drug therapy of heart failure dr. munir gharaibeh november 2009
TRANSCRIPT
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Drug Therapy of Heart FailureDrug Therapy of Heart Failure
Dr. Munir GharaibehDr. Munir Gharaibeh
November 2009November 2009
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Drug Therapy of Heart FailureDrug Therapy of Heart Failure
Definition of Heart FailureDefinition of Heart Failure
CausesCauses
ClassificationsClassifications
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New York Heart Association Classification
Functional Capacity
Objective Assessment
Class I Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain.
Class II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
Class III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.
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Compensatory MechanismsCompensatory Mechanisms inin Heart FailureHeart Failure
• Frank Starling Mechanism
• Increased Activity of SNS:– a- Tachycardia and increased CO.– b- Increased myocardial contractility – c- Vasoconstriction leading to
redistribution of blood to important viscera– d- Renin release leading to increased plasma volume
• Myocardial Hypertrophy leading to increased
wall tension.
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Factors that May Precipitate Acute Decompensation in Patients with Chronic Heart Failure
Dietary indiscretion
Myocardial ischemia/infarction
Arrhythmias (tachycardia or bradycardia)
Discontinuation of HF therapy
Infection
Anemia
Initiation of medications that worsen HF:
Calcium antagonists (verapamil, diltiazem)
Beta blockers
Nonsteroidal anti-inflammatory drugs
Antiarrhythmic agents [all class I agents, sotalol (class III)]
Anti-TNF antibodies
Alcohol consumption
Pregnancy
Worsening hypertension
Acute valvular insufficiency
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Objectives of Long Term Management of Chronic Cardiac Failure:
• Improve cardiac performance at rest and during exercise.
• Improve myocardial efficiency.
• Improve quality of life (particularly symptom-free and effort tolerance).
• Improve patient survival.
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Drug Groups Commonly Used in Heart Failure.
Diuretics
Aldosterone receptor antagonists
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Beta blockers
Cardiac glycosides
Vasodilators
Beta agonists
Bipyridines
Natriuretic peptide
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Causes of Diuretic Resistance in Heart Failure
*Noncompliance with medical regimen; excess dietary Na+ intake
*Decreased renal perfusion and glomerular filtration rate due to:
*Excessive intravascular volume depletion and hypotension due to aggressive diuretic or vasodilator therapy
*Decline in cardiac output due to worsening heart failure, arrhythmias, or other primary cardiac causes
*Selective reduction in glomerular perfusion pressure following initiation (or dose increase) of ACE inhibitor therapy
*Nonsteroidal antiinflammatory drugs
*Primary renal pathology (e.g., cholesterol emboli, renal artery stenosis, drug-induced interstitial nephritis, obstructive uropathy)
*Reduced or impaired diuretic absorption due to gut wall edema and reduced splanchnic blood flow
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Potential Roles of Aldosterone in the Pathophysiology of Heart Failure
MECHANISM PATHOPHYSIOLOGICAL EFFECT
Increased Na+ and water retention
Edema, elevated cardiac filling pressures
K+ and Mg2+ loss
Arrhythmogenesis and risk of sudden cardiac death
Reduced myocardial norepinephrine uptake
Potentiation of norepinephrine effects: myocardial remodeling and arrhythmogenesis
Reduced baroreceptor sensitivity
Reduced parasympathetic activity and risk of sudden cardiac death
Myocardial fibrosis, fibroblast proliferation
Remodeling and ventricular dysfunction
Alterations in Na+ channel expression
Increased excitability and contractility of cardiac myocytes
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Angiotensin Converting Enzyme InhibitorsAngiotensin Converting Enzyme Inhibitors"ACEI""ACEI"
• Pharmacological Actions:• Reduce angiotensin II levels.• Increase bradykinin.• Inhibit SNS, leading to decreased NE
release and upregulation of 1 receptors.• Balanced vasodilators.• Reduce myocyte & fibroblast growth factors• Reduce salt and water retention.• Reduce K+ loss. • Reduce ventricular arrhythmias.
