Congestive Heart Failure Case Study. Congestive Heart Failure.
Congestive hf lect
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CONGESTIVE HEART FAILURE
DR. MA. LENY ALDA G. JUSAYAN
INTERNAL MEDICINE, FPSECP, RN, RMT
Department of Pharmacology
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COURSE OBJECTIVES:
• Explain the pathophysiology of heart failure
• Discuss the different drugs used in the treatment of heart failure as to its pharmacokinetics, pharmacodynamics, drug interactions, adverse effects
• Clinical application of the use of drugs in acute and chronic types of heart failure
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HEART FAILURE
• Inability of the heart to pump an adequate amount of blood to the body’s needs
• CONGESTIVE HEART FAILURE – refers to the state in which abnormal circulatory congestion exists a result of heart failure
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Heart Failure (Pump Failure)• A disorder in which the heart
loses its ability to pump blood efficiently throughout the body
• Affects Cardiac Output– SV X HR
• End result:↓Cardiac Output
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PATHOPHYSIOLOGY:
– Heart failure results in DEPRESSION of the ventricular function curve
– COMPENSATION in the form of stretching of myocardial fibers
– Stretching leads to cardiac dilatation which occurs when the left ventricle fails to eject its normal end diastolic volume
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Heart Failure Pathophysiology: Impaired Cardiac Function
• Failure to pump: Failure to empty ventricles
& reduced delivery of blood into circulation (↓ CO)
• Increased ventricular pressures
• Elevated pulmonary and systemic pressures
• further ↓ CO• Series of compensatory
mechanisms
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Heart Failure Compensatory mechanisms of low CO…
1. SNS stimulation… ↑ HR and
cardiac contractility… ↑ CO
3. Ventricular hypertrophy … cardiac contractility… ↑ CO
2. Starling’s Law/…
Ventricular dilation: ↑ CO
44. Decreased renal blood flow…. Decreased renal blood flow…increasing Na & H20 retention…increasing Na & H20 retention…increases blood volume, ↑ HR & CO.increases blood volume, ↑ HR & CO.
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Heart Failure Compensatory mechanisms of low CO…
1. SNS stimulation… ↑ HR and
cardiac contractility… ↑ CO
3. Ventricular hypertrophy … cardiac contractility… ↑ CO
2. Starling’s Law/…
Ventricular dilation: ↑ CO
44. Decreased renal blood flow…. Decreased renal blood flow…increasing Na & H20 retention…increasing Na & H20 retention…increases blood volume, ↑ HR & CO.increases blood volume, ↑ HR & CO.
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Compensatory Mechanisms in Heart Failure
• Mechanisms designed for acute loss in cardiac output
• Chronic activation of these mechanisms worsens heart failure
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PATHOPHYSIOLOGY:
• STARLING’S LAW“Within limits, the force of ventricular contraction is a function of the end-diastolic length of the cardiac muscle, which in turn is closely related to the ventricular end-diastolic volume.”
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CARDIAC FAILURE VENOUS PRESSURE
CARDIAC OUTPUT
BLOOD PRESSURE
SYMPATHETIC ACTIVITY
RENAL BLOOD FLOW
RENIN ANGIOTENSIN II
ALDOSTERONE
SODIUM RETENTION CAPILLARY FILTRATION
EDEMA
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NEUROHUMORAL ACTIVATION DURING MYOCARDIAL FAILURE
MYOCARDIAL FAILURE
CARDIAC OUTPUT
BLOOD PRESSURE/TISSUE PERFUSION
ACTIVATION OF ADRENERGIC SYSTEM
ARTERIOLAR CONSTRICTION
INCREASED SYSTEMIC VASCULAR RESISTANCE
INCREASED RESISTANCE TO EJECTION
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Pathophysiology of Cardiac Performance
Factor Mechanism Therapeutic Strategy
1. PRELOAD (work or stress the heart faces at the end of diastole)
increased blood volume and increased venous tone--->atrial filling pressure
-salt restriction-diuretic therapy-venodilator drugs
2. AFTERLOAD (resistance against which the heart must pump)
increased sympathetic stimulation & activation of renin-angiotensin system ---> vascular resistance ---> increased BP
- arteriolar vasodilators-decreased angiotensin II(ACE inhibitors)
3. CONTRACTILITY decreased myocardial contractility ---> decreased CO
-inotropic drugs (cardiac glycosides)
4. HEART RATE decreased contractility and decreased stroke volume ---> increased HR (via activation of adrenoceptors)
