DRUGS USED IN THE TREATMENT OF CONGESTIVE HEART FAILURE

TRULY SITORUS

Congestive Heart Failure

CHF is a condition in which the heart is unable to pump suffient blood to meet the needs of the body. Underlying disease: Hypertensiv Heart Disease Coronary Heart Disease Valvular Heart Disease Cardiomyopathy Congenital Heart Disease Others

Compensatory mechanism:
Pre Load Cardiac Output

Compensatory Na+ - H2O Retention Renin-Angiotensin, Aldosteron Sympathetic Activity Systemic Vascular Resistance Na+-H2O Retention

Cardiac Failure Venous pressure Cardiac output

Sympathetic activity

Blood pressure
Renal blood flow Renin, angiotensin II Aldosteron

capillary filtration Edema

Sodium retention

Drug used to treat CHF

I. Inotropic Agents Increase the strength of contraction of cardiac muscle II. Diuretics Decrease ECF volume III. Vasodilator Reduce the load on the myocardium

Drug used to treat CHF

I. Inotropic Agents 1.1. Cardiac Glicosides - Digoxin - Digitoxin - Quabain 1.2. Adrenergic Agonist - Dobutamin - Dopamin

1.3. Phosphodiesterase Inhibitors - Amrinone - Milrinone II. Diuretics Furosemid - Hydrochlorothiazide III. Vasodilators 3.1. ACE Inhibitors - Captopril - Enalapril - Fosinopril - Lisinopril - Quinapril 3.2. Others

DIGOXIN
Therapeutic use of glycosides is confounded by: 1. Variable pharmacokinetics 2. Numerous drug interaction 3. Narrow therapeutic index

Mechanism of action
Inhibiting membran Na+,K+ ATP ase intracellular Na+ intracellular Ca+ myofibril contraction Cardiac Output!! Modifying autonomic neural discharge the rate of impulse formation by the S-A node High concentration (depress) conduction of the impulses through the A-V Node

Effect
Inotropic Chronotropic Domotropic Oxygen consumption?

Toxic effect of digoxin

Gastrointestinal Anorexia, nausea, vomiting, abdominal pain Visual Disturbed color vision (green or yellow halo around lights) Psychiatric Delirium, fatigue, malaise, confusion, dizziness, abnormal dream Respiratory Ventilatory response to hypoxia

 Cardiac Dysrhytmia, Ventricular fibrillation and cardiac arrest are the most common causes of death

Factors that alter patient sensitivity to digoxin

Serum electrolyte abnormalities: Hypokalemia Hypomagnesia Hypercalcemia Acid base imbalance Thyroid (hypothyroid) Renal failure

Drug interaction
Increased digitalis Concentration may occur during Concurrent therapy
Amiodarone Erythromycin base Quinidine Tetracycline Verapamil

Enhanced potential for cardiotoxicity

Corticosteroids Thiazide diuretics Loop diuretics

Decreased levels of Blood potassium

Indication Congestive Heart Failure Other condition: Cardiac Arrhythmias

Contraindication: Arrhythmias Potassium depletion

Beta Adrenergic Agonist

I. Dopamine Stimulated effect on the: receptor inotropic chronotropic Dopamine receptor blood flow to the kidney, viscera receptor vasoconstriction Indication: Refractory Cardiac Failure Cardiogenic Shock

II.

Dobutamin Asynthetic analog of dopamin Dopamine increase Cardiac Output with little change in the HR and does not significantly elevated oxygen demands of the myocard. Indication: Refractory Heart Failure Severe acute myocardial failure (after cardiac surgery) Cardiogenic shock

Diuretics
I. Loop Diuretics: Furosemid Torsemid Bumetamid Thiazide Diuretics: Chlorothiazide Hydrochlorothiazide Chlorthalidone Potassium Sparing Diuretics: Spironolactone

II.

III.

Effect
Relieve peripheral edema Relieve pulmonary congestion symptoms: orthopnea, paroxysmal nocturnal dyspnea. Decreased plasma volume preload cardiac load and O2 afterload demand BP Hypokalemia

Thiazide
Decrease the reabsorption Na+ by inhibition of Na+ / Cl- cotransporter Increase excretion of Na+ and Clloose of K+ Decreased urinary Ca++ excretion Reduced peripheral vascular resistance Furosemid (?) Spironolactone (?)

Angiotensin Converting Enzime (ACE) Inhibitors

Vasodilatation Bradikinin AI AII Preload Afterload
Cardiac output

Sympathetic NS Na-water retention

ACE Inhibitor
Captopril Enalapril Lisinopril Benazepril Quinapril Rapipril Fosinopril

ADR
Skin rash, dysgeusia and proteinuria Angioedema Neutropenia, agranulocytosis, glomerulonephritis (rare)

Indication
CHF in a symptomatic patient (left ventricular dysfunction) Patient who have had a recent myocardial infarction

Angiotensin II Receptor Blockers

Losartan Condersartan Valsartan Iberstan Eprosartan Tazosartan Telmisartan Zolasartan