Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 22 Heart Failure Drugs

2 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure  The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs  Symptoms depend on the cardiac area affected  Systolic dysfunction  Diastolic dysfunction Less common Less common

3 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure: Causes  Cardiac defect  Myocardial infarction  Valve deficiency  Defect outside the heart  Coronary artery disease  Pulmonary hypertension  Diabetes  Supraventricular dysrhythmias  Atrial fibrillation  Atrial flutter

4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

5 Drug Therapy for Heart Failure  Positive inotropic drugs  Increase the force of myocardial contraction  Positive chronotropic drugs  Increase heart rate  Positive dromotropic drugs  Accelerate cardiac conduction  Used to treat heart muscle failure

6 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Therapy for Heart Failure  ACE inhibitors  Angiotensin II receptor blockers  B-type natriuretic peptides  Phosphodiesterase inhibitors  Cardiac glycosides

7 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. ACE Inhibitors  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

8 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Angiotensin II Receptor Blockers  Potent vasodilators; decrease systemic vascular resistance (afterload)  Examples: valsartan, candesartan, losartan

9 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. B-type Natiuretic Peptides  nesiritide (Natrecor)  Used in severe, life-threatening heart failure

10 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. B-type Natiuretic Peptides: Mechanism of Action  Vasodilating effects on arteries and veins  Indirectly increases cardiac output  Suppresses renin-angiotensin system  Diuresis

11 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. B-type Natiuretic Peptides: Adverse Effects  Hypotension  Dysrhythmia  Headache  Abdominal pain

12 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Phosphodiesterase Inhibitors  Work by inhibiting the enzyme phosphodiesterase  Results in:  Positive inotropic response  Vasodilation  Two drugs (inodilators)  Inamrinone and milrinone

13 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

14 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

15 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

16 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Area between SA node and AV node

17 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Drug Effects  Positive inotropic effect  Increased force and velocity of myocardial contraction (without an increase in oxygen consumption)  Negative chronotropic effect  Reduced heart rate  Negative dromotropic effect  Decreased automaticity at SA node, decreased AV nodal conduction, and other effects

18 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Drug Effects (cont’d)  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

19 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Indications  Heart failure  Supraventricular dysrhythmias  Atrial fibrillation and atrial flutter

20 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Adverse Effects  digoxin (Lanoxin)  Very narrow therapeutic window  Drug levels must be monitored 0.5 to 2 ng/mL 0.5 to 2 ng/mL  Low potassium levels increase its toxicity  Electrolyte levels must be monitored

21 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Adverse Effects (cont’d)  digoxin (Lanoxin) (cont’d)  Cardiovascular Dysrhythmias, including bradycardia or tachycardia Dysrhythmias, including bradycardia or tachycardia  CNS Headaches, fatigue, malaise, confusion, convulsions Headaches, fatigue, malaise, confusion, convulsions

22 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Adverse Effects (cont’d)  digoxin (Lanoxin) (cont’d)  Eye Colored vision (seeing green, yellow, purple), halo vision, flickering lights Colored vision (seeing green, yellow, purple), halo vision, flickering lights  GI Anorexia, nausea, vomiting, diarrhea Anorexia, nausea, vomiting, diarrhea

23 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

24 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Conditions That Predispose to Digoxin Toxicity  Hypokalemia  Use of cardiac pacemaker  Hepatic dysfunction  Hypercalcemia  Dysrhythmias  Hypothyroid, respiratory, or renal disease  Advanced age

25 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

26 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  Assess clinical parameters (cont’d)  Weight, I&O measures  ECG  Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies

27 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  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

28 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  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)

29 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  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

30 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  Nesiritide, inamrinone, or milrinone  Use an infusion pump  Monitor I&O, heart rate and rhythm, BP, daily weights, respirations, and so on  IV inamrinone  Do not mix with dextrose  Solution color is true yellow

31 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Failure Drugs: Nursing Implications (cont’d)  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