Medications for heart failure Flashcards
What is heart failure?
Progressive disease where the heart cannot pump efficient amount of blood for the body
Is there a cure for heart failure?
no
What is important to think about when talking about heart failure?
The flow of deoxygenated vs. oxygenated blood flow
List 11 risk factors for heart failure:
- HTN
- obesity
- pre-diabetes
- diabetes
- cardiac disease (esp. MI)
- familial / genetic cardiomyopathies
- cardiotoxicity r/t cancer
- substance abuse
- autoimmune disease
- iron overload
- inflammatory disorders (covid)
There is a greater incidence of heart failure in what race/ ethnic group?
African americans & hispanics
What is the biggest etiology of heart failure?
Chronic hypertension
Etiologies of heart failure:
Ischemic heart disease
R/t ischemic insults to myocardium, weakens the strength of ventricular contraction
COPD is the leading cause of ____ ____ failure
Right ventricular failure
COPD can cause RV changes and HF called ___ _____
cor pulmonale
COPD can cause development of what and explain how?
Pulmonary HTN → due to constriction of arterial vessels & increased workload & exhaustion of RV
Cardiomyopathies can be _____ or _____
restrictive or hypertrophic
Does HF lead to an increase or decrease in cardiac output?
decrease → decreases ability of the heart to get oxygenated blood where it needs to go
List 3 underlying problems in HF
- muscle damage
- ↑ in workload to maintain an efficient output
- structural abnormality
Underlying problems in HF:
Muscle damage
Atherosclerosis (hypertrophy) or cardiomyopathy
Underlying problems in HF:
↑ in workload to maintain an efficient output is seen in pts with:
HTN; alcoholism; MI; A-fib; or valvular disease
Underlying problems in HF:
Structural abnormality
Congenital cardiac defects
Left sided HF occurs when…
LV is unable to pump re-oxygenated blood from the lungs to the heart’s LA
Which sided heart failure is more common?
Left sided
In left sided HF the ventricles are too ____
stiff (not contracting properly)
Left sided HF can lead to what 2 things?
- Decreased cardiac output
- pulmonary congestion
Left sided HF is a common cause of _____
right sided heart failure
What are the 2 types of left sided HF?
- systolic HF
- Diastolic HF
Systolic HF (left sided)
LV cannot contract forcefully enough to keep blood circulating normally throughout the body
Which left sided HF is not able to maintain adequate cardiac output?
Systolic HF
Diastolic HF (left sided)
LV has grown stiff or thick & is unable to fill the heart properly, which reduces the amount of blood pumped out to the body
Which type of left sided HF is the remodeling of the LV?
Diastolic HF → unable to relax to allow the blood to get in
Diastolic HF:
A decrease in the amount of blood getting into the heart leads to ____
A decrease in the amount of blood able to get out of the heart
Systolic HF deals with ____ of the heart
Contraction of the heart
Systolic HF (left-sided) has an EF of ____
< 40% (low)
List 9 symptoms of systolic HF (left sided)
- Tiredness/ fatigue
- ↓ urine production
- ↑ HR; may be irregular
- ↑ BP
- enlarged heart
- pulmonary congestion (SOB)
- Coughing
- Weight gain
- ↓ blood flow to extremities
Symptoms of Systolic HF (left sided)
Tiredness/ fatigue
Lack of O2
Symptoms of Systolic HF (left sided)
↓ urine production
B/c fluid is backing up not being filtered by the kidneys
Symptoms of Systolic HF (left sided)
↑ HR; may be irregular
b/c the heart is trying to do its job
Symptoms of Systolic HF (left sided)
What time of day is coughing often worse?
Often worse at night; when lying flat
Symptoms of Systolic HF (left sided)
Why does pulmonary congestion occur?
Fluid or blood coming from the lungs CANNOT go anywhere → leads to build up in the lungs (↓ gas exchange)
Diastolic HF deals with ventricles being too ____ to properly ___ the heart
too stiff to properly fill the heart
What does the EF look like in diastolic HF
> 50% (normal)
What does diastolic HF often result from?
Hypertension
What type of left sided HF does not have any medications available to fix it?
Diastolic HF
List 10 Sx associated with left sided HF as a whole:
- Paroxysmal nocturnal dyspnea
- elevated pulmonary capillary wedge pressure
- pulmonary congestion
- restlessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- fatigue
- cyanosis
What secondary Sx are associated with pulmonary congestion in left sided HF?
- cough
- crackles
- wheezes
- blood-tinged sputum (frothy)
- tachypnea
Why do we see blood tinged sputum or secretions in left sided HF?
