This powerpoint is a case presentation, that explains the case of ADCHF, with comorbidities, comprising HTN, CAD and DLP. A summary on the recent advancements in HF management, along with justification of therapy provided, has been elucidated. A note on home remedies and counselling tips has also been provided.

1. PRESENTED BY:
VISHNU.R.NAIR,
PHARM.D INTERN,
NATIONAL COLLEGE OF PHARMACY(NCP).

2.  Name: Mr.X
 Age: 60 years
 Sex: Male
 Weight: 56 kg
 Height: 163 cm
 I.P: 265540
 Department: Cardiology
 BMI: 21.63
 DOA: 26.04.2019
 DOD: 30.04.2019
 DURATION OF HOSPITAL STAY: 5 days.

3. C/O
Breathlessness on
exertion (6 weeks)
Chest
pain(radiating to
left arm)
Palpitation

4. HISTORY OF….. MEDICATION TAKEN DURATION OF DISEASE AND
THERAPY…
i. HTN i. T. Ramistar(Ramipril) i. 3 years
i. CAD i. T. Ecospirin(Aspirin) i. 1.5 years
i. DLP i. T. Atorva(Atorvastatin) i. 2 years

5. DATE D1 D2 D3 D4 D5
Temperature N N N N N
B.P 140/90 160/80 120/80 130/80 140/90
Pulse 88 80 80 82 80
RR 22 18 20 22 20

6. PARAMETER VALUE OBSERVED
Hemoglobin 15.0 g/dl
TLC 7,410 cells/mm3
Platelets 2.21 lakh cells/mm3
PCV 44.6
RBC 5.47 * 106 cells/mm3
RBS 169 mg/dl
FBS 108 mg/dl

7. PARAMETER VALUE OBSERVED
Urea 33.71
S.Cr 1.56
Uric acid 4.70

8. DATE D1 D2 D3 D4 D5
Sodium 127 133 135 135 140
Potassium 3.3 3.4 3.3 3.5 3.9

9. DATE D1 D2 D3 D4 D5
Troponin-I 99 91 65 67 61
ECHO FINDINGS Concentric LVH, significant LV
dysfunction

10. +Patient complaints Medical history of patient
Patient was diagnosed as “Acutely
decompensated HF, severe LV
dysfunction, moderate PAH, severe TR”.

11. Staging, as per New York Heart Association(NYHA), of HF!

12. HEART FAILURE AND ITS MANAGEMENT:
IMPORTANT CATCHPOINTS

13. …..a complex clinical syndrome that results from any structural or
functional cardiac impairment of ventricle filling or ejection of blood
Congestive heart failure (CHF) is a subset of HF, characterized by left
ventricular (LV) systolic dysfunction and volume excess
HF is further subdivided into HF with reduced left ventricular ejection
fraction (HFrEF) or HF with preserved left ventricular ejection
fraction (HFpEF), previously known as diastolic HF.

14. DRUGS INVOLVED SIGNIFICANT COMMENTS…..
Beta-blockers - Most with propranolol & associated non-selective
agents
- Less risk with ISA(acebutolol, carteolol, pindolol)
- Timolol eye drops also carry risk!
CCBs - Verapamil has most negative inotropic & AV-
blocking effects
- Amlodipine has least!
Antiarrhythmics - Disopyramide, flecainide, dronedarone!

15. DRUGS INVOLVED SIGNIFICANT COMMENTS…..
Cocaine, amphetamines - Occurs with overdose
- Also associated with long-term myopathy
Anthracyclines - Daunorubicin & doxorubicin
- Usually dose-related
- Total cumulative dose <600 mg/m2

16. DRUGS INVOLVED SIGNIFICANT COMMENTS…..
Class IA, III antiarrhythmic drugs - QT-interval widening
- TdP possible
- If above altered rhythm  distorts cardiac
functioning  HF may occur!
Non-arrhythmic drugs - Same mechanism as above
- Clinically significant drug interactions  increase
“C” of offending drug  HF can occur!

17. DRUGS INVOLVED SIGNIFICANT COMMENTS……
TNF-ANTAGONISTS There have been various case reports of new-onset HF
OR exacerbation of previous HF in patients treated
with infliximab and etanercept, when treated for
Crohn’s disease or RA!

