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Cardiotonic
Drugs
SHERWYN HATAB
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Cardiotonic Agents

 Cardiotonic agents are drugs used to

increase the contractility of the heart
muscle for patients experiencing heart
failure (HF)
 The primary treatment for HF involves
helping the heart muscle to contract
more efficiently to restore system
balance.
Sherwyn Hatab 10/28/2023
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Heart Failure

 Heart failure is a clinical

syndrome that results from the
progressive process of
remodeling, in which
mechanical and biochemical
forces alter the size, shape,
and function of the ventricle’s
ability to fill and pump enough
oxygenated blood to meet
the metabolic demands of the
body.
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HF Etiology

 Caused by disorders of heart

muscle resulting in decreased
contractile properties of the heart
 CHD leading to MI
 Hypertension
 valvular heart disease
 congenital heart disease
 Cardiomyopathies
 Dysrhythmias.
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HF Clinical Manifestations

 Left-Sided Heart Failure (Forward Failure)

1. Shortness of breath, dyspnea on exertion,
tachypnea, paroxysmal nocturnal dyspnea,
orthopnea, cyanosis, pulmonary edema,
and hemoptysis
2. Cough—may be dry, unproductive; usually
occurs at night.
3. Fatigability.
4. Insomnia, restlessness
5. Tachycardia—ventricular gallop (S3 and S4).
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HF Clinical Manifestations

 Right-Sided Heart Failure (Backward Failure)

1. Edema of ankles; unexplained weight gain (pitting edema is
obvious only after retention of at least 4.5 kg of fluid)
2. Liver congestion—may produce upper abdominal pain
3. Distended jugular veins, increased CVP, pulmonary
hypertension (increased PCWP)
4. Abnormal fluid in body cavities (pleural space, abdominal
cavity), splenomegaly.
5. Anorexia and nausea
6. Nocturia
7. Weakness
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CVP and PCWP

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Pitting Edema and Distended Jugular

Neck vein
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Cardiotonic Drug

 Cardiotonic (inotropic) drugs affect the intracellular calcium levels in

the heart muscle, leading to increased contractility.
 This increase in contraction strength leads to increased cardiac
output, which causes increased renal blood flow and increased urine
production.
 Increased renal blood flow decreases renin release
 The result is a decrease in the heart’s workload and relief of HF
 Two types of cardiotonic drugs are used: classic cardiac glycosides
and phosphodiesterase inhibitors.

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Cardiac
Glycosides
 The cardiac
glycosides were
originally derived
from the foxglove
or digitalis plant.
 digoxin (Lanoxin)
is the drug most
often used to
treat HF.

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digoxin (Lanoxin)

 Usual Dosage:
 Adult: loading dose 0.75–1.25 mg PO
or 0.125–0.25 mg IV, then
maintenance dose of 0.125–0.25
mg/d PO; decrease dose with renal
impairment
 Pediatric: 10–60 mcg/ kg PO or 8–50
mcg/kg IV loading dose;
maintenance is 25%–30% of loading
dose
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Therapeutic Actions and Indications

 The primary action of digoxin is specifically to

inhibit adenosine triphosphatase and thus sodium-
potassium (Na+-K+) exchange activity, the
altered ionic distribution across the membrane
resulting in an augmented calcium ion influx and
thus an increase in the availability of calcium at
the time of excitation-contraction coupling.
 Digoxin increases intracellular calcium and allows
more calcium to enter myocardial cells during
depolarization causing the following effects:
1. Increased force of myocardial contraction (a
positive inotropic effect)
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Therapeutic Actions and Indications

2. Increased cardiac output and renal perfusion

3. Slowed heart rate, owing to slowing of the rate of
cellular repolarization (a negative chronotropic effect)
4. Decreased conduction velocity through the
atrioventricular (AV) node. (negative dromotropic
action)

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Therapeutic Actions and Indications

 Digoxin is also used to

correct atrial fibrillation
and atrial flutter. This is
accomplished by the
negative chronotropic
effects and negative
dromotropic effects.

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atrial
flutter

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atrial
fibrillation

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Normal Sinus Rhythm
 Sinus Arrhythmias

 The SA node is influenced by the

autonomic nervous system to
change the rate of firing to meet
the body’s demands for oxygen.
 Sinus tachycardia is a faster-than-
normal heart rate with a normal-
appearing ECG pattern.
 Sinus bradycardia is a slower-
than-normal heart rate with a
normal-appearing ECG pattern.
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Pharmacokinetics of Digoxin

 Digoxin is available for

oral and parenteral
administration.
 The drug has a rapid
onset of action and
rapid absorption

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Pharmacokinetics of Digoxin

 Digoxin is widely distributed throughout the body.

The protein binding power for digoxin is 30%.
 Thirty percent of digoxin is metabolized by the liver,
and 50% to 70% is excreted by the kidneys mostly
unchanged.

