1. CONGESTIVE HEART FAILURE, Cadiotonic drug and Cardiac glycosides
DR BUSARI. A.A
(MB.BS, M.Sc., MMCP, FWACP)
Consultant Nephrologist & Lecturer
Dept. Of Pharmacology, Therapeutics and Toxicology

2. outline Definition Physiology Epidemiology and Clinical feature
Classification
Causes
Therapeutic goal
Drug used in heart failure

3. Heart failure
Heart failure is defined as inability of heart to pump blood (CO) at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.
Heart is major contributor of
morbidity and mortality
worldwide.

4. Heart failure
HF is due to an impaired ability of the heart to adequately fill with and/or eject blood.
It is often accompanied by abnormal increases in blood volume and interstitial fluid, hence the term congestive.
The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure.

5. Heart failure
BVF term is used when both ventricular chambers fail resulting into fluid overload.
There is approximately 5 million people (6 -10% of adult population) suffering for CHF in USA.
Mortality of advanced disease exceed 50%
In Africa, it affects 3-4% of adult population with greater severity.

6. Physiology of HF

7. Physiology of HF
Heart failure triggers ‘counter-regulatory’ responses which make the situation worse, not better.
Treatment of heart failure is aimed at reversing these counterregulatory changes, which include:
activation of the renin–angiotensin–aldosterone system;
activation of the sympathetic nervous system;
release of vasopressin (an antidiuretic hormone, see

8. Compensatory counter-regulatory responses in heart failure and their consequences.

9. Action potential of a Purkinje fiber. ATPase = adenosine triphosphatase.

10. Cardiac performance
is determined by preload,
afterload,
myocardial contractility
and heart rate.
Treatment targets these
aspects, often by
blocking one or
other of the
counterregulatory
mechanisms.

11. Circulatory system

12. Physiology of HF PRELOAD
Cardiac preload, the cardiac filling pressure, is determined by blood volume – increased by salt and water retention – and capacitance vessel tone, increased by sympathetic nervous system activation.
Drugs can reduce blood volume (diuretics) and reduce capacitance vessel tone (venodilators).
AFTERLOAD
Afterload is determined by the systemic vascular resistance and by aortic stiffness.
Drugs that relax arterial smooth muscle reduce cardiac afterload.

13. Physiology of HF MYOCARDIAL CONTRACTILITY
Positive inotropes (i.e. drugs that increase the force of contraction of the heart) can improve cardiac performance temporarily by increasing contractility, but at the expense of increased oxygen consumption and risk of dysrhythmia.
HEART RATE
Cardiac function deteriorates as heart rate increases beyond an optimum, due to insufficient time for filling during diastole.
Heart rate can usefully be slowed by negative chronotropes (i.e. drugs that slow the heart).

14. Causes of heart failure
Myocardial infarction
Coronary artery disease
Valve disease
Idiopathic cardiomyopathy
Viral or bacterial cardiomyopathy
Myocarditis
Pericarditis
Arrhythmias
Chronic hypertension
Thyroid disease
Pregnancy
Septic shock

15. Signs and symptoms of heart failure include the following
Exertional dyspnea and/or dyspnea at rest
Orthopnea
Acute pulmonary edema
Chest pain/pressure and palpitations
Tachycardia
Fatigue and weakness
Nocturia and oliguria
Anorexia, weight loss, nausea
Central or peripheral cyanosis, pallor
Exophthalmos and/or visible pulsation of eyes
Distention of neck veins
Weak, rapid, and thready pulse
Rales, wheezing
S 3 gallop a4w338nd/or pulsus alternans
Increased intensity of P 2 heart sound
Hepatojugular reflux
Ascites, hepatomegaly, and/or anasarca

16. The New York Heart Association (NYHA) classification
Class I: No limitation of physical activity
Class II: Slight limitation of physical activity
Class III: Marked limitation of physical activity
Class IV: Symptoms occur even at rest; discomfort with any physical activity

17. THERAPEUTIC OBJECTIVES AND GENERAL MEASURES FOR CHRONIC HEART FAILURE
Therapeutic objectives in treating heart failure are
to improve symptoms and
to prolong survival.

18. Drug used in heart Failure
Accordingly, six classes of drugs have been shown to be effective:
(1) inhibitors of the renin-angiotensin system,
(2) ß-adrenoreceptor blockers,
(3)diuretics,
(4) direct vasodilators,
(5) aldosterone antagonists
(6) inotropic agents e.g Digoxin

20. Treatment options for various stages of heart failure.

21. Nonpharmacologic therapy:
Oxygen and noninvasive positive pressure ventilation,
dietary sodium restriction.
fluid restriction.
physical activity as appropriate.
and attention to weight gain.

22. Thanks