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Pharmacology Exam #2 > Agents for treating Heart Failure > Flashcards

Agents for treating Heart Failure Flashcards

1
Q

What are the 4 stages of Heart Failure?

A
  • Stage A: High risk for HF, but no structural disease or symptoms
  • Stage B: Structural heart disease (ie., enlarged heart), but NO signs or symptoms of disease
  • Stage C: Structural heart disease with prior or current symptoms of HF
  • Stage D: Refractory HF requiring specialized interventions
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2
Q

What are the 4 Functional Classes of Heart Failure?

A
  • Class I: No limitation of physical activity
  • Class II: Slight limitation of physical activity
  • Class III: Marked limitation of physical activity
  • Class IV: Unable to perform any physical activity without symptoms, or symptoms at rest
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3
Q

Causes of
Congestive Heart Failure

A

Dysfunction of the cardiac muscle brought on by:
* Coronary Artery Disease
* Cardiomyopathy
* Hypertension
* Valvular Heart Disease

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4
Q

What are the compensatory mechanisms for Heart Failure?

A
  • Decreased cardiac output
  • Sympathetic stimulation
  • Positive inotropic effect (process or drug that causes a stronger muscle contraction)
  • Release of renin

Effects of these compensatory methods:
* Muscle stretches or becomes thicker (hypertrophy)
* Chambers are not able to effectively pump blood
* Leads to worsened heart failure

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5
Q

What drugs are used to treat CHF?

A

Cardiotonic (inotropic) drugs
* Cardiac glycosides
* Phosphodiesterase inhibitors
* HCN Blocker: Hyperpolization-activated Cyclic Nucleotide-gated

Combination Drugs
* Angiotension Receptor Neprilysin Inhibitor (ARNI)

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6
Q

Lifespan Considerations for Heart Failure Agents
In Children

A
  • Digoxin is used
  • Dosage should be double checked by another nurse
  • DO NOT use phosphodiesterase inhibitors
  • HCN blockers used for stable symptomatic HF (as young as 6 months old)
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7
Q

Lifespan Considerations for Heart Failure Agents
In Adults

A
  • Instruct patients to take their pulse
  • Daily weights
  • Avoid switching between brands of digoxin
  • Avoid pregnancy and lactation
  • Report any dietary or GI medication changes to provider
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8
Q

Lifespan Considerations for Heart Failure Agents
In Older Adults

A

In additon to adult considerations:
* More susceptible to digitalis (digoxin) toxicity
* Adjust dose for renal impairment

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9
Q

Cardiac Glycosides: Digoxin
Mechanism of Action

A
  • Increases intracelluar calcium
  • Allows more calcium to enter the myocardial cell during depolarization
  • Positive inotropic effect (stronger muscle contraction)
  • Increased renal perfusion, with a diuretic effect leading to a decrease in renin
  • Slowed conduction through the AV node

Overall: Increased Cardiac Output

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10
Q

Cardiac Glycosides
Drug Name

A

Digoxin

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11
Q

Cardiac Glycosides: Digoxin
Indications

A
  • Treatment of Heart Failure
  • Atrial fibrillation
  • Atrial flutter
  • Paroxysmal atrial tachycardia
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12
Q

Cardiac Glycosides: Digoxin
Contraindications

A

Absolute:
* Allergy
* Ventricular tachycardia or fibrillation
* Heart Block or sick sinus syndrome
* Ideopathic hypertrophic subaortic stenosis
* Acute MI
* Renal insufficiency, Electrolyte Abnormalities

Caution:
* Pregnancy and lactation

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13
Q

Cardiac Glycosides: Digoxin
Adverse Effects

A
  • CNS: Headache, weakness, drowsiness, vision changes
  • GI: upset, anorexia
  • CV: arrythmia development
  • Digoxin toxicity (DigiFab is the antidote)
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14
Q

What is the antidote for Digoxin?

