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Drugs Affecting Cardiac and Renal Systems. Jan Bazner-Chandler MSN, CNS, C-PNP, RN. Positive Inotropic Drugs. Chapter 21. Inotropic Drugs. Drugs that increase the force of myocardial contractions. . Chronotropic Drugs. Drugs that increase the rate at which the heat beats. .

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Drugs Affecting Cardiac and Renal Systems

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Drugs Affecting Cardiac and Renal Systems

Jan Bazner-Chandler


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Positive Inotropic Drugs

Chapter 21

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Inotropic Drugs

  • Drugs that increase the force of myocardial contractions.

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Chronotropic Drugs

  • Drugs that increase the rate at which the heat beats.

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Dromotropic Drugs

  • Drugs that accelerate conduction.

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Heart Failure

  • Congestive heart failure (CHF), or heart failure (HF), is a condition in which the heart can't pump enough blood to the body's other organs. This can result from

    • narrowed arteries that supply blood to the heart muscle — coronary artery disease (CAD)

    • past heart attack, or myocardial infarction (MI), with scar tissue that interferes with the heart muscle's normal work

    • high blood pressure

    • heart valve disease due to past rheumatic fever or other causes

    • primary disease of the heart muscle itself, called cardiomyopathy.

    • heart defects present at birth — congenital heart defects.

    • infection of the heart valves and/or heart muscle itself — endocarditis and/or myocarditis

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Heart Valve Disease

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Heart Failure

  • As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down.

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Heart Failure

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Signs and Symptoms of Heart Failure or HF

  • Often no symptoms at rest

  • Dyspnea (difficulty breathing) and fatigue occur with increased activity

  • Edema of ankles and feet

  • Distention of jugular veins

  • In acute cases pulmonary edema – cough and shortness of breath

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Pitting Edema

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Distended Jugular Vein

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Drugs in first-line treatment

  • Digoxin

  • Diuretics

  • ACE Angiotension-converting enzyme inhibitors

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Cardiac Glycosides

  • Oldest and most effective group of cardiac drugs.

  • Comes from the plant “fox glove”.

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Cardiac Glycosides or Digoxin

  • Digoxin or Lanoxin is the only commonly used digitalis glycoside.

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digoxin (Lanoxin, Digitek)

  • Classification Pharmacologic: digitalis, glycoside

  • Classification Therapeutic: antiarrhythmic, inotropic

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  • Digoxin improves the pumping ability of the heart

  • Increases the force of myocardial contraction by inhibiting the Na, K-adenosine triphosphatase, an enzyme in cardiac cell membrane that decreases the movement of sodium out of myocardial cell after contraction.

  • Calcium enter the cell in exchange for sodium.

  • The calcium activates the contractile proteins and increased myocardial contractility.

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  • Can be given orally or IV

  • IV peaks within 10 to 30 minutes

  • PO peaks within 1 to 2 hours

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Serum Blood Levels

  • Maximum drug action occurs when steady tissue concentration has been achieved – takes about 1 week

  • Loading dose or digitalizing dosage will be higher until the therapeutic level has been reached.

  • Dosage 0.75 to 1.5 mg every 6 to 8 hours

  • When adequate levels have been reached than a maintenance dose can be started

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Maintenance Dose

  • Dosing is 0.125 – 0.5 mg

  • Average dose is 0.25 mg

  • Take daily at same time of day

  • Give with food or after meals

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Dosing by mcg/kg in Adults

  • IV digitalizing dose = 0.6 to 1 mg (10 -15 mcg/kg) given at 50% initially and additional fractions given at 4-8 hour intervals.

  • PO adults digitalizing dose 0.75 – 1.25 mg (10 – 15 mcg/kg)

  • PO children digitalizing dose 10 to 15 mcg/kg

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Nursing Responsibilities

  • Take apical pulse for one full minute before giving the medication – listen for any irregular heart beats

  • Specific guidelines for holding the drug and notifying physician

    • Adults: apical pulse less than 60

    • Older child: apical pulse less than 60

    • Infant or younger child: apical pulse less than 100

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Nursing Responsibilities

  • Notify physician if bradycardia (heart rate less than 60 bpm) or new arrhythmias occur.

