Yusra Pintaningrum
• HF is defined, clinically,
as a syndrome in which patients have typical
symptoms (e.g.breathlessness, ankle swelling,
and fatigue) and signs (e.g. Elevated jugular
venous pressure, pulmonary crackles, and
displaced apex beat) resulting from an
abnormality of cardiac structure or function.
A. MECHANICAL ABNORMALITIES
1. Primary
a) cardiomyopathy
b) myocarditis
2. Secondary
a) oxygen deprivation (e.g. coronary heart disease)
2. extreme tachycardias
3. extreme bradycardias
Many etiologies of CHF
1. forward failure:
symptoms result from inability of the heart to pump enough
blood to the periphery (from left heart), or to the lungs (from
the right heart)
Disease
progression
Intervention
Failing heart
causes increased Effect of intervention on
sympathetic drive heart rate and outcome
Compensatory
mechanisms heart heart
rate rate
heart rate
b1 or b1/b2
Selective or
Failing heart
non-selective
beta-blocker
causes increased
sympathetic drive
Carvedilol
b1/b2/a1
Parasympathetic
drive Indirect effect
ACE
inhibitors
Heart rate: a goal for the treatment of heart failure (3)
Pool, 1998
Neurohormones: a goal for therapeutic
intervention in heart failure (2)
ACE Aldosterone
AIIAs
inhibitors antagonists
Angiotensin I
Aldosterone
secretion
Angiotensin II Responses in:
Brain
Vasculature
Myocardium
Adrenal gland
Cardiac remodelling: a goal for therapeutic intervention in heart failure
Calcium ACE
sensitising drugs inhibitors
Myofilaments Ca++
Na+
CONTRACTILITY
Cardiac glycosides
• William Withering used
foxglove to treat edema in 1785:
An Account of the Foxglove,
and Some of Its Medical Uses
• Inhibits Na-K ATPase, intracellular
Na, Ca through Na-Ca exchange
• Recent studies show digoxin
– Sensitizes cardiac baroreceptors
– Decreases sympathetic nervous outflow
– Decreases renin secretion
• Neurohormonal modulator NEJM 1993;329:1-7
NEJM 2002;347:1403-11
Ann Int Med 2005;142:132-4
Digitalis as an Antiarrhythmic
• Purpose: protect the ventricle
from rapid atrial rates
• Types of arrhythmias
Atrial tachyarrhythmias
Paroxysmal supraventricular
tachycardia
Atrial tachycardia
Atrial flutter
Atrial fibrillation
Diuretics in CHF
Almost always
necessary
Diuretic Effects
Volume and preload
- Improve symptoms of congestion
Neurohormonal activation
Levels of NA, Ang II and PRA
Exception: with spironolactone
Diuretics
• Unsuccessful as monotherapy
• Potential for electrolyte
imbalance
• Less improvement in exercise
capacity
• More frequent reoccurrence
Angiotensin Converting
Enzyme Inhibitors
b-Blockers in CHF
• Improve survival.
• Low doses
ß-Adrenergic Antagonists
Possible Beneficial Effects
Density of b1 receptors
Inhibit cardiotoxicity of catecholamines
Neurohormonal activation
HR
Antihypertensive and antiangina
Antiarrhythmic
Antioxidant
Antiproliferative
Positive inotropes:
Conclusions
May increase mortality
Safer in lower doses
Use only in refractory CHF
NOT for use as chronic therapy
Suspicion of heart failure
Discharge
FOR YOUR ATTENTION