Transcript 1-Diuretics

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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1-Introduction :
-Definition.
Outline :
-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.
Types of heart failure :
According to function:
1-Systolic HF.
2-Diastolic HF.
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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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ABC of heart failure
Pathophysiology
G Jackson, C R Gibbs, M K Davies, G Y H
Lip
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Pathophysiology:
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.
-ECHO.)EF<40).
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Hunt SA et al. J Am
coff
2001:83:2101.13.
Hunt
SA etcardiot
al.j AM coff
cardio 2001:38:2101-13
Farrell MH et al .JAMA 2002:287:890-7
Farrett MH et al.JAMA.2002:287:890-7.
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:
2-Pharmacological:
1-Nonpharmacological .
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1-Diuretics.
2-ACEI or ARBS.
3-Beta blockers.
4-Aldosterone antagonist.
5-Digoxin.
6-Vasodilators.
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
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
Contraindications of thiazide diuretics :
- 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.
Contraindications:
-Pregnancy.
-Hypotension.
-Bilateral renal stenosis.
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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) is < 30 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 :
Groups :
Diuretic
ACEI
&ARBS
Aldosterone Digoxin.
antagonist
BB
Hydralazin
e &ISDN
.
Symptoms:
+
+
+
+
+
+
Mortality:
_
+
+
+
_
+
Hospitalization:
-
+
+
+
+
+
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Yancy, CW et al.
2013 ACCF/AHA
Heart Failure Guideline
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Summary :
References :
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Pharm.D candidate :
Fatimah Al-Shehri.
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