1. Lines of Treatment
 General measures e.g. rest, sedatives, frequent small meals with salt restriction.
Treatment of the cause.
Angiotensin coverting enzyme inhibitors.
Diuretics
Spironolactone. > potassium retaining Diuretics
*Positive inotropic agents e.g. cardiac glycosides, dopamine, dobutamine, prenalterol, 2 agonist, and pde inhibitors.
Vasodilators.
Beta blockers.( don’t use with H.failure ) contraindicated in H.failure
نستخدم نوع واحد مع بيشنت معين,. رح ينذكر بالسلايدات الجاية بس بشكل عام ما نستخدم
B.B + H.F

2. POSITIVE INOTROPIC DRUGS
 1-CARDIAC GLYCOSIDES= Digitalis
The most important cardiac glycosides is Digoxin
Pharmacokinetics
Absorption: from duodenum
Distribution: all over the body
concentrated n heart(15-30 times) اكثر من البلازما.
concentrated in sk.m.(10-15 times).
bound to pl.pr(25%).
Plasma concentration=0.5-2 ng/ml. > narrow therapeutic index

3. MOA A) Positive Inotropic Action
↑ force of contraction by ↑ intracellular Ca++
B) Vagal effects. ANS - بيقلل معدل ضربات القلب
predominates n small dose.
causes →↓ S,A.N., ↑ atrial Conductivity,
↓ A.V.N. conductivity

4. Pharmacological Effects
 Cardiovascular System
 Heart
Contractility: It has a strong +ve inotropic effect , ↑ cardiac output
Heart rate: It ↓ the heart rate due to:
Vagal causes
 Extravagal causes

5. Heart
Excitability= ability of H to respond to stimulation: S.D.→↑ excitability, while L.D.→↓ excitability
Automaticity= ability of heart to initiate it own impulse : L.D.→↑ automaticity
E.C.G.: ↓ H.R.
Long P-R interval> delay conduction in Av node
Short Q.R.S. and short Q-T interval> increased force of contraction
Depressed S-T segment
Arrhythmia .= ↑ automaticity
Circulation
COP: Increased in HF.
A.B.P: Normalization.
Venous pressure: ↓.
Blood volume : ↓ ( diuresis)

6. 2. Effects on the Kidney: 3+4 with toxic does
 In congestive heart failure, digitalis produces diuresis due to:
↑ renal plasma flow and glomerular filtration rate.
↓ of tubular Na reabsorption.
3. Effects on the Gastrointestinal Tract
It causes nausea, vomiting anorexia and diarrhea.  
4. Effects on the CNS
Yellow + green vision.
Black dots with white hollows
3+4 with toxic does

7. Therapeutic Uses A. Absolute Indications:
Chronic congestive heart failure associated with atrial fibrillation.
B. Relative Indications: استخدمه او استخدم شي ثاني بداله
1. Treatment of heart failure failing to respond to diuretics .
2. Atrial fibrillation.
3. Atrial flutter.
4. Paroxysmal atrial tachycardia .

8. Contraindications A. Absolute Contraindications Heart block.
Hypertrophic obstructive cardiomyopathy.
B. Relative Contraindications
Cardiopulmonary disease
Renal and hepatic insufficiency
In hypertensive heart failure:The first line is antihypertensive with the emphasis on vasodilators.

9. Factors Modifying Response to Digitalisa
Renal failure.
Hepatic failure.
Chronic pulmonary diseases, hypoxia, Cardiac disorders:
Acute myocardial infarction leads to increase sensitivity
Acute Rheumatic carditis increases the risk of heart block.

10. Dosage and Administration of Cardiac Glycosides
Slow digtitalization “Cumulative method”:
Digitalization started with 0.5 mg twice per day for two days or 0.5 mg 3 times per day for one day
followed by the maintenance dose. : 0.25 mg daily نص قرص لقرص
Rapid digitalization “ Rapid loading method”:
In emergency, we give a large initial loading dose “”. It is given in 3 or 4 divided doses at 6 hours intervals. In 24 hrs

11. Assessment of Response to Digitalis
Relief of dyspnea and orthopnea= dyspnea on lying down.
Disappearance of tachycardia.
Disappearance of edema, congested neck veins and basal lung crepitations.

