drugs for the treatment of chronic heart failure

7/30/2019 Drugs for the Treatment of Chronic Heart Failure

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Drugs for the Treatment of Chronic Heart Failure (EF


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Drugs for the Treatment for Acute Heart Failure

Initiating Dose Maximal Dose

Vasodilators

Nitroglycerin20 g/min 40400 g/min

Nitroprusside10 g/min 30350 g/min

NesiritideBolus 2 g/kg 0.010.03 g/kg per min

a

Inotropes

Dobutamine12 g/kg per min 210 g/kg per minb

MilrinoneBolus 50 g/kg 0.10.75 g/kg per min

b

Dopamine12 g/kg per min 24 g/kg per min

b

LevosimendanBolus 12 g/kg 0.10.2 g/kg per min

c

Vasoconstrictors

Dopamine for hypotension5 g/kg per min 515 g/kg per min

Epinephrine0.5 g/kg per min 50 g/kg per min

Phenylephrine0.3 g/kg per min 3 g/kg per min

Vasopression 0.05 units/min 0.10.4 units/min

aUsually


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Antiarrhythmic Drug Actions

Class Actions

Drug I II III IV Miscellaneous Action

Quinidine ++ ++-Adrenergic blockade

Procainamide ++ ++ Ganglionic blockade

Flecainide +++ +

Propafenone ++ +

Sotalol ++ +++

Dofetilide +++

Amiodarone ++ ++ +++ +-Adrenergic blockade

Ibutilide +++ Na+

channel activator


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Etiologies of SA Node Dysfunction

Extrinsic Intrinsic

Autonomic Sick sinus syndrome (SSS)

Carotid sinus hypersensitivity Coronary artery disease (chronic and acute MI)

Vasovagal (cardioinhibitory) stimulation Inflammatory

Drugs Pericarditis

Beta blockers Myocarditis (including viral)

Calcium channel blockers Rheumatic heart disease

Digoxin Collagen vascular diseases

Antiarrhythmics (class I and III) Lyme disease

Adenosine Senile amyloidosis

Clonidine (other sympatholytics) Congenital heart disease

Lithium carbonate TGA/Mustard and Fontan repairs

Cimetidine Iatrogenic

Amitriptyline Radiation therapy

Phenothiazines Post surgical

Narcotics (methadone) Chest trauma

Pentamidine Familial

Hypothyroidism AD SSS, OMIM #163800 (15q24-25)

Sleep apnea AR SSS, OMIM #608567 (3p21)

Hypoxia SA node disease with myopia, OMIM 182190

Endotracheal suctioning (vagal

maneuvers)

Kearns-Sayre syndrome, OMIM #530000

Hypothermia Myotonic dystrophy

Increased intracranial pressure Type 1, OMIM #160900 (19q13.2-13.3)

Type 2, OMIM #602668 (3q13.3-q24)

Friedreich's ataxia, OMIM #229300 (9q13, 9p23-

p11)

Note: MI, myocardial infarction; TGA, transposition of the great arteries; AD, autosomal

dominant; AR, autosomal recessive; OMIM, Online Mendelian Inheritance in Man

(database).


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Table 225-2 Etiologies of Atrioventricular Block

Autonomic

Carotid sinus hypersensitivity Vasovagal

Metabolic/endocrine

Hyperkalemia Hypothyroidism

Hypermagnesemia Adrenal insufficiency

Drug-related

Beta blockers AdenosineCalcium channel blockers Antiarrhythmics (class I & III)

Digitalis Lithium

Infectious

Endocarditis Tuberculosis

Lyme disease Diphtheria

Chagas disease Toxoplasmosis

Syphilis

Heritable/congenital

Congenital heart disease Facioscapulohumeral MD, OMIM #158900 (4q35)

Maternal SLE

Kearns-Sayre syndrome, OMIM

#530000

Emery-Dreifuss MD, OMIM #310300 (Xq28)

Myotonic dystrophy Progressive familial heart block, OMIM #113900

(19q13.2-q13.3, 3p21)Type 1, OMIM #160900

(19q13.2-13.3)

Type 2, OMIM #602668 (3q13.3-

q24)

Inflammatory

SLE MCTD

Rheumatoid arthritis Scleroderma

Infiltrative

Amyloidosis Hemochromatosis

Sarcoidosis

Neoplastic/traumatic

Lymphoma Radiation


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Mesothelioma Catheter ablation

Melanoma

Degenerative

Lev disease Lengre disease

Coronary artery disease

Acute MI

Note: SLE, systemic lupus erythematosus; OMIM, Online Mendelian Inheritance in Man

(database); MCTD, mixed connective tissue disease; MI, myocardial infarction.


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Commonly Used Antiarrhythmic AgentsIntravenous Dose Range/Primary Indication

Drug Loading Maintenance Primary Indication Classa

Adenosine 618 mg (rapid

bolus)

N/A Terminate reentrant SVT

involving AV node

Amiodarone 15 mg/min for 10

min, 1 mg/min for 6

h

0.51 mg/min AF, AFL, SVT, VT/VF III

Digoxin 0.25 mg q2h until

1.0 mg total

0.1250.25

mg/d

AF/AFL rate control

Diltiazem 0.25 mg/kg over 35

min (max 20 mg)

515 mg/h SVT, AF/AFL rate control IV

Esmolol500 g/kg over 1min

50 g/kg permin

AF/AFL rate control II

Ibutilide 1 mg over 10 min if

over 60 kg

N/A Terminate AF/AFL III

Lidocaine 13 mg/kg at 2050

mg/min

14 mg/min VT IB

Metoprolol 5 mg over 35 min

times 3 doses

1.255 mg q6h SVT, AF rate control;

exercise-induced VT; long QT

II

Procainamide 15 mg/kg over 60

min

14 mg/min Convert/prevent AF/VT IA

Quinidine 610 mg/kg at 0.3

0.5 mg/kg per min

N/A Convert/prevent AF/VT IA

Verapamil 510 mg over 35

min

2.510 mg/h SVT, AF rate control IV

aClassification of antiarrhythmic drugs: Class Iagents that primarily block inward sodium

current; class IA agents also prolong action potential duration; class II

antisympathetic

agents; class IIIagents that primarily prolong action potential duration; class IVcalcium

channel-blocking agents.