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EFFECTS:
• DOWN-REGULATORY CHANGES IN THE β1-ADRENOCEPTOR-G PROTEIN EFFECTOR SYSTEM
• BETA 2 RECEPTORS ARE NOT DOWN REGULATED – COUPLING WITH IP3-DAG CASCADE
• BETA 3 RECEPTORS ARE NOT DOWN REGULATED – MEDIATE NEGATIVE INOTROPHIC EFFECTS
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• EXCESSIVE BETA ACTIVATION:– LEAKAGE OF CALCIUM FROM THE SR
VIA RyR2 CHANNELS – VENTRICULAR STIFFENING & ARRYHTHMIAS
• INCREASED ANGIOTENSIN II PRODUCTION LEADS – INCREASED ALDOSTERONE SECRETION – INCREASED AFTERLOAD– REMODELLING
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INTRINSIC COMPENSATORY RESPONSE:
• MYOCARDIAL HYPERTROPHY– Increase in muscle mass to help maintain cardiac
performance– Ischemic changes, impairment of diastolic filling,
alterations in ventricular geometry
• REMODELLING– Dilatation & other slow structural changes that occur in
the stressed myocardium– Proliferation of connective tissue cells & myocardial
cells– Accelerated apoptosis
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Causes of Heart Failure
Acute/Chronic ♥ Problems
• HTN -#1
• CAD
• MI
• Valvular ♥ Disease
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CAUSES OF HEART FAILURE:
• Final common pathway of many kinds of heart diseases– Ischemic, alcoholic, restrictive, hypertrophic
– Optimal treatment requires identification of primary & secondary factors leading to CHF
– HELPFUL RESULT of dilatation: increases cardiac output
– HARMFUL RESULT of dilation: more wall tension, more oxygen is needed to produce any given stroke volume
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CLASSIFICATION:
• SYSTOLIC DYSFUNCTION:– Inadequate force is generated to eject blood
normally – Reduce cardiac output, ejection fraction
(< 45%)– Typical of acute heart failure– Secondary to AMI– Responsive to inotropics
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CLASSIFICATION:
• DIASTOLIC DYSFUNCTION– Inadequate relaxation to permit normal
filling – Hypertrophy and stiffening of myocardium– Cardiac output may be reduced – Ejection fraction may be normal– Do not respond optimally to inotropic agents
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CLASSIFICATION:
• HIGH OUTPUT FAILURE– Increase demand of the body with insufficient
cardiac output– Hyperthyroidism, beri-beri, anemia, AV shunts– Treatment is correction of underlying cause
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CLASSIFICATION:
• ACUTE HEART FAILURE– Sudden development of a large myocardial
infarction or rupture of a cardiac valve in a patient who previously was entirely well, usually predominant systolic dysfunction
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CLASSIFICATION:
• CHRONIC HEART FAILURE– Typically observed in patients with dilated
cardiomyopathy or multivalvular heart diseases that develops or progresses slowly
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PRECIPITATING CAUSES OF HEART FAILURE:• Infection• Anemia• Thyrotoxicosis & pregnancy• Arrythmias• Rheumatic, viral & other forms of myocarditis• Infective endocarditis• Systemic hypertension• Myocardial infarction• Physical, dietary, fluid, environmental & emotional
excesses• Pulmonary embolism
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CLINICAL MANIFESTATIONS:
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LEFT HEART FAILURE
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Pulmonary EdemaThe most severe manifestation of The most severe manifestation of Left Heart Failure Left Heart Failure
Fluid leak into the pulmonary Fluid leak into the pulmonary interstitial spaces (Pulmonary interstitial spaces (Pulmonary congestion/edema)congestion/edema)
Hypoxia and poor 02 exchangeHypoxia and poor 02 exchange
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PULMONARY CONGESTION & RESPIRATORY SYMPTOMS:
• Result of dilatation & increasing left ventricular end diastolic pressure, left atrial pressure & capillary pressures– Results to pulmonary vascular congestion &
symptoms associated with cough with blood tinged sputum
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Clinical picture…Left Heart Failure• Dyspnea/Dyspnea on
exertion (most sensitive: absence indicates Tx effective)
• Cough orthopnea• Paroxysmal nocturnal
dyspnea (PND)• Productive cough with pink
frothy sputum• Tachypnea • Pale, possible cyanotic• Clammy and cold skin• Crackles/Wheezes• Extra heart sounds – S3, S4• Heart murmur
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Cont.
