- Given in conjunction with Diuretics and with EF less than 35
4 ACE Inhibitor Meds
Fosinopril (Monopril)Reduce SS
Quinapril (Accupril) Reduce SS
Ramipril (Altace) Rx. HF/LVD
Trandolopril (Mavik) Rx. HF/LVD
5 Goals of Treatment
Increase ejection fraction and reduce cardiac workload.
6 Mechanism of Action
Hypovolemia Hypotension Decrease BF
Renin release Angiotensinogen
Angiotensin Converting Angiotensin I
I I I
Peripheral Na and H2O Noeepinephrine
Vasoconstriction Retention Release
Initiate low doses
Renal function should be assessed routinely.(Within the first two weeks of initiating treatment)
Doses should be increased to those doses that are effective and do not present any negative events.
Capropril at least 150md/day
Initiate treatment at 6.25mg tid to 12md tid to 25mg tid if tolerated. Can increase to 50mg tid as target dose.
Lisinopril at least 20mg/day
5mg initial dose- first 24hr followed by 10 mg 48hr/daily maint.
titrate dosage according to patient symptomology.
Enalapril at least 20mg/day
5mg initial dose first 24hr followed by 10mg 48hr/daily mainenance titrate according to patient
Decrease BP lt 80mmHg systolic
Increase Serum Creatinine gt3mg/dl
Bilateral renal artery stenosis
Elevated serum potassium gt5.5mmol/L
10 Adverse Effects
Taken in conjunction with ACE inhibitors and Beta Blockers
Low dose diuretic therapy
Titrate according to patient symptoms
12 Diuretic Interactions
NSAIDS (including ASA)
Blunt the diuretic effect may need to increase dosage of diuretic
Decrease Lithium clearance- levels may be increased in blood.
Diuretics are ototoxic at higher levels
13 Digoxin (Lanoxin)
Decreases cardiac workload
Increase Cardiac Output
Regulates heart rate and cardiac overall performance
Use in HF patients (LV systolic dysfunction)
14 Digoxin Dosage
.125mgdaily for reduced renal function small and elderly
Therapeutic levels .9 1.2mg/ml
with levels as high as 2 mg/ml
Digibind Digoxin Toxicity
15 Beta Blockers
Originally were contraindicated related to the negative inotropic effects bradycardia
Use is limited to experiental
16 Angiotensin II Type I Receptor Antagonists
Do not block the degradation of vasoactive substances (eg. Bradykinin enkephalins)
Decreases the adverse effects associated with ACE inhibitors such as cough- related to bradykinin accumulation
17 ARB or AT1
Increase Cardiac Index
Decrease DOE and HF exacerbation
18 Calcium Channel Blockers
Currently recommended to be avoided with patients in HF and LV dysfunction.
Avoid in HF even when patient also presents with angina or hypertension.
19 Calcium Channel Dosage
Amlodipine (Norvasc) and Felodipine (Plendil) should be prescribed for treating hypertension or angina in the amount of 5 10mg daily.
20 HF Treatment Algorhythm
Assessment of LV function (Echo)
Ejection Fraction lt40
Assessment of Volume Status (SS of fluid retention)
I (Yes) I (No)
Diuretic ACE Inhibitor
(Titrate as necessary) I gt Digoxin
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