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Treatment of heart failure(CHF)

Done by:Fatimah Al-Shehri

Pharm.D candidate .King abdulaziz university

Supervised by :Dr.Sara Al-Khansa.

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Outline: 1-Introduction:

-Definition.

-Types.-Causes.

2-Pathophysiology.3-Diagnosis.

-Signs and symptoms .

-Classification of HF.

4-Mangment of CHF.

-Goals of therapy.-Non-pharmacological therapy.

-Pharmacological therapy.-Summary of guidelines treatment.

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Heart failure:

Abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues, despite normal filling pressures.

According to function:1-Systolic HF.2-Diastolic HF.

Types of heart failure:

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Pathophysiology:Left sided heart failure: Systolic failure(systolic dysfunction) :

The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation.

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Pathophysiology:ABC of heart failurePathophysiologyG Jackson, C R Gibbs, M K Davies, G Y H Lip

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Signs and symptoms:

-Edema of feet , ankles , abdomen and lungs .-Congested jugular veins.-Loss of appetite.-Shortness of breath.-Fatigue and weakness.-↓↓ Alertness or concentration.

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CAUSES: 1-Coronary artery disease .

2 -Cardiomyopathy.3-Hypertension .

4-Thyroid disease 5-Valvular heart disease .

6-Cardiotoxins. 7-Myocarditis.

8-Idiopathic .

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Diagnosis:1-Medical history.

2-Physical examinations.3-Laboratory tests.

E.g:(B-type Natriuretic Peptide(BNP).

4-Radilogical methods:-Chest X- rays&CT scan&MRI.

-ECG.EF<40).)-ECHO.

Hunt SA et al. J Am coff cardiot 2001:83:2101.13.Farrett MH et al.JAMA.2002:287:890-7.

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Hunt SA et al.j AM coff cardio 2001:38:2101-13Farrell MH et al .JAMA 2002:287:890-7

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Management of CHF:

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Principles and goals of therapy:

1-Block the compensatory neurohormonal activation caused by decreased CO.

2-Prevent/minimize Na and water retention. 3-Eliminate or minimize symptoms of HF.

4-Slow the progression of cardiac dysfunction 5-Decrease mortality.

6-Prevent hospital admission.7 -Improve survival.

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Management of CHF:

1-Nonpharmacological

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2-Pharmacological:1-Diuretics.

2-ACEI or ARBS.3-Beta blockers.

4-Aldosterone antagonist.5-Digoxin.

6-Vasodilators.

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1-Nonpharmacological: Life style changes:

1-Decrease fluid intake(2/L MAXIMUM.)

2-Decease sodium.3-Decreae weight.

4-Moderate exercise .

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2-Pharmacological:

1-Diuretics: Place of therapy :all patients with heart failure.

Types of diuretics: A- loop diuretics :(Furosemide,Torsemide,Ethycranic acid,Bumetinde.)

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Mechanism of action

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1-Diuretics: Side effects of loop diuretics :

-Hypokalemia,hyponatermia,hypomagnesemis,hypocalcemia,

-Dehydration. ototoxicity.-Hyperuercemia,hyperglycemia,

hyperlipidemia.

-Conistipation,Dryness of the mouth .-Muscle weakness.

-wieght loss,Skin rashes,hypotension ..

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1-Diuretics: Contraindications of loop diuretics:Hypersensitivity.

Monitoring: -Monitor electrolyte ,(K,Na,Ca).

-Uric acid ,glucose.

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1-Diuretics :

B-Thaiazide diuretics:

e.g: Hydrochlorothiazide.

Mechanism of action

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1-Diuretics: Side effects of thiazide diuretics:

-Hypokalemia,Hyponatremia-Increased uric acid and glucose.

-Increased cholesterol. -Hypomagnesemia

-Hypotension.-Photosensitivity.

-Headaches, Allergy

thiazide diuretics : of Contraindications -Allergy to (sulphur-containing medications).

-Gout. -Hypotension. -Renal failure.

-Lithium therapy. -Hypokalemia.

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Diuretics and recommended doses:

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2-ACEI: Place in therapy: For all patients with heart failure.

e.g:(Lisinopril,Prendopril,Captopril,Enalpril,)

Mechanism of action :(-Blocks production (AgII

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2-ACEI :Side effects:

- Dry cough. - Protinuria. Allergy .

- Decrease taste. - Neutropenia .

- Hyperkalemia. - Angioedema.

-Acute renal failure.

-Pregnancy.-Hypotension.

-Bilateral renal stenosis.

Contraindications:

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2-ACEI:

Monitoring:

1-SCr,and K in 1–2 weeks after starting or increasing the dose.

2-Monitor BP and symptoms of hypotension (e.g., dizziness, light-headedness).

3-Use cautiously in those with a baseline K greater than 5.0 mEq/L .

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ACEI and recommended doses:

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2-ARBs:e.g:(Losartan.Candesartan.Valsartan)

Place in therapy :If the patient cannot tolerate the side effect that produced by ACEI (dry cough).

Side effects: the same as ACEI but with less cough .

