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CHAPTER 22CHAPTER 22

Heart Failure DrugsHeart Failure Drugs

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Heart FailureHeart Failure

The heart is unable to pump blood in The heart is unable to pump blood in sufficient amounts from the ventricles to meet sufficient amounts from the ventricles to meet the body’s metabolic needsthe body’s metabolic needs

Symptoms depend on the cardiac area Symptoms depend on the cardiac area affectedaffected Systolic dysfunctionSystolic dysfunction Diastolic dysfunctionDiastolic dysfunction

• Less commonLess common

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Heart Failure: CausesHeart Failure: Causes

Cardiac defectCardiac defect Myocardial infarctionMyocardial infarction Valve deficiencyValve deficiency

Defect outside the heartDefect outside the heart Coronary artery diseaseCoronary artery disease Pulmonary hypertensionPulmonary hypertension DiabetesDiabetes

Supraventricular dysrhythmiasSupraventricular dysrhythmias Atrial fibrillationAtrial fibrillation Atrial flutterAtrial flutter

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Drug Therapy for Heart FailureDrug Therapy for Heart Failure

Positive inotropic drugsPositive inotropic drugs Increase the force of myocardial contractionIncrease the force of myocardial contraction

Positive chronotropic drugsPositive chronotropic drugs Increase heart rateIncrease heart rate

Positive dromotropic drugsPositive dromotropic drugs Accelerate cardiac conductionAccelerate cardiac conduction

Used to treat heart muscle failureUsed to treat heart muscle failure

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Drug Therapy for Heart FailureDrug Therapy for Heart Failure

ACE inhibitorsACE inhibitors Angiotensin II receptor blockersAngiotensin II receptor blockers B-type natriuretic peptidesB-type natriuretic peptides Phosphodiesterase inhibitorsPhosphodiesterase inhibitors Cardiac glycosidesCardiac glycosides

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ACE InhibitorsACE InhibitorsMechanism of ActionMechanism of Action

Prevent sodium and water resorption by Prevent sodium and water resorption by inhibiting aldosterone secretioninhibiting aldosterone secretion

Diuresis results, which decreases preload, or Diuresis results, which decreases preload, or the left ventricular end-volume, and the work the left ventricular end-volume, and the work of the heartof the heart

Examples: lisinopril, enalapril, captopril, Examples: lisinopril, enalapril, captopril, othersothers

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Angiotensin II Receptor BlockersAngiotensin II Receptor BlockersMechanism of ActionMechanism of Action

Potent vasodilators; decrease systemic Potent vasodilators; decrease systemic vascular resistance (afterload)vascular resistance (afterload)

Examples: valsartan, candesartan, losartanExamples: valsartan, candesartan, losartan

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B-type Natiuretic Peptides B-type Natiuretic Peptides

nesiritide (Natrecor)nesiritide (Natrecor) Used in severe, life-threatening heart failureUsed in severe, life-threatening heart failure

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B-type Natiuretic Peptides:B-type Natiuretic Peptides:Mechanism of Action Mechanism of Action

Vasodilating effects on arteries and veinsVasodilating effects on arteries and veins Indirectly increases cardiac outputIndirectly increases cardiac output Suppresses renin-angiotensin systemSuppresses renin-angiotensin system DiuresisDiuresis

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B-type Natiuretic Peptides:B-type Natiuretic Peptides:Adverse Effects Adverse Effects

HypotensionHypotension DysrhythmiaDysrhythmia HeadacheHeadache Abdominal painAbdominal pain

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Phosphodiesterase InhibitorsPhosphodiesterase InhibitorsMechanism of ActionMechanism of Action

Work by inhibiting the enzyme phosphodiesteraseWork by inhibiting the enzyme phosphodiesterase Results in:Results in:

Positive inotropic responsePositive inotropic response Vasodilation Vasodilation

Two drugs (inodilators)Two drugs (inodilators) Inamrinone and milrinoneInamrinone and milrinone

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Phosphodiesterase Inhibitors:Phosphodiesterase Inhibitors:IndicationsIndications

Short-term management of heart failureShort-term management of heart failure Given when patient does not respond to Given when patient does not respond to

treatment with digoxin, diuretics, and/or treatment with digoxin, diuretics, and/or vasodilatorsvasodilators

AHA and ACC advise against weekly AHA and ACC advise against weekly infusionsinfusions No improvement of clinical statusNo improvement of clinical status

