Pharmacology for Heart Failure & Angina

Causes of Heart Failure

- Coronary Artery Disease (CAD) _ Cardiomyopathy - Hypertension -valvular heart disease - any conditions that causes chronic burden on the heart

Nitrates A/E:

- R/t vasodilation and decreased blood flow -CNS: headache, dizziness, weakness GI: Nausea, vomiting CV: hypotension Misc: Flushing, pallor and increased perspiration Drug-Drug: Ergot Derivatives, Heparin

What does the heart do to fix HF

- enlarges overtime from stretching to contract more strongly and pump more blood - Heart muscle Mass increases (cardiomegaly) _ blood vessels narrow to increase blood pressure (atherosclerosis and htn) -Pumps faster to increase output (tachycardia) - Body diverts blood from less important organs(like kidneys) to heart and brain

Cardiac Glycosides

- increase the force of myocardial contraction, cardiac output, renal perfusion, renal output, and decreases blood volume to slow heart rate and conduction velocity through the AV node.

Beta Blockers CI:

-Bradycardia -Heart block -Cardiogenic shock -Asthma or COPD -Pregnancy of Breastfeeding Caution: DM, PVD, Thyrotoxicosis

Adverse Effects of Cardiac Glycosides

-Dizzy, headache, weakness, drowsiness, and vision changes (blurred or yellow (xanthopsia) ) - GI upset and anorexia - Arrythmia development (both fast, slow, and irregular)

Common causes of Decompensated Heart Failure

-Excessive salt or water intake -medications -Arrythmias (heart beats too fast, too slow, or irregularly) -Fever and infections -Alcohol consumption -pregnancy

Cardiac Glycosides CI/caution

-allergy -V Tach or V Fib, Heart block or Sick Sinus Syndrome -Idiopathic hypertrophic subaortic stenosis -Acute MI, renal insufficiency, electrolyte abnormalities (mag, K, Ca) -Pregnancy and lactation -Pediatric & Geriatric patients

Nitrate CI:

-allergy -severe anemia -head trauma, cerebral hemorrhage -pregnancy, breastfeeding Caution: hepatic or renal disease, hypotension, hypovolemia, conditions that limit cardiac output

Phosphodiesterase Inhibitors A/E:

-arrythmias -hypotension -nausea, vomiting -thrombocytopenia -pericarditis -pleuritis -fever -chest pain -irritation/burning at injection site

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blockers A/E:

-bradycardia -HTN - Atrial fibrillation -Luminous phenomena (visual changes) -Drug/Drug interaction with: CYP3A4 inhibitors or inducers and negative chronotropic drugs

Phosphodiesterase Inhibitors types

-cardiotonic Inotropic Agents -Inamrinone (Incor) -Mirinone (Primacor)

Treatments of HF

-lifestyle management + meds+ monitoring

CAD (coronary artery disease)

-usual cause of angina -CAD is the leading cause of death in the U.S.

What is Heart Failure

A chronic condition where the heart is unable to pump enough blood to meet the demands of the body.

Beta Blockers

Block the stimulatory effects of the SNS. Block beta-adrenergic receptors in heart and kidneys; decreases the influence of the SNS on the heart and kidneys; decreases cardiac output and release of renin.

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blockers action:

Blocking the HCN slows sinus node in repolarizing phase of the action potential. Absorbed in GI tract, reaches peak level in 1 hour, it is metabolized in the liver and intestines. Excreted in feces and bile. Approved in 2015 for treatment of CHF.

_____________ are widely absorbed and distributed throughout body, excreted in urine

Cardiac Glycosides

Example of Cardiac Glycosides

Digoxin (Lanoxin)

Digoxin Toxicity Tx:

Digoxin Immune fab is taken for overdose.

Piperazine Acetamide Agent (Ranolazine (Ranexa) is an oral _______-release tablet

Extended

The primary treatment for congestive heart failure is to make the heartbeat harder and faster?

False. primary is to increase muscle contractility, bringing the system back into balance.

Beta Blockers are absorbed in ______

GI tract, metabolized in liver and excreted in the urine.

Nitroglycerin A/E:

Hypotension, headache, dizziness, tachycardia, rash, flushing, nausea, vomiting, sweating, chest pain

Nitroglycerin routes

IV Sublingual Translingual Spray Transmucosal Tablet Oral, SR Tablet Topical Ointment Transdermal

How does Cardiac Glycosides work?

Increases intracellular calcium, allows more calcium to enter the myocardial cell during depolarization; positive inotropic effect, increased renal perfusion and diuretic effect and decrease in renin release, and slowed conduction through the AV node.

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blockers Example:

Ivabradine (Corlanor) affects pacemaker of heart without affecting muscular contraction

Piperazine Acetamide Agent (Ranolazine (Ranexa) drug-drug interactions

Ketoconazole, Diltiazem, Verapamil, Macrolide abx, HIV protease Inhibitors, Digoxin, TCAs and antipsychotics

Signs/Symptoms Digoxin Toxicity

Nausea, vomiting, anorexia, neurological changes, and arrythmias

Beta Blockers A/E:

R/T blockage of SNS CNS: dizziness, fatigue, emotional depression GI: N, V, colitis CV: CHF, decreased cardiac output, arrhythmias. RESP: Bronchospasm, dyspnea, cough Drug-Drug: clonidine, NSAIDS

Mirinone (Primacor)

Short-term management of HF in patients who are receiving digoxin and diuretics.