• EDEMA OF THE BRONCHIAL MUCOSA– Increases resistance to airflow producing
respiratory distress similar to asthma (cardiac asthma)
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Cont:
• DYSPNEA– Results from reflexes initiated by vascular
distention– Increased rigidity of lungs & impaired gas
exchange resulting from interstitial edema– Accumulation of fluid in ALVEOLARS
SACS (pulmonary edema)
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Cont.
TACHYCARDIAAn early compensatory response mediated by
increased sympathetic tone
EDEMA compensatory response mediated by the renin
angiotensin aldosterone system & by increased sympathetic outflow
CARDIOMEGALYa compensatory structural response
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Right Heart Failure
• Clinical picture…(Congestion)– JVD,
hepatomegaly and dependent edema (LEs, thighs, abdomen-ascites)
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Heart Failure Clinical manifestations : Pulmonary Congestion (L)
and Systemic Congestion (R)
Right Heart Failure Left Heart Failure
Pulmonary fluid overloadPeripheral fluid overload
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PHYSICAL EXAM:
• Jugular venous distention
• S3• Rales• Pleural effusion• Edema• Hepatomegaly• Ascites
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Review: Subjective Data
Pt. may c/o• anxiety• DOE• PND• orthopnea• productive cough
with pink frothy sputum
• Fatigue and weakness
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Review: Objective DataPA may reveal:
Left heart Failure• Tachypnea/SOB• Use of accessory
muscles• Wheezes/Crackles• skin
– Clammy/cold– pale/cyanotic
Right Heart Failure• peripheral edema• JVD• Ascites, enlarged
spleen/liver
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FRAMINGHAM CRITERIA FOR DIAGNOSIS OF CHF:
• MAJOR CRITERIA– PND– NECK VEIN
ENGORGEMENT– RALES– CARDIOMEGALY– ACUTE PULMONARY
EDEMA– S3 GALLOP VENOUS PRESSURE
(>16 cmH2O)– (+) HEPATOJUGULAR
REFLUX
• MINOR CRITERIA– EXTREMITY EDEMA– NIGHT COUGH– DYSPNEA ON
EXERTION– HEPATOMEGALY– PLEURAL EFFUSION– VITAL CAPACITY
REDUCED BY 1/3 – TACHYCARDIA
• ONE MAJOR + 2 MINOR
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NEW YORK HEART ASSOCIATION
FUNCTIONAL CLASSSIFICATION:
• CLASS I : no limitations on ordinary physical activities and symptoms that occur only with greater than ordinary exercise
• CLASS II: slight limitation of ordinary activities, which result in fatigue & palpitations with ordinary physical activity
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• CLASS III: results in no symptoms at rest, but fatigue with less than ordinary physical activity
• CLASS IV: associated with symptoms even when the patient is at rest
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“All the signs of CHF are the consequences of inadequate force of contraction"
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Potential Therapeutic Targets in Heart Failure
• Preload
• Afterload
• Contractility
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CLINICAL MANAGEMENT OF CONGESTIVE HEART FAILURE
• OBJECTIVES:Increase cardiac contractilityDecrease preload ( left ventricular
pressure)Decrease afterload (systemic vascular
resistance)Normalize heart rate and rhythm
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Approaches:Reduce workload of heart1.Limit activity level reduce weight control hypertension
2. Restrict sodium (low salt diet)
3. Give diuretics (removal of retained salt and water)
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• 4. Give angiotensin-converting enzyme inhibitors(decreases afterload and retained salt and water)
5. Give digitalis (positive inotropic effect on depressed heart)
6. Give vasodilators (decreases preload & afterload)
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DRUGS COMMONLY USED IN HEART FAILURE
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Positive Inotropic Agents
• Cardiac Glycosides
• Phosphodiesterase inhibitors
• -adrenoceptor agonists and dopamine receptor agonists
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Cardiac Glycosides
• digoxin • digitoxin • deslanoside • ouabain
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DIGITALIS
• Derived from foxglove plant Digitalis lanata
• Prototype – DIGOXIN
• Steroid nucleus linked to a lactone ring at the 17 position and series of sugars at carbon 3 of the nucleus
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BASIC PHARMACOLOGY OF DRUGS USED IN CONGESIVE HEART
FAILURE:DIGITALIS
PHARMACOKINETICS:
DIGOXINDIGITOXIN
LIPID SOLUBILITY MEDIUM HIGH ORAL AVAILABILITY 75% >90% HALF-LIFE 40 HRS 168 HRS PLASMA PROTEIN BINDING 20-40 HRS >90 HRS PERCENTAGE METABOLIZED <20 >80 VOLUME OF DISTRIBUTION 6.3 L/KG 0.6 L/KG