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Phosphodiesterase Inhibitors:Phosphodiesterase Inhibitors:Adverse EffectsAdverse Effects

inamrinoneinamrinone Thrombocytopenia, most worrisomeThrombocytopenia, most worrisome Dysrhythmia, nausea, hypotensionDysrhythmia, nausea, hypotension Elevated liver enzymes with long-term useElevated liver enzymes with long-term use

milrinonemilrinone Dysrhythmia, mainly ventricularDysrhythmia, mainly ventricular Hypotension, angina, hypokalemia, tremor, Hypotension, angina, hypokalemia, tremor,

thrombocytopeniathrombocytopenia

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Cardiac GlycosidesCardiac Glycosides

No longer used as first-line treatmentNo longer used as first-line treatment Originally obtained from Originally obtained from DigitalisDigitalis plant, plant,

foxglovefoxglove Digoxin is the prototypeDigoxin is the prototype Used in heart failure and to control ventricular Used in heart failure and to control ventricular

response to atrial fibrillation or flutterresponse to atrial fibrillation or flutter

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Cardiac Glycosides:Cardiac Glycosides:Mechanism of ActionMechanism of Action

Increase myocardial contractilityIncrease myocardial contractility Change electrical conduction properties of Change electrical conduction properties of

the heartthe heart Decrease rate of electrical conductionDecrease rate of electrical conduction Prolong the refractory periodProlong the refractory period

• Area between SA node and AV nodeArea between SA node and AV node

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Cardiac Glycosides:Cardiac Glycosides:Drug EffectsDrug Effects

Positive inotropic effectPositive inotropic effect Increased force and velocity of myocardial Increased force and velocity of myocardial

contraction (without an increase in oxygen contraction (without an increase in oxygen consumption)consumption)

Negative chronotropic effectNegative chronotropic effect Reduced heart rateReduced heart rate

Negative dromotropic effectNegative dromotropic effect Decreased automaticity at SA node, decreased Decreased automaticity at SA node, decreased

AV nodal conduction, and other effectsAV nodal conduction, and other effects

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Cardiac Glycosides:Cardiac Glycosides:Drug Effects (cont’d)Drug Effects (cont’d)

Increased stroke volumeIncreased stroke volume Reduction in heart size during diastoleReduction in heart size during diastole Decrease in venous BP and vein Decrease in venous BP and vein

engorgementengorgement Increase in coronary circulationIncrease in coronary circulation Promotion of diuresis because of improved Promotion of diuresis because of improved

blood circulationblood circulation Palliation of exertional and paroxysmal Palliation of exertional and paroxysmal

nocturnal dyspnea, cough, and cyanosisnocturnal dyspnea, cough, and cyanosis

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Cardiac Glycosides:Cardiac Glycosides:IndicationsIndications

Heart failureHeart failure Supraventricular dysrhythmiasSupraventricular dysrhythmias

Atrial fibrillation and atrial flutterAtrial fibrillation and atrial flutter

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Cardiac Glycosides:Cardiac Glycosides:Adverse EffectsAdverse Effects

digoxin (Lanoxin)digoxin (Lanoxin) Very narrow therapeutic windowVery narrow therapeutic window Drug levels must be monitoredDrug levels must be monitored

• 0.5 to 2 ng/mL0.5 to 2 ng/mL

Low potassium levels increase its toxicityLow potassium levels increase its toxicity Electrolyte levels must be monitoredElectrolyte levels must be monitored

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Cardiac Glycosides: Cardiac Glycosides: Adverse Effects (cont’d)Adverse Effects (cont’d)

digoxin (Lanoxin) (cont’d)digoxin (Lanoxin) (cont’d) CardiovascularCardiovascular

• Dysrhythmias, including bradycardia or tachycardiaDysrhythmias, including bradycardia or tachycardia

CNSCNS• Headaches, fatigue, malaise, confusion, convulsionsHeadaches, fatigue, malaise, confusion, convulsions

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Cardiac Glycosides: Cardiac Glycosides: Adverse Effects (cont’d)Adverse Effects (cont’d)

digoxin (Lanoxin) (cont’d)digoxin (Lanoxin) (cont’d) EyeEye

• Colored vision (seeing green, yellow, purple), halo vision, Colored vision (seeing green, yellow, purple), halo vision, flickering lightsflickering lights

GIGI• Anorexia, nausea, vomiting, diarrheaAnorexia, nausea, vomiting, diarrhea

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Digoxin ToxicityDigoxin Toxicity

digoxin immune Fab (Digibind) therapydigoxin immune Fab (Digibind) therapy Hyperkalemia (serum potassium greater than Hyperkalemia (serum potassium greater than

5 mEq/L) in a digitalis-toxic patient5 mEq/L) in a digitalis-toxic patient Life-threatening cardiac dysrhythmiasLife-threatening cardiac dysrhythmias Life-threatening digoxin overdoseLife-threatening digoxin overdose

