1. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chapter 24
Heart Failure Drugs
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2. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Heart Failure
The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs
Symptoms depend on the cardiac area affected
Systolic dysfunction
Diastolic dysfunction
Less common
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Heart Failure: Causes
Cardiac defect
Myocardial infarction
Valve deficiency
Defect outside the heart
Coronary artery disease
Pulmonary hypertension
Diabetes
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4. Conduction System of the Heart
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5. The New York Heart Association
Class I
Class II
Class III
Class IV
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6. 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
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7. Drug Therapy for Heart Failure (cont’d)
ACE inhibitors
Angiotensin II receptor blockers
Beta blockers
Aldosterone antagonists
B-type natriuretic peptides
Phosphodiesterase inhibitors
Cardiac glycosides
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ACE Inhibitors
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
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9. Angiotensin II Receptor Blockers (ARBs)
Potent vasodilators; decrease systemic vascular resistance (afterload)
Examples: valsartan (Diovan), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), telmisartan (Micardis), olmesartan (Benicar), and losartan (Cozaar)
All ARBs are similar in action
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Beta Blockers
Beta blockers work by reducing or blocking sympathetic nervous system stimulation to the heart and the heart’s conduction system
Reduced heart rate, delayed AV node conduction, reduced myocardial contractility, and decreased myocardial automaticity result
Examples: metoprolol, carvedilol (Coreg)
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11. Aldosterone Antagonist
spironolactone (Aldactone)
Potassium-sparing diuretic
Also acts as an aldosterone antagonist, which has been shown to reduce the symptoms of heart failure
eplerenone (Inspra)
Selective aldosterone blocker
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12. Miscellaneous Drugs to Treat Heart Failure
hydralazine/isosorbide dinitrate (BiDil)
First drug approved for a specific ethnic group, namely African Americans
dobutamine
Beta1-selective vasoactive adrenergic drug
Structurally similar to dopamine
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13. B-type Natriuretic Peptides
nesiritide (Natrecor)
Used in the intensive care setting as a final effort to treat severe, life-threatening heart failure, often in combination with several other cardiostimulatory medications
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14. B-type Natriuretic Peptides: Mechanism of Action
Effects include diuresis (urinary fluid loss), natriuresis (urinary sodium loss), and vasodilation
Vasodilating effects on both arteries and veins
Indirectly increases cardiac output
Suppresses renin-angiotensin system
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15. Classroom Response Question
Which patient is the best candidate to receive nesiritide therapy?
A patient with atrial fibrillation who has not responded to other drugs
A patient needing initial treatment for heart failure
A patient with reduced cardiac output
A patient with acutely decompensated heart failure who has dyspnea at rest
Correct answer: D
Rationale: At this time, nesiritide is generally used in the intensive care setting as a final effort to treat severe, life-threatening heart failure, often in combination with several other cardiostimulatory medications. The manufacturer recommends that nesiritide not be used as a first-line drug for this purpose. In 2005, an expert panel reviewed nesiritide at the request of the U.S. Food and Drug Administration in response to reports of worsened renal function and mortality. The expert panel stated that the use of nesiritide should be strictly limited to treatment of patients with acutely decompensated heart failure who have dyspnea at rest. It should not be used to replace diuretics and should not be used repetitively or to improve renal function.
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Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

16. B-type Natriuretic Peptides: Adverse Effects
Hypotension
Dysrhythmia
Headache
Abdominal pain
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17. Phosphodiesterase Inhibitors
Work by inhibiting the enzyme phosphodiesterase
Results in:
Positive inotropic response
Vasodilation
milrinone (Primacor)
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18. Phosphodiesterase Inhibitors: Indications
Short-term management of heart failure
Given when patient does not respond to treatment with digoxin, diuretics, and/or vasodilators
AHA and ACC advise against long-term infusions
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19. Phosphodiesterase Inhibitors: Adverse Effects
milrinone
Dysrhythmia
Hypotension
Angina (chest pain)
Hypokalemia
Tremor
Thrombocytopenia
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Cardiac Glycosides
No longer used as first-line treatment
Originally obtained from Digitalis plant, foxglove
Digoxin is the prototype
Used in heart failure and to control ventricular response to atrial fibrillation or flutter
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21. 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 SA node and AV node
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22. 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
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23. Cardiac Glycosides: Drug Effects (cont’d)
Increased stroke volume
Reduction in heart size during diastole
Decrease in venous BP and vein engorgement
Increase in coronary circulation
Promotion of diuresis because of improved blood circulation
Palliation of exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis
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24. Cardiac Glycosides: Indications
Heart failure
Supraventricular dysrhythmias
Atrial fibrillation and atrial flutter
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25. Classroom Response Question
A patient is in the emergency department with new onset atrial fibrillation. Which order for digoxin would most likely have the fastest therapeutic effect?
Digoxin 0.25 mg PO daily
Digoxin 1 mg PO now, then 0.25 mg PO daily
Digoxin 0.5 mg IV push daily
Digoxin 1 mg IV push now, then 0.25 mg IV daily
Correct answer: D
Rationale: 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.
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Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