12. Precautions for Digitalis Therapy
Never give I.V. digitalizing dose before being sure that the patient has not received any digitalis during previous 14 days to avoid digitalis toxicity.
Make sure that K+ level is normal.
What increase activity of digitalis ? = decrease K+ = diuretics
What decrees effect of digitalis ? Pectin, kaolin, cholestyramine

13. DIGITALIS TOXICITY Manifestation of digitalis toxicity I- Cardiac:‏
Variable degree of A.V. block
Sinus bradycardia; complete sinoatrial block.
atrial tachycardia.
II- Extracardiac:
‏Anorexia, nausea, vomiting
‏Neurological effects: headache, muscle weakness, malaise, drowsiness and parasthesia disorientation, confusion, aphasia, delirium and hallucination “digitalis delirium”
White borders or halos may appear on dark objects.
Yellow and green.

14. Management of digitalis toxicity
Stop digitalis administration.
Hypokalaemia can be corrected by slow IV infusion of K.
Antiarrhythmic drugs:
Fab fragments of digitalis

15. 2- OTHER +ve INOTROPIC DRUGS
DOPAMINE
DOBUTAMINE  
increase in cardiac output due to stimulation of 1 receptors. Given IV
PRENALTEROL
Similar to dobutamine but has longer duration +given orally.

16. 3-PHOSPHODIESTERASE INHIBITORS
 CARDIO-ACTIVE BIPYRIDINES Amrinone, Milrinone .
INHIBIT PHOSPHODIESTERASE = ↑level of cAMP ↑ Ca2+
METHYLXANTHINES
Same

17. VASODILATORS effective in heart failure?
venodilators = nifedipine ↓in preload
Arteriodilators= nitrates ↓ in afterload
or both(Mixed) sodium nitroprusside, ACEIs

18. Vasodilators can be used in the Following Situations
Pump failure-complicating AMI, valvular heart disease postoperative in cardiac surgery.
Chronic congestive heart failure.

19. VASODILATORS ACEIs. the, best, if not tolerated
ARBs Angiotensin II Receptor Blockers: Losartan ,valsartan.
Nitrates, the oral preparations for CHF, and I.V. nitroglycerine for acute pulmonary edema.

20. DIURETICS They are used in order to:
(1) Prevent fluid retention. = decrees plasma volume
(2) Relieve edema.
(3) Decrease systemic pulmonary venous pressure.
Thiazides: In mild and moderate heart failure.
Frusemide: In server heart failure.
Potassium retaining diuretics: Spironolactone : In-patient with heart failure with secondary hyperaldosteronism.

21. RATIONAL FOR USE OF BETA-BLOCKERS IN HEART FAILURE
The potential benefits of therapy with B-blockers are due to the ability of these drugs to reduce excessive sympathetic stimulation which cause.
tachycardia and increased myocardial oxygen demand, cardiac hypertrophy,.
-blocker Carvedilol has considerable
1- vasodilator activity
Vasodilator cus it has alpha and beta blocking activity .
2-Antioxidant properties.
3-Up-regulation of beta-receptors
هذا الوحيد اللي استخدمه للهارت فيلير 

22. Rapid digitalizationAminophylline
Mention 2 drugs used in treatment of ACUTE PULMONARY EDEMA\ Acute heart failure \ Cardiac asthma
Hospitalization.
Semisitting or sitting position.
Treatment of the cause MI
Morphine: I.V. in low dose dose of 2-5 mg,
Relieving pain.
Arteriolar dilatation.
Venodilatation.
Sedation.
Oxygen
Diuretics
Vasodilators
Rapid digitalizationAminophylline