Congestive Cardiac Failure.pptx pharmacothrapeutics

Congestive Cardiac Failure

1. CONGESTIVE CARDIAC FAILURE [CCF] Dr. SARITA SHARMA Associate Professor Department of Pharmacology MMCP (MMDU)

2. CCF is a chronic condition in which the heart doesn't pump blood as it should do normally. Heart failure can occur if the heart cannot pump (systolic) or fill (diastolic) adequately. Chronic heart failure results from a deficiency in heart’s pumping function, in which the delivery of blood, oxygen, and nutrients becomes inadequate for fulfilling the tissues needs. Heart failure is a common condition that affects the quality of life, causing fatigue, breathlessness, and oedema. Blood and fluids collect in lungs and legs. Heart failure has poor prognosis. It is a maladaptive condition that deals with hemodynamic and neurohormonal disturbances.

3. In heart failure, the heart may not provide tissues with adequate blood for metabolic needs; elevation of pulmonary or systemic venous pressures may result in organ congestion. This condition is due to abnormalities of systolic or diastolic function or, commonly, both. Although a primary abnormality is changes in the cardiomyocyte function, secondarily changes in the collagen turnover of the extracellular matrix. Cardiac structural defects (congenital defect, valvular disorder), rhythm abnormalities (persistently high heart rate), and high metabolic demands (due to thyrotoxicosis) also can cause HF.

4. Systolic heart failure Diastolic heart failure Coronary artery disease Diabetes mellitus Arterial hypertension Arterial hypertension Valvular heart disease (Volume load) Valvular heart disease (pressure load) Arrhythmia Hypertrophic cardiomyopathy Inflammatory diseases Restrictive cardiomyopathy Idiopathic cardiomyopathy Constrictive pericarditis Toxic cardiomyopathy (alcohol) Amyloidosis (storage disease) C linical situations for systolic and diastolic heart failure

5. Symptoms for congestive heart failure include: Shortness of breath. Waking up at night due to dyspnea. Chest pain. Heart palpitations. Fatigue (feeling of tiredness). Swelling in ankles, legs and abdomen. Weight gain. Need to urinate while resting at night. A dry, hacking cough. A full (bloated) or hard stomach. Loss of appetite or upset stomach (nausea).

6. Risk factors for congestive heart failure include: Being older than 65 . Using tobacco products, cocaine or alcohol. Having an inactive (sedentary) lifestyle. Eating foods that have a lot of salt and fat. High blood pressure. Coronary artery disease. Heart attack. Family history of congestive heart failure.

7. Causes for congestive heart failure include: Left-sided heart failure is the most common cause of right-sided heart failure. When left ventricle isn’t working correctly, it allows blood to back up. At some point, this backup affects right ventricle. Cardiomyopathy (genetic or viral). Heart issues present at birth (congenital heart disease). Diabetes. Arrhythmia. Kidney disease. A body mass index (BMI) higher than 30 . Tobacco and recreational drug use. Medications such as cancer drugs (chemotherapy).

8. Pathophysiology: Heart Failure (HF) is a syndrome of ventricular dysfunction. Left Ventricular (LV) failure causes shortness of breath and fatigue; while Right Ventricular (RV) failure causes peripheral and abdominal fluid accumulation. Cardiac contractility, ventricular performance, and myocardial oxygen requirements are determined by Preload Afterload Substrate availability (eg, oxygen, fatty acids, glucose) Heart rate and rhythm Amount of viable myocardium

9. A decrease in cardiac output stimulates neuroendocrine system with the releasing of epinephrine, norepinephrine, endothelin -1 vasopressin. They cause vasoconstriction & increase afterload. A decrease in cardiac output also stimulates renin-angiotensin-aldosterone system (RAAS), leading to increased salt and water retention; with increased vasoconstriction. This further fuels the maladaptive mechanisms in heart cause progressive heart failure. In HFpEF ( Heart Failure with Preserved Ejection Fraction ), due to an increase in ventricular afterload; there is a decrease in myocardial relaxation and an increase in the stiffness of the ventricle and leads to progressive heart failure.

10. Diagnosis: Serum sodium levels have played a role in the prediction of short-term mortality for patients with decompensated heart failure. Chest radiographs are used to assess the degree of pulmonary congestion and to determine the presence of cardiomegaly. Echocardiography is the most commonly used test for diagnosis of HF. It assess systolic, diastolic dysfunction & elucidate presence of heart muscle motion abnormalities; valvular pathology. Computed tomography (CT); magnetic resonance imaging (MRI) in patients with HF are used principally for the diagnosis of congenital cardiac abnormalities. Cardiac MRI is also the gold standard test for evaluating right ventricular (RV) function.

11. Framingham Diagnostic Criteria: It is a commonly used diagnostic tool that requires the presence of 2 major criteria or 1 major and 2 minor criteria.  Major Criteria Acute pulmonary edema. Radiographic cardiomegaly. Hepatojugular reflex. Neck vein distention. Paroxysmal nocturnal dyspnea or orthopnea (lying position). Pulmonary rales (explosive respiratory sounds). Third heart sound (S3 Gallop, triple rhythm in diastole). Weight loss of 4.5 kg or more in 5 days in response to treatment.

