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Pharmacology Exam 3 Study Guide.
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Pharmacology Exam 3 Study GuideCompensated Heart Failure
-home/stable/chronic/controlled
-Medications designed to prevent worsening
-Target RAAS, SNS
•Decompensated Heart Failure (heart failure exacerbation)
-acute/hospitalization/uncontrolled
-Diuretics
-Vasodilators (dilate arteries)
•+ Inotropic Support
-Kidneys>Heart - correct answer-Drug therapy in heart failure
INOTROPIC
•Contractility
•Cardiac Muscle
•+ increase the FORCE of myocardial contraction (STRENGTH)
•- decrease the force
•CHRONOTROPIC
•Heart rate
•SA Node
•+ increase the RATE of the heart beat
•- decrease the RATE of the heart beat
•DROMOTROPIC
•Conduction Velocity
•AV node ,bundle of His, Purkinje Fibers
•+ increases CONDUCTION of electrical impulses
- decreases CONDUCTION of electrical impulses
Note: Heart failure patients should weigh in daily!
◦If 2 lb weight gain in 1 day OR 5 lb in 1 week, need to notify provider (developing fluid
overload) - correct answer-Heart failure definitions
Used to treat:
◦1) Heart Failure (negative chronotropic)
◦2) Atrial Fibrillation (negative dromotropic, negative chronotropic)
-Adverse effects:
◦Due to Digoxin + Potassium competing, we must have normal potassium levels
(magnesium and calcium too)!
◦Dig Tox= Hypokalemia, Hypomagnesemia, HYPERcalcemia
TOXICITY EFFECTS (usually suggesting toxicity)
◦Heart Related-
,◦Dysrhythmias!
◦Bradycardia or another dysrhythmia
◦Can also see hyperkalemia due to toxicity
◦GI related-
◦Anorexia (loss of appetite ---> weight loss), Nausea, Vomiting
◦CNS related-
Fatigue, Confusion
◦Vision disturbances- yellow tint, "Halos", blurred vision•
What can cause toxicity?◦hypokalemia, hypomagnesemia, hypercalcemia
◦Digoxin Normal range (narrow therapeutic drug)= 0.5 -2 ng/ml
HOW TO TREAT TOXICITY?
◦What if we see EKG changes or symptomatic?-
Check a digoxin level
◦ANTIDOTE-
Digibind ®- Digoxin specific A - correct answer-Digoxin
P - phenytoin
S - Smoking
P - phenobarbital
O - Oxcarbazepine
R - rifampin
C -carbamazepine
S - St. John's Wort (OTC herb) - correct answer-Inducers: PS - PORCS
P - protease inhibitor (HIV)
A - azole antifungal (fluconazole,ketoconazole)
C - cimetidine
M - macrolides (Azithromycin ACE?)
A - amiodarone
N - non-DHP Calcium Channel Blockers (diltiazem, verapamil)
♥'s
Grapefruit juice - correct answer-Inhibitors: PACMAN loves Grapefruit juice!
Cardiac Glycoside
-Digoxin
◦Vasodilator
-BiDil® (hydralazine+isosorbide)
◦Angiotensin Receptor- Neprilysin Inhibitor (ARNI)- Sacubitril + Valsartan
◦ Inodilator
-Milrinone
•VASOPRESSORS/SHOCK
-Dopamine
-Dobutamine
-Phenylephrine
-Isoproterenol
,-Norepinephrine
-Epinephrine - correct answer-Heart Failure (HF) drugs
In general, heart failure patients should weight in daily! If 2 lb. weight gain in 1 day OR 5 lb.
in 1 week, NEED TO NOTIFY PROVIDER (fluid overload development)
Goals for treatment:
1) If fluid overloaded- remove excess fluid (loop diuretics such as furosemide)
2) Increase cardiac output to reduce end organ dysfunction
◦Inodilator:
◦Milrinone
◦Inotropic Support:
◦Dobutamine/Dopamine - correct answer-Heart failure exacerbation
Used:
◦PDE3- CHF
◦MILRINONE:
◦Severe, decompensated HF (late stages, palliative care)/heart failure exacerbation
◦Bridge to await a heart transplant
◦Palliative therapy
◦GOAL: To increase cardiac output and reduce end-organ dysfunction
-Mechanism:
"Inodilator"- VASODILATOR AND POSITIVE INOTROPIC AGENT (lowers BP, Increases
CO)
-Adverse effects:
◦dysrhythmias (ventricular)
◦Hypotension
CONTRA-INDICATIONS:
◦Can't use if MI or dysrhythmia
-Nursing considerations:
Nurses should assess blood pressure periodically
Nurses should monitor EKG for abnormalities
-Administration: IV continuous drip, check EKG, assess vitals - correct
answer-Phosphodiesterase 3 Inhibitor: Milrinone (inotropic agent)
Used to treat:
-Heart failure/shock! (late stages)
◦Hemodynamic Support
◦Inotropic Support for Heart Failure
-Adverse effects:
◦Alpha 1- Hypertension
◦Beta 1-Too much demand on heart (tachycardia, dysrhythmias, ischemic damage)- EKG
, IV infusion- risk of infiltration/extravasation- SERIOUS DAMAGE! (Antidote: Phentolamine)
Intended outcomes:
Depending on indication what is our goal?
LOW Dose- increased urine output! (DA/dopamine= renal perfusion, oxygenate kidneys ---->
inc. urine output)
MODERATE Dose- increased Cardiac Output (DA and Beta 1)
HIGH Dose- Improved BP (DA + Beta 1 + Alpha 1)
NURSING CONSIDERATIONS:
◦DA- urine output, improvement of the AKI/ARF (SCr/BUN down)
◦Beta- inotropic support
◦Alpha- BP - correct answer-Dopamine
Manifested by agitation, twitching, hyperactive reflexes, nausea, vomiting, and ECG changes
- correct answer-Hypomagnesemia
-Nonadherence with medication regimen, sodium and/or fluid restriction
-Acute myocardial ischemia
-Uncorrected high blood pressure
-AF and other arrhythmias
-Recent addition of negative inotropic drugs (e.g.,verapamil, diltiazem, beta blockers)
-Pulmonary embolus
-Initiation of drugs that increase salt retention (e.g.,steroids, thiazolidinediones, NSAIDs)
-Excessive alcohol or illicit drug use
-Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)
-Concurrent infections (e.g., pneumonia, viral illnesses)
-Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis,
aortic dissection) - correct answer-Common Factors That Precipitate Acute Decompensated
HF
Milrinone
Dopamine
Dobutamine - correct answer-Heart Failure: Positive Inotropic Agents
Manifested by muscle weakness, confusion, lethargy, anorexia, nausea, and changes in the
ECG - correct answer-Hypokalemia
1) POSITIVE INOTROPIC activity- Blocking the Na+/K+ ATPase pump (treats HF by helping
heart pump more blood out to the rest of the body, such as kidneys)
2)NEGATIVE CHRONOTROPIC activity- Digoxin has been found to be
parasympathomimetic (causes vagal stimulation) and also increases baroreceptor sensitivity
(treats atrial fibrillation by slowing heart beat down)
3) NEGATIVE DROMOTROPIC activity- Cholinergic activation in atria (AV node), less at
Purkinje (treats Atrial fibrillation by slowing down any crazy rhythms)
RESULT?- Improved Cardiac Output and Increased Renal Perfusion= Increased Urine
Production and decreased RAAS activation - correct answer-Digoxin mechanism of action
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