A

DigiFab

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15
Q

Cardiac Glycosides: Digoxin
Drug Interactions

A

Numerous

Some are: Diuretics, thryoid meds, antacids

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16
Q

Cardiac Glycosides: Digoxin
Assessment

A

History:
* Contraindications or cautions (allergy, vtach, heart block, sick sinus syndrome, acute MI, renal insufficiency, electrolyte abnormalities, ideopathic hypertrophic subaortic stenosis, pregnancy, lactation)

Physical:
* Obtain baseline weight and daily weights
* Pulse, BP, heart sounds, ECG
* Skin and mucous membranes, cap refill
* CNS: affect, orientation, reflexes
* Respiratory rate and lung sounds
* Abdomen for distension, bowel sounds, voiding patterns, urinary output

Labs:
* Digoxin levels
* serum electrolyte levels
* renal function tests

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17
Q

Cardiac Glycosides: Digoxin
Nursing Diagnoses/Conclusions

A
  • Altered heart rate (r/t cardiac effects)
  • Impaired comfort (r/t GI upset)
  • Risk of altered perfusion (r/t dysrhythmias)
  • Injury risk (r/t CNS effects)
  • Knowledge deficit
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18
Q

Cardiac Glycosides: Digoxin
Implementation/Patient Teaching

A
  • Monitor apical pulse for one minute, hold if under 60 bpm
  • Monitor pulse for change in quality or rhythm
  • Check dose, especially pediatric dose carefully
  • Administer IV doses slowly over at least 5 minutes, avoid IM administration
  • Daily weights at the same time each day
  • Avoid administering with food or antacids
  • Maintain emergency equipment on hand (potassium salts, lidocaine, phenytoin, atropine, and a cardiac monitor)
  • Watch digoxin levels as ordered. Therapeutic dose is 0.5-2 ng/mL
  • Stress importance of follow up appts.
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19
Q

Phosphodiesterase Inhibitors: Milrinone
Mechanism of Action

A
  • Blocks the enzyme Phosphodiesterase
  • Leads to an increase in myocardial cell cyclic adenosine monophosphate (cAMP) which leads to an increase in calcium levels in the cell.
  • Causes a stronger contraction and prolonged response to sympathetic stimulation
  • Directly relaxes vascular smooth muscle

Overall effect: Increased Cardiac Output

20
Q

Phosphodiesterase Inhibitors: Milrinone
Indications

A
  • Short term treatment of acute HF in patients who are unresponsive to digoxin, diuretics, or vasodilators
  • Use is limited to severe situations
21
Q

Phosphodiesterase Inhibitors
Drug Name

A

Milrinone

22
Q

Phosphodiesterase Inhibitors: Milrinone
Contraindications

A

Absolute:
* Allergy
* Severe aortic or pulmonic disease
* Acute MI
* Fluid volume deficit
* ventricular arrhythmias

Caution:
* Pregnancy and lactation (effects are unknown)

23
Q

Phosphodiesterase Inhibitors: Milrinone
Adverse Effects

A
  • CV: Arrythmias, hypotension, chest pain
  • GI: N, V, constipation, loss of appetite
  • Thrombocytopenia
  • Burning at injection site
24
Q

Phosphodiesterase Inhibitors: Milrinone
Drug Interactions

A
  • Furosemide (can lead to embolisms)
25
Q

Phosphodiesterase Inhibitors: Milrinone
Assessment

A

History:
* Check for contraindications and cautions: allergy, severe aortic or pulmonary disease, acute MI, fluid volume deficit, ventricular arrhythmias

Physical:
* Pulse, BP, heart sounds, weights, baseline ECG
* Inspect skin and mucous membranes for color, check cap refill
* Abdominal distension, bowel sounds, voiding patterns, urinary output

Labs:
* Electrolyte levels
* CBC (checking for thrombocytopenia)
* Renal and Hepatic Function tests

26
Q

Phosphodiesterase Inhibitors: Milrinone
Nursing Diagnoses/Conclusions

A
  • Altered cardiac output (r/t development of arrythmias or hypotension)
  • Injury risk (r/t CNS or CV effects)
  • Altered tissue perfusion (r/t hypotension, thrombocytopenia, or arrhythmias)
  • Knowledge deficit
27
Q

Phosphodiesterase Inhibitors: Milrinone
Implementation/Patient Teaching

A
  • Protect the drug from light
  • Monitor IV access, injection site, and provide comfort measures
  • Monitor pulse and BP regularly
  • Monitor input/output and record daily weight
  • Monitor platelet counts before and regularly during therapy
  • Provide life support equipment on standby
28
Q

