This document discusses anti-anginal drugs and heart failure. It begins by explaining the pathophysiology of angina and congestive heart failure. It then discusses different types of heart failure and the etiologies of left-sided and right-sided heart failure. The document outlines the pharmacology of various drugs used to treat heart failure, including diuretics, ACE inhibitors, beta-blockers, and vasodilators. It concludes by discussing treatment options for acute heart failure.
presentation for drugs used to treat different types of angina pectoris : stable, unstable and vasospastic and the best for each type and side effects,
Individualized Webcam facilitated and e-Classroom USMLE Step 1 Tutorials with Dr. Cray. 1 BMS Unit is 4 hr. General Principles and some Organ System require multiple units to complete in preparation for the USMLE Step 1 A HIGH YIELD FOCUS IN Biochemistry / Cell Biology, Microbiology / Immunology and the 4 P’s-Phiso, Pathophys, Path and Pharm. Webcam Facilitated USMLE Step 2 Clinical Knowledge and Clinical Skills diadactic tutorials /1 Unit is 4 hours, individualized one-on-one and group sessions, Including all Internal Medicine sub-sub-specitialities. For questions or more information.. drcray@imhotepvirtualmedsch.com
This Presentation explains the type of cardiac arrythmias occur commonly and their treatment mechanishm of action & Etiology .
This explains how a normal arrythmia takes place in heart how cardiac rhythm gets disrupted .
This Presentation also explains a detailed overview of #Anti-Arrythmic Drugs with short and simple tricks.
This explains about the #Arterial arrythmias #Ventricular_Arrythmias # Junctional_Arrythmias. and their treatment
This presentation is meant for the students of Pharmacy , MBBS, nursuing and any other field having interes in #Pharmacology and other medical subjects .
#Mdical_students #Pharmacy # Nursing_students . #Pharmacology #Physiology
presentation for drugs used to treat different types of angina pectoris : stable, unstable and vasospastic and the best for each type and side effects,
Individualized Webcam facilitated and e-Classroom USMLE Step 1 Tutorials with Dr. Cray. 1 BMS Unit is 4 hr. General Principles and some Organ System require multiple units to complete in preparation for the USMLE Step 1 A HIGH YIELD FOCUS IN Biochemistry / Cell Biology, Microbiology / Immunology and the 4 P’s-Phiso, Pathophys, Path and Pharm. Webcam Facilitated USMLE Step 2 Clinical Knowledge and Clinical Skills diadactic tutorials /1 Unit is 4 hours, individualized one-on-one and group sessions, Including all Internal Medicine sub-sub-specitialities. For questions or more information.. drcray@imhotepvirtualmedsch.com
This Presentation explains the type of cardiac arrythmias occur commonly and their treatment mechanishm of action & Etiology .
This explains how a normal arrythmia takes place in heart how cardiac rhythm gets disrupted .
This Presentation also explains a detailed overview of #Anti-Arrythmic Drugs with short and simple tricks.
This explains about the #Arterial arrythmias #Ventricular_Arrythmias # Junctional_Arrythmias. and their treatment
This presentation is meant for the students of Pharmacy , MBBS, nursuing and any other field having interes in #Pharmacology and other medical subjects .
#Mdical_students #Pharmacy # Nursing_students . #Pharmacology #Physiology
This presentation deals with the use of various drugs in the treatment of heart failure such as Digoxin, ace inhibitors, beta bloockers, calcium channel blockers
nitrates mechanism of action,overview of nitroglycerin[short acting], iso sorbide dinitrates, iso sorbide mononitrates, amyl nitrates and nitroprusside,
These slides were used for discussion in B. Pharmacy 2nd year Pharmacotherapy theory class. Students are suggested to refer textbooks for further information.
This presentation deals with the use of various drugs in the treatment of heart failure such as Digoxin, ace inhibitors, beta bloockers, calcium channel blockers
nitrates mechanism of action,overview of nitroglycerin[short acting], iso sorbide dinitrates, iso sorbide mononitrates, amyl nitrates and nitroprusside,
These slides were used for discussion in B. Pharmacy 2nd year Pharmacotherapy theory class. Students are suggested to refer textbooks for further information.