26. 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
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27. Cardiac Glycosides: Adverse Effects (cont’d)
digoxin (Lanoxin) (cont’d)
Cardiovascular
Dysrhythmias, including bradycardia or tachycardia
CNS
Headaches, fatigue, malaise, confusion, convulsions
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28. Cardiac Glycosides: Adverse Effects (cont’d)
digoxin (Lanoxin) (cont’d)
Eye
Colored vision (seeing green, yellow, purple), halo vision, flickering lights GI
Anorexia, nausea, vomiting, diarrhea
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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
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30. Classroom Response Question
A patient is receiving digoxin 0.25 mg daily as part of treatment for heart failure. The nurse assesses the patient before medication administration. Which assessment finding would be of most concern?
Apical heart rate of 58 beats/min
Ankle edema +1 bilaterally
Serum potassium level of 2.9 mEq/L
Serum digoxin level of 0.8 ng/mL
Correct answer: C
Rationale: The hypokalemia may precipitate digoxin toxicity; therefore it is the biggest concern. The apical pulse is slightly under 60, but bradycardia may occur with digoxin therapy and the heart rate should be monitored. The ankle edema may be a manifestation of his heart failure and not a new concern. The digoxin level is within normal range.
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Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

31. Conditions That Predispose to Digoxin Toxicity
Hypokalemia
Use of cardiac pacemaker
Hepatic dysfunction
Hypercalcemia
Dysrhythmias
Hypothyroid, respiratory, or renal disease
Advanced age
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32. Heart Failure Drugs: Nursing Implications
Assess history, drug allergies, contraindications
Assess clinical parameters, including: BP
Apical pulse for 1 full minute
Heart sounds, breath sounds
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33. Heart Failure Drugs: Nursing Implications (cont’d)
Assess clinical parameters (cont’d)
Weight, I&O measures
ECG
Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies
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34. Heart Failure Drugs: Nursing Implications (cont’d)
Before giving any dose, count apical pulse for 1 full minute
For apical pulse less than 60 or greater than 100 beats/min
Hold dose
Notify prescriber
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35. Heart Failure Drugs: Nursing Implications (cont’d)
Hold dose and notify prescriber if patient experiences signs/symptoms of toxicity
Anorexia, nausea, vomiting, diarrhea
Visual disturbances (blurred vision, seeing green or yellow halos around objects)
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36. Heart Failure Drugs: Nursing Implications (cont’d)
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
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37. Heart Failure Drugs: Nursing Implications (cont’d)
Nesiritide or milrinone
Use an infusion pump
Monitor I&O, heart rate and rhythm, BP, daily weights, respirations, and so on
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38. Heart Failure Drugs: Nursing Implications (cont’d)
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
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Case Study
A patient with a history of heart failure presents to the emergency department with difficulty breathing, cough, and edema of the lower extremities. The nurse anticipates administration of which type of medication?
Positive chronotrope
Negative chronotrope
Positive inotrope
Negative inotrope
Correct answer: C
Rationale: Positive inotropes are used to increase the force of myocardial contraction in the treatment of a patient with heart failure. Negative inotropes would cause the heart to have a decreased force of myocardial contraction and would not be effective. Positive chrontropes increase the rate at which the heart beats, and negative chronotropes decrease the rate at which the heart beats.
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Case Study (cont’d)
The patient is prescribed an ACE inhibitor. The nurse understands the primary mechanism by which the ACE inhibitors exert their therapeutic effect in a patient in heart failure is:
to inhibit catecholamine release.
to inhibit acetylcholine release.
to inhibit aldosterone secretion.
to prevent vagal stimulation.
Correct answer: C
Rationale: The ACE inhibitors are beneficial in the treatment of heart failure because they prevent sodium and water resorption by inhibiting aldosterone secretion. This causes diuresis, which decreases blood volume and blood return to the heart. This in turn decreases preload, or the left ventricular end-diastolic volume, and the work required of the heart.
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Case Study (cont’d)
The patient is discharged home and returns to the emergency department 4 days later. The patient is admitted to the intensive care unit with acute decompensated heart failure with dyspnea at rest. The nurse anticipates administration of which medication?
atropine
carvedilol (Coreg)
lisinopril (Prinivil)
nesiritide (Natrecor)
Correct answer: D
Rationale: Nesiritide is used in the intensive care setting as a final effort to treat severe, life-threatening heart failure, often in combination with several other cardiostimulatory medications. Lisinopril (Prinivil) is an ACE inhibitor that is used in the management of heart failure. Carvedilol (Coreg) has been shown to slow the progression of heart failure and to decrease the frequency of hospitalization in patients with mild to moderate (class II or III) heart failure. Atropine is used to increase heart rate.
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