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What are the goals of therapy for heart failure?
Clinical improvement and stabilization
Reduction in morbidity and mortality risks
What are the lifestyle modifications needed for HF therapy?
Cessation of smoking
Restriction of alcohol consumption
Salt and fluid restriction
Weight reduction
What are the drugs that may contribute to HF?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Antiarrhythmic drugs
Calcium channel blockers
Thiazolidiones
What causes of HF require treatment?
Hypertension
Renovascular disease
Ischemic heart disease
Valvular disease
Therapy of mild congestive heart failure has often involved
_____ and the use of _____ to reduce tissue edema and
blood volume, decreases _____ only
salt restriction
diuretic drugs
morbidity
What drugs mechanism of action involves vasodilation reducing afterload, or the arterial
pressure against which the heart has to pump in?
What other mechanism of action does this drug have?
moving blood
Thiazide Diuretics

Also gives a boost to loop diuretic therapy
What are the Thiazide Diuretics?
What is their dosage?
Hydrochlorothiazide (Microzide)
- 25-100 mg/day
Chlorthalidone (Thalitone)
- 50-100 mg/day
Metolazone (Zaroxolyn)
- 2.5-10 mg/day – usually given 30 minutes prior to loop diuretic
What is the most commonly used Thiazide diuretic?
Metolazone (Zaroxolyn)
What are the adverse affects of Metolazone?
Hypokalemia
What drug interaction do you avoid with Metolazone?
Dofetilide
What are the contraindications for using Metolazone?
Pregnancy and Sulfa Allergy
What drug's mechanism of action inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule,
interfering with the chloride-binding cotransport system, thus causing increased excretion of water,
sodium, chloride, potassium, magnesium, and calcium?
What else does it do?
Loop Diuretics

Used to improve edematous status
What are the loop diuretics drugs and what are their dosages?
Furosemide (Lasix) – 20-80 mg
Bumetanide (Bumex) - 0.5-2 mg
Torsemide (Demadex) - 0-20 mg
Ethacrynic acid (Edecrin) - 50-200 mg/day
What is the most commonly used Loop Diuretic?
Furosemide (Lasix)
What Loop Diuretic is commonly used in Sulfa allergy patients?
Ethacrynic acid (Edacrin)
What are the adverse events for Furosemide (Lasix)?
Acute hypotension
Photosensitivity
Exfoliative dermatitis
Hypokalemia
Hyponatremia
Allergic interstitial nephritis
What are the drug interactions to watch with Furosemide (Lasix)?
Ethacrynic Acid (Edecrin)
What are the contraindications for using Furosemide?
Anuria and Sulfa Allergy
What are the 3 classes of diuretics?
Thiazide Diueretics
Loop Diuretics
Potassium Supplements
What is the most common Potassium supplement diuretic and what is its dosage?
Potassium Chloride (KDur, Klor-Con)
40 meq/80mg of Furosemide
What class of drugs is used in later stages of HF – New York Heart
Association Class III and IV, and decreases morbidity and mortality
Aldosterone Antagonists
What are the mechanisms of action for the Aldosterone Antagonists?
Antagonist:
- Aldosterone at the convoluted tubule of the kidney
- Blocks secretion which decreases
sodium and water retention
- Blocks parasympathetic nerve response
- Potassium sparing
What are the Aldosterone Antagonistic drugs and what are their dosages?
Spironolactone (Aldactone)
12.5-25 mg/day (max dose of 50 mg/day)
Eplerenone (Inspra)
25 mg daily initially, titrate to 50 mg/day
What is the most commonly used Aldosterone Antagonist?
Spironolactone (Aldactone)
What drug is used in patients who have experienced gynecomastia?
Eplerenone (Inspra)
Which Aldosterone Antagonist is more expensive?
Epleronone (Inspra)
What are the adverse effects of using an Aldosterone Antagonist?
Gynecomastia and breast pain
Hyperkalemia
Renal dysfunction
What are the drug interactions of Aldosterone Antagonists?
Tacrolimus
May increase the effects of ACE inhibitors
What are the contraindications for using Aldosterone Antagonists?
Anuria
Acute renal insufficiency
Hyperkalemia
What is an ACE inhibitor and what does it decrease?
Angiotensin-Converting Enzyme inhibitors

