This document discusses various pharmacologic interventions for congestive heart failure, cardiomyopathy, and valve disease. It describes the mechanisms of action, therapeutic effects, adverse effects and nursing implications of several classes of heart failure medications including: ACE inhibitors, angiotensin receptor blockers, beta blockers, loop diuretics, thiazide diuretics, potassium sparing diuretics, nitrates, digoxin, milrinone, morphine, nesiritide, sacubitril/valsartan, and ivabradine. The document provides details on specific drugs within each class and how they are used to treat symptoms and improve outcomes for patients with heart failure.

1. C O N G E S T I V E H E A R T
F A I L U R E , C A R D I O M Y O P A T H Y ,
V A L V E D I S E A S E
P H A R M A C O L O G Y I N T E R V E N T I O N S

2. Heart Failure Therapeutics
• ACE Inhibitors
• Angiotensin Receptor
• Beta Blockers
• Nitrates
• Loop Diuretic
• Thiazide Diuretic
• Potassium Sparing Diuretic
• Narcotic Analgesic
• Human B-type Natriuretic Peptide
(vasodilator)
• Angiotensin receptor
Blocker/Neprilysin
Inhibitor
• HCN Channel Blocker
• Inotropic Medications
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

3. ACE
Inhibitors:
Mechanism
of Action
Low blood volume, low sodium and high potassium-
Causes release of RENIN from kidneys-
Renin cleaves angiotensinogen (from liver) to form
angiotensin I-
Enzyme ACE converts angiotensin I to angiotensin II-
Results in blood vessel constriction and increase in BP
Also causes release of Aldosterone which causes water
and salt reabsorption-
increase blood volume and BP
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

4. ACE Inhibitor Action
Decreases
angiotensin II in
kidneys, heart, blood
vessels, brain, and
adrenals. This causes
vasodilatation lowering
blood pressure
Blocks the breakdown of
bradykinin which also leads to
vasodilatation (may cause
cough)
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

5. Therapeutic
Effect Pearl
ACE inhibitors block
production of angiotensin II
thus causing
blood vessel dilatation,
increases sodium and water
excretion,
decrease cardiac output
(CO), stroke work and stroke
volume (SV).
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

6. Benefits (and cautions) of ACE Inhibitors in
Congestive Heart Failure
Improve symptoms, clinical status,
and exercise capacity.
Improves cardiac function.
Reduces hospitalizations.
Attenuates remodeling.
Prolongs survival.
Reduces vascular events.
Can be used to treat Hypertension
and MI.
 Avoid salt substitutes
Cautions
African Americans and older adults don’t
respond well and should be treated along
with a diuretic.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

7. Common Ace Inhibitors
Enala pril (enalapril)
Capto pril (captopril)
Rami pril (ramipril)
Lisino pril (Lisinopril)
Other ACE Inhibitors:
 Fosinopril
 Benazepril
 Quinapril
 Moexepril
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

8. Side Effects
Dry
persistent
cough
Dizziness
Fatigue Hypotension
Chest pain Anorexia
Diarrhea Hyperkalemia
• Renal insufficiency
• Proteinuria
• Skin rashes
• Hyperglycemia
• Angioedema
• Monitor for Steven
Johnson Syndrome
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

9. Nursing Implications
Monitoring
 BP
Renal Function
Blood Glucose
Assess urine for protein
Teaching
Change positions slowly
Avoid OTC cold medicines
Teach patient to monitor BP
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

10. Angiotensin
Receptor Blocker
(ARB)
• Candesar tan (candesartan)
• Losar tan (losartan)
• Valsar tan (valsartan)
Blocks release of aldosterone. ARB’s block angiotensin II causing vasodilation.
Used to treat hypertension and heart failure. ACEI usually first choice
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

11. Adverse Side Effects and Nursing Implications
Adverse Side
Effects
Hyperkalemia
 Renal insufficiency
 Hypotension
Nursing Implications
 Monitor vital signs and labs
 Teach patient to change
positions slowly.
 Monitor for difficulty
swallowing
 Teach patient about alcohol
consumption and drop in
BP.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

