Medications for Heart Failure

What is the definition of heart failure?

Complex clinical condition where the heart cannot effectively pump enough blood to meet the body’s O2 and nutritional needs

Heart failure may result from what?

• impaired myocardial contraction during systole

• impaired relaxation and filling of ventricles during diastole

• combination of both

What are some causes of heart failure?

Cellular changes

• Dysfunction of contractile myocardial and endothelial cells that line the heart and vessels

  • leads to HTN, cardiomyopathy, MI

  • Dysrhythmias, heart valve disorders

• Endothelial dysfunction allows narrowing of vessel lumen

  • leads to clot formation and vasoconstriction, which furthers narrowing

  • Major factors in CAD and HTN

Other causes

• Impaired pumping ability or increase in cardiac workload

• Hyperthyroidism

• Excessive IF fluids or blood transfusions — fluid volume overload

• Antidysrhytmic medications

• Drugs that cause sodium and water retention

• Corticosteroids, estrogens, NSAIDs

Which typically happens first, left sided or right sided heart failure?

Left sided because left of heart pumps blood out to body

• if left ventricle fails, heart isn’t pumping blood out as well and blood backs up into lungs

• overtime, left sided HF causes right HF bc blood backs up into right side

What are some signs/symptoms of left sided heart failure?

• Fatigue

• Tachypnea

• Difficulty breathing

• Cardiomegaly

• Tachycardia

• Nausea, ab pain

• Decrease peripheral pulses

• Hypoxia

What are some signs/symtpoms of right sided heart failure?

• jugular venous distention

• hepatomegaly

• spelonmegaly

• decreased renal perfusion

• pitting edema

Why are the stages of heart failure important?

Important because the meds patients are on are going to depend on which stage they’re at

What is Stage A of heart failure?

At-risk for HF

• Pts at risk for HF but without current or previous symptoms

What is stage b of heart failure?

Pre-heart failure

• Pts without current or previous signs/symptoms of HF but evidence of one of the following: structural heart disease, increased filling pressures, risk factors

What is stage c of heart failure?

Symptomatic heart failure

• Patients with current or previous signs/symptoms of HF

What is stage D of heart failure?

Advanced heart failure

• Marked HF symptoms that interfere with daily life and with recurrent hospitalizations

What are the medications for heart failure?

• Sodium Glucose Cotransporter 2 Inhibitiors-SGLT2i (dapagliflozin)

• Angiotensin II receptor blockers/ARBs (Losartan)

• Angiotensin-converting enzyme/ACE inhibitors (Captopril)

• Beta adrenergic blcokers (metoprolol)

• Angiotensin receptor/neprilysin inhibitor - ARNI (sacubitril/valsartan)

• Aldosterone antagonist (spironolactone)

• Loop diuretics (furosemide)

• Cardiac glycosides (digoxin)

• Phosphodiesterase inhibitor (Milrinone)

What is the prototype for sodium glucose contransporter 2 inhibitors-SGLT2i ?

Dapagliflozin

What is the mechanism of action of sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin)?

• Block the sodium-glucose cotransporter in the proximal renal tubule which normally reabsorbs glucose and sodium back into the bloodstream

• Blocking causes increased glucose and sodium in the urine and osmotic diuresis

  • will cause pt to have decreased preload and decrease BP without side effects of some other meds

What are the uses/indications of sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin)?

• Heart failure - all stages

• Reduces risk of hospitalization and cardiac events

• Type 2 diabetes

• Chronic kidney disease

What are the responsibilities of the nurse when giving sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin)?

• Assess for effect

• Monitor blood glucose, renal function, fluid volume status

• Monitor for s/s of dehydration

• Use with caution in patients taking other diuretics

What are the side effects of sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin)?

• Hypotension

• Fluid volume depletion/dehydration

• Vulvovaginal candidiasis - yeast infection

• increased urination

• Diabetic ketoacidosis

• UTI

• Hypoglycemia

What education should be given to patients taking sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin)?