Anti anginal drugs, uses, mechanism of action, adverse effectsKarun Kumar
A presentation outlining the causes of angina, mechanism of action of various anti-anginal drugs, their uses and side effects alongwith contraindications
Nowadays Cardiac Failure is the most common disease faced by many people so awareness on this one is very important.In my presentation i included types of cardiac failure, classification of cardiac failure,cardiac drugs,mechanism of action of cardiac drugs,drug therapy.
Endomyocardial fibrosis (EMF) is a disease that is characterized by fibrosis of the apical endocardium of the right ventricle (RV), left ventricle (LV), or both.
The clinical manifestations are largely related to the consequences of restrictive ventricular filling, including left and right sided heart failure.
The heart failure is associated with atrioventricular-valve regurgitation.
Endomyocardial fibrosis is a major cause of illness and death in areas where it is endemic, and in its severest form carries a very poor prognosis, with an estimated survival of 2 years after diagnosis.
A case of missed diagnosis. Presentation can be in form of heart failure. Differentials can be of Constrictive pericarditis. Restrictive cardiomyopathy/Endomyocardial fibrosis, DCM. This presentation contains clinical presentation, differentials, hemodynamics of cath study, echocardiogrpahy in a case of CP
A Global Problem
HIGHLY LETHAL 5 yr Survival rate “50%”
More M.I. cases now survive More Incidence of CHF due to damaged myocardium
Better options than before now available to treat CHF
2. Objectives
• Explain the pathophysiology of angina and
congestive heart failure
• Discuss the kinetics, pharmacologic
actions, dosage, and interactions of
– Anti anginal drugs
– Heart failure drugs
!2
5. Types of Heart Failure:
Left-sided HF vs Right-sided HF
Systolic HF vs Diastolic HF (Heart failure with low
EF vs Heart failure with preserved EF)
Acute HF vs Chronic heart failure
Low-output HF vs High-output HF
!5
6. Etiologies of Left-sided and
Right-sided Heart Failure
Left-sided Heart Failure Right-sided Failure
LV end diastolic
Left-sided heart failure
pressure (MI, CAD,
dilated cardiomyopathy,
RV systolic overload
valvular heart disease, AI,
(cor pulmonale, 1° PHPN,
AS, hypertension) congenital HD with shunt
anomaly)
↑ LA pressure (MS)
↑ RA pressure (TS, TR)
Fluid overload (renal failure,
iatrogenic)
!6
29. g
rlin
nk
- St
a
Ventricular
a
Fr
end-diastolic
SV volume Atrial
La
Pressur CHF
Pl e
ac
e Ventricular
mass
!29
30. Decreased BP
Sympa NS
R-A system
ADH
Contractility
HR
Vasoconstriction
Circulating vol
Arteriolar Venous
Maintain
BP Venous return to
heart ( preload)
(+)
C.O. (-) Pulmonary
(+) congestion
S.V. !30
31. NYHA Classification of CHF:
Functional Description General Guide
Class
I Dyspnea occurs with Climbs ≥ 2 flights of
greater than ordinary stairs with ease
physical activity.
II Dyspnea occurs with Can climb 2 flights of
ordinary physical stairs but with difficulty
activity.
III Dyspnea occurs with Can climb ≤ 1 flight of
less than ordinary stairs
physical activity.
IV Dyspnea may be Dyspnea at rest
present even at rest.
!31
32. Signs and symptoms of Left-sided and
Right-sided Heart Failure:
Symptoms of Left HF:
Easy fatigability
Exertional dyspnea
Confusion
Orthopnea
PND
Cough
Signs of Left HF:
Tachypnea
Tachycardia
Rales
S3/4 Gallop
Wheezes
!32
33. Signs and symptoms of Left-sided and
Right-sided Heart Failure:
Symptoms of Right HF:
Easy fatigability
Early satiety
RUQ discomfort
Signs of Right HF:
Elevated JVP
Hepatomegaly
Ascites
Lower extremity edema
!33
44. 3. Assess which of the following
contributes to a decrease in cardiac
output and must be corrected:
a. Increase in afterload
b. Increase in preload
c. Decrease in contractility
d. Increase in heart rate
!44
45. 4. If poor response to medical
treatment:
a. Maximize medical treatment.