12. Beta Blockers
Action/ Therapeutic Effect:
Beta Blockers reduce cardiac output by
diminishing the sympathetic nervous
system.
Continued use leads to decreased
vascular resistance and lower BP.
Can improve survival by as
much as 35%
 Metopro lol (metoprolol)
 Ateno lol (atenolol)
 Carvedi lol (carvedilol)
 Sota lol (Sotalol)
 Bisopro lol ( bisoprolol)
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

13. Adverse Side Effects and Nursing Implications
Adverse side effects
Decreased heart rate
Decreased Blood Pressure
Dizziness
Fatigue
Elevated LFT’s
May cause heart failure
Nursing Implications:
 DO NOT initiate in the
patient with heart failure
who is acutely
decompensating.
 monitor vital signs
 monitor EKG
 input/output
 weights
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

14. Loop Diuretics Action/Therapeutic Effects
Inhibits reabsorption of Na and Cl in the
Loop of Henley resulting in excretion of
Na, K, Cl, and water by the kidney. The
effects are decreased preload,
decreased fluid retention.
 Furosemide
 Bumetanide
 Torsemide
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

15. Adverse Side Effects
Diarrhea, cramps
Ototoxicity
Renal
Insufficiency
Steven Johnson
Syndrome
Hypokalemia
Hyponatremia
Decreased Magnesium
Diuresis can cause hypovolemia
and hypotension and GI upset.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

16. Nursing
Implications
Monitor BP,
input/output, and daily
weights.
Monitor electrolytes.
Monitor for signs and
symptoms of
dehydration.
Assess for hearing loss
(administer slow IV
push).
Take medication in
morning. Change
positions slowly
Take with food. Licorice
may increase
potassium (K) loss.
Loop Diuretics
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

17. Thiazide Diuretics Action/Therapeutic
Effects
 Works in the distal tubules to
promote diuresis.
 Decreases pre-load and after
load.
Increases urine output to treat heart
failure, edema, and hypertension.
 Hydrochlorothiazide
 Metollazone
 Chlorothiazide
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

18. Adverse/Side
Effects
Dizziness Hypokalemia
Headache Hyperglycemia
Weakness Hyperlipidemia
Nausea and vomiting Steven Johnson
Syndrome
Blurred vision
Muscle cramps
Hypotension
Hyponatremia
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

19. Nursing
Implication
s
Monitor electrolytes, cholesterol, and
blood sugar.
Interacts with digoxin.
Causes hypokalemia which potentiates
the action of digoxin.
Take this medication in the morning.
Take this medication with food to avoid
GI upset.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

20. P O T A S S I U M
S P A R I N G
D I U R E T I C
S P I R O N O L A C T O N E
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

21. Action/Therapeutic
Effects.
Blocks myocardial and
vascular fibrosis , coronary
inflammation, hypertrophy.
Interferes with renin
system.
Increases urine excretion
of Na and decreases K
excretion.
Not a great effect of
diuresis.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

22. Nursing Implications
Caution
Caution in
administering with
an ACE inhibitor.
Monitor
Monitor
electrolytes.
Take
Take medication
in the morning.
Avoid
Avoid sun
exposure.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

23. Nitrates
 Nitroglycerin
IV(Tridil)
 Nitroglycerin
patch.
 Nitroglycerin
paste.
Action/Therapeutic
Effects
Coronary and peripheral vasodilation.
Decreases preload and afterload.
Used to treat hypertension and increas
cardiac output.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

24. Adverse/Side Effects
HEADACHE DIZZINESS TACHYCARDIA HYPOTENSION
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

25. Nursing
Implications Nitroglycerin
patch:
Nitroglycerin
Paste:
o Place patch on
in the morning
and remove in
the evening
o Ordered in
inches. Applied
to chest wall.
o Wear gloves
when applying.
 IV Infusion bottle (Tridil)
can be in NS or D5W.
 IV medication must be
on IV pump.
 Must be on a cardiac
monitor
 Titrate dose until
desired outcome.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

26. Inotropic Medications
DIGOXIN
(cardiac glycoside)
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

27. Action/Therapeutic
Effects
• Increases force of myocardial
contraction.
• Decreases conduction through the
SA and AV node
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