Signs and symptoms of HF

Swelling, weight gain, SOB, lightheaded, fatigue, dizziness, confusion, depression, fainting, nausea or lack of appetite

Nitrates

act on smooth muscle to cause relaxation and depress muscle tone. Prevent and tx of angina pectoris. Metabolized in liver. Excreted in urine>

Antianginal agents

aim to restore appropriate supply-demand ration in O2 delivery to heart in 2 ways: -dilate blood vessels -decrease the work of the heart

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blockers CI:

allergy decompensated HF; hypotension, sick sinus syndrome of AV block, resting heart rate under 60 bpm (bradycardia), patient completely dependent on pacemaker; severe hepatic impairment

Phosphodiesterase Inhibitors C/I:

allergy, severe aortic and pulmonic disease, MI, fluid volume deficit, ventricular arrythmias

Inamrinone (Inocor)

approved for use in patient with HF that has not responded to digoxin, diuretics or vasodilators.

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blockers caution:

atrial fibrillation, moderate heart block

Action of Cardiotonic Inotropic Agents

blocks the phosphodiesterase enzyme, leads to increase in myocardial cell cyclic adenosine monophosphate (cAMP), which increases calcium levels in the cell, causing stronger contraction and prolonged response to sympathetic stimulation; directly relaxes vascular smooth muscle.

Drugs used to treat heart failure

cardiotonic(inotropic) HCN Blockers Nitrate vasodilators Adrenergic blockers Human-B type natriuretic peptides Diuretics

Prinzmetal Angina

caused by spasm of blood vessel + vessel narrowing. Usually, a daily event and ECG changes associated.

Angina pectoris

chest pain from when the supply for O2 for the heart muscle does not meet the demand.

Piperazine Acetamide Agent (Ranolazine (Ranexa) A/E:

dizziness, headache, nausea, constipation

Nitroglycerin

fastest onset is IV or Transmucosal Tab (1-2 min), Translingual Spray (2 min) and Sublinguinal Tab (1-3 min)

Substance P

is released from the ischemic myocardial cells and when it reacts with pain receptors, pain is felt. Pain often in chest, can be jaw, teeth, left arm.

Piperazine Acetamide Agent (Ranolazine (Ranexa) C/I:

known sensitivity, hepatic impairment, breastfeeding. Caution with pregnancy and renal impairment

Digoxin Toxicity

life-threatening Arrythmias + Hyperkalemia

Primary treatment of heart failure:

lifestyle management to minimize factors that worsen HF + medications that allow the heart to contract more efficiently.

Phosphodiesterase Inhibitors is metabolized in ________ and excreted in _______

liver & urine

Atherosclerosis

narrowing of the heart vessels by atheromas (fatty tumors) that line the vessels.

MI (myocardial infarction)

near or complete occlusion in coronary vessel causing area of heart muscle to become necrotic. Excruciating pain, nausea, severe SNS stress reaction.

3 types of antianginal drugs

nitrates, beta blockers, calcium channel blockers

Stable Angina

no damage to heart muscle, activity is stopped, blood restored. Can become chronic angina and not lead to an MI for a long time, but limiting on QOL.

Phosphodiesterase Inhibitors cautions:

pregnancy, lactation, elderly

Phosphodiesterase Inhibitors indications

short-term treatment of HF in patients unresponsive to digoxin, diuretics, or vasodilators

Beta Blockers indications

stable angina pectoris, HTN, stable CHF, prevents reinfarction after MI

Unstable Angina

with more narrowing of arteries, the ischeumia episodes can occur at rest. Increased risk for complete blockage.

cardiotonic (inotropic) drugs

work to increase the force of cardiac muscle contraction. -Cardiac glycosides -Phosphodiesterase inhibitors

Calcium Channel Blockers C/I:

•Allergy •Heart Block of Sick Sinus Syndrome •Renal or Hepatic Dysfunction •Pregnancy or Breastfeeding

Calcium Channel Blockers examples

•Amlodipine (Norvasc), Diltiazem (Cardizem), Nicardipine (Cardene), Nifedipine (Procardia), Verapamil (Calan)

Piperazine Acetamide Agent (Ranolazine (Ranexa)

•Effective in treating angina and has added benefits of decreasing blood glucose levels in diabetic patients and decreasing incidence of ventricular fibrillation, atrial fibrillation, and bradycardia in chronic angina patients. Usually paired with other meds like ACE-I, ARBs, CCBs, Beta Blockers, Nitrates, Anti-Platelet, Lipid-lowering)

Calcium Channel Blockers A/E:

•Hypotension •Cardiac Arrhythmias •GI Upset •Skin reactions •Headache •Drug-Drug: Cyclosporine, Digoxin, Vary with each drug

Calcium Channel Blockers

•Inhibit the movement of calcium ions across the membranes of myocardial and arterial muscle cells, altering the action potential and blocking the muscle cell contraction

Calcium Channel Blockers indications

•Prinzmetal Angina, HTN, Arrhythmias

Ex of Nitrate:

Amyl nitrate, Isosorbide dinitrate (Isordil), Isosorbide mononitrate (Monoket), Nitroglycerin (Nitro-Bid, Nitrostat)

Beta Blockers example

Atenolol (Tenormin), Metoprolol (toprol XL), Propranolol (inderal), Nadaolol (Corgard)

The nurse is caring for a patient in the ER who has presented with signs and symptoms of an acute MI. While making an initial assessment the nurse notes the patient has had an adverse reaction to digoxin and a history of congestive heart failure. Which of the following orders would be concerning for this patient?

B. Milrinone (Primacor)