Drugs for Heart Failure

1. Drugs for Heart Failure Nursing Department

2. Learning Objectives At the end of the session, each student will be able to: 1.Identify the major diseases that accelerate the progression of heart failure. 2. Relate how the symptoms associated with heart failure may be caused by weakened heart muscle and diminished cardiac output. 3. Explain how heart failure is classified. 4. Describe the nurse’s role in the pharmacologic management of heart failure. 5. For each of the drug classes, know representative drug examples, and explain their mechanisms of action, primary actions, and important adverse effects. 6. Use the nursing process to care for patients who are receiving pharmacotherapy for heart failure.

3. Heart Failure (HF) • Inability of ventricles to pump enough blood for body’s needs • Weakening of heart muscle due to aging or disease

4. Diseases Associated with Heart Failure • Coronary artery disease (CAD) • Mitral stenosis • Myocardial infarction (MI) • Chronic HTN • Diabetes mellitus • No cure, only prevention and slowing of progression

5. Left-Sided Heart Failure • Blood accumulates in left ventricle • Left ventricle thickens and enlarges: hypertrophy • Cardiac remodeling • Blood backs up into lungs • Cough and shortness of breath result

6. Right-Sided Heart Failure • Blood backs up into veins • Causes peripheral edema and organ engorgement • Less common than left-sided HF

7. Pharmacologic Management of Heart Failure • Mechanisms: • Slowing the heart rate • Increasing contractility • Reducing myocardial workload

8. ACE Inhibitors • Reduce afterload • Drugs of choice for heart failure • Enhance excretion of sodium and water • Lower peripheral resistance and reduce blood volume • Increase cardiac output

9. Angiotensin-converting enzyme(ACE Inhibitors) • Prototype drug: lisinopril (Prinivil, Zestril) • Mechanism of action: To inhibit ACE enzyme and decrease aldosterone secretion. • Primary use: To decrease blood pressure and reduce blood volume; dilate veins. • Adverse effects: First-dose hypotension, cough, hyperkalemia, renal failure.

10. Angiotensin Receptor Blockers (ARBs) • Actions very similar to ACE inhibitors • Usually used for patients who are unable to tolerate the adverse effects of ACE inhibitors

11. Diuretics • Increase urine flow • Reduce blood volume and cardiac workload • Reduce edema and pulmonary congestion • Prescribed in combination with other drugs

12. Cardiac Glycosides • Increase force of heartbeat, slow heart rate • Improve cardiac output • Second-line treatment for HF • Narrow therapeutic range

13. Cardiac Glycosides • Prototype drug: digoxin (Lanoxin) • Mechanism of action: To cause more forceful heartbeat, slower heart rate. • Primary use: To increase contractility or strength of myocardial contraction. • Adverse effects: Neutropenia, dysrhythmias, digitalis toxicity

14. Beta-Adrenergic Blockers • Slow heart rate and reduce blood pressure • Inotropic effect • Reduce workload of heart

15. Direct Vasodilators • Minor role in HF treatment • Lower blood pressure • Relax blood vessels

16. Phosphodiesterase Inhibitors • Prototype drug: milrinone (Primacor) • Mechanism of action: To block enzyme phosphodiesterase in cardiac and smooth muscle, increasing myocardial contraction force and cardiac output. • Primary use: As short-term therapy for heart failure. • Adverse effects: Hypokalemia, hypotension, ventricular dysrhythmias

17. Role of the Nurse • Obtain health history • Assess vital signs, urinary and cardiac output before and throughout therapy

18. Drugs for Heart Failure • Treat symptoms: • Slow heart rate • Increase contractility • Reduce heart workload

19. Role of the Nurse: ACE Inhibitors • Monitor CBC • Assess for hypotension • Monitor for impaired kidney function, hyperkalemia, autoimmune disease

20. Patient Teaching • Therapeutic response time: weeks or months • Sodium and potassium restrictions • Don't use with other medications, OTCs, herbals, vitamins • Monitor sodium intake • Report weight loss • Report fatigue and muscle cramps • Change position slowly

21. Patient Teaching • Monitor blood pressure/pulse • Report pulse below 50 • Report signs/symptoms of worsening heart failure • Do not stop taking abruptly • Monitor therapeutic levels with laboratory tests • Know signs/symptoms of toxicity • Monitor pulse rate • Report weight gain • Eat foods high in potassium

