Heart Failure

By: Medical Pharmacology Department

 Definition of heart failure

Heart failure is clinical syndrome consisting of symptoms (e.g. dyspnea ,

ankle swelling, and fatigue) that may be accompanied by signs
(e.g.elevated JVP , pulmonary crackles, and peripheral oedema).

It is due to a structural and/or functional abnormality of the heart that

results in elevated intracardiac pressures and/or inadequate cardiac
output.
 Causes of Heart Failure
 Pressure overload
e.g. Hypertension

 Volume overload
e.g. Mitral incompetence

Diseased Myocardium
e.g. Myocarditis, MI

44 Other causes: Thyrotoxicosis,

Anemia
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 Classification of heart failure

Duration Side of heart affected Cardiac output

Acute heart failure (AHF) Left sided HF Low COP failure

Chronic heart failure (CHF) Right sided HF High COP failure
Combined HF
 New York Heart
Association (NYHA)
functional classification
of HF
Class I • No limitation of physical activity

Class II • Slight limitation of physical activity

Class • Marked limitation of physical activity

III
Class • Symptoms occur even at rest; discomfort with any physical
IV activity.
 Types of Heart Failure (HF)
Types of HFrEF HFmrEF HFpEF
HF HF reduced HF mild reduced HF preserved Ejection fraction
Ejection fraction Ejection fraction
1 Symptoms ± Symptoms ± Symptoms ± Signs
CRITERIA
Signs Signs
2 LVEF ≤ 40% LVEF 41- 49% LVEF ≥ 50%

3 structural and/or functional

abnormalities
1-LV diastolic Dysfunction
2- Raised natriuretic peptides
 Classification of HF
Heart failure is usually divided into two presentations:
Chronic heart failure (CHF)
describes those who have had an established diagnosis of HF

Acute heart failure (AHF).

If CHF deteriorates, either suddenly or‘decompensated’ HF that
required hospital admission or treatment with I.V diuretics
 Pathophysiology of heart failure Cardiac remodeling:

1. Hypertrophy & 2. Sympathetic activity:

Dilatation  C.O.P •  H.R.

• E.D.V • V.C

 Pre-load.  After-load

Angiotensin

Na+ & water

retention  Aldosterone
 Treatment of heart failure
β-blockers
1. Hypertrophy &  C.O.P 2. Sympathetic activity:
Dilatation Positive
•  H.R.
Inotropics

• E.D.V
• V.C

 Pre-load.  After-load

vasodilators

ARBs
Angiotensin
Diuretics
ACE-I
Spironolactone
Aldosterone &
Na+ & water  Eplerenone
retention
*Heart failure with preserved ejection fraction
(HFpEF)

1- Screening for comorbidities and

providing effective treatment.

2-Diuretics, in congested patients.

 *Heart failure with mildly reduced ejection fraction
(HFmrEF)

The diagnosis of HFmrEF requires the presence of

symptoms and/or signs of HF, and

mildly reduced EF

elevated NPs(Natriuretic peptides )

 Pharmacological treatments
HF with reduced ejection fraction(HFrEF)
HF with mildly reduced ejection fraction(HFmrEF)

Modulation of (RAAS) and sympathetic nervous systems

(ACE-I) or (ARNI),
Beta-blockers,
Mineralocorticoid receptor antagonists (MRA)
This triad is recommended as cornerstone therapies for these
patients. improve survival, reduce the risk of HF hospitalizations,and
reduce symptoms in patients with HFrEF.
 Pharmacological treatments
Heart failure with reduced ejection fraction(HFrEF)

The sodium-glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin

and empagliflozin added to therapy with ACE-I/ARNI/ BB / MRA reduced the

risk of CV death and worsening HF in patients with HFrEF.