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PHARMACOKINETICS:
• T1/2 = (40 hrs)• Therapeutic plasma concentration:
– 0.5-2 ng/ml
• Toxic plasma concentration: >2 ng/ml• *digitalis must be present in the body in certain
"saturating" amount before any effect on congestive failure is noted
• this is achieved by giving a large initial dose in a process called "digitalization"
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after intial dosages, digitalis is given in "maintenance" amounts sufficient to replace that which is excreted to avoid exceeding therapeutic range during digitalization:
- the loading dose should be adjusted according to the health of the patient
- slow digitalization (over 1 week) is the safest techniqueplasma digoxin levels should be monitored
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METABOLISM & EXCRETION:• Digoxin – not extensively metabolized,
2/3 excreted unchanged in the kidneys
• Digitoxin – metabolized in the liver and excreted into the gut via the bile
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PROPERTIES OF CARDIAC GLYCOSIDES:
OUABAIN DIGOXIN DIGITOXIN
Lipid solubility (oil/water coefficient)
Low Medium High
Oral availability (% absorbed)
0 75 > 90
Half-life in the body (hrs)
21 40 168
Plasma protein binding (% bound)
0 <20 >80
Volume of distribution
18 6.3 0.6
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MECHANICAL EFFECTS:
• Inhibit the monovalent cation transport enzyme coupled Na+- K+ ATPase & increased intracellular Na+ content increases intracellular Ca2+ through a Na+ - Ca2+ exchange carrier mechanism
• Increases myocardial uptake of Ca2+ augments Ca2+ release to the myofilaments during excitation invokes a positive inotropic response
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Mechanism of Digitalis Action: Molecular
• Inhibition of Na/K ATPase
• blunting of Ca2+ extrusion
• Ca2+i
• sarcomere shortening
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ELECTRICAL EFFECTS:
• Produces alterations in the electrical properties of both contractile cells and the specialized automatic cells increased automaticity & ectopic impulse activity
• Prolongs the effective refractory period of the AV node slow ventricular rate in atrial flutter & fibrillation
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Direct Electrophysiological Effects:Cellular Action Potential
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Afterdepolarizations
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TISSUE OR VARIABLE
EFFECTS AT THERAPEUTIC DOSAGE
EFFECTS AT TOXIC DOSAGE
Sinus node rate rate
Atrial muscle Refractory period Refractory period, arrhythmias
Atrioventricular node Conduction velocity, refractory period
Refractory period, arrhythmias
Purkinje system, ventricular muscle
Slight refractory period
Extrasystoles, tachycardia, fibrillation
Electrocardiogram PR interval, QT interval
Tachycardia, fibrillation, arrest at extremely high dosage
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EFFECTS IN HEART FAILURE:• Stimulates myocardial contractility• Improves ventricular emptying• Increase cardiac output• Augments ejection fraction• Promotes diuresis• Reduces elevated diastolic pressure & volume &
end –systolic volume• Reduces symptoms resulting from pulmonary
vascular congestion & elevated systemic venous pressure
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Summary Direct Electrophysiological Effects
• Less negative membrane potential: decreased conduction velocity
• Decreased action potential duration: decreased refractory period in ventricles
• Enhanced automaticity due to– Steeper phase 4– Afterdepolarizations
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Parasympathomimetic Effects
• Decreased conduction velocity in the AV node
• increased effective refractory period in the AV
• Heart block (toxic concentrations)
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EKG Effects of Digitalis
• decrease in R-T interval
• inversion of T wave • Uncoupled P waves
(Toxic concentrations) • Bigeminy (toxic
concentrations)
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Therapeutic Uses of Digitalis
• Congestive Heart Failure
• Atrial fibrillation
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Overall Benefit of Digitalis to Myocardial Function
• cardiac output
• cardiac efficiency
• heart rate
• cardiac size
NO survival benefit
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Other Beneficial Effects
• Restoration of baroreceptor sensitivity
• Reduction in sympathetic activity
• increased renal perfusion, with edema formation
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Adverse Effects
• Cardiac – AV block – Bradycardia – Ventricular extrasystole – Arrhythmias
• CNS
• GI
Therapeutic index is ~ 2!
