1. Congestive cardiac failure (CCF) occurs when the heart cannot pump enough blood to meet the body's needs due to conditions like coronary artery disease, hypertension, or cardiomyopathy. 2. Treatment depends on the cause, severity, and patient's health, and may include medications, surgery, or lifestyle changes. Common medications include diuretics, ACE inhibitors, beta blockers, and cardiac glycosides like digoxin. 3. Surgery such as valve replacement or angioplasty may be used in some cases. Lifestyle modifications involve reducing sodium and fluid intake, exercising mildly, and taking diuretics as prescribed. Current clinical trials are investigating new treatments and comparing existing medications.

1. By
MOHD SHAKEEL,B.Pharm
Asst. CRA
ALTREE LABS

2. What is CCF?
A state in which the heart cannot provide sufficient
cardiac output to satisfy the metabolic needs of the
body.
Causes:
• Coronary artery disease
• Hypertension
• Valvular heart disease
• Cardiomyopathy
• Cor pulmonale

3. TREATMENT
The treatment of heart failure depends on
several factors, such as:
 Its causes
 Its severity
 The patient’s health condition

4. Mode of treatments
Pharmacotherapy
Surgery
Life style modifications

5. Pharmacotherapy of CCF
Cardiac glycosides: Digoxin, Digitoxin, Deslanoside
Vasodilators:
• ACE inhibitors: Captopril, Enalapril, Lisinopril, Benazipril,
Ramipril.
• Angoitensin receptor blockers : Candesartan,
Losartan,Valsartan
• Hydralazine and Isosorbide dinitrate
Beta blockers : Carvedilol, Metoprolol, Bisoprolol.
Diuretics: Benzothiazides, HCL diuretics, Potassium sparing
diuretics, Osmotic diuretics

6. APPROACH TO THE PATIENT WITH HEART FAILURE
Assessment of LV
function(echocardiography, MRI)
EF < 40%
Assessment of
volume status
Signs and symptoms
of fluid retention
No signs and symptoms of
fluid retention
Diuretic ACE Inhibitor
b-blocker
Digoxin

7. CARDIAC GLYCOSIDES
Digoxin: increase force of cardiac contraction.
MOA:
• Inhibits Na-K-ATPase enzyme.
• Indirectly accumulates Ca2+.
• Reduce the sympathetic out flow from the CNS.
• Reduce the heart rate and relief the symptom.
• Indications: LV dysfunction, atrial fibrillation

9. PK:
• Lipid soluble, polar.
• Presence of food delays absorption.
• Volume of distribution is larger.
• Metabolised in liver.
• Primarily excreted unchanged by glomerular filtration.
• Therapeutic index: 1.5-3
Dose
• Oral: 0.0625mg,0.125mg,and 0.25mg
• Parentral: 0.25mg/ml
• Oral dose effective with in 35-45minutes
• Digitilizing dose, effect with in 35-45 minutes last for 2-6days

10. Adverse effects
• Cardiac : AV block ,Bradycardia ,Ventricular extrasystole ,
Arrhythmias
• Central Nervous System
• Gastro Intestinal .
Contra indications: Hypokalemia, MI, Myxoedema, Ventricular
tachycardia
Interactions: Diuretics, Calcium, Adrenergic drugs
Uses: CCF, Cardiac arrhythmias
Brands available: Digitran Tab, Digox Tab, Digoxin Inj, Lanoxin Tab
• Only symptomatic relief, no survival benefit.

11. Vasodilators
• Venodialators: Isosorbide dinitrate, GTN
• Arteriolar dialators: Hydralazine, Nifedipine
• Mixed dialators: ACE inhibitors, ARBs

12. MECHANISM OF ACTION
 Venodilators : Reduction of preload By venous dilation  ↓ the
venous return ↓ the load on both ventricles.
 Arteriolar dilators: Reduction of after load by arteriolar
vasodilatation  reduce LVEDP, O2 consumption, improve
myocardial perfusion.
 Usually the maximum benefit is achieved by using agents with both
action.

13. ACE Inhibitors
Captopril, enalapril, lisinopril, benazepril, ramipril, fosinopril, etc.
Mechanism of action of captopril
 Inhibits pressor action of A-I
 Blocks formation of A-II
 Block kinase-II decrease degradation of kinin
prolong the effect of kinin
(vasodilator)

14. Pharmaco Kinetics:
• 70% orally.
• Presence of food decrease absorption.
• Poor BBB penetration.
• Partly metabolized and excreted unchanged in urine.
• Plasma t½ ~2hrs, action lasts for 6-12hrs.
Adverse Effects:
Hypotension, Cough, Hyperkalaemia, Fetal damage, Angioedemia,
Rashes, Dysguesia, Acute renal failure.
Interactions: NSAIDS, K+ sparing diuretics, Antacids.
Uses: HTN, CHF, MI
Brands available: Acezide Tab (captopril+hydrochlorothiazide), Aceten
tab(wockhardt), Capotril Tab(lupin), Capotril-H Tab.

