Heart Failure- Chapter 24.pptx

Chapter 24 Heart Failure Drugs  Heart Failure  Not a specific disease  Complex clinical syndrome resulting from any functional or structural impairment to the heart, specifically ejection of blood or ventricular filling  The heart is unable to pump blood in suf...

Chapter 24 Heart Failure Drugs  Heart Failure  Not a specific disease  Complex clinical syndrome resulting from any functional or structural impairment to the heart, specifically ejection of blood or ventricular filling  The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs. 2  Heart Failure (Cont.)  Symptoms depend on the cardiac area affected  Common symptoms: dyspnea, fatigue, fluid retention and/or pulmonary edema  “Left-sided” heart failure (HF): pulmonary edema, coughing, shortness of breath, and dyspnea  “Right-sided” HF: systemic venous congestion, pedal edema, jugular venous distension, ascites, and hepatic congestion 3  Heart Failure: Causes  Myocardial infarction (MI)  Coronary artery disease  Cardiomyopathy  Valvular insufficiency  Atrial fibrillation  Infection  Tamponade  Ischemia 4  Heart Failure: Causes (Cont.)  Pulmonary hypertension  Systemic hypertension  Outflow obstruction  Hypervolemia  Congenital abnormalities  Anemia  Thyroid disease  Infection  Diabetes 5  American College of Cardiology Foundation/American Heart Association Stages of Heart Failure  Stage A: At high risk for heart failure but no symptoms or structural heart disease  Stage B: Structural heat disease but no symptoms  Stage C: Structural heart disease with symptoms  Stage D: Refractory HF requiring interventions 6  New York Heart Association Stages of Heart Failure  CLASS I: No limitations of physical activity; ordinary physical activity does not cause symptoms of heart failure.  CLASS II: Slight limitations of physical activity. Comfortable at rest but ordinary physical activity results in symptoms of heart failure.  CLASS III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of heart failure.  CLASS IV: Unable to have physical activity without symptoms of heart failure, or symptoms at rest. 7  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 8 Drug Therapy for Heart Failure (Cont.)  Positive inotropic drugs  Phosphodiesterase inhibitors  Cardiac glycosides  Sinoatrial modulators  Angiotensin receptor-neprilysin inhibitors(ARNI)  Angiotensin-converting enzyme (ACE) inhibitors  Angiotensin receptor blockers (ARBs)  Beta blockers  Diuretics 9 Drugs of Choice for Early Treatment of Heart Failure  Focus on reducing effects of the renin- angiotensin-aldosterone system and the sympathetic nervous system  ACE inhibitors (lisinopril, enalapril, captopril, and others)  ARBs (valsartan, candesartan, losartan, and others)  Certain beta blockers (metoprolol, a cardioselective beta blocker; carvedilol, a nonspecific beta blocker) 10 Drugs of Choice for Early Treatment of Heart Failure (Cont.)  Loop diuretics (furosemide) are used to reduce the symptoms of HF secondary to fluid overload.  Aldosterone inhibitors (spironolactone, eplerenone) are added as the HF progresses.  Only after these drugs are used is digoxin added. 11 Drugs of Choice for Early Treatment of Heart Failure (Cont.)  Dobutamine: positive inotropic drug  Hydralazine and isosorbide dinitrate became the first drug approved for a specific ethnic group. Hydralazine/isosorbide dinitrate (BiDil) was approved specifically for use in Blacks. 12  ACE Inhibitors  Inhibit angiotensin-converting enzyme.  Responsible for converting angiotensin I to angiotensin II  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, fosinopril, quinapril, captopril, ramipril, trandolapril, and perindopril 13  Lisinopril (Prinivil, Zestril)  Uses: hypertension, HF, and acute MI  Hyperkalemia  Common adverse effect: dry cough, hyperkalemia, decreased renal function 14  Angiotensin II Receptor Blockers (ARBs)  Potent vasodilators; decrease systemic vascular resistance (afterload)  Used alone or in combination with other drugs such as diuretics in the treatment of hypertension or HF  Examples: valsartan (Diovan), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), telmisartan (Micardis), olmesartan (Benicar), and losartan (Cozaar) 15  Valsartan (Diovan)  Valsartan shares many of the same adverse effects as lisinopril.  