Failing heart (general & where is pharmacotherapy aimed)

Failing heart = decreased CO

Defects in cardiac contractility trigger the SNS big time to try and return CO and BP back to normal

Eventually leads to increased preload, afterload, edema, dilated heart (remodeling)

Pharmacotherapy aimed at:

↓ preload: diuretics, ACEI, ARB, venodilators

↓ afterload: ACEI, ARB, arteriodilators

↓ remodeling: ACEI, ARB, spironolactone

Increase contractility: digoxin, beta agonists

DOC for the management of CHRONIC CHF

Management of ACUTE CHF

Inotropes = Digoxin

MOA: inhibits Na/K ATPase pump in cardiac myocyte which increases intracellular Na & Ca2+ (which can be used for cardiac contraciton) indirectly also causes vagal/parasympathetic stimulation

1/2life: long so need a loading dose, and displaced from tissue binding by verapamil, quinodine)

Uses: CHF, SVT except WPW syndrome

SE: early = anorexia, nausea, ECG changes

later = disorientation, visual effects (halos)

DI:diuretics, quinidine, verapamil, sympathomimtics

Other Inotropes (PDE inhbitors)

INamrinone, milrinone

increases cAMP in heart m. = increased inotropy

increases cAMP in sm. muscle = decreased TPR

used only acutely b/c in long term can increase mortality

Other Inotropes (sympathomimetics)

Dobutamine & Dopamine

acute CHF b/c long term tachyphylaxis (rapid tolerance)

Nesiritide

Recombinant form of human type B natriuretic peptide (binds to natriuretic peptide receptors)

increases cGMP resulting in vasodilation (cGMP is assoc. w/ NO!!!)

Used: acutely decompensated CHF

Cilostazol

Phosphodiesterase III inhibitor

Used for intermittent claudication (leg cramps)

BLACK BOX warning: contraindicated in CHF!