Treatment of chronic heart failure

Heart failure is a state, when the heart is not able to pump enough blood.

The drugs used for treatment of chronic heart failure are devided into two groups:

Drugs reducing strain on myocardium


 * ACE inhibitors,
 * AT1 - receptor blockers,
 * Other vasodilators,
 * Beta-blockers,
 * Diuretics.

Drugs with positive inotropic effects


 * Heart glycosides,
 * Other drugs with positive inotropic effects.

ACE inhibitors

 * Angiotensin converting enzyme inhibitors. The work by decreasing the concentration of circulating angiotensin II, leading to reduced degradation of bradykinin, which stimulates vasodilatory NO synthase.
 * Simultaneous suppresses the sympathetic nervous system - they are also used in the treatment of arterial hypertension.
 * There is an increase in cardiac output, which improves organ perfusion.

Contraindications
Pregnancy, hyperkalaemia, bilateral renal artery stenosis, angioneurotic edema.

Side effects
Irritant cough, skin rash, angioneurotic edema.

Examples
Enalapril, kaptopril, perindopril, ramipril.

AT1 receptor blockers

 * They antagonize the action of angiotensin on AT1 receptors (the difference from ACE inhibitors is, that they do not lead to a delayed degradation of bradykinin, which is responsible for ACE inhibitors side effects).
 * They are recommended for intolerance to ACE inhibitors.

Contraindications
Pregnancy, hyperkalaemia, bilateral renal artery stenosis.

Examples
Losartan, valsartan, telmisartan, candesartan.

Other vasodilatators

 * A wide group of substances whose mechanism and site of action differ.
 * We divide them into arterial, venous and combined vasodilators (arteries and veins).

Examples
Dihydralazin, nitroprusid.

Beta-blockers

 * They suppress the sympathoadrenal system, reduce the heart rate and prolong diastole.
 * They are used in stabilized patients.

Contraindications
More pronounced bradycardia, AV conduction disorders, hypotension, bronchial asthma.

Examples
Metoprolol, succinate, karvedilol, bisoprolol, nebivolol.

Diuretics

 * Used only with congestion in small or large circulation.
 * Indicated especially in mild and moderate heart failure - swelling occurs.

Contraindications
Patients without swelling, circulatory overload and dyspnoea.

Side effects
Hypokalaemia (loop and thiazide diuretics only).

Examples

 * loop - furosemid,
 * thiazide - hydrochlorthiazid,
 * aldosterone receptor inhibitors - spironolakton.

Cardiac glycosides

 * These are cardiotonics, which are substances that increase myocardial contractility.
 * They induce ionic changes caused by inhibition of Na + / K + -ATPase in cardiomyocytes.
 * They alleviate symptoms, but do not improve the prognosis of the disease.

Side effects
They are relatively common - anorexia, nausea, bradycardia, etc.

Examples
Digoxin.

Other drugs with positive inotropic effects.

 * These are drugs given for short periods in acute conditions (long-term use has a negative effect).
 * Indications are acute heart failure or exacerbation of chronic failure.

Examples
Dopamin, dobutamin.

Inhibitors of phosphodiesterase III

 * I.v. application especially in acute heart failure.

Examples
Amrinon, milrinon.

Calcium sensitizers

 * They increase the sensitivity of troponin C to calcium.
 * They are used as adjunctive therapy in acutely decompensated chronic heart failure.

Examples
Levosimendan.