ARBs are not as likely to cause the cough associated with the ACE inhibitors.  ARBs are not as likely to cause hyperkalemia. 16  Valsartan/Sacubitril  Combination drug: ARB and neprilysin inhibitor (ARNI)  New class used for management of heart failure with reduced ejection fraction  Can cause hyperkalemia, decreased renal function, other effects  Not for use in pregnancy  Several drug interactions, including ACEIs and NSAIDs 17  Angiotensin Receptor-Neprilysin Inhibitors (ARNI)  Newer class of drugs  Valsartan/sacubitril (Entresto)  Blocks the degradation of vasoactive peptides by inhibiting the neprilysin enzyme  Common adverse effects: hypotension, hyperkalemia, increased serum creatinine 18  Beta Blockers  Cardioprotective quality of beta blockers: prevent catecholamine-mediated actions on the heart by reducing or blocking sympathetic nervous system stimulation to the heart and the heart’s conduction system  Intended effects: reduced heart rate, delayed AV node conduction, reduced myocardial contractility, decreased myocardial automaticity  Beta blockers used for heart failure:  Metoprolol  Carvedilol (Coreg) 19  Aldosterone Antagonists  Useful in severe stages of HF  Action: activation of the renin-angiotensin- aldosterone system causes increased levels of aldosterone, which causes retention of sodium and water, leading to edema that can worsen HF. 20  Aldosterone Antagonists (Cont.)  Spironolactone (Aldactone): potassium-sparing diuretic and aldosterone antagonist shown to reduce the symptoms of HF  Eplerenone (Inspra): selective aldosterone blocker, blocking aldosterone at its receptors in the kidney, heart, blood vessels, and brain 21  Miscellaneous Drugs to Treat Heart Failure  Hydralazine/isosorbide dinitrate (BiDil)  First drug approved for a specific ethnic group, namely Blacks  Dobutamine  Beta1-selective vasoactive adrenergic drug  Structurally similar to dopamine 22  Phosphodiesterase Inhibitors (PDIs)  Work by inhibiting the enzyme phosphodiesterase  Result in  Intracellular increase in cAMP  Positive inotropic response  Vasodilation  Increase in calcium for myocardial muscle contraction.  Inodilators (inotropics and dilators) 23  Phosphodiesterase Inhibitors: Indications  Short-term management of HF for patients in the intensive care unit (ICU)  AHA and ACC advise against long-term infusions. 24  Milrinone  Only available phosphodiesterase inhibitor  Milrinone is available only in injectable form.  Adverse effects: cardiac dysrhythmias, headache, hypokalemia, tremor, thrombocytopenia, and elevated liver enzyme levels  Interactions: diuretics (additive hypotensive effects) and digoxin (additive inotropic effects) 25  Cardiac Glycosides  One of the oldest groups of cardiac drugs  No longer used as first-line treatment  Not been shown to reduce mortality in HF patients  Originally obtained from Digitalis plant, foxglove  Digoxin is the prototype.  Used in HF and to control ventricular response to atrial fibrillation 26  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 sinoatrial (SA) node and atrioventricular (AV) node 27  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 28  Cardiac Glycosides: Drug Effects (Cont.)  Increased stroke volume  Reduction in heart size during diastole  Decrease in venous BP and vein engorgement  Increase in coronary circulation  Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis  Improved symptom control, quality of life, and exercise tolerance  No apparent reduction in mortality 29  Audience Response System Question #1 A patient is in the emergency department with new- onset atrial fibrillation. Which order for digoxin would most likely have the fastest therapeutic effect? A. Digoxin 0.25 mg PO daily B. Digoxin 1 mg PO now; then 0.25 mg PO daily C. Digoxin 0.5 mg IV push daily D. Digoxin 1 mg IV push now; then 0.25 mg IV daily NOTE: No input is required to proceed. 30  Answer to System Question #1 ANS: D A digitalizing dose is often used to quickly bring serum levels of the drug up to a therapeutic level. IV doses would accomplish this more quickly. 31  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. 