19.6 Adjunct Medications Used in Heart Failure
5 min read•june 18, 2024
Heart failure treatment involves a range of medications beyond standard therapies. These adjunct drugs target different aspects of cardiac function, offering additional benefits for patients. From to , each medication plays a unique role in managing heart failure symptoms and improving outcomes.
Understanding these adjunct therapies is crucial for nurses. They need to know how these drugs work, their side effects, and important nursing considerations. This knowledge enables better patient care, from monitoring vital signs to educating patients about their medications and potential complications.
Adjunct Medications in Heart Failure Treatment
Key adjunct medications for heart failure
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- Digoxin
- medication used to treat heart failure and
- Increases cardiac contractility by inhibiting the , leading to increased levels
- Reduces heart rate through , decreasing the workload on the heart ()
- combination
- Vasodilator medications that work together to reduce cardiac workload and improve
- acts as an , reducing afterload on the heart (amlodipine)
- functions as a , reducing preload on the heart (nitroglycerin)
- Ivabradine
- Selective that reduces heart rate without affecting cardiac contractility
- Blocks hyperpolarization-activated cyclic nucleotide-gated (HCN) channels in the , slowing the heart rate
- Useful in patients with heart failure who have elevated heart rates despite optimal beta-blocker therapy
- Vericiguat
- Soluble that improves cardiac function and reduces the risk of hospitalization in heart failure patients
- Enhances the production of (cGMP), leading to vasodilation and reduced
- Helps to alleviate symptoms and improve exercise tolerance in patients with worsening chronic heart failure (sacubitril/valsartan)
Additional key medications for heart failure
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- Reduce the production of angiotensin II, leading to vasodilation and decreased workload on the heart
- Improve survival and reduce hospitalizations in heart failure patients
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- Slow heart rate and reduce the heart's workload, improving left ventricular function over time
- Particularly beneficial in patients with reduced
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- Help manage fluid overload by increasing urine output and reducing congestion
- Improve symptoms such as shortness of breath and edema
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- Block the effects of aldosterone, reducing fluid retention and improving cardiac remodeling
- Particularly useful in patients with severe heart failure or post-myocardial infarction
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- Used as biomarkers to diagnose and monitor heart failure progression
- Elevated levels indicate increased cardiac stress and may guide treatment decisions
Mechanisms of adjunct heart failure drugs
- Digoxin
- Inhibits the sodium-potassium ATPase pump, leading to increased intracellular sodium and calcium levels
- Higher intracellular calcium concentrations enhance cardiac contractility by facilitating stronger
- Vagal stimulation by digoxin slows the heart rate, reducing the metabolic demands on the heart
- Hydralazine and isosorbide dinitrate
- Hydralazine dilates arteries by relaxing smooth muscle cells, reducing and afterload on the heart
- Isosorbide dinitrate dilates veins by releasing nitric oxide, increasing and reducing preload on the heart
- The combination of reduced preload and afterload improves cardiac output and decreases the workload on the failing heart
- Ivabradine
- Blocks in the sinoatrial node, which are responsible for the spontaneous depolarization of pacemaker cells
- Selective reduction of heart rate without affecting cardiac contractility or blood pressure
- Particularly beneficial in heart failure patients with elevated heart rates who cannot tolerate higher doses of beta-blockers
- Vericiguat
- Stimulates , an enzyme that catalyzes the conversion of (GTP) to cGMP
- Increased cGMP levels promote vasodilation, reduce vascular resistance, and decrease cardiac remodeling
- Improves cardiac function, reduces symptoms, and decreases the risk of hospitalization in patients with worsening chronic heart failure
Side effects of adjunct heart failure medications
- Digoxin
- Nausea, vomiting, and loss of appetite due to gastrointestinal irritation
- Visual disturbances, such as blurred vision or yellow-green halos around objects
- , particularly in the setting of or electrolyte imbalances ()
