Heart Failure & Antiarrhythmics Flashcards
Which drugs block the RAAS compensatory mechanisms?
- ARNIs (Sacubitril/Valsartan)
- ACE Inhibitors (Captopril/Lisinopril)
- ARBs
An aldosterone antagonist should be added for most patients as long as:
- Kidney function can tolerate the medication
- They do not have hyperkalemia
Example: Spironolactone
When would Ivabradine be indicated for treatment?
When heart rates are high despite maximal beta-blocker doses.
Which drugs decrease the sympathetic stimulation of compensatory mechanisms?
Beta Blockers (Bisoprolol, Carvedilol, and Metoprolol)
What are the prototypes for ACE Inhibitors? Include the MOA and possible adverse effects.
Prototypes: Captopril and Lisinopril
MOA: slows progression of HF and reduces mortality
- Lowers peripheral resistance
- Lowers blood volume
- Dilates veins which will decrease preload, pulmonary congestion, and edema
What would be the prototype for beta blockers r/t HF? What are the most important adverse effects and contraindications of these drugs?
Prototypes: Bisoprolol, Carvedilol, and Metoprolol
A/E:
- Bronchospasms in nonselective
- Hypotension/Bradycardia
- Box Warning: Do not stop abruptly taking the medication, may cause rebound excitation.
Contraindications:
- Asthma/COPD
- Hypotension, Severe Bradycardia, and Shock.
What are the benefits of vasodilators? Name 2 of them.
Benefits: they decrease blood pressure and relax blood vessels.
- Hydralazine with Isosorbide
- Nesiritide
What are the 3 key points about Hydralazine with Isosorbide?
- They are only approved for black patients.
- They decrease the workload of the heart
- Hypotension and reflex tachycardia are common.
What are the 5 key points with Nesiritide?
- It is a B-type Natriuretic Peptide
- It lowers preload and afterload
- It is only available as an IV infusion
- It can cause severe hypotension
- Only available in the hospital
Which drug classes are cardiotonic inotropic drugs? What will they do and what do they affect?
Classes:
1. Cardiac Glycosides (Digoxin)
2. Phosphodiesterase Inhibitors (Milrinone)
3. HCN Blockers (Ivabradine)
4. ARNIs (Sacubitril/Valsartan)
They affect the intracellular calcium cells in the heart muscle leading to increased contractility.
What is digitalization?
A procedure done where a dose of digoxin is gradually increased until tissue becomes saturated with the medication and symptoms of HF disppear.
It can be done rapidly with IV digoxin or over 7 days as an outpatient with PO digoxin.
What is the MOA of Digoxin, the route, and onset of the medication?
MOA:
- Inhibits enzyme responsible for sodium and potassium ion exchange
- increases intracellular calcium and allows more calcium to enter myocardial cells
Results in:
- Increased force of contraction
- Increased renal perfusion and cardiac output
- Slowed HR
- Decreased conduction velocity through the AV node
Routes: PO and IV
- Onset of IV: 5-30 minutes
- Onset of PO: 30-120 minutes
When caring for a patient on Digoxin, which labs will need to be monitored and what are the therapeutic ranges?
Labs: Potassium and Digoxin levels
- Digoxin levels should be drawn 6-12 hours after a dose
Therapeutic Range: 0.5-2ng/mL
What are the adverse effects of digoxin? Include contraindications.
A/E:
- arrhythmias
- vision changes
- digoxin toxicity (anorexia, n/v, malaise, depression, life-threatening arrhythmias)
Contraindications:
- allergy
- heart block, MI, ventricular dysrhythmias
- pregnancy/lactation
- renal insufficiency
What are the drug interactions with Digoxin? How do those drugs interact with the medication?
- St. John’s Wort and Psyllium (decreases the effectiveness of digoxin)
- Ginseng, Hawthorn, and black Licorice (increase digoxin toxicity)
- Potassium Losing Diuretics (increase the risk of arrhythmias)
What is the prototype for Phosphodiesterase III Inhibitors, the MOA, and the route?
Prototype: Milrinone
MOA:
- Inhibits phosphodiesterase III which increases calcium level in the cell
- Increased contractility and cardiac output
Route: IV
- Immediate onset
- Peak effects occur in 2 minutes
What are the therapeutic uses for milrinone? Include contraindications and drug interactions. Lastly, include the adverse effects.
Used for short term treatment of acute decompensated HF. Therapy is limited to 2-3 days.
Contraindications: allergy to the medication or bisulfates.
Interactions: you cannot combine milrinone and furosemide IV.