• Expect more frequent urination (let them know to expect more urination)

• Maintain proper hydration

• Stand up slowly if dizzy

• Recognize symptoms of DKA (teach them to recognzie these sxs bc it’s an emergent situation):

  • nausea/vomiting

  • abdominal pain

  • unusual fatigue

  • difficulty breathing

Patients taking sodium glucose contransporter 2 inhibitors-SGLT2i (dapagliflzoin) should expect more or less frequent urination?

More

What is the prototype for angiotensin II blockers/ARBs?

Losartan

Generally, ARBs are started when?

Started if ACEs aren’t tolerated, but some new recs to start ARBs earlier

What is the biggest difference between ARBs and ACE inbitors?

You don’t have the cough and hyperkalemia with ARBs that you have with ACEs

What is the mechanism of action for ARBs (losartan)?

• Block the action of angiotensin II at various sites in the body, which results in:

  • vasodilation

  • excretion of sodium and water, retention of potassium

What are the uses/indications of angiotensin II receptor blockers/ARBs losartan)?

• Hypertension

• Heart failure

• Prevention of mortality following MI

• Delay progression of diabetic nephropathy

What are the responsibilities of the nurse when giving angiotensin II receptor blockers/ARBs (losartan)?

• Assess for effect

• Assess kidney and liver function tests, serum electrolytes and serum potassium levels

• Intervene if patient has angioedema

• Ensure patient is on contraceptives (teratogenic medication)

Why must you ensure your patient is on contraceptives before giving losartan (Angiotensin II receptor blocker/ARB)?

It is a teratogenic medication

What are the side effects of angiotensin II receptor blockers/ARBs (losartan)?

• Hyperkalemia (not as much as with ACE)

• Angioedema (less than with ACEi)

• Dizziness, muscle cramps, or weakness

• Heartburn, diarrhea

• Decreased sensitive to touch

• BLACK BOX - pregnancy risk category D during the second and third trimester, related to fetal injury

What education should be given to patients taking angiotensin II receptor blockers/ARBs (losartan)?

• Lifestyle changes

• Avoid pregnancy

• Therapy is usually long-term

• Know the names of medications you take (list)

• Do not stop taking unless directed by PCP

• Stand slwoly, wear compression socks, exercise legs, avoid prolonged standing

• Avoid potassium supplements and salt substitutes because risk of hyperkalemia

Is therapy with ARBs (losartan) usually short term or long term?

long term

What is the prototype for angiotensin-converting enzyme/ACE inhibitors?

Captopril

What is the mechanism of action for angiotensin-converting enzyme/ACE inhibitors (captopril)?

• Blocks an enzyme conversion of angiotensin 1 to angiotensin II

  • decreases vasoconstriction

  • decreases aldosterone production → excretion of sodium and water

What are the uses/indications of ACE inhibitors (captopril)?

• Hypertension

• Heart failure

  • Prevent or reverse remodeling of heart and blood vessels (can reduce morbidity/mortality in HF pts with reduced ejection fraction)

• Diabetic and nondiabetic nephropathy - reduced proteinuria

• Often used in combination with other antihypertensives

What are the responsibilities of the nurse when giving angiotensin-converting enzyme/ACE inhibitors (captopril)?

• Assess for effect

• Assess kidney and liver function tests, serum electrolytes and serum potassium levels

• Intervene if pt has angioedema

  • angioedema can lead to acute hypotension

• Ensure patient on contraceptives (teratogenic medication)

• Prevent interactions (digoxin and lithium)

• Give 1 hour before or 2 hours after meals (better on empty stomach)

• Monitor response to therapy

What does captopril interact with?

Digoxin and lithium

What are the side effects of angiotensin-converting enzyme/ACE inhibitors (Captopril)?

• Neutropenia, hyperkalemia

• Angioedema

• persistent cough

• acute hypotension when med started

• Hyperkalemia in pts with diabetes mellitus or renal impairment

• Rash and dysguesia

• BLACK BOX - pregnancy risk category D during the second and third trimester, related to fetal injury and death

What education should be given to patients taking angiotensin-converting enzyme/ACE inhibitors (captopril)?

