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Introduction to Heart Failure & Hypertension & Associated Cardiac Medications NUR 152 MESA COMMUNITY COLLEGE CHAPTER 35-IGGY (678-692) & ASSOCIATED CHARTS IN IGGY CHAPTER 36-IGGY (PG 709-718) & ASSOCIATED CHARTS IN IGGY Learning Objectives Describe left, right, and high output heart failure Describe causes, diagnostics, clinical manifestations, and compensatory mechanisms of left and right heart failure Describe common treatments for heart failure Describe & differentiate the various prototype medications used to enhance cardiac functioning Describe essential and secondary hypertension & it’s causes, diagnostics, clinical manifestations, and treatments Describe & differentiate the various drug therapies for hypertension Describe & differentiate the various anticoagulant drug therapies Heart Failure Pg. 679 Also called pump failure; inability of heart to work effectively as a pump Major types: Left-sided Right-sided High-output Etiology Pg. 681 Table 35-1 ▪ Systemic hypertension is the cause of heart failure in most cases ▪ About one third of patients experiencing MI also develop heart failure ▪ Structural heart changes (e.g., valvular dysfunction) cause pressure or volume overload on heart Heart failure patients must be unloaded! Pg 684 Decrease preload & afterload by decreasing blood volume and peripheral vascular resistance thus Improving cardiac output! Left Sided Heart Failure Pg. 682 ▪ Formerly known as congestive heart failure ▪ Typical causes ▪ Hypertension ▪ Coronary artery disease ▪ Valvular disease ▪ Not all cases involve fluid accumulation ▪ Two types: ▪ Clinical manifestations ▪ ▪ ▪ ▪ Weakness Fatigue Dizziness Acute confusion ▪ (low flow) ▪ Pulmonary congestion ▪ Residual LV volume-backs up ▪ Breathlessness ▪ Oliguria ▪ Systolic ▪ Diastolic 6 Right Sided Heart Failure Pg. 682 ▪ Causes ▪ Left ventricular failure ▪ Right ventricular MI ▪ Pulmonary hypertension ▪ Right ventricle cannot empty completely ▪ Increased volume and pressure in venous system and peripheral edema ▪ Clinical manifestations ▪ ▪ ▪ ▪ ▪ ▪ ▪ Jugular vein distention Increased abdominal girth Dependent edema Hepatomegaly Hepatojugular reflux Ascites Weight most reliable indicator of fluid gain/loss ▪ Assessment: ▪ Laboratory Electrolytes Hemoglobin and hematocrit BNP Urinalysis (proteinuria/high specific gravity) ▪ ABGs ▪ ▪ ▪ ▪ ▪ Imaging ▪ CXR ▪ Echocardiography (best diagnostic tool) ▪ ECG ▪ Pulmonary artery catheter 8 Pulmonary Artery Catheter (Swan-Ganz) (Nice to know not need to know for block I - provided as visual only) Blood Studies/Other tests Pg. 683-684 ▪ Electrolytes ▪ Renal studies ▪ Drug levels ▪ BNP (helps with differential) ▪ CBC ▪ UA ▪ ABG ▪ Echocardiogram ▪ ECG ▪ Chest X-Ray Chest X-Ray ▪ Gives information on the size of the heart ▪ Position of the heart ▪ Condition of the lungs ▪ Routine screening ▪ Often old films available for comparison High Output Failure-Not a common type of HF ▪ Cardiac output remains normal or above normal ▪ Caused by increased metabolic needs of hyperkinetic conditions ▪ Septicemia ▪ Anemia ▪ Hyperthyroidism Compensatory Mechanisms Pg 679 ▪ When cardiac output is insufficient to meet body’s demands, these mechanisms operate to increase cardiac output: ▪ Sympathetic nervous system stimulation ▪ Other renin-angiotensin system activation ▪ Chemical