CHAPTER 22

Heart Failure Drugs

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Heart Failure

The heart is unable to pump blood in sufficient amounts from the ventricles to meet the bodys metabolic needs Symptoms depend on the cardiac area affected

Systolic dysfunction Diastolic dysfunction Less common

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Heart Failure: Causes

Cardiac defect

Myocardial infarction Valve deficiency

Coronary artery disease Pulmonary hypertension Diabetes

Defect outside the heart

Supraventricular dysrhythmias

Atrial fibrillation Atrial flutter

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Drug Therapy for Heart Failure

Positive inotropic drugs

Increase the force of myocardial contraction Increase heart rate Accelerate cardiac conduction

Positive chronotropic drugs

Positive dromotropic drugs

Used to treat heart muscle failure

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Drug Therapy for Heart Failure

ACE inhibitors Angiotensin II receptor blockers B-type natriuretic peptides Phosphodiesterase inhibitors Cardiac glycosides

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ACE Inhibitors Mechanism of Action

Prevent sodium and water resorption by inhibiting aldosterone secretion Diuresis results, which decreases preload, or the left ventricular end-volume, and the work of the heart Examples: lisinopril, enalapril, captopril, others

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Angiotensin II Receptor Blockers Mechanism of Action

Potent vasodilators; decrease systemic vascular resistance (afterload) Examples: valsartan, candesartan, losartan

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B-type Natiuretic Peptides

nesiritide (Natrecor)

Used in severe, life-threatening heart failure

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B-type Natiuretic Peptides: Mechanism of Action

Vasodilating effects on arteries and veins Indirectly increases cardiac output Suppresses renin-angiotensin system Diuresis

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B-type Natiuretic Peptides: Adverse Effects

Hypotension Dysrhythmia Headache Abdominal pain

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Phosphodiesterase Inhibitors Mechanism of Action

Work by inhibiting the enzyme phosphodiesterase Results in:

Positive inotropic response Vasodilation Inamrinone and milrinone

Two drugs (inodilators)

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Phosphodiesterase Inhibitors: Indications

Short-term management of heart failure Given when patient does not respond to treatment with digoxin, diuretics, and/or vasodilators AHA and ACC advise against weekly infusions

No improvement of clinical status

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Phosphodiesterase Inhibitors: Adverse Effects

inamrinone

Thrombocytopenia, most worrisome Dysrhythmia, nausea, hypotension Elevated liver enzymes with long-term use

milrinone

Dysrhythmia, mainly ventricular Hypotension, angina, hypokalemia, tremor, thrombocytopenia

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Cardiac Glycosides

No longer used as first-line treatment Originally obtained from Digitalis plant, foxglove Digoxin is the prototype Used in heart failure and to control ventricular response to atrial fibrillation or flutter

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Cardiac Glycosides: Mechanism of Action

Increase myocardial contractility Change electrical conduction properties of the heart

Decrease rate of electrical conduction Prolong the refractory period Area between SA node and AV node

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Cardiac Glycosides: Drug Effects

Positive inotropic effect

Increased force and velocity of myocardial contraction (without an increase in oxygen consumption) Reduced heart rate

Negative chronotropic effect

Negative dromotropic effect

Decreased automaticity at SA node, decreased AV nodal conduction, and other effects

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Cardiac Glycosides: Drug Effects (contd)

Increased stroke volume Reduction in heart size during diastole Decrease in venous BP and vein engorgement Increase in coronary circulation Promotion of diuresis because of improved blood circulation Palliation of exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis

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Cardiac Glycosides: Indications

Heart failure Supraventricular dysrhythmias

Atrial fibrillation and atrial flutter

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Cardiac Glycosides: Adverse Effects

digoxin (Lanoxin)

Very narrow therapeutic window Drug levels must be monitored 0.5 to 2 ng/mL Low potassium levels increase its toxicity Electrolyte levels must be monitored

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Cardiac Glycosides: Adverse Effects (contd)

digoxin (Lanoxin) (contd)

Cardiovascular Dysrhythmias, including bradycardia or tachycardia CNS Headaches, fatigue, malaise, confusion, convulsions

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Cardiac Glycosides: Adverse Effects (contd)

digoxin (Lanoxin) (contd)

Eye Colored vision (seeing green, yellow, purple), halo vision,

flickering lights

GI Anorexia, nausea, vomiting, diarrhea

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Digoxin Toxicity

digoxin immune Fab (Digibind) therapy

Hyperkalemia (serum potassium greater than 5 mEq/L) in a digitalis-toxic patient Life-threatening cardiac dysrhythmias Life-threatening digoxin overdose

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Conditions That Predispose to Digoxin Toxicity

Electrolyte imbalances

Hypokalemia Hypomagnesemia Hypercalcemia

Acid-base imbalances Hypothyroidism Renal or Hepatic dysfunction Dehydration

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Heart Failure Drugs: Nursing Implications

Assess history, drug allergies, contraindications Assess clinical parameters, including:

BP Apical pulse for 1 full minute Heart sounds, breath sounds

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Heart Failure Drugs: Nursing Implications (contd)

Assess clinical parameters (contd)

Weight, I&O measures ECG Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies

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Heart Failure Drugs: Nursing Implications (contd)

Before giving any dose, count apical pulse for 1 full minute For apical pulse less than 60 or greater than 100 beats/minute

Hold dose Notify prescriber

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Heart Failure Drugs: Nursing Implications (contd)

Hold dose and notify prescriber if patient experiences signs/symptoms of toxicity

Anorexia, nausea, vomiting, diarrhea Visual disturbances (blurred vision, seeing green or yellow halos around objects)

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Heart Failure Drugs: Nursing Implications (contd)

Check dosage forms carefully, and follow instructions for giving Avoid giving digoxin with high-fiber foods (fiber binds with digitalis) Patients should immediately report a weight gain of 2 or more pounds in 1 day or 5 or more pounds in 1 week

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Heart Failure Drugs: Nursing Implications (contd)

Nesiritide, inamrinone, or milrinone

Use an infusion pump Monitor I&O, heart rate and rhythm, BP, daily weights, respirations, and so on Do not mix with dextrose Solution color is true yellow

IV inamrinone

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Heart Failure Drugs: Nursing Implications (contd)

Monitor for therapeutic effects

Increased urinary output Decreased edema, shortness of breath, dyspnea, crackles, fatigue Resolution of paroxysmal nocturnal dyspnea Improved peripheral pulses, skin color, temperature

Monitor for adverse effects

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Critical Thinking
A patient has been receiving digoxin therapy for 2 months. During todays visit, he tells you that he has been seeing yellowish rings around lights and has had no appetite. His latest blood potassium level is 5.6 mEq/L. What is the concern with this patient, and what should be done?

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