  • Assess for peripheral edema and auscultate lunge for rales/crackles.

  • Check kidney function since you want to know they can excrete excess digoxin and avoid build up in body.

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Laboratory Values

  • Electrolyte imbalance: potassium, calcium and magnesium values need to be monitored

  • Hypokalemia (low potassium)

  • Hypomagnesemia (low magnesium)

  • Both can lead to irregular heart rate.

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Digoxin Toxicity

  • Anorexia, nausea, and confusion are symptoms of digoxin toxicity

  • HR below 60 in adults and 100 in infants and small children

  • Digoxin should be discontinued by MD only– takes about 1 week for drug to be eliminated from the body.

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Evaluation of Effectiveness

  • Increased urinary output

  • Decreased edema

  • Decreased shortness of breath, dyspnea and crackles

  • Decreased fatigue

  • Improved peripheral pulses, skin color and temperature

  • Serum digoxin levels 0.5 to 2 ng/mL

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digoxin Overdose

  • digoxin immune Fab or DigiFab

  • Therapeutic classification: antidotes

  • Pharmacologic classification: antibody fragments

  • Indications: serious life-threatening over dosage with digoxin.

  • Action: An antibody produced in sheep that binds anti-genetically to unbound digoxin in serum.

  • Therapeutic effect: Binding and subsequent removal of digoxin, preventing toxic effects in overdose.

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Antianginal Drugs

Chapter 23

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Coronary Arteries

  • Arteries that deliver oxygen to the heart muscle.

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Coronary Arteries

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Angina Pectoris

  • Chest pain occurring when the heart’s supply of blood carrying oxygen and energy-rich nutrients is insufficient to meet demands of the heart.

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  • Poor blood flow to an organ

  • Ischemic heart disease = poor blood flow to heart

  • Myocardial infarct = damage done to heart muscle after an ischemic event

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  • Angina pectoris is a clinical symptoms characterized by episodes of chest pain.

  • There is deficit in myocardial oxygen supply (myocardial ischemia) in relation to myocardial oxygen demand.

  • Pain can be caused by coronary vasospasm

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Classification of Angina

  • Class I: ordinary physical activity does not cause angina – strenuous activity only.

  • Class II: angina occurs with walking or climbing stairs rapidly or up hill.

  • Class III: marked limitation in ordinary daily activity.

  • Class IV: anginal symptoms may be present at rest.

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Antianginal Drugs

  • Nitrates are used to treat and prevent attack of angina.

  • Only nitrates can be used in the acute treatment of angina pectoris.

  • Calcium channel blockers and beta blockers are used prophylactically or in long-term management of angina.

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  • Most widely used nitrate

  • Antianginal

  • Used to relieve acute angina

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  • Classification Pharmacologic: nitrates

  • Classification Therapeutic: antianginals

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  • Action: Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions. Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume. Reduces myocardial oxygen consumption.

  • Therapeutic effects:

    • Relief or prevention of anginal attacks.

    • Reduction of blood pressure.

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  • Oral dosage is rapidly metabolized in the liver and only small doses reach the systemic circulatory system

  • For more effective absorption drug is given:

    • Sublingually – under the tongue – acts in 1 to 3 minutes

    • PO: sustained-released tablet

    • Transdermal ointments – applied on hairless area on back, chest or upper arm

    • Patches – takes a 40 minutes to an hour to start working

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Sublingual Nitroglycerine

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Sublingual Administration

  • Tablet should be held under tongue until dissolved. Avoid eating, drinking, or smoking until tablet is dissolved.

  • Acute anginal attacks:

    • Advise patient to sit down.

    • Relief should occur in 5 minutes

    • May be repeated every 5 minutes for 3 doses.

    • If no relief call 911.

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Sustained Released Tablet

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Sustained Released Tablet

  • Administer dose 1 hour before or 2 hours after meal with a full glass of water for faster absorption.

  • Note: Sustained released preparations should be swallowed whole, do not crush, break or chew.

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Nitroglycerine Patch

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Nitroglycerin Patch

  • Place the patch on a hairless area of chest or upper arm each day.