HCN Blockers: Ivabradine
Mechanism of Action

A
  • Blocking the HCNs slows the hearts pacemaker (SA node) in the repolarizing phase of the action potential
  • Leads to a reduced heart rate
29
Q

HCN Blockers: Ivabradine
Indications

A
  • Reduce the risk of hospitalization for worsening HF
30
Q

HCN Blockers: Ivabradine
Contraindications

A

Absolute:
* Allergy
* Active, decompensated HF: hypotension, sick sinus syndrome, AV block, resting heart rate under 60bpm, patients completely dependent on a pacemaker, severe hepatic impairment

Caution:
* Atrial fibrillation
* Moderate heart block
* Pregnancy and lactation

31
Q

HCN Blockers: Ivabradine
Adverse Effects

A
  • Bradycardia
  • Hypertension
  • Atrial fibrillation
  • Luminous phenomena (significant visual changes)
32
Q

HCN Blockers: Ivabradine
Drug Interactions

A
  • CYP3A4 Inhibitors or inducers (ie calcium channel blockers, antifungals)
  • Negative chronotropic drugs
  • Grapefruit juice
33
Q

HCN Blockers
Drug Name

A

Ivabradine

34
Q

HCN Blockers: Ivabradine
Assessment

A

History:
* Cautions and contraindications: allergy, active decompensated HF: hypotension, sick sinus syndrome, AV block, resting HR <60bpm, pts completely dependent on a pacemaker, severe hepatic impairment, pregnancy, lactation, atrial fibrillation, moderate heart block

Physical:
* Pulse, BP, heart sounds, weight, baseline ECG
* Skin and mucous membranes, cap refill
* Voiding patterns, urinary output

Labs:
* Electrolyte levels
* CBC
* Renal & hepatic function tests

35
Q

HCN Blockers: Ivabradine
Nursing Diagnoses/Conclusions

A
  • Altered cardiac output (r/t development of arrhythmias or hypotension)
  • Injury Risk (r/t visual or CV effects)
  • Altered tissue perfusion (r/t hypotension or bradycardia)
  • Knowledge deficit
36
Q

HCN Blockers: Ivabradine
Implementation/Patient Teaching

A
  • Monitor HR and BP regularly
  • Stress follow up appts
  • Barrier contraception
  • Monitor input and output and record daily weights
  • Safety measures for visual disturbances
37
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Mechanism of Action

A
  • Blocks breakdown of natriuretic peptides
  • Inhibits effects of RAAS
  • Leads to decreased cardiac workload, lower vascular volume, lower blood pressure, improved HF symptoms
38
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Indications

A
  • Reduce the risk of CV death and hospitalization in adults with chronic HF
  • Treatment of symptomatic HF with systemic left ventricular systolic dysfunction in pediatric patients 1+ years old
39
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Contraindications

A

Absolute:
* Allergy
* History of angioedema with ACEI or ARB medications
* Concurrent use with ACEI
* Concurrent use with Aliskiren (Renin inhibitor)
* Pregnancy and lactation

40
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI)
Drug Name

A

Sucubitril/Valsartan

41
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Adverse Effects

A

Most common:
Hypotension
Hyperkalemia
Cough
Dizziness
Renal Impairment

42
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Drug Interactions

A

Numerous
ie. ARBs, ACEIs, Lithium, other nephrotoxic drugs

43
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Assessment

A

History:
* Check for contraindications/cautions: allergy, history of angioedema with ACEIs or ARBs, concurrent use of ACEIs, concurrent use of Aliskiren, pregnancy, lactation

Physical:
* Pulse, BP, heart sounds, pt. weight, baseline ECG
* Inspect skin and mucous membranes, cap refill
* Voiding patterns, urinary output

Labs:
* Electrolyte levels
* CBC
* Renal and hepatic function tests

44
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Nursing Diagnoses/Conclusions

A
  • Altered cardiac output (r/t development of arrhythmias or hypotension)
  • Injury risk (r/t visual or CV effects)
  • Altered tissue perfusion (r/t hypotension or bradycardia)
  • Knowledge deficit
45
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan
Implementation/Patient Teaching

A
  • Monitor HR and BP regularly
  • Monitor input and output
  • Record daily weights
  • Comfort and safety measures

Pharmacology Exam #2 (14 decks)

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