The blood is trying to find any means to get to where it needs to be; way of getting rid of excess in the lungs
What is normal EF range?
55-70%
Explain normal role of diastole & systole
Diastole (filling) → ventricles fill normally with blood
Systole (pumping) → ventricles pump out ~ 60% of the blood
Explain what happens in the heart when there is systolic dysfunction
- The enlarged ventricles fill with blood
- the ventricles pump out < 40-50% of the blood
Is Systolic dysfunction stiffening of ventricles or hypertrophy?
Hypertrophied → more blood coming in but EF is low meaning less blood is leaving → causing traffic jam leading to the lungs
Explain what happens in the heart when there is diastolic dysfunction
- stiff ventricles fill with less blood than normal
- ventricles pump out ~ 60% of blood, but amount may be lower than normal
Is diastolic dysfunction hypertrophy or stiffening of the ventricles?
Stiffening of ventricles → less blood coming into heart; meaning less will exit
List the vicious cycle of LV failure:
LVF → ↓ renal perfusion → renin production stimulated → persistent cycling of RAAS → further deterioration of heart function
Is right sided HF more or less common than left sided?
Less common
What happens in right sided HF?
Deoxygenated blood coming from the body, but right side of heart NOT pumping as well as it should → leads to “back-up” of blood in body
List 10 symptoms of right sided HF:
- Weakness/ fatigue
- Leg/ feet edema (dependent)
- vein distention → JVD
- Weight gain
- Increased urination
- Hepatomegaly / splenomegaly
- Increased abdominal girth (ascites)
- Increased peripheral venous pressure
- anorexia & complaints of GI distress
- secondary to chronic pulmonary problems
What is ascites?
Fluid distention in abdomen; very hard (looks pregnant) → can be seen in cancer patients
Right sided HF has less ____ and more ____
Less O2; More CO2 → can still have some impaired gas exchange
What organ gets less blood in right sided HF?
Kidneys
Why can hepatomegaly (enlarged liver) be seen in Right sided HF?
Portal vein is very close → so we see congestion here
What type of patients is right sided HF seen in?
COPD/ smokers
When we talk about right sided HF we should think _____ _____
peripheral swelling
Activation of the SNS causes what 7 things:
- ↑ HR & contractility tachycardia
- vasoconstriction
- activates the renin-angiotensin system (RAS)
- direct cardiotoxicity
- ↑ myocardial O2 demand
- ↑ wall stress
- ↓ preload/ ↑ afterload
About 50% of patients with HF have ____ or more comorbidities
three or more
What are the 4 goals of Tx for HF?
- address effects of HF on ABCs
- Tx of the existing Sx of the crisis situation
- Prevention of further or expanding complications
- Tx of the underlying cause
Stage A HF
At risk for HF
At risk but w/o current or previous S/S and w/o structural/ functional heart disease or abnormal biomarkers
List types of patients that would be in stage A HF (7):
- HTN
- CVD
- Diabetes
- Obesity
- Exposure to cardiotoxic agents
- genetic variant for cardiomyopathy
- Family Hx of cardiomyopathy
Stage B HF
Pre-Heart failure
patients w/o current or previous S/S of HF but evidence of 1 of the following:
1. structural heart disease
2. evidence of ↑ filling pressures
List risk factors for Stage B HF:
- ↑ natriuretic peptide levels
- Persistently elevated cardiac troponin in absence of competing diagnoses
What three things will a person at stage B (pre) HF have?
- ↓ in EF
- Impaired ventricular function
- some ventricular hypertrophy
Stage C HF
Symptomatic HF
Patients with current or previous S/S of HF
Stage D HF
Advanced HF
Marked HF Sx that interfere with daily life & with recurrent hospitalizations despite attempts to optimize GDMT (guideline directed med therapy)
Classification of HF:
New onset/ De Novo HF:
- Newly diagnosed HF
- No previous Hx of HF
Classification of HF:
Resolution of Sx:
Resolution of S/S of HF
1. stage C w/ previous Sx of HF w/ persistent LV dysfunction
2. HF in remission w/ resolution of previous structural &/or functional heart disease
Classification fo HF:
Worsening HF:
Worsening S/S or functional capacity
Classification of HF:
Persistent HF
Persistent HF with ongoing S/S &/or limited functional capacity
Three medication classes for Tx of HF:
- Vasodilators
- Loop diruetics
- Beta-adrenergic antagonists
The worse the stage of HF gets the higher chance of ____ or ____
Morbidity or mortality
List examples of vasodilators
ACE inhibitors
Nitrates
Hydralazine
ACE inhibitors prevent conversion of _____ to _____
Angiotensin I to angiotensin II
How do vasodilators work?