• Lifestyle changes

• Therapy is longterm

• Know the names of medications you take (list)

• Do not stop taking unless directed by pcp (rebound hypertension)

• stand up slowly, wear compression socks, exercise legs, avoid prolonged standing

• avoid potassium supplements and salt substitutes

What is the prototype for beta adrenergic blockers?

Metoprolol

Why are beta adrenergic blockers (metoprolol) not considered first line therapy?

Not considered first line therapy because don’t want to necessarily decrease myocardial contractions

What is the mechanism of action for beta adrenergic blockers (metoprolol)?

• Inhibits SNS effect on myocardium — beta 1 receptors in heart decrease HR, contraction, and cardiac output

• Decreases HR

• Decreases myocardial contraction (negative inotropy)

• Decreases cardiac output overall

What are the uses/indications of beta adrenergic blockers (metoprolol)?

• HTN

• Heart failure

• Angina, MI

• Tachyarrhythmias

What are the responsibilities of the nurse when giving beta adrenergic blockers (metoprolol)?

• Obtain baseline EKG

• Monitor HR and hold if <50 bpm

• Use cautiously with diabetics (masks tachycardia)

• Avoid in patients with asthma (can hit Beta 2 receptors in lungs)

When administering beta adrenergic blockers (metoprolol), you should hold the medication if the patient’s HR is below was rate?

<50 bpm

Why should you use beta adrenergic blockers (metoprolol) cautiously in patients with diabetes?

It can mask tachycardia

What data should you obtain prior to administering beta adrenergic blockers (metoprolol)?

Baseline EKG

What are some side effects of beta adrenergic blockers (metoprolol)?

• Hypotension

• Bradycardia

• Orthostatic hypotension

• Bronchoconstriction

• Hypoglycemia (especially in diabetics)

Why should beta adrenergic blockers (metoprolol) be avoided in patients with asthma?

It can hit Beta 2 receptors in lungs

What education should be given to patients taking beta adrenergic blockers (metoprolol)?

• Observe for signs of worsening HF: difficulty breathing, swelling, weight gain, fatigue

• Sit down if feeling dizzy or faint

• Do not stop abruptly - has to be gradually weaned off by provider

• Monitor HR and BP at home

What is the prototype for Angiotensin receptor/neprilysin inhibitor-ARNI?

Sacubitril/Valsartan (combo of two diff meds)

What is the mechanism of action for Angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsartan)?

• Sacubitril inhibits meprilysin, decreases breakdown of natriuretic peptides — promotes diuresis and vasodilation

• Valsarten blocks angiotensin II receptors — decreases vasoconstriction and aldosterone secretion

What are the uses/indications of angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran)?

• Heart failure with reduced ejection fraction

• Used in place of ACE or ARB as part of GDMT

Which heart failure medication is indicated for heart failure with reduced ejection fraction?

Sacubitril/valsartan (angiotensin receptro/neprilysin inhibitor-ARNI)

What are the responsibilities of the nurse when administering angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran)?

• Assess for angioedema

• Assess blood pressure before and during therapy

• Monitor serum potassium and renal function

• Do not administer within 36 hours of ACE (will lead to severe hypertension)

• Do not administer with ARB (will lead to severe hypertension)

Angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran) cannot be administerd within how many hours of an ACE?

36

Which medication can you not adminster with angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran)?

ARB

What are the side effects of angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran)?

• Hypotension

• Hyperkalemia

• Renal impairment

• Dizziness

• Angioedema

What education should you give to a patient taking angiotensin receptor/neprilysin inhibitor-ARNI (sacubitril/valsatran)?

• Observe for sigs of worsening HF

• Take consistently as prescribed

• Change positions slowly

• Avoid potassium supplements or salt substitutes

• Seek immediate medical attention for swelling of face, lips, tongue or throat

What is the prototype of aldosterone antagonist?

