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Cardiotonic drugs. Inotropic agents Congestive Heart Failure (CHF). Heart pumps less blood than it receives, so excess blood pools in the chambers and stretches the walls of the heart. 2 MAIN TYPES of CHF. SYSTOLIC CHF – insufficiency of output DIASTOLIC CHF - insufficiency of input. - PowerPoint PPT Presentation
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Cardiotonic drugs
Inotropic agentsCongestive Heart Failure (CHF)
• Heart pumps less blood than it receives, so excess blood pools in the chambers and stretches the walls of the heart
2 MAIN TYPES of CHF
SYSTOLIC CHF – insufficiency
of output
DIASTOLIC CHF - insufficiency of
input
• Occurs in 10% of the population over 75
• Can result in death through progressive heart damage or sudden death
• Overworking of the heart leads to cardiomegaly and myocardial hypertrophy
CHF
Causes of Congestive Heart Failure
• Primary causes:– Cardiomyopathy
– Coronary artery disease
– Hypertension
• Secondary causes:– High salt intake
– Noncompliance with treatment
– Side effects of drug therapy
– Kidney failure
– Stress
– Infection and inflammation
– Cigarette smoking
– Obesity
DRUGS FOR СONGESTIVE HEART FAILURE (CHF)
CARDIAC GLYCOSIDES
Strophantus
Purple Foxglove
Foxglove
Lily of the valley
Lychnis
Chemical structure of cardiac glycosides
Pharmacodynamics
Cardiac action
Extracardiac action
Cardiac action
• Positive inotropic
• Positive bathmotropic
• Negative chronotropic
• Negative dromotropic
Cardiac Glycosides
MECHANISM OF CARDIOTONIC (POSITIVE
INOTROPIC) ACTION Of CG • Promote increasing of Calcium ions
concentration in myocardiocytes cytoplasm
- Transport of Са inside the cell
- Stimulate exit of Са from sarcoplasmic reticulum
- Block К, Na-АTP-ase (braking repolarization)
• Improve usage of macroergic substances by cells, decrease myocardium need in oxygen
• Increase tone of sympathetic nervous system
• Changes which correlate to positive inotropic action
Narrowing QRS complex Decreasing ST
T-blip – double-phased, negative
• Changes which correlate to negative dromotropic action
Prolongation of PQ interval• Changes which correlate to negative chronotropic action
Increase of RR interval
ECG changes under the influence of CGchanges under the influence of CGVvvvvvvvvvvvvvvvvvvvvvvv
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Extracardiac action of CG
• Diuretic • Sedative
• Stimulating influence on smooth muscles
The following manifestations testify about
therapeutic action of CG
1. Improving of general state of the patient (decreasing of weakness, short breath, sleep
normalization, disappearing of edema, cyanosis, etc.)
2. Tachycardia transforms into normo (brady)cardia
3. Increasing of diuresis 4. Typical changes in ECG
Agents for CHF
• digoxin (Lanoxicaps, Lanoxin)
Antidote for digoxin toxicity:
• digoxin immune Fab (Digibind)
Drug List
digoxin (Lanoxicaps, Lanoxin)
• Increases force of contraction
• Increases effective refractory period
• Affects SA node, causing direct stimulation
• “dig toxicity”– Systemic accumulation
Happens frequently -
6-23 %
Mortality -
over 40 %
Warning!
Intoxication with CGIntoxication with CGCardiac symptomsCardiac symptoms
Worsening of contractive function of Worsening of contractive function of myocardiummyocardium, , increasing of circulation increasing of circulation insufficiencyinsufficiency ((1818--26 %)26 %)Disturbance of heart rhythmDisturbance of heart rhythm(90(90--95 %, 65 % 95 %, 65 % -- single symptom of single symptom of intoxicationintoxication))
-- tachyarrhythmiatachyarrhythmia ((increasing of automatismincreasing of automatism))-- blockadesblockades-- combined disorders of rhythmcombined disorders of rhythm
Intoxication with CGIntoxication with CG
ExtracardiacExtracardiac symptomssymptoms
GastroGastro--intestinalintestinal (40(40--50 %)50 %)
Neurological and psychical Neurological and psychical (25 %)(25 %)
Eye symptomsEye symptoms (65 %)(65 %)
Worsening of kidneys functionWorsening of kidneys function
Agents for CHFVasodilators
• milrinone (Primacor)
• nitroprusside (Nitropress)
Drug List
ACE Inhibitors• Inhibits conversion of angiotensin I to
angiotensin II
• Lowers blood pressure and lowers the stress on the heart
INHIBITORS OF ANGIOTENSINE INHIBITORS OF ANGIOTENSINE CONVERTING ENZYMECONVERTING ENZYME ( (IACE)IACE)
In case of CHF they brake pathological consequences of activation of renin-angiotesine
system by inhibiting ACE:• production of angiotensine II decreases
(vasoconstrictor, inductor of aldosterone, norepinephrine, endothelin secretion, myocardium hypertrophy)
• Accumulation of bradikinin (inductor of prostacycline and nitrogen oxide synthesis)
captopril (capoten), ramipril, enalapril etc.
ACE Inhibitor Dispensing Issues
• Stand slowly to prevent orthostatic hypotension
• Avoid salt substitutes
• Do not take potassium supplements
Warning!
Agents for CHFACE Inhibitors
• benazepril (Lotensin)
• captopril (Capoten)
• enalapril (Vasotec)
• fosinopril (Monopril)
• lisinopril (Prinivil, Zestril)
Drug List
Agents for CHFACE Inhibitors
• moexipril (Univasc)
• perindopril (Aceon)
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)
Drug List
INHIBITORS OF ANGIOTESINE CONVERTING ENZYME
(IACE) captopril (capoten), ramipril, enalapril etc.
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