Ch 47 Drugs For Heart Failure

Front 1

What are considered the initial phases of HF?

As a result of these changes what is reduced?

Back 1

• The initial phase of HF consists of cardiac remodeling—a process in which the ventricles dilate (grow larger), hypertrophy (increase in wall thickness), and become more spherical—coupled with cardiac fibrosis and myocyte death.

As a result of these changes, cardiac output is reduced.

Front 2

Reduced Cardiac Output leads to these four things

Back 2

Reduced cardiac output leads to (1) cardiac dilation
(2) increased sympathetic tone,
(3) retention of water, and
(4) expansion of blood volume. As a result of volume expansion, cardiac dilation increases.

Front 3

In response to stretching of the atria and dilation of the ventricles, the heart releases two natriuretic peptides:

Back 3

atrial natriuretic peptide (ANP) and
B-natriuretic peptide (BNP).

Front 4

Measuring a _____ tells us about the extent of heart failure, and can be helpful to assess the success of therapy as levels fall.

Back 4

BNP (B-natriuretic peptide)

Front 5

Treatment of heart failure with a synthetic form of natriuretic peptide, like nesiritide (Natrecor) will ____ veins causing what two things to happen

Back 5

Natrecor will result in a reduction in both preload and afterload through the action of dilating arterioles and veins.

precaution needs to be taken with a patient becasue there is increased risk of hypotension

Front 6

The only way that Natrecor can be given is via _____?

Back 6

IV

Front 7

Treatment with cardiotoxic drugs (eg,_______ , _______) combined with hypertension and diabetes correlates with a high risk of the development of heart failure.

Back 7

doxorubicin trastuzumab

Front 8

If the _______ ________ are not sufficient to maintain adequate production of urine, body water will continue to accumulate, eventually causing death (from complete cardiac failure secondary to and cardiac edema).

Back 8

compensatory responses

Front 9

What are the three drugs used for heart failure (HF)?

Back 9

There are three major groups of drugs for heart failure: diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs),
and beta blockers. Cardiac glycosides (eg, digoxin), which had been used widely in the past, may be added as indicated.

Front 10

First line therapy for heart failure now consists of three drugs, what are they?

Back 10

a diuretic, an ACE Inhibitor or angiotensin-receptor blocker (ARB), and a beta blocker.

Front 11

Thiazide diuretics are ineffective when _______ is low and hence cannot be used if cardiac output is greatly ______.

Back 11

glomerular filtration rate (GFR)

reduced

Front 12

Instesad of using Thiazide diuretics when GFR is low what type of diuretic should be used?
Which drug in particular is favored?

Back 12

Loop diuretic (Furosemide)

Front 13

• Thiazide diuretics and loop diuretics can cause h____kalemia and can thereby increase the risk of _______-induced dysrhythmias.

Back 13

hypodigoxin

digoxin

Front 14

______ _____ _____ are used to counteract potassium loss caused by thiazide diuretics and loop diuretics.

Additionally they can cuase hyperkalemia.

Back 14

Potassium-sparing diuretics
such as Sprironalactone (Aldactone)

Front 15

Potassium sparing diuretics (e.g. Spironalactone (Aldactone)) have been demonstrated to prolong survival and improve symptoms of heart failure primarily by blocking receptors for _______. Spironolactone causes minimal diuresis, but with heart failure, the priority action that assists in preventing worsening heart failure is the blocking of _______.

Back 15

aldosterone

aldosterone

Front 16

Side effects of ACE inhibitors include:?

Back 16

hypotension, hyperkalemia, cough, angioedema, and birth defects.

One of the principal side effects is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II.

Patients taking ACE Inhibitors need to be monitored for hyperkalemia.

Front 17

Overall, ACE Inhibitors have a long-term positive effect, because they cause increased release of _____; this improves cardiac remodeling, which has been shown to reduce mortality with heart failure.

Also, inhibition of ______ __ for any length of time has a positive effect on cardiovascular health.

Back 17

kinin

angiotensin II

There is no concrete evidence that ACE Inhibitors have a long-term effect regarding a positive or negative impact on cardiovascular and/or renal function; although evidence indicates that ACE Inhibitors do have a significant positive effect on patients diagnosed with heart failure.

