CARDIOTONIC

MEDICATIONS
✔ Drugs used to increase the
contractility of the heart
muscle for patients
experiencing heart failure.
 MECHANISM OF ACTIONS
✔ 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, interfering with the
effects of the RAAS, and increases
urine output, leading to decreased
blood volume.
✔ The result is a decrease in the
heart’s workload and relief of HF.
 1.) CARDIAC
GLYCOSIDES
✔ Originally derived from the foxglove
or digitalis plant.
✔ These plants were once ground up
to make digitalis leaf.
✔ Digoxin (Lanoxin) is the drug most
often used to treat heart failure.
 ACTIONS &
✔
INDICATIONS
Digoxin increases intracellular calcium
and allows more calcium to enter
myocardial cells during depolarization.
✔ This results to increased force of
myocardial contraction (positive inotropic
effect).
✔ Increased cardiac output and renal
perfusion.
✔ Slowed heart rate, owing to slowing of the
rate of cellular repolarization (negative
chronotropic effect)
✔ Decreased conduction velocity through
the atrioventricular (AV) node.
✔ Indicated for the treatment of HF, atrial
flutter, atrial fibrillation, and paroxysmal
atrial tachycardia.
✔ It has a very narrow margin of safety.
 PHARMACOKINETICS
✔ It can be for oral and parenteral
administration.
✔ It has a rapid onset of action and
rapid absorption (30–120 minutes
when taken orally, 5–30 minutes
when given intravenously).
✔ Primarily excreted unchanged in
the urine.
✔ Because of this, caution should
be exercised in the presence of
renal impairment because the
drug may not be excreted and could
accumulate, causing toxicity.
 CONTRAINDICATIONS
✔ Patients with ventricular tachycardia or
fibrillation, which are potentially fatal arrhythmias
and should be treated with other drugs.
✔ Heart block or sick sinus syndrome, which
could be made worse by slowing of conduction
through the AV node.
✔ Renal insufficiency because the drug is
excreted through the kidneys and toxic levels could
develop.
✔ Idiopathic hypertrophic subaortic stenosis
(IHSS) because the increase in force of contraction
could obstruct the outflow tract to the aorta and
cause severe problems.
✔ Acute MI because the increase in force of
contraction could cause more muscle damage and
infarct.
✔ Electrolyte abnormalities (increased calcium,
decreased potassium, decreased magnesium),
which could alter the action potential and change
the effects of the drug.
 ADVERSE EFFECTS
✔ Headache, weakness, drowsiness, and
vision changes (a yellow halo around
objects).
✔ GI upset, anorexia, arrhythmias,
ventricular tachycardia, malaise,
depression.
✔ ANTIDOTE: Digoxin Immune Fab
(DigiFab).
 DRUG- DRUG
INTERACTIONS
✔ Increased therapeutic effects and toxic if
it is taken with verapamil, amiodarone,
quinidine, quinine, erythromycin,
tetracycline, or cyclosporine.
✔ If combined with any of these drugs, it
may be necessary to decrease the
digoxin dose to prevent toxicity.
✔ The risk of cardiac arrhythmias
could increase if these drugs are
taken with potassium-losing
diuretics. Check potassium levels
regularly.
✔ Less effective if it is combined with
thyroid hormones, metoclopramide,
or penicillamine, and increased digoxin
dose may be needed.
✔ Absorption of oral digoxin may be decreased if
it is taken with cholestyramine, charcoal,
colestipol, antacids, bleomycin,
cyclophosphamide, or methotrexate.
✔ If it is used in combination with any of these
agents, administer 2 to 4 hours apart.
✔ St. John’s wort and psyllium have been
shown to decrease the effectiveness of digoxin.
✔ Increased digoxin toxicity has been reported
with ginseng, hawthorn, and licorice.
 NURSING
✔
CONSIDERATIONS
Monitor apical pulse for 1 full minute
before administering the drug.
✔ Hold the dose if the pulse is less than 60
beats/min in an adult or less than 90
beats/min in an infant.
✔ If the pulse remains low after one hour,
withhold the drug, and notify the prescriber
because this could indicate digoxin toxicity.
✔ Administer IV doses very slowly over at
least 5 minutes to avoid cardiac arrhythmias.
✔ Avoid IM doses are painful.
✔ Weight daily to rule out fluid retention and
check for edema
✔ Have the cardiac monitor standby, have
potassium salts and lidocaine for
arrtythmias, phenytoin for seizure,
atrophine to increase heart rate.
✔ Monitor the patient for therapeutic
digoxin level (0.5–2 ng/mL).
✔ Small, frequent meals to help alleviate GI
upset or nausea, access to bathroom
previlleges due to increased urination
related to increased cardiac output.
✔ Must have adequate room lighting due to
vison changes (yellow halo around
objects).
 2.) PHOSPHODIESTERASE
INHIBITORS
✔ It belongs to a second class of
drugs that act as cardiotonic (inotropic)
agents.
✔ These include milrinone (Primacor).
✔ Indicated for the short-term treatment
of HF that has no or poor response to
digoxin, diuretics, and vasodilators.
 MECHANISM OF ACTION
✔ It bloks the enzyme phosphodiesterase that
leads to an increase in myocardial cell cyclic
adenosine monophosphate (cAMP), which
increases calcium levels in the cell.
✔ Increased cellular calcium causes a stronger
contraction