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Heart Failure Pharmacologic Therapy

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Kelly Beswick

on 15 August 2015

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Transcript of Heart Failure Pharmacologic Therapy

Heart Failure
Pharmacologic Therapy

Heart Failure In United States
About 5.1 million people in the United States have heart failure.
One in 9 deaths in 2009 included heart failure as contributing cause.
About half of people who develop heart failure die within 5 years of diagnosis.
Heart failure costs the nation an estimated $32 billion each year.
What is Heart Failure?
Heart failure (HF) is a clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood.
Causes of Heart Failure
Atherosclerosis
Coronary artery disease
Hypertension
Cardiomyopathy
Valvular disorders
Renal dysfunction with volume overload
Diabetes
Treatment Goals
Treatment of the underlying conditions, such as coronary heart disease, high blood pressure, or diabetes
Reducing associated symptoms
Stopping the heart failure from getting worse
Increasing the patients lifespan & improving their quality of life
Current Treatment
Reducing the GFR in patients with HF has shown relative risk reductions and improvement in associated symptoms of heart failure.
Trials testing the major classes of drugs including ACEi, beta-blockers, MRAs, and ARBs and devices (ICD/CRT) showed greater improvement
ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; CRT = cardiac resynchronization therapy; GFR = glomerular filtration rate; H-ISDN = hydralazine and isosorbide-dinitrate; ICD = implantable cardioverter-defibrillator; MRA = mineralocorticoid receptor antagonist; RAAS = renin angiotensin aldosterone system; SNS = sympathetic nervous system.
ACE Drug Class
Lisinopril
Pharmacologic Class
: Angiotensin-converting enzyme inhibitor
Therapeutic Class:
Drug for heart failure and hypertension
Indications
:
Used in the treatment of both heart failure and hypertension. Improve survival in patients when given within 24 hours of an acute MI. Fixed-dose combinations of lisinopril and hydrochlorothiazide are marketed for hypertension as Prinzide and Zestoretic. Lisinopril is also used off-label to treat migraines.
Nursing Considerations
Treatment of hypertension and CHF
ACE inhibitors are effective at slowing the progression of heart failure & reducing the mortality from the disease
2 Primary Actions
ACE inhibitors are to lower peripheral resistance
Inhibiting aldosterone secretion
Adverse Effects
& Interactions
Adverse Effects: cough, headache, dizziness, orthostatic hypotension, rash, angioedema (swelling that occurs under the skin and is typically seen in the eyes and lips as well as the throat, hands and feet)
Interactions

Drug-Drug
: Indomethacin and other NSAIDs may interact with lisinopril causing decreased antihypertensive activity. Also, combination with other antihypertensive drugs should be carefully monitored because of the additive hypotensive action of lisinopril. When lisinopril is taken with potassium-sparing diuretics, hyperkalemia may result. Lisinopril may also increase lithium levels and cause lithium toxicity.

Lab Tests:
May cause positive ANA titer and increase values of the following: BUN, serum bilirubin, serum alkaline phosphatase, AST, and ALT.

Herbal/food:
Excessive intake of foods rich in potassium and potassium-based salt substitutes should be avoided because of the possibility of hyperkalemia.

Treatment of Overdose:
Overdose causes hypotension, which may be treated with the administration of normal saline or a vasopressor.

-Geriatric patients may have higher blood levels related to renal failure.
-Safety and efficacy have been established for the use of this medication in children ages 9 and older.
-Contraindicated in patients who are pregnancy as well as in patients with hyperkalemia. Also contraindicated in those who have previously experienced angioedema caused by ACE inhibitor therapy.
Assess blood pressure just prior to administering lisinopril to be certain that effects are lasting for 24 hours and to determine whether the patient’s blood pressure is within the acceptable range.
Angiotensin II Receptor Blockers
ACE inhibitors in that they both inhibit angiotensin
Angiotensin II Receptor Blockers cause vasodilation
Pharmacologic Class:
Angiotensin II receptor antagonist
Therapeutic Class:
Antihypertensive
Indications:
Used for the treatment of hypertension alone or in combination with other antihypertensives. Also used for the treatment of heart failure. Valsartin reduces the mortality in high-risk patients following an MI.