Spironolactone

What is the mechanism of action of aldosterone antagonist (spironolactone)?

• Inhibits mineralocorticoid receptors and blocks effects of aldosterone

• Blocks aldosterone-induced retention of sodium and water

• Also known as aldosterone receptor antagonists (blockers)

What are the uses/indications of aldosterone antagonist (spironolactone)?

• Heart failure and inadequate renal function

• Ascites

• Hypokalemia (if blocking aldosterone then will retain more K+; sometimes use with other diuretics that lower K+ level to balance)

• HTN

• Primary and secondary aldosteronism

• Adjunctive therapy for HF—allows smaller doses of loop diuretics and potassium supplements

What are the responsibilities of the nurse when giving aldosterone antagonist (spironolactone)?

• Monitor potassium and sodium levels

• Avoid during first trimester of pregnancy (feminization of male fetuses)

• Increases half-life of digoxin

Why should you avoid use of aldosterone antagonist (spironolactone) during the first trimester of pregnancy?

It can cause feminization of male fetuses

What effect does aldosterone antagonist (spironolactone) have on digoxin?

Increases the half-life of digoxin

What are the side effects of aldosterone antagonist (spironolactone)?

• Hypotension

• Fluid or electrolyte imbalance (hyponatremia, hyperkalemia)

  • is a indicated for hypokalemia by blocking aldosterone, secreting more water and sodium, so possibility it could overcorrect

• GI upset

• Dizziness, headache

• Gynecomastia, hirsutism, loss of libido, impotence

What education should be provided for patients taking aldosterone antagonist (spironolactone)?

• Report severe side effects to provider

• Don’t take potassium supplements or use salt substitutes

• Avoid grapefruit juice (can inhibit production of an enzyme that’s needed for metabolism; if they drink grapefruit juice it can increase level of med in body)

What juice should patients taking spironolactone (aldosterone antagonist) avoid drinking?

grapefruit juice

What is the prototype for loop diuretics?

Furosemide

Why are loop diuretics (Furosemide) considered alternate agents?

Alternate agents because thiazide-type diuretics preferred for more long-term care, whereas loop diuretics preferred in acute illness/critically ill plts

Are loop diuretics used for long term care or acutely ill patients?

Acutely ill

What is the mechanism of action for loop diuretics (furosemide)?

• Block the chloride pump in the ascending loop of Henle

  • this blocks reabsorption of sodium and chloride

  • causes significant diuresis even with severe renal impairment

What are the uses/indications of loop diuretics (furosemide)?

• Emergent need for rapid mobilization of fluid

  • Acute pulmonary edema

• Heart failure

• Hepatic and renal disease

What are the responsibilities of the nurse when giving loop diuretics (furosemide)?

• Monitor electrolyte levels (particularly K+)

• Not given if anuric

• Cross reactivity with sulfonamides

• Avoid during pregnancy bc can decrease blood flow through placenta

Similar to thiazide-type diuretics, you loop diuretics have cross reactivity with what?

Sulfonamides

Similar to thiazide-type diuretics, you cannot give a patient loop diuretics if they are what?

Anuric

Why should loop diuretics (furosemide) be avoiding during pregnancy?

They can decrease blood flow through the placenta

What are the side effects of loop diuretics (furosemide)?

• Dehydration

• Electrolyte imbalances: hypokalemia, hyponatremia, hypocholermia, decrease in calcium and magnesium levels

• Hypotension

• Ototoxicity

• Hyperglycemia

• Hyperuricema

What education should be given to patients taking loop diuretics (furosemide)?

• Take it in the morning

• Stand up slowly

• Monitor blood pressure and weight daily

• Report muscle weakness, cramps, palpitations, or unusual fatigue — indications of hypokalemia

• Report excessive thirst, dry mouth

• Keep appointments for labs

What is the prototype for cardiac glycosides?

Digoxin

Why are cardiac glycosides (digoxin) not used frequently anymore?