22. Patient Teaching • Report irregular or rapid heart rate • Report fever of 101 degrees F or higher or increase in chest pain • If given I V, report fever of 101 degrees F or higher or pain/swelling at infusion site

23. Role of the Nurse: Diuretics • Assess renal function • Monitor electrolyte levels • Monitor vital signs, intake/output • Monitor blood glucose and blood-urea nitrogen (BUN)

24. Role of the Nurse: Beta-Adrenergic Blockers • Monitor for worsening symptoms • Monitor liver function/hepatic toxicity • Be aware of contraindications

25. Role of the Nurse: Cardiac Glycosides • Evaluate for ventricular dysrhythmias • Assess renal function • Monitor for drug interactions • Know restriction on use with antidiarrheals/antacids

26. Role of the Nurse: Phosphodiesterase Inhibitors • Assess potassium levels • Monitor for hypotension • Assess for renal impairment • Assess for dysrhythmias • For I V: Monitor for ventricular dysrhythmias

27. Prototype Drug: Lisinopril (Prinivil, Zestril) Therapeutic Class: Drug for heart failure and HTN Pharmacologic Class: ACE inhibitor Actions : Lisinopril acts by inhibiting ACE and decreasing aldosterone secretion. Blood pressure is decreased and cardiac output is increased. Uses : 1- To improve survival in patients when given within 24 hours of an acute MI. 2- Treatment of migraines.

28. Prototype Drug: Lisinopril (Prinivil, Zestril) Administration Alerts: • Assess blood pressure just prior to administering lisinopril. • Safety and efficacy have been established for the use of this medication in children age 6 and older. • Older adults, especially those with chronic kidney disease should receive lower doses to prevent toxicity. • Pregnancy category C (first trimester) or D (second and third trimesters). Discontinue use as soon as pregnancy is suspected.

29. Prototype Drug: Lisinopril (Prinivil, Zestril) Pharmacokinetics

30. Prototype Drug: Lisinopril (Prinivil, Zestril) Adverse Effects The most common adverse effects are: 1- Cough, headache, dizziness, orthostatic hypotension, and rash. 2- Hyperkalemia may occur during therapy; thus, electrolyte levels are usually monitored periodically. 3- Other effects include taste disturbances, chest pain, nausea, vomiting, and diarrhea.

31. Prototype Drug: Lisinopril (Prinivil, Zestril Contraindications: 1- In patients with hyperkalemia 2- Those who have previously experienced angioedema. 3- It should not be used during pregnancy.

32. Prototype Drug: Lisinopril (Prinivil, Zestril Lab Tests: May increase values of the following: blood urea nitrogen (BUN), serum bilirubin, serum alkaline phosphatase. Herbal/Food: Excessive intake of foods rich in potassium and potassium-based salt substitutes should be avoided because of the possibility of hyperkalemia. Treatment of Overdose: Overdose causes hypotension, which may be treated with the administration of normal saline or a vasopressor.

33. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) Therapeutic Class: Drug for heart failure Pharmacologic Class: Cardiac glycoside The primary benefit of digoxin is its ability to increase the contractility or strength of myocardial.

34. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) • Administration Alerts • Take the apical pulse for 1 full minute, noting rate, rhythm, and quality before administering. If the pulse is below the parameter established by the healthcare provider (usually 60 beats per minute), withhold the dose and notify the provider. • Check for recent serum digoxin level results before administering. If the level is higher than the parameter established by the healthcare provider (usually 1.8 n g/m L), withhold the dose and notify the provider. • Use with caution in older adult and pediatric patients because these populations may have inadequate renal and hepatic metabolic enzymes. • Pregnancy category A.

35. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) Pharmacokinetics

36. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) Adverse Effects The most dangerous adverse effect of digoxin is 1- Dysrhythmias, particularly in patients who have hypokalemia or CKD. 2- Nausea, vomiting, fatigue, anorexia, and visual disturbances such as seeing halos, a yellow-green tinge, or blurring

37. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) Contraindications: 1- Patients with AV block or ventricular dysrhythmias. 2- Digoxin should be administered with caution to older adults because these patients experience a higher incidence of adverse effects. 3- Patients with CKD should receive lower doses of digoxin because the drug is excreted by this route. 4- The drug should be used with caution in patients with MI, or hypothyroidism.