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Conditions That Predispose Conditions That Predispose to Digoxin Toxicityto Digoxin Toxicity

Electrolyte imbalancesElectrolyte imbalances HypokalemiaHypokalemia HypomagnesemiaHypomagnesemia HypercalcemiaHypercalcemia

Acid-base imbalancesAcid-base imbalances HypothyroidismHypothyroidism Renal or Hepatic dysfunctionRenal or Hepatic dysfunction DehydrationDehydration

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Heart Failure Drugs:Heart Failure Drugs:Nursing ImplicationsNursing Implications

Assess history, drug allergies, Assess history, drug allergies, contraindicationscontraindications

Assess clinical parameters, including:Assess clinical parameters, including: BPBP Apical pulse for 1 full minuteApical pulse for 1 full minute Heart sounds, breath soundsHeart sounds, breath sounds

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Heart Failure Drugs:Heart Failure Drugs:Nursing Implications (cont’d)Nursing Implications (cont’d)

Assess clinical parameters (cont’d)Assess clinical parameters (cont’d) Weight, I&O measuresWeight, I&O measures ECGECG Serum labs: potassium, sodium, magnesium, Serum labs: potassium, sodium, magnesium,

calcium, renal, and liver function studiescalcium, renal, and liver function studies

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Heart Failure Drugs:Heart Failure Drugs:Nursing Implications (cont’d)Nursing Implications (cont’d)

Before giving any dose, count apical pulse for Before giving any dose, count apical pulse for 1 full minute1 full minute

For apical pulse For apical pulse less than 60 or greater than less than 60 or greater than 100 beats/minute100 beats/minute Hold doseHold dose Notify prescriberNotify prescriber

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Heart Failure Drugs:Heart Failure Drugs: Nursing Implications (cont’d) Nursing Implications (cont’d)

Hold dose and notify prescriber if patient Hold dose and notify prescriber if patient experiences signs/symptoms of toxicityexperiences signs/symptoms of toxicity Anorexia, nausea, vomiting, diarrheaAnorexia, nausea, vomiting, diarrhea Visual disturbances (blurred vision, seeing green Visual disturbances (blurred vision, seeing green

or yellow halos around objects)or yellow halos around objects)

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Heart Failure Drugs: Heart Failure Drugs: Nursing Implications (cont’d) Nursing Implications (cont’d)

Check dosage forms carefully, and follow Check dosage forms carefully, and follow instructions for givinginstructions for giving

Avoid giving digoxin with high-fiber foods Avoid giving digoxin with high-fiber foods (fiber binds with digitalis)(fiber binds with digitalis)

Patients should immediately report a weight Patients should immediately report a weight gain of 2 or more pounds in 1 day or 5 or gain of 2 or more pounds in 1 day or 5 or more pounds in 1 weekmore pounds in 1 week

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Heart Failure Drugs: Heart Failure Drugs: Nursing Implications (cont’d) Nursing Implications (cont’d)

Nesiritide, inamrinone, or milrinoneNesiritide, inamrinone, or milrinone Use an infusion pumpUse an infusion pump Monitor I&O, heart rate and rhythm, BP, daily Monitor I&O, heart rate and rhythm, BP, daily

weights, respirations, and so onweights, respirations, and so on IV inamrinoneIV inamrinone

Do not mix with dextroseDo not mix with dextrose Solution color is true yellowSolution color is true yellow

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Heart Failure Drugs: Heart Failure Drugs: Nursing Implications (cont’d)Nursing Implications (cont’d)

Monitor for therapeutic effectsMonitor for therapeutic effects Increased urinary outputIncreased urinary output Decreased edema, shortness of breath, dyspnea, Decreased edema, shortness of breath, dyspnea,

crackles, fatiguecrackles, fatigue Resolution of paroxysmal nocturnal dyspneaResolution of paroxysmal nocturnal dyspnea Improved peripheral pulses, skin color, Improved peripheral pulses, skin color,

temperaturetemperature Monitor for adverse effectsMonitor for adverse effects

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Critical ThinkingCritical Thinking

A patient has been receiving digoxin therapy for A patient has been receiving digoxin therapy for 2 months. During today’s visit, he tells you 2 months. During today’s visit, he tells you that he has been seeing yellowish rings that he has been seeing yellowish rings around lights and has had no appetite. His around lights and has had no appetite. His latest blood potassium level is 5.6 mEq/L. latest blood potassium level is 5.6 mEq/L.

What is the concern with this patient, and what What is the concern with this patient, and what should be done?should be done?