Valsartan (Diovan)
Adverse Effects & Interactions
Over dosage may manifest as hypotension or tachycardia
Drug-drug- NSAIDs may decrease antihypertensive effect. Potassium-sparing drugs, potassium supplements may increase serum potassium. Diuretics may also produce additive hypotensive effects.
Herbal- Ginger, ginseng and licorice may worsen hypertension.
Lab values- Valsartan may increase serum bilirubin, BUN, AST, ALT, creatinine and potassium. It may also decrease Hgb, Hct and WBC.
Nursing Considerations
Important: Obtain BP and apical pulse immediately before each dose, in addition to regular monitoring and be alert for fluctuations.
Patient Teaching
Patient Teaching
Direct Vasodilators
Direct vasodilators lower blood pressure by dilating the blood vessels allowing for blood to flow more easily, which lowers blood pressure. These types of medications are used to treat hypertension (blood pressure > or = 140/90 mmHg and congestive heart failure.
Direct Vasodilator: Neseritide (Natrecor)
Pharmacologic Class
: Human B-type natriuretic peptides
Therapeutic Class:
Vasodilators
Indications:
Used in the treatment of acutely decompensated heart failure patients with dyspnea at rest or with minimal activity.
Action:
increases cGMP levels, relaxes smooth muscle, and dilates veins and arteries. This drug reduces pulmonary capillary wedge pressure and systemic arterial pressure in patients with heart failure.
Adverse Effects & Interactions
Adverse effects:
Serious effects include bradycardia, ventricular tachycardia, and apnea. Other mild adverse effects include confusion, dizziness, fever, headache, abdominal pain, vomiting, cramping and rash.

Drug-Drug interactions
: ACE inhibitors may increase hypotension symptoms. Monitor blood pressure closely.

Lab Values:
May increase creatanine levels, decrease hemoglobin, and decrease hematocrit.
Nursing Considerations
This drug may cause hypotension so monitor blood pressure closely, especially if patient also takes an ACE inhibitor. Also, drug binds to heparin which decreases the amount of Neseritide delivered.
Patient teaching:
Report any symptoms of hypotension, such as dizziness, light-headed, blurred vision, or sweating.
Dosages
Dosages:
adults should take 2mcg/kg by I.V. bolus over 60 seconds followed by continuous infusion of 0.01 mcg/kg/minute. If hypotension develops the dosage should be reduced by 30% with no bolus doses.
Drug Metabolism:
unknown
Half life:
approximately 18 minutes
Phosphodiesterase Inhibitor
These types of drugs work by blocking one or more five subtypes of the enzyme phophodiesterase which prevents the inactivation of cAMP and cGMP by their respective phosphodiesterase enzyme.
Pharmacologic Class:
Biphyridine
Therapeutic Class:
Inotropes
Indications:
Used for short term treatment of acutely decompensated heart failure
Action:
Produces inotropic action by increasing cellular levels of cAMP and vasodilation by relaxing vascular smooth muscle.
Phosphodiesterase Inhibitor:
Milrinone
Cardiac Glycoside
Digoxin
Pharmacologic Class- Cardiac glycoside

Therapeutic Class- Treats heart failure and abnormally rapid atrial rhythms such as atrial fibrillation, atrial flutter and atrial tachycardia.

Indications- Digoxin is used to treat certain heart rhythm problems such as atrial fibrillation. It’s also used to treat heart failure, usually in combination with a diuretic and an angiotensin-converting enzyme inhibitor. In lay terms, digoxin helps make the heart beat stronger and with a more regular rhythm. Digoxin is also called digitalis.

