complex disorder with

impaired ability of the

heart to adequately fill
with and/or eject blood.

ASSOCIATED WITH ABNORMAL INCREASES IN

BLOOD VOLUME AND INTER- STITIAL FLUID
 SYMPTOMS

DYSPNEA,

FATIGUE

AND

FLUID RETENTION
UNDERLYING CAUSES
 Arteriosclerotic heart disease
 Myocardial infarction
 Hypertensive heart disease
 Valvular heart disease
 Dilated cardiomyopathy
 and
 Congenital heart disease.
DRUG CLASSIFICATION
 1) inhibitors of the renin-angiotensin
system,
 2) β-adrenoreceptor blockers,
 3) diuretics,
 4) direct vasodilators,
 5) ino- tropic agents,
 And
 6) aldosterone antagonists
 Goals of DRUG
THERAPY

TO
ALLEVIAT
E
AN
SYMPTOM
S, D
ACE INHIBITORS
[inhibitors of the renin-angiotensin
system]
 Captopril CAPOTEN
 Enalapril VASOTEC
 Fosinopril MONOPRIL
 Lisinopril PRINIVIL, ZESTRIL
 Quinapril ACCUPRIL
 Ramipril ALTACE
 ACE INHIBITORS
Mode of action

 These drugs block the enzyme that cleaves

angiotensin I to form the potent
vasoconstrictor angiotensin II
 They also diminish the rate of bradykinin

inactivation.
 By reducing circulating angiotensin II levels,

ACE inhibitors also decrease the secretion of

aldosterone, resulting in decreased sodium
and water retention.
 
 INDICATIONS

SINGLE-AGENT
SINGLE-AGENT THERAPY
THERAPY IN
IN MILD
MILD DYSPNEA
DYSPNEA WITH
WITH NO
NO SYMPTOMS
SYMPTOMS OF
OF VOLUME
VOLUME OVERLOAD
OVERLOAD (EDEMA).
(EDEMA).

PATIENTS
PATIENTS WITH
WITH ALL
ALL STAGES
STAGES OF
OF LEFT
LEFT VENTRICULAR
VENTRICULAR FAILURE
FAILURE

THE
THE DISEASE
DISEASE SEVERITY,
SEVERITY, ACE
ACE INHIBITORS
INHIBITORS MAY
MAY BE
BE USED
USED IN
IN COMBINATION
COMBINATION WITH
WITH DIURETICS,
DIURETICS, Β-BLOCKERS,
Β-BLOCKERS, DIGOXIN,
DIGOXIN,
AND
AND ALDOSTERONE
ALDOSTERONE ANTAGONISTS.
ANTAGONISTS.
PHARMACOKINETIC
S: administererd
orally -- adequately
but incom- pletely
absorbed.
Food may decrease
absorption==
should be taken on
an empty stomach.
`
ADVERSE
EFFECTS:

ANGIOED
POSTUR RENAL HYPER EMA
AL INSUF- - AND
A
HYPOTE FICIEN KALE PERSISTE
N-SION,
-CY, MIA, NT DRY
COUGH.
CONTRAINDICATIO
NS

NOT BE USED IN PREGNANT

WOMEN, BECAUSE THESE
AGENTS ARE TOXIC TO THE
FETUS
ANGIOTENSIN-RECEPTOR BLOCKERS
[inhibitors of the renin-angiotensin
system]
 Candesartan ATACAND
 Losartan COZAAR
 Telmisartan MICARDIS
 Valsartan DIOVAN
•COMPETITIVE ANTAGONISTS OF THE ANGIOTENSIN TYPE
1 RECEPTOR.

•SUBSTITUTE IN THOSE PATIENTS WHO CANNOT TOLERATE

ACE INHIBITORS (THOSE PATIENTS WITH SEVERE COUGH
OR ANGIOEDEMA)

•ALL THE ARBS ARE APPROVED FOR TREATMENT OF

HYPERTENSION BASED ON THEIR CLINICAL EFFICACY IN
LOWERING BLOOD PRESSURE AND REDUCING THE
MORBIDITY AND MORTALITY ASSOCIATED WITH
HYPERTENSION.

•AS WITH ACE INHIBITORS, ARBS ARE CONTRAINDICATED

IN PREGNANCY.
•
ADVERSE EFFECTS

ARBS HAVE AN ADVERSE EFFECT PROFILE SIMILAR TO

THAT OF ACE INHIBITORS.
H

HOWEVER, ARBS DO NOT PRODUCE COUGH.