- Confusion, disorientation, and delirium, especially in older patients or those with renal impairment
- Hydralazine and isosorbide dinitrate
- Headache, dizziness, and lightheadedness due to vasodilation and potential
- as a compensatory response to reduced blood pressure
- Flushing, skin rash, and itching as a result of histamine release
- Ivabradine
- , particularly in patients with pre-existing conduction disorders or those taking other heart rate-lowering medications
- Visual disturbances, such as luminous phenomena () or blurred vision
- Atrial fibrillation, which may paradoxically increase heart rate and reduce the effectiveness of ivabradine
- Vericiguat
- Hypotension, especially when combined with other or antihypertensive medications
- Headache and dizziness related to vasodilation and reduced blood pressure
- Anemia due to the potential for decreased and hemoglobin levels
Nursing considerations for adjunct therapies
- Digoxin
- Monitor serum digoxin levels regularly to ensure therapeutic concentrations and avoid toxicity
- Assess electrolyte levels, particularly potassium, as hypokalemia can increase the risk of digoxin toxicity
- Educate patients on the signs and symptoms of digoxin toxicity and the importance of regular follow-up visits
- Hydralazine and isosorbide dinitrate
- Monitor blood pressure and heart rate closely, especially during dose titration and when combining with other vasodilators
- Educate patients on proper medication administration, including taking isosorbide dinitrate on an empty stomach and avoiding abrupt discontinuation
- Instruct patients to report any persistent or severe side effects, such as headache or dizziness
- Ivabradine
- Assess heart rate and rhythm regularly, particularly in patients with a history of conduction disorders or
- Educate patients on the importance of reporting any visual disturbances or signs of excessive bradycardia
- Monitor for the development of atrial fibrillation, which may require additional treatment or modification of ivabradine therapy
- Vericiguat
- Monitor blood pressure closely, especially when initiating therapy or adjusting doses
- Assess hemoglobin levels periodically to detect and manage potential anemia
- Educate patients on the signs and symptoms of hypotension and anemia, and encourage them to report any concerns
- General considerations for all adjunct therapies
- Assess medication adherence and provide strategies to improve compliance, such as pill organizers or reminder systems
- Encourage lifestyle modifications, including salt restriction, physical activity, and stress management, to optimize heart failure management
- Reinforce the importance of regular follow-up appointments and prompt reporting of any changes in symptoms or overall health status
- Regularly assess the patient's to monitor disease progression and guide treatment adjustments
Key Terms to Review (48)
Aldosterone Antagonists: Aldosterone antagonists are a class of medications that block the action of the hormone aldosterone, which is involved in regulating fluid and electrolyte balance in the body. These drugs are used to treat conditions related to the renin-angiotensin-aldosterone system, heart failure, and diuretic-induced potassium depletion.
Angiotensin-Converting Enzyme (ACE) Inhibitors: Angiotensin-converting enzyme (ACE) inhibitors are a class of medications primarily used to treat high blood pressure, heart failure, and other cardiovascular conditions. These drugs work by blocking the action of the angiotensin-converting enzyme, which is responsible for converting angiotensin I to angiotensin II, a potent vasoconstrictor that can increase blood pressure.
Arrhythmias: Arrhythmias refer to any abnormal or irregular heart rhythm that occurs due to disruptions in the electrical activity of the heart. These disturbances in the heart's normal pacing can lead to a wide range of symptoms and potentially serious complications if left untreated.
Arterial Vasodilator: An arterial vasodilator is a type of medication that acts to relax and widen the blood vessels, specifically the arteries, resulting in reduced resistance to blood flow. This property makes arterial vasodilators an important class of adjunct medications used in the management of heart failure, as they can help improve cardiac output and reduce the workload on the heart.
Atrial Fibrillation: Atrial fibrillation is an irregular and often rapid heart rate that can increase the risk of stroke, heart failure, and other heart-related complications. It occurs when the upper chambers of the heart (the atria) quiver instead of beating effectively, leading to an irregular and sometimes rapid heartbeat.