responses (BNP) ▪ Myocardial hypertrophy Indications for Worsening or Recurrent Heart Failure ▪ Rapid weight gain ▪ Decrease in exercise tolerance ▪ Cold symptoms ▪ Excessive awakening at night to urinate ▪ Development of dyspnea/angina at rest ▪ Increased edema in feet, ankles hands The heart is special because... Uses all oxygen delivered by coronary arteries. Skeletal muscle uses 25-30%. Only way to increase oxygen supply is to vasodilate and increase heart rate. Strengthen contraction to increase output Starling’s Law (fiber length and tension) Nice to know but not need to know: ↓ Atrial and ventricular muscle cells have own intrinsic timer. SA node paces 60-100 times per minute AV node paces 40-60 times per minute Ventricular muscle cells pace 20-40 times per minute Extrinsic Control of Cardiac Output Sympathetic nervous system alpha fibers - increased rate (chronotropic) beta fibers - increased force of contraction (inotropic) Parasympathetic nervous system Vagus nerve - slowing of heart rate, reduces contractility to decrease stroke volume Common Cardiac Related Medications Pg. 686 ▪ Prototype- Digoxin (Lanoxin) Cardiac Glycoside ▪ Actions ▪ Positive inotropic action ▪ Negative chronotropic action ▪ Negative dromotropic action ▪ Increase stroke volume For further knowledge: ATI- Pharmacology Made Easy- Drug Therapy for Heart Failure- Cardiac Glycosides Cardiac Glycoside: Pg. 686 Digoxin (Lanoxin) ▪ Therapeutic Effect/Use ▪ Treatment of HF ▪ Treatment of atrial tachycardia, flutter, and fibrillation 20 Cardiac Glycoside: Digoxin ▪ Mode of Action/Pharmacodynamics ▪ Inhibits sodium-potassium ATPase => ▪ Increases intracellular calcium => ▪ Cardiac muscle fibers contract more efficiently ▪ Heart rate slows 21 Cardiac Glycoside: Digoxin Digitalis Toxicity (drug alert pg 687) Skyscape ▪ Side Effects Anorexia N/V HA Blurred vision (halos) Fatigue Severe (symptomatic) bradycardia ▪ CHF therapeutic drug levels: ▪ ▪ ▪ ▪ ▪ ▪ ▪ Adverse Reactions ▪ Bradycardia ▪ AV block ▪ Dysrhythmias ▪ 0.5-0.8 ng/mL ▪ Toxic = >2 ng/mL 22 Cardiac Glycoside: Digoxin/Digitalis Toxicity ▪ Treatment for Digitalis Toxicity ▪ Digoxin immune Fab (digibind) ▪ Binds with digoxin and is excreted in the urine 23 Cardiac Glycoside: Digoxin ▪ Interactions ▪ Increase risk of digoxin toxicity ▪ Thiazide diuretics ▪ Loop diuretics ▪ Why? 24 Cardiac Glycoside: Digoxin ▪ Nursing Implications ▪ Assessment ▪ Apical Pulse: if <60 Hold and notify MD ▪ ECG ▪ Labs: potassium level, Digoxin Level ▪ Evaluation ▪ After dose given watch for SE ▪ Teaching ▪ How to take pulse ▪ S/S of toxicity 25 NITRATES (Pg . 686) (Nice to know, not need to know for block I) ▪ Nitroglycerin ▪ Dilate Veins ▪ Decreased Preload ▪ Dilate Coronary Arteries ▪ O2 supply ▪ Dilate Arterioles ▪ Decreased Afterload ▪ ▪ ▪ ▪ Side effects: BP, Headache Develop resistance Manufactured in many forms: oral, SL, spray, paste, IV 12 hour nitrate free period Factors Affecting Myocardial Oxygen Demand and the Effect of Various Cardiac Medications Actions of Antianginal Drugs ▪ Improve blood delivery to the heart muscle by dilating blood vessels ▪ Increase the supply of oxygen ▪ Improve blood delivery to the heart muscle by decreasing the work of the heart ▪ Decrease the demand for oxygen Nitroglycerin (Nice to know, not need to know for block I) ▪ Side effects ▪ ▪ ▪ ▪ ▪ N/V Dizziness Flush Pallor