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Drugs for CCFDrugs for CCF

Heart failure is the progressive Heart failure is the progressive inability of the heart to supply inability of the heart to supply adequate blood flow to vital adequate blood flow to vital organs.organs.

It is classically accompanied by It is classically accompanied by significant fluid retention.significant fluid retention.

It is a leading cause of mortality It is a leading cause of mortality and morbidity. and morbidity.


The most common symptoms of The most common symptoms of CCF includes shortness of breath, CCF includes shortness of breath, edema and fatigue.edema and fatigue.

Causes of heart failure includes Causes of heart failure includes Coronary artery disease (CAD), Coronary artery disease (CAD), Hypertension, Diabetes, Mitral Hypertension, Diabetes, Mitral valve disease and Chronic valve disease and Chronic alcohol.alcohol.


Vasodilators – ACE InhibitorsVasodilators – ACE Inhibitors DiureticsDiuretics Beta blockersBeta blockers Digoxin Digoxin Other Cardiac Inotropes – Other Cardiac Inotropes –

Dobutamine, MilrinoneDobutamine, Milrinone


Angiotensin Converting Enzyme Angiotensin Converting Enzyme (ACE) Inhibitors :(ACE) Inhibitors :

ACE inhibitors improve mortality, ACE inhibitors improve mortality, morbidity, exercise tolerance, left morbidity, exercise tolerance, left ventricular ejection fraction.ventricular ejection fraction.

Captopril, Lisinopril, Enalapril, Captopril, Lisinopril, Enalapril, Ramipril, Quinapril.Ramipril, Quinapril.

ACE Inhibitors for ACE Inhibitors for CCFCCF

ACE Inhibitors for CCFACE Inhibitors for CCF


Angiotensin Converting Enzyme Angiotensin Converting Enzyme (ACE) Inhibitors :(ACE) Inhibitors :

Reduction in arterial resistance Reduction in arterial resistance (afterload)(afterload)

Reduction in venous tension Reduction in venous tension (preload)(preload)

Reduction in aldosterone secretionReduction in aldosterone secretion Inhibition of cardiac and vascular Inhibition of cardiac and vascular

remodeling remodeling


Angiotensin Converting Enzyme Angiotensin Converting Enzyme (ACE) Inhibitors : (ACE) Inhibitors :

Adverse effects :Adverse effects : Dry irritating persistent coughDry irritating persistent cough HyperkalemiaHyperkalemia AngioedemaAngioedema Fetal toxicityFetal toxicity


Angiotensin Receptor AT-1 Angiotensin Receptor AT-1 blockers (ARB) :blockers (ARB) :

Losartan, Irbesartan, CandesartanLosartan, Irbesartan, Candesartan Competitive antagonists of Competitive antagonists of

Angiotensin II (AT-1).Angiotensin II (AT-1). No inhibition of ACE or Cough.No inhibition of ACE or Cough.


Vasodilators :Vasodilators : Isosorbide dinitrate and Isosorbide dinitrate and

hydralazine also used specially in hydralazine also used specially in patients who cannot tolerate ACE patients who cannot tolerate ACE inhibitors.inhibitors.

Amlodipine and prazosin are other Amlodipine and prazosin are other vasodilators can be used in CCF.vasodilators can be used in CCF.

Nitrates in CCFNitrates in CCF


Diuretics :Diuretics :

These are useful in reducing the These are useful in reducing the symptoms of volume overload by symptoms of volume overload by

decreasing the extra cellular decreasing the extra cellular volume volume

decreasing the venous returndecreasing the venous return


Diuretics :Diuretics : Loop diuretics like furosemide Loop diuretics like furosemide

and bumetanide are the most and bumetanide are the most effective and commonly used.effective and commonly used.

Thiazides are effective in mild Thiazides are effective in mild cases only.cases only.


Diuretics :Diuretics : Adverse effects :Adverse effects : Loop diuretics and thiazides Loop diuretics and thiazides

cause hypokalemia.cause hypokalemia. Potassium sparing diuretics help Potassium sparing diuretics help

in reducing the hypokalemia due in reducing the hypokalemia due to these diuretics.to these diuretics.