First line of defense and decreases mortality and morbidity
What is the mechanism of action for ACE inhibitors?
Inhibit the production of angiotensin II or blocking its receptor:
- less aldosterone secretion = less sodium and water retention,
- reduces sympathetic
discharge
What is the major effect of ACE inhibitors?
To reduce afterload and preload
What effects do ACE inhibitors have on patients with heart problems?
- Improve symptoms in patients with HF
- Progressive deterioration of the heart is slowed
- Control remodeling that occurs with chronic HF, decreases mortality
What are the ACE inhibitors and what are their dosages?
Lisinopril (Prinvil) – 5 mg/day, max dose 40 mg/day
Enalapril (Vasotec) - 5-20 mg/day in 2 divided doses, target of 40 mg/day
Benazepril (Lotensin) -10 mg/day, max dose 40 mg/day
Ramipril (Altace) - Starting dose of 2.5 mg twice daily, target 5 mg
twice daily
What is the most commonly used ACE inhibitor?
Lisinopril (Prinvil)
What are the adverse effects of ACE inhibitors?
Hypotension
Hyperkalemia
Decreased renal function
Dry cough
Angioedema
What are the potential interactions with ACE inhibitors to be aware of?
Potassium supplements
ARBs
What are the contraindications to using ACE inhibitors?
Aldosterone antagonists
Non-steroidal anti-inflammatory drugs
Do not use in pregnancy
Fill in the Blanks to mechanisms of action for the Angiotensin II Blockers:
- Angiotensin II _____
- Blocks the _____ and _____ effects of angiotensin II
- Interacts reversibly at the _____ receptors
- Angitoensin II receptor antagonists may induce a more
complete inhibition of the _____system than _____
- Do not affect the response to _____ – less likely to be
associated with the dry cough and _____
- Share same benefits of _____
Antagonist
vasoconstrictor, aldosterone-secreting
AT1 and AT2
RAAS, ACEI's
bradykinin, angioedema
ACEIs
What are the Angiotensin II receptor blocking drugs?
What are their dosages?
Losartan (Cozaar)
- 50 mg/day, max 100 mg/day
- Can be given once a day or twice day
Valsartan (Diovan)
- 40 mg/twice daily, titrate 80-160
mg/twice daily, max dose 320 mg/day
Irbesartan (Avapro)
- 150 mg/day, max 300 mg/day
Olmesartan (Benicar)
- 20 mg/day, max 40 mg/day
What are the adverse effects of Angiotensin II receptor blocking drugs?
Hypotension
Hyperkalemia
Diabetic nephropathy
Chest pain
Hypoglycemia
What are the drug interactions with Angiotensin II Receptor Blockers?
May increase levels of ACEI's
What are the contraindications to using Angiotensin II Receptor Blockers?
DO not use when pregnant
Fill in the blank of B-Adrenergic receptor antagonists mechanisms of action:
- _____ the work of the heart, reduce _____ secretion,
prevent remodeling of the _____, act as _____ drugs,and reduce the down regulation of _____ – all of these effects are beneficial in heart failure
- Reduces _____ response produced from the _____
system
- _____ and _____ are selective beta-blockers
- _____ is a non-selective beta-blocker and selective
alpha blocker
- _____ reduces remodeling of the heart
- _____ reduce preload and afterload
Reduce, rennin, heart, antiarrhytmic, beta-adrenergicreceptors
sympathetic, RAAS
Bisoprolol, metoprolol
Carvedilol
Beta-blockade
Alpha-blockade
What are the B-Adrenergic Receptor Antagonist drugs?
Metoprolol Succinate (Toprol XL)
Carvedilol (Coreg and Coreg CR)
Bisoprolol (Zebata)
What is the specific dosage for Metoprolol (Toprol XL)?
Start 25 mg/day, titrate every 2 weeks as tolerated –
target dose of 200 mg/day
What is the specific dosages for Carvedilol (Coreg and Coreg CR)?
Immediate release 3.125 mg twice a day, increase over 2 week intervals to max dose tolerated