Atrial fibrillation with rapid ventricular response: Atrial fibrillation with rapid ventricular response (AFib with RVR) is a condition where the atria beat irregularly and frequently, leading to a fast heart rate in the ventricles. This can result in poor blood flow and increased risk of stroke.
Beta-Blockers: Beta-blockers are a class of medications that work by blocking the effects of the hormone epinephrine (adrenaline) on the body. They are primarily used to treat various cardiovascular conditions, such as hypertension, angina, and heart failure, by reducing the heart's workload and oxygen demand.
BiDil: BiDil is a combination medication containing isosorbide dinitrate and hydralazine, used specifically to treat heart failure in self-identified Black patients. It works by dilating blood vessels to reduce the workload on the heart.
Black clients: Black clients are patients who identify as Black or African American. Special considerations in pharmacology may be necessary due to genetic, socio-economic, and cultural factors that affect drug efficacy and safety.
Bradycardia: Bradycardia is a slower than normal heart rate, typically defined as fewer than 60 beats per minute in adults. It can be a sign of an underlying health issue or a side effect of certain medications.
Bradycardia: Bradycardia is a condition characterized by an abnormally slow heart rate, typically less than 60 beats per minute. This term is relevant in the context of various cardiovascular and pharmacological topics, as it can be a side effect or complication associated with certain medications and disease states.
Cardiac Glycoside: Cardiac glycosides are a class of naturally occurring compounds that have a direct positive inotropic effect on the heart, increasing the force of cardiac muscle contraction. They are commonly used as adjunct medications in the management of heart failure.
Cardiac glycosides: Cardiac glycosides are a class of organic compounds that increase the force of heart contractions and are used in the treatment of heart failure and certain arrhythmias. They function by inhibiting the sodium-potassium ATPase enzyme.
Cardiac Output: Cardiac output is the volume of blood pumped by the heart per minute. It is a critical measure of the heart's pumping ability and a key determinant of tissue perfusion and oxygen delivery throughout the body. This term is essential in understanding the fundamental mechanics of the cardiovascular system and its role in various cardiovascular conditions and their management.
Cardiac Remodeling: Cardiac remodeling refers to the structural and functional changes that occur in the heart in response to various pathological conditions, such as heart failure, hypertension, or myocardial infarction. This process involves alterations in the size, shape, and composition of the heart, which can ultimately impact its ability to effectively pump blood throughout the body.
Corlanor: Corlanor (ivabradine) is a medication used to reduce the heart rate in patients with chronic heart failure. It works by inhibiting the 'funny' current (If) in the sinoatrial node, leading to slower heart rate without affecting myocardial contractility.
Cyclic guanosine monophosphate: Cyclic guanosine monophosphate (cGMP) is a signaling molecule that plays a crucial role in various physiological processes, including vasodilation, smooth muscle relaxation, and regulation of cellular functions. It is closely associated with the mechanisms of action of nitrates, medications used in heart failure, and phosphodiesterase 5 (PDE5) inhibitors.
Digoxin: Digoxin is a cardiac glycoside used to treat certain heart conditions such as atrial fibrillation and heart failure. It works by increasing the force of myocardial contractions and modulating the autonomic nervous system.
Digoxin Toxicity: Digoxin toxicity refers to the adverse effects that can occur when the concentration of the cardiac glycoside medication digoxin reaches toxic levels in the body. This can happen due to overdose, drug interactions, or impaired digoxin clearance, and can have serious consequences for patients, especially those with heart conditions.
Diuretics: Diuretics are a class of medications that increase the excretion of water and electrolytes, primarily sodium, from the body. They are commonly used to manage conditions related to fluid imbalance, such as hypertension, heart failure, and edema.
