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Heart Failure, An inotropic agent is a substance that affects the strength…

- - - - IV loop diuretcs
        
        recommended in the presence of symptoms secondary to congestion and volume overload
        
        However patients with hypotension ( SBP < 90 mmHg ), severe hyponatraemia, or acidosis may not respond to diuretic therapy. High doses of diuretics may lead to hypovolaemia and hyponatraemia, and increase the likelihood of hypotension on initiation of ACE inhibitors or ARBs
      - Vasodilators
        
        Vasodilators recommended as early as possible in hypoxaemic patients to achieve an arterial oxygen saturation >95% ( > 90% in COPD patients )
      - Inotropic agents
        
        why use them?
        
        considered in patients with low output states, in the presence of hypoperfusion or congestion despite the use of vasodilators and/or diuretics to improve symptoms
        
        patients with low SBP
        
        Dobutamine is a positive inotropic agent that stimulates ß 1 receptors
      - Morphine
        
        considered for patients with severe AHF who present with restlessness, anxiety or chest pain
      - Oxygen
        
        recommended as early as possible in hypoxaemic patients to achieve an arterial oxygen saturation >95% ( > 90% in COPD patients )
    - - Patient presents with increasing breathlessness, cough productive of clear sputum and orthopnoea – the CXR shows acute pulmonary oedema.
- - - - Ramipril (ACE inhibitor of choice)
        
        clinical indications
        
        HTN, renal disease Heart failure - first line therapy in all patients,who have reduced LVEF ( < 40 – 45% )
        
        MOA
        
        inhibits angiotensin converting enzyme thus, decreases blood volume and causes vasodilation
        
        Adverse effects
        
        renal failure, hyperkalemia(K levels above 5.5)
        
        if not tolerated, use angiotensin receptor blocker such as candesartan
      - Candesartan (ARB of choice)
        
        recommended for patients with HF and an LVEF less than 40% who remain symptomatic despite optimal treatment with an ACE or beta blocker
        
        can be used as an alternative to ACE inhibition in symptomatic patients intolerant to ACE inhibitors
        
        ARBs can be considered in combination with ACE inhibitors in patients who remain symptomatic to reduce mortality and hospital admissions
      - ACEi cause chronic cough in 17% - ARB used instead
    - - Bisoprolol
        
        used in all symptomatic patients with an EF of <40%
        
        Reduces mortalitly and hospitalisation by 30%
        
        improves ventricular function and patient well being
        
        heart rate should be above 50
    - - Salcubatril + Valsartan
        
        salcubitril is a nephrylysin inhibitor which inhibits the breakdown of natriuretic peptides
        
        this results in increased natriuretic peptides - increased sodium and water excretion - decreased blood volume and pressure and increased vasodilation
        
        valsartan is an ARB
        
        this combination was proven to be better than ACE inhibitors and reducing mortality (paradigm)
        
        patient MUST be symptomatic despite being on ACE/ARB and LVEF<35%
    - - Spironolactone, Eplerenone
        
        decreases mortality
        
        used with main 3 for LVEF <35% + severe symptomatic heart failure
        
        Improves survival and morbidity (RALES trial)
        
        contraindicated by high serum creatinine and hyperkalemia
        
        CANNOT be used by patients recieving both ACE inhibitors and ARB - causes arrhythmias
    - - DAPAGLIFOZIN/ EMPAGLIFOZIN
        
        MOA: acts on proximal tubule to inhibit reabsorption of glucose and sodium
        
        Thus increases glucose and sodium excretion, decreasing blood pressure
        
        beneficial cardiovascular effects are thought to be associated with improved ventricular loading due to a reduction in preload
        
        Side effects include UTIs/pyelonephritis and DKA(rare)
    - - Digoxin
        
        use
        
        recommended in patients with symptomatic heart failure and afib and LVEF<40%(slows rapid ventricular rate)
        
        should be used in addition to B blocker (for rate control)
        
        moa
        
        MOA: inhibit the sodium-potassium ATPase pump (Na+/K+ ATPase) in cardiac myocytes
      - Ivabradine
        
        moa
        
        MOA: inhibits cardiac pacemaker that controls the sinus node which causes dose dependent reduction in heart rate
        
        use
        
        clinical use: chronic stable angina pectoris and chronic heart failure
        
        contraindications
        
        metabolised by CYP450 3A4 and therefore contraindicated by azoles, protease inhibitors, verapamil, diltiazem (CYP3A4 inhibitors)
        
        recommended use with a beta blocker, ACE/ARB and spironolactone
        
        adverse effects = bradycardia, visual effects and phosphenes
    - - Furosemide
        
        use
        
        Clinical use: recommended in patients with heart failure and clinical signs or symptoms of congestion
        
        MOA
        
        MOA: Inhibition of Na+/K+/2Cl- Co-transporter - decreases reabsorption of sodium, potassium and chloride ions + increase excretion of these ions + water which relieves fluid overload (congestion, oedema)