DRUGS USED IN HEART FAILURE 2016 A

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U HEART FAILURE
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TOYA RIAWAN
HEART FAILURE
is a complex clinical
syndrome that results
Left HF
Right HF from any structural or High-output HF
Biventricular HF functional impairment Low-output HF
of ventricular filling or
ejection of blood.
Acute HF
Systolic dysfunction
Chronic HF Forward HF
Diastolic dysfunction
Backward HF
CHRONIC
Force
Rate
Preload
Afterload
Heart Load
VENOUS BLOOD ARTERIOLAR
TONE TONE
VOLUME
VENOUS PERIPHERAL
RETURN RESISTANCE
PRELOAD AFTERLOAD
IMPROVEMENT CARDIAC
OUTPUT
1. Optimizing preload
OR
Reducing afterload
2. Increasing contractility
REDUCING REDUCING AFTERLOAD
PRELOAD or
INCREASING
CONTRACTILITY
BACKWARD FORWARD
FAILURE FAILURE
High filling pressure Low output failure

Dyspnea Fatigue
Venodilators Diuretics ACEI Arteriolodilators
ARB
VENOUS BLOOD ARTERIOLAR

TONE TONE
VOLUME
VENOUS PERIPHERAL
RETURN RESISTANCE
PRELOAD AFTERLOAD
THE GOAL OF TREATMENT
☻ relieve symptoms and signs

(e.g. dyspnea, edema)
☻ prevent hospital admission
☻ improve survival
Therapeutic strategies
☻ Removal of sodium & water retention
 Diuretics
☻ Reduction of preload or afterload
• ACE Inhibitors /ARB☻
 Vasodilators
☻ Direct treatment of depressed heart
 Positive inotropes
Chronic heart failure
SYSTOLIC HF DIASTOLIC HF
Diuretic Diuretic
ACEI /ARB Control hypertension
Betablockers Control ischemia
Aldosterone receptor Control ventricular rate in AF
antagonist (ARA)
Digoxin
Ivrabradine
Acute heart failure
 Diuretic (Furosemide)
 Morphine
 Vasodilator
 Positive inotropes
 Beta agonist
 Phosphodiesterase inhibitor
DIURETICS
Increase sodium & water excretion

→ relieve edema
→ decrease preload
FUROSEMIDE (preferred)
SPIRONOLACTONE
HYDROCHLOROTHIAZIDE (mild EPLERENONE
edema, hypertension) Reduce hospitalizatoion
ALDOSTERONE RECEPTOR and
ANTAGONIST (Spironolactone, risk of death
eplerenone)
IN ACUTE HEART FAILURE
Most patients with dyspnoea caused by pulmonary
oedema obtain rapid symptomatic relief from
administration of an i.v. furosemide, as a result of both an
immediate venodilator action
and subsequent removal of fluid.
ACE INHIBITORs/ARBs
Decrease afterload and preload
Decrease sympathetic activity Reduce hospitalization
and
Reduce remodelling of the heart and vessels
risk of death
COMBINATION WITH
SPIRONOLACTONE Should be initiated
May cause severe hyperkalemia at low doses,
followed by gradual
ACE INHIBITOR dose increments
if lower doses have
been well tolerated
ARB
NITRATE (venodilator) + HYDRALAZINE (arterial dilator)

BETA-BLOCKERS
Bisoprolol
Metoprolol SR/XL
Upregulation of beta receptor Carvedilol
Decrease heart rate
Reduce remodelling through inhibition of
mitogenic activity of catecholamine
Reduce the risk of arrhhythmias and sudden death
Reduce hospitalization
START IN SMALL DOSE and
INCREASED GRADUALLY TO A risk of death
TARGET MAINTENANCE DOSE
POSITIVE INOTROPES
 DIGITALIS
 BETA AGONIS
DOPAMINE
DOBUTAMINE
 PDE INHIBITORS
MILRINONE
ENOXIMONE
 LEVOSIMENDAN
DIGITALIS
(CARDIAC GLYCOSIDES)
Digitalis Reduce
hospitalization
EFFECTS :
POSITIVE INOTROPIC EFFECT Heart Failure
i  AV CONDUCTION VELOCITY
Atrial Fibrillation
 AV REFRACTORY PERIODE
Levosimendan
DIGOXIN
Primary elimination : kidney
Quinidine decreases digoxin clearance
Low Therapeutic Index FUROSEMIDE
Some electrolyte imbalance (hypokalemia,

