Slide 1Extras from lecture 9/23Case studyCase studyHow do we decide which drugs to use for HTN?HEART FAILUREPathoAdaptation to decrease COMaladaptive Changes in Heart FailureCHF (continued…)Drug Management Guidelines for Heart Failure (ACC/AHA)Digoxin (Lanoxin®)Digoxin (continued…)Other Inotropic DrugsCase studyCORONARY HEART DISEASE (CHD)“Statins”Main Groups of Drugs Used to Treat Hypercholesterolemia:Bile-acid SequestrantsBile-acid SequestrantsExamples of Bile-acid SequestrantsNicotinic Acid (Niacin)FibratesEzetimibe (Zetia®)Case studyANGINA PECTORISAnginaNitroglycerinNitroglycerin (continued…)Nitrate-free IntervalNitratesCase studyAnti-dysrhythmic drugsElectrical system of the heartClassification of Anti-dysrhythmic drugsCase studyNSG 325 PharmModule 4 part II1Extras from lecture 9/23•Aldactone should not be given with ACE or ARB as it will increase the risk for hyperkalemia•Nitroprusside is used to treat HTN emergencies in critical care unit or ED. Short ½ life (2 min) continuous infusion that is titrated to effect. Oral agents are added as medication is weaned off.2Case study•Mr. Cassidy is 55 years old and has a past medical history of CAD, HTN, HL. He is schedule for orthopedic surgery today. Home meds HCTZ 50 mg QD, Lisinopril 20 mg day. (If this is all medication patient lists, is it all patient takes?)Pre-operative lab work reveals: Na 142, Cl 108, K 5.4, Bun 42, Cr 2.1, Hgb 14.5, Hct 47As the nurse what would you be concerned about? What actions would you take? 3Case study•ACE inhibitors can decrease renal function•Ibuprofen can increase the risk for renal impairment in presence of ACE (and ARB)4How do we decide which drugs to use for HTN?•Failure due to non-compliance•If no complicating factor (no comorbidity):•Thiazide diuretic, beta blocker or most others•Comorbid condition present:•Diabetes: ACEI’s, ARB’s, CCB’s, low dose diuretics•Renal disease: ACEI’s, ARB’s•MI: beta-blockers, ACEI’s, potassium-sparing diuretic•Special populations:•African Americans: thiazide diuretics•Beta-blockers, ACE inhibitors less effective•Elderly: beta-blockers or thiazide diuretics5HEART FAILURE •What is it?: a serious, progressive cardiac condition characterized by ventricular dysfunction, decreased CO, decreased tissue perfusion, signs of fluid retention.•“Congestive heart failure”: term often used if signs of pulmonary or systemic congestion•Signs and symptoms of CHF:•Decreased exercise tolerance/fatigue•Shortness of breath•Increased heart size•Tachycardia•Peripheral edema (swelling of feet/ankles)•Enlargement of the liver•Weight gain from fluid overload•Decreased urine output6Patho•The heart is unable to ump enough blood to meet the metabolic needs of the body•Inadequate tissue perfusion•Fatigue, shortness of breath, exercise intolerance•Volume overload•Venous distention, peripheral and pulmonary edema•Underlying causes:Chronic HTNMIValvular diseaseCAD Congenital heart disease7Adaptation to decrease CO•Cardiac dilation•Increase venous pressure, and reduced contraction force•Increases sympathetic tone•Arterial pressure decreases•Increased HR•Increased contractility•Water retention and increased blood volume•Decreased CO=decrease GFR•Activation of RAAS8Maladaptive Changes in Heart Failure9CHF (continued…)•Some causes:•Hypertension•Coronary artery disease (CAD)•Cardiotoxic drugs•Goals of treatment:•Relief of symptoms•Improve quality of life•Prolong life•Classification of heart failure severity:•NYHA: 4 classes based on functional limitations•ACC/AHA: 4 stages based on degree of structural heart disease10Drug Management Guidelines for Heart Failure (ACC/AHA)•Stage A: no symptoms and no disease, but high risk for HF•ACEI if diabetes, HTN, or CHD•Stage B: no symptoms but heart disease present•ACEI + beta-blocker if reduced cardiac function or history of MI•Stage C: symptoms of HF and heart disease present•ACEI + beta-blocker•Diuretic if signs of fluid retention•Aldosterone antagonist•Digoxin if needed•Stage D: marked symptoms at rest and significant heart disease•Maximal therapy as in Stage C•Heart transplant11NYHA ACC/AHA Treatment (ACC/AHA)Class 1- no limitation of ordinary physical activityStage A- at high risk for HF but without structural hear disease or symptoms of HFACE, ARB, StatinDiureticStage B- Structural heart disease but without symptoms of HFConsider ICD for EF<30ACE, ARB, BB. diureticClass II- sight limitation of physical activity, normal activity produces fatigue, dyspnea, palpitations and dyspneaStage C- Structural heart disease with prior or current symptoms of HFDiuretic, ACE or ARB, BBAdosterone antagonist?Hydralizine, ? Isosorbide? digoxinClass III Marked limitations of physical activity, even mild activity produces symptomsClass IV- Symptoms occur at restStage D- Advanced structural heard disease with marked symptoms of HF at rest requiring specialized interventionChronic inotropes, palliative careHospiceHeart transplant12Digoxin (Lanoxin®)•Mechanism of action: increases force of ventricular contractions  increases CO  decreases signs and symptoms of CHF.•A cardiac glycoside•Main uses:•Second-line drug for heart failure. Used with ACEI’s, beta-blockers, diuretics if inadequate response.•Dysrhythmias•Most significant ADR: cardiac dysrhythmias•Most commonly due to hypokalemia from diuretic use13Digoxin (continued…)•Non-cardiac ADR’s due to toxicity (which usually precede cardiac dysrhythmias):•GI: anorexia, nausea, vomiting•CNS: fatigue, visual disturbances (blurred vision, yellow-tinged vision, halos around objects)•Important drug interactions:•Thiazide and loop diuretics (cause hypokalemia which may increase digoxin level)•Verapamil, and many others•Toxicity considerations: low TI•Monitor digoxin level and potassium•Extreme overdose: Digibind®14Other Inotropic Drugs•Dopamine•Mechanism: a catecholamine that activates receptors of sympathetic nervous system•Beta-1 receptors in heart•Dopamine receptors in kidney, •Alpha-1 of vessels at high doses•Main use: rescue drug for severe heart failure•Administered: only IV, constant monitoring•Increase BP, HR, cause skin necrosis if extravasate•Dobutamine•Mechanism: a synthetic catecholamine that activates only beta-1 receptors•Main use: rescue drug for severe heart failure•May cause tachycardia,