12. Minor Criteria Ankle edema. Dyspnea on exertion. Hepatomegaly. Nocturnal cough. Pleural effusion. Tachycardia (heart rate greater than 120 beats per minute). Evaluation Comprehensive laboratory analysis for iron deficiency anemia, renal dysfunction, and liver dysfunction, is needed to elucidate the cause and/or severity of heart failure.

13. Angiotensin Converting Enzyme inhibitors, Beta blockers, mineralocorticoid receptor antagonists are first-line options in treating patients with systolic dysfunction. Angiotensin II receptor blockers are alternative choice in patients intolerant to ACE inhibitors or mineralocorticoid receptor antagonist therapy. Diuretics are used for symptomatic management of heart failure and are combined with other agents in the treatment of systolic dysfunction.

14. Utilization of sacubitril /valsartan should be considered under specialist advice in treating systolic dysfunction patients who have ongoing symptoms of heart failure despite optimal therapy. Ivabradine drug should be considered under specialist advice in patients suffering with systolic dysfunction who had a hospital admission for heart failure in preceding 12 months. Digoxin still have a role in improving symptoms, reducing rate of hospitalisation for heart failure patients. The combination of hydralazine and nitrate still have a place for specific patients on advice of specialist.

15. Treatment: Medicines to treat heart failure include:  Angiotensin-converting enzyme (ACE) inhibitors: These drugs relax blood vessels to lower blood pressure, improve blood flow and decrease strain on the heart. Examples include enalapril , Lisinopril, and captopril. Angiotensin II receptor blockers (ARBs): These drugs have the same benefits as ACE inhibitors and may be an option for patients who can't tolerate ACE inhibitors. Examples include losartan, valsartan, and candesartan.

16. Beta blockers:  These medicines slow the heart rate and lower blood pressure. They reduce the symptoms of heart failure and help the heart to work better. Beta blockers increase QOL and may help live longer. Examples include carvedilol, metoprolol, and bisoprolol . Diuretics: Often called as water pills, these medicines make patient for urination more frequently. This helps in preventing fluid buildup in the body. Diuretics, such as furosemide decrease fluid in the lungs, so it's easier to breathe.

17. Some diuretics also lowers potassium & magnesium. So; Health care provider may recommend supplements. It is advisable to have regular blood tests of potassium and magnesium levels. Angiotensin receptor plus neprilysin inhibitors (ARNIs): This medicine consists of two blood pressure lowering drugs to treat heart failure i.e., sacubitril -valsartan. It's used to treat some people with heart failure with reduced ejection fraction. It helps to prevent the need for hospital stay.

18. Digoxin: This drug also called digitalis, helps heart squeezing better so that it pumps blood normally. It also slowdown the heartbeat. Digoxin reduces heart failure symptoms in people with HFrEF . It is usually given to patients with a heart rhythm problem, such as atrial fibrillation. Hydralazine & isosorbide dinitrate : This drug combination helps to relax blood vessels. It may be added to treatment plan incase of severe heart failure symptoms and ACE inhibitors or beta blockers haven't been effective.

19. Sodium-glucose cotransporter- 2 (SGLT2) inhibitors:   These medicines lower the blood sugar levels. They are often prescribed with diet and exercise to treat type 2 diabetes. SGLT 2 inhibitors considered as one of the first line treatments for heart failure; because several studies showed that the medicine has lowered the risk of hospital stays and death in people with heart failure — even if patients didn't diagnosed as diabetes. Examples canagliflozin , dapagliflozin , empagliflozin .

20. Devices for heart failure: It is a procedure to implant a small device in their chest that helps to control or monitor the heart's rhythm. The most commonly used devices are: Pacemakers Cardiac resynchronisation therapy (CRT) devices Implantable cardioverter defibrillators (ICDs) Improving muscle strength: If patient was having a bad flare-up and unable to exercise, electrical stimulation may be offered to make muscles stronger. This is where electrodes are placed on skin and small electrical impulses are sent to weak muscles, usually in arms or legs.

21. Surgery: Medicines are the main treatment for heart failure, but for some people surgery is advised. Operations that are performed in heart failure include: Heart valve surgery Coronary angioplasty or bypass Left ventricular assist devices Heart transplant

22. Angioplasty or bypass: If heart failure is related to coronary heart disease, doctor may recommend a: Coronary angioplasty:  where a tiny balloon is used to stretch & to open a narrowed or blocked artery; usually a small mesh tube called a stent is put in the artery to support it. Coronary artery bypass graft (CABG):  where a blood vessel from another part of the body is used to divert blood around narrowed or clogged parts of an artery.

23. Heart transplant: A heart transplant may be necessary in severe heart failure conditions that can't be treated effectively with medication or other types of surgery. A heart transplant is a complex procedure that carries serious risks, so it's not suitable for everyone with severe heart failure. There's also a shortage of hearts for transplantation, so some people have to wait years for a suitable donor heart to become available.