3Inotropic DrugsDrugs that increase the force of myocardial contractions.
4Chronotropic DrugsDrugs that increase the rate at which the heat beats.
5Dromotropic DrugsDrugs that accelerate conduction.
6Heart FailureCongestive 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.
7Causes of Heart Failure 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 workhigh blood pressureheart valve diseaseprimary 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
11Heart FailureAs 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.
13Signs and Symptoms of Heart Failure or HF Often no symptoms at restDyspnea (difficulty breathing) and fatigue occur with increased activityEdema of ankles and feetDistention of jugular veinsIn acute cases pulmonary edema – cough and shortness of breath
20Actions 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 enters the cell in exchange for sodium.The calcium activates the contractile proteins and increased myocardial contractility.
21Administration Can be given orally or IV IV peaks within 10 to 30 minutesPO peaks within 1 to 2 hours
22Serum Blood LevelsMaximum drug action occurs when steady tissue concentration has been achieved – takes about 1 weekLoading 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 hoursWhen adequate levels have been reached than a maintenance dose can be started
23Maintenance Dose Dosing is 0.125 – 0.5 mg Average dose is 0.25 mg Take daily at same time of dayGive with food or after meals
24Dosing by mcg/kg in Adults IV digitalizing dose = 0.6 to 1 mg ( 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
25Nursing Responsibilities Take apical pulse for one full minute before giving the medication – listen for any irregular heart beatsSpecific guidelines for holding the drug and notifying physicianAdults: apical pulse less than 60Older child: apical pulse less than 60Infant or younger child: apical pulse less than 100
26Nursing Responsibilities Notify physician if bradycardia (heart rate less than 60 bpm) or new arrhythmias occur.Assess for peripheral edema and auscultate lungs for rales/crackles.Check kidney function since you want to know they can excrete excess digoxin and avoid build up in body.
27Laboratory ValuesElectrolyte imbalance: potassium, calcium and magnesium values need to be monitoredHypokalemia (low potassium)Hypomagnesemia (low magnesium)Both can lead to irregular heart rate.
28Digoxin ToxicityAnorexia, nausea, and confusion are symptoms of digoxin toxicityHR below 60 in adults and HR below100 in infants and small childrenDigoxin should be discontinued by MD only– takes about 1 week for drug to be eliminated from the body.
29Evaluation of Effectiveness Increased urinary outputDecreased edemaDecreased shortness of breath, dyspnea and cracklesDecreased fatigueImproved peripheral pulses, skin color and temperatureSerum digoxin levels 0.5 to 2 ng/mL
30digoxin Overdose digoxin immune Fab or DigiFab Therapeutic classification: antidotesPharmacologic classification: antibody fragmentsIndications: 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.
34Angina PectorisChest pain occurring when the heart’s supply of blood carrying oxygen and energy-rich nutrients is insufficient to meet demands of the heart.
35Ischemia Poor blood flow to an organ Ischemic heart disease = poor blood flow to heartMyocardial infarct = damage done to heart muscle after an ischemic event
36AnginaAngina 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
39Classification 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.
40Antianginal DrugsNitrates 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 (to prevent) or in long-term management of angina.
42nitroglycerineAction: 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 attacksReduction of blood pressureIncrease blood flow to heart / decrease in HR
43DosingOral dosage is rapidly metabolized in the liver and only small doses reach the systemic circulatory systemFor more effective absorption drug is given:Sublingually – under the tongue – acts in 1 to 3 minutesPO: sustained-released tabletTransdermal ointments – applied on hairless area on back, chest or upper armPatches – takes 40 minutes to an hour to start working
45Sublingual 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 1 to 3 minutesMay be repeated every 5 minutes for 3 doses.If no relief call 911.
47Sustained 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.