Front 18

beta blockers can improve patient status by ?

Back 18

improving LV ejection fraction, increasing exercise tolerance, slowing progression of HF, reducing the need for hospitalization, and, most importantly, prolonging survival.

Front 19

AE's of beta blcokers (4)?

Back 19

Adverse effects of these agents include
(1) fluid retention and worsening of HF
(2) fatigue
(3) hypotension, and
(4) bradycardia or heart block.

Front 20

What should the patient on a beta blocker be monitored for?

Back 20

Dizziness due to the hypotension

monitor heart block and bradycardia as well.

Front 21

Why are Digoxin and the other cardiac glycosides used in tx of heart failure?

Back 21

best known for their positive inotropic actions, that is, their ability to increase myocardial contractile force

Front 22

Isosorbide dinitrate, a cardiac glycoside (which dilates veins) plus hydralazine (which dilates arterioles) can be used in place of an ACE inhibitor if an ACE inhibitor cannot be used.

Back 22

ACE inhibitor

Front 23

BiDil, a fixed-dose combination of ______ and ________ , is approved specifically for treating HF in African Americans.

Back 23

hydralazine

isosorbide dinitrate

Front 24

• Digoxin increases contractility by inhibiting myocardial Na+,K+-ATPase, thereby (indirectly) increasing intracellular calcium, which in turn facilitates the interaction of actin and myosin. Outcomes that can be expected with administration of digoxin are?(3)


Digoxin does not increase the heart rate or blood pressure.

Back 24

decreased heart rate, a slowed cardiac conduction speed, and strengthened cardiac contractions

Front 25

________ competes with digoxin for binding to Na+,K+-ATPase. Hence, if _______ levels are low, excessive _______ of Na+,K+-ATPase can occur, resulting in toxicity. Conversely, if ______ levels are high, insufficient inhibition can occur, resulting in loss of therapeutic effects.

Back 25

Potassium

Potassium

inhibition

Front 26

By increasing cardiac output, digoxin can reverse all of the overt manifestations of HF:

Can it prolong life?

Back 26

cardiac output improves, heart rate decreases, heart size declines, constriction of arterioles and veins decreases, water retention reverses, blood volume declines, peripheral and pulmonary edema decreases, weight is lost (owing to water loss), and exercise tolerance improves.

no

Front 27

• In patients with HF, benefits of digoxin are not due solely to improved cardiac output: ________effects are important too.

Back 27

Neurohormonal

Front 28

What is the most serious AE of digoxin?

Back 28

dysrythmias

Front 29

The most common reason for digoxin-related dysrhythmias is what?

Back 29

diuretic-induced hypokalemia

Front 30

If Digoxin levels are too high and Dysrythmias are too serious what drug can be administered as an antidote?

Back 30

Fab anitbind fragments (Digibind)

Front 31

Digoxin in addition to dysrythmias can cause __ and ___ effects often precede dysrhythmias and therefore can provide advance warning of serious toxicity.

Back 31

GI and CNS

Front 32

See yellow halos around lights indicates what?

What should be monitored afte this is reported?

Back 32

Digoxin toxicity

nausea, vomiting, headache

Front 33

Digoxin has a ______ theapeutic range

Back 33

narrow

Front 34

When a patient is on Digoxin it is not necessary to constantly monitor the patient however _____ ______ _______ are needed to monitor electrolyte balance adn renal function.

Back 34

routine chemistry profiles

Front 35

Maintenance doses of digoxin are based primarily on observation of the patient:
How do you dose for Digoxin?

When Digoxin is first prescribed for a patient, they should be told that it may take ____ to ____ months for the Dig to exert its full effects.

Back 35

Doses should be large enough to minimize symptoms of HF but not so large as to cause adverse effects.

1 to 3

Front 36

Whenever Digoxin is to be administered, check to make sure that the patient’s dig level is within normal range, and check the patient’s apical pulse to make sure it is also within a safe range

Back 36

0.5 to 0.8 mEq/mL

(60-100 bpm).

Front 37

When digoxin is giveN IV, cardiac status should be monitored continuously for ___ TO ____ hrs. (pts should be on a telemetry floor or in a monitored bed).

Back 37

1 to 2 hours