Digoxin Doses
Tablets:
Initial: 500 to 750 mcg usually produces a detectable effect in 0.5 to 2 hours with a maximal effect in 2 to 6 hours. Additional doses of 125 to 375 mcg may be given at 6 to 8 hour intervals until clinical evidence of an adequate effect is noted. The usual amount of digoxin tablets that a 70 kg patient requires to achieve 8 to 12 mcg/kg peak body stores is 750 to 1250 mcg.
Capsules:
Initial: 400 to 600 mcg of digoxin capsules generally produces a detectable effect in 0.5 to 2 hours with a maximal effect in 2 to 6 hours. Additional doses of 100 to 300 mcg may be given cautiously at 6 to 8 hour intervals until clinical evidence of an adequate effect is noted. The usual amount of digoxin capsules that a 70 kg patient requires to achieve 8 to 12 mcg/kg peak body stores is 600 to 1000 mcg.
Injection:
Initial: 400 to 600 mcg of digoxin intravenously usually produces a detectable effect in 5 to 30 minutes with a maximal effect in 1 to 4 hours. Additional doses of 100 to 300 mcg may be given cautiously at 6 to 8 hour intervals until clinical evidence of an adequate effect is noted. The usual amount of digoxin injection that a 70 kg patient requires to achieve 8 to 12 mcg/kg peak body stores is 600 to 1000 mcg. The injectable route is frequently used to achieve rapid digitalization, with conversion to digoxin tablets or digoxin capsules for maintenance therapy
Adverse Effects & Interactions
Adverse Effects: Dizziness, fainting, fast, pounding, or irregular pulse, slow heartbeat are all adverse effects of using digoxin and should be reported immediately to your doctor.
Digoxin has many known interactions
ranging from serve to moderate. Some serve interactions include: amoxicillin, arbutamine, calcium gluconate, and parathyroid hormone
Nursing Considerations
Assessment
If apical pulse is less than 60 bpm withhold drug and contact physician
Interventions
Monitor for bradycardia, assess for GI disturbances , neurological abnormalities.
Monitor potassium, magnesium & calcium levels
Digoxin Patient Teaching
Teach patient to take pulse and to contact health care professional before taking medication if pulse rate is <60 or >100.
Do not increase or skip a dose
Notify physician if any signs of toxicity occurs.
Beta Andrenergic Blockers
Metoprolol
Clinical Classification:
Anti-anginal, antihypertensive, and MI adjunct
Indications
: hypertension, alone or with other drugs, especially diuretics
Immediate release tabs and injection: prevention of reinfarction in MI patients who are hemodynamically stable or within 3-10 days of an acute MI
Long term treatment of angina pectoris
ER forms only: treatment of stable, symptomatic heart failure of ischemic, hypertensive, or cardiomyopathic origin

Adverse Effects & Interactions
Common Adverse Effects: Heart failure, cardiac arrhythmias, gastric pain, flatulence, constipation, nausea, vomiting, impotence decreased libido, decreased exercise tolerance
Interactions
Increased effects of metoprolol with verapamil, cimetidine, methimazole, and propylthiouracil
Increased effects of both drugs if metoprolol is taken with hydralazine
increased serum levels and toxicity of IV lidocaine, if given concurrently
increased risk of orthostatic hypotension with prazosin
decreased antihyptensize effects with NSAIDs, clonidine, rifampin
decreased therapeutic effect with barbituates
hypertension followed by severe bradycardia if given concurrently with epinephrine
Nursing Considerations
History
: sinus bradycardia (HR less than 45 BPM), second or third degree heart block, cardiogenic shock, heart failure, systolic BP less than 100 mmHg, diabetes or thyrotoxicosis, asthma or COPD, lactation, pregnancy

Physical:
weight, skin condition, neurologic status, Pulse, BP, ECG, respiratory status, renal and thyroid function tests, blood and urine glucose

Black box warning
: Do not discontinue drug abruptly after long term therapy – taper gradually over 2 weeks with monitoring


Loop Diuretics
Furosemide
Indications: given orally or via IV for edema associated with heart failure, cirrhosis, renal disease; given via IV for acute pulmonary edema or given orally for hypertension
Drug action: loop diuretic. Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to sodium rich diuresis