18. DRUGS INVOLVED SIGNIFICANT COMMENTS…..
Antidiabetics - Thiazolidinediones(Pioglitazone, rosiglitazone 
cause Na+ retention)
- DPP-IV inhibitors(gliptins)
NSAIDs - Prostaglandin blocking
- Na+ retention
Glucocorticoids, androgens, estrogens - Mineralocorticoid effect
- Na+ retention
Licorice - Aldosterone-mimicking effect
- Na+ retention
Antihypertensives(hydralazine, methyldopa, prazosin,
minoxidil)
- Renal blood flow reduced  RAAS activation!
Drugs, high in Na+ - Selected i.v penicillins, cephalosporins
- Bicarbonate-containing antacids & analgesics

21. SUBJECTIVE
MANIFESTATIONS
OBJECTIVE FINDINGS
 DOE(Dyspnea on
exertion),
 SOB,
 Orthopnea,
PND(Paroxysmal
nocturnal dyspnea),
 cough,
 weakness,
 fatigue,
 confusion, etc.
 LVH
 EF <40%
 RALES
 S3 gallop rhythm
 Reflex tachycardia
 Increased BUN(Poor
renal perfusion)
SUBJECTIVE
MANIFESTATIONS
OBJECTIVE FINDINGS
 Peripheral edema  Weight gain(fluid
retention)
 Neck vein distension
 Hepatomegaly
 Hepatojugular reflex
Left ventricular dysfunction Right ventricular dysfunction

24.  Include “inamrinone(amrinone), milrinone, enoximone & vesnarinone”
 Have both inotropic & vasodilatory effects
 Drugs  block Phosphodiesterase III  increase cyclic AMP conc.  increase
calcium influx in heart & blood vessels
 Indicated for short-term severe & refractory CHF
 Inamrinone  causes thrombocytopenia  substituted by milrinone!
 Levosimendan  newer molecule!
 Drug  binds to troponin C  increases Ca++ sensitization
 Drug  opens potassium channels  causes vasodilation!

25.  BNP  secreted by ventricles
 BNP  helps to differentiate cardiac from pulmonary causes of dyspnea
 Nesiritide  recombinant BNP
 Drug  increases cyclic GMP  vasodilation!
 Can be used for acute CHF with dyspnea at rest
 Demerit: Breakdown of drug by enzyme neutral endopeptidase(NEP)
 Remedy: Inhibit the enzyme using sacubitril!

26. Funny current blocker
Indicated in angina pectoris
Drug  causes bradycardia  reduces myocardial oxygen demand
According to European guidelines  ivabradine  recommended for
patients with :
a. HR > 70 bpm
b. EF < 35%
c. Refractory to beta-blockers, ACE-inhibitors & aldosterone antagonists!

27.  Include: “Omapatrilat & sampatrilat”
 Inhibit enzymes ACE & NEP
 Major ADR: Angioedema
 Alternative: Usage of combo of valsartan + sacubitril!

28.  “Alstaroxime”
Investigational steroid
Under Phase II trials currently
Same mechanism as digoxin
Benefits over digoxin:
- Increased influx of Ca++ in sarcoplasmic reticulum
- Lesser arrhythmic side effects, compared to digoxin!

29. BACK TO THE CASE!

30. Sl No. Brand name Generic name Dosage D1 D2 D3 D4 D5
1. Inj. Lasix Furosemide 40 mg, i.v, TID Y Y Y Y Y
2. T. Lanoxin Digoxin 0.125 mg, OD Y Y Y Y Y
3. T. Ramistar Ramipril 5 mg, OD Y Y Y Y Y
4. T. GTN Sorbitrate Nitroglycerin 2.6 mg, (1-0-1) Y Y Y Y Y
5. T. Cardivas Carvedilol 6.25 mg, (1-0-1) Y Y Y Y Y
6. T. Aztolet Atorvastatin+ Clopidogrel 20/75 mg, HS Y Y Y Y Y
7. T. Pan D Pantoprazole+ Domperidone P/O, (1-0-0) Y Y Y Y Y
8. T. Natrise Tolvaptan 15 mg, (1-0-1) Y Y Y Y Y
9. Syp. Potklor KCl (1-0-1) Y Y Y Y Y
10. Inj. Heparin Heparin 5000 IU, s.c, Q8H Y Y Y Y Y

38. DAY OBSERVATIONS
1 - Patient complaints
- Chest discomfort high, hypokalemic
- Palpitations (+), Trop.I high
2 - Hypokalemia persists
- Trop.I reduced, but still significant
- Manifestations reduced
3 - Trop.I reduced, but still significant
- No fresh complaints
- Potassium levels normalized
4 - No fresh complaints
- Trop.I reduced, but still significant
5 - No fresh complaints, patient discharged.