32  Cardiac Glycosides: Adverse Effects (Cont.)  Digoxin (Lanoxin)  Cardiovascular: dysrhythmias, including bradycardia or tachycardia  Central nervous system: headaches, fatigue, malaise, confusion, convulsions  Eyes: colored vision (seeing green, yellow, purple), halo vision, flickering lights  Gastrointestinal: anorexia, nausea, vomiting, diarrhea 33  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 34  Audience Response System Question #2 A patient is receiving digoxin 0.25 mg/day as part of treatment for HF. The nurse assesses the patient before medication administration. Which assessment finding would be of most concern? A. Apical heart rate of 58 beats/min B. Ankle edema +1 bilaterally C. Serum potassium level of 2.9 mEq/L D. Serum digoxin level of 0.8 ng/mL NOTE: No input is required to proceed. 35  Answer to System Question #2 ANS: C The hypokalemia may precipitate digoxin toxicity; therefore, it is the biggest concern. The apical pulse is slightly under 60 beats/min, but bradycardia may occur with digoxin therapy, and the heart rate should be monitored. The ankle edema may be a manifestation of his HF and not a new concern. The digoxin level is within the normal range. 36  Conditions That Predispose to Digoxin Toxicity  Hypokalemia  Use of cardiac pacemaker  Hepatic dysfunction  Hypercalcemia  Dysrhythmias  Hypothyroid, respiratory, or renal disease  Advanced age 37  Heart Failure Drugs: Nursing Implications  Assess history, drug allergies, and contraindications.  Assess clinical parameters, including:  BP  Apical pulse for 1 full minute  Heart sounds, breath sounds 38  Heart Failure Drugs: Nursing Implications (Cont.)  Assess clinical parameters (Cont.)  Weight, input, and output measures  Electrocardiogram  Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies 39  Heart Failure Drugs: Nursing Implications (Cont.)  Before giving any dose, count apical pulse for 1 full minute.  For an apical pulse less than 60 or greater than 100 beats/min:  Hold dose.  Notify prescriber. 40  Heart Failure Drugs: Nursing Implications (Cont.)  Hold dose and notify prescriber if the patient experiences signs or symptoms of toxicity.  Anorexia, nausea, vomiting, diarrhea  Visual disturbances (blurred vision, seeing green or yellow halos around objects) 41  Heart Failure Drugs: Nursing Implications (Cont.)  Check dosage forms carefully and follow instructions for administering.  Avoid giving digoxin with high-fiber foods (fiber binds with digitalis).  Patients should immediately report a weight gain of 2 lb or more in 1 day or 5 lb or more in 1 week. 42  Heart Failure Drugs: Nursing Implications (Cont.)  Nesiritide or milrinone  Use an infusion pump.  Monitor input and output, heart rate and rhythm, BP, daily weights, respirations, and so on. 43  Heart Failure Drugs: Nursing Implications (Cont.)  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. 44  Case Study A patient with a history of HF presents to the emergency department with difficulty breathing, cough, and edema of the lower extremities. 1. The nurse anticipates administration of which type of medication? A. Positive chronotrope B. Negative chronotrope C. Positive inotrope D. Negative inotrope NOTE: No input is required to proceed. 45 Answer to Case Study Question #1 ANS: C Positive inotropes are used to increase the force of myocardial contraction in the treatment of patients with HF. Negative inotropes would cause the heart to have a decreased force of myocardial contraction and would not be effective. Positive chronotropes increase the rate at which the heartbeats, and negative chronotropes decrease the rate at which the heartbeats. 46  Case Study The patient does not respond well to current medication therapy and is started on a milrinone infusion. 3. The nurse will monitor which laboratory results during this infusion? Select all that apply A. Serum potassium levels B. Creatinine and BUN C. WBC count D. Liver function studies E. Platelet count NOTE: No input is required to proceed. 47 Answer to Case Study Question #3 ANS: D Adverse effects of milrinone include cardiac dysrhythmias, headache, tremor, as well as hypokalemia, thrombocytopenia, and elevated liver enzyme levels. 48