Congestive Heart Failure

Heart Failure to meet the

in the
inability of Heart
•

demands
of body .

Can be due to
•

systolic dysfunction or Diastolic

dysfunction
systolic dysfunction : The ventricles are dictated and unable

to
develop sufficient wall tension to
eject adequate
quantity of blood .

• Occurs in cis Ischaemic heart disease

cii , Valvular Incompetence

iii, Dilated
cardiomyopathy
livs
Myocarditis
in
Tacky arrhythmias
Diastolic dysfunction : The ventricular wall is thickened
and unable to diastole
properly during
relax :

ventricular
filing is
impaired became
of
which

output in low .

Occurs Sustained
Hypertension
•

in ii.

Iii , Aortic stenosis

iii.
Congenital Heart disease

( in A -
V shunts

in
Hypertrophic Cardiomyopathy .

Most patients
•
,
up
.

longstanding CHF ,
have both
dysfunction
 Pharmacotherapy Aimed at :

•
A, Preload : Diuretics ,
ACE Is ,
A RBS and Xeno dilators

He
After load : ACE -7s ARB and Artemio dilators
•

. ,

•
A
Contractility :
Digoxin ,
P
Agonists ,
PDE inhibitors

*
Remodeling of Spironolactone
•

: ACE -7s ,
ARBS . ,

Cardiac muscle
p blockers .

does not improve survival

Digoxin
°

, ACE Is ,
ARBS ,

blockers have been beneficial

B &
Spironolactone proven
.

•
ACE Is & ARBS are
currently drug of
choice
for Chronic

management ] CHF -

•
Ino tropes are more beneficial in Acute CHF .

Diuretics
• In heart
failure ,
there in accumulation
of fluid in the

to
lungs and
peripheral organs leading congestive sym
-

ptoms
-
.

Diuretics of choice Diuretics like

•
are
loop Furosemide &

diuretic
Bumetanide which
posses high ceiling effect .
 diuretics decrease preload
•

loop or Thiazide .

Diuretics do not alter basic

pathology therefore have
•

no
effect mortality except spironolactone which
on ,

decrease
mortality .

Inotropic Drugs term

→ Short
management y
Acute CHF .

Inotropic drug, used in CHF are :

ii. Do but amine

iiii
Dopamine
iiii Ino dilators

Cardiac
(in
glycosides .

A. Dobutamine

Selective B.
Agonist
Increases CAMP in heart A Cardiac
Contractility
•

A Cardiac
Output
Given
by Infusion
•

I. Y . .

B.
Dopamine
( D1 )
•
Acts on
dopamine ,
P and
,
✗
. Receptors depending on

concentration .

At Renal Vasodilation
2µg / kg / min Receptor
•
1- D,

At / / min B Receptor Heart stimulation

2
-10µg kg ,
 At > 10
Pg 1kg 1min ✗
Receptor Intense
Vasoconstriction .

c. Ino dilators

Drugs : Inamrinone
•

Milrinone

Vesna ri none

Ino dilators has Ino tropics Vasodilation

Properly
•
+ .

Ino
dilators
Act
inhibiting Phosphodiesterase
•
via II and thus increase

CAMP in heart & Blood Vessels .

influx of Cells and

-
CAMP increases ca in
Myocardial
°

A
contractility whereas it Results Relaxation g

vascular smooth muscle y Blood Vessels .

Cardiac
D.
Glycosides
•

Digitalis glycosides are no

longer considered as First-line

drugs in treatment of Heart Failure .

• Cardiac
glycosides are Positive Inotropic drugs but

unlike other
inotropes do not Rate
,
they increase Heart .

Can be Atrial Fibrillation Atrial Flutter and

given in
•

Paroxysmal supraxentncnlar tachycardia .

Digitalis -

Only Inotropic drug that can be

given Orally .
 Mechanism
of Action :

Inhibition
of / K+
by digitalis
Nat ATPase
of cell membrane
•

is considered to be 1° biochemical mechanism

y Action
.

• Inhibition of Nat / K+ ATPase results in small increase

intracellular
in Mat . The increased Nat alters the
driving
force for Exchanger ( "
Na - ca Mex ) ,
so that less Ca is

removed
from cell .
•
The increased Ca
"
as stored in SER and release
,
upon
contractile
increases
force .

Binding of cardiac
glycosides to Na -1kt ATPase slow &
•

in

also
after binding intracellular
"
,
ca increase

gradually These factors

.
are
responsible for delayed
action
of digitalis ( even on i. v
injection) .

f-
 Effects :

Digitalis increases the

force of contraction and
•

decreases the heart rate .

Also decreases An conduction .

contra indicated Parkinson hite

•
It in -
in
Hoff -
- IN

because it decreases conduction

syndrome through
Node but not aberrant
Av
through Pathway .

Digitoxin is Digoxin
{ No
longer
used .

Side
Effects :

Early Signs : Anorexia ,

Nausea , ECG
changes
later Disorientation Visual
•

Signs : ,
effects ( Yellow green
disturbances
colour ,
blurry vision )

In toxic doses
• :
Any Cardiac
Arrhythmias .
 • Most Common Arrhythmias :
,
i.
Ventricular Premature beats

ii.
Bigeminy
characteristic
Most
Arrhythmia of Digitalis toxicity
•

Non -

paraoxysmal supra Ventricular Tachycardia with

a trio ventricular
-
block .

For
• severe
toxicity -

Digoxin Antibody ( Digi bind ) is

preferred
.

Contraindications :

in
Myocarditis
(2)
Hypercalcemia
(3) 14PM
Syndrome
141
Hypokalemia &
Hypomagnesemia
(5)
Elderly
(6) AV Block
(7) Renal Failure
(8)
Thyroid ( Hyper or
Hypo )

C
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