1. Cardiac Glycosides, Antianginals, and Antidysrhythmics
Chapter 42
Cardiac Glycosides, Antianginals, and Antidysrhythmics
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2. Heart Failure Heart failure Pathophysiology Right-sided Left-sided
Preload
Afterload
Right-sided
Blood backs up in periphery
Left-sided
Blood backs up in lungs
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3. ACC/AHA Stages of Heart Failure
Stages Characteristics
1 (A) High risk for HF without symptoms or structural disease
2 (B) Some levels of cardiac changes (e.g., decrease ejection fraction without symptoms of heart failure)
3 (C) Structural heart disease with symptoms of HF (e.g., fatigue, SOB, edema, decreased physical activity)
4 (D) Severe structural heart disease and marked symptoms of HF at rest
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4. Heart Failure (Cont.) Nonpharmacologic treatment Laboratory tests
Limit salt intake.
Limit or avoid alcohol intake.
Stop smoking.
Decrease saturated fat intake.
Perform mild exercise as possible.
Laboratory tests
Atrial natriuretic peptide (ANP)–20 to 77 pg/mL; 20 to 77 ng/L (SI units)
Brain natriuretic peptide (BNP)–Desired value: less than 100 pg/mL; positive value: greater than 100 pg/mL
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5. Cardiac Glycosides Digitalis preparations (digoxin) Actions
Positive inotropic
Increases myocardial contractility
Negative chronotropic
Decreases heart rate
Negative dromotropic
Decreases conduction
Increase stroke volume
Increases cardiac output
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6. Cardiac Glycosides (Cont.)
Atrial fibrillation
Atrial flutter
Other drugs used if digoxin not effective:
Calcium channel blocker: verapamil (Calan)
Warfarin (Coumadin)
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7. Cardiac Glycosides (Cont.)
Digoxin
Drug interactions
Diuretics
Glucocorticoids
Antacids
Herbal interactions
Hypokalemia
Digitalis toxicity
Anorexia, diarrhea, nausea and vomiting, bradycardia, premature ventricular contractions, cardiac dysrhythmias, headaches, malaise, blurred vision, visual illusions, confusion, and delirium
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8. Cardiac Glycosides (Cont.)
Antidote for digitalis toxicity: digoxin immune Fab (ovine, Digibind)
Treatment cardiotoxicity
Phenytoin
Lidocaine
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9. Nursing Process: Digoxin
Assessment
Nursing diagnoses
Planning
Nursing interventions
Patient teaching
Cultural considerations
Evaluation
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10. Phosphodiesterase Inhibitors
Milrinone lactate (Primacor)
Positive inotrope
Used to treat acute HF
Action
Increase stroke volume and cardiac output and promote vasodilation
Caution: Administered IV for no longer than 48 to 72 hours to avoid severe cardiac dysrhythmias
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11. Other Agents Used to Treat Heart Failure
Vasodilators
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor antagonists
Diuretics (thiazides, furosemide), spironolactone (Aldactone)
Some beta blockers
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12. Vasodilators Decrease venous blood return to the heart
Decrease preload
Decrease oxygen demand on the heart
Arteriolar dilators
Reduce cardiac afterload
Improve renal perfusion
Improve circulation to skeletal muscles
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13. ACE Inhibitors and ARBs
Dilate venules and arterioles, improving renal blood flow and decreasing blood fluid volume
Decrease release of aldosterone
Angiotensin II receptor blocker (ARB) agents
Valsartan (Diovan) and candesartan (Atacand) approved for HF in patients who cannot tolerate an ACE inhibitor.
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14. Diuretics First-line drug treatment for reducing fluid volume
Spironolactone (Aldactone)
Blocks production of aldosterone; improves heart rate variability; decreases myocardial fibrosis cardioprotective effect of blocking aldosterone in the heart and blood vessels to promote cardiac remodeling
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15. Beta Blockers Carvedilol (Coreg) Metoprolol tartrate (Toprol-XL)
Bisoprolol (Zebeta)
Doses should be low initially and gradually increased.
