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Drugs for CCF
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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.
Drugs for CCF
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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.
Drugs for CCF
Drugs for CCF
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Vasodilators – ACE Inhibitors
Diuretics
Beta blockers
Digoxin
Other Cardiac Inotropes –
Dobutamine, Milrinone
Drugs for CCF
Angiotensin Converting Enzyme (ACE)
Inhibitors :
 ACE inhibitors improve mortality,
morbidity, exercise tolerance, left
ventricular ejection fraction.
 Captopril, Lisinopril, Enalapril,
Ramipril, Quinapril.
ACE Inhibitors for CCF
ACE Inhibitors for CCF
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
Drugs for CCF
Angiotensin Converting Enzyme (ACE)
Inhibitors :
Adverse effects :
 Dry irritating persistent cough
 Hyperkalemia
 Angioedema
 Fetal toxicity
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.
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.
Nitrates in CCF
Drugs for CCF
Diuretics :
These are useful in reducing the
symptoms of volume overload by
 decreasing the extra cellular volume
 decreasing the venous return
Drugs for CCF
Diuretics :
 Loop diuretics like furosemide and
bumetanide are the most effective and
commonly used.
 Thiazides are effective in mild cases
only.
Drugs for CCF
Diuretics : Adverse effects :
 Loop diuretics and thiazides cause
hypokalemia.
 Potassium sparing diuretics help in
reducing the hypokalemia due to these
diuretics.
Drugs for CCF
Potassium Sparing Diuretics :
Spironolactone :
 Aldosterone inhibition minimize
potassium loss, prevent sodium and
water retention, endothelial
dysfunction and myocardial fibrosis.
Drugs for CCF
Spironolactone : Aldosterone antagonist
 Spironolactone can be added to loop
diuretics to modestly enhance the
diuresis; more importantly, improve
survival.
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.
Beta blockers in CCF
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
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.
Digoxin in CCF
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.
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.
Drugs for CCF
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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.
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.
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.
STAGE
DISABILITY
CLASS 1
MILD
No symptoms Can perform ordinary
activities without any limitations
CLASS 2
MILD
Mild symptoms - occasional
swelling Somewhat limited in ability to
exercise or do other strenuous activities
CLASS 3
Noticeable limitations in ability to
exercise or participate in mildly
strenuous activities
Comfortable only at rest
MODERATE
CLASS 4
SEVERE
Unable to do any physical activity
without discomfort Some HF symptoms
at rest
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