1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 21 Positive Inotropic Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Definition  Drugs that increase the force of myocardial contraction  Used to treat heart muscle failure  Cardiac glycosides  digoxin  Phosphodiesterase inhibitors

3. Mosby items and derived items © 2007, 2005, 2002 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 cardiac area affected  Left ventricular failure  Right ventricular failure

4. Mosby items and derived items © 2007, 2005, 2002 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

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Cardiac Glycosides  Originally obtained from Digitalis plant, foxglove  Digoxin is the prototype  Used in heart failure and to control ventricular response to atrial fibrillation or flutter

7. Mosby items and derived items © 2007, 2005, 2002 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 Result: reduced heart rate and improved cardiac efficiency

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Effects: General Terms  Inotropic  Force or energy of muscular contractions  Chronotropic  Rate of the heartbeat  Dromotropic  The conduction of electrical impulses

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Drug Effects  Positive inotropic effect  Increase in force and velocity of myocardial contraction (without an increase in oxygen consumption)  Negative chronotropic effect  Reduced heart rate  Negative dromotropic effect  Decreases automaticity at SA node, decreases AV nodal conduction, and other effects

10. Mosby items and derived items © 2007, 2005, 2002 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 due to improved blood circulation  Palliation of exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Indications  Heart failure  Supraventricular dysrhythmias  Atrial fibrillation and atrial flutter

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides: Adverse Effects  digoxin (Lanoxin)  Very narrow therapeutic window  Drug levels must be monitored  Low potassium levels increase its toxicity  Electrolyte levels must be monitored

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Digoxin: Adverse Effects  Cardiovascular  Dysrhythmias, including bradycardia or tachycardia  CNS  Headaches, fatigue, malaise, confusion, convulsions

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Digoxin: Adverse Effects (cont’d)  Eye  Colored vision (seeing green, yellow, purple), halo vision, flickering lights  GI  Anorexia, nausea, vomiting, diarrhea

15. Mosby items and derived items © 2007, 2005, 2002 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

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Conditions That Are Predisposing to Digoxin Toxicity  Hypokalemia  Use of cardiac pacemaker  Hepatic dysfunction  Hypercalcemia  Dysrhythmias  Hypothyroid, respiratory, or renal disease  Advanced age

17. Mosby items and derived items © 2007, 2005, 2002 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

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Phosphodiesterase Inhibitors: Indications  Short-term management of heart failure  Given when patient has not responded to treatment with digoxin, diuretics, and/or vasodilators  Often given as weekly 6-hour infusions  Improved quality of life  Decreased readmissions for heart failure episodes

19. Mosby items and derived items © 2007, 2005, 2002 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

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic Drugs: Nursing Implications  Assess history, drug allergies, contraindications  Assess clinical parameters, including:  BP  Apical pulse for 1 full minute  Heart sounds, breath sounds

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic Drugs: Nursing Implications (cont’d)  Assess clinical parameters (cont'd)  Weight, I&O measures  EKG  Serum labs: potassium, sodium, magnesium, calcium, renal and liver function studies

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic 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 120 beats/minute  Hold dose  Notify prescriber

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic 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)

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic 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 report immediately a weight gain of 2 or more pounds in 1 day or 5 or more pounds in 1 week

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic Drugs: Nursing Implications (cont’d)  inamrinone or milrinone  Use an infusion pump  Monitor I&O, heart rate, BP, daily weights, respirations, etc.  IV inamrinone  Do not mix with dextrose  Solution color is true yellow

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Positive Inotropic Drugs: Nursing Implications (cont’d)  Monitor for therapeutic effects  Increased urinary output  Decreased edema, shortness of breath, dyspnea, crackles, fatigue  Resolving of paroxysmal nocturnal dyspnea  Improved peripheral pulses, skin color, temperature  Monitor for adverse effects