Digitalis Lecture

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  • Digitalis Lecture

    1. 1. Drugs Used In the Treatment of Congestive Heart Failure Garrett J. Gross, Ph.D.
    2. 2. Prototype drugs to know for treatment of heart failure <ul><li>Inotropes – digoxin, inamrinone,dobutamine, dopamine </li></ul><ul><li>Diuretics - hydrochlorothiazide, furosemide, amiloride, spironolactone </li></ul><ul><li>ACE inhibitors – captopril, enalapril,lisinopril </li></ul><ul><li>AII receptor blockers-valsartan,losartan </li></ul><ul><li>Sympatholytics – propranolol, carvedilol </li></ul><ul><li>Vasodilators – glyceryl trinitrate, hydralazine, sodium nitroprusside </li></ul>
    3. 5. DEFINITION “ The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. &quot; E. Braunwald
    4. 8. EVOLUTION OF CLINICAL STAGES NORMAL Asymptomatic LV Dysfunction Compensated CHF Decompensated CHF No symptoms Normal exercise Normal LV fxn No symptoms Normal exercise Abnormal LV fxn No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Refractory CHF Symptoms not controlled with treatment Chronic Congestive Heart Failure
    5. 33. DIGOXIN NEUROHORMONAL EFFECTS Plasma Noradrenaline Peripheral nervous system activity RAAS activity Vagal tone Normalizes arterial baroreceptors
    6. 38. <ul><li>Dig. Converts At.-Flutter At. Fibrillation (benefit) </li></ul><ul><li>At. Flutter 300 (Atrial) 150 bpm (Vent.) </li></ul><ul><li>At. Fib. 400 (Atrial) 100 bpm(Vent.) </li></ul><ul><li>Dig. Vagal Tone to Atrial Muscle - Ach Acts on M Receptor to  ERP in atrium </li></ul>2:1 4:1 <ul><li>Block A-V Node </li></ul><ul><li>with Dig. Vent. </li></ul><ul><li>Rate Further </li></ul>Ach Digitalis Normal
    7. 50. DIGOXIN TOXICITY CARDIAC MANIFESTATIONS ARRHYTHMIAS : - Ventricular (PVCs, VT, VF) - Supraventricular (PACs, SVT) BLOCKS: - S-A and A-V blocks CHF EXACERBATION
    8. 56. % WORSENING OF CHF p = 0.001 DIGOXIN: 0.125 - 0.5 mg /d (0.7 - 2.0 ng/ml) EF < 35% Class I-III (digoxin+diuretic+ACEI) Also significantly decreased exercise time and LVEF. DIGOXIN EFFECT ON CHF PROGRESSION RADIANCE N Engl J Med 1993;329:1 Placebo n=93 DIGOXIN Withdrawal DIGOXIN n=85 30 10 0 20 100 80 20 0 40 60 Days
    9. 57. Placebo n=3403 DIGOXIN n=3397 48 0 12 24 36 OVERALL MORTALITY % DIG N Engl J Med 1997;336:525 Months p = 0.8 50 40 30 20 10 0

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