38. Prototype Drug: Digoxin (Lanoxin, Lanoxicaps) Herbal/Food: Potassium supplements or potassium salt substitute should not be taken unless approved by the healthcare provider. Treatment of Overdose: Digoxin overdose can be fatal. Specific therapy involves IV infusion of digoxin immune fab (Digibind), which contains antibodies specific for digoxin.

39. Beta-Adrenergic Blockers • Prototype drug: metoprolol (Lopressor, Troprol XL) • Mechanism of action: block cardiac action of sympathetic nervous system to slow heart rate and BP, reducing workload of heart

40. Beta-Adrenergic Blockers • Primary use: To reduce symptoms of heart failure and slow progression of disease. • Adverse effects: 1- Fluid retention 2-Worsening of heart failure 3- Fatigue, hypotension 4- Bradycardia, heart block

41. Prototype Drug Milrinone (Primacor) Therapeutic Class: Drug for heart failure Pharmacologic Class: Phosphodiesterase inhibitor Actions and Uses: Action: * Milrinone is generally preferred because it has a shorter half-life and fewer side effects. It is given only IV and is primarily used for the short-term therapy of advanced HF. The drug has a rapid onset of action. * Immediate effects of milrinone include an increased force of myocardial contraction and an increase in cardiac output.

42. Prototype Drug Milrinone (Primacor) Administration Alerts • When administered IV, a microdrip set and an infusion pump should be used. • Safety and efficacy have not been established in older adult and pediatric patients. • Pregnancy category C. Pharmacokinetics

43. Prototype Drug Milrinone (Primacor) Adverse Effects: 1- The most serious adverse effect of milrinone is ventricular dysrhythmia, which may occur in 1 of every 10 patients taking the drug. 2- Less serious side effects include headache, nausea, and vomiting. Contraindications: The only contraindication to milrinone is 1- Previous hypersensitivity to the drug. 2- Milrinone should be used with caution in patients with pre-existing dysrhythmias. Treatment of Overdose: Overdose causes hypotension, which is treated with the administration of normal saline or a vasopressor.

44. Drug Therapy for Heart Failure • Assessment: • Complete health history, vital signs, urinary output • Cardiac output • Reason for medication • Patient’s knowledge

45. Drug Therapy for Heart Failure • Nursing diagnoses: • Decreased Cardiac Output • Excess Fluid Volume • Deficient Knowledge related to drug therapy • Risk for Reduced Cardiac Tissue Perfusion

46. Drug Therapy for Heart Failure • Planning: patient goals and expected outcomes • Decreased symptoms • Improved organ function • Understanding of drug therapy • Reporting drug side effects

47. Drug Therapy for Heart Failure • Implementation • Monitor ECG • Observe for side effects • Obtain daily weight • Monitor serum drug levels • Observe for signs of toxicity • Monitor electrolyte levels

48. Drug Therapy for Heart Failure • Evaluate effectiveness of drug therapy • Goals met • Expected outcomes met

49. Nursing Practice Application Assessment Baseline assessment prior to administration: • Obtain a complete health history and drug history, including allergies, current prescription, herbal preparations, and alcohol use. Be alert to possible drug interactions. • Obtain baseline weight, vital signs (especially pulse and blood pressure), breath sounds, and E C G. Assess for location and character of edema if present. • Evaluate appropriate laboratory findings; electrolytes, especially potassium level; kidney function studies; and lipid profiles.

50. Nursing Practice Application Assessment Assessment throughout administration: • Assess for desired therapeutic effects (e.g., heart rate and blood pressure return to, or remain within, normal limits; urine output returns to, or is within, normal limits; respiratory congestion (if present) is improved; peripheral edema (if present) is improved; level of consciousness, skin color, capillary refill, and other signs of adequate perfusion are within normal limits; fatigue lessens. • Continue periodic monitoring of electrolytes, especially potassium, kidney function, and drug levels. • Assess for adverse effects: hypotension, bradycardia, nausea, vomiting, anorexia, visual changes, fatigue, dizziness, or drowsiness. A pulse rate below 60 or above 100, palpitations, significant dizziness or syncope, persistent anorexia or vomiting, or visual changes should be immediately reported to the healthcare provider. • Lifespan: Exercise caution when giving the drug to the older adult, paediatric patients, or patients with CKD.