Ejection Fraction: Ejection fraction is a measure of the percentage of blood that is pumped out of the heart's main pumping chamber, the left ventricle, with each contraction. It is a crucial indicator of the heart's overall pumping ability and is commonly used to assess cardiac function in various cardiovascular conditions.
Erythropoiesis: Erythropoiesis is the process by which red blood cells, also known as erythrocytes, are produced in the body. This process is essential for maintaining adequate oxygen delivery to tissues throughout the body, as red blood cells are responsible for transporting oxygen from the lungs to the body's cells.
Guanosine Triphosphate: Guanosine triphosphate (GTP) is a high-energy nucleotide that plays a crucial role in various cellular processes, including energy metabolism, signal transduction, and protein synthesis. It is closely related to the more well-known adenosine triphosphate (ATP), and the two molecules often work in tandem to power the body's energy-requiring functions.
Guanylate Cyclase Stimulator: A guanylate cyclase stimulator is a class of medications that work by activating the enzyme guanylate cyclase, which plays a crucial role in the regulation of cardiovascular function. These drugs are commonly used as adjunct treatments in the management of heart failure, as they can help improve cardiac output and reduce the workload on the heart.
HCN Channels: HCN channels, also known as hyperpolarization-activated cyclic nucleotide-gated channels, are a family of ion channels that play a crucial role in regulating the electrical activity of cells, particularly in the context of heart failure management. These channels are responsible for generating a unique pacemaker current that helps control the rhythmic firing of cardiac pacemaker cells and modulate the heart's contractility.
Hydralazine: Hydralazine is a direct-acting vasodilator medication primarily used as an adjunct therapy in the management of heart failure. It works by relaxing the smooth muscle of blood vessels, leading to vasodilation and reduced peripheral resistance, which can help improve cardiac output and reduce the workload on the heart.
Hydralazine and isosorbide dinitrate: Hydralazine and isosorbide dinitrate are medications used in combination to manage heart failure by reducing the workload on the heart. Hydralazine acts as a vasodilator, while isosorbide dinitrate helps to dilate veins and arteries.
Hypokalemia: Hypokalemia is a condition characterized by an abnormally low level of potassium in the blood. Potassium is an essential electrolyte that plays a crucial role in maintaining homeostasis, regulating fluid balance, and supporting proper nerve and muscle function throughout the body.
Hypotension: Hypotension is a medical condition characterized by an abnormally low blood pressure, where the systolic blood pressure falls below 90 mmHg and the diastolic blood pressure falls below 60 mmHg. This can have significant implications on the body's ability to circulate blood and deliver oxygen and nutrients to vital organs.
If current inhibitor: If current inhibitors are a class of drugs that selectively inhibit the 'funny' pacemaker currents (I_f) in the sinoatrial node. They are primarily used to reduce heart rate in patients with chronic stable angina or heart failure.
Intracellular Calcium: Intracellular calcium refers to the calcium ions (Ca2+) present within the cells of the body. These calcium ions play a crucial role in various cellular processes, including muscle contraction, neurotransmitter release, and cell signaling, particularly in the context of heart failure management.
Isosorbide Dinitrate: Isosorbide dinitrate is a nitrate medication primarily used to treat angina pectoris, a type of chest pain caused by reduced blood flow to the heart. It works by dilating blood vessels, improving blood flow and oxygen supply to the heart muscle.
Ivabradine: Ivabradine is a medication used to reduce heart rate in patients with certain types of chronic heart failure. It works by inhibiting the 'funny' (If) current in the sinoatrial node, thereby lowering the heart rate without affecting myocardial contractility.
Myocardial Contractions: Myocardial contractions refer to the rhythmic and coordinated contraction of the heart muscle, or myocardium, which is responsible for the pumping action of the heart. These contractions are essential for the heart's ability to circulate blood throughout the body, delivering oxygen and nutrients to tissues while removing waste products.