Unless contraindicated or not tolerated, dapagliflozin or empagliflozin are

recommended for all patients with HFrEF, regardless of whether they have
diabetes or not.
 Other Pharmacological treatment in selected patients:

Ivabradine should be considered, to reduce the risk of

hospitalization and deaths
•In symptomatic patients with LVEF≤35%, despite
If- channel receiving a beta blocker at maximum tolerated dose.
inhibitor •patients who are unable to tolerate or have
contraindication for beta blockers (in this case, it will be
combined with ACEI & MRA).
•N.B, Patients should be in a sinus rhythm with a heart rate
≥70 bpm at rest.
Other Pharmacological treatment in selected patients:

•In patients with LVEF<45% combined with

Hydralazine dilated LV in NYHA class III-IV despite
treatment with ACEI, beta blockers & MRA.
&
Isosorbide •In symptomatic patients with HFrEF who
dinitrate cannot tolerate (or have a contraindication)
to ACE inhibitor or ARB therapy.
Heart Failure with comormidities
 Co-morbidity First line treatment

Beta blocker: the cornerstone of treatment.

Coronary artery disease
Ivabradine(on top of beta blocker or if beta blocker is
contraindicated): in suitable HFrEF patients sinus rhythm and
a resting HR≥70 bpm.

ACEI (or ARB), beta blocker or MRA or combinations of all.

Hypertension Loop diuretic agents in patients who have
symptoms or signs for volume overload.
Amlodipine or Hydralazine: if hypertension persiste despite
combination of ACEI(or ARB)+beta blocker+MRA+diuretic.
 HF and AF

 Beta-blockers should be considered for short- and long term rate control in patients with HF and
AF.


Digoxin: decrease A-V conduction
 NOACs (novel oral Anti-Coagulants) are recommended in preference to VKAs(vitamin K
anatagonists as warfarin) in patients with HF, except in those with moderate or severe mitral
stenosis or mechanical prosthetic heart valves

 In iron deficiency anemia the patient must recieved ferric carboxymaltase to correct the anemia.
 HF and AF

Long-term treatment with an oral anticoagulant should be considered for stroke

prevention in AF patients with a CHA2DS2-VASc score of 1 in men or 2 in women.
 Congestive Heart Failure (1)
 High blood pressure (1)
 Age (2 if above 75)
 Diabetes (1)
 stroke (2)
 Vascular disease (1)
 Age (one point if between 65 and 74)
 Sex (one point if female)
 HF and Diabetes

SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) are

recommended in patients with T2DM at risk of CV events to reduce

hospitalizations for HF, major CV events, end-stage renal dysfunction, and

CV death.
Management of acute heart failure
(Pulmonary edema)
 Acute Heart Failure:
(Acute Pulmonary Edema)

Diagnosis
dyspnoea with orthopnoea, respiratory failure (hypoxaemia-hypercapnia),
tachypnoea, >25 breaths/min,
 Three therapies should be commenced, if indicated.(ODD)
First:
Oxygen, given as continuous positive airway pressure, non-invasive
positive pressure- ventilation and/or high-flow nasal cannula,
Second :
I.V Diuretics loop diuretics are recommended for all patients with AHF
with signs/symptoms of fluid overload to improve symptoms.
Combination of a loop diuretic with thiazide type should be considered in
patients with resistant oedema
Third I.V vasoDilators(Nitrates ,Na nitropruuside ) may be given if
(SBP) is high, to reduce LV afterload
 Acute Heart Failure:
(Acute Pulmonary Edema)

In a few cases of advanced HF,

acute pulmonary oedema may be associated with low cardiac

output and, in this case,

inotropes, vasopressors, and/or MCS(mechanical

circulatory support) are indicated to restore organ perfusion.
 Acute Heart Failure + low BP
Inotropic agents:
Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of
hypoperfusion who do not respond to standard treatment, including fluid challenge