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INTERACTIONS:
• POTASSIUM– HYPERKALEMIA: reduces enzyme inhibiting actions
of digitalis, abnormal cardiac automaticity is inhibited– HYPOKALEMIA: facilitates enzyme inhibiting actions
• CALCIUM – Facilitates the toxic actions digitalis by accelerating the
overloading of intracellular calcium stores that appears to be responsible for abnormal automaticity
– HYPERCALCEMIA: increases the risk of digitalis induced arryhythmia
• MAGNESIUM– Opposite to those of calcium
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Serum Electrolytes Affect Toxicity
• K+
– Digitalis competes for K binding at Na/K ATPase
– Hypokalemia: increase toxicity
– Hyperkalemia: decrease toxicity
• Mg2+
– Hypomagnesemia: increases toxicity
• Ca2+
– Hypercalcemia: increases toxicity
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DIGITALIS INTOXICATION:
• Serious & potentially fatal complication• Anorexia, nausea & vomiting = earliest signs of
digitalis intoxication• Arrythmias: ventricular premature beats,
bigeminy, ventricular & atrial tachycardia w/ variable AV block
• Chronic digitalis intoxication = exacerbations of heart failure, weight loss, cachexia, neuralgias, gynecomastia, yellow vision, delirium
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TREATMENT OF DIGITALIS INTOXICATION:
Tachyarrythmias: withdrawal of the drug, treatment with beta blocker or lidocaine
Hypokalemia: potassium administration by the oral route
Digitoxin Ab (Fab fragments)
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Treatment of Digitalis Toxicity
• reduce dose: 1st degree heart block, ectopic beats• Atropine: advanced heart block• KCl: increased automaticity• Antiarrythmics: ventricular arrhythmias• Fab antibodies: toxic serum concentration; acute
toxicity
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PHOSPHODIESTERASE INHIBITORS
• BIPYRIDINES– Inamrinone & Milrinone– Levosimendan– Parenteral forms only– Half-life: 2-3 hrs– 10-40% excreted in the urine– MOA: increase inward calcium influx in the heart
during action potential & inhibits phosphodiesterase– ADVERSE EFFECTS: nausea, vomiting,
thrombocytopenia, liver enzyme changes
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Phosphodiesterase Inhibitors: Therapeutic Use
• short term support in advanced cardiac failure
• long term use not possible
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Adverse Effects of Phosphodiesterase Inhibitors
• Cardiac arrhythmias
• GI: Nausea and vomiting
• Sudden death
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-Adrenoceptor and Dopamine Receptor Agonists
• Dobutamine • Dopamine
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BETA ADRENOCEPTOR STIMULANTS:• DOBUTAMINE
– Increases cardiac output – Decrease in ventricular filling pressure– Given parenterally– CONTRAINDICATIONS: pheochromocytoma,
tachyarrythmias– ADVERSE EFFECTS: precipitation or exacerbation
of arrythmia
• DOPAMINE– Raise blood pressure
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Mechanism of Action: Dobutamine
• Stimulation of cardiac adrenoceptors: inotropy > chronotropy
• peripheral vasodilatation
• myocardial oxygen demand
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Mechanism of Action: Dopamine
• Stimulation of peripheral postjunctional D1 and prejunctional D2 receptors
• Splanchnic and renal vasodilatation
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Therapeutic Use
• Dobutamine: management of acute failure only
• Dopamine: restore renal blood in acute failure
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Adverse Effects
• Dobutamine – Tolerance – Tachycardia
• Dopamine – tachycardia – arrhythmias – peripheral vasoconstriction
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DRUGS WITHOUT POSITIVE INOTROPIC EFFECTS USED IN HEART FAILURE:
• DIURETICS– Reduce salt & water retention reduce
ventricular preload– Reduction in venous pressure reduction of
edema & its symptoms, reduction of cardiac size improved efficiency of pump function
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Diuretics: Mechanism of Action in Heart Failure
• Preload reduction: reduction of excess plasma volume and edema fluid
• Afterload reduction: lowered blood pressure
• Reduction of facilitation of sympathetic nervous system
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ACE Inhibitors in Heart Failure
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ANGIOTENSIN-CONVERTING ENZYME INHIBITORS:• Reduce peripheral resistance reduce
afterload• Reduce salt & water retention ( by reducing
aldosterone secretion) reduce preload• Reduce the long term remodelling of the
heart vessels ( maybe responsible for the observed reduction in the mortality & morbidity)
