University:
West Coast University
Course:
PHAR 740 | IPC Cardiopulmonary and Renal III
Academic year:

2024
Views:

281

Pages:

19
Author:

Asal A.

Management of Heart Failure Adam Kassan, PhD Associate Professor, Pharmaceutical Sciences West Coast University, School of Pharmacy Spring 2023 Management of Heart Failure Heart Failure HFrEF HFpEF Not inotropic Inotropic • Diuretics • Vasodilators • Ivabradine • Positive inotropic: • digitalis glycosides • PDE3I • Negative inotropic • β-adrenergic agonists Acute HF Treatment of HFrEF Diuretics • No direct effect on contractility • Major mechanism of action:  reduce preload and improve pump efficiency o important in pulmonary or peripheral edema • • • a: represents the failing heart • LVEDP is increased b: therapy with a diuretic • reduces LV b′: excessive diuresis • undesired fall in SV with hypotension Treatment of HFrEF Diuretics • Drugs of choice in congestive heart failure • Loop diuretics  furosemide, torsemide, bumetanide  more potent than thiazides • Add thiazide  when refractoriness happens with the loops • Add spironolactone to protect against  hypokalemia  remodeling side effect of aldosterone seen in HF Treatment of HFrEF Vasodilators • ACEIs  ↓produc on of AngII o ↑ vasodila on  ↓ aldosterone o ↓ intravascular volume  ↑ bradykinin o beneficial vasodilatation in HF • ARBs  no beneficial rise in bradykinin ACEI: Angiotensin-converting enzyme inhibitors ARB: Angiotensin receptor blockers Treatment of HFrEF Vasodilators • Nesiritide  human recombinant BNP  rapid and potent vasodilatation o in acute (not chronic) HF Treatment of HFrEF Vasodilators • Venous vasodilators (nitrates)  decrease preload  similar effects to diuretics • Arteriolar vasodilators (hydralazine)  reduce TPR and afterload  results in an augmented SV • May be used in combination Ivabradine: Mechanism of Action not Theyallow • Inhibits or If channel, thereby ↓ phase 4 depolariza on in SA node  ↓ HR o ↑diastole, ventricular ﬁlling, SV, coronary perfusion  ↓ myocardial O2 demand • Contraindicated in preexisting bradycardia Management of Heart Failure Heart Failure HFrEF HFpEF Not inotropic Inotropic • Vasodilators • Diuretics • Ivabradine • Positive inotropic: • digitalis glycosides • PDE3I • Negative inotropic • β-adrenergic agonists Acute HF Treatment of HFrEF Positive Ionotropic Drugs • Increase intracellular Ca2+  enhance ventricular contraction  SV and CO are augmented • Useful with systolic dysfunction (HFrEF)  not with HFpEF MOA Treatment of HFrEF A Positive Ionotropic Drugs: Digoxin • Inhibits Na+/K+-ATPase  ↑intracellular [Na+]  ↑intracellular [Ca2+] o enhancing contraction o ↑CO • Not for HFpEF • Usually given when diuretics and ACEIs have failed • Risk of delayed after depolarization DAD Treatment of HFrEF Positive Ionotropic Drugs: PDE3I • Used for short term  PDE3Is (e.g., milrinone):  limited to IV treatment of acute congestive HF • Risk of arrhythmia and thrombocytopenia Treatment of HFrEF Negative Ionotropic Drugs: β-Blockers • 3 β-blockers  metoprolol and bisoprolol o β1-selective  carvedilol o nonselective with weak α-blocking properties Treatment of HFrEF Negative Ionotropic Drugs: β-Blockers • Started at low dosage and augmented gradually • Main protective effect is against excessive sympathetic activity  reduce HR and thus O2 consumption  reduce arrhythmia  inhibition of renin release o reduce AngII and thus heart remodeling • Only used in compensated HF Treatment of HFpEF • Most clinical trials have been carried out in patients with systolic dysfunction  little evidences in HFpEF • Same drugs as HFrEF except positive inotropes • Addressing correctable causes of the impaired diastolic function  hypertension  hyperlipidemia should be treated  revascularization in case of coronary artery disease Treatment of Acute Heart Failure • IV treatment is the rule in drug therapy of acute heart failure • Diuretics  furosemide is the most commonly used • Vasodilators  nitroprusside, nitroglycerine, and nesiritide are commonly used • β1 receptor agonists  dobutamine Additional Therapies Cardiac Mechanical Circulatory Support • Alternative mechanical therapies  ventricular assist devices (VADs) and implantable artificial hearts o 1-year survival rates > 80%, compared to less than 25% with medical therapy alone o ~50% after 7 years* *Circulation: Heart Failure- 2020;13:e006252 Heart Transplant • ~ 4,000 heart transplants/year* (~8,500 worldwide**)  many fewer than the number of patients with HF  ~85-90% survival after one year, ~75% after 3 years+ *UNOS: United Network for Organ Sharing **GODT: Global Observatory on Donation and Transplantation +J Heart Lung Transplant 2021. PMID: 34419370

Management of Heart Failure

Related Documents

Recommended Documents

Description

Related Documents

Free up your schedule!

Take 5 seconds to unlock