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  • continuous positive airway pressure, or CPAP.
  • Quinidine, verapamil, and amiodarone increases plasma levels of digoxin (by displacing tissue binding sites and depressing renal digoxin clearance) so plasma digoxin must be monitored carefully.
  • Digitalis-induced progressive elevation of the serum potassium concentration also suggests imminent cardiac arrest. If the potassium concentration exceeds 5 mEq/L in the setting of severe digitalis intoxication, therapy with DIGIBIND is indicated.
  • Milrinone (Primacor) is a phosphodiesterase III inhibitor. Chronotropic, arrhythmogenic, and vasodilative effects are negligible with dobutamine.
  • Conre2

    1. 2. Drugs for CCF <ul><li>Heart failure is the progressive inability of the heart to supply adequate blood flow to vital organs. </li></ul><ul><li>It is classically accompanied by significant fluid retention. </li></ul><ul><li>It is a leading cause of mortality and morbidity. </li></ul>
    2. 3. Drugs for CCF <ul><li>The most common symptoms of CCF includes shortness of breath, edema and fatigue. </li></ul><ul><li>Causes of heart failure includes Coronary artery disease (CAD), Hypertension, Diabetes, Mitral valve disease and Chronic alcohol. </li></ul>
    3. 8. Drugs for CCF
    4. 9. Drugs for CCF <ul><li>Vasodilators – ACE Inhibitors </li></ul><ul><li>Diuretics </li></ul><ul><li>Beta blockers </li></ul><ul><li>Digoxin </li></ul><ul><li>Other Cardiac Inotropes – Dobutamine, Milrinone </li></ul>
    5. 10. Drugs for CCF <ul><li>Angiotensin Converting Enzyme (ACE) Inhibitors : </li></ul><ul><li>ACE inhibitors improve mortality, morbidity, exercise tolerance, left ventricular ejection fraction. </li></ul><ul><li>Captopril, Lisinopril, Enalapril, Ramipril, Quinapril. </li></ul>
    6. 11. ACE Inhibitors for CCF
    7. 12. ACE Inhibitors for CCF
    8. 13. Drugs for CCF <ul><li>Angiotensin Converting Enzyme (ACE) Inhibitors : </li></ul><ul><li>Reduction in arterial resistance (afterload) </li></ul><ul><li>Reduction in venous tension (preload) </li></ul><ul><li>Reduction in aldosterone secretion </li></ul><ul><li>Inhibition of cardiac and vascular remodeling </li></ul>
    9. 14. Drugs for CCF <ul><li>Angiotensin Converting Enzyme (ACE) Inhibitors : </li></ul><ul><li>Adverse effects : </li></ul><ul><li>Dry irritating persistent cough </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Angioedema </li></ul><ul><li>Fetal toxicity </li></ul>
    10. 15. Drugs for CCF <ul><li>Angiotensin Receptor AT-1 blockers (ARB) : </li></ul><ul><li>Losartan, Irbesartan, Candesartan </li></ul><ul><li>Competitive antagonists of Angiotensin II (AT-1). </li></ul><ul><li>No inhibition of ACE or Cough. </li></ul>
    11. 16. Drugs for CCF <ul><li>Vasodilators : </li></ul><ul><li>Isosorbide dinitrate and hydralazine also used specially in patients who cannot tolerate ACE inhibitors. </li></ul><ul><li>Amlodipine and prazosin are other vasodilators can be used in CCF. </li></ul>
    12. 17. Nitrates in CCF
    13. 18. Drugs for CCF <ul><li>Diuretics : </li></ul><ul><li>These are useful in reducing the symptoms of volume overload by </li></ul><ul><li>decreasing the extra cellular volume </li></ul><ul><li>decreasing the venous return </li></ul>
    14. 19. Drugs for CCF <ul><li>Diuretics : </li></ul><ul><li>Loop diuretics like furosemide and bumetanide are the most effective and commonly used. </li></ul><ul><li>Thiazides are effective in mild cases only. </li></ul>