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Mechanism of Action
• Afterload reduction
• Preload reduction
• Reduction of facilitation of sympathetic nervous system
• Reduction of cardiac hypertrophy
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ACE Inhibitors: Therapeutic Uses
• Drugs of choice in heart failure (with diuretics)
• Current investigational use: Acute myocardial infarction
• ATII antagonists
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VASODILATORS
– Reduce the preload (through venodilatation), or reduction in afterload (through arteriolar dilatation) or both
– Decrease the load of the myocardium
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VASODILATORS:
• HYDRALAZINE, ISDN
– Reduction in preload through venodilatation
– Reduction in afterload through arteriolar dilation
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VASODILATORS
• NESIRITIDE– Brain natriuretic peptide (BNP)– Approved for acute heart failure– Increases cGMP in smooth muscle cells &
reduces venous & arteriolar tone – Causes diuresis– T ½ = 18 minutes– Intrvenous dose
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VASODILATORS
• BOSENTAN– Competitive inhibitor of endothelin– Oral– Approved for use in pulmonary hypertension– Teratogenic & hepatotoxic effects
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-Blockers in Heart Failure: Mechanism of Action
• Standard -blockers: – Reduction in damaging sympathetic influences
in the heart (tachycardia, arrhythmias, remodeling)
– inhibition of renin release
• Carvedilol: – Beta blockade effects– peripheral vasodilatation via 1-adrenoceptor
blockade (carvedilol)
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BETA-ADRENOCEPTOR BLOCKERS:
• BISOPROLOL, CARVEDILOL, METOPROLOL– Reduction in mortality in patients with stable
Class II & Class III heart failure– Attenuation of the adverse effects of
cathecolamines (apoptosis)– Up regulation of Beta receptors– Decreased HR, & remodelling
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DIURETICS
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Principles important for understanding effects of diuretics
• Interference with Na+ reabsorption at one nephron site interferes with other renal functions linked to it
• It also leads to increased Na+ reabsorption at other sites
• Increased flow and Na+ delivery to distal nephron stimulates K + (and H +) secretion
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• Diuretics act only if Na+ reaches their site of action. The magnitude of the diuretic effect depends on the amount of Na+ reaching that site
• Diuretic actions at different nephron sites can produce synergism
• All, except spironolactone, act from the lumenal side of the tubular cellular membrane
Principles important for understanding effects of diuretics
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From Knauf & Mutschler Klin. Wochenschr. 1991 69:239-250
70%
20%
5%
4.5%
0.5%Volume 1.5 L/dayUrine Na 100 mEq/LNa Excretion 155 mEq/day
100%GFR 180 L/day Plasma Na 145 mEq/LFiltered Load 26,100 mEq/day
CA InhibitorsProximal tubule
Loop DiureticsLoop of Henle
ThiazidesDistal tubule
Antikaliuretics
Collecting duct
Thick Ascending Limb
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RENAL TRANSPORT MECHANISM:
• PROXIMAL CONVOLUTED TUBULE:
– Carries out isosmotic reabsorption of amino acids, glucose and cations
– Bicarbonate reabsorption
– 40-50% Na reabsorption
– Via specific transport systems:• NaHCO3 – Na/H exchanger (NHE3)
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LOOP OF HENLE:
• Pumps Na, K & Cl out of the lumen into the interstitium
• Provides the concentration gradient for the countercurrent concentrating mechanism
• Diluting segment – thick ascending limb of the loop of henle
• Ca & Mg reabsorption
• Na/K/2Cl cotransporter (NKCC2)
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DISTAL CONVOLUTED TUBULE:
• Actively pumps Na & Cl out of the lumen nephron
• 10 % Na reabsorbed
• Impermeable to water
• Ca & Mg reabsorption
• Na/Ca exchanger (NCC)
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COLLECTING TUBULE:• Final site of NaCl reabsorption• Tight regulation of body fluid volume• Determines the final Na concentration of the urine• Influenced by mineralocorticoids• Important site of K secretion by the kidney• Principal cells are the major sites of Na, K and H20
transport• Intercalated cells are the primary sites of H secretion• Do not contain cotransport system for Na
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• Reabsorption of Na via the epithelial Na channel (ENaC) and its coupled K secretion is regulated by aldosterone
• ADH/AVP controls the permeability of the segment to water
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DIURETICS