  • Move patch to a different place on your body each day to prevent skin irritation.

  • Remove the patch for 8 to 12 hours each night and put on a fresh patch each day.

  • Do not leave on all the time.

  • Remove for defibrillation

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Nitroglycerine Ointment

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Nitroglycerine Ointment

  • Comes with paper with a ruled line for measuring the dose

  • Squeeze ointment onto the paper, carefully measuring the amount specified on the prescription label

  • Use the paper to spread ointment in a thin layer on a hair-free area of skin (2 by 3 inches)

  • Keep paper in place with bandage or tape

  • Ointment is applied three or four times a day

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Side Effects

  • Dizziness or light-headedness

  • Flushing of face and neck

  • Increased heart rate

  • Restlessness

  • Rare side effects:

    • Blurred vision

    • Dry mouth

    • Weakness

    • Fatigue

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B-adrenergic Blockers

  • B-blockers (beta 1)

  • Primary drug effect is related to the cardiovascular system.

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When Used

  • Angina

  • Myocardial infarct

  • Dysrhythmias

  • Hypertension

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Action of Beta 1 Blockers

  • Decrease energy demands on heart to decrease angina attacks.

  • Block the B receptors on the SA node to slow heart rate

  • Block the harmful release of catecholamines (epinephrine and norepinephrine)

  • Blocks the release of renin a potent vasoconstrictor in the kidney to decrease blood pressure.

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  • Systolic heart failure

  • Systolic cardiac (heart) dysfunction (or systolic heart failure) occurs when the heart muscle doesn't contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body.

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  • Conductive disturbances

  • Bronchial asthma

  • Diabetes: blocks hypo-glycemic induced tachycardia.

  • Reduced metal alertness

  • Peripheral vascular disease

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Adverse Effects

  • Decrease in HR blow the 60 bpm

  • Decreased cardiac output

  • Bronchocontriction in patients with asthma or COPD.

  • Cardiac rhythm problems due to decreased SA or AV node conduction

  • Hypo or hyperglycemia

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Beta Blocker Drugs

  • Three most common drugs used

    • carvedilol or Coreg

    • metoprolol or Lopressor

    • atenolol or Tenormin

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Calcium Channel Blockers

  • Three chemical classifications

    • Phenylalkylamines

    • Benzothiazepines

    • Dihydrophyridines

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  • Prevents calcium from entering into contraction process of the heart thus promoting smooth muscle relaxation and coronary artery dilation.

  • Increased blood flow to ischemic heart

  • Useful in treating dysrhythmias

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  • First line drugs used to treat

    • Angina

    • Hypertension

    • Supraventricular tachycardia

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Supraventricular Tachycardia

  • Supraventricular tachycardia is one type of heart rhythm disorder.

  • Tachycardia's are rhythm disorders in which the heart beats faster than normal.

  • Supraventricular means "above the ventricles," in other words, originating from the atria, the upper chambers of the heart.

  • Supraventricular tachycardia, then, is a rapid heartbeat originating in the atria.

  • These AV node may be involved.

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One Important Consideration When Prescribing

  • May not be as effective in controlling exercise induced elevation of heart rate or blood pressure.

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  • Drug allergy

  • Acute Myocardial Infarction (MI)

  • Atrial ventricular block

    • Bradycardia

    • Pacemaker

  • Hypotension

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Adverse Effects

  • Cardiovascular:

    • Hypotension

    • Heart palpitations

    • Tachycardia / bradycardia

    • Heart Failure

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  • Action: works directly on arteriolar and venous muscles to cause relaxation.

  • Very useful in managing hypertensive emergencies.

  • Blood pressure needs to be brought down slowly.

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  • Intravenous (IV) diazoxide and sodium nitroprusside are useful in managing hypertensive emergencies.

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Nursing Assessment

  • Monitor for adverse effects:

    • Orthostatic hypotension

    • Dizziness

    • fatigue

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Nursing Assessment

  • Monitor effectiveness of the drug therapy

    • Client will return to baseline activities

    • Client will report improved energy.

    • Blood pressure reading will be lowered with the goal to bring back to normal levels.

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