β–ADRENORECEPTOR
BLOCKERS
 Atenolol TENORMIN
 Carvedilol COREG, COREG CR
 Metoprolol LOPRESSOR, TOPROL-XL
β–ADRENORECEPTOR BLOCKERS

 Improved systolic functioning and reverse cardiac

remodeling
 Prevent the direct deleterious effects of norepinephrine on
the cardiac muscle fibers, decreasing remodeling,
hypertrophy, and cell death.
 Recommended for all patients with heart disease except
those who are at high risk but have no symptoms and
those who are in acute HF.
 Carvedilol and metoprolol reduce morbidity and mortality
associ- ated with HF.
 Treatment with β-blocker should be started at low doses
and gradually titrated to effective doses based on patient
tolerance.
DIURETICS
 Bumetanide BUMEX
 Furosemide LASIX
 Hydrochlorothiazide (HCTZ) MICROZIDE
 Metolazone ZAROXOLYN
DIURETICS
 Relieve pulmonary congestion and peripheral edema.
 Reduce the symptoms of volume overload
 Decrease plasma volume and, subsequently, decrease
venous return to the heart (preload). This decreases
the cardiac workload and the oxygen demand.
 Decrease afterload by reducing plasma volume,
thereby decreasing blood pressure.
 Loop diuretics are used for patients who require
extensive diuresis and those with renal insufficiency.
 Loop diuretics are the most commonly used diuretics
in HF
DIRECT VASODILATORS
 Hydralazine APRESOLINE
 Isosorbide dinitrate DILATRATE-SR, ISORDIL
 Isosorbide mononitrate ISMO
 Sodium nitroprusside NITROPRESS
DIRECT VASODILATORS
.DILATION OF VENOUS BLOOD VESSELS LEADS TO A
DECREASE IN CARDIAC PRELOAD BY INCREASING
THE VENOUS CAPACITANCE.
ARTERIAL DILATORS REDUCE SYSTEMIC
ARTERIOLAR RESISTANCE AND DECREASE
AFTERLOAD.
NITRATES ARE COMMONLY USED VENOUS
DILATORS FOR PATIENTS WITH CONGESTIVE HF.
. IF THE PATIENT IS INTOLER- ANT OF ACE INHIBITORS
OR Β-BLOCKERS, OR IF ADDITIONAL VASODILATOR
RESPONSE IS REQUIRED, A COMBINATION OF
HYDRALAZINE [HYE DRAL A ZEEN] AND ISOSORBIDE
DINITRATE [EYE SOE SOR BIDE DYE NYE TRATE] MAY
BE USED.
HYDRALAZINE DECREASES AFTERLOAD, AND THE
ORGANIC NITRATE REDUCES PRELOAD.
INOTROPIC AGENTS
 Digoxin LANOXIN
 Dobutamine DOBUTREX
 Inamrinone (formerly amrinone) INOCOR
 Milrinone PRIMACOR
INOTROPIC AGENTS
 Positive inotropic agents enhance cardiac
muscle contractility and, thus, increase
cardiac output

 Inotropic action is the result of an increased

cytoplasmic calcium concentration that
enhances the contractility of cardiac muscle.
 ALDOSTERONE
ANTAGONISTS

Eplerenone
INSPRA
Spironolactone
ALDACTONE
ALDOSTERONE ANTAGONISTS

 PATIENTS WITH ADVANCED HEART DISEASE HAVE

ELEVATED LEVELS OF ALDOSTERONE DUE TO
ANGIOTENSIN II STIMULATION AND REDUCED HEPATIC
CLEARANCE OF THE HORMONE.
 SPIRONOLACTONE [SPY-RO-NO-LAC-TONE] IS A DIRECT
ANTAGONIST OF ALDOSTERONE, THEREBY PREVENTING
SALT RETENTION, MYOCARDIAL HYPERTROPHY, AND
HYPOKALEMIA.
 SPIRONOLACTONE THERAPY SHOULD BE RESERVED FOR
THE MOST ADVANCED CASES OF HF.
 BECAUSE SPIRONOLACTONE PROMOTES POTASSIUM
RETENTION, PATIENTS SHOULD NOT BE TAKING
POTASSIUM SUPPLEMENTS.
ADVERSE EFFECTS

ALDOSTERONE ANTAGONISTS

GASTRIC DISTURBANCES, SUCH AS GASTRITIS AND PEPTIC

ULCER;

CENTRAL NERVOUS SYSTEM EFFECTS, SUCH AS LETHARGY

AND CONFUSION;

and
ENDOCRINE ABNORMALITIES, SUCH
AS GYNECOMASTIA, DECREASED
LIBIDO, AND MENSTRUAL
IRREGULARITIES
THERAPEUTIC ORDER
 PHARMACOLOGY EXPERTS CLASSIFIED HF
INTO FOUR STAGES, FROM LEAST SEVERE TO
MOST SEVERE.
 PROGRESSION FROM MONO TO POLY

THERAPY
 OVERT HEART FAILURE --- IST LOOP

DIURETICS --- RELIEF SIGNS OR SYMPTOMS

OF VOLUME OVERLOAD, SUCH AS DYSPNEA
AND PERIPHERAL EDEMA.
THERAPEUTIC ORDER

 ##THEN ACE INHIBITORS OR ARBS

 GRADUALLY TITRATTION OF THE DOSAGE
 ##$ON STABILITY, Β-BLOCKERS ARE

INITIATED WTH TITRATION OF DOSES

 ##$$DIGOXIN IS INITIATED IN PATIENTS WHO

CONTINUE TO HAVE SYMPTOMS OF HEART

FAILURE DESPITE THE MULTIPLE DRUG
THERAPY.
 Think NURSE
think BIG,
have a dream
and turn the dream
into execution
 in g
e n
l i st
f o r
Thank you for listening

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