Pharmacological Approach to Congestive Heart Failure Disease

1. Pharmacological Approach to Congestive Heart Failure Disease

2. Congestive Heart Failure • Heart failure occurs when cardiac output is inadequate to provide the oxygen needed by the body. • It is a highly lethal condition, with a 5-year mortality rate conventionally is about 50%. • The most common cause of heart failure in the USA is coronary artery disease. • Two major types of failure may be distinguished. • In systolic failure, the mechanical pumping action (contractility) and the ejection fraction of the heart are reduced. • In diastolic failure stiffening and loss of adequate relaxation plays a major role in reducing cardiac output and ejection fraction may be normal. • Because other cardiovascular conditions are now being treated more effectively (especially myocardial infarction), more patients are surviving long enough for heart failure to develop, making this one of the cardiovascular conditions that is actually increasing in prevalence.

3. Congestive Heart Failure • The primary defect in early heart failure resides in the excitation-contraction coupling machinery of the heart • Congestive Heart Failure also involves many other processes and organs, including; • the baroreceptor reflex, • the sympathetic nervous system, • the kidneys, • angiotensin II and other peptides, • aldosterone, and • apoptosis of cardiac cells.

4. Drug groups commonly used in heart failure. • Diuretics • Aldosterone receptor antagonists • Angiotensin-converting enzyme inhibitors • Angiotensin receptor blockers • Beta blockers • Cardiac glycosides • Vasodilators • Beta agonists, dopamine • Bipyridines • Natriuretic peptide

5. Congestive Heart Failure • Clinical research has shown that therapy directed at noncardiac targets is more valuable in the long-term treatment of heart failure than traditional positive inotropic agents (cardiac glycosides [digitalis]). • Careful clinical trials have shown that angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, aldosterone receptor antagonists, and combined hydralazine-nitrate therapy are the only agents in current use that actually prolong life in patients with chronic heart failure. • Positive inotropic drugs, on the other hand, can be very helpful in acute failure. • They also reduce symptoms in chronic failure.

6. Control of Normal Cardiac Contractility • The vigor of contraction of heart muscle is determined by several processes that lead to the movement of actin and myosin filaments in the cardiac sarcomere. • Ultimately, contraction results from the interaction of activator calcium (during systole) with the actin-troponin-tropomyosin system, thereby releasing the actin-myosin interaction. • The calcium is released from the sarcoplasmic reticulum (SR). • The amount released depends on the amount stored in the SR and on the amount of trigger calcium that enters the cell during the plateau of the action potential.

7. A. SENSITIVITY OF THE CONTRACTILE PROTEINS TO CALCIUM • The determinants of calcium sensitivity, ie, the curve relating the shortening of cardiac myofibrils to the cytoplasmic calcium concentration, are incompletely understood, but several types of drugs can be shown to affect it in vitro. Levosimendan is the most recent example of a drug that increases calcium sensitivity (it may also inhibit phosphodiesterase) and reduces symptoms in models of heart failure.B. THE AMOUNT OF CALCIUM RELEASED FROM THE SARCOPLASMIC RETICULUMA small rise in free cytoplasmic calcium, brought about by calcium influx during the action potential, triggers the opening of ryanodine-sensitive calcium channels (RyR2) in the membrane of the cardiac SR and the rapid release of a large amount of the ion into the cytoplasm in the vicinity of the actin-troponin-tropomyosin complex. The amount released is proportional to the amount stored in the SR and the amount of trigger calcium that enters the cell through the cell membrane. (Ryanodine is a potent negative inotropic plant alkaloid that interferes with the release of calcium through cardiac SR channels.)C. THE AMOUNT OF CALCIUM STORED IN THE SARCOPLASMIC RETICULUMThe SR membrane contains a very efficient calcium uptake transporter, known as the sarcoplasmic endoplasmic reticulum Ca2+-ATPase (SERCA). This pump maintains free cytoplasmic calcium at very low levels during diastole by pumping calcium into the SR. The amount of calcium sequestered in the SR is thus determined, in part, by the amount accessible to this transporter. This in turn is dependent on the balance of calcium influx (primarily through the voltage-gated membrane calcium channels) and calcium efflux, the amount removed from the cell (primarily via the sodium-calcium exchanger, a transporter in the cell membrane).

8. D. THE AMOUNT OF TRIGGER CALCIUMThe amount of trigger calcium that enters the cell depends on the availability of membrane calcium channels (primarily the L type) and the duration of their opening. Sympathomimetics cause an increase in calcium influx through an action on these channels. Conversely, the calcium channel blockers reduce this influx and depress contractility.E. ACTIVITY OF THE SODIUM-CALCIUM EXCHANGERThis antiporter uses the sodium gradient to move calcium against its concentration gradient from the cytoplasm to the extracellular space. Extracellular concentrations of these ions are much less labile than intracellular concentrations under physiologic conditions. The sodium-calcium exchanger's ability to carry out this transport is thus strongly dependent on the intracellular concentrations of both ions, especially sodium.F. INTRACELLULAR SODIUM CONCENTRATION AND ACTIVITY OF NA+/K+ ATPASENa+/K+ ATPase, by removing intracellular sodium, is the major determinant of sodium concentration in the cell. The sodium influx through voltage-gated channels, which occurs as a normal part of almost all cardiac action potentials, is another determinant although the amount of sodium that enters with each action potential is much less than 1% of the total intracellular sodium. As described below, Na+/K+ ATPase appears to be the primary target of cardiac glycosides.