Potassium Sparing Diuretics : Potassium Sparing Diuretics : Spironolactone :Spironolactone :

Aldosterone inhibition minimize Aldosterone inhibition minimize potassium loss, prevent sodium potassium loss, prevent sodium and water retention, endothelial and water retention, endothelial dysfunction and myocardial dysfunction and myocardial fibrosis.fibrosis.


Spironolactone : Spironolactone : Aldosterone Aldosterone antagonistantagonist

Spironolactone can be added to Spironolactone can be added to loop diuretics to modestly loop diuretics to modestly enhance the diuresis; more enhance the diuresis; more importantly, improve survival.importantly, improve survival.


Beta blockers for congestive Beta blockers for congestive cardiac failure :cardiac failure :

Acts primarily by inhibiting the Acts primarily by inhibiting the sympathetic nervous system.sympathetic nervous system.

Increases beta receptor Increases beta receptor sensitivity (up regulation).sensitivity (up regulation).

Anti-arrhythmic properties.Anti-arrhythmic properties. Anti-oxidant properties.Anti-oxidant properties.

Beta blockers in CCFBeta blockers in CCF


Beta blockers for CCF :Beta blockers for CCF : Start at low dose and monitor for Start at low dose and monitor for

bradycardia bradycardia Carvedilol and Metoprolol are the Carvedilol and Metoprolol are the

most commonly used for CCF most commonly used for CCF amongst beta blockersamongst beta blockers


Cardiac glycosides : Cardiac glycosides : Digoxin : Digoxin : Inhibition of Na/K ATPase pump Inhibition of Na/K ATPase pump

increase intracellular sodium increase intracellular sodium concentration – eventually concentration – eventually increase cytosolic calcium.increase cytosolic calcium.

It restores the vagal tone and It restores the vagal tone and abolishes the sympathetic over abolishes the sympathetic over activity.activity.

Digoxin in CCFDigoxin in CCF


Cardiac glycosides : Cardiac glycosides : Digoxin :Digoxin : Increase the refractoriness of AV Increase the refractoriness of AV

node thus decrease ventricular node thus decrease ventricular response to atrial rate.response to atrial rate.

Digoxin is used as a first-line drug Digoxin is used as a first-line drug in patients with congestive heart in patients with congestive heart failure who are in atrial failure who are in atrial fibrillation.fibrillation.


Digoxin : Digoxin : Adverse effects / Adverse effects / Precautions :Precautions :

Nausea, vomiting, gynecomastia, Nausea, vomiting, gynecomastia, visual disturbances and psychosis.visual disturbances and psychosis.

Ventricular bigeminy, AV block and Ventricular bigeminy, AV block and bradycardia.bradycardia.

Amiodarone and verapamil can Amiodarone and verapamil can increase the plasma concentration increase the plasma concentration of digoxin by inhibiting its excretion.of digoxin by inhibiting its excretion.


Digoxin toxicity treatment: Toxicity can be treated with

higher than normal doses of potassium.

Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose.


Cardiac Inotropes :Cardiac Inotropes : Phosphodiesterase III Inhibitors Phosphodiesterase III Inhibitors

Positive inotropic and vasodilator Positive inotropic and vasodilator – INO-DILATOR ; Eg., Milrinone– INO-DILATOR ; Eg., Milrinone

DobutamineDobutamine is a beta-1 agonist is a beta-1 agonist which increase contractility and which increase contractility and cardiac outputcardiac output..


Conclusion :Conclusion : ACE inhibitors are cornerstone in the ACE inhibitors are cornerstone in the

treatment of CCF.treatment of CCF. Beta blockers are used in selected Beta blockers are used in selected

patients (mild/moderate failure, low patients (mild/moderate failure, low dose) dose)

Diuretics and digoxin are other drugs Diuretics and digoxin are other drugs useful in CCF in select patients. useful in CCF in select patients.

STAGE DISABILITYCLASS 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 activitiesComfortable only at rest

CLASS 4 SEVERE

Unable to do any physical activity without discomfort Some HF symptoms at rest

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Conre2

Health & Medicine

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