Dosing
Initially 20-80 mg/day PO as a single dose. If needed a second dose may be given in 6-8 hr. If response is unsatisfactory, dose may be increased in 20 – to 40- mg increments at 6- to 8- hours intervals. Up to 600 mg/day may be given
Intermittent dosage schedule (2-4 consecutive days/week) is preferred for maintenance, OR 20-40 mg Im or IV ( slow IV injection over 1-2 min).
Acute pulmonary edema: 40 mg IV over 1-2 min. May be increased to 80 mg IV given over 1-2 min is response is unsatisfactory after 1 hour.
Hypertension: 40 mg bid PO. If needed, additional antihypertensives may be added
half-life:
Adverse Effects & Interactions
Common side effects include dizziness, vertigo, paresthesias, xanthopsia, weakness, orthostatic hypotension, thrombophlebitits, photosensitivity, rash, pruritits, urticaria, nausea, anorexia, vomiting, oral and gastric irritation, constipation, urinary bladder spasm, leukopenia, anemia, thrombocytopenia, muscle cramps and muscle spasms
Dosages
Dosages:
Give first loading dose of 50 mcg/kg I.V. slowly over 10 minutes; then give continuous I.V. infusion of 0.375 to 0.75 mcg/kg/minute. Titrate infusion dose based on clinical and hemodynamic responses. Don't exceed 1.13 mg/kg/day.
Drug Metabolism
: This drug is metabolized by the liver.
Half life:
2.5 to 3.75 hours
Adverse Effects & Interactions
Adverse effects: serious adverse effects include ventricular arrhythmias, sustained ventricular tachycardia, and ventricular fibrillation.

Drug-Drug interactions
: No significant interactions

Lab Values: This drug may cause abnormal liver function test values.
Nursing Considerations
This drug is typically given with digoxin and diuretics. In patients with an atrial flutter or fibrillation give digoxin before milrinone. An improvement in cardiac output may increase urine output. The diuretic medication dosage should be reduced when heart failure improves. Potassium loss may cause digitalis toxicity. Monitor fluid and electrolyte status, blood pressure, heart rate, and renal function during use of this drug. Excessive decrease in blood pressure requires stopping or slowing rate of infusion.
Patient Education:
The patient should report any adverse reactions, especially angina. This drug may cause headaches, but can be treated with analgesics.
Nursing Considerations
Assessment:
Check vital signs. Assess baseline serum electrolytes. Obtain baseline weight and initiate I & O monitoring

Interventions: Monitor vital signs, electrolytes and I&Os.
Thiazide
Thiazide
Diuretic
Antihypertensive
Therapeutic Effects: promotes diuresis and reduces BP
Edema: 25-100mg daily PO until dry weight is attained. Then 25-100 mg daily PO or intermittently, up to 200 mg/day

For hypertension: 12.5-50 mg PO; maximum dose, 50 mg/day

Geriatrics: initiate with 12.5 mg/day PO; increase in 12.5 mg increments, monitoring patient closely

Route Onset Peak Duration
Oral 2 hr 4-6 hr 6-12 hr
Dosing
Adverse Effects & Interactions
Adverse effects: dizziness, vertigo, nausea, anorexia, vomiting, dry mouth, polyuria, & nocturia.
Interactions: drug to drug:
altered electrolytes with loop diuretics, amphotericin C, corticosteroids
increased neuromuscular blocking effects and respiratory depression with non-depolarizing muscle relaxants
decreased absorption with cholestyramine, colestipol
increased risk of cardiac glycoside toxicity if hypokalemia occurs
increased risk of lithium toxicity
decreased effectiveness of anti-diabetic drugs
Nursing Considerations
Baseline Assessment: Check vital signs. Assess baseline electrolytes. Baseline weight and I & Os.
Interventions: Monitor BP/ electrolytes, I&O, and daily weights. Always watch for changes from initial assessment
Eplerenone
Potassium Sparing Diuretic
Treatment of hypertension, alone or in combination with other antihypertensive drugs
For Heart failure, post MI, improvement in the survival of patients with left ventricular dysfunction after a heart attack
Dosing
Hypertension: initially, 50 mg/day PO as a single daily dose, if necessary, may be increased to 50 mg PO bid after a minimum of a 4-week trial period. Maximum, 100 mg/day

