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Treatment of heart failure(CHF)

Treatment of heart failure(CHF). Done by: Fatimah Al- Shehri Pharm.D candidate . King abdulaziz university Supervised by : Dr.Sara Al- Khansa. Outline :. 1-Introduction : - Definition. -Types. -Causes. 2-Pathophysiology. 3-Diagnosis. - Signs and symptoms. -Classification of HF.

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Treatment of heart failure(CHF)

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  1. Treatment of heart failure(CHF) Done by:Fatimah Al-ShehriPharm.D candidate .King abdulaziz university Supervised by :Dr.Sara Al-Khansa.

  2. Outline : 1-Introduction : -Definition. -Types. -Causes. 2-Pathophysiology. 3-Diagnosis. -Signs and symptoms. -Classification of HF. 4-Mangment of CHF. -Goals of therapy. -Non-pharmacological therapy. -Pharmacological therapy. -Summary of guidelines treatment.

  3. Heart failure : Abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues, despite normal filling pressures. Types of heart failure : According to function: 1-Systolic HF. 2-Diastolic HF.

  4. Pathophysiology: Left sided heart failure : Systolic failure(systolic dysfunction): The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation.

  5. ABC of heart failure Pathophysiology G Jackson, C R Gibbs, M K Davies, G Y H Lip Pathophysiology:

  6. Signs and symptoms : -Edema of feet , ankles , abdomen and lungs . -Congested jugular veins. -Loss of appetite. -Shortness of breath. -Fatigue and weakness. -↓↓Alertness or concentration.

  7. CAUSES : 1-Coronary artery disease. 2- Cardiomyopathy. 3-Hypertension. 4-Thyroid disease 5-Valvular heart disease. 6-Cardiotoxins . 7-Myocarditis . 8-Idiopathic.

  8. Diagnosis: 1-Medical history. 2-Physical examinations. 3-Laboratory tests. E.g:(B-type Natriuretic Peptide(BNP). 4-Radilogical methods: -Chest X- rays&CTscan&MRI. -ECG. EF<40).)-ECHO.

  9. Hunt SA et al. J Am coffcardiot 2001:83:2101.13. Farrett MH et al.JAMA.2002:287:890-7. Hunt SA et al.j AM coff cardio 2001:38:2101-13 Farrell MH et al .JAMA 2002:287:890-7

  10. Management of CHF:

  11. Principles and goals of therapy: 1-Block the compensatory neurohormonal activation caused by decreased CO . 2-Prevent/minimize Na and water retention . 3-Eliminate or minimize symptoms of HF . 4-Slow the progression of cardiac dysfunction 5-Decrease mortality. 6-Prevent hospital admission. 7- Improve survival.

  12. Management of CHF: 1-Nonpharmacological . 2-Pharmacological: 1-Diuretics. 2-ACEI or ARBS. 3-Beta blockers. 4-Aldosterone antagonist. 5-Digoxin. 6-Vasodilators.

  13. 1-Nonpharmacological : Life style changes : 1-Decrease fluid intake (2/L MAXIMUM). 2-Decease sodium. 3-Decreae weight. 4-Moderate exercise.

  14. 2-Pharmacological : 1-Diuretics : Place of therapy :all patients with heart failure. Types of diuretics : A- loop diuretics :(Furosemide,Torsemide, Ethycranicacid,Bumetinde).

  15. Mechanism of action

  16. 1-Diuretics : -Hypokalemia,hyponatermia,hypomagnesemis, hypocalcemia, -Dehydration. ototoxicity. -Hyperuercemia,hyperglycemia, hyperlipidemia. -Conistipation,Dryness of the mouth. -Muscle weakness. -wieghtloss,Skinrashes,hypotension. . Side effects of loop diuretics :

  17. 1-Diuretics : Contraindications of loop diuretics: Hypersensitivity. Monitoring : - Monitor electrolyte ,(K,Na,Ca). - Uric acid ,glucose.

  18. 1-Diuretics : B-Thaiazide diuretics: e.g:Hydrochlorothiazide. Mechanism of action

  19. 1-Diuretics : Side effects of thiazide diuretics: -Hypokalemia,Hyponatremia -Increased uric acid and glucose. -Increased cholesterol . -Hypomagnesemia -Hypotension. -Photosensitivity. -Headaches, Allergy thiazide diuretics :ofContraindications - Allergy to (sulphur-containing medications). - Gout. - Hypotension. - Renal failure. - Lithium therapy. - Hypokalemia.

  20. Diuretics and recommended doses:

  21. 2-ACEI : Place in therapy : For all patients with heart failure . e.g:(Lisinopril,Prendopril,Captopril,Enalpril,) Mechanism of action : (-Blocks production (AgII

  22. 2-ACEI : Side effects: -Dry cough. - Protinuria. Allergy. - Decrease taste . - Neutropenia. - Hyperkalemia. - Angioedema. - Acute renal failure. -Pregnancy. -Hypotension. -Bilateral renal stenosis. Contraindications:

  23. 2-ACEI: Monitoring : 1-SCr,and K in 1–2 weeks after starting or increasing the dose. 2-Monitor BP and symptoms of hypotension (e.g., dizziness, light-headedness). 3-Use cautiously in those with a baseline K greater than 5.0 mEq/L.