15. Angiotensin Antagonists / ARBs
Losartan, candesartan, irbesartan, valsartan,
telmisartan, etc.
• For patients who are unable to tolerate the ACE inhibitors
(angioneurotic edema, cough).
• Act on the same hormonal pathway as the ACE inhibitors, but
• Block the action of angiotensin II at its receptor site directly.
Brands available:
Adpace 4 Tab(sun), candesar Tab(rbxy), diovan cap(novartis),
valent cap(lupin) {ramipril+losartan}, acord l
tab(intra){amlodipine+losartan}

16. β – ADRENERGIC BLOCKERS
Carvedilol, Metoprolol,Bisoprolol, Bucindolol
Mechanism of action:
• Reduction in damaging sympathetic influences in the heart
(tachycardia, arrhythmias, LVEDP, remodeling,
necrosis/apoptosis)
• inhibition of renin release
• Beta blockers improve EF
• peripheral vasodilatation via a1-adrenoceptor blockade
(carvedilol)

17. 3.125 mg
bid
2 weeks Doubled
every
2 weeks
Max dose 25 mg bid
(<85 kg); 50 mg bid
(>85 kg)
Dosage guideline for Carvedilol
Metoprolol: 12.5 to 50mg BD
Bisoprolol : 2.5-10mg OD
Bucindolol: 12.5-50mg BD
The dose is increased every 2-4 weeks till a target dose is achieved
Uses: CHF, HTN, Angina pectoris, cardiac arrhythmias, MI

18. Brands available:
• Carvedilol Carca tab (intas), Cardivas tab( sun), Carloc tab(cipla)
• Metoprolol Betaloc H tab {hydrochlorothiazide+metoprolol(AZ)},
Betaone-xl tab, Ramic forte tab {metoprolol+ramipril}
• Bisoprolol lodoz tab{bisoprolol fumarate +
hydrochlorothiazide}

19. DIURETICS
Drugs used : Furosemide, Hydrochlorothiazide, Spironolactone,
Triamterene Amiloride
Indication:
• Prescribed for patients who have fluid retention
• Eliminate sign and symptoms of fluid retention
• Produce symptomatic relief more rapidly
Mechanism of action:
• Block the reabsorption of Na+, K+, Cl-
from glomerular filtrate at proximal tubule
and ascending loop of Henle
• Spironolactone binds with with aldosterone lowering the blood pressure.
• Reduction of facilitation of sympathetic nervous system

20. Dose:
• Therapy is initiated with a low dose of 20-40mg/day
• The dose is increased till signs and symptoms of patient is
reduced
• Oral dose: 20-120mg/day, the action starts with in 2 hours and
may last for 6-8hrs or more
• Acute pulmonary edema slow iv 4mg/min to a dose of 40 mg

21. Brands Avilable:
•Amiloride+furosemide amifru tab(elder),
•amimide tab(gsk)
•amilochlor tab (finecure) {Amiloride hydrochloride+
hydrochlorothiazide},
•Amiloride hydrochloride + atenolol +
hydrochlorothiazide beta-biduret cap(gsk),
•benzthiazide + triamterene ditide tab(gsk)
•furosemide + triamterene furosemene tab

22. SURGERY
 The Final Option
Valve surgery
Angioplasty
Heart transplantation
Implantation of artificial heart

23. Life style Modifications
• Treatment should be started immediately
• Sodium intake should be reduced (2gm
per day)
• Fluid consumption should be reduced (2 to 3
glass per day)
• Should take Diuretics
• Mild exercises

24. CURRENT TRIALS
Effects of Exenatide in Type 2 Diabetic Patients With Congestive
Heart Failure
• Phase IV
• This study is currently recruiting participants.
• Primary Outcome Measures:Cardiac Magnetic Resonance (CMR) will be used to assess
global cardiac function (LV ejection fraction).
• VU University Medical Center, Amsterdam, Noord-Holland, Netherlands
• Eli Lilly and Company
• Exenatide: ExperimentalDrug: exenatideExenatide 5 mcg BID for 4 weeks, subsequently
increased to 10 mcg BID for the remainder of the study (total of 26 weeks).
• Estimated Enrollment:42. Study Start Date:May 2009. Estimated Study Completion
Date:June 2011. Estimated Primary Completion Date:June 2011.

25. Comparison of Long- and Short-Acting Diuretics
in Congestive Heart Failure (J-MELODIC)
This study is ongoing, but not recruiting participants.
Efficacy study.
• Hyogo College of Medicine, The Hospital of Hyogo College of
MedicineNishinomiya, Hyogo, Japan,
• Ministry of Health, Labour and Welfare
• Estimated Enrollment:300. Study Start Date:June 2006. Estimated
Study Completion Date:August 2010. Estimated Primary
Completion Date:August 2010.
Drug: Furosemide, Azosemide

26. Correlation of Intrathoracic Impedance Measures With Blood
Plasma Volume in Congestive Heart Failure (Optivol)
Observational
• This study is currently recruiting participants.
• Blood Volume Analysis, Echocardiogram
• Estimated Enrollment:10. Study Start Date:January 2007.
Estimated Study Completion Date:June 2009.
Medical University of South Carolina
United States, South Carolina Medical University of South Carolina
Recruiting Charleston, South Carolina, United States

27. Effect of Vildagliptin on Left Ventricular Function in Patients
With Type 2 Diabetes and Congestive Heart Failure
• Phase IV
•This study is not yet open for participant recruitment.
• Estimated Enrollment:490. Study Start Date: May 2009. Estimated
Primary Completion Date:May 2011.
• Primary Outcome Measures:To evaluate the effect of vildagliptin on
left ventricular function in patients with T2DM and CHF by showing
that vildagliptin is at least not inferior to placebo with respect to change
in left ventricular ejection fraction (LVEF).
•Novartis Pharmaceuticals

28. Questions ???