• Drugs that increase the rate of urine flow
• Increase the rate of Na & Cl excretion
• Decrease reabsorption of K, Ca & Mg
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DIURETICS
CLASSIFICATION:1. CARBONIC ANHYDRASE
INHIBITORS
2. OSMOTIC DIURETICS
3. LOOP DIURETICS
4. THIAZIDE DIURETICS
5. POTASSIUM SPARING DIURETICS
SITE OF ACTION: Proximal tubule
Proimal tubule, Loop of Henle, Collecting tubule
Ascending limb of the loop of Henle
Distal convoluted tubule
Collecting tubule
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CARBONIC ANHYDRASE INHIBITORS:
• CLASSIFICATION & PROTOTYPES: ACETAZOLAMIDE (Diamox) – a sulfonamide derivative
• MECHANISM OF ACTION:– Inhibit carbonic anhydrase w/c slows the ff. rxn:
H + HCO3 H2O + CO2
– Inhibit the dehydration of H2C03Drug effect occurs throughout the bodyBlock NaHCO3 reabsorptionHCO3 diuresis
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PHARMACOKINETICS:
• Well absorbed after oral administration
• Onset of action: 30 minutes
• Duration: 12 hrs
• Excretion: proximal tubule
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PHARMACODYNAMICS:
• Depresses the HC03 reabsorption in the PCT
• Significant HC03 losses – hyperchloremic metabolic acidosis
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CLINICAL USES:
• Treatment of glaucoma – major application
• Urinary alkalinization
• Epilepsy
• Acute mountain sickness
• Correction of metabolic alkalosis
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TOXICITY:
• Hyperchloremic metabolic acidosis
• Renal stones
• Renal potassium wasting
• Drowsiness & paresthesias – large doses
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CONTRAINDICATIONS:
• HYPERAMMONEMIA– Decrease urinary excretion of NH4 due to
alkalinization of the urine
• HEPATIC ENCEPHALOPATHY
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LOOP DIURETICS
CLASSIFICATION & PROTOTYPES: Furosemide – prototype & sulfonamide derivative
Bumetanide- sulfonamide
Ethacrynic Acid – phenoxyacetic acid
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PHARMACOKINETICS:
• Rapidly absorbed
• Diuretic response is extremely rapid following IV injection
• Duration of effect: 2-3 hrs
• Half life: dependent on renal function
• Excreted in the kidney
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PHARMACOKINETICS:
TORSEMIDE• Absorption: 1 hr• Duration: 4-6 hrs
FUROSEMIDE• Absorption: 2-3 hrs• Duration: 2-3 hrs
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MECHANISM OF ACTION:
• Inhibits the coupled Na+/K+/2Cl transport system (NKCC2) in the luminal membrane of the thick ascending limb of the loop of henle reduce NaCl reabsorption
• Increases Mg & Ca+ excretion• Induces synthesis of renal prostaglandins• Increases renal blood flow• Reduces pulmonary congestion & left
ventricular filling pressures
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CLINICAL USES:
• Treatment of edematous states (CHF & ascites)• Acute pulmonary edema in w/c a separate pulmonary
vasodilating action may play a useful additive role• Sometimes used in hypertension if response to
thiazide is inadequate but their short duration of action is a disadvantage
• Treatment of severe hypercalcemia induced by a carcinoma – less common
• Acute renal failure• Hyperkalemia
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TOXICITY:
• Hypokalemic metabolic alkalosis
• Hyperuricemia
• Hypovolemia & cardiovascular complications
• Ototoxicity – important toxic effect of the loop agents
• hypomagnesemia
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THIAZIDE DIURETICS
• CLASSIFICATION & PROTOTYPE:– HYDROCHLOROTHIAZIDE – sulfonamide derivative
– INDAPAMIDE – new thiazide like agent with a significant vasodilating effect than Na diuretic effect
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MECHANISM OF ACTION:
• Inhibit NaCl transporter (NCC) in the early segment of the distal convoluted tubule
REDUCE THE DILUTING CAPACITY OF THE NEPHRON
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EFFECTS:
• Urinary excretion– Full doses – produce a moderate Na & Cl diuresis
hypokalemic metabolic alkalosis– Reduced the blood pressure by reduction of the
blood volume but with continued use these agents appear to reduce vascular resistance
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CLINICAL USE:
• Hypertension – major application, for w/c their long duration of action & moderate intensity of action are useful
• Chronic therapy for edematous conditions (CHF) another common application
• Recurrent renal calcium stone formation can sometimes be controlled with thiazides
• Nephrogenic diabetes insipidus
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TOXICITY:
• Hypokalemic metabolic alkalosis & hyperuricemia
• Chronic therapy is often associated with potassium wasting