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ARBS and recommended doses:

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3-Beta Blockers:

BB use in heart faliure: -Bisoprolol.-Metoprolo.-Carvedilol.

Place in therapy:Should be used in all stable patients.

Mechanism of action :

-Blocks the effect of NE and other sympathetic NT on the heart and vascular system.

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3-Beta blockers:

SIDE EFFECTS: 1-Hypoglycemia.

2-Hypotension.3-Bradycardia.

4-Depression.5-Edema .

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3-Beta blockers:Contraindications:

1-Uncontrolled heart failure.2-Prinzmetal's angina.

3-Bradycardia.4-Hypotension.

5-Certain problems: (sinus syndrome) .

Monitoring: -BP, HR, and symptoms

of hypotension( monitor in 1–2 weeks .)

-IF hypotension alone is the problem ,

try reducing the dose of the ACE inhibitor first. -Increased edema/fluid retention (monitor in 1–2 weeks).

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BB and recommended doses:

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4-Aldosterone antagonist:E.g: Spironolactone,Eplerenone.

Place in therapy:

1-Should be considered in patients after an acute MI ,

with clinical HF signs and symptoms or history of (diabetes, and an LVEF less than

40%) .2 -Class III and IV HF .

3-LV dysfunction immediately after MI.

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4-Aldosterone antagonists:

Mechanism of action :Blocks effects of aldosterone in the kidneys, heart, and

vasculature :(a )↓K and Mg loss: Decreases ventricular arrhythmias .

(b )↓ Na retention; decreases fluid retention.

(c )Eliminates catecholamine; decreases BP .

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4-Aldosterone antagonists:

Side effects : Hyperkalemia.Gynecomastia.Dry mouth.Muscle weakness.Confusion, nausea, vomiting.

Eplerenone :alternative

to spironolactone in painful gynecomastia.

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4-Aldosterone antagonists: Contraindications:

1-SCr is greater than 2.5 mg/dL ,2(-CrCl ) < 30 /is mL min ,

3-K is >5.0 mEq/L .

MONITORING : 1-K and SCr within 1 week of starting therapy.

2 -Decrease dose by 50% or discontinue if K is greater than 5.5 mEq/L .Dosing :

(1 )Spironolactone 12.5–25 mg/day. (2 )Eplerenone 25–50 mg/day.

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5-Digoxin:

Place in therapy :In patients with LVEF of ≤40%,who have signs or symptoms of HF while receiving standard therapies including ACEI or ARBs and β-blockers.

DOSING: 0.125 mg/day

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5-Digoxin:Mechanism of action:Inhibits Na-K ATPase:i. Decreases central sympathetic outflow by sensitizing cardiac baroreceptors ii. Decreases renal reabsorption of Na .iii. Minimal increase in COP .Side effects:

GIT disturnances.Bradycardia.Ventricular arrythmia.confusion, hallucinations ,

unusual thoughts or behavior.Abdominal pain, headache.

Visual busturbances .

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5-Digoxen:CONTRAINDICATIONS:

-hypersensitivity. -Ventricular fibrillation.

-Pregnancy

Monitoring: 1-Serum concentrations should be less than 1.0

ng/mL, in general, concentrations of 0.7–0.9 ng/mL are effective in HF .

2 -Risk of toxicity increases in the presence of hypokalemia or hypomagnesemia, older age ,RF .

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6-Hydralazine and isosorbide dinitrate:

Place in therapy: In Patients unable to take an ACE I OR ARBS.Due to:

severe renal insufficiency, hyperkalemia, or angioedema.

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6-Hydralazine and isosorbide dinitrate:

Mechanism of action A-Hydralazine:

(a ) ) (Arterial vasodilator reduces afterload .(b ) Enhances effect of nitrates through antioxidant

mechanisms

B- Isosorbide dinitrate :(a ) Stimulates nitric acid signaling in the endothelium

(b ) Effective in reducing preload.

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6-Hydralazine and isosorbide dinitrate:

Side effects: A-Hydralazine:

-Hypersensitivity. -Systemic lupus erythremataus.

-Hypotension. -Headache. -GIT upset.

B-Isosorbide dinitrate: -Blurred vision ,dry mouth.

-Nausea, vomiting, sweating, pale skin. -Headache, hypotension ,mild dizziness.

-Weakness.

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6-Hydralazine and isosorbide dinitrate(ISDN):

Monitoring: 1 -Hypotension .

2-Drug-induced lupus with hydralazine.

Dosing: -Hydralazine (25–75 mg 3-4times/day).

-Isosorbide dinitrate (10–40 mg 3times/ day) .

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Benefits of each group:

Hydralazine &ISDN

Digoxin. Aldosteroneantagonist

BB ACEI &ARBS

Diuretic Groups:

+ + + + + + Symptoms:

+ _ + + + _ :Mortality

+ + + + + - Hospitalization:

.

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Summary: Yancy, CW et al.

2013 ACCF/AHA Heart Failure Guideline

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References:

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Pharm.D candidate :Fatimah Al-Shehri.

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