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Chapter 42
Cardiac Glycosides, Antianginals,
and Antidysrhythmics
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
1
Heart Failure

Heart failure

Pathophysiology
• Preload
• Afterload
 Right-sided
• Blood backs up in periphery
 Left-sided
• Blood backs up in lungs
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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ACC/AHA Stages of Heart Failure
Stages
Characteristics
1 (A)
High risk for HF without symptoms or
structural disease
2 (B)
Some levels of cardiac changes (e.g.,
decrease ejection fraction without symptoms of
heart failure)
3 (C)
Structural heart disease with symptoms of HF
(e.g., fatigue, SOB, edema, decreased
physical activity)
4 (D)
Severe structural heart disease and marked
symptoms of HF at rest
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
3
Heart Failure (Cont.)

Nonpharmacologic treatment






Limit salt intake.
Limit or avoid alcohol intake.
Stop smoking.
Decrease saturated fat intake.
Perform mild exercise as possible.
Laboratory tests


Atrial natriuretic peptide (ANP)–20 to 77 pg/mL; 20
to 77 ng/L (SI units)
Brain natriuretic peptide (BNP)–Desired value:
less than 100 pg/mL; positive value: greater than
100 pg/mL
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
4
Cardiac Glycosides

Digitalis preparations (digoxin)

Actions
• Positive inotropic

Increases myocardial contractility

Decreases heart rate

Decreases conduction

Increases cardiac output
• Negative chronotropic
• Negative dromotropic
• Increase stroke volume
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
5
Cardiac Glycosides (Cont.)



Atrial fibrillation
Atrial flutter
Other drugs used if digoxin not effective:


Calcium channel blocker: verapamil (Calan)
Warfarin (Coumadin)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
6
Cardiac Glycosides (Cont.)

Digoxin


Drug interactions
• Diuretics
• Glucocorticoids
• Antacids
• Herbal interactions
• Hypokalemia
Digitalis toxicity

Anorexia, diarrhea, nausea and vomiting,
bradycardia, premature ventricular contractions,
cardiac dysrhythmias, headaches, malaise, blurred
vision, visual illusions, confusion, and delirium
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
7
Cardiac Glycosides (Cont.)


Antidote for digitalis toxicity: digoxin
immune Fab (ovine, Digibind)
Treatment cardiotoxicity


Phenytoin
Lidocaine
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
8
Nursing Process: Digoxin




Assessment
Nursing diagnoses
Planning
Nursing interventions



Patient teaching
Cultural considerations
Evaluation
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
9
Phosphodiesterase Inhibitors

Milrinone lactate (Primacor)



Positive inotrope
Used to treat acute HF
Action
• Increase stroke volume and cardiac output and
promote vasodilation

Caution: Administered IV for no longer than
48 to 72 hours to avoid severe cardiac
dysrhythmias
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
10
Other Agents Used to Treat Heart
Failure





Vasodilators
Angiotensin-converting enzyme (ACE)
inhibitors
Angiotensin II receptor antagonists
Diuretics (thiazides, furosemide),
spironolactone (Aldactone)
Some beta blockers
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
11
Vasodilators




Decrease venous blood return to the heart
Decrease preload
Decrease oxygen demand on the heart
Arteriolar dilators



Reduce cardiac afterload
Improve renal perfusion
Improve circulation to skeletal muscles
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
12
ACE Inhibitors and ARBs

ACE inhibitors



Dilate venules and arterioles, improving renal
blood flow and decreasing blood fluid volume
Decrease release of aldosterone
Angiotensin II receptor blocker (ARB) agents

Valsartan (Diovan) and candesartan (Atacand)
approved for HF in patients who cannot tolerate
an ACE inhibitor.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
13
Diuretics


First-line drug treatment for reducing fluid
volume
Spironolactone (Aldactone)

Blocks production of aldosterone; improves heart
rate variability; decreases myocardial fibrosis
cardioprotective effect of blocking aldosterone in
the heart and blood vessels to promote cardiac
remodeling
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14
Beta Blockers





Carvedilol (Coreg)
Metoprolol tartrate (Toprol-XL)
Bisoprolol (Zebeta)
Doses should be low initially and gradually
increased.
Beneficial effect:1 to 3 months
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
15
Atrial Natriuretic Peptide

Nesiritide (Natrecor)



Inhibits antidiuretic hormone (ADH) by increasing
urine sodium loss
Promotes vasodilation, natriuresis, and diuresis
Used for treatment of acute decompensated HF
with dyspnea at rest, dyspnea with little physical
exertion
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
16
BiDil


Combination of hydralazine (for blood
pressure) and isosorbide dinitrate (a dilator to
relieve heart pain)
FDA approval for treating HF, especially in
African Americans
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
17
Angina



Classic (stable): Occurs with predictable stress
or exertion
Unstable (preinfarction): Occurs frequently
with progressive severity unrelated to activity;
unpredictable regarding stress/exertion and
intensity
Variant (Prinzmetal, vasospastic): Occurs
during rest
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Types of Antianginal Drugs



Nitrates: reduction of venous tone, decreased
workload of the heart, vasodilation
Beta blockers: decrease the workload of the
heart and decrease oxygen demands
Calcium channel blockers: decrease the
workload of the heart and decrease oxygen
demands
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
19
Nitrates




