This document discusses congestive heart failure and cardiotonics. It begins by defining heart failure and its causes. It then focuses on congestive heart failure, symptoms, and compensatory physiological responses. The aim of treatment is to reduce cardiac workload, relieve pulmonary congestion, and increase contractility. Cardiotonics, also called cardiac glycosides, are discussed as a treatment option. Digitalis is a cardiotonic that increases cardiac output and strength of contraction through inhibition of sodium-potassium ATPase pumps. Side effects and interactions are also summarized.

1. CONGESTIVE CARDIAC
FAILURE AND
CARDIOTONICS
Mr. Sujit Karpe
PRINCIPAL,
SOJAR COLLEGE OF PHARMACY, KHANDVI

2. • Heart failure is the progressive inability of the heart to
supply adequate blood flow to vital organs.
• It is classically accompanied by significant fluid retention.
• It is a leading cause of mortality and morbidity.
CONGESTIVE HEART FAILURE

3. CONGESTIVE HEART FAILURE

5. EJECTION FRACTION

6. SYMPTOMS

7.  CHF results when the output of the heart is
insufficient to supply adequate levels of oxygen for
the body.
 Components of failure:
Impaired contractility
circulatory congestion
 Compensatory elevation in angiotensin II production
results in sodium retention and vasoconstriction and
increases both matrix formation and remodeling.
OVERVIEW

8. Compensatory physiological responses in HF
Increased sympathetic activity
Activation of the renin-angiotensin system
Myocardial hypertrophy

9.  By reducing cardiac work load
 By relieving the pulmonary congestion
 By increasing force of contractility
AIM OF TREATMENT

10. CARDIOTONICS
 Steroidal glycoside (Digitalis) also called
Cardiac glycoside
 Increases cardiac output
 Affect electrical function of heart
 Obtained from Digitalis purpurea or
foxglove, Digitalis lanata, Strophanthus
gratus and Strophanthus kombe
Digitalis plant

11. CARDIOTONICS - MOA
2. Increased Na+ reduces the normal exchange of
intracellular Ca2+ for extracellular Na+ and yields
somewhat elevated intracellular Ca2+.
1.Cardiac glycosides
inhibit Na+/K+-
ATPase, resulting
in increased
•intracellular
Na+
•decreased
intracellular K+.

12. CARDIOTONICS - MOA
 There are multiple isoforms of Na+/K+-ATPase;
 The cardiac isoform has the highest affinity for
digitalis.
 Following treatment, each action potential produces a
greater release of Ca2+ to activate the contractile
process.
 The net result is a positive inotropic effect.
(increase the strength of muscular contraction)

13. CARDIOTONICS - MOA
Effects of cardiac glycosides
• Cardiac glycosides have both:
 direct effects on the heart
 indirect effects mediated by an increase
in vagal tone.

14. DIGITALIS AS CARDIOTONICS
• Directly act on myocardium, increases force of contraction of heart.
• This result in more output with complete ventricular emptying.
• At same time duration of systole is reduced, allowing greater time for
ventricular filling as well as rest.
• It also reduces diastolic size of heart.
• Oxygen consumption is directly proportional to length of cardiac
muscle. So decreased size of heart reduces oxygen consumption.
• Thus digitalized heart can do same work with less energy of more
work with same energy expenditure.

15. Heart on DigoxinHeart Failure

16. CARDIOTONICS – PHARMACOLOGICAL ACTION
Cardiac Action:
i. Automaticity: increases ability of purkinje fibres and ventricular muscles to
initiate impulse
ii. Conduction velocity: slightly increased in atria and ventricles.
iii. Blood pressure: increase mean arterial pressure in normal individual only.
iv. Heart rate: not affect heart rate in normal individuals, but reduces in
congestive heart failure patients.

17. CARDIOTONICS – PHARMACOLOGICAL ACTION
Extra cardiac Action:
i. On kidney:
increases rate of excretion of Na+ and water by kidney (Diuresis effect)
ii. On gastro-intestinal tract:
high dose produces diarrhea, nausea and vomiting.

18. CARDIOTONICS – SIDE EFFECTS
i. Anorexia, nausea, vomiting and diarrhea.
ii. Headache, fatigue, insomnia.
iii. Yellow/green vision, blurred vision.
iv. Cardiac arrhythmia.

19. CARDIOTONICS – THERAPEUTIC EFFECTS
i. To treat heart failure.
ii. To treat atrial fibrillation.
iii. To treat atrial flutter.
iv. To treat paroxysmal atrial tachycardia.

20. CARDIOTONICS – CONTRAINDICATIONS
i. Myocardial infraction
ii. Ventricular tachycardia
iii. Partial heart block
iv. Previous digitalis therapy
v. Calcium administration

21. CARDIOTONICS – DRUG INTERACTIONS
i. Digitalis and Calcium
ii. Digitalis and quinidine
CARDIOTONICS – PREPARATIONS
i. Digoxin tablet IP – 0.25mg
ii. Digoxin injection IP – 0.5mg/2ml ampoule I/V
iii. Ouabaine injection - 0.5mg/2ml ampoule I/V

22. OVER DIGITALISATION
 Therapeutic level – 0.5 – 2.5 mg/ml
 Treatment:
i. Immediately stop the administration of digitalis.
ii. Stop if any diuretic administration is in continuation.
iii. Mild tachycardia can be treated with atropine
iv. Mild toxicity can be treated by administration of potassium salts (KCl – 5 to
7.5 g orally)
v. Ventricular tachycardia can be treated with Phenytoin (250mg well diluted)