1. Drugs Affecting Cardiac and Renal Systems
Jan Bazner-Chandler
MSN, CNS, C-PNP, RN

2. Positive Inotropic Drugs
Chapter 21

3. Inotropic Drugs
Drugs that increase the force of myocardial contractions.

4. Chronotropic Drugs
Drugs that increase the rate at which the heat beats.

5. Dromotropic Drugs
Drugs that accelerate conduction.

6. 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.

7. Causes 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 work
high blood pressure
heart valve disease
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

8. CAD

9. Heart Valve Disease

10. Endocarditis

11. 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.

12. Heart Failure

13. 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

14. Pitting Edema

15. Distended Jugular Vein

16. Drugs in first-line treatment
Digoxin
Diuretics
ACE Angiotension-converting enzyme inhibitors

17. Cardiac Glycosides Oldest and most effective group of cardiac drugs.
Comes from the plant “fox glove”.

18. Cardiac Glycosides or Digoxin
Digoxin or Lanoxin is the only commonly used digitalis glycoside.

19. digoxin (Lanoxin, Digitek)
Classification Pharmacologic: digitalis, glycoside
Classification Therapeutic: antiarrhythmic, inotropic

20. Actions 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.

21. Administration Can be given orally or IV
IV peaks within 10 to 30 minutes
PO peaks within 1 to 2 hours

22. 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

23. 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

24. Dosing 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

25. 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

26. Nursing 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.

27. 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.

28. Digoxin Toxicity
Anorexia, nausea, and confusion are symptoms of digoxin toxicity
HR below 60 in adults and HR below100 in infants and small children
Digoxin should be discontinued by MD only– takes about 1 week for drug to be eliminated from the body.

29. 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

30. 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.

31. Antianginal Drugs
Chapter 23

32. Coronary Arteries
Arteries that deliver oxygen to the heart muscle.

33. Coronary Arteries

34. 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.

35. Ischemia 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

36. Angina
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

37. Angina

38. Angina

39. 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.

40. 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 (to prevent) or in long-term management of angina.

41. nitroglycerine Classification Pharmacologic: nitrates
Classification Therapeutic: antianginals

42. nitroglycerine
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
Increase blood flow to heart / decrease in HR

43. Dosing
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 40 minutes to an hour to start working

44. Sublingual Nitroglycerine

45. 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 1 to 3 minutes
May be repeated every 5 minutes for 3 doses.
If no relief call 911.

46. Sustained Released Tablet

47. 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.

48. Nitroglycerine Patch

49. 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

50. Nitroglycerine Ointment

51. 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

52. Side Effects
Dizziness
Headache
Hypotension
Tachycardia
Syncope

53. Antiaginal Drugs Nitrates to manage the chest pain
Beta blockers to manage the chest pain plus hypertension
Calcium channel blockers to manage the chest pain plus hypertension

54. Blood Pressure Medications
ACE inhibitors: angiotension-converting enzyme inhibitors
Beta blockers
Calcium channel blockers
Diuretics
Vasodilators: used in hypertensive crisis only

55. B-adrenergic Blockers
B-blockers (beta 1)
Primary drug effect is related to the cardiovascular system.

56. When Used Angina Myocardial infarct Dysrhythmias Hypertension
Used when a client has a combination of any of the above diagnoses

57. 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.

58. Contraindications 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.

59. Contraindications Conductive disturbances Bronchial asthma
Diabetes: blocks hypo-glycemic induced tachycardia.
Reduced metal alertness
Peripheral vascular disease

60. 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
Hypotension

61. Nursing Responsibilities
Monitor blood pressure
Assess for orthostatic hypotension when a client stands up
Check medication refills for adherence
Assess for angina
Monitor for signs of overdose

62. Beta Blocker Drugs Three most common drugs used carvedilol or Coreg
metoprolol or Lopressor
atenolol or Tenormin

63. Clinical Pearl
Beta blockers are good to use in clients who like to exercise.
It does not allow the heart rate to elevate to dangerous levels
Client may report inability to generate a increase heart rate while exercising

64. Calcium Channel Blockers
Three chemical classifications
phenylalkylamines
benzothiazepines
dihydrophyridines

65. Action
Block 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 heart
Useful in treating dysrhythmias

66. Indications First line drugs used to treat Angina Hypertension
Supraventricular tachycardia: cardiac dysrhythmia

67. One 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.

68. Contraindications Drug allergy Acute Myocardial Infarction (MI)
Atrial ventricular block
Bradycardia
Pacemaker
Hypotension

69. Adverse Effects Cardiovascular: Hypotension Heart palpitations
Tachycardia / bradycardia
Heart Failure

70. ACE Inhibitors – Angiotensin Receptor Antagonists
Lotensin
Capoten
Vasotec
Accupril
Altace
Mavik

71. ACE inhibitors Indication: Action:
used alone or with other agents in the management of hypertension
used in patients with congestive heart failure
Action:
blocks the vasoconstrictor and aldosterone producing effects of angiotensin II at various receptor sites, including vascular smooth muscle and the adrenal glands.

72. ACE Inhibitors Therapeutic Effects: Lowering of blood pressure
Decreased after load in patients with Congestive Heart Failure
Decreased development of Heart Failure
Increased survival after Myocardial infarct
Decreased progression of diabetic neuropathy

73. Evaluation of Effectiveness
Decrease in blood pressure
Decrease in signs and symptoms of CHF
Reduction of risk of developing CHF (congestive heart failure) after a MI (myocardial infarct)

74. Nursing Responsibilities
Monitor blood pressure
Monitor for signs of fluid overload
Monitor weight
Edema
Jugular distension
Lung congestion
Monitor frequency of prescription refills to determine adherence

75. Most common side effect
Cough
Hyperkalemia (due to decrease in secretion of potassium)
Metallic taste

76. Vasodilators
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.

77. Vasodilators
Intravenous (IV) diazoxide and sodium nitroprusside are useful in managing hypertensive emergencies.
Blood pressure need to be brought down slowly.

78. Nursing Responsiblities
Monitor for adverse effects:
Orthostatic hypotension
Dizziness
fatigue

79. 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.