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Chapter 24
Heart Failure Drugs
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Heart Failure
Not a specific disease
Complex clinical syndrome resulting from any functional or structural impairment to the heart, specifically ejection of blood or ventricular filling
The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs.
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Heart Failure (Cont.)
Symptoms depend on the cardiac area affected
“Left-sided” heart failure (HF): pulmonary edema, coughing, shortness of breath, and dyspnea
“Right-sided” HF: systemic venous congestion, pedal edema, jugular venous distension, ascites, and hepatic congestion
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Heart Failure: Causes
Myocardial infarction (MI)
Coronary artery disease
Cardiomyopathy
Valvular insufficiency
Atrial fibrillation
Infection
Tamponade
Ischemia
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5. Heart Failure: Causes (Cont.)
Pulmonary hypertension
Systemic hypertension
Outflow obstruction
Hypervolemia
Congenital abnormalities
Anemia
Thyroid disease
Infection
Diabetes
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6. Conduction System of the Heart
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American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) Stages of Heart Failure
STAGE A: At high risk for Heart Failure but no symptoms or structural heart disease
STAGE B: Structural heart disease but no symptoms
STAGE C: Structural heart disease with symptoms
STAGE D: Refractory HF requiring interventions
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8. 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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9. Drug Therapy for Heart Failure (Cont.)
Positive inotropic drugs
Phosphodiesterase inhibitors
Cardiac glycosides
B-type natriuretic peptides
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Beta blockers
Diuretics
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10. Drugs of Choice for Early Treatment of Heart Failure
ACE inhibitors (lisinopril, enalapril, captopril, and others)
ARBs (valsartan, candesartan, losartan, and others)
Certain beta blockers (metoprolol, a cardioselective beta blocker; carvedilol, a nonspecific beta blocker)
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11. Drugs of Choice for Early Treatment of Heart Failure (Cont.)
Loop diuretics (furosemide) are used to reduce the symptoms of HF secondary to fluid overload.
Aldosterone inhibitors (spironolactone, eplerenone) are added as the HF progresses.
Only after these drugs are used is digoxin added.
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12. Drugs of Choice for Early Treatment of Heart Failure (Cont.)
Dobutamine: positive inotropic drug
Hydralazine and isosorbide dinitrate became the first drug approved for a specific ethnic group. Hydralazine/isosorbide dinitrate (BiDil) was approved specifically for use in the African-American population.
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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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14. Lisinopril (Prinivil, Zestril)
Uses: hypertension, HF, and acute MI
Hyperkalemia
Dry cough
Decreased renal function
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15. Angiotensin II Receptor Blockers (ARBs)
Potent vasodilators; decrease systemic vascular resistance (afterload)
Used alone or in combination with other drugs such as diuretics in the treatment of hypertension or HF
Examples: valsartan (Diovan), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), telmisartan (Micardis), olmesartan (Benicar), and losartan (Cozaar)
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Valsartan (Diovan)
Valsartan shares many of the same adverse effects as lisinopril.
ARBs are not as likely to cause the cough associated with the ACE inhibitors.
ARBs are not as likely to cause hyperkalemia.
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Beta Blockers
Cardioprotective quality of beta blockers: prevent catecholamine-mediated actions on the heart by reducing or blocking sympathetic nervous system stimulation to the heart and the heart’s conduction system
Metoprolol
Carvedilol (Coreg)
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18. Aldosterone Antagonists
Spironolactone and eplerenone
Useful in severe stages of HF
Action: activation of the renin-angiotensin-aldosterone system causes increased levels of aldosterone, which causes retention of sodium and water, leading to edema that can worsen HF.
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19. Aldosterone Antagonists (Cont.)
Spironolactone (Aldactone): potassium-sparing diuretic and aldosterone antagonist shown to reduce the symptoms of HF
Eplerenone (Inspra): selective aldosterone blocker, blocking aldosterone at its receptors in the kidney, heart, blood vessels, and brain
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20. 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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21. B-Type Natriuretic Peptides
nesiritide (Natrecor)
Synthetic version of human B-type natriuretic peptide
Vasodilating effects on both arteries and veins
Effects of nesiritide
Diuresis (urinary fluid loss)
Natriuresis (urinary sodium loss)
Vasodilation
Indirect increase in cardiac output and suppression of neurohormonal systems such as the renin-angiotensin system
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22. B-Type Natriuretic Peptides: Adverse Effects
Nesiritide is used in the intensive care setting as a final effort to treat severe, life-threatening HF, often in combination with several other cardiostimulatory medications.