Vasopressors
A vasopressor, preferably norepinephrine, may be considered in patients with
cardiogenic shock to increase blood pressure
Inotropes and/or vasopressors used to treat acute heart failure
 Acute heart failure
Thromboembolism prophylaxis
Anticoagulantion (e.g. with LMWH) is recommended in patients not
already anticoagulated and with no contraindication to
anticoagulation, to reduce the risk of deep venous thrombosis(DVT)
opiates
Routine use of opiates is not recommended, unless in selected
patients with severe/intractable pain or anxiety
Patient Education
 Cardiac glycosides
1. Stress the importance of taking the drug exactly as prescribed
even he feels well.
2. Instruct patient signs of improvement regarding: (cough,
shortness of breath, weight and swelling of ankles, legs).
3. Teach the patient how to take apical, radial pulse & rhythm.
Withhold the drug and notify the physician if pulse rate < 60
beats/min.sign of toxicity or GI sysmptoms (nusea ,vomiting )
1- A female patient aged 58 years complaining of fatigability and dyspnea on exertion. Clinical
examination and echo cardiology confirmed the diagnosis of HF with reduced ejection
fraction(HFrEF)
. How to manage this patient?

A- The following measure should be taken in patients suffering from heart failure EXCEPT:
a- Decrease physical activity b- Weight reduction c- Stop smoking
d- Dietary sodium restriction e- Increase fat content in diet
B- The following drug is recommended to start with in treatment of C.H.F. in this patient:
a- Sodium nitroprusside b- Physostigmine c- Diltiazem
d- Captopril e- Quinidine
2- Regarding angiotensin converting enzyme inhibitors, they improve heart failure by
which of the following action:
a- decreases both preload and after load b- has positive inotropic effect
c- increases sympathetic drive to the heart d- increases glomerular filtration rate
e- decreases rennin secretion
3- Angiotensin converting enzyme inhibitors (ACEIs) are indicated if the patient has in
addition:
a- bilateral renal artery stenosis b- second trimester of pregnancy
c- diabetes mellitus d- bronchial asthma
e- hyperkalemia
4- ACEIs may produce which of the following adverse effect:
a- dry irritant cough b- tachycardia c- neutrophillia
d- initial hypertensive reaction e- hyperglycemia.
5- IF the patient is asthmatic, which of the following is reasonable substitute to ACEIs:
a- enalapril b- valsartan c- bradykinin
d- neostigmine e- diazoxide
6- After reaching the target dose of ACEIs in heart failure, which of the following drug
could be added:
a- adrenaline b- fosinopril c- verapamil
d- bisoprolol e- morphine
7- Regarding the use of beta blockers in heart failure, which of the followings is the
beneficial effect for adding them to the regimen:
a- has an inotropic effect b- has a diuretic effect
c- decreases preload on the heart d- has intrinsic sympathetic activity
e- protects the heart from the increased sympathetic activity

8- Beta blockers are contraindicated in:

a- hypertension b- heart block c- hyperthyroidism
d- angina pectoris e- glaucoma

9- A male patient with HF with reduced ejection fraction(HFrEF)

, is complaining of hypervolemia and edema, which of the following drugs is indicated:
a- furosemide b- hydrocortisone c- hydralazine
c- salbutamol d- ranitidine
10- All of the following are the beneficial effects for adding diuretics in treatment of heart failure
EXCEPT:
a- improve congestive symptoms b- decreases preload
c- decreases blood volume d- increases cardiac output
e- antagonizes hyperkalemia induced by the used drugs
11- Regarding the use of diuretics in heart failure, they produce the following adverse reactions
EXCEPT:
a- hyperkalemia b- hyperglycemia c- hyperuricem
d- hyponatremia e- ototoxicity
12- A patient with myocardial infarction (MI) complicated into acute left ventricular failure with
pulmonary edema, all of the following measures are adopted EXCEPT:
a- sitting position and dangling the legs b- oxygen c- slow I.V. morphine
d- I.V. mannitol e- sodium nitroprusside I.V. infusion
KEY: 1A- e 1B- d 2- a 3- c 4-a 5- b 6- d 7- e 8-
b
9- a 10- d 11- a 12- d