    15. 20. Drugs for CCF <ul><li>Diuretics : Adverse effects : </li></ul><ul><li>Loop diuretics and thiazides cause hypokalemia. </li></ul><ul><li>Potassium sparing diuretics help in reducing the hypokalemia due to these diuretics. </li></ul>
    16. 21. Drugs for CCF <ul><li>Potassium Sparing Diuretics : Spironolactone : </li></ul><ul><li>Aldosterone inhibition minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis. </li></ul>
    17. 22. Drugs for CCF <ul><li>Spironolactone : Aldosterone antagonist </li></ul><ul><li>Spironolactone can be added to loop diuretics to modestly enhance the diuresis; more importantly, improve survival. </li></ul>
    18. 23. Drugs for CCF <ul><li>Beta blockers for congestive cardiac failure : </li></ul><ul><li>Acts primarily by inhibiting the sympathetic nervous system. </li></ul><ul><li>Increases beta receptor sensitivity (up regulation). </li></ul><ul><li>Anti-arrhythmic properties. </li></ul><ul><li>Anti-oxidant properties. </li></ul>
    19. 24. Beta blockers in CCF
    20. 25. Drugs for CCF <ul><li>Beta blockers for CCF : </li></ul><ul><li>Start at low dose and monitor for bradycardia </li></ul><ul><li>Carvedilol and Metoprolol are the most commonly used for CCF amongst beta blockers </li></ul>
    21. 26. Drugs for CCF <ul><li>Cardiac glycosides : Digoxin : </li></ul><ul><li>Inhibition of Na/K ATPase pump increase intracellular sodium concentration – eventually increase cytosolic calcium. </li></ul><ul><li>It restores the vagal tone and abolishes the sympathetic over activity. </li></ul>
    22. 27. Digoxin in CCF
    23. 29. Drugs for CCF <ul><li>Cardiac glycosides : Digoxin : </li></ul><ul><li>Increase the refractoriness of AV node thus decrease ventricular response to atrial rate. </li></ul><ul><li>Digoxin is used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation. </li></ul>
    24. 30. Drugs for CCF <ul><li>Digoxin : Adverse effects / Precautions : </li></ul><ul><li>Nausea, vomiting, gynecomastia, visual disturbances and psychosis. </li></ul><ul><li>Ventricular bigeminy, AV block and bradycardia. </li></ul><ul><li>Amiodarone and verapamil can increase the plasma concentration of digoxin by inhibiting its excretion. </li></ul>
    25. 31. Drugs for CCF <ul><li>Digoxin toxicity treatment: </li></ul><ul><li>Toxicity can be treated with higher than normal doses of potassium. </li></ul><ul><li>Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose. </li></ul>
    26. 32. Drugs for CCF <ul><li>Cardiac Inotropes : </li></ul><ul><li>Phosphodiesterase III Inhibitors Positive inotropic and vasodilator – INO-DILATOR ; Eg., Milrinone </li></ul><ul><li>Dobutamine is a beta-1 agonist which increase contractility and cardiac output . </li></ul>
    27. 33. Drugs for CCF <ul><li>Conclusion : </li></ul><ul><li>ACE inhibitors are cornerstone in the treatment of CCF. </li></ul><ul><li>Beta blockers are used in selected patients (mild/moderate failure, low dose) </li></ul><ul><li>Diuretics and digoxin are other drugs useful in CCF in select patients. </li></ul>
    28. 34. STAGE DISABILITY CLASS 1 MILD No symptoms Can perform ordinary activities without any limitations CLASS 2 MILD Mild symptoms - occasional swelling Somewhat limited in ability to exercise or do other strenuous activities CLASS 3 MODERATE Noticeable limitations in ability to exercise or participate in mildly strenuous activities Comfortable only at rest CLASS 4 SEVERE Unable to do any physical activity without discomfort Some HF symptoms at rest