PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya

College of Pharmacy

Drugs in Heart Failure

Drugs used in HF

Definition of Heart Failure

 HF is a clinical syndrome characterized by typical symptoms
 Breathlessness
 ankle swelling and;
 fatigue
 that may be accompanied by signs elevated jugular venous pressure
 pulmonary crackles and;
 peripheral edema
 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)
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
 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%.
Treatment Objective
To improve:
 Clinical Status
 Functional capacity
 Quality of life
To reduce:
 Deteorioration
 Recurrent hospital admission
 Progression
 Mortality
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
Pathophysiology and Site of drug action
Pharmacological treatment of heart failure with reduced ejection fraction

Pharmacological treatments indicated in all patients with symptomatic (NYHA Class II-IV)
heart failure with reduced ejection fraction
Beta Blocker and mortality
Other treatments recommended in selected symptomatic patients with heart failure with reduced ejection
fraction
 PLT COLLEGE, INC.
Bayombong, Nueva Vizcaya

College of Pharmacy

Treatment strategy for the use of drugs (and devices) in patients with HFrEF (Esc 2016)
AHA 2016
Doses of diuretics commonly used in patients with heart failure
Angiotensin receptor neprilysin inhibitor
 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

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).
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

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.

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.

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.
Oral anticoagulants and antiplatelet therapy:
 PLT COLLEGE, INC.
Bayombong, Nueva Vizcaya

College of Pharmacy

 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

Treatments (or combinations of treatments) that may cause harm in patients with symptomatic (NYHA
Class II–IV) heart failure with reduced ejection fraction
Treatment of heart failure with preserved ejection fraction
Recommendations for treatment of patients with heart failure with preserved ejection fraction and heart
failure with mid-range ejection fraction