For heart failure port MI: start with 25 mg/day PO titrated to 50 mg/day over 4 weeks
For heart failure: if serum potassium is lower the 5, increase dose; if 5-5.4, no adjustment necessary; if 5.5-5.9, decrease dose; if 6 or higher, withhold the dose

Route Onset Peak
Oral Slow 1.5 hr

Adverse Effects & Interactions
Side Effects:
Dizziness
Diarrhea
Cough & Fatigue
Flu-like symptoms
Adverse Effects:
Hyperkalemia may occur in pts with type 2 diabetes
- Increased risk of hyperkalemia if combined with ACE inhibitors and ARB’s, monitor patient closely
- Possible risk of lithium toxicity if combined with lithium, monitor serum lithium levels closely if the combination is necessary
- Possible risk of decreased antihypertensive effect if combined with NSAIDs; monitor BP carefully
- Risk for hyperkalemia also with potassium supplements, potassium sparing diuretics such as spironolactone, amiloride, triamterene, avoid concomitant
Nursing Considerations
Baseline Assessment: Blood pressure & apical pulse.

Interventions: Assist with ambulation if dizziness occurs. Monitor potassium levels and assess blood pressure for hypertension and hypotension.
Patient Teaching
Lasix
Other Treatment
&
Research

Novel Therapies
Uncoupling of nitric oxide synthase (NOS) has emerged as an important contributor to pathologic concentric chamber remodeling and diastolic dysfunction in animal models of HF, in addition to promoting endothelial dysfunction
PDE5I on exercise capacity, functional status, and ventricular form and function
References
Borlaug, B. A., & Paulus, W. J. (2010). Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. European heart journal, ehq426.
Damman, K., Tang, W. W., Felker, G. M., Lassus, J., Zannad, F., Krum, H., & McMurray, J. J. (2014). Current evidence on treatment of patients with chronic systolic heart failure and renal insufficiency: practical considerations from published data. Journal of the American College of Cardiology, 63(9), 853-871.
Non-Pharmacological
Treatment & Study Results
Low sodium diet
Restrict the amount of fluid
Weigh themselves daily
Follow recommendations on exercise
Contact a healthcare provider in case of worsening symptoms
Non-Pharmacological
Treatment
Van der Wal, M. H., van Veldhuisen, D. J., Veeger, N. J., Rutten, F. H., & Jaarsma, T. (2010). Compliance with non-pharmacological recommendations and outcome in heart failure patients. European Heart Journal, 31(12), 1486-1493.
Compliance - Pharmacological & Non-Pharmacological
Diet—ensure adequate general nutrition and, in obese patients, weight reduction
Salt—advise patients to avoid high salt content foods and not to add salt
Fluid—urge overloaded patients and those with severe congestive heart failure to restrict their fluid intake
Alcohol—advise moderate alcohol consumption
Smoking—avoid smoking
Exercise—regular exercise should be encouraged
Gibbs, C. R., Jackson, G., & Lip, G. Y. H. (2000). ABC of heart failure: non-drug management. BMJ: British Medical Journal, 320(7231), 366.
Gibbs, C. R., Jackson, G., & Lip, G. Y. H. (2000). ABC of heart failure: non-drug management. BMJ: British Medical Journal, 320(7231), 366.
Adams, M., Holland, L. N., & Urban, C. Q. (2014). Pharmacology for nurses: a pathophysiologic approach. 4th ed. Upper Saddle River, N.J.: Pearson.
Hodgson, B., & Kizior, R. (2013). Saunders nursing drug handbook 2014. St. Louis, Mo.: Elsevier.
Borlaug, B. A., & Paulus, W. J. (2010). Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. European heart journal, ehq426.
By: Kelly Beswick, Holly Driscoll, Christine Campbell, & Bridgette Buckley
Please check BP & refer to drug guidelines before administering this drug. Guidelines are usually listed in the MAR and subject to facility policy
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