Digoxin (Class all by itself)

Digoxin is in a class all by itself; used for the treatment of atrial fibrillation. Digoxin works by
inhibiting sodium-potassium ATPase, an enzyme that regulates the influx of sodium and potassium
in cardiac muscle cells. Altering SA node conductivity, conduction velocity through the heart, and
rest time between beats; increases force and velocity of muscle contraction, making the heart pump
more efficiently.

Side effects include a narrow therapeutic window – the amount of drug to cause the desired effect
is not much greater than the amount of drug that causes toxicity. 

Other side effects include gynecomastia (breast enlargement), anorexia, mental disturbances
(anxiety, depression, delirium, hallucination), and heart block (extremely slow heartbeat).

Patients hypersensitive to digitalis, digoxin, or diagnosed with ventricular fibrillation should not take
digoxin.

Patients should not change between brand and generic digoxin because small differences in tablet
strength can affect blood concentrations.

Vasodilators
Vasodilators – relax smooth muscle and dilate blood vessels. Dilation allows greater oxygen and
nutrient supply to reach cardiac muscle tissue, relieving chest pain and ischemia (low blood supply).
Nitrates are the most common vasodilator. They are short-acting products used for angina attacks;
long-acting forms are used to prevent frequent angina attacks. Nitroglycerin is a short-acting form,
designed to produce rapid absorption after one dose.

Side effects include headache, dizziness, blurred vision, flushing, increased heart rate, hypotension,
and agitation.

Nitrates are contraindicated for patients taking phosphor-diesterase-5 inhibitors (ED medications);
as well as patients with increased intracranial pressure and severe anemia. Short-acting forms
should not be swallowed, they are meant to go under the tongue (sublingual) and buccal (cheek).

Nitroglycerin must be kept in its original, amber-colored container and protected from light, heat, and
moisture.

Nitroglycerin tablets lose their effectiveness when exposed to warm and moist conditions; tablets
are only good for 6 months after the bottle is opened. Transdermal patches should be removed
before bedtime and left off overnight; a new patch should be applied in the morning.

Other Drugs for Angina (ACE inhibitors, Beta Blockers, and

Calcium-Channel Blockers):
Ace inhibitors, beta blockers, and calcium-channel blockers are all used to treat angina and heart
attack.

These drugs have shown beneficial effects on heart tissue that has already experienced ischemia.

They increase oxygen supply, increase pumping efficiency, and can reduce stress on the heart that
has suffered an infarction. Side effects are drug specific. Contraindications are class specific for
ACE inhibitors, beta blockers, and calcium-channel blockers.

Heart Failure
Heart failure is characterized by weakness, fatigue, severe fluid retention, and difficulty breathing
due to pulmonary edema.

High blood pressure and coronary blockage, over time, can cause the heart to no longer work
properly, resulting in enlargement and weakening. With the heart unable to pump sufficiently vital
organs will shut down due to lack of blood supply.
Factors that can contribute to this condition include hypertension and coronary artery disease, which
are primary causes; other factors include alcoholism, liver disease, kidney disease, valvular heart
disease, anemia, and drug therapy.

Drug Regimens and Treatments:

Drug therapy includes diuretics, ACE inhibitors, and beta blockers; some patients may use
vasodilators and digoxin.

Loop Diuretics
Loop diuretics work primarily in the ascending loop of Henle and distal renal tubule, sites of water
and sodium recovery.

These drugs work by inhibiting reabsorption of sodium, chloride and water, leading to fast and
profound diuresis (urine production). Loop diuretics include bumetanide, ethacrynate, furosemide
and torsemide.

Side effects include dizziness, headache, skin rash, upset stomach, diarrhea, and constipation. Not
to be used in patients with anuria.

Electrolyte balance, kidney function, and hydration must be monitored in patients taking loop
diuretics.

Patients often take potassium supplements with loop diuretics.