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Looks like there are several drugs to keep me going. I just love variety!
Pharmacologic management of left ventricular systolic dysfunction (LVSD) is standard and evidence-based, prescribed based on the patients stage of heart failure (HF). Lets take a closer look.
ACE inhibitors
Angiotensin-converting enzyme (ACE) inhibitors are the gold standard for treating HF. This class of medication lessens neurohormonal responses and prevents the conversion of angiotensin I to angiotensin II. ACE inhibitors also ofoad uid and pressure from the heart and lungs and provide cellular effects that improve heart function over time. In cases where ACE inhibitors cant be used due to adverse reactions such as a persistent, dry cough (from bradykinin release or angioedema), an angiotensin receptor blocker (ARB), such as candesartan and valsartan, may be used. ARBs block receptors that usually bind with angiotensin II, preventing vasoconstriction and causing balanced vasodilation. Several members of this class of medication have been found effective for treating HF. Both ACE inhibitors and ARBs have potential adverse reactions. The most notable to watch for include hypotension, hyperkalemia, and pre-renal azotemia. If creatinine rises more than 50% or goes over 3 mg/dL upon initiation or up-titration, the ARB should be discontinued. A note should be placed in the patients medical record that the agent caused this effect so it isnt retrialed. See Nursing considerations for ACE inhibitors for more important interventions when administering this class of medication.
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When an ACE inhibitor or an ARB cant be used, a combination of hydralazine and isosorbide dinitrate may be prescribed to provide the same balanced vasodilatory effect. Hydralazine prevents the tolerance effects of the nitrate, and nitrate enhances the effectiveness of hydralazine. Additionally, a combination of hydralazine and nitrate can augment the protective effects of ACE inhibitors or ARBs and beta-blockers.
Beta-blockers
Beta-blockers are a powerful class of medication used in the treatment of LVSD. Agents approved for LVSD include carvedilol, metoprolol succinate (long acting), and bisoprolol. Several of these agents have been demonstrated to improve heart function in the long term. Beta-blockers block epinephrine and norepinephrine receptors; blocking these chemicals lowers heart rate, BP, and myocardial oxygen consumption that would otherwise worsen HF. If the patient is euvolemic, a beta-blocker should be initiated and titrated up over time to the target dosage. In the short term (over several weeks) additional diuretic may be needed to combat fluid retention caused by beta-blocker therapy; in the long term, the benefit outweighs the risk. Beta-blockers should be started when patients are stable to diminish progression of the disease, not as rescue therapy when patients are decompensating.
Aldosterone antagonists
Another class of medication useful in the treatment of LVSD is the aldosterone antagonists, such as spironolactone and eplerenone. Although these agents are potassium-sparing diuretics, theyre used to
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prevent the build up of sodium in the body that leads to uid retention. These medications compete for aldosterone-dependent sodium-potassium exchange sites in the distal tubule cells, ridding the body of sodium and water while sparing potassium. Aldosterone antagonists are useful when chronic HF causes shortness of breath with minimal exertion or at rest. Be watchful for hyperkalemia and an elevated creatinine level.
Loop diuretics
A loop diuretic is the diuretic of choice for treating a uid overloaded HF patient, regardless of type. Furosemide, bumetanide, and torsemide are examples of loop diuretics generally administered in response to uid overload. High doses can lead to diminished hearing or hearing loss and kidney dysfunction, electrolyte imbalances, volume depletion, and ventricular arrhythmias. Observe for these adverse reactions and notify the healthcare provider if evident. See Administering and monitoring diuretic therapy for more nursing considerations. When a patient presents with worsening uid overload, an increased dose of diuretic may be prescribed. But if the overload is moderate to severe, the healthcare provider may order hospital observation or admission for I.V. diuretic therapy and cardiac monitoring. If diuretic response isnt sufcient, the dose can be titrated up or another
class of diuretic may be given in conjunction with the loop diuretic to strengthen the effectiveness of diuresis. For decompensated HF, the next choice of diuretic is often a thiazide-like diuretic such as metolazone. A thiazide-like drug should be administered about a half hour before the loop diuretic to achieve the best possible synergy and most potent diuresis. The goal of therapy for HF is to cut back on the diuretic when possible and to optimize the agents known to quell the neurohormonal stimulation that triggers HF exacerbation.
Digoxin
Digoxin is the only oral positive inotrope available. It helps to improve the pumping action of the heart while reducing myocardial oxygen demand. Its used in HF patients with shortness of breath on mild exertion or at rest (New York Heart Association Classes III and IV). Studies show digoxin is useful in improving symptoms and preventing rehospitalization. Unfortunately, theres a very narrow therapeutic window with this medication and too much can build up in the bloodstream quickly, especially when kidney dysfunction is present. Watch for bradycardia, nausea, vomiting, or increasing fatigue. See Digoxin use and toxicity in HF for more nursing considerations.
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heart matters
separate I.V. site so it doesnt interact with many preservatives found in other I.V. drugs the patient may be receiving. Other I.V. medications that may be prescribed include milrinone and dobutamine to improve the contractility of the heart and forward blood ow in patients not responding well to other therapy. Milrinone is known as an inodilator because its a balanced vasodilator and has a positive inotropic effect. Its used 24/7 as a bridge to transplant for some patients. Milrinone can produce thrombocytopenia. Dobutamine is a synthetic catecholamine-like epinephrine used for refractory decompensated HF and often for cardiogenic shock. Long-term use of these agents can increase mortality; in the short term, they do help improve HF symptoms. Both of these agents increase myocardial oxygen demand and arrhythmias, and they both carry the risk of ventricular arrhythmias.
The healthcare provider may ask you to draw a digoxin level from time to time to assess for a therapeutic range. In this case, dont administer the dose on the day blood is to be drawn until after the lab specimen result is available to prevent a falsely high serum level.
Providing patients with this knowledge will help optimize outcomes and slow the progression of the disease.
Goebel JA, Van Bakel AB. Rational use of diuretics in acute decompensated heart failure. Curr Heart Fail Rep. 2008;5(3):153-162. Golan DE, Tashjian AH, Armstrong EJ, Armstrong AW. Principles of Pharmacology. Philadelphia, PA: Lippincott Williams and Wilkins; 2008. Heart Failure Society of America. HFSA 2006 comprehensive heart failure practice guideline. J Card Fail. 2006;12 (1):e1-e2. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddharths Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008: 952,955,956.
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