This document discusses drugs used to treat heart failure. It defines heart failure and provides global statistics on prevalence. The goals of pharmacotherapy are to relieve symptoms, improve cardiac function, prevent disease progression and prolong survival. Drugs discussed include ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists, ARNIs, diuretics, digoxin, ivabradine, and omega-3 fatty acids. Recommendations are provided on use of these drugs for heart failure with reduced ejection fraction based on guidelines. The document also briefly discusses treatment of heart failure with preserved ejection fraction.

1. Drugs used in HF
 BY
Dr. SamiaTasneem
MDThesis Part Student
Department of Cardiology
Dhaka Medical College Hospital

2. Definition of heart failure
 HF is a clinical syndrome characterized by typical
symptoms (e.g. breathlessness, ankle swelling
and fatigue) that may be accompanied by signs
(e.g. elevated jugular venous pressure,
pulmonary crackles and peripheral oedema)
caused by a structural and/or functional cardiac
abnormality, resulting in a reduced cardiac
output and/or elevated intracardiac pressures at
rest or during stress.
(Esc Guideline 2016)

3. ESC 2016 guidelines `

4. AHA 2016

5. Global trend in Heart failure

6. A Contemporary Appraisal of the HF
Epidemic
 prevalence of HF is approximately 1–2% of the
adult population in developed countries, rising to
10% among people >70 years of age.
 Among people >65 years of age one in six will
have unrecognized HF (mainly HFpEF).
 The lifetime risk of HF at age 55 years is 33% for
men and 28% for women.
 The proportion of patients with HFpEF ranges
from 22 to 73%.

10. Treatment Objective
To improve
 Clinical Status
 Functional capacity
 Quality of life
To reduce
 Deteorioration
 Recurrent hospital
admission
 Progression
 Mortality

12. Goals of Pharmacotherapy
Relief of congestion/low cardiac output symptoms &
restoration of cardiac performance:
 Inotropic drugs-digoxin, dobutamine,amrinone/milrinone.
 Diuretics: furosemide, thiazides.
 Vasodilators:ACE inhibitors/AT1 antagonist, hydralazine,
nitrate.
 Beta blockers: metoprolol,bisprolol,carvedilol
Arrest/reversal of disease progression & prolongation of
survival
 ACE inhibitors/AT1 antagonist (ARBs)
 Beta-blockers
 Aldosterone antagonist- spironolactone
 ARNI

13. Pathophysiology and Site of drug action

16. M/A of Aldosterone

18. Pharmacological treatment of heart
failure with reduced ejection
fraction

19. Pharmacological treatments indicated in all
patients with symptomatic (NYHA Class II-IV) heart
failure with reduced ejection fraction

22. Beta Blocker and mortality

24. Other treatments recommended in
selected symptomatic patients with heart
failure with reduced ejection fraction

25. Treatment strategy for the use of drugs (and
devices) in patients with HFrEF (Esc 2016)

26. AHA 2016

29. Doses of diuretics commonly used in
patients with heart failure

30. Angiotensin receptor neprilysin
inhibitor

42.  Acts by inhibiting the If
channel, present in the
cardiac SA node
 •Reduces persistently
elevated heart rate
 •Evaluated as treatment of
HFrEF who have a resting
HR of at least 70 beats per
minute, in sinus rhythm,
and who are also taking the
highest tolerable dose of a
beta blocker
Ivabradine

45. Ivabradine
Indication To reduce the risk of hospitalization for worsening HF in patients with
stable, symptomatic chronic HF with LVEF ≤35% who are in sinus
rhythm with resting HR ≥70 bpm and either are on maximally
tolerated doses of beta-blockers or have a contraindication to beta-
blocker use.
Dosage Start with 5 mg twice daily.After 2 weeks of treatment, adjust dose
based on HR. Max is 7.5 mg twice daily. In patients with conduction
defects or in whom bradycardia could lead to hemodynamic
compromise, start with 2.5 mg twice daily.
Contraindications Acute decompensated HF; BP <90/50 mmHg; sick sinus syndrome or
third-degreeAV block, unless a functioning demand pacemaker is
present; resting HR <60 bpm prior to treatment; severe hepatic
impairment; pacemaker dependence.WARNING –fetal toxicity
Side effects Occurring in ≥1% of patients are bradycardia, hypertension, atrial
fibrillation, and luminous phenomena (phosphenes).

46. Practical Points on Use of
Ivabradine
 Starting dose is 5 mg twice daily
 •Target HR is 50-60 bpm
 •After 2 weeks:If HR >60 bpm: Increase dose to 7.5 mg
twice daily (Max dose)
 If HR 50-60 bpm: Maintain initial dose
 If HR <50 bpm or symptomatic bradycardia: Lower
dose to 2.5 mg twice daily
 If HR <50 bpm or symptomatic bradycardia and dose is
2.5 mg twice daily: Discontinue

47. Other treatments with less certain benefits
in symptomatic patients with heart failure
with reduced ejection fraction
Digoxin and other digitalis glycosides:
 may be considered in patients in sinus rhythm with symptomatic
HFrEF to reduce the risk of hospitalization
 In patients with symptomatic HF and AF, digoxin may be useful
 to slow a rapid ventricular rate, but it is only recommended for
the treatment of patients with HFrEF and AF with rapid
ventricular rate when other therapeutic options cannot be
pursued
 Caution should be exerted in females, in the elderly and in
patients with reduced renal function.

48. n-3 polyunsaturated fatty acids:
 Only preparations with eicosapentaenoic acid (EPA)
and docosahexaenoic acid (DHA)
 preparations containing > 850 mg/g has been shown
in either HFrEF or post-myocardial infarction.
 May be considered as an adjunctive therapy in
patients with symptomatic HFrEF who are already
receiving optimized recommended therapy with an
ACEI (or ARB), a beta-blocker and an MRA.

49. Treatments not recommended (unproven
benefit) in symptomatic patients with heart
failure with reduced ejection fraction
Statins:
 The two major trials that studied the effect of statin
treatment in patients with chronic HF did not demonstrate
any evidence of benefit.
 In patients who already receive a statin because of
underlying CAD or/and hyperlipidaemia, a continuation of
this therapy should be considered.

50. Oral anticoagulants and antiplatelet therapy:
 There is no evidence that an oral anticoagulant reduces
mortality/morbidity compared with placebo or aspirin.
 Patients with HFrEF receiving oral anticoagulation
because of concurrentAF or risk of venous
thromboembolism should continue anticoagulation
Renin inhibitors:
 Not presently recommended as an alternative to an ACEI
orARB as failed to improve outcomes for patients
hospitalized for HF.

51. Treatments (or combinations of treatments) that may cause
harm in patients with symptomatic (NYHA Class II–IV) heart
failure with reduced ejection fraction

52. Treatment of heart failure with
preserved ejection fraction

54. Recommendations for treatment of patients with heart
failure with preserved ejection fraction and heart
failure with mid-range ejection fraction