b. Consider a surgical option
!45
47. Usual Progression of Symptoms in
Left-sided HF
• Dyspnea upon exertion
• PND
– Cardiac type: occurs 2-4 hrs after sleep
– Pulmonary type: variable onset
• Orthopnea
– Cardiac type: occurs after 5 mins
– Pulmonary type: immediate onset
• Dyspnea at rest
• Lower extremity edema
!47
48. Clinical Manifestations Based on Severity
of Heart Failure:
• Early CHF (NYHA Class I):
– May be asymptomatic
• Mild to Moderate CHF (NYHA Class II-III):
– Mild, non-specific symptoms
– PE may be normal
• Severe CHF (NYHA Class IV):
– Signs and symptoms are obvious
– Patients in marked distress: (orthopneic with distended
neck veins)
!48
49. Usual Cause of Death in Patients with CHF:
• Fatal ventricular arrhythmia
(sudden cardiac death)
• Refractory heart failure
• Pulmonary embolism
!49
53. Basic Pharmacology of Drugs used in
Heart Failure
• Digitalis
– Purple foxglove (Digitalis purpurea)
– Digoxin is the prototype
– 65-80% absorbed after oral administration
– Widely distributed in tissues
– 2/3 is excreted unexchanged in the kidneys
– Half life is 36-40 hours
!53
54. Digitalis
• Inhibits Na+, K+, ATPase pump, or the
sodium pump
• Increases contraction of the sarcomere by
increasing free calcium concentration
• Done by: increase of intracellular sodium
via Na+, K+, ATPase inhibition, second,
relative reduction in calcium expulsion
!54
55. Digitalis
• Net effect is a distinctive increase in
cardiac contractility
• Useful in dilated cardiomyopathy
• Given at a slow loading dose of 0.125
-0.25 mg per day or rapid loading of 0.5
mg-0.75 mg q 8 hours for three doses
• Digoxin has no net effect on mortality but
reduces hospitalization
!55
57. Effects in other organs
• Since cardiac glycosides affect all
excitable tissues, smooth muscle and CNS
effects are notable.
– Nausea, vomiting, diarrhea, anorexia
– Disorientation, hallucinations, visual
disturbances
!57
58. Interactions with K+, Ca++, Mg++
• Potassium and digitalis inhibit each other’s
binding to Na+, K+, ATPase; therefore
hyperkalemia reduces the enzyme binding
of cardiac glycosides, where are
hypokalemia reduces its actions.
• Hyperkalemia can precipitate bradycardia
and hypokalemia can limit the effects of
digitalis
!58
59. Interactions with K+, Ca++, Mg++
• Ca facilitates the effects of digitalis by
overloading of intracellular calcium stores.
• Digitalis-induced abnormal automaticity
!59
60. Positive Inotropics
• Bipyridines
– Milrinone is a phosphodiestarase isoenzyme 3
inhibitor (PDE 3 inhibitor)
– Increase myocardial contractility by increasing
calcium influx in the cardiac muscle during the
action potential.
– Compared to inamrinone, milrinone is less
likely to cause arrhythmias and can be used in
acute heart failure or severe exacerbation of
chronic heart failure.
!60
61. Positive Inotropics
• Beta adrenoceptor stimulants
– Dobutamine
– Selective B1 agonist
– Increases cardiac output by decreasing
ventricular filling pressure
– Produce angina or arrhythmia
– Given in mcg/kg BW
– Maximum dose is 20 mcg/kg BW
!61
62. Positive Inotropics
• Dopamine
– May also be used in acute heart failure where
there is a need to increase the BP
– It stimulates dopaminergic, beta, alpha effects
at different doses
– Given in mcg/kg BW, max 20 mcg/Kg BW
!62
64. Diuretics
• Prototype: Furosemide
• Mainstay of heart failure
• No direct effect on cardiac contractility
• Major action is to reduce venous pressure
and ventricular preload
• Reduction in salt and water retention
• Concomitant hypokalemia may develop
• Usual dose: 40 mg IV or PO dose,
increased until signs of heart failure
improve
!64
65. Diuretics
• Thiazide type diuretics
– Hydrochlorothiazide
– May result to hyponatremia secondary to
potassium excretion
– Usual dose 12.5 mg to 25 mg OD, in
combination with ARBs or ACEi
• K+ sparing diuretics
– Spironolactone or eplerenone
– Aldosterone antagonist
– Usual dose: 25-50 mg OD PO
!65
66. ACE Inhibitors
• Blockade of RAAs
• Given to patients with LV dysfunction
• Reduction of preload (reduce salt & water
retention) and afterload (reduce peripheral
resistance)
• Slow the progression of ventricular dilatation
• Decrease long term remodeling of the heart
and vessels
!66
67. ACE Inhibitors
• Prototype: captopril
• Most commonly used: enalapril
• Patient may benefit from asymptomatic to
severe heart failure
• Usual dose: captopril 25 mg q 6, enalapril
10 mg OD,
!67
68. Angiotensin Receptor Blockers
• Produce similar benefits as ACEi
• Given to patients who are incessant to
cough.