  24. ACEI and recommended doses :

  25. 2-ARBs: e.g:(Losartan.Candesartan.Valsartan) Place in therapy :If the patient cannot tolerate the side effect that produced by ACEI (dry cough). Side effects: the same as ACEI but with less cough.

  26. ARBS and recommended doses:

  27. 3-Beta Blockers : BB use in heart faliure : -Bisoprolol. -Metoprolo. -Carvedilol. Place in therapy: Shouldbe used in all stable patients. Mechanism of action: - Blocks the effect of NE and other sympathetic NT on the heart and vascular system.

  28. 3-Beta blockers: SIDE EFFECTS : 1-Hypoglycemia. 2-Hypotension. 3-Bradycardia. 4-Depression. 5-Edema.

  29. 3-Beta blockers: Contraindications: 1-Uncontrolled heart failure. 2-Prinzmetal's angina. 3-Bradycardia. 4-Hypotension. 5-Certain problems: (sinus syndrome). Monitoring : -BP, HR, and symptoms of hypotension (monitor in 1–2 weeks). -IF hypotension alone is the problem, try reducing the dose of the ACE inhibitor first. - Increased edema/fluid retention (monitor in 1–2 weeks).

  30. BB and recommended doses :

  31. 4-Aldosterone antagonist: E.g: Spironolactone,Eplerenone. Place in therapy: 1-Should be considered in patients after an acute MI, with clinical HF signs and symptoms or history of (diabetes, and an LVEF less than 40%). 2- Class III and IV HF. 3-LV dysfunction immediately after MI.

  32. 4-Aldosterone antagonists : Mechanism of action: Blocks effects of aldosterone in the kidneys, heart, and vasculature: (a) ↓K and Mg loss: Decreases ventricular arrhythmias. (b) ↓Na retention; decreases fluid retention . (c) Eliminates catecholamine; decreases BP.

  33. 4-Aldosterone antagonists: Side effects : Hyperkalemia. Gynecomastia. Dry mouth. Muscle weakness. Confusion, nausea, vomiting. Eplerenone:alternative to spironolactone in painful gynecomastia.

  34. 4-Aldosterone antagonists : Contraindications: 1-SCr is greater than 2.5 mg/dL, 2-(CrCl) is < 30 mL/min, 3-K is >5.0 mEq/L. MONITORING : 1-K and SCr within 1 week of starting therapy . 2- Decrease dose by 50% or discontinue if K is greater than 5.5 mEq/L. Dosing: (1) Spironolactone 12.5–25 mg/day . (2) Eplerenone 25–50 mg/day .

  35. 5-Digoxin: Place in therapy: In patients with LVEF of ≤40%,who have signs or symptoms of HF while receiving standard therapies including ACEI or ARBs and β-blockers. DOSING: 0.125 mg/day

  36. 5-Digoxin: Mechanism of action: Inhibits Na-K ATPase: i. Decreases central sympathetic outflow by sensitizing cardiac baroreceptors ii. Decreases renal reabsorption of Na. iii. Minimal increase in COP. Side effects : GIT disturnances.Bradycardia. Ventricular arrythmia. confusion, hallucinations, unusual thoughts or behavior. Abdominal pain, headache. Visual busturbances .

  37. 5-Digoxen: CONTRAINDICATIONS: - hypersensitivity. - Ventricular fibrillation. - Pregnancy Monitoring : 1-Serum concentrations should be less than 1.0 ng/mL, in general, concentrations of 0.7–0.9 ng/mL are effective in HF. 2- Risk of toxicity increases in the presence of hypokalemia or hypomagnesemia, older age ,RF.

  38. 6-Hydralazine and isosorbidedinitrate : Place in therapy: In Patients unable to take an ACE I OR ARBS. Due to : severe renal insufficiency, hyperkalemia, or angioedema.

  39. 6-Hydralazine and isosorbidedinitrate: Mechanism of action A-Hydralazine: (a) Arterial vasodilator (reduces afterload). (b) Enhances effect of nitrates through antioxidant mechanisms B- Isosorbidedinitrate: (a) Stimulates nitric acid signaling in the endothelium (b) Effective in reducing preload .

  40. 6-Hydralazine and isosorbidedinitrate: Side effects : A-Hydralazine : - Hypersensitivity. - Systemic lupus erythremataus . - Hypotension . -Headache. - GIT upset. B-Isosorbidedinitrate : - Blurred vision ,dry mouth. - Nausea, vomiting, sweating, pale skin. - Headache, hypotension ,mild dizziness. - Weakness.

  41. 6-Hydralazine and isosorbidedinitrate(ISDN): Monitoring : 1- Hypotension. 2-Drug-induced lupus with hydralazine. Dosing : - Hydralazine(25–75 mg 3-4times/day). - Isosorbidedinitrate (10–40 mg 3times/ day).

  42. Benefits of each group : .

  43. Summary : Yancy, CW et al. 2013 ACCF/AHA Heart Failure Guideline

  44. References :

  45. Pharm.D candidate :Fatimah Al-Shehri.

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