Medications for heart failure Flashcards
Is the incidence of heart failure increasing or decreasing in the US?
increasing
What are large portions of the U.S. population at risk for?
HF or stage A
What are risk factors for heart failure? (10)
- HTN
- obesity
- pre-diabetes
- diabetes
- cardiac disease (esp. MI)
- familial or genetic cardiomyopathy
- cardiotoxicity r/t cancer
- substance abuse
- autoimmune disease
- iron overload
- inflammatory disorders (covid)
What races/ethnicities have greater incidence of heart failure?
- african americans
- hispanics
What are the 4 etiologies of heart failure?
- ischemic heart disease
- chronic HTN
- COPD
- cardiomyopathies
How does ischemic heart disease cause heart failure?
r/t ischemic insults to myocardium, weakens the strength of ventricular contraction
How does COPD lead to heart failure?
- leading cause of right ventricular failure
- can cause RV changes & HF called cor pulmonale
- development of pulmonary HTN due to constriction of arterial vessels & increased workload & exhaustion of RV
What kind of cardiomyopathies can lead to HF?
- restrictive
- hypertrophic
What are the underlying problems in HF related to muscle damage?
artherosclerosis or cardiomyopathy
What may cause the heart to increase workload to maintain an efficient output?
- HTN
- alcoholism
- MI
- A-fib
- valvular disease
____________ ____________ are an underlying problem in HF resulting from congenital cardiac defects.
structural abnormalities
What is left-sided heart failure?
when lt ventricles are unable to pump re-oxygenated blood from the lungs to the heart’s left atrium; ventricles are too stiff and not contracting properly
What does left-sided heart failure lead to?
- decreased cardiac output
- pulmonary congestion
what is a common cause of right-sided heart failure?
left-sided heart failure
What are the two types of left-sided heart failure?
systolic heart failure
diastolic heart failure
What is happening in systolic HF?
LV cannot contract forcefully enough to keep blood circulating normally throughout the body
What is happening in diastolic HF?
LV has grown stiff or thick & is unable to fill the heart properly, which reduces the amount of blood pumped out of the body
Left-sided systolic HF deals with __________ of the heart
contraction
What is ejection fraction in left- sided systolic HF?
low (<40%)
What are the 9 symptoms of left-sided systolic heart failure?
- fatigue
- decreased urine production
- increased HR; may be irregular
- elevated BP
- enlarged heart
- pulmonary “congestion” - SOB
- coughing (often worse at night)
- weight gain
- decreased blood flow to extremities
left-sided HF is an issue with ventricles being ____ _____ to properly _____ heart; able to contract (ventricular _____________)
too stiff; fill; hypertrophy
What is ejection fraction in left-sided diastolic HF?
typically normal (>50%)
What does lef-sided diastolic HF often result from?
HTN
Is there medication available to help with diastolic dysfunction?
no
What are sx of left-sided HF? (picture;10)
- paroxymal nocturnal dyspnea
- elevated pulmonary capillary wedge pressure
- pulmonary congestion
- restlessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- fatigue
- cyanosis
What are sx of pulmonary congestion?
- cough
- crackles
- wheezes
- blood-tinged frothy sputum
- tachypnea
What is the vicious cycle of LV failure?
LVF leads to decreased renal perfusion which causes renin production and triggers persistent cycling RAAS which causes futher deterioration of heart function
Is left-sided or right-sided HF more common?
left-sided HF
What is the problem in right-sided Heart failure?
deoxygenated blood is coming from the body but the rt-side of the heart is not pumping as well as it should leading to “back-up of blood in the body
What are the 8 sx of right-sided HF? (on slide; 7)
- fatigue
- vein distension
- weight gain
- increased urination
- hepatomegaly
- increased abdominal girth
- peripheral swelling
What are the 9 sx of right-sided HF? (picture)
- fatigue
- increased peripheral venous pressure
- ascites
- enlarged liver & spleen
- may be secondary to chronic pulmonary problems
- distended jugular veins
- anorexia & complaints of GI distress
- weight gain
- dependent edema
What 7 things does activation of the sympathetic nervous system cause?
- increased HR & contractility tachycardia
- vasoconstriction
- activates the renin-angiotensin system (RAS)
- direct cardiotoxicity
- increased myocardial O2 demand
- increase wall stress
- decreased preload & increases afterload
About ____ of pts with HF have three or more comorbidities
50%
The average HF pt is taking ___ medications
6
___ of HF pts had at least two admissions per year
78%
only ___ completed their annual prescription regimen
10%
____ of HF pt never refilled any HF prescriptions
1/3`
What should HF treatment address?
the effects of HF on airway, breathing & circulation
What are the 3 main goals of HF treatment?