39.  A 60 year old male patient  with k/c/o HTN, DLP & CAD
Presented with breathlessness & chest pain
 Trop.I  highly significant
 Patient was diagnosed as ADCHF
 Treated with diuretics, digoxin, ACE-I and other supportive measures
 Discharged in clinically stable condition.

40.  T. Lasix, 40 mg, [1-1-1/2]
 T. GTN Sorbitrate, 2.6 mg, [1-0-1]
 T. Cardivas, 6.25 mg, [1-0-1]
 T. Aztolet, 75/20 mg, [0-0-1]
 T. Natrise, 15 mg, [1-0-0]
 T. Lanoxin, 0.125 mg, [OD]
 T. Ramistar, 5 mg, [1-0-0]
 T. Pan, 40 mg, [1-0-0]
 Syp. Potklor, 1 tsp., [1-0-1]
Review after 2
weeks in
Cardiology OPD!

41. PHARMACIST
OBSERVATIONS

42. Drugs
involved
Severity Mechanism Consequence Management Reference
Atorvastatin +
Digoxin
Major Unknown High “C” of digoxin TDM of
digoxin, modify
dose as needed
Stockley’s drug
interactions, 2015
Carvedilol +
Digoxin
Major Pharmacodynamic
synergism
High risk of complete
heart block
TDM of
digoxin, modify
dose as needed
SDI, 2015
Clopidogrel +
Heparin
Major Pharmacodynamic
synergism
High risk of bleeding Monitor for
bleeding
SDI, 2015
Tolvaptan +
Digoxin
Major Unknown High “C” of digoxin TDM of
digoxin, modify
dose as needed
SDI, 2015
Digoxin +
Furosemide
Moderate Enhanced K+ loss High risk of digoxin
toxicity
Monitoring of
K+
SDI, 2015

43. 1. T.Lasix(Furosemide):
- Potent risk of hypokalemia  good intake of potassium supplements worthwhile!
- Avoid activities requiring mental alertness & co-ordination, since it may cause
dizziness
2. T.GTN Sorbitrate(Nitroglycerin):
- Report severe hypotension
- Avoid activities requiring mental alertness & co-ordination, since it may cause
dizziness

44. 3. T.Cardivas(Carvedilol):
- Avoid activities requiring mental alertness & co-ordination, since it may cause
dizziness
- Report signs & symptoms of severe hypotension
- Drug should be taken with food
- Avoid sudden drug discontinuation
4. T. Ramistar(Ramipril):
- Avoid activities requiring mental alertness & co-ordination, since it may cause
dizziness
- Rise slowly from a sitting or lying position
- Report symptoms of angioedema(deep swelling around eyes & lips)

45. - Maintain sufficient hydration to prevent volume depletion and subsequent
hypotension
5. T. Lanoxin(Digoxin):
- Report symptoms of drug toxicity(anorexia, nausea, vomiting, vision
disturbances, halo-effect, arrhythmias)
6. T. Aztolet(Atorvastatin + Clopidogrel):
- Report manifestations of myopathy(muscle pain, tenderness, weakness)
- Report manifestations of liver injury(dark urine, upper abdominal discomfort)
- Can be taken at any time of day!!!!!!

46. 7. T. Pan(Pantoprazole):
- Should be taken at least 30 minutes before or 2 hours after food
- Report if non-resolving diarrhea occurs
- Report manifestations of hypomagnesemia(dizziness, palpitations, seizures)
8. T. Natrise(Tolvaptan):
- Report manifestations of osmotic demyelination syndrome(dysarthria, mutism,
lethargy, dysphagia, spastic quadriparesis)
- Report manifestations of liver injury
- Maintain adequate hydration to prevent risk of dehydration & hypovolemia!

47. Cucurbocitrin  powerful
vasodilation!
Lemon juice

48. Rich in potassium, magnesium &
Vitamin C  Help to reduce SBP!

49. Honey Fenugreek seeds

51. Add good amount of sleep,
balanced diet, avoidance of
saturated fats, sufficient
exercise and stress removal
as CONDIMENTS!

52. ANY QUERIES?