9. Congestive Heart Failure Disease Schematic diagram of a cardiac muscle sarcomere, with sites of action of several drugs that alter contractility (numbered structures). Site 1 is Na+/K+ ATPase, the sodium pump. Site 2 (NaxC) is the sodium/calcium exchanger. Site 3 is the voltage-gated calcium channel. Site 4 (SERCA) is a calcium transporter that pumps calcium into the sarcoplasmic reticulum (SR). Site 5 (RyR) is a calcium channel in the membrane of the SR that is triggered to release stored calcium by activator calcium. Site 6 is the actin-troponin-tropomyosin complex at which activator calcium brings about the contractile interaction of actin and myosin.

10. (1) Preload: • left ventricular filling pressure or end-diastolic fiber length, • Preloads greater than 20-25 mm Hg result in pulmonary congestion. • Preload is usually increased in heart failure because of increased blood volume and venous tone. • Because the curve of the failing heart is lower, the plateau is reached at much lower values of stroke work or output. • Increased fiber length or filling pressure increases oxygen demand in the myocardium. • Reduction of high filling pressure is the goal of salt restriction and diuretic therapy in heart failure. • Venodilator drugs (eg, nitroglycerin) also reduce preload by redistributing blood away from the chest into peripheral veins.

11. (2) Afterload: • Afterload is the resistance against which the heart must pump blood and is represented by aortic impedance and systemic vascular resistance. • As cardiac output falls in chronic failure, there is a reflex increase in systemic vascular resistance, mediated in part by increased sympathetic outflow and circulating catecholamines and in part by activation of the renin-angiotensin system. • Endothelin, a potent vasoconstrictor peptide, may also be involved. • This sets the stage for the use of drugs that reduce arteriolar tone in heart failure.

12. (3) Contractility: • Heart muscle obtained by biopsy from patients with chronic low-output failure demonstrates a reduction in intrinsic contractility. • As contractility decreases in the patient, there is a reduction in the velocity of muscle shortening, the rate of intraventricular pressure development (dP/dt), and the stroke output achieved. • However, the heart is still capable of some increase in all of these measures of contractility in response to inotropic drugs.

13. (4) Heart rate: • The heart rate is a major determinant of cardiac output. • As the intrinsic function of the heart decreases in failure and stroke volume diminishes, an increase in heart rate (through sympathetic activation of beta adrenoceptors) is the first compensatory mechanism that comes into play to maintain cardiac output.

14. Relation of left ventricular (LV) performance to filling pressure in patients with acute myocardial infarction, an important cause of heart failure. The upper line indicates the range for normal, healthy individuals. If acute heart failure occurs, function is shifted down and to the right. Similar depression is observed in patients with chronic heart failure. (Modified and reproduced with permission, from Swan HJC, Parmley WW: Congestive heart failure. In: Sodeman WA Jr, Sodeman TM [editors]. Pathologic Physiology. Saunders, 1979.)

15. Positive Inotropic Drugs Cardiac Glycosides Digoxin Digitoxin Ouabain Bipyridines Inamrinone Milrinone Beta adrenoceptor Stimulants Dobutamine Dopamine Calcium Sensitizers Levosimendan Diuretics Furacemide Hydrochlorothiazide Spironolactone ACE inhibitors Captopril Enalapril Lisinopril Vasodilators Nitroprusside Isosorbide dinitrate Hydralazine Beta blockers Carvedilol Bismolol Metoprolol Drugs Commonly used in Heart Failure

16. Congestive Heart Failure Disease

17. Congestive Heart Failure Disease

18. Electrocardiographic record showing digitalis-induced bigeminy. The complexes marked NSR are normal sinus rhythm beats; an inverted T wave and depressed ST segment are present. The complexes marked PVB are premature ventricular beats and are the electrocardiographic manifestations of depolarizations evoked by delayed oscillatory afterpotentials. (Modified and reproduced, with permission, from Goldman MJ: Principles of Clinical Electrocardiography, 12th ed. Lange, 1986.)

22. Autonomic and hormonal control of cardiovascular function. Two feedback loops are present: the autonomic nervous system loop and the hormonal loop. The sympathetic nervous system directly influences four major variables: peripheral vascular resistance, heart rate, force, and venous tone. It also directly modulates renin production (not shown). The parasympathetic nervous system directly influences heart rate. In addition to its role in stimulating aldosterone secretion, angiotensin II directly increases peripheral vascular resistance and facilitates sympathetic effects (not shown). The net feedback effect of each loop is to compensate for changes in arterial blood pressure. Thus, decreased blood pressure due to blood loss would evoke increased sympathetic outflow and renin release. Conversely, elevated pressure due to the administration of a vasoconstrictor drug would cause reduced sympathetic outflow, reduced renin release, and increased parasympathetic (vagal) outflow.