First agents used to relieve angina
Action: Generalized vascular and coronary
vasodilation
Side effects and adverse reactions:
Headache, hypotension, dizziness,
weakness, and faintness
Sublingual, topical (ointment, transdermal
patch), buccal extended-release tablet, oral
extended-release capsule and tablet,
aerosol spray (inhalation), and IV
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
20
Beta Blockers




Block the action of the catecholamines
(epinephrine and norepinephrine)
Decrease heart rate and blood pressure
Do not abruptly discontinue
Selective beta blockers: atenolol
(Tenormin), metoprolol (Lopressor, ToprolXL)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
21
Calcium Channel Blockers







Relax coronary artery spasm (variant angina)
Relax peripheral arterioles (stable angina)
Decrease cardiac oxygen demand
Decrease cardiac contractility (negative inotropic
effect that relaxes smooth muscle)
Decrease afterload
Decrease peripheral resistance
Reduce the workload of the heart
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
22
Antianginal Drugs
Types of anginal pectoris with treatment
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
23
Nursing Process: Antianginal Drugs




Assessment
Nursing diagnoses
Planning
Nursing interventions


Patient teaching
Evaluation
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
24
Antidysrhythmic Drugs


Dysrhythmia vs. arrhythmia
Cardiac action potentials

Phase 0 to phase 4
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
25
Antidysrhythmic Drugs (Cont.)


Mechanism of drug action
Class I

Sodium channel blockers
• 1A: slow conduction, prolongs repolarization
(quinidine, procainamide, disopyramide)
• 1B: slow conduction, shortens repolarization
(lidocaine, mexiletine)
• 1C: prolonged conduction with little/no effect on
repolarization (flecainide, propafenone)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
26
Antidysrhythmic Drugs (Cont.)

Class II

Beta-adrenergic blockers
• Reduce calcium entry, decrease conduction velocity,
•
•
•
•
automaticity, and recovery time
Propranolol (Inderal)
Acebutolol (Sectral)
Esmolol (Brevibloc)
Sotalol (Betapace)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
27
Antidysrhythmic Drugs (Cont.)

Class III



Prolong repolarization
Amiodarone (Cordarone)
Class IV



Block calcium influx (calcium channel blockers)
Verapamil (Calan, Isoptin)
Diltiazem (Cardizem)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
28
Nursing Process: Antidysrhythmics




Assessment
Nursing diagnoses
Planning
Nursing interventions


Patient teaching
Evaluation
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
29
Practice Question #1
A patient has angina pectoris. The patient’s
BP is 100/60 mm Hg. The nurse
administers nitroglycerin 0.4 mg sublingual
(SL). It is most important for the nurse to
assess the patient for the development of
A.
B.
C.
D.
bradycardia.
hypotension.
bradypenia.
hypokalemia.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
30
Practice Question #2
A nurse is administering digoxin, 0.125 mg,
to a patient. Which nursing interventions will
the nurse implement? (Select all that apply.)
A. Checking the apical pulse rate before
administration
B. Monitoring the patient’s serum digoxin level
C. Instructing patient to report pulse rate less than
60
D. Advising patient to avoid foods high in potassium
E. Always giving an antacid with digoxin to reduce
GI distress
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
31
Practice Question #3
A patient is ordered to receive digoxin
(Lanoxin) to treat congestive heart failure.
The nurse is most concerned about which
assessment finding?
A.
B.
C.
D.
Heart rate 56 beats/min
BP 138/90 mm Hg
RR 18 breaths/min
1+ pitting edema of the lower extremities
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
32
Practice Question #4
A nurse is preparing to administer digoxin
(Digitalis) to a patient. Which laboratory
result is the nurse most concerned about?
A.
B.
C.
D.
Sodium 138 mEq/L
Potassium 3.0 mEq/L
Digitalis level 1.8 ng/mL
BNP 200 pg/mL
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33
Practice Question #5
When administering antianginal drugs, the
nurses identifies which as the most common
response?
A.
B.
C.
D.
Tachycardia
Bradypnea
Hypotension
Dry mouth
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
34
Practice Question #6
Which drug group is most effective for the
treatment of variant (vasospastic) angina?
A.
B.
C.
D.
Calcium channel blockers
Beta blockers
Cardiac glycosides
Phosphodiesterase inhibitors
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
35
Practice Question #7
The nurse should teach the patient to report
which of the following to the health care
provider immediately if experienced after
taking nitroglycerin?
A.
B.
C.
D.
Dizziness
Faintness
Headache
Persistent pain
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
36
Practice Question #8
The nurse identifies which drug as a calcium
channel blocker used for the treatment of
dysrhythmias?
A.
B.
C.
D.
Diltiazem (Cardizem)
Esmolol (Brevibloc)
Flecainide (Tambocor)
Sotalol HCl (Betapace)
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37
Practice Question #9
A patient with angina and a long history of
severe chronic obstructive pulmonary disease
is ordered beta blocker therapy. Which beta
blocker would be most effective for this
patient?
A.
B.
C.
D.
Propranolol (Inderal)
Nadolol (Corgard)
Pindolol (Visken)
Atenolol (Tenormin)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
38