Drugs for CCF • Heart failure is the progressive inability of the heart to supply adequate blood flow to vital organs. • It is classically accompanied by significant fluid retention. • It is a leading cause of mortality and morbidity.
Drugs for CCF • The most common symptoms of CCF includes shortness of breath, edema and fatigue. • Causes of heart failure includes Coronary artery disease (CAD), Hypertension, Diabetes, Mitral valve disease and Chronic alcohol.
Drugs for CCF
Drugs for CCF • Vasodilators – ACE Inhibitors • Diuretics • Beta blockers • Digoxin • Other Cardiac Inotropes – Dobutamine, Milrinone
Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors : • ACE inhibitors improve mortality, morbidity, exercise tolerance, left ventricular ejection fraction. • Captopril, Lisinopril, Enalapril, Ramipril, Quinapril.
ACE Inhibitors for CCF
ACE Inhibitors for CCF
Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors : • Reduction in arterial resistance (afterload) • Reduction in venous tension (preload) • Reduction in aldosterone secretion • Inhibition of cardiac and vascular remodeling
Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors : Adverse effects : • Dry irritating persistent cough • Hyperkalemia • Angioedema • Fetal toxicity
Drugs for CCF Angiotensin Receptor AT-1 blockers (ARB) : Losartan, Irbesartan, Candesartan • Competitive antagonists of Angiotensin II (AT-1). • No inhibition of ACE or Cough.
Drugs for CCF Vasodilators : • Isosorbidedinitrate and hydralazine also used specially in patients who cannot tolerate ACE inhibitors. • Amlodipine and prazosin are other vasodilators can be used in CCF.
Nitrates in CCF
Drugs for CCF Diuretics : These are useful in reducing the symptoms of volume overload by • decreasing the extra cellular volume • decreasing the venous return
Drugs for CCF Diuretics : • Loop diuretics like furosemide and bumetanide are the most effective and commonly used. • Thiazides are effective in mild cases only.
Drugs for CCF Diuretics :Adverse effects : • Loop diuretics and thiazides cause hypokalemia. • Potassium sparing diuretics help in reducing the hypokalemia due to these diuretics.
Drugs for CCF Potassium Sparing Diuretics : Spironolactone : • Aldosterone inhibition minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.
Drugs for CCF Spironolactone : Aldosterone antagonist • Spironolactone can be added to loop diuretics to modestly enhance the diuresis; more importantly, improve survival.
Drugs for CCF Beta blockers for congestive cardiac failure : • Acts primarily by inhibiting the sympathetic nervous system. • Increases beta receptor sensitivity (up regulation). • Anti-arrhythmic properties. • Anti-oxidant properties.
Beta blockers in CCF
Drugs for CCF Beta blockers for CCF : • Start at low dose and monitor for bradycardia • Carvedilol and Metoprolol are the most commonly used for CCF amongst beta blockers
Drugs for CCF Cardiac glycosides : Digoxin : • Inhibition of Na/K ATPase pump increase intracellular sodium concentration – eventually increase cytosolic calcium. • It restores the vagal tone and abolishes the sympathetic over activity.
Digoxin in CCF
Drugs for CCF Cardiac glycosides : Digoxin : • Increase the refractoriness of AV node thus decrease ventricular response to atrial rate. • Digoxin is used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation.
Drugs for CCF Digoxin : Adverse effects / Precautions : • Nausea, vomiting, gynecomastia, visual disturbances and psychosis. • Ventricular bigeminy, AV block and bradycardia. • Amiodarone and verapamil can increase the plasma concentration of digoxin by inhibiting its excretion.
Drugs for CCF • Digoxin toxicity treatment: • Toxicity can be treated with higher than normal doses of potassium. • Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose.
Drugs for CCF Cardiac Inotropes : • Phosphodiesterase III Inhibitors Positive inotropic and vasodilator – INO-DILATOR ; Eg., Milrinone • Dobutamine is a beta-1 agonist which increase contractility and cardiac output.
Drugs for CCF Conclusion : • ACE inhibitors are cornerstone in the treatment of CCF. • Beta blockers are used in selected patients (mild/moderate failure, low dose) • Diuretics and digoxin are other drugs useful in CCF in select patients.
