Stable Heart Failure and Dysrhythmia Drugs

Question 1

Describe Furosemide aka LASIX (type of drug, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)

Answer 1

Diuretic

Indication: Edema due to heart failure

Mechanism of action:
- Inhibits the reabsorption of sodium, potassium, and chloride from the loop of Henle and distal renal tubule
- Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium

Evaluation/desired outcome:
- Decreases in edema
- Increases in urinary output

Contraindication: No common ones

Use cautiously in:
- Electrolyte depletion
- Diabetes mellitus – Diuretics lead to hyperglycemia. Exact mechanism is unknown. Theory: worsening insulin resistance, inhibition of glucose uptake, and decreased insulin release.
- Severe renal impairment

Adverse effects/side effects:
- Hypotension
- Dehydration
- Hypocalcemia – Increases renal calcium excretion. Mechanism -> not known
- Hypokalemia
- Hypochloremia
- Hypomagnesemia

Drug-drug interactions:
- Increased risk of hypotension with antihypertensives or nitrates
- Increased risk of hypokalemia

Question 2

What should you describe in Furosemide aka LASIX nursing implication and patient/family teaching?

Answer 2

Nursing implications:
- Assess fluid status. Monitor daily weight, intake, and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes.
- Monitor BP and pulse before and during administration
- In older adults, diuretic use increases risk for falls. Assess for risk of falls when administering in older adults
- Closely monitor electrolytes, renal function, and serum glucose.

Patient/family teaching:
- Caution patient to change positions slowly to decrease the effects of orthostatic hypotension.
- Consult a healthcare provider regarding a diet with high potassium.
- Consult a healthcare provider if weight gain more than 3 pounds in a day.

Question 3

Describe Potassium Chloride (Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects)

Answer 3

Indication: Treatment/prevention of potassium depletion

Action: Simple replacement

Evaluation and directed outcomes: Replacement and/or prevention of potassium depletion

Contraindications:
- Hyperkalemia
- Severe renal impairment

Use cautiously in:
- Cardiac disease
- Renal impairment
- Diabetes

Adverse effects/side effects:
- Arrhythmias
- Abdominal pain, diarrhea, nausea and vomiting – Potassium increases the release of hydrogen ions into the lumen of the GI tract

Question 4

What should you describe in Potassium Chloride nursing implication and patient/family teaching?

Answer 4

Nursing implications:
- Assess for signs and symptoms of hypokalemia [weakness, fatigue, ECG changes]
- Assess for signs and symptoms of hyperkalemia [slow, irregular heartbeat, fatigue, muscle weakness, confusion, dyspnea, ECG changes]

Patient/family teaching:
- Emphasize the importance of regular follow-up exams to monitor serum levels of potassium
- Instruct patient to report dark, tarry, or blood stools

Question 5

What is one similarity and difference between Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP)? What do they promote? Lastly, how does Neprilysin affect these peptides?

Answer 5

Similarity: In response to high pressure/volume, myocardial stretching occurs

Difference: ANP is released from the atrial wall, while BNP is released from the ventricle wall

They promote balanced vasodilation by:
- dec. preload, by dec. Na+/H2O retention
- dec. afterload by dec. production and action of vasoconstrictor peptides
- inhibiting sympathetic tone

Neprilysin is an enzyme that degrades natriuretic peptides

Question 6

Describe Sacubitril/Valsartan - Entresto (Type of Drug, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)

Answer 6

Angiotensin Receptor and Neprilysin Inhibitor

Indication:
- Chronic HF in adults

Action:
- Sacubitril: A pro-drug converted to LBQ657 (active form of the drug) -> inhibits the enzyme neprilysin.
- Neprilysin is an ezyme that degrades natriuretic peptides.
- Valsartan: Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at the receptor sites

Evaluation and directed outcomes:
- Decreased heart-failure-related hospitalization in patients with heart failure

Contraindications:
- History of angioedema from previous ACE-Inhibitors or ARBs
- Concurrent use of ACE-Inhibitors during or for 36 hr before or after

Use cautiously in:
- Volume or salt depleted patients or patients receiving high doses of diuretics
- Impaired renal function

Adverse effects/side effects:
- Hypotension
- Hyperkalemia – Secondary to the valsartan.

Drug-drug interactions:
- Increased risk of hypotension with other antihypertensives and diuretics
- Concurrent use of potassium-sparing diuretics or potassium supplements
- Concurrent use of ACE-Inhibitors

Question 7

What should you describe in Entrestro (Sacubitril/Valsartan) nursing implication, patient/family teaching, and recommendation?

