HEART FALURE

• Drugs Affecting Heart and Blood Vessels


  • Alpha Blockers
  • Beta Blockers
  • Alpha/Beta blockers
  • Centrally Acting Alpha Agonists
  • ACEs
  • ARBs
  • Direct Renin Inhibitors
  • Vasodilators
  • CCB's
  • Drugs for Heart Failure
• Beta Blockers


  • Propranolol
  • Metoprolol (Lopressor)
• Propranolol


  • No selective beta 1 and beta 2
  • Worried bronchoconstriction
  • Decreases heart rate
  • Decrease myocardial contraction
  • Slow conduction through AV
  • BRONCHOCONSTRICTION
  • BLOCKS EPINEPHRINE ON AIRWAYS
  • INHIBITION OF GLYCOLISIS- BREAKS DOWN SUGAR SLOWER SO SUGAR LEVEL CAN FALL REALLY LOW ( HYPOGLYCEMIA)
• Metoprolol (Lopressor)


  • ONLY SELECTIVE BETA 1 BLOCKER
  • HIGH DOSE= LESS SELECTIVE
• Alpha/Beta blockers

  CARVEDILOL (COREG)
• CARVEDILOL (COREG)


  • BLOOD VESSELS DILATE
  • NOT SELECTIVE
  • BLOCKS ALPHA 1, BETA 2, BETA 2
  • DECREASES CARDIAC OUTPUT, HR,BP, AND CAUSE VASODILATION
• Centrally Acting Alpha Agonists


  • Clonidine
  • Methyldopa
• Clonidine


  • Inhibits sympathetic nervous system
  • Decreases heart rate and B, vasoconstriction
• Methyldopa


  • Its safe for pregnancy
  • Converts methylnorpenephrine and displaces norepinephrine from storage sits
• ACEs


  • Blocks conversion of angiotensin I into angiotensin II resulting in
  • Vasodilation and decreased peripheral resistance
  • Reduction in blood volume or reversal of pathologic changes in the heart and blood vessels mediated by angiotensin II and aldosterone
• ACEs


  • Absorption: Most given orally (enalaprilat can be given IV)
  • Most can be given with food (NOT captopril or moexipril)
  • Metabolism: Most are prodrugs converted into active form in small intestine and the liver (NOT lisinopril—active as given)
  • Excretion: Renal
  • Reduce dose in renal impairment
  • Dosing: once daily to TID depending on drug
• Adverse Effects of ACEs

  • COUGH- PERSISTANT DRY HACKING COUGH CAN CAUSE NONCOMPLIANCE
  • ANGIOEDEMA- AIRWAY EMERGENCY
  • FIRST DOSE HYPOTENSION- HAVE PT SIT IN CHAIR
• Drug Interactions of ACEs

  • LITHIUM
  • OTHER HYPOTENSIVE MEDS
  • NSAIDS
  • POTASSIUM MEDS= HYPERKALEMIA
• ARBs


  • BLOCKS ANGIOTENSIN 2 AT THE SITE
  • BLOCKS ALDOSTERONE= DECREAEE BP
• ARBs


  • Vasodilation = decreased peripheral resistance
  • Decreased release of aldosterone by adrenals = increased sodium and water excretion
  • Reduces pathologic changes to the heart
• Adverse Effects of ARBs

  • LOW RISK OF ANGIOEDEMA AND COUGH
  • CONTRADICTED IN RENAL STENTOSIS
• Direct Renin Inhibitors


  • ALISKERIN( TEKTURNA)
  • BINDS WITH RENIN AT THE KIDNEYS
  • BLOCKS ENTIRE RAAS SYSTEM
• Adverse Effects of Direct Renin Inhibitors

  • GI- DIARHEA DOSE RELATED TO WOMEN AND OLDER ADULTS
  • FETAL TOXICITY
  • LOW RISK OF ANGIOEDMA, COUGH AND HYPERKALEMIA
• Vasodilators


  • Hydralazine (Apresoline)
  • Nitroprusside (Nitropress, Nipride)
• Hydralazine (Apresoline)


  • Selective dilation of arterioles = ↓Peripheral resistance
  • Adverse effects: Lupus like syndrome, Reflex tachycardia, Fluid retention
  • Combine with beta blocker to prevent reflex tachycardia
  • Combine with a diuretic to offset fluid retention
• Nitroprusside (Nitropress, Nipride)


  • Drug of choice for hypertensive crisis (DBP>120)
  • Relaxes vascular smooth muscle by releasing nitric oxide
  • Dilates veins and arteries = ↓ preload and afterload
  • ↓ BP dramatically and quickly, effect reverses quickly after discontinuation
  • IV use only
  • MUST use a pump
  • Protect from light
• CCB's