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Contraindications of Digoxin

1. allergy to any component of the digitalis preparation.

2. heart block or sick sinus syndrome, which could be made worse by
slowing of conduction through the AV node.
3. acute MI because the increase in force of contraction could cause
more muscle damage and infarct
4. renal insufficiency
5. electrolyte abnormalities (e.g., increased calcium, decreased
potassium, decreased magnesium)
6. ventricular tachycardia or fibrillation
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Vt to
VF

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Heart Block

 AV blocks are divided into three categories: first-, second-

, and third-degree.
 First degree AV block

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Heart Block

 Second-Degree AV Block Type I (Mobitz 1)

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Heart Block

 Second-Degree AV Block . Type II (Mobitz II)

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Heart Block

 Third-Degree AV Block

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Caution
 Pregnancy and lactation
 It is not known whether digoxin causes fetal
toxicity; it should be given during pregnancy
only if the benefit to the mother clearly
outweighs the risk to the fetus.
 Digoxin does enter breast milk, but it has not
been shown to cause problems for the
neonate.
 Pediatric and geriatric patients also are at
higher risk for adverse effects and should be
monitored closely.

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Side Effects and Adverse Reactions of Digoxin

 Side Effects:
 Anorexia, nausea, vomiting, diarrhea,
abdominal pain, headache, blurred vision
(yellow-green halos), diplopia, photophobia,
drowsiness, dizziness, fatigue, confusion.
 Adverse Reactions:
 Bradycardia, visual disturbances
 Life-threatening: Atrioventricular block,
cardiac dysrhythmias

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Digoxin Toxicity

 Overdose or accumulation of digoxin

causes digitalis toxicity.
 Signs and symptoms include anorexia,
diarrhea, nausea and vomiting,
bradycardia, PVC, cardiac
dysrhythmias, headaches, malaise,
blurred vision, visual illusions, confusion,
and delirium.
 Cardiotoxicity is a serious adverse
reaction to digoxin; ventricular
dysrhythmias result.
 Hyperkalemia

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PVC

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Antidote for Digitalis

 Digoxin immune Fab (DigiFab, Digibind) may be given

to treat severe digitalis toxicity. This agent binds with
digoxin to form complex molecules that can be
excreted in the urine; thus, digoxin is unable to bind
at the cellular site of action.
 Digoxin immune Fab is used for the treatment of
life-threatening digoxin intoxication (serum levels
>10 ng/mL with serum potassium >5 mEq/L in a
setting of digoxin intoxication) and potential life-
threatening digoxin overdose.
 Onset of action: 30 min Duration of action: 15 to 20
hrs
 Elimination half-life: 15 hours for DigiFab, 23 hours for
Digibind
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 Digoxin Clinically 32
Important Drug—
Drug Interactions

 There is a risk of increased

therapeutic effects and
toxic effects of digoxin if it is
taken with verapamil,
amiodarone, quinidine,
quinine, erythromycin,
tetracycline, or
cyclosporine.

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Digoxin Clinically
Important Drug—Drug
Interactions

 The risk of cardiac

arrhythmias could
increase if these drugs
are taken with
potassium-losing
diuretics.
 Thiazide Diuretics:
Chlorothiazide (Diuril),
Hydrochlorothiazide
(Microzide), Indapamide,
Metolazone.

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Digoxin Clinically
Important Drug—
Drug Interactions
 Digoxin may be
less effective if it
is combined with
thyroid
hormones,
metoclopramide,
or penicillamine.

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Digoxin and Herbal

 St. John’s wort and

psyllium have been
shown to decrease the
effectiveness of
digoxin; this
combination should be
avoided.

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Digoxin and Herbal

 Increased digoxin
toxicity has been
reported with
ginseng. Patients
should be advised
to avoid these
combinations.

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Nursing Considerations for
Patients Receiving Digoxin
 Assessment
 Obtain a drug and herbal history.
Report if drug-drug or drug-herb
interaction is probable.
 Obtain a baseline pulse rate for
future comparisons. Apical pulse
should be taken for a full minute and
should be greater than 60 beats/min.
 Assess for signs and symptoms of
digitalis toxicity
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Nursing Considerations for Patients
Receiving Digoxin

 Nursing Diagnoses
 Decreased cardiac output related to
decreased cardiac pumping ability
 Ineffective peripheral tissue perfusion
related to decreased cardiac
pumping ability
 Anxiety related to threat to cardiac
health status
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Nursing Considerations for Patients
Receiving Digoxin
 Nursing Interventions:
 Ascertain apical pulse rate before
administering digoxin. Do not administer if
pulse rate <60 beats/min.
 Hold the dose if the pulse is less than 60
beats/min in an adult or less than 90
beats/min in an infant
 Retake the pulse in 1 hour. If the pulse remains
low, document it, withhold the drug, and
notify the physician
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Nursing Considerations for Patients
Receiving Digoxin