A/E:
- Ventricular dysrhythmias
- Hypotension
- Thrombocytopenia
What will the nurse monitor when they have a patient receiving Milrinone?
Blood pressure and ECG
What is the prototype for HCN Channel Blockers? Include the MOA, route, adverse effects, and 2 important things to monitor. Lastly, how will this medication be stored?
Prototype: Ivabradine
MOA: blocks HCN which slows the heart’s pacemaker.
Route: PO
A/E:
- Bradycardia, HTN, A-Fib
- Changes in visual field
Monitor:
- BP and HR
Protect the medication from light.
What are the contraindications for Ivabradine and what are the drug-interactions?
Contraindications:
- allergy to medication or bisulfites
- active decompensated HF
- Hypotension
- Heart block
- Resting HR less than 60
- Complete dependence on a pacemaker
- Severe hepatic impairment
Interactions:
- CYP3A4 Inhibitors or Inducers
- Other negative chronotropic drugs
What are the prototypes for ARNIs? What is the MOA, indications, and route?
Prototype: Sacubitril/Valsartan
MOA:
- blocks neprilysin enzyme that breaks down natriuretic peptides
- causes greater sodium and water loss
Indicated to reduce hospitalization, death, and is used in children with low left ventricular systolic function.
Route: PO
What are the adverse effects of ARNIs. Include contraindications and drug-interactions?
A/E:
- Hypotension
- Hyperkalemia
- Renal impairment
- Cough
- Angioedema
Contraindicated in allergies or history of angioedema.
Interactions:
- cannot be used with ACE inhibitor, need to discontinue the ACE inhibitor 36 hours before starting ARNI
- Potassium-sparing diuretic
Class 1b Antidysrhythmics
What is the prototype, MOA, route, and indications?
Prototype: Lidocaine
MOA: blocks sodium channels and shortens the duration of action potential.
Route: IM or IV
What is the therapeutic range of lidocaine? Include adverse effects, contraindications, and drug-interactions.
Therapeutic Range: 1.5-5mcg/mL
A/E:
- CV: proarrhythmic, hypotension, vasodilation, cardiac arrest
- Respiratory arrest or depression
Contraindications: allergy, bradycardia, heart block, HF, hypotension, electrolyte disturbances.
Interactions:
- Other antiarrhythmics
- Beta-blockers
- Phenytoin
Class II Antidysrhythmics: Beta Blockers
Name the prototype, MOA, Adverse effects, and contraindications.
Prototypes: acebutolol, esmolol, and propanolol.
MOA:
- slows HR, cardiac excitation, and cardiac output.
- slows conduction through the AV node
- decreases renin release
A/E:
- Hypotension
- Bradycardia
- Cardiac Excitation
Contraindicated in severe bradycardia or heart block.
Class II Antidysrhythmics: Potassium Channel Blockers
What is the prototype, route, and MOA?
Prototype: Amiodarone
Route: PO or IV
MOA: blocks potassium ions in myocardial cells which delays repolarization and prolongs refractory period to decrease automaticity.
Class II Antidysrhythmics: Potassium Channel Blockers
What are the adverse effects, contraindications, and drug interactions with amiodarone?
A/E:
- liver toxicity
- weakness, phototoxicity
- bradycardia, creates or worsens dysrhythmias, hypotension
- Box warning: possibility of Pneumonia syndrome
Interactions:
- digoxin
- antihistamines
- TCAs
- Phenothiazines
When a patient is administered amiodarone, what labs will the nurse be responsible for monitoring? What should the therapeutic range be?
- Monitor lung function
- Therapeutic range should be 1-2.5 mcg/mL
Class IV Antidysrhytmics: Calcium Channel Blockers
What is the prototype, MOA, route, and therapeutic indications?
Prototype: Diltiazem/Verapamil
MOA: blocks movement of calcium ions in cardiac and smooth muscle cells.
Route: PO or IV
Indicated only for atrial dysrhythmias.
What are the adverse effects of diltiazem and verapamil? Include contraindications and drug interactions.
A/E:
- dizzy, Ha, hypotension, HF, shock, arrhythmias
Contraindications: allergy, severe block, HF, hypotension
Interactions: alcohol, grapefruit juice, and beta-blockers.
Honorable Mention: Adenosine
- How is this medication administered?
- What does this medication do?
- What does this medication terminate?
- Push this medication super fast, 1-2 seconds IV
- It stops heart rhythm and lets the SA node/pacemaker of the heart start rhythm again
- Terminates paroxysmal super ventricular tachycardia