Decrease the workload of overworked cardiac muscle
How do loop diuretics work?
Decrease BV, which decreases venous return & BP
How do Beta-adrenergic antagonists (beta blockers) work?
Block beta receptors in the SNS, decreasing calcium flow into the myocardial cells, & causing decreased contraction & workload
ACE inhibitors have a ____ improvement that reduces _____ and improves survival
symptomatic improvement; reduces hospitalizations
What type of HF patients should be on ACE inhibitors if they can tolerate?
ALL patients with systolic HF
ACE inhibitors decrease what two things?
preload & afterload
ACE inhibitors work by…
vasodilation & by blocking RAAS/ aldosterone
ACE inhibitors help prevent…
cardiovascular remodeling
What ethnic groups do ACE inhibitors not work as well in?
African Americans & Asians
If someone cannot tolerate an ACE inhibitor what should they be prescribed instead?
ARB → angiotensin receptor blocker
What is entresto?
Combination drug
Sacubitril (neprilysin inhibitor) plus valsartan (ARB)
Entresto is used for…
Systolic HF to improve Sx & reduce remodeling
What three things does entresto increase?
- Natriuretic peptides (ex. BNP)
- Bradykinin (vasodilation)
- Other mediators which increase vasodilation
List 5 side effects of entresto
- angioedema
- hypotension
- hyperkalemia
- renal failure
- can cause cough
Entresto is contraindicated for what patients?
Pregnancy → can cause fetal harm
Why should patients avoid NSAIDs while on entresto?
NSAIDs vasoconstrict & entresto vasodilates (they contraindicate)
What two things does entresto inhibit?
Inhibits the RAAS system as well as angiotensin II
Loop diuretics inhibit…
reabsorption of Na or Cl at the loop of henle
What do loop diuretics decrease?
- workload on heart
- preload
- stroke volume
- cardiac output
Which type of HF medication can help decrease pulmonary congestion?
Loop diuretics
Explain administration of loop diuretics
Initially given IV then changed to oral
List three examples of Loop diuretics
- Bumetanide
- Furosemide (lasix)
- Torsemide
List 6 side effects of loop diuretics:
- hyponatremia
- hypokalemia
- hypovolemia
- hypomagnesemia
- hyperglycemia
- ototoxicity
List 2 nursing considerations of loop diuretics:
- monitor potassium levels
- monitor I & O
Why is it important to check blood sugar levels in a diabetic taking loop diuretics?
Because it can cause hyperglycemia → last thing we want to do is increase blood sugar
What two medications are mineralocorticoid receptor antagonists?
Spironolactone & Eplerenone
What medication class are spironolactone & Eplerenone considered?
Aldosterone receptor blockers
List 2 indications for taking Spironolactone or Eplerenone
- HTN
- HF
When are Aldosterone receptor blockers used?
When one drug is not enough to Tx Sx
How do aldosterone receptor blockers work?
Block the exchange of Na for potassium in the distal tubules
How would you instruct a patient to take aldosterone receptor blockers?
with meals
List three things to monitor in patient taking aldosterone receptor blockers
- potassium levels (can ↑)
- LFTs
- BUN/ Creatinine
Aldosterone receptor blockers are contraindicated in what kind of patients?
Patients with renal insufficiency
Aldosterone receptor blockers (specifically spironolactone) can cause _____ in males
gynecomastia
Patients taking aldosterone receptor blockers should be instructed to avoid taking what meds?
- ACE inhibitors/ ARBs
- Heparin
- NSAIDs
Beta blockers are ONLY used if
patient has STABLE HF
Beta blockers help to improve _____ , reduces _____, & enhances survival in patients with ______
improves Sx; reduces hospitalizations; HFrEF (heart failure w/ reduced ejection fraction)
List the things Beta blockers slow down:
- Slows HR
- Decreases afterload
- Decreases catecholamine stimulation
- decreases myocardial energy demands
- reduces remodeling due to cardiac myocyte hypertrophy & death
- arrhythmia promotion
Do beta blockers affect preload?
no
Beta blockers stimulate other detrimental systems such as _____
RAAS
List 3 drugs in beta blocker class
- carvedilol
- metoprolol succinate
- bisoprolol
Suffix for beta blocker meds
“olol”
Beta blockers should always be started at very ____ doses
low doses → can make HF worse
Are you able to stop taking beta blockers abruptly?
NO → need to taper off
if stopped it will cause a sympathetic surge & go from one extreme to another
What must always be checked for patients taking beta blockers?