HA ▪ Adverse Reactions ▪ Hypotension ▪ Tachycardia ▪ Circulatory collapse Nitrate: nitroglycerin (Nitro-Dur, Nitrostat) (Pg 765-766) (Nice to know not need to know for block I) ▪ Therapeutic Effects/Uses ▪ Control angina pectoris ▪ Acute MI ▪ Management of CHF Nitrate: Nitroglycerin (Nice to know not need to know for Block I) ▪ Nursing Implications ▪ Assessment ▪ VS ▪ Pain assessment ▪ Nursing Diagnoses ▪ Decreased cardiac output ▪ Anxiety ▪ Acute Pain Nitrate: Nitroglycerin (Nice to know not need to know for block I) ▪ Nursing Interventions ▪ ▪ ▪ ▪ ▪ ▪ Monitor VS: Q5 min Positioning? Ointment: Do not use fingers Where to place transdermal application? On 12 hours/Off 12 hours Teaching ▪ How to self administer SL nitroglycerin? ▪ Storing NTG ▪ Avoid alcohol ▪ Self administration of transdermal patch. Prototype Potassium-Sparing Diuretic: Spironolactone (Aldactone) (Pg. 686) ▪ Therapeutic Effects/Uses ▪ Counteract K+ loss with other diuretics ▪ Edema & Hypertension ▪ When combined with other diuretics Prototype Potassium-Sparing Diuretic: Spironolactone (Aldactone) Mode of Action ▪ Promote Na+ and H2O excretion and K+ retention in the collecting duct renal tubules. ▪ Blocks action of aldosterone Prototype Potassium-Sparing Diuretic: Spironolactone (Aldactone) ▪ Side Effects ▪ ▪ ▪ ▪ Dizziness Clumsiness HA Constipation ▪ Adverse Reactions ▪ Hyperkalemia ▪ Arrhythmias Prototype Potassium-Sparing Diuretic: Spironolactone (Aldactone) ▪ Nursing Interventions ▪ ▪ ▪ ▪ ▪ Monitor UO Monitor VS Monitor for s/s of hyperkalemia When to administer? Teaching ▪ When to take at home? ▪ High Potassium Foods Thiazide diuretics: Prototype hydrochlorothiazide (HCTZ) – Microzide (Pg. 686) ▪ Mechanism of action: ▪ Inhibits H2O, Na+, Cl- reabsorption ▪ Used in conjunction with other antihypertensives to ↓BP ▪ Diuresis occurs and K+ Mg+ lost Common Cardiac Related Medications cont.(Pg 685-686) ▪ Prototype: Furosemide (Lasix) ▪ Loop Diuretic ▪ Inhibits Na+ & H20 reabsorption in renal tubules ▪ Decreased Na+ reabsorption → ▪ Increased Na+ excretion through the kidneys→ ▪ Increased H20 excretion through the kidneys (H20 usually follows Na+) ▪ Decreased reabsorption of other electrolytes is also common with use of diuretics (K+) ▪ Main Uses: ▪ Decrease edema ▪ Decrease HTN (indirectly) ▪ Potassium “wasting” vs. “sparing” ▪ For further knowledge: Refer to ATIPharmacology Made Easy- Drug Therapy for Heart Failure- Loop Diuretics Common Cardiac Related Medications Continued ▪ Potassium Supplements (Potassium acetate) ▪ Treats potassium depletion (in the use of potassium wasting diuretics, ACE inhibitors, or angiotensin II antagonists) p.o. route ▪ Tablets are very large: assess swallowing ability ▪ Treats hypokalemia (usually I.V. route: slowly and carefully!) Nursing Diagnoses for HF ▪ Activity Intolerance ▪ Excess Fluid Volume ▪ Impaired Gas Exchange ▪ Anxiety ▪ Deficient Knowledge 41 DRUGS FOR HYPERTENSION Pg 715-716 – Chart 36-1 Hypertension (>60 y.o. BP>150/90 <60 y.o. BP>140/90) JNC 8 Guidelines for HTN http://www.aafp.org/afp/2014/1001/p449.html Essential Secondary ▪ Results in damage to vital organs ▪ Common causes ▪ Causes medial hyperplasia (thickening) of arterioles ▪ Common risk factors ▪ ▪ ▪ ▪ Obesity Smoking Stress Family history ▪ Table 36-4/Pg 710 ▪ Renal disease ▪ Primary aldosteronism ▪ Pheochromocytoma ▪ Cushing’s syndrome ▪ Medications ▪ Table 36-4/Pg 710 Hypertension Pg 709 Assessment Life Style Changes ▪ Patient history ▪ Sodium restriction ▪ Physical assessment ▪ Weight reduction ▪ Psychological assessment ▪ Diagnostic assessment ▪ Reduce alcohol intake ▪ Exercise ▪ Decrease stress levels ▪ Avoid smoking Prototype: metoprolol (Lopressor) ▪ Beta-Adrenergic Blockers ▪ ↓ vascular resistance → ↓ BP ▪ Monitor for orthostatic hypotension ▪ Check pulse daily ▪ Can cause fatigue, depression, sexual dysfunction Beta Adrenergic Blockers ▪ Reduce cardiac output (CO) => decreased vascular resistance => decreased BP ▪ Decrease renin release ▪ Less effective in African Americans ▪ Non-selective vs cardioselective beta blockers ▪ “OLOL” Prototype Beta-Adrenergic Blocker: Metoprolol (Lopressor) ▪ Therapeutic Effect/Uses ▪ ▪ ▪ ▪ ▪ HTN Angina Prevent MI Decrease mortality in pts. with recent MI Ventricular arrhythmias ▪ Mode of Action ▪ Cardioselective blockade of B1 adrenergic receptors. Prototype Beta-Adrenergic Blocker: Metoprolol (Lopressor) ▪ Contraindications ▪ ▪ ▪ ▪ Uncompensated CHF Bradycardia or heart block Pulmonary edema Cardiogenic shock Prototype Beta-Adrenergic Blocker: Metoprolol (Lopressor) ▪ Side Effects ▪ ▪ ▪ ▪ ▪ N/V/D Dizziness Fatigue Weakness Impotence ▪ Adverse Reaction ▪ Bradycardia ▪ Complete heart block ▪ Bronchospasm Prototype Beta-Adrenergic Blocker: Metoprolol (Lopressor) ▪ Nursing Interventions ▪ Monitor VS ▪ Monitor BUN ▪ Teaching ▪ ▪ ▪ ▪ Do not abruptly stop taking medication OTC: check with MD first How to take pulse and BP Orthostatic hypotension teaching Vasodilator – Prototype: hydralazine (Apresoline) Skyscape /ATI ▪ Hydralazine (Apresoline) ▪ Hypertensive emergency/urgency ▪ Peripheral vasodilator: ↓ BP and ↑HR, stroke volume, cardiac output Prototype-Lisinopril (Zestril) ▪ Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors) ▪ Inhibits formation of angiotensin II (vasoconstrictor) → ↓BP ▪ Lose Na+ and H2O → ↓BP ▪ Monitor BP carefully: √ for orthostatic hypotension Antihypertensives: ACE Inhibitors ▪“PRIL” ▪ These drugs inhibit ACE ▪ ACE converts Angiotension I to Angiotension II ▪ They also block the release of Aldosterone Prototype ACE Inhibitor: lisinopril (Zestril) ▪ Therapeutic Effect/Use ▪ ▪ ▪ ▪ HTN CHF Reduction of risk of death or development of CHF post-MI Decreases progression of diabetic nephropathy Prototype ACE Inhibitor: lisinopril (Zestril) Mode of Action ▪ Block ACE from converting angiotensin I to angiotensin II, leading to a decrease in blood pressure, a decrease in aldosterone production, and a small increase in serum potassium levels along with sodium and fluid loss Prototype ACE Inhibitor: lisinopril (Zestril) ▪ Side Effects ▪ N/V/D ▪ HA ▪ Dizziness ▪ Adverse Reactions ▪ ▪ ▪ ▪ COUGH Hyperkalemia Hypotension Angioedema Report nagging cough to prescriber Prototype ACE Inhibitor: lisinopril (Zestril) ▪ Nursing Interventions ▪ VS ▪ UO ▪ Teaching ▪ ▪ ▪ ▪ Do not abruptly stop taking the medication Teach how to take own BP Dizziness may be present during 1st week Take 20 min to 1 hour before meals Antihypertensives: ARBs (Angiotension II Receptor Blockers) ▪ “Sartan” ▪ Block Angiotension II from receptors in the tissue. ▪ Blocks angiotensin II at the receptors in vascular smooth muscle → ↓ BP ▪ Prevent release of Aldosterone Prototype ARB: Losartan (Cozaar) (Nice to know, not need to know