49Nitroglycerin PatchPlace 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
51Nitroglycerine Ointment Comes with paper with a ruled line for measuring the doseSqueeze ointment onto the paper, carefully measuring the amount specified on the prescription labelUse 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 tapeOintment is applied three or four times a day
53Antiaginal Drugs Nitrates to manage the chest pain Beta blockers to manage the chest pain plus hypertensionCalcium channel blockers to manage the chest pain plus hypertension
54Blood Pressure Medications ACE inhibitors: angiotension-converting enzyme inhibitorsBeta blockersCalcium channel blockersDiureticsVasodilators: used in hypertensive crisis only
55B-adrenergic Blockers B-blockers (beta 1)Primary drug effect is related to the cardiovascular system.
56When Used Angina Myocardial infarct Dysrhythmias Hypertension Used when a client has a combination of any of the above diagnoses
57Action of Beta 1 Blockers Decrease energy demands on heart to decrease angina attacks.Block the B receptors on the SA node to slow heart rateBlock the harmful release of catecholamines (epinephrine and norepinephrine)Blocks the release of renin a potent vasoconstrictor in the kidney to decrease blood pressure.
58Contraindications 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.
60Adverse Effects Decrease in HR blow the 60 bpm Decreased cardiac outputBronchocontriction in patients with asthma or COPD.Cardiac rhythm problems due to decreased SA or AV node conductionHypo or hyperglycemiaHypotension
61Nursing Responsibilities Monitor blood pressureAssess for orthostatic hypotension when a client stands upCheck medication refills for adherenceAssess for anginaMonitor for signs of overdose
62Beta Blocker Drugs Three most common drugs used carvedilol or Coreg metoprolol or Lopressoratenolol or Tenormin
63Clinical PearlBeta blockers are good to use in clients who like to exercise.It does not allow the heart rate to elevate to dangerous levelsClient may report inability to generate a increase heart rate while exercising
64Calcium Channel Blockers Three chemical classificationsphenylalkylaminesbenzothiazepinesdihydrophyridines
65ActionBlock calcium entry into cells of vascular smooth muscle an myocardium. Dilate coronary arteries in both normal and ischemic myocardium and inhibit coronary artery spasm.Increased blood flow to ischemic heartUseful in treating dysrhythmias
66Indications First line drugs used to treat Angina Hypertension Supraventricular tachycardia: cardiac dysrhythmia
67One Important Consideration When Prescribing Calcium Channel Blockers may not be as effective in controlling exercise induced elevation of heart rate or blood pressure.A beta 1 blocker would be best for the client that exercises – drug would keep heart rate and blood pressure from rising during exertion.
68Contraindications Drug allergy Acute Myocardial Infarction (MI) Atrial ventricular blockBradycardiaPacemakerHypotension
71ACE inhibitors Indication: Action: used alone or with other agents in the management of hypertensionused in patients with congestive heart failureAction:blocks the vasoconstrictor and aldosterone producing effects of angiotensin II at various receptor sites, including vascular smooth muscle and the adrenal glands.
72ACE Inhibitors Therapeutic Effects: Lowering of blood pressure Decreased after load in patients with Congestive Heart FailureDecreased development of Heart FailureIncreased survival after Myocardial infarctDecreased progression of diabetic neuropathy
73Evaluation of Effectiveness Decrease in blood pressureDecrease in signs and symptoms of CHFReduction of risk of developing CHF (congestive heart failure) after a MI (myocardial infarct)
74Nursing Responsibilities Monitor blood pressureMonitor for signs of fluid overloadMonitor weightEdemaJugular distensionLung congestionMonitor frequency of prescription refills to determine adherence
75Most common side effect CoughHyperkalemia (due to decrease in secretion of potassium)Metallic taste
76VasodilatorsAction: works directly on arteriolar and venous muscles to cause relaxation.Very useful in managing hypertensive emergencies.Blood pressure needs to be brought down slowly.
77VasodilatorsIntravenous (IV) diazoxide and sodium nitroprusside are useful in managing hypertensive emergencies.Blood pressure need to be brought down slowly.
78Nursing Responsiblities Monitor for adverse effects:Orthostatic hypotensionDizzinessfatigue
79Nursing Assessment Monitor effectiveness of the drug therapy Client will return to baseline activitiesClient will report improved energy.Blood pressure reading will be lowered with the goal to bring back to normal levels.