treatment of heart failure(chf) done by: fatimah al-shehri pharm.d candidate. king abdulaziz...
TRANSCRIPT
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Treatment of heart failure(CHF)
Done by:Fatimah Al-Shehri
Pharm.D candidate .King abdulaziz university
Supervised by :Dr.Sara Al-Khansa.
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Outline: 1-Introduction:
-Definition.
-Types.-Causes.
2-Pathophysiology.3-Diagnosis.
-Signs and symptoms .
-Classification of HF.
4-Mangment of CHF.
-Goals of therapy.-Non-pharmacological therapy.
-Pharmacological therapy.-Summary of guidelines treatment.
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Heart failure:
Abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues, despite normal filling pressures.
According to function:1-Systolic HF.2-Diastolic HF.
Types of heart failure:
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Pathophysiology:Left sided heart failure: Systolic failure(systolic dysfunction) :
The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation.
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Pathophysiology:ABC of heart failurePathophysiologyG Jackson, C R Gibbs, M K Davies, G Y H Lip
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Signs and symptoms:
-Edema of feet , ankles , abdomen and lungs .-Congested jugular veins.-Loss of appetite.-Shortness of breath.-Fatigue and weakness.-↓↓ Alertness or concentration.
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CAUSES: 1-Coronary artery disease .
2 -Cardiomyopathy.3-Hypertension .
4-Thyroid disease 5-Valvular heart disease .
6-Cardiotoxins. 7-Myocarditis.
8-Idiopathic .
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Diagnosis:1-Medical history.
2-Physical examinations.3-Laboratory tests.
E.g:(B-type Natriuretic Peptide(BNP).
4-Radilogical methods:-Chest X- rays&CT scan&MRI.
-ECG.EF<40).)-ECHO.
Hunt SA et al. J Am coff cardiot 2001:83:2101.13.Farrett MH et al.JAMA.2002:287:890-7.
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Hunt SA et al.j AM coff cardio 2001:38:2101-13Farrell MH et al .JAMA 2002:287:890-7
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Management of CHF:
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Principles and goals of therapy:
1-Block the compensatory neurohormonal activation caused by decreased CO.
2-Prevent/minimize Na and water retention. 3-Eliminate or minimize symptoms of HF.
4-Slow the progression of cardiac dysfunction 5-Decrease mortality.
6-Prevent hospital admission.7 -Improve survival.
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Management of CHF:
1-Nonpharmacological
.
2-Pharmacological:1-Diuretics.
2-ACEI or ARBS.3-Beta blockers.
4-Aldosterone antagonist.5-Digoxin.
6-Vasodilators.
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1-Nonpharmacological: Life style changes:
1-Decrease fluid intake(2/L MAXIMUM.)
2-Decease sodium.3-Decreae weight.
4-Moderate exercise .
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2-Pharmacological:
1-Diuretics: Place of therapy :all patients with heart failure.
Types of diuretics: A- loop diuretics :(Furosemide,Torsemide,Ethycranic acid,Bumetinde.)
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Mechanism of action
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1-Diuretics: Side effects of loop diuretics :
-Hypokalemia,hyponatermia,hypomagnesemis,hypocalcemia,
-Dehydration. ototoxicity.-Hyperuercemia,hyperglycemia,
hyperlipidemia.
-Conistipation,Dryness of the mouth .-Muscle weakness.
-wieght loss,Skin rashes,hypotension ..
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1-Diuretics: Contraindications of loop diuretics:Hypersensitivity.
Monitoring: -Monitor electrolyte ,(K,Na,Ca).
-Uric acid ,glucose.
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1-Diuretics :
B-Thaiazide diuretics:
e.g: Hydrochlorothiazide.
Mechanism of action
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1-Diuretics: Side effects of thiazide diuretics:
-Hypokalemia,Hyponatremia-Increased uric acid and glucose.
-Increased cholesterol. -Hypomagnesemia
-Hypotension.-Photosensitivity.
-Headaches, Allergy
thiazide diuretics : of Contraindications -Allergy to (sulphur-containing medications).
-Gout. -Hypotension. -Renal failure.
-Lithium therapy. -Hypokalemia.
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Diuretics and recommended doses:
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2-ACEI: Place in therapy: For all patients with heart failure.
e.g:(Lisinopril,Prendopril,Captopril,Enalpril,)
Mechanism of action :(-Blocks production (AgII
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2-ACEI :Side effects:
- Dry cough. - Protinuria. Allergy .
- Decrease taste. - Neutropenia .
- Hyperkalemia. - Angioedema.
-Acute renal failure.
-Pregnancy.-Hypotension.
-Bilateral renal stenosis.
Contraindications:
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2-ACEI:
Monitoring:
1-SCr,and K in 1–2 weeks after starting or increasing the dose.
2-Monitor BP and symptoms of hypotension (e.g., dizziness, light-headedness).
3-Use cautiously in those with a baseline K greater than 5.0 mEq/L .
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ACEI and recommended doses:
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2-ARBs:e.g:(Losartan.Candesartan.Valsartan)
Place in therapy :If the patient cannot tolerate the side effect that produced by ACEI (dry cough).