  • CALCIUM CHANNEL- REGULATES ELECTRICAL CONDUCTION OF AV NODES
  • REGULATES CONDUCTION OF SMOOTH MUSCLE
  • DECREASE PERIPHERAL RESISTANCE
  • DECREASE CONTRACTILITY
  • DECREASE HR
• Types of CCB's


  • NONDIHYDROPYIDINES(EX- VERAPAMIL/DILTIAZEM)
  • DIHYDRO[YDIDINES(EX- AMLODIPINE)
• Nondihydrophines (ex- Verapamil/Diltiazem)


  • MORE POTENT ON THE HEART> ARTERIOLES
  • ACTS ON SMOOTH MUSCLE IN THE HEART
• Dihydrozides (ex- Amlodipine)


  • MORE POTENT ON THE ARTERIOLES
  • ACTS ON SMOOTH MUSCLE OF ARTERIOLES
• Adverse Effects of CCB's

  • Constipation- more common in older adults
  • Flushing of skin
  • HA
  • Dizzness
  • Peripheral edema
  • Gingivital hyperplasia
  • IV CALCIUM GLUCONATE- ANTIDOTE
  • Reflex tachycardia with immediate release formulation*
• Uses of CCB's


  • ANGINA
  • HTN
  • DYSRTHYMIAS
• Drugs for Heart Failure


  • Loop Diuretics
  • ACE/ARB/
  • Entresto
  • Aldosterone Antagonists
  • Digoxin
  • Vasodilators
• Loop Diuretics


  • First-line drugs with s/s of fluid overload diuretics: mild
  • Thiazide diuretics: moderate diuresis; not effective if cardiac output /GFR is low
  • Loop diuretics: profound diuresis; effective if cardiac output is low
  • Potassium sparing diuretics: mild diuresis; risk for hyperkalemia
• ACE Inhibitors


  • Block production of angiotensin II
  • Dilate arterioles & veins
  • Decrease release of aldosterone
  • Favorable impact on cardiac remodeling
• Angiotensin Receptor Blockers


  • Reserved for use when patients cannot tolerate ACE inhibitors
  • Should NOT be used together with ACE
• Entresto


  • Increase BNP and decreases fluid
  • Blocks angiotensin 2
  • NYHA CLASS IN PLACE OF ARBS/ACE
  • ALLOW 36 HOUR WASH PERIOD – ANGIOEDEMA RISK
• Aldosterone Antagonists


  • BLOCK THE ACTION OF ALDOSTERONE
  • Promote myocardial remodeling
  • Promote myocardial fibrosis
  • Activate SNS
  • Hyperkalemia and gynecomastia
• Digoxin


  • NARROW THERAPEUTIC RANGE- TOXICITY QUICKLY
  • Antidote- FAB/ expensive so just monitor patients
• Vasodilators


  • Nitroglycerine
  • Synthetic form of human B-type natriuretic peptide
  • Direct dilation of vascular smooth muscle of arterioles and veins
  • Suppression of sympathetic outflow from CNS
  • Suppresses renin secretion
  • Decreases Aldosterone (decreases sodium & water)
• DIGOXIN TOXICITY S/S


  VISULA DISTURBANCES- YELLOW HALOS, SEEK HELP IMMEDIATELY, ANOREXIA, NAUSEA, VOMITTING, DYSRTHYMIAS
• INOTROPIC AGENTS( SYMPATHOMIMETIC)

  SHORT TERM- SEVER FAILURE

  DOPAMINE- SSTIMULATS BETA 1 ADRENERGENIC RECEPTOR IN HEART, IN HIGH DOSES ALPHA 1 STIMULATION

  CV ADVERSE EFFECTS

  DOBUTAMINE- STIMULATE ON BETA 1 RECPETORS ONLY
• Beta Blockers

  • Propranolol
  • Metoprolol (Lopressor)
• Propranolol


  • No selective beta 1 and beta 2
  • Worried bronchoconstriction
  • Decreases heart rate
  • Decrease myocardial contraction
  • Slow conduction through AV
  • BRONCHOCONSTRICTION
  • BLOCKS EPINEPHRINE ON AIRWAYS
  • INHIBITION OF GLYCOLISIS- BREAKS DOWN SUGAR SLOWER SO SUGAR LEVEL CAN FALL REALLY LOW (HYPOGLYCEMIA)
• Metoprolol (Lopressor)


  • ONLY SELECTIVE BETA 1 BLOCKER
  • HIGH DOSE= LESS SELECTIVE