- treatment of the existing sx of the crisis situation
- prevention of further or expanding complications
- treatment of underlying cause
What are the 4 stages of HF?
stage A: at-risk for HF
stage B: pre-heart failure
Stage C: symptomatic HF
stage D: advanced HF
What is happening during stage A of HF?
pt is at risk for HF but w/o current of previous S/S of HF & w/o structural/ functional heart disease or abnormal biomarkers; pt has other disease process/ family hx related to HF
What are the risk factors for those in Stage A of HF?
- HTN
- CVD
- diabetes
- abesity
- exposure to cardiotoxic agents
- genetic variant doe cardiomyopathy
- family hx of cardiomyopathy
What is happening in Stage B of HF?
pt w/o currect or previous S/S of HF but has evidence of:
- structural heart disease
-evidence of increased filling pressures
- increased natriuretic peptide levels
- persistently elevated cardiac troponin
What is happening in Stage C of HF?
pt with current or previous S/S of HF
What is happening in stage D of HF?
marked HF sx that interfere with daily life with recurrent hospitalizations despite attempts to optimize GDMT (treatment)
what are the 4 classifications of HF?
new onset/ de novo HF
resolution of sx
persistent HF
worsening HF
What is new onset/ de novo HF?
- newly dx HF
- no previous hx of HF
What is happening if Hf is classified as resolution of sx?
resolution of S/S of HF
- HF in remission w/ resolution of previous structural and/or functional heart disease
What is persistent HF?
persistent HF w/ ongoing S/S and/or limited functional capacity
What is worsening HF?
worsening S/S or functional capacity
What are the three classes of medication used to treat Hf?
- vasodilators
- loop diuretics
- beta- adrenergic antagonists (beta blockers)
What are the three types of vasodilators that can be used?
- ACE inhbitors
- nitrates
- hydralazine
How to vasodilators help with HF?
decrease the workload of overworked cardiac muscle
How do loop diuretics help with HF?
decrease blood volume, which decreases venous return & BP
How do beta blockers help with HF?
block the beta-receptors in the SNS, decreasingn calcum flow into the myocardial cells, & causing decreased contraction & workload
How do ACE inhibitors work?
prevent the conversion of angiotensin I to angiotensin II; blocking RAAS & causing vasodilation
What do ACE inhibitors help prevent?
cardiac remodeling
ACE inhibitors allow for symptomatic improvement, reduced _______________ and _________ survival
hospitalization; improved
if tolerated; all pts with _________ heart failure should be on an ACE inhibitor
systolic
What affect do ACE inhibitors have on preload & afterload?
ACE inhibitors decrease preload & afterload
In what ethnic groups do ACE inhibitors tend to not be as effective?
black & asian people
What can be used as an alternative to ACE inhibitors for those ethnicities or in case of ACE intolerance?
angiotensin receptor blockers (ARBs)
What is entresto?
sacubitril (neprilysin inhibitor) plus valsartan (ARB)
What is entresto used for?
used for systolic heart failure to improve sx and reduce remodeling
What does entresto do?
- increases naturetic peptides (like BNP)
- bradykinin (vasodilation)
- increases other mediators which increase vasodilation
What are the side effects of entresto?
- angioedema
- hypotension
- hyperkalemia
- renal failure
What can entresto cause?
a cough
is entresto safe for pregnancy?
no; contraindicated
What type of medications cannot be taken with entresto?
NSAIDS
How do loop diuretics work?
inhibit reabsorption of sodium or chloride at the loop of henle
How do look diuretics help the heart?
- decrease workload on heart
- decrease preload
- decrease stroke volume
- decrease cardiac output
How are loop diuretics typically given?
initially given Iv then changed to oral
What are three examples of loop diuretics?
bumetanide
furosemide
torsemide
What are possible side effects of loop diuretics?
- hyponatremia
- hypokalemia
- hypovolemia
- hypomagnesemia
- hyperglycemia
- ototoxicity
What should you monitor with pts on loop diuretics?
- potassium
- I & Os
What are spironolactone & eplerenone considered to be?
mineralocorticoid receptor antagonists(AKA: aldosterone receptor blockers)
What are spironolactone & eplerenone taken for?
hypertension & HF
When are spironolactone & eplerenone taken as opposed to other medications?
used when one drug is not enough to treat sx
How do spironolactone & eplerenone work?
block the exchange of sodium for potassium in the distal tubules
Should spironolactone & eplerenone be taken with or without food?
should be taken with meals
What should be monitored in pts taking spironolactone & eplerenone?