• Hyperlipidemia
• Hyponatremia
• Allergic reactions
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CONRAINDICATIONS:
• HEPATIC CIRRHOSIS
• BORDERLINE RENAL FAILURE
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POTASSIUM SPARING DIURETICS:
• CLASSIFICATION & PROTOTYPESo SPIRINOLACTONE, EPLERENONE–
antagonist of aldosterone in the collecting tubules
• Has a slow onset & offset of action (24-72 hrs)
o TRIAMTERENE & AMILORIDE – inhibitors of Na flux in the collecting tubule
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CLINICAL USE:
• Hyperaldosteronism – important indication
• Potassium wasting caused by chronic therapy with loop diuretic or thiazide if not controlled by dietary K supplements
• Most common use is in the form of products that combine a thiazide with a K sparing agent
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ADVERSE EFFECTS:
• Decrease K & H ion excretion and may cause hyperchloremic metabolic acidosis
• Interfere with steroid biosynthesis
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TOXICITY:
• Hyperkalemia – most important toxic effect
• Metabolic acidosis in cirrhotic patients
• Gynecomastia & antiandrogenic effects
• Hyperchloremic metabolic acidosis
• Acute renal failure
• Kidney stones - triamterene
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CONTRAINDICATIONS:
• Oral K administration
• Concomittant use of other agents that blunt the RAS (Beta blockers, ACE inhibitors) – HYPERKALEMIA
• Liver disease
• CYP3A4 inhibitors (ketoconazole, itraconazole) – increase blood levels of EPLERENONE
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OSMOTIC DIURETICS
• CLASSIFICATION & PROTOTYPE:– MANNITOL – prototype osmotic diuretic given
intravenously
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MECHANISM OF ACTION:
• Holds water in the lumen by virtue of its osmotic effect
• Major location for this action is the proximal convoluted tubule, where the bulk of isosmotic reabsorption takes place
• Reabsorption of H2O is also reduced in the descending limb of the loop of henle & the collecting tubule
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EFFECTS:
• Volume or urine is increased
• Most filtered solutes will be excreted in larger amounts unless they are actively reabsorbed
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CLINICAL USES:
• Maintain high urine flow (when renal blood flow is reduced & in conditions of solute overload from severe hemolysis or rhabdomyolysis)
• Useful in reducing intraocular pressure in acute glaucoma & increase intracranial pressure in neurologic conditions
• Removal of renal toxins
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ANTIDIURETIC HORMONE AGONISTS
• VASOPRESSIN
• DESMOPRESSIN
• Treatment of central diabetes insipidus
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TOXICITY:
• Nephrogenic Diabetes Insipidus
• Renal failure
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ANTIDIURETIC HORMONE ANTAGONISTS
• CONIVAPTAN – Receptor antagonist
• LITHIUM
• DEMECLOCYLINE
• Oral administration
• T ½ = 5-10 hrs
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PHARMACODYNAMICS
• Inhibits the effects of ADH in the collecting tubule
• Conivaptan – pharmacologic antagonist at V1a & V2 receptors
• Lithium & Demeclocyline – reduce the formation of cAMP in response to ADH, interfere with the actions of cAMP in the collecting tubule cells
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CLINICAL INDICATIONS:
• Syndrome of Inappropriate ADH Secretion (SIADH)– When water restriction is not effective
• Other elevations of ADH
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TOXICITY:
• Extracellular volume expansion
• Dehydration
• Hyperkalemia
• Hypernatremia
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Asymptomatic LV Dysfunction
Mild to moderate CHF
Moderate to severe CHF
ACE inhibitor Digoxin Digoxin
Beta blocker Diuretics Diuretics
ACE inhibitor ACE inhibitor
Beta blocker Beta blocker
Spironolactone
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POST TEST1. Site of action of loop diuretics:
A. loop of henle B. distal convoluted tubule2. Site of action of thiazide diuretics:
A. Loop of henle B. distal convoluted tubule3. Site of action of K sparing diuretics:
A. Collecting tubule B. loop of henle4. Toxic level of digitalis:
A. .2 ng/ml B. 2.0 ng/ml5. Prevents early remodelling of the heart:
A. ACE inhibitors B. diuretics6. A vasodilator:
A. Nitrates B. furosemide7. Decreases intracranial pressure:
A. Digitalis B. Mannitol8. Decreases intraocular pressure:
A. acetazolamide B. furosemide9. Potent vasoconstrictor:
A. bradykinin B. angiotensin II10. Early compensatory response of the heart to a decrease cardiac output:
A. tacchycardia B. cardiomegaly