28. Nursing Implications
Teach patient to
monitor heart rate.
Monitor for s/s of
digoxin toxicity
• Vision changes
• Nausea and vomiting
• Bradycardia
• Monitor digoxin levels. Digoxin
levels reserved for change in renal
function, drug interactions,
confirmation of toxicity (not for
titration).
• Do not take digoxin within 1 hour of
ingesting an antacid.
• Medication can be given IVP or po

29. Inotropic Medications
Milrinone
(phosphodiesterase)
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

30. Milrinone
Enhances entrance of calcium into cells to increase contractility
Adverse/Side Effects
 Hypotension
Atrial fibrillation
Hypokalemia
Headache
Nursing Implications
 Monitor vital signs
Monitor electrocardiogram and labs
Administer medications through IV on a
pump.
Not compatible with Lasix IV.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

31. Narcotic Analgesic
Morphine Sulfate
Mechanism of Action:
Increases venous pooling to decrease preload. Decreases pain and
anxiety. Decreases work of breathing.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

32. Adverse /Side
Effects
• Confusion
• Dizziness
• Constipation
• Hypotension
• Nausea and Vomiting
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)
Morphine Sulfate

33. Nursing Implications
Assess level of
consciousness.
1
Assess vital signs
prior to
administration.
2
Monitor patient for
respiratory
depression.
3
Titrate dose to
patients’ response.
4
Have Narcan
available to
reverse respiratory
depression
5
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

34. Human B-type
Natriuretic Peptide
(Vasodilator)
Action/Therapeutic
effect
• Used to reduce dyspnea at rest or
with minimal activity in patients with
acute decompensated heart failure.
• Reduces percutaneous wedge
pressures (PCWP) and systemic
arterial pressure thereby decreasing
the heart’s work-load and relieving
dyspnea.
• Relaxes smooth muscle and causes
vasodilation.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

35. Human B-type Natriuretic Peptide (Vasodilator)
Nursing Interventions:
Do not run medication in same line as bumetanide, enalapril, furosemide or heparin.
Don’t shake the vial of medication.
Monitor vital signs and electrocardiogram, lung sounds, and respirations throughout administration.
Report any changes in assessments from above.
Administer bolus first intravenously followed by continuous drip.
Weight based protocol.
Evaluation is based on improvement of dyspnea.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

36. Valsartan/Sacubitril
• Blocks Angiotensin II
• Neprilysis inhibitor increases
availability of natriuretic peptides.
• Helps bradykinin achieve
vasodilation.
• Excretion of sodium helps lower BP.
• Used for patients in heart failure to
reduce the risk of hospitalization.
• Patients with low EVF benefit most.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

37. Angiotensin Receptor Blocker/ Neprilysin Blocker
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

38. Valsartan/Sacubitril
Adverse/Side Effects
Hypotension
Renal failure
Hyperkalemia
Angioedema
Dizziness
Nursing Interventions
 Change positions slowly.
Monitor BUN/CR.
Do not take if history of
angioedema.
Do not take Entresto for at least 36
hrs. before or after you take an
ACE inhibitor.
Recommended starting dose 49-
51mg orally twice daily and titrate
to 97-103mg in 2-4 weeks.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

39. HCN Channel Blocker
Ivabradine
Action/Therapeutic Effects
Slows the heart rate by inhibiting a specific channel in the SA node.
Used for heart failure patients who have an ejection fraction <35% who is in
sinus rhythm with resting heart rate of >70 bpm.
Used for patients who are either on the maximally tolerated dose of beta
blocker therapy or have contraindication to it.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

40. Ivabradine
• Bradycardia
• Dizziness
• Hypertension
• Atrial Fibrillation
• Visual Brightness
• Fetal Toxicity
Adverse/Side Effects:
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

41. • Nursing Implications:
• Contraindicated in patients with:
• Hypotension
• Sick sinus syndrome
• Pacemaker dependence
• Third degree heart block
• Hepatic impairment
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)

42. Nursing Implications
Take medication with
meals.
Avoid St. John’s wart
Avoid grapefruit
juice.
Teach patient to
check radial pulse.
Starting dose is 5mg,
can titrate up to
7.5mg with a target
heart rate of 50-60
bpm.
Monitor closely in
patients taking
digoxin or beta
blockers.
JFK Muhlenberg Harold B. and Nancy A. Snyder Schools of Nursing and Medical Imaging (2022)