Note: SVT, supraventricular tachycardia; AV, atrioventricular; AF, atrial fibrillation; AFL,

atrial flutter; VT, ventricular tachycardia; VF, ventricular fibrillation.


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Commonly Used Antiarrhythmic AgentsChronic Oral Dosing/Primary Indications

Drug Dosing Oral,

mg,

Maintenance

Half-

Life,

h

Primary Route(s) of

Metabolism/Elimination

Most Common

Indication

Classa

Acebutolol 200400 mg

q12h

67 Renal/hepatic AF rate

control/SVT

II

Long

QT/RVOT VT

Amiodarone 100400 qd 4055

d

Hepatic AF/VT

prevention

III

Atenolol 25100 mg/d 69 Renal AF rate

control/SVT

II

Long

QT/RVOT VT

Digoxin 0.1250.5 qd 3848 Renal AF rate control

Diltiazem 3060 q6h 34.5 Hepatic AF rate

control/SVT

IV

Disopyramide 100300 q68h 410 Renal 50%/hepatic AF/SVT

prevention

Ia

Dofetilide 0.1250.5 q12h 10 Renal AF prevention III

Flecainide 50200 q12h 722 Hepatic 75%/renal AF/SVT/VT

prevention

Ic

Metoprolol 25100 q6h 38 Hepatic AF rate

control/SVT

II

Long

QT/RVOT VT

Mexiletine 150300 q8

12h

1014 Hepatic VT prevention Ib

Moricizine 100400 q8h 313 Hepatic 60%/renal AF prevention Ic

Nadolol 40240 mg/d 1024 Renal Same as

metoprolol

II

Procainamide 250500 q36h 35 Hepatic/renal AF/SVT/VT

prevention

Ia

Propafenone 150300 q8h 28 Hepatic AF/SVT/VT

prevention

Ic

Quinidine 300600 q6h 68 Hepatic 75%/renal AF/SVT/VT

prevention

Ia


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Sotalol 80160 q12h 12 Renal AF/VT

prevention

III

Verapamil 80120 q68h 4.5

12

Hepatic/renal AF rate

control/RVOT

VT

IV

Idiopathic LV

VT

aClassification of antiarrhythmic drugs: Class Iagents that primarily block inward sodium

current; class IIantisympathetic agents; class IIIagents that primarily prolong action

potential duration; class IVcalcium channel-blocking agents.


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Common Nonarrhythmic Toxicity of Most Frequently Used Antiarrhythmic Agents

Drug Common Nonarrhythmic Toxicity

Amiodarone Tremor, peripheral neuropathy, pulmonary inflammation, hypothyroidismand hyperthyroidism, photosensitivity

Adenosine Cough, flushing

Digoxin Anorexia, nausea, vomiting, visual changes

Disopyramide Anticholinergic effects, decreased myocardial contractility

Dofetilide Nausea

Flecainide Dizziness, nausea, headache, decreased myocardial contractility

Ibutilide Nausea

Lidocaine Dizziness, confusion, delirium, seizures, comaMexiletine Ataxia, tremor, gait disturbances, rash, nausea

Moricizine Mood changes, tremor, loss of mental clarity, nausea,

Procainamide Lupus erythematosuslike syndrome (more common in slow acetylators),

anorexia, nausea, neutropenia

Propafenone Taste disturbance, dyspepsia, nausea, vomiting

Quinidine Diarrhea, nausea, vomiting, cinchonism, thrombocytopenia

Sotalol Hypotension, bronchospasm


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Proarrhythmic Manifestations of Most Frequently Used Antiarrhythmic Agents

Drug Common Proarrhythmic Toxicity

Amiodarone Sinus bradycardia, AV block, increase in defibrillation threshold

Rare: long QT and torsades des pointes, 1:1 ventricular conduction with atrial

flutter

Adenosine All arrhythmias potentiated by profound pauses, atrial fibrillation

Digoxin High-grade AV block, fascicular tachycardia, accelerated junctional rhythm,

atrial tachycardia

Disopyramide Long QT and torsades des pointes, 1:1 ventricular response to atrial flutter;

increased risk of some ventricular tachycardias in patients with structural

heart disease

Dofetilide Long QT and torsades des pointes

Flecainide 1:1 Ventricular response to atrial flutter; increased risk of some ventricular

tachycardias in patients with structural heart disease; sinus bradycardia

Ibutilide Long QT and torsades des pointes

Procainamide Long QT and torsades des pointes, 1:1 ventricular response to atrial flutter;

increased risk of some ventricular tachycardias in patients with structural

heart disease

Propafenone 1:1 Ventricular response to atrial flutter; increased risk of some ventricular

tachycardias in patients with structural heart disease; sinus bradycardia

Quinidine Long QT and torsades des pointes, 1:1 ventricular response to atrial flutter;increased risk of some ventricular tachycardias in patients with structural

heart disease

Sotalol Long QT and torsades des pointes, sinus bradycardia

Note: AV, atrioventricular.

drugs for the treatment of chronic heart failure

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