- potassium
- LFTs
- BUN & creatinine
When should a pt not recieve spironolactone or eplerenone?
when they have renal insufficiency
What can spironolactone & eplerenone cause?
gynecomastia
With what medications should spironolactone & eplerenone not be taken?
ACE inhibitors
ARBs
heparin
NSAIDS
what do beta blockers help with?
help to improve sx, reduce hospitalization & enhance survival in pts with HF with reduced ejection fraction
how do beta blockers help the heart?
- decrease catecholamine stimulation
- decrease myocardial energy demands
- reduce remodeling due to cardiac myocyte hypertrophy & death
- stimulation of other detrimental systems such as the renin-angiotensin-aldosterone syestem
- anti-arrhythmia promotion
What are the drugs in the beta blocker class?
- carvedilol
- metoprolol Succinate
- bisprolol
how should a beta blocker be started?
at a very low dose, as it can worsen HF
What should you never do when taking a beta blocker?
never stop abruptly, need to taper off
What are adverse effects of beta blockers?
- worsening HF especially when first started
- hypotension
- bradycardia
- bronchospasm (COPD,asthma)
- exacerbation of peripheral vascular disease
What should a nurse always do before giving a beta blocker?
take an apical HR, call MD if less than 60
When are nitrates indicated?
prevention & treatment of attacks of angina pectoris & HF
how do nitrates work on the body?
- arterial & venous dilator
- decrease preload & afterload
- increase oxygen to the heart; decrease myocardial oxygen demands
how quickly are nitrates absorbed?
very rapidly
Can people develop tolerance to nitrates?
yes; tolerance develops easily, must have drug-free periods
What drug-drug interaction with nitrates causes hypotension?
sildenafil (viagra)
What are the routes of administration for nitroglycerin?
- sublingual
- translingual spray
- transmucosal tablet
- oral, SR tablet
- intravenous
- topical ointment
- transdermal
what should you do when administering any type of nitrate to a pt?
always wear gloves
How long do nitroglycerin patches work?
patch is placed for 24 hrs but stops working before that to prevent tolerance
how often can sublingual NTG be given?
every 5 minutes for a max 3 doses; if no relief, call 911
How must a pt be positioned before taking NTG
sitting or laying
where should NTG be stored?
in its original bottle & protected from sunlight
What are some side effects that may be experienced with NTG?
- tingles or burns under tongue
- dizziness
- headache
What should the nurse do before and after giving NTG?
take a BP
What is the name for oral nitrate?
isosorbide
What are the forms of oral isosorbide?
short acting or sustained release
how long does isosorbide work?
works for about 18 hrs; has a drug free period in the delivery system
What was the first drug regimen shown to improve the sx of HF?
hydralazine & nitrate (isosorbide)
how does the combination of hydralazine & nitrate (isosorbide) affect the body?
- decreases preload & aferload by achieving both venous & arterial vasodilation
- decreases systemic & pulmonic vascular resistance
- positive inotropic effect on heart
With what pts is hydralazine & nitrate typically used?
- pt who have sx despite ACE inhibitors, beta blockers, & diuretic therapy
- those who cannot tolerate routine therapy
When is digoxin indicated?
heart failure
atrial fibrilation
is digoxin a first-line tx for HF?
no
What does digoxin do?
- increases intracellular calcium
- allows more calcium to enter the myocardial cell during depolarization
- positive inotropic effect (increase contraction)
- increased renal perfusion w/ a diuretic effect ( decrease in renin release)
- slowed conduction through the AV node (decrease HR)
is the therapeutic margin for digoxin narrow or broad?
very narrow
What is the normal and desired level for digoxin?
normal level: 0.5-2.0
desired level: 0.8
What should be drawn when taking digoxin?
peak & troughs
What are the risks with digoxin?
digoxin toxicity & increased risk of hypokalemia
How is digoxin given?
orally or IV (not the same dosing)
What is the onset & absorption of digoxin?
rapid
How is digoxin excreted?
renal excretion
What should be checked before giving digoxin?
always check apical HR, call MD if less than 60
What labs should be monitored when taking digoxin?
- BUN & creatinine
- potassium
What are sx of digoxin toxicity?
- vision changes
- N/V
- dizziness
What is the antidote to digoxin?
digibind
With what pt populations should digoxin be used with caution?
- pregnancy & lactation
- children
- geriatrics
- renal insufficiency
What are some nursing interventions for those with HF?
- monitor lungs
- monitor HR & BP
- monitor BUN & creatinine
- monitor potassium
- monitor weight daily
- question orders for IV fluids
- pt education: no sodium, no OTC meds