Hypotension
Dysrhythmia
Headache
Abdominal pain
Insomnia
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23. Audience Response System 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 HF
A patient with reduced cardiac output
A patient with acutely decompensated HF 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 HF, 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 HF 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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24. Phosphodiesterase Inhibitors
Work by inhibiting the enzyme phosphodiesterase
Result in
Intracellular increase in cAMP
Positive inotropic response
Vasodilation
Increase in calcium for myocardial muscle contraction.
Inodilators (inotropics and dilators)
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25. Phosphodiesterase Inhibitors: Indications
Short-term management of HF for patients in the intensive care unit (ICU)
AHA and ACC advise against long-term infusions
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Milrinone
Only available phosphodiesterase inhibitor
Milrinone is available only in injectable form.
Adverse effects: cardiac dysrhythmias, headache, hypokalemia, tremor, thrombocytopenia, and elevated liver enzyme levels
Interactions: diuretics (additive hypotensive effects) and digoxin (additive inotropic effects)
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Cardiac Glycosides
No longer used as first-line treatment
Not been shown to reduce mortality
Originally obtained from Digitalis plant, foxglove
Digoxin is the prototype
Used in HF and to control ventricular response to atrial fibrillation
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28. 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 sinoatrial (SA) node and atrioventricular (AV) node
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29. 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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30. Cardiac Glycosides: Drug Effects (Cont.)
Increased stroke volume
Reduction in heart size during diastole
Decrease in venous BP and vein engorgement
Increase in coronary circulation
Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis
Improved symptom control, quality of life, and exercise tolerance
No apparent reduction in mortality
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31. Audience Response System 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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32. 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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33. Cardiac Glycosides: Adverse Effects (Cont.)
digoxin (Lanoxin) (Cont.)
Cardiovascular: dysrhythmias, including bradycardia or tachycardia
Central nervous system: headaches, fatigue, malaise, confusion, convulsions
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34. Cardiac Glycosides: Adverse Effects (Cont.)
digoxin (Lanoxin) (Cont.)
Eyes: colored vision (seeing green, yellow, purple), halo vision, flickering lights
Gastrointestinal: 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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36. Audience Response System Question
A patient is receiving digoxin 0.25 mg/day as part of treatment for HF. 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 beats/min, but bradycardia may occur with digoxin therapy, and the heart rate should be monitored. The ankle edema may be a manifestation of his HF and not a new concern. The digoxin level is within the normal range.
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37. 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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38. Heart Failure Drugs: Nursing Implications
Assess history, drug allergies, and contraindications.
Assess clinical parameters, including: BP
Apical pulse for 1 full minute
Heart sounds, breath sounds
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39. Heart Failure Drugs: Nursing Implications (Cont.)
Assess clinical parameters (Cont.)
Weight, input and output measures
Electrocardiogram
Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies
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40. Heart Failure Drugs: Nursing Implications (Cont.)
Before giving any dose, count apical pulse for 1 full minute.
For an apical pulse less than 60 or greater than 100 beats/min:
Hold dose.
Notify prescriber.
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41. Heart Failure Drugs: Nursing Implications (Cont.)
Hold dose and notify prescriber if the patient experiences signs or symptoms of toxicity.
Anorexia, nausea, vomiting, diarrhea
Visual disturbances (blurred vision, seeing green or yellow halos around objects)
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42. Heart Failure Drugs: Nursing Implications (Cont.)
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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43. Heart Failure Drugs: Nursing Implications (Cont.)
Nesiritide or milrinone
Use an infusion pump
Monitor input and output, heart rate and rhythm, BP, daily weights, respirations, and so on
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44. Heart Failure Drugs: Nursing Implications (Cont.)
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 HF 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 patients with HF. Negative inotropes would cause the heart to have a decreased force of myocardial contraction and would not be effective. Positive chronotropes 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.)
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 HF 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 HF 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.)
The patient is discharged home and returns to the emergency department 4 days later. The patient is admitted to the ICU with acute decompensated HF 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 ICU setting as a final effort to treat severe, life-threatening HF, often in combination with several other cardiostimulatory medications. Lisinopril (Prinivil) is an ACE inhibitor that is used in the management of HF. Carvedilol (Coreg) has been shown to slow the progression of HF and to decrease the frequency of hospitalization in patients with mild to moderate (class II or III) HF. Atropine is used to increase heart rate.
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