There are other meds that have less severe side effects

What is the mechanism of action for cardiac glycosides (digoxin)?

• inhibits sodium-potassium pump during re-polarization which allows more calcium into cell

• More calcium leads to positive inotropy (increased contractility) and negative chronotropy (decreased HR)

What are the uses/indications of cardiac glycosides (digoxin)?

• Second line treatment for heart failure

• Atrial fibrillation

What are the responsibilities of the nurse when administering cardiac glycosides (digoxin)?

• Hold for apical HR < 60 beats/min in adult

• Monitor for and treat hypokalemia before administering

• Monitor for toxicity (at any level) - dose is dependent on each individual person

• Use cautiously in acute MI, heart block, wolf parkinson white’s syndrome (WPW)

• Must reduce dose in renal failure

When administering cardiac glycosides (digoxin) you must hold for an apical heart beat at what beat/min in adults?

< 60 bpm

Reduce the dose for cardiac glycosides (digoxin) in ____ failure

renal

What are the side effects of cardiac glycosides (digoxin)?

• Severe myocarditis, bradycardia, V-tach, V-fib

• Hypokalemia

• Toxicity at any serum level

• Renal failure

• Anorexia

• Fatigue, weakness vision changes

What education should be given to patients taking cardiac glycosides (digoxin)?

• Take as prescribed

• Report fatigue, weakness, vision changes, or GI effects (may be toxicity)

• Monitor pulses for rate and rhythm and notify provider with changes

What is digitalization?

Means getting to a steady state in tissue concentration—sometimes involves a loading dose

What are some key facts about the administration and digitalization of digoxin?

• Maximum drug effect occurs when steady-state tissue concentration is achieved

• Occurs in approximately 1 week unless loading doses are used

  • higher doses given 6-8 hours apart over a 24 hour period

• Rapid digitalization - has higher risks of toxicity (not usually recommended to do this in HF patients)

  • usually for atrial tachydysrhytmia with continuous cardiac monitoring rather than HF

• slow digitalization - giving regular maintenance dose everyday

  • achieved by initiating therapy with maintenance dose

True or false: Digoxin has a a narrow therapeutic index

True

What must you do regarding digoxin labs prior to any dose of digoxin or change in dose?

Must make sure digoxin level is drawn prior to dose and anytime dose changes. Blood sample must be drawn at least 6 hours after last dose because distribution to tissues requires ~6 hours

What are some toxicity signs and symptoms of digoxin?

• potentially life-threatening heart rhythm disturbances

• blurred vision; halo vision; altered color perception

• nausea/vomiting

• abdominal discomfort

• appetite suppressed

• mental changes

What is the prototype for phosphodiesterase inhibitor?

Milrinone

What is the mainstay of treatment once you get to later stages of heart failure?

Phosphodiesterase inhibitor (milrinone)

If a patient is on milrinone infusion and they are adjusting the dosage, they need to be in what kind of care environment

Critical care

What is the mechanism of action of phosphodiesterase inhibitor (milrinone)?

• Inhibits phosphodiesterase, an enzyme which breaks down cyclic AMP, resulting in increased levels of cyclic AMP

  • Results in increased contractility, vasodilation, and decreased afterload

What are the uses/indications of phosphodiesterae inhibitor (milrinone)?

• Intermediate and long-term use to support severe or advanced heart failure

• Often a bridge to more definitive treatment or transplant

What are the responsibilities of the nurse when administering phosphodiesterase inhibitor (milrinone)?

• Monitor blood pressure, heart rate/rhythm, perfusion

• Monitor renal function, potassium and magnesium levels

• Maintain IV access — has to be given via IV

What are the side effects of phosphodiesterase inhibitor (milrinone)?

• Hypotension

• Potential for ventricular dysrhythmias (so want K+ and Mg+ levels to be good)

• Long half-life; 80 hours

What education should be given with patients taking phosphodiesterase inhibitor (milrinone)?

Record palpitations, chest pain, dizziness, or worsening dyspnea