for Block I) ▪ Therapeutic Effect/Use ▪ HTN ▪ CHF ▪ Type II Diabetic Nephropathy ▪ Less cough than ACEI Prototype CCB: diltiazem (Cardizem) ATI ▪ Ca++ = increases contractility, peripheral resistance, and blood pressure ▪ Calcium Channel Blockers ▪ Interferes with calcium ions → vasodilation → ↓BP ▪ Slows calcium channels found in the myocardium ▪ Slows heart conduction→ Monitor BP & P daily ▪ Ca++ = increases contractility, peripheral resistance, and blood pressure ▪ “dipine” except Verapamil & Diltiazem Prototype CCB: diltiazem (Cardizem) ▪ Therapeutic Effects/Uses ▪ HTN ▪ Angina (Chest Pain) ▪ Dysrhythmias (irregular rhythms) ▪ SVT (supraventricular tachycardia) ▪ A-fib ▪ A-flutter ▪ Mode of action: ▪ Inhibits transport of Ca++ into myocardial and vascular smooth muscle cells Prototype Calcium Channel Blocker: diltiazem (Cardizem) ▪ Contraindications ▪ ▪ ▪ ▪ Hypersensitivity SSS-sick sinus syndrome (not a need to know for block I) 2nd or 3rd degree AV block (not a need to know for block I) BP < 90mmHG Prototype Calcium Channel Blocker: diltiazem (Cardizem) ▪ Side Effects ▪ Dizziness ▪ Peripheral edema ▪ Adverse Reactions ▪ CHF ▪ Dysrhythmias/Arrhythmias Prototype Calcium Channel Blocker: diltiazem (Cardizem) ▪ Drug-Lab-Food Interactions ▪ Drugs ▪ Increased hypotension with other anti-hypertensives ▪ Increased bradycardia with beta-blockers or digoxin ▪ Food ▪ Increased drugs effects with grapefruit juice Prototype Calcium Channel Blocker: diltiazem (Cardizem) ▪ Nursing Interventions ▪ May administer with food if GI upset ▪ DO NOT open or crush SR capsules ▪ Teaching ▪ ▪ ▪ ▪ Take same time each day How to take and monitor BP & pulse Chest Pain teaching Avoid foods high in K+ Anticoagulants ▪ aspirin (ASA) (Chart 38-4) ▪ ▪ ▪ ▪ NSAID Blocks pain impulses in CNS Reduces Inflammation Prophylaxis for MI, stroke, angina ▪ Anti-platelet action ▪ Can cause GI bleeding ▪ Not for use in children (Reye’s syndrome) (ASA is not on med list for block one but important drug to know) ▪ Subcut heparin/enoxaparin (Lovenox) (chart 32-4) ▪ Anticoagulant injection ▪ Binds to antithrombin II factors ▪ Prevents DVT, PE post surgery, acute MI, unstable angina ▪ Bleeding complications Anticoagulant Prototype: Heparin (Chart 324) ▪ Nursing Interventions ▪ ▪ ▪ ▪ Monitor VS Monitor PTT Monitor platelet count Monitor for bleeding ▪ Mouth, urine, stool… ▪ Antidote? ▪ Teaching ▪ ▪ ▪ ▪ ▪ ▪ Notify MD or DDS Soft toothbrush Electric razor Lab tests: PTT Medical ID bracelet OTC drugs ▪ ASA ▪ External hemorrhage 67 Anticoagulants continued ▪ warfarin (Coumadin) (chart 32-4) ▪ Anticoagulant ▪ Depresses synthesis of vitamin K (factors II, VVII, IX, X) ▪ DVT, MI, CVA prophylaxis, post MI ▪ A-fib embolism prevention ▪ Lab values PT & INR ▪ Bleeding complications Oral Anticoagulant Prototype: Warfarin (Coumadin) ▪ Nursing Interventions ▪ Monitor PT/INR ▪ Depends on your patient ▪ KNOW YOUR patient ▪ Administer at same time each day. ▪ Initially may be given with Heparin/enoxaparin (bridge) ▪ Teaching ▪ Take as prescribed, do not double dose ▪ Food teaching ▪ Bleeding precautions ▪ OTC medications ▪ Medical ID bracelet ▪ How long to be effective? ▪ Antidote? 69 Anti-platelet ▪ clopidogrel (Plavix) Chart 38-4 ▪ Platelet aggregation Inhibitor ▪ Reduces risk of stroke, MI, TIA’s vascular death, PAD ▪ Weekly platelet count labs ▪ Can cause bleeding The End