Apical HR
If apical HR is < _____ patient should call the doctor
< 60
List adverse effects of beta blockers:
- worsening HF
- Hypotension, bradycardia
- bronchospasm (COPD & asthma → cause more bronchoconstriction)
- Exacerbation of PVD
Nitrates fall under what class of drugs?
Vasodilators
When are nitrates indicated?
preventions & Tx of attacks of angina pectoris & HF
What are the actions/ functions of nitrates?
- arterial & venous dilator
- decreases preload & afterload
- increase O2 to heart
- decrease myocardial O2 demand
Pharmacokinetics of Nitrates:
- very rapidly absorbed
- tolerance develops easily, must have drug-free periods
- drug-drug interaction w/ sildenafil
What kind of drug is Sildenafil & why should nitrates not be given with use of this?
Sildenafil → viagra
→ can cause abrupt drop in BP
List all the administration routes for nitroglycerin
- sublingual (common)
- translingual spray
- transmucosal tablet
- oral, SR tablet
- intravenous
- topical ointment
- transdermal
How do the transdermal nitroglycercin patches work?
it’s a 24 hr patch; but stops working few hrs before that so that the patient has a break before the next patch is applied (↓ ability of developing drug tolerance)
What are the dosing guidelines for sublingual nitroglycerin?
every 5 minutes for a max of 3 doses
if no relief, then call 911
What happens if nitroglycerin pill bottle is stored in light?
the light will degrade the med
How should the patient be instructed to position themselves when taking NTG sublingual tabs?
must be sitting or laying
List side effects of NTG sublingual tabs
- tingles or burns under tongue
- H/A; dizziness
What VS should be monitored before & after taking NTG sublingual tabs?
blood pressure
What type of med is isosorbide?
oral nitrate
About how long does isosorbide work for?
~ 18 hrs
has drug free period in delivery system
What two forms does isosorbide come in?
Short acting
Sustained release
Side effects of isosorbide are similar to what other med?
Nitroglycerin
What is the first drug regimen to improve Sx of HF?
Hydralazine & nitrates → isosorbide
Isosorbide decreases both preload & afterload by …
achieving venous & arterial vasodilation
Isosorbide decreases ____ & ____ vascular resistance
systemic & pulmonic
Isosorbide has a ______ effect on the heart
positive
Isosorbide (hydralazine/ nitrates) are used in patients who:
- have Sx despite ACEI, BB, diuretic therapy
- those who CANNOT tolerate routine therapy
List an example of a cardiac glycoside
Digoxin
Indications for using digoxin
- heart failure
- atrial fibrillation
Is digoxin a first line treatment?
no
Actions of cardiac glycosides (digoxin)
- ↑ intracellular Ca
- allows more Ca to enter myocardial cells during depolarization
- (+) iontropic effect (↑ contraction)
- ↑ renal perfusion with a diuretic effect
→ ↓ in renin release - slowed conduction through the AV node (↓ HR)
Describe the therapeutic margin of digoxin
Narrow therapeutic margin
→ normal level: 0.5-2.0
→ desired level: 0.8
What is required due to narrow therapeutic margin with digoxin use?
Monitoring of drug levels (peak & trough levels)
What two routes can digoxin be administered?
Oral or IV
Pharmacokinetics of digoxin
rapid onset & absorption
excreted by kidneys
what VS must be checked when taking digoxin?
apical HR (call MD if < 60)
What 2 labs should be monitored for a pt taking digoxin?
BUN/ Cr & potassium
What can digoxin toxicity cause?
- vision changes
- N/V
- dizziness
- increased risk of hypokalemia
What is the antidote for digoxin?
Digibind
Digoxin should be used with caution in what patients?
- pregnant & lactating
- pediatric & geriatric
- renal insufficiency
Summary of HF:
Right sided
Blood returns from the body (deoxygenated)
1. ascites
2. edema
Summary of HF:
Left sided
Blood returns from lungs (oxygenated)
1. crackles in lungs
2. expect SOB
List some nursing interventions for those with HF? (6)
- monitor lungs
- monitor HR & BP
- Monitor BUN/ Cr & potassium
- Monitor weight daily
- Question any orders for IV fluids
- patient education
Why should the nurse question any orders for IV fluids?
Sx can get way worse → b/c patient is holding onto fluid & not urinating
What should be included in patient education?
- NO sodium
- No OTC medications
- When to report S/S to provider
- Weight gain of 3lbs in 2 days
How do we know as the nurse if the Tx was successful?
- Lungs sound clearer
- Decreased HR/ decreased workload
