Pharmacological treatment of cardiac failure Flashcards
Name some non pharmacological treatments for HF?
- Lifestyle factors - as per all CVD conditions remember mental health factors
- Device therapy
Pacing
Cardiac resynchronisation therapy
Implantable cardiac defibrilators
Coronary revascularisation
Heart transplant
What are the main drugs used in CHF?
- Loop diuretics
- ACE inhibitors
- ARBs
- Beta blockers
- Aldosterone receptor antagonists
Name an aldosterone receptor antagonist
Spironalactone
What is the pharmacological treatment of HF?
ABBA
- ACEI or ARB
- Beta Blocker
- Aldosterone antagonist
- Waterloo diuretics can be added sometimes
What is the step 1 treatment of CHF?
DABB
- Diuretic if fluid retention
- ACE inhibitor or ARB
- Beta-Blocker
Name two loop diuretics
Furosemide, bumetanide
What does the patient have to look for when using loop diuretics?
- Daily weight - if varies in either direction, alter dose
- Symptom review - breathlessness, peripheral oedema
- Thirst level, dizziness, “washed out”
- GP checks blood chemistry within a week of any dose change
What are the common side-effects of loop diuretics?
- Electrolyte distrurbances
- Hypotension
- Renal impairment
- Hypovolaemia
- Nocturia if taken too late in day (troublesome)
- Acute gout common with high doses
Name some ARBs
- Candesartan
- Valsartan
- Losartan
What are the effect of using the ACEi and ARBs in HF
- Reduce salt and water retention
- Reduce vasoconstriction
- Reduce vascular resistance
- Reduce afterload
- Improve tissue perfusion
- Reduces ventricular remodelling and hypertrophy
- Less effective in African or Caribbean ethnicity (try hydralazine + nitrate)
- Start low lose dose, monitoring BP and blood chemistry and symptoms and uptitrating to maximum tolerated or target doses
What are the contraindications to ACEi and ARBs?
- Severe bilateral renal artery stenosis
- Severe aortic stenosis
- Known history of angioedema
- Pregnancy/risk of pregnancy
What can some third generation Beta blockers do to reduce afterload?
E.g Carvedilol cause vasodilation through blockage of alpha-receptors
How do Beta-blockers work in HF?
- Allow ventricle to fill more completely during diastole
- Reduce renin release by kidney
When would Beta blockers be used in HF?
- Start if reduced ejection fraction but stable NYHA class II-IV
- Start low, go slow
What drugs should beta-blockers not be used with?
- Risk of bradycardia / AV block with:
- Digoxin
- Amiodarone
- Verapamil
- Dilitiazem
What are the side-effects of Beta-blockers?
- Bradycardia/HB (contra-indicated)
- Fatigue
- Shortness of breath (contra-indicated in Asthma)
- Dizziness, cold peripheries, imponenc/reduced libido, insomnia (more with older versions)
What is another name for Aldosterone antagonists?
Mineralocorticoid receptor antagonists
When is spironalactone used?
Added in when there are still symptoms after ACEI or ARB + BB + diuretic
- In NYHA class II-IV failure
- Low doses used (larger doses used in hepatic cirrhosis)
What are Aldosterone Receptor Antagonists common side-effects?
- Hyperkalaemia
- Hyponatraemia
- Nausea
- Hypotension
- Gynaecomastia with spironalactone
- Renal impairment
What is used in step 3 or 4 HF?
- Sacubitril + Valsartan (Valsartan counteracts angiotensin 2 produced by sacubitril)
- Ivabradine
What is Sacubitril?
Nephrilysin inhibitor
What is a Valsartan?
An ARB
when would digoxin be used in HF?
Atrial fibrilation
How does digoxin work to treat HF?
- Increases force of myocardial contraction
- Inhibits Na/K pump, thus affecting Na/Ca exchanger, elevating intracellular calcium levels in SR then when Ca released results in strenghtened contractility