Beneficial effect:1 to 3 months
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16. Atrial Natriuretic Peptide
Nesiritide (Natrecor)
Inhibits antidiuretic hormone (ADH) by increasing urine sodium loss
Promotes vasodilation, natriuresis, and diuresis
Used for treatment of acute decompensated HF with dyspnea at rest, dyspnea with little physical exertion
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17. BiDil
Combination of hydralazine (for blood pressure) and isosorbide dinitrate (a dilator to relieve heart pain)
FDA approval for treating HF, especially in African Americans
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18. Angina Classic (stable): Occurs with predictable stress or exertion
Unstable (preinfarction): Occurs frequently with progressive severity unrelated to activity; unpredictable regarding stress/exertion and intensity
Variant (Prinzmetal, vasospastic): Occurs during rest
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19. Types of Antianginal Drugs
Nitrates: reduction of venous tone, decreased workload of the heart, vasodilation
Beta blockers: decrease the workload of the heart and decrease oxygen demands
Calcium channel blockers: decrease the workload of the heart and decrease oxygen demands
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20. Nitrates First agents used to relieve angina
Action: Generalized vascular and coronary vasodilation
Side effects and adverse reactions: Headache, hypotension, dizziness, weakness, and faintness
Sublingual, topical (ointment, transdermal patch), buccal extended-release tablet, oral extended-release capsule and tablet, aerosol spray (inhalation), and IV
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21. Beta Blockers
Block the action of the catecholamines (epinephrine and norepinephrine)
Decrease heart rate and blood pressure
Do not abruptly discontinue
Selective beta blockers: atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL)
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22. Calcium Channel Blockers
Relax coronary artery spasm (variant angina)
Relax peripheral arterioles (stable angina)
Decrease cardiac oxygen demand
Decrease cardiac contractility (negative inotropic effect that relaxes smooth muscle)
Decrease afterload
Decrease peripheral resistance
Reduce the workload of the heart
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23. Antianginal Drugs Types of anginal pectoris with treatment
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24. Nursing Process: Antianginal Drugs
Assessment
Nursing diagnoses
Planning
Nursing interventions
Patient teaching
Evaluation
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25. Antidysrhythmic Drugs
Dysrhythmia vs. arrhythmia
Cardiac action potentials
Phase 0 to phase 4
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26. Antidysrhythmic Drugs (Cont.)
Mechanism of drug action
Class I
Sodium channel blockers
1A: slow conduction, prolongs repolarization (quinidine, procainamide, disopyramide)
1B: slow conduction, shortens repolarization (lidocaine, mexiletine)
1C: prolonged conduction with little/no effect on repolarization (flecainide, propafenone)
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27. Antidysrhythmic Drugs (Cont.)
Class II
Beta-adrenergic blockers
Reduce calcium entry, decrease conduction velocity, automaticity, and recovery time
Propranolol (Inderal)
Acebutolol (Sectral)
Esmolol (Brevibloc)
Sotalol (Betapace)
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28. Antidysrhythmic Drugs (Cont.)
Class III
Prolong repolarization
Amiodarone (Cordarone)
Class IV
Block calcium influx (calcium channel blockers)
Verapamil (Calan, Isoptin)
Diltiazem (Cardizem)
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29. Nursing Process: Antidysrhythmics
Assessment
Nursing diagnoses
Planning
Nursing interventions
Patient teaching
Evaluation
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30. Practice Question #1
A patient has angina pectoris. The patient’s BP is 100/60 mm Hg. The nurse administers nitroglycerin 0.4 mg sublingual (SL). It is most important for the nurse to assess the patient for the development of
bradycardia.
hypotension.
bradypenia.
hypokalemia.
Answer: B
Rationale: A side effect of nitroglycerin is hypotension owing to the vasodilation of blood vessels.