Extended release 10 mg/day, max dose of 80
mg/day
What is the dosage for Bisoprolol?
1.25 mg – 10 mg/day
What are the adverse effects for using B-Adrenergic receptor antagonists?
Bradycardia
Hypotension
What are the drug interactions for B-Adrenergic receptor antagonists?
Methacholine and topotecan
What are the contraindications for using B-Adrenergic receptor antagonists?
- Bronchial asthma / related bronchospastic conditions
- Severe bradycardia
- Caution in pregnancy, not usually used
FIll in the blanks for the mechanisms of action of the directly acting vasodilators:
- _____ workload on the heart, improve tissue _____
- Disadvantages of _____ and _____ include the
indirect enhancement of _____ discharge and
activation of the _____ system
Combination found to be effective in _____ descent with
class _____
- Useful as _____ in resistant cases or in patients
who cannot tolerate other _____
- Reduce, perfusion
- nitrates, hydralazine, sympathetic, RAAS
- African, III and IV HF
- added therapy, HF medications
What are the direct acting vasodilator drugs?
What are their dosages?
Isosorbide Dinitrate 20 mg Hydralazine 37.5 mg

- 1 tablet three times a day, titrate to 2 tablets three
times a day
What direct acting vasodilator drug is no longer available?
BiDil
What are the adverse effects for using a direct acting vasodilator?
Hypotension
Nausea and vomiting
Tachycardia
What are the drug interactions to be aware of with direct acting vasodilators?
Phosphodiesterase 5 inhibitors such as sildenafil – can
cause prolonged hypotension
What are the contraindications to using direct acting vasodilators?
Phosphodiesterase 5 inhibitors
What 2 classes of HF drugs decrease morbidity only?
Diuretics
Cardiac Glycoside
Fill in the blank on the mechanisms of action for Cardiac Glycoside drugs:
- Direct _____ effect on the heart, directly _____ the force of contraction
- Has direct action on heart cells, _____ mycocardial contractility and it alters _____ activity throughout the heart
- Due to increased heart size in HF, the heart cannot contract
as strong, _____ increases the force of contraction and the
amount of _____ forced out of the heart
- _____ agent for treatment of HF unless there is an
underlying reason from other comorbidities due to narrow
_____ and adverse events
ionotropic, increases
increasing, electrical
digoxin, blood
Last line, therapeutic index
What are the Cardiac glycoside drugs?
What is its dosage?
Digoxin (Lanoxin)
- 0.125-0.25 mg once daily
What are the therapeutic concentrations of Digoxin (Lanoxin)?
0.5 - 0.8 mg/ml
What are the adverse effects for using Cardiac Glycosides?
- Decreased heart rate
- Toxic signs are often seen at roughly twice the minimum
effective dose
- Adverse reactions from accumulation of the drug or from
potassium depletion
- GI disturbance
- Yellow – green visual discoloration along with seeing halos
What are the drug interactions to be cautious of when using Cardiac Glycosides?
- Cautious with any drug that effects the heart
- Caution with local anesthetic injections that have
catehcolamines
What are the contraindications with using Cardiac glycosides?
Patients with AV block
Use with concurrent beta-blockers
_____ in local anesthetic injections increase the risk of digoxin-induced _____.
Is it contraindicated?
Cathecholamines, arrhythmias
No
Use of gingival retraction cords impregnated with _____ is
not recommended in patients taking _____.
What is contraindicated for the use of this drug?
epinephrine, digoxin
Heart disease
Use caution in the use of _____ use with patients taking _____
as it can raise _____serum levels and lead to _____.
antibiotic, digoxin, digoxin, toxicity