 Monitor the pulse for any change in quality or

rhythm
 Check the dose and preparation carefully
 Check pediatric dose with extreme care. Have
the dose double-checked by another nurse
before administration.
 Monitor serum digoxin level (the therapeutic
range is 0.5 to 1 ng/mL.), serum digoxin level
greater than 2 ng/mL is indicative of digitalis
toxicity.
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Nursing Considerations for Patients
Receiving Digoxin

 Arrange for the patient to be weighed at the same time

each day, in the same clothes. Assess dependent areas for
edema; note the amount and degree of pitting.
 Avoid administering the oral drug with food or antacids
 Provide thorough patient teaching, including the name of
the drug, dosage prescribed, technique for monitoring
pulse and acceptable pulse parameters warning signs of
possible toxicity and need to notify health care provider,
and the need for periodic monitoring and evaluation,
including ECGs and laboratory testing
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for Patients Receiving
Digoxin
 Maintain emergency
equipment on standby:
1. lidocaine (for treatment of
arrhythmias)
2. phenytoin (for treatment
of seizures)
3. atropine (to increase heart
rate)
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 PHOSPHODIESTERASE 43
INHIBITORS

 The phosphodiesterase
inhibitors belong to a
second class of drugs
that act as cardiotonic
(inotropic) agents.
These include milrinone
(Primacor)

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milrinone (Primacor)

 Indicated for short-term

management of HF in adults
receiving digoxin and diuretics
 50 mcg/kg IV bolus over 10 min, then
0.375– 0.75 mcg/kg/min IV infusion;
do not exceed 1.13 mg/kg/d; reduce
dose in renal impairment.

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Milrinone Therapeutic Actions

 Blocks the enzyme phosphodiesterase, which leads to an increase

in myocardial cell adenosine monophosphate (cAMP), which
increases calcium levels in the cell, causing a stronger contraction
and prolonged response to sympathetic stimulation which can lead
to vasodilation, increased oxygen consumption, and arrhythmias.
 These drugs are indicated for the short-term treatment of HF that
has not responded to digoxin or diuretics alone or that has had a
poor response to digoxin, diuretics, and vasodilators.

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Milrinone Pharmacokinetics

 milrinone are available only for intravenous use.

 Distribution: Widely distributed after injection. Protein
binding: About 70%.
 Metabolism: About 12% metabolized hepatically.
 Excretion: Eliminated via urine (85% as unchanged
drug). Elimination half life: About 2.5 hr-3.5 hrs
 Onset: Immediately
 Peak: 10 Minutes
 Duration: 8 Hours

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Milrinone Contraindications

1. presence of allergy to milrinone

2. severe aortic or pulmonic valvular
disease.
3. acute MI
4. fluid volume deficit
5. ventricular arrhythmias

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Cautions

 Caution should be exercised in the elderly

 There are no adequate studies about the effects of these
drugs during pregnancy, and their use should be reserved
for situations in which the benefit to the mother clearly
outweighs the potential risk to the fetus
 It is not known whether these drugs enter breast milk, so
caution should be exercised if patient is breast-feeding.

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Milrinone Adverse Effects

1. ventricular arrhythmias (which can

progress to fatal ventricular fibrillation,
hypotension, and chest pain.
2. GI effects include nausea, vomiting,
anorexia, and abdominal pain
3. Thrombocytopenia
4. Burning at the intravenous injection
site.
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Drug—Drug Interactions
of Milrinone

 Precipitates form
when these
drugs are given
in solution with
furosemide.
Avoid this
combination in
solution.

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Nursing Considerations for Patients Receiving
Milrinone
 ASSESSMENT:
1. Assess for contraindications or cautions
2. Assess cardiac status closely, including pulse and, blood pressure,
auscultate heart sounds, noting any evidence of abnormal sounds.
3. Obtain the patient’s weight, noting any recent increases or
decreases
4. Inspect skin and mucous membranes for color, and check nail beds
and capillary refill
5. Assess voiding patterns and urinary output
6. Obtain a baseline electrocardiography
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Nursing Considerations for Patients Receiving
Milrinone

1. Protect the drug from light to prevent drug

degradation.
2. Monitor pulse and blood pressure frequently during
administration.
3. Monitor input and output and record daily weight
4. Monitor platelet counts before and regularly during
therapy. Inspect the skin for bruising or petechiae
5. Monitor intravenous injection sites
6. Provide life-support equipment on standby
7. Monitor patient response to the drug (alleviation of
Sherwyn Hatab
signs and symptoms of HF). 10/28/2023
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Thank
You ☺

Sherwyn Hatab 10/28/2023