INSPRA
Spironolactone ALDACTONE
 4. - Adrenoreceptor blockers
improved systolic functioning and reverse cardiac remodeling
to prevent the changes that occur because of chronic activation
of the SNS
decrease heart rate and inhibit release of renin in the kidneys
prevent the deleterious effects of norepinephrine on the
cardiac muscle fibers, decreasing remodeling, hypertrophy, and
cell death
for patients with chronic, -ADRENORECEPTOR BLOCKERS
stable HF Bisoprolol ZEBETA
Carvedilol COREG, COREG CR
Metoprolol succinte TOPROL XL
Metoprolol tartrate LOPRESSOR
 5. Diuretics
relieve pulmonary congestion and peripheral edema
reducing the symptoms of volume overload, including
orthopnea and paroxysmal nocturnal dyspnea
decrease plasma volume and venous return to the heart
(preload)
decreases cardiac workload and oxygen demand
decreasing blood pressure DIURETICS
Bumetanide BUMEX
Furosemide LASIX
Metolazone ZAROXOLYN
Torsemide DEMADEX
 6. Vaso- and Venodilators
decrease in cardiac preload by increasing venous
capacitance
reduce systemic arteriolar resistance and decrease
afterload
DIRECT VASO- AND VENODILATORS
Adverse effects: Headache, Hydralazine APRESOLINE
hypotension, and tachycardia Isosorbide DILATRATE-SR,
dinitrate ISORDIL
FDC Hydralazine/ BIDIL
Isosorbide
dinitrate
 7. Inotropic agents- Digitalis
glycosides: Digoxin (Lanoxin)
by inhibiting the Na+/K+ ATPase enzyme, digoxin reduces the ability of
the myocyte to actively pump Na+ from the cell.
Actions: (+) inotropic, (-) chronotropic
Uses: for treating moderate to severe HF not responsive to diuretics and
ACEi
Side effects: arrhythmias, electrolyte imbalances
Antidote for Digoxin toxicity:
Digoxin immune FAB (Digibind)
INOTROPIC AGENTS
Digoxin LANOXIN
Dobutamine DOBUTREX
Milrinone PRIMACOR
 Therapeutic strategies
Fluid limitations (<1.5 to 2 L daily)
Low dietary intake of Na (<2000mg/d)
Tx of comorbid conditions
Judicious use of diuretics

Note: Drugs that may precipitate or exacerbate HF,

such as nonsteroidal anti-inflammatory drugs
(NSAIDs), alcohol, nondihydropyridine calcium channel
blockers, and some antiarrhythmic drugs, should be
avoided if possible.
Order of therapy