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31. Practice Question #2
A nurse is administering digoxin, mg, to a patient. Which nursing interventions will the nurse implement? (Select all that apply.)
Checking the apical pulse rate before administration
Monitoring the patient’s serum digoxin level
Instructing patient to report pulse rate less than 60
Advising patient to avoid foods high in potassium
Always giving an antacid with digoxin to reduce GI distress
Answer: A, B, C
Rationale: The apical pulse should be taken before digoxin administration and the drug withheld if the heart rate is less than 60. The patient’s serum digoxin level should be monitored and withheld if in toxic range. Therapeutic level is 0.5 to 2 ng/mL. Patient should be advised to eat foods high in potassium. Patient should be advised to avoid taking antacids with digoxin because they decrease absorption.
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32. Practice Question #3
A patient is ordered to receive digoxin (Lanoxin) to treat congestive heart failure. The nurse is most concerned about which assessment finding?
Heart rate 56 beats/min
BP 138/90 mm Hg
RR 18 breaths/min
1+ pitting edema of the lower extremities
Answer: A
Rationale: A baseline pulse rate for the patient should be obtained for future comparisons. Apical pulse should be taken for a full minute and should be greater than 60 beats/min. The prescriber should be notified if the patient’s pulse is less than 60 beats per minute.
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33. Practice Question #4
A nurse is preparing to administer digoxin (Digitalis) to a patient. Which laboratory result is the nurse most concerned about?
Sodium 138 mEq/L
Potassium 3.0 mEq/L
Digitalis level 1.8 ng/mL
BNP 200 pg/mL
Answer: B
Rationale: A low serum potassium level enhances the action of digoxin and can cause digitalis toxicity.
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34. Practice Question #5
When administering antianginal drugs, the nurses identifies which as the most common response?
Tachycardia
Bradypnea
Hypotension
Dry mouth
Answer: C
Rationale: The most common side effect of antianginal drugs is hypotension.
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35. Practice Question #6
Which drug group is most effective for the treatment of variant (vasospastic) angina?
Calcium channel blockers
Beta blockers
Cardiac glycosides
Phosphodiesterase inhibitors
Answer: A
Rationale: Nitrates and calcium channel blockers are effective in treating variant (vasospastic) angina pectoris.
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36. Practice Question #7
The nurse should teach the patient to report which of the following to the health care provider immediately if experienced after taking nitroglycerin?
Dizziness
Faintness
Headache
Persistent pain
Answer: D
Rationale: Dizziness, faintness, and headache can occur when taking nitroglycerin. It is important to teach the patient about avoiding complications related to orthostatic hypotension. Persistent pain indicates the possibility of acute coronary syndrome.
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37. Practice Question #8
The nurse identifies which drug as a calcium channel blocker used for the treatment of dysrhythmias?
Diltiazem (Cardizem)
Esmolol (Brevibloc)
Flecainide (Tambocor)
Sotalol HCl (Betapace)
Answer: A
Rationale: Diltiazem (Cardizem) is a calcium channel blocker used to treat dysrhythmias. Esmolol (Brevibloc) is a beta blocker. Flecainide (Tambocor) is a sodium channel blocker. Sotalol HCl (Betapace) is a beta blocker.
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38. Practice Question #9
A patient with angina and a long history of severe chronic obstructive pulmonary disease is ordered beta blocker therapy. Which beta blocker would be most effective for this patient?
Propranolol (Inderal)
Nadolol (Corgard)
Pindolol (Visken)
Atenolol (Tenormin)
Answer: D
Rationale: Cardioselective beta blockers act more strongly on the beta1 receptor, which decreases the heart rate but avoids bronchoconstriction. Examples of selective beta blockers are atenolol (Tenormin) and metoprolol (Lopressor, Toprol-XL). Examples of nonselective beta blockers are propranolol (Inderal), nadolol (Corgard), and pindolol (Visken). These drugs decrease the heart rate and can cause bronchoconstriction.
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