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Angiotensin Converting Enzyme InhibitorsAngiotensin Converting Enzyme Inhibitors"ACEI""ACEI"
Therapeutic Value:• Nowadays drugs of choice.
• No tolerance.
• Retard progression of HF.
• Decrease arrhythmias.
• Decrease mortality only with the highest tolerated doses.
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Angiotensin Converting Enzyme InhibitorsAngiotensin Converting Enzyme Inhibitors"ACEI""ACEI"
• Captopril
• Enalapril
• Lisinopril
• Quinapril
• Fosinopril
All are similarly effective
Might differ in toxicity
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Angiotensin Converting Enzyme InhibitorsAngiotensin Converting Enzyme Inhibitors"ACEI""ACEI"
Toxicity:• Hypotension
• Renal Impairment ............ proteinurea
• K+ retention
• Cough
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Angiotensin (AT1) Receptor BlockersAngiotensin (AT1) Receptor BlockersARBsARBs
• Losartan.
• Candesartan.
• Valsartan.
• Irbesartan.
• Telmisartan.
Not superior to ACEIs, but may be useful for patients who can not tolerate ACEIs because of cough.
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Positive Inotropic AgentsPositive Inotropic Agents • Cyclic AMP Independent Agents:
• Cyclic AMP Dependant Agents:
-adrenergic Agonists
Phosphodiesterase Inhibitors
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Positive Inotropic AgentsPositive Inotropic Agents Cyclic AMP Independent Agents:
• Digitalis: inhibits Na/KATPase.
• Pimobendan: sensitizes myocytes to Ca++, also inhibits
PDE.
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Digitalis GlycosidesDigitalis Glycosides History:• Egyptians ------- Squill
• Chinese -------- Toad skin
• William Withering ----- Foxglove 1785
• Digitalis purpura
• Digitalis lanata
• Strophanthus
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Digitalis GlycosidesDigitalis Glycosides
Mechanism:• Inhibition of Na+/K+ ATPase
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Digitalis GlycosidesDigitalis GlycosidesActions: • Positive Inotropic
• Vascular Muscle
• Vagal Stimulation
• Electrical Stimulation
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Effects of Digoxin on Electrical Properties of Cardiac Tissues.
Tissue or Variable
Effects at Therapeutic Dosage
Effects at Toxic Dosage
Sinus node Rate Rate
Atrial muscle Refractory period Refractory period, arrhythmias
Atrioventricular node
Conduction velocity, refractory period
Refractory period, arrhythmias
Purkinje system, ventricular muscle
Slight refractory period Extrasystoles, tachycardia, fibrillation
Electrocardiogram PR interval, QT interval Tachycardia, fibrillation, arrest at extremely high dosage
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Digitalis GlycosidesDigitalis GlycosidesToxicity:• G.I.T.
• Visual.
• Neurologic.
• Cardiac.
• Interactions.
Treatment of Toxicity:
Reduce the dose.
Cardiac pacemeker.
Digitalis antibodies( Digoxin Immune Fab)
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Digitalis GlycosidesDigitalis GlycosidesTherapeutic Benefits:• CCHF with supraventricular
arrhythmia
• Morbidity
• ? Withdrawal
• ? Mortality
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Positive Inotropic AgentsPositive Inotropic AgentsCyclic AMP Dependent Agents:
-adrenergic Agonists:NE
Dopamine
Dobutamine
Phosphodiesterase Inhibitors:Amrinone
Inamrinone
Milrinone
Vesanirone
Sildenafil
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Positive Inotropic AgentsPositive Inotropic AgentsCyclic AMP Dependent Agents:
-adrenergic Agonists:
All increase myocardial oxygen consumption, so not helpful for chronic use.
May be used (IV) for short term or in acute heart failure.
NE:
Was used in cardiogenic shock, but caused severe vasospasm and gangrene .
Ep:
Still used in cardiac arrest, by intracardiac injection.
