2. Drugs for CCF
Heart failure is the progressive inability of the heart to supply adequate blood flow to vital organs.
It is classically accompanied by significant fluid retention.
It is a leading cause of mortality and morbidity.

3. Drugs for CCF
The most common symptoms of CCF includes shortness of breath, edema and fatigue.
Causes of heart failure includes Coronary artery disease (CAD), Hypertension, Diabetes, Mitral valve disease and Chronic alcohol.

8. Drugs for CCF
continuous positive airway pressure, or CPAP.

9. Drugs for CCF Vasodilators – ACE Inhibitors Diuretics Beta blockers
Digoxin
Other Cardiac Inotropes – Dobutamine, Milrinone

10. Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors :
ACE inhibitors improve mortality, morbidity, exercise tolerance, left ventricular ejection fraction.
Captopril, Lisinopril, Enalapril, Ramipril, Quinapril.

11. ACE Inhibitors for CCF

12. ACE Inhibitors for CCF

13. Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors :
Reduction in arterial resistance (afterload)
Reduction in venous tension (preload)
Reduction in aldosterone secretion
Inhibition of cardiac and vascular remodeling

14. Drugs for CCF Angiotensin Converting Enzyme (ACE) Inhibitors :
Adverse effects :
Dry irritating persistent cough
Hyperkalemia
Angioedema
Fetal toxicity

15. Drugs for CCF Angiotensin Receptor AT-1 blockers (ARB) :
Losartan, Irbesartan, Candesartan
Competitive antagonists of Angiotensin II (AT-1).
No inhibition of ACE or Cough.

16. Drugs for CCF Vasodilators :
Isosorbide dinitrate and hydralazine also used specially in patients who cannot tolerate ACE inhibitors.
Amlodipine and prazosin are other vasodilators can be used in CCF.

17. Nitrates in CCF

18. Drugs for CCF Diuretics :
These are useful in reducing the symptoms of volume overload by
decreasing the extra cellular volume
decreasing the venous return

19. Drugs for CCF Diuretics :
Loop diuretics like furosemide and bumetanide are the most effective and commonly used.
Thiazides are effective in mild cases only.

20. Drugs for CCF Diuretics : Adverse effects :
Loop diuretics and thiazides cause hypokalemia.
Potassium sparing diuretics help in reducing the hypokalemia due to these diuretics.

21. Drugs for CCF Potassium Sparing Diuretics : Spironolactone :
Aldosterone inhibition minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.

22. Drugs for CCF Spironolactone : Aldosterone antagonist
Spironolactone can be added to loop diuretics to modestly enhance the diuresis; more importantly, improve survival.

23. Drugs for CCF Beta blockers for congestive cardiac failure :
Acts primarily by inhibiting the sympathetic nervous system.
Increases beta receptor sensitivity (up regulation).
Anti-arrhythmic properties.
Anti-oxidant properties.

24. Beta blockers in CCF

25. Drugs for CCF Beta blockers for CCF :
Start at low dose and monitor for bradycardia
Carvedilol and Metoprolol are the most commonly used for CCF amongst beta blockers

26. Drugs for CCF Cardiac glycosides : Digoxin :
Inhibition of Na/K ATPase pump increase intracellular sodium concentration – eventually increase cytosolic calcium.
It restores the vagal tone and abolishes the sympathetic over activity.

27. Digoxin in CCF

29. Drugs for CCF Cardiac glycosides : Digoxin :
Increase the refractoriness of AV node thus decrease ventricular response to atrial rate.
Digoxin is used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation.

30. Drugs for CCF Digoxin : Adverse effects / Precautions :
Nausea, vomiting, gynecomastia, visual disturbances and psychosis.
Ventricular bigeminy, AV block and bradycardia.
Amiodarone and verapamil can increase the plasma concentration of digoxin by inhibiting its excretion.
Quinidine, verapamil, and amiodarone increases plasma levels of digoxin (by displacing tissue binding sites and depressing renal digoxin clearance) so plasma digoxin must be monitored carefully.

31. Drugs for CCF Digoxin toxicity treatment:
Toxicity can be treated with higher than normal doses of potassium.
Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose.
Digitalis-induced progressive elevation of the serum potassium concentration also suggests imminent cardiac arrest. If the potassium concentration exceeds 5 mEq/L in the setting of severe digitalis intoxication, therapy with DIGIBIND is indicated.

32. Drugs for CCF Cardiac Inotropes :
Phosphodiesterase III Inhibitors Positive inotropic and vasodilator – INO-DILATOR ; Eg., Milrinone
Dobutamine is a beta-1 agonist which increase contractility and cardiac output.
Milrinone (Primacor) is a phosphodiesterase III inhibitor.
Chronotropic, arrhythmogenic, and vasodilative effects are negligible with dobutamine.

33. Drugs for CCF Conclusion :
ACE inhibitors are cornerstone in the treatment of CCF.
Beta blockers are used in selected patients (mild/moderate failure, low dose)
Diuretics and digoxin are other drugs useful in CCF in select patients.

34. STAGE DISABILITY CLASS 1 MILD CLASS 2 CLASS 3 MODERATE CLASS 4 SEVERE
No symptoms Can perform ordinary activities without any limitations
CLASS 2
Mild symptoms - occasional swelling Somewhat limited in ability to exercise or do other strenuous activities
CLASS 3
MODERATE
Noticeable limitations in ability to exercise or participate in mildly strenuous activities
Comfortable only at rest
CLASS 4 SEVERE
Unable to do any physical activity without discomfort Some HF symptoms at rest