Side effects: the same as ACEI but with less cough .
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ARBS and recommended doses:
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3-Beta Blockers:
BB use in heart faliure: -Bisoprolol.-Metoprolo.-Carvedilol.
Place in therapy:Should be used in all stable patients.
Mechanism of action :
-Blocks the effect of NE and other sympathetic NT on the heart and vascular system.
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3-Beta blockers:
SIDE EFFECTS: 1-Hypoglycemia.
2-Hypotension.3-Bradycardia.
4-Depression.5-Edema .
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3-Beta blockers:Contraindications:
1-Uncontrolled heart failure.2-Prinzmetal's angina.
3-Bradycardia.4-Hypotension.
5-Certain problems: (sinus syndrome) .
Monitoring: -BP, HR, and symptoms
of hypotension( monitor in 1–2 weeks .)
-IF hypotension alone is the problem ,
try reducing the dose of the ACE inhibitor first. -Increased edema/fluid retention (monitor in 1–2 weeks).
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BB and recommended doses:
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4-Aldosterone antagonist:E.g: Spironolactone,Eplerenone.
Place in therapy:
1-Should be considered in patients after an acute MI ,
with clinical HF signs and symptoms or history of (diabetes, and an LVEF less than
40%) .2 -Class III and IV HF .
3-LV dysfunction immediately after MI.
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4-Aldosterone antagonists:
Mechanism of action :Blocks effects of aldosterone in the kidneys, heart, and
vasculature :(a )↓K and Mg loss: Decreases ventricular arrhythmias .
(b )↓ Na retention; decreases fluid retention.
(c )Eliminates catecholamine; decreases BP .
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4-Aldosterone antagonists:
Side effects : Hyperkalemia.Gynecomastia.Dry mouth.Muscle weakness.Confusion, nausea, vomiting.
Eplerenone :alternative
to spironolactone in painful gynecomastia.
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4-Aldosterone antagonists: Contraindications:
1-SCr is greater than 2.5 mg/dL ,2(-CrCl ) < 30 /is mL min ,
3-K is >5.0 mEq/L .
MONITORING : 1-K and SCr within 1 week of starting therapy.
2 -Decrease dose by 50% or discontinue if K is greater than 5.5 mEq/L .Dosing :
(1 )Spironolactone 12.5–25 mg/day. (2 )Eplerenone 25–50 mg/day.
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5-Digoxin:
Place in therapy :In patients with LVEF of ≤40%,who have signs or symptoms of HF while receiving standard therapies including ACEI or ARBs and β-blockers.
DOSING: 0.125 mg/day
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5-Digoxin:Mechanism of action:Inhibits Na-K ATPase:i. Decreases central sympathetic outflow by sensitizing cardiac baroreceptors ii. Decreases renal reabsorption of Na .iii. Minimal increase in COP .Side effects:
GIT disturnances.Bradycardia.Ventricular arrythmia.confusion, hallucinations ,
unusual thoughts or behavior.Abdominal pain, headache.
Visual busturbances .
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5-Digoxen:CONTRAINDICATIONS:
-hypersensitivity. -Ventricular fibrillation.
-Pregnancy
Monitoring: 1-Serum concentrations should be less than 1.0
ng/mL, in general, concentrations of 0.7–0.9 ng/mL are effective in HF .
2 -Risk of toxicity increases in the presence of hypokalemia or hypomagnesemia, older age ,RF .
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6-Hydralazine and isosorbide dinitrate:
Place in therapy: In Patients unable to take an ACE I OR ARBS.Due to:
severe renal insufficiency, hyperkalemia, or angioedema.
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6-Hydralazine and isosorbide dinitrate:
Mechanism of action A-Hydralazine:
(a ) ) (Arterial vasodilator reduces afterload .(b ) Enhances effect of nitrates through antioxidant
mechanisms
B- Isosorbide dinitrate :(a ) Stimulates nitric acid signaling in the endothelium
(b ) Effective in reducing preload.
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6-Hydralazine and isosorbide dinitrate:
Side effects: A-Hydralazine:
-Hypersensitivity. -Systemic lupus erythremataus.
-Hypotension. -Headache. -GIT upset.
B-Isosorbide dinitrate: -Blurred vision ,dry mouth.
-Nausea, vomiting, sweating, pale skin. -Headache, hypotension ,mild dizziness.
-Weakness.
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6-Hydralazine and isosorbide dinitrate(ISDN):
Monitoring: 1 -Hypotension .
2-Drug-induced lupus with hydralazine.
Dosing: -Hydralazine (25–75 mg 3-4times/day).
-Isosorbide dinitrate (10–40 mg 3times/ day) .
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Benefits of each group:
Hydralazine &ISDN
Digoxin. Aldosteroneantagonist
BB ACEI &ARBS
Diuretic Groups:
+ + + + + + Symptoms:
+ _ + + + _ :Mortality
+ + + + + - Hospitalization:
.
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Summary: Yancy, CW et al.
2013 ACCF/AHA Heart Failure Guideline
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References:
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Pharm.D candidate :Fatimah Al-Shehri.
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