hypomagnesemia, hypercalcemia) ---
 digitalis toxicity
CONTRA INDICATION
Significant SA or AV block
(unless used permanent pace maker)
USED CAUTIOUSLY
in patients taking other drugs that

can depress sinus or atrioventricular nodal function
or
affect digoxin levels (eg, amiodarone or a beta
blocker),
BETA AGONIS
DOPAMINE
<2 ug/kg/min renal vasodilatation,
increase RBF
renal dopaminergic receptor agonist
2-10 positive inotropic effects DOBUTAMINE
beta 1 agonist Start at 2-3 ug/kg/min and titrate
5 – 20 peripheral vasoconstriction afterward
alpha agonist positive inotropic effect
little change in heart rate
beta 1 agonist
PDE INHIBITORS
Milrinone, Enoximone
ATP
MYOCARDIUM
AC
Positive inotropic effect
through increase in cardiac intra-
cellular calcium
cAMP
VASCULAR
PDE PDE3 Arterial & venous dilatation
-
Inhibitor through phosphorilation of myosin
light chain kinase – decrease
sensitivity to calmodulin and cal-
AMP cium complex
AC :adenylyl cyclase PDE3 :phosphodiesterase 3

LEVOSIMENDAN
MYOCARDIUM
Ca sensitizers
Positive inotropic effect
Inhibit PDE
VASCULAR
Arterial & venous dilatation
IVABRADINE
Inhibit the If channel in the SA node

(If : funny current, is a slow, inward
(depolarizing) Na+ currents)
To slow the heart rate in sinus rhythm
despite treatment with ACEI and beta
blockers
MORPHINE
may be useful in some patients with acute pulmonary

edema, because :
* reduce anxiety and relieve distress associated
with dyspnoea
* venodilators reducing preload
* reduce sympathetic drive
Side effect :
nausea (necessitating the concomitant administration of
an antiemetic)
depress respiratory drive ( potentially increasing the
need for invasive ventilation)
VASODILATOR
May be considered an adjuvant to diuretic therapy for

relief of dyspnea in patients admitted with acutely
decompensated HF, if symptomatic hypotension is
absent
Examples : intravenous nitroglycerin, nitroprusside, or
nesiritide
Should be avoided if systolic blood pressure < 110
mm Hg
VASODILATOR
NITROGLYCERINE
venodilator
preload Ideal candidates for HF with

hypertension, coronary
Pulmonary ischemia,
significant mitral
congestion regurgitation
Tachypylaxis
VASODILATOR
SODIUM NITROPRUSSIDE
venodilator arteriolodilatorr
preload afterload Ideal candidates for

HF with
Pulmonary hypertension, or
significant mitral
congestion regurgitation
Invasive hemodynamic blood pressure monitoring
(such as an arterial line) is typically required; in such
cases, blood pressure and volume status should be monitored
frequently.
VASODILATOR
NESIRITIDE (human BNP)
Venodilator & arteriolodilator

( by increasing cGMP)
Diuresis
adverse effects such as hypotension may persist

longer than nitroglycerin or nitroprusside.
ANTIARRHYTHMIC AGENTS
Amiodarone and dofetilide are the only

antiarrhythmic agents to have neutral effects on
mortality in clinical trials of patients with HF
and thus are the preferred drugs for treating
arrhythmias in this patient group
Antidiabetic

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C

High filling pressure Low output failure

VENOUS BLOOD ARTERIOLAR

☻ relieve symptoms and signs

☻ prevent hospital admission

Increase sodium & water excretion

NITRATE (venodilator) + HYDRALAZINE (arterial dilator)

Some electrolyte imbalance (hypokalemia,

in patients taking other drugs that

AC :adenylyl cyclase PDE3 :phosphodiesterase 3

Inhibit the If channel in the SA node

may be useful in some patients with acute pulmonary

May be considered an adjuvant to diuretic therapy for

preload Ideal candidates for HF with

preload afterload Ideal candidates for

Venodilator & arteriolodilator

adverse effects such as hypotension may persist

Amiodarone and dofetilide are the only

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