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Positive Inotropic AgentsPositive Inotropic AgentsDopamine:
Widely used in cardiogenic shock.Low doses: stimulates DA1 receptors leading to renal vasodilation and improved renal function.Intermediate doses: works on β1 receptors leading to positive inotropic actions.High doses: stimulates α receptors leading to vasoconstriction and elevation of blood pressure. Can cause arrhythmias and ischemic changes.
Dobutamine:Selective β1 agonist, used intermittently (IV) in CCHF.Has more inotropic than chronotropic actions.
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Positive Inotropic AgentsPositive Inotropic AgentsPhosphodiesterase Inhibitors:
PDE inhibition leads to accumulation of cAMP and cGMP leading to positive inotropic activity and peripheral vasodilation.
Toxic: arrhythmias, and thrombocytopenia.
Short acting, so reserved for parenteral therapy of acute heart failure.
Inamrinone (PDE-3)
Milrinone (PDE-3)
Vesanirone (PDE-3)
Sildenafil (PDE-5)
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VasodilatorsVasodilators
• Affect preload and/or afterload without directly affecting contractility.
• Consequently can decrease myocardial ischemia, enhance coronary blood flow and decrease MVO2.
• Can be used in acute heart failure and for short periods in CCHF.
• Hydralazine-Isosorbide dinitrate combination was found to decrease mortality, maybe by reducing remodeling of the heart.
• Can be combined with ACEI, Diuretics and digitalis.
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Vasodilator Drugs Used to Treat Heart FailureDRUG CLASS EXAMPLES MECHANISM OF
VASODILATING ACTIONPRELOAD REDUCTION
AFTERLOAD REDUCTION
Organic nitrates Nitroglycerin, isosorbide dinitrate
NO-mediated vasodilation +++ +
Nitric oxide donors Nitroprusside NO-mediated vasodilation +++ +++
Angiotensin-converting enzyme inhibitors
Captopril, enalapril, lisinopril
Inhibition of Ang II generation, decreased bradykinin degradation
++ ++
Angiotensin receptor blockers
Losartan, candesartan
Blockade of AT1 receptors
++ ++
Phosphodiesterase inhibitors
Milrinone, inamrinone
Inhibition of cyclic AMP degradation
++ ++
Direct-acting K+-channel agonist
Hydralazine Unknown + +++
Minoxidil Hyperpolarization of vascular smooth muscle cells
+ +++
α 1 Adrenergic
antagonists
Doxazosin, prazosin Selective 1 adrenergic
receptor blockade
+++ ++
Nonselective adrenergic antagonists
Phentolamine Nonselective adrenergic receptor blockade
+++ +++
Vasodilating / β 1
adrenergic antagonists
Carvedilol, labetalol Selective 1 adrenergic
receptor blockade
++ ++
Ca2+ channel blockers
Amlodipine, nifedipine, felodipine
Inhibition of L-type Ca2+ channels
+ +++
β adrenergic agonists
Isoproterenol Stimulation of vascular 2
adrenergic receptors
+ ++
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Steps in the Prevention and Treatment of Chronic Heart Failure.
ACC/AHA Stage Step1 Intervention
A, B 1 Control hypertension, hyperlipidemia, glucose metabolism (diabetes), obesity
C 2 Reduce workload of the heart (limit activity, put on temporary bed rest)
3 Restrict sodium intake, give diuretics
4 Restrict water (rarely required)
C, D 5 Give angiotensin-converting enzyme inhibitor or angiotensin receptor blocker
6 Give digitalis if systolic dysfunction with third heart sound or atrial fibrillation is present
7 Give blockers to patients with stable class II–IV heart failure
8 Give aldosterone antagonist
9 Give vasodilators
D 10 Cardiac resynchronization if wide QRS interval is present in normal sinus rhythm
11 Cardiac transplant
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Errors in Management of HFErrors in Management of HF• Missed diagnosis.
• Improper dosage of diuretics.
• Failure to assess quality of life.
• Failure to consider long term therapeutic goals.
• Use of potentially harmful drugs.
• Underprescribing of ACEI.
• Failure to use hydralazine-isosorbide combination.