Management of chf

MANAGEMENT OF CHF


MANAGEMENT OF CHF

  • Aim of treatment for compensated/chronic CHF:
    • Decreasing work of heart – By decreasing preload & afterload.
    • Decreasing mortality – By reversing cardiac remodeling.
  • Major drugs used: Vasodilators, ACE inhibitors, ARBs, beta blockers & aldosterone antagonists.

1. Vasodilators:

MOA:

  • Acts by reducing preload (venodilators), afterload (arteriolar dilators) or both (combined arteriolar & venodilators).

Important drugs:

  • Nitrates: 
    • Preferentially dilate veins (venodilator) & reduces preload.
  • Hydralazine & minoxidil:
    • Primarily arteriolar dilators (arteriolar dilators) & reduces afterload.
    • Preferred in forward failure with low cardiac index (central venous pressure).

Note:  Calcium channel blockers contraindicated in CHF – Due to reflex sympathetic activation (nifedipine) & direct cardio-depressant action (verapamil & diltiazem) –> increasing mortality.

  • ACE inhibitors, angiotensin 2 receptor blockers (ARBs), nitroprusside & alpha blockers:
    • Reduces both preload & afterload
  • ACE inhibitors & angiotensin receptor blockers (ARBs):
    • Indicated for all CHF grades unless contraindicated specifically.
    • Decreases mortality – 
      • By prevention & reversal of cardiac remodeling due to decreased aldosterone activation (final mediator for remodeling).
  • Combination of hydralazine & isosorbide dinitrate:
    • Decreases mortality.
    • Other vasodilators do not prolong survival in CHF.

2. Aldosterone antagonists:

  • Mainly potassium-sparing diuretics – Spironolactone & epleronone.
  • Reduces mortality (at doses lower than diuretic doses) – By antagonizing aldosterone effect(reversal of remodeling). Tolerance prevented by adding thiazides.

3. Beta-blockers:

  • Contra-indicated due to their negative ionotropic action – Needs careful usage.
  • Important drugs: 
    • Carvedilol (most commonly used) –>metoprolol → bisoprolol.
  • Drug effects:
    • Increases longevity of CHF patients.
    • Causes renin release stimulating RAAS & increased aldosterone.
    • Antagonizes RAAS pathway → Causing reversal of remodeling.
  • Indication: 
    • Mild to moderate heart failure (NYHA class II & III) with dilated cardiomyopathy.
  • Contraindication: 
    • Absolutely in decompensated heart failure – As it reduces cardiac contractility.
    • Started at very low doses à gradually increased for maximum benefit.

4. Ivabradine:

  • Funny current blocker used in angina pectoris.
  • European guidelines recommend for CHF patients with heart rate >70 bpm with ejection fraction < 35%, symptomatic despite treatment with beta blockers, ACE inhibitors & aldosterone antagonists.
  • Not FDA approved for this indication.
  • Decreases myocardial oxygen demand by causing bradycardia.

5. Vasopeptidase inhibitors:

  • MOA: Inhibits two enzymes, ACE & NEP.
  • Drugs included: Omapatrilat & sampatrilat.
  • Drug effects: 
    • Possess all ACE inhibitors effects.
    • Causes natriuresis – Due to increased BNP & decreased metabolism by NEP inhibition.
  • Use: Oral treatment of chronic CHF.
  • Adverse effect: Angioedema (major).

Exam Important

  • Beta blockers are contra-indicated in CHF due to their negative ionotropic action & need careful usage.
  • Beta-blockers increases longevity of CHF patients.
  • Beta-blockers are absolutely contraindicated in decompensated heart failure, as it reduces cardiac contractility.
  • Aldosterone antagonists mainly potassium-sparing diuretics like spironolactone & eplerenone are useful in CHF.
  • Aldosterone antagonists reduce mortality (at doses lower than diuretic doses) – By antagonizing aldosterone effect(reversal of remodeling). Tolerance prevented by adding thiazides.
  • ACE inhibitors, angiotensin 2 receptor blockers (ARBs), nitroprusside & alpha blockers all reduces both preload & afterload.
  • ACE inhibitors & angiotensin receptor blockers (ARBs) indicated for all CHF grades unless contraindicated specifically.
  • ACE inhibitors & angiotensin receptor blockers (ARBs) decreases mortality.
  • Combination of hydralazine & isosorbide dinitrate decreases mortality in CHF patients.
  • Nitrates preferentially dilate veins (venodilator) & reduce preload.
  • Hydralazine & minoxidil are Primarily arteriolar dilators (arteriolar dilators) & reduces afterload.
  • Aim of treatment for compensated/chronic CHF is to decreasing work of heart – By decreasing preload & afterload & decreasing mortality – By reversing cardiac remodeling.

 

Don’t Forget to Solve all the previous Year Question asked on MANAGEMENT OF CHF

Module Below Start Quiz

Leave a Reply

Free Mini Course on Stomach

Mini Course – Stomach

22 High Yield Topics in Stomach

in Just 2 Hours

Submission received, thank you!

Close Window
%d bloggers like this:
Malcare WordPress Security