Natriuretic Peptides: Natriuretic peptides are a group of hormones produced primarily by the heart that play a crucial role in regulating fluid and electrolyte balance, as well as cardiovascular function. These peptides are closely associated with the pathophysiology and management of heart failure, a condition characterized by the heart's inability to effectively pump blood throughout the body.
New York Heart Association (NYHA) Functional Classification: The New York Heart Association (NYHA) Functional Classification is a system used to assess the severity of heart failure and its impact on a patient's daily activities and quality of life. It categorizes patients based on their symptoms and the limitations they experience during physical activity.
Peripheral Resistance: Peripheral resistance refers to the opposition or hindrance to blood flow through the blood vessels, particularly the small arteries and arterioles. It is a crucial factor in the regulation of blood pressure and the overall cardiovascular system's function.
Phosphenes: Phosphenes are the perception of light in the absence of actual light entering the eye. They are caused by the mechanical stimulation of the retina, resulting in the brain interpreting these signals as visual sensations, even when no external light is present. Phosphenes are particularly relevant in the context of adjunct medications used in heart failure, as certain drugs can induce this phenomenon as a side effect.
Sinoatrial Node: The sinoatrial (SA) node is a specialized group of cells located in the right atrium of the heart that acts as the heart's natural pacemaker. It is responsible for generating the electrical impulses that initiate the regular contraction of the heart muscle, thereby regulating the heart rate and maintaining the normal rhythm of the heart.
Sinus Node Inhibitor: A sinus node inhibitor is a type of medication that acts on the sinus node, the natural pacemaker of the heart, to slow down the heart rate. These medications are commonly used as adjunct therapies in the management of heart failure, as they can help control the heart's rhythm and improve overall cardiac function.
Sodium-Potassium ATPase Pump: The sodium-potassium ATPase pump, also known as the Na+/K+ ATPase, is a crucial membrane-bound enzyme that plays a vital role in maintaining the electrochemical gradient across the cell membrane. This gradient is essential for various physiological processes, including nerve impulse transmission, muscle contraction, and nutrient absorption.
Soluble Guanylate Cyclase: Soluble guanylate cyclase (sGC) is an enzyme that plays a crucial role in the regulation of cardiovascular function, particularly in the context of heart failure. It acts as a receptor for the signaling molecule nitric oxide (NO), catalyzing the conversion of guanosine triphosphate (GTP) to cyclic guanosine monophosphate (cGMP), which then mediates various physiological responses related to cardiovascular health.
Tachycardia: Tachycardia refers to a rapid heart rate, typically defined as a resting heart rate exceeding 100 beats per minute. This abnormally fast heart rhythm can have various underlying causes and is an important consideration in several medical conditions and drug therapies.
Vagal Stimulation: Vagal stimulation refers to the activation or enhancement of the parasympathetic nervous system's vagus nerve, which plays a crucial role in regulating various physiological functions, including those related to heart failure management.
Vasodilators: Vasodilators are a class of drugs that work by causing the blood vessels to dilate or widen, which in turn reduces the resistance to blood flow and lowers blood pressure. This property makes vasodilators particularly useful in the management of heart failure and shock, as they can help improve blood circulation and oxygen delivery to tissues.
Venous Capacitance: Venous capacitance refers to the ability of the venous system to store and accommodate changes in blood volume. It is an important factor in the regulation of cardiovascular function, particularly in the context of heart failure management.
Venous Vasodilator: A venous vasodilator is a medication that causes the dilation or widening of the veins, which helps to improve blood flow and reduce the workload on the heart. This term is particularly relevant in the context of adjunct medications used in the management of heart failure, as venous vasodilation can help alleviate the symptoms and progression of this condition.
Vericiguat: Vericiguat is a soluble guanylate cyclase (sGC) stimulator that is used as an adjunct medication in the treatment of heart failure. It works by increasing the production of cyclic guanosine monophosphate (cGMP), which helps to relax and dilate blood vessels, ultimately improving heart function and reducing the symptoms of heart failure.