• Prototype: losartan
• Usual dose: losartan 50 mg OD, eposartan
600 mg OD, candesartan 8 mg OD,
irbesartan 150 mg OD, telmisartan 40 mg
OD, olmesartan 20 mg OD
!68
69. Vasodilators
• Nesiritide
• Endogenous peptide (brain natriuretic
peptide) or BNP
• Increases cGMP in smooth muscle cells
and reduces venous & arteriolar tone
• Causes diuresis
• Preload reducing agent
!69
70. Beta Blockers
• Bisoprolol, carvedilol & metoprolol
• Attenuate the high concentrations of
circulating cathecolamines
• Decreasing heart rate, decrease
remodeling by reduction of the mitogenic
activity of cathecolamines
!70
76. Determinants of Coronary Blood Flow &
Myocardial Oxygen Supply
• Coronary blood flow is directly related to:
– perfusion pressure (aortic diastolic pressure)
– Duration of diastole (vs tachycardia)
• Coronary blood flow is inversely
proportional to the coronary vascular bed
resistance
!76
77. Determinants of Vascular Tone
• Increasing cGMP (dephosphorylation of
myosin light chains)
– Nitric oxide
• Decreasing intracellular Ca2+ (calcium
channel blockers which cause vasodilatation,
decrease heart rate)
• Stabilizing or preventing depolarization of
vascular smooth muscle cell membrane
(increase the permeability of K+ channels
• Increasing cAMP (inactivation of myosin light
chain kinase which causes vasodilatation)
this mechanism is caused by beta blockers.
!77
79. Nitrates & Nitrites
• Nitroglycerin
– Prototype
– Causes activation of guanylyl cyclase and an
increase in cGMP, the first step in smooth
muscle relaxation
– Oral bioavailability is low
– Sublingual dose eliminated first pass effect
!79
80. Nitrates
• No effect on skeletal muscles
• Direct effect of NTG is increased venous
capacitance and decreased ventricular
preload
• Decreases platelet aggregation
• Oral controlled release tablets, sublingual
tablets, buccal spray, transdermal patch & IV
• Must NOT be taken with ED meds
!80
81. Nitrates
• IV may be started at 0.5 mg/hr up to 5 mg/
hr
• Oral preparations can be given 30 mg to
60 mg OD
!81
83. Calcium Channel Blockers
• L-type calcium channel blocker
• Dihydropyridines vs non dihydrophyridines
• Reduces the frequency of opening in
smooth muscle content this gives
decreased transmembrane content
• Decreased heart rate via dec sinus node
pacemaker rate
!83
85. Beta blockers
• Effects are due to dec HR, dec BP, dec
contractility
• Effect would be decreased oxygen
demand at rest and exercise
• Longer diastolic perfusion time
!85
86. Beta blockers
• Contraindicated with:
– Asthma
– Severe bradycardia, AV dysfunction
– Severe LV dysfunction
– CHF NYHA IV
!86
87. Partial Fatty acid Oxidation (pFOX)
• Trimetazidine
• metabolic mediators, inhibit the fatty
oxidation pathway in the myocardium
!87
88. Ivabradine
• Activation of the If channel or the funny
bone channel
• Decreases the heart rate without the effect
of hypotension
!88