Answer 7

Nursing implications:
- Assess BP (lying, sitting, standing) and pulse frequently during initial dose adjustment and periodically.
- Correct volume or salt depletion prior to administration of therapy.
- Monitor daily weight and assess patient routinely for resolution of fluid overload.
- Assess patients for signs of angioedema (dyspnea, facial swelling).
- Monitor renal function

Patient/family teaching:
- Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care provider.
- Instruct patient to notify health care professional if swelling of face, eyes, lips, or tongue or if difficulty swallowing or breathing occur

Recommendation: ARNI be used in place of an ACEI or ARB, in patients with HFrEF, who remain symptomatic despite treatment

Question 8

Describe Spironolactone (Type of Drug, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)

Answer 8

Mineralocorticoid Receptor Antagonist (MRA)

Indication:
- New York Heart Association (NYHA) class III-IV Heart Failure

Action:
- Inhibition of sodium reabsorption in the kidney, while saving potassium and hydrogen ions
- Binds to Mineralocorticoid receptors (receptors to which aldosterone normally binds to) -> blocks the activity of aldosterone -> decreased absorption of sodium and water, and decreased secretion of potassium

Evaluation and directed outcomes:
- Increases in diuresis and decrease in edema while maintaining serum potassium level
- Improved survival in patients with NYHA class II-IV HF

Contraindications:
- Hyperkalemia
- Acute renal insufficiency – Can dangerously cause hyperkalemia
- Significant renal impairment (CCr [creatinine clearance test < or equal to 30 mL/min)

Use cautiously in:
- Diabetes (increases risk of hyperkalemia) – Insulin causes potassium to move from extracellular space into intracellular space via the Na-H antiporter and Na-K ATPase. Therefore, in patients with DM, this mechanism may be less effective.
- Concurrent use of potassium supplements

Adverse effects/side effects:
- Stevens Johnson Syndrome (SJS)

Drug-drug interactions:
- Increased hypotension with other antihypertensives or nitrates

Question 9

What should you describe in Spironolactone nursing implication, patient/family teaching, and recommendation?

Answer 9

Nursing implications:
- Monitor intake and output ratios and daily weight during therapy
- Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, confusion, ECG changes)
- Assess patient for the development of rash

Patient/family teaching:
- Caution patient to avoid foods that contain high potassium levels
- Advise patient to notify health care professional of rash or muscle weakness or cramps

Recommendation: MRA treatment for patients with actute MI and LVEF </= 40% and HF symptoms or diabetes

Question 10

Describe Canagliflozin (Type of Drug, MOA, Contraindication, Adverse Reactions/Side Effects)

Answer 10

SGLT-2 Inhibitors

Mechanism of action:
- Kidney Nephrons: Glucose is reabsorbed through co-transporter (sodium glucose cotransporter2)
- SGLT-2 inhibitors: inhibiting the reuptake of glucose. Glucose will pass through and get urinated out.

Adverse effect: Glucosuria, UTI, Vaginal infection, dehydration.

Contraindication: Severe renal impairment (eGFR <30 mL/min/1.73 m2)

Question 11

What should you describe in Canagliflozin nursing implication, patient/family teaching?

Answer 11

Nursing implications:
- Observe patient for signs and symptoms of hypoglycemia
- Monitor for signs and symptoms of volume depletion after initial therapy
- Monitor for infection - UTI
- Monitor renal function prior to and periodically during therapy

Patient/family teaching:
- Instruct patient to take medication at the same time each day, as directed
- Review signs of hypoglycemia and hyperglycemia with patient
- If hypoglycemia occurs, instruct them to take 2-3 tsp of sugar or a glass of orange juice

Question 12

Describe Dopamine (Indication, MOA, Evaluation and Directed Outcomes, Contraindications, Cautious Usage, Adverse effects/Side effects)

Answer 12

Indication: Adjunct to standard measures to improve: BP and cardiac output

Action: Dose dependent stimulation of beta1-adrenergic receptors → cardiac stimulation

Evaluation and directed outcomes: Increased cardiac output, increased BP

Contraindications: Tachyarrhythmias

Use cautiously in:
- Hypovolemia
- Myocardial infarction

Adverse effects/side effects:
- Arrhythmias
- Hypotension – dopamine 1 receptors cause vasodilation

Question 13

What should you describe in Dopamine nursing implication, patient/family teaching?

Answer 13

Nursing implications:
- Monitor BP, HR, ECG, cardiac output closely
- Palpate peripheral pulses and assess appearances of extremities routinely during dopamine administration
- IV vasoactive medications are dangerous. Always have a second RN to check original orders

Patient/family teaching:
- Explain purpose of dopamine to patient
- Advice patient to inform nurse immediately if chest pain, dyspnea, numbness, tingling of extremities occurs

Question 14

Describe Atropine (Indication, MOA, Evaluation and Directed Outcomes, Contraindications, Cautious Usage, Adverse effects/Side effects)

Answer 14

Indication: IV: Treatment of sinus bradycardia and heart block

Action: Competes with acetylcholine for cholinergic receptor sites on the SA and AV nodes.

Evaluation and directed outcomes: Increased HR

Contraindications: Tachycardia

Use cautiously in: Older adults – increased sensitivity to adverse reactions

Adverse effects/side effects: Tachycardia

Question 15

What should you describe in Atropine nursing implication, patient/family teaching?

Answer 15

Nursing implications: Closely monitor VS and ECG

Patient/family teaching: Explain purpose of atropine to patient

Question 16

Describe Amiodarone (Indication, MOA, Evaluation and Directed Outcomes, Contraindications, Cautious Usage, Adverse effects/Side effects)

Answer 16

Indication: Management of supraventricular tachyarrhythmias

Action: Inhibits adrenergic stimulation, prolongs action potential and refractory period

Evaluation and directed outcomes: Suppression of arrhythmias

Contraindications:
- Patients with cardiogenic shock
- Bradycardia
- Heart blocks

Use cautiously in: No common ones

Adverse effects/side effects:
- Bradycardia
- Hypotension
- Acute Respiratory Distress Syndrome (ARDS)
- Increased liver enzymes – Amiodarone an inhibitor of phospholipase A. Phospholipase A is responsible for breakdown of lipids. Therefore, with amiodarone → increased lipids in liver.

Question 17

What should you describe in Amiodarone nursing implication, patient/family teaching?

Answer 17

Nursing implications:
- Closely monitor VS and ECG when initially started
- Assess for signs of ARDS [dyspnea, tachypnea, rales/crackles]
- Monitor for liver function

Patient/family teaching:
- Instruct patient to take amiodarone as directed and if dose is missed, to not take at all
- Advise patient to avoid drinking grapefruit juice during therapy. Grapefruit juice inhibits the metabolism of amiodarone → increased serum concentrations

Question 18

What are the 2 types of Heparin?

Answer 18

1. Low Molecular Weight Heparin (LMWH) – Standard Heparin: Form a complex with antithrombin (AT) → inhibit several activated blood coagulation factors: thrombin (factor IIa), factor IXa, Xa, XIa and XIIa → prevent fibrin formation and inhibit thrombin-induced activation of platelets and factors V, VIII, and XI.
2. Unfractionated Heparin (UFH) – Enoxaparin: Have more predictable pharmacokinetic properties compared with UFH which allows LMWHs to be administered in fixed doses and without the need for dose adjustment based on laboratory monitoring

Question 19

Describe Heparin/Enoxaparin (Indication, MOA, Evaluation and Directed Outcomes, Contraindications, Cautious Usage, Adverse effects/Side effects)

Answer 19

Indication: Prophylaxis and treatment of thromboembolic disorders including DVT, pulmonary embolism, and atrial fibrillation with embolism

Action: Actions for each type are indicated above

Evaluation and directed outcomes: Prevention of thrombus formation or prevention of extension of thrombi

Contraindications:
- History of HIT – Heparin-induced thrombocytopenia within the past 100 days
- Uncontrolled bleeding
- Severe thrombocytopenia (platelet counts of < 150,000 microliters for adults)

Use cautiously in:
- Severe liver for both Heparin and Enoxaparin - as discussed last week, the liver is responsible for the formation of factors I, II, V, VII, VIII, IX, X, XI, XIII
- Severe kidney impairment for Enoxaparin – excreted by kidneys

Adverse effects/side effects: Bleeding and anemia

Question 20

What should you describe in Heparin/Enoxaparin nursing implications?

Answer 20

Nursing implications:

For both Heparin and Enoxaparin:
- Assess for signs of bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, black, tarry stools, hematuria)
- Monitor platelet count every 2-3 days to ensure to thrombocytopenia. HIT usually comes on, on the 8th day of therapy

For Heparin:
- Monitor activated partial thromboplastin time (aPTT) and make dose adjustments according to protocol.
- Heparin prolongs aPTT

Question 21

Describe Beta-Blockers in the context of Heart Failure (Indication, MOA, Recommendation)

Answer 21

Indication: Management of stable or symptomatic (class II or III) heart failure due to ischemic, hypertensive, or cardiomyopathic origin.

Mechanism of action:
- Selective beta-blockers: block stimulation of beta1 (myocardial)-adrenergic receptors
- Non-selective beta-blockers: block stimulation of beta1 and beta 2 (pulmonary, vascular, uterine)-adrenergic receptors
- Decreased HR -> decreased O2 demand
- Decreased HR -> increased duration of diastole (time during which coronary arteries are perfused) -> increased O2 supply
- Decreased contractility -> decreased O2 demand

Recommendation: B-blockers should be initiated ASAP after the diagnosis of HF, including during the index hospitalization, provided that the patient is hemodynamically stable

Question 22

Describe ACE Inhibitors/Angiotensin II Receptor Antagonists in the context of Heart Failure (Indication, MOA, Recommendation)

Answer 22

Indication:
- ACE-Inhibitors: Management of Heart Failure
- Angiotensin II Receptor Antagonists: Management of Heart Failure

Mechanism of action:
- ACE-Inhibitors: Blocks the conversion of angiotensin I to the vasoconstrictor angiotensin II
- Angiotensin II Receptor Antagonists: Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at the receptor sites
- Impact on O2 supply and demand (applicable to both): Systemic vasodilation -> decreased afterload (decreases in O2 demand)

Recommendation: Recommend an ACEI or ARB in those with ACEI intolerance, in patients with acute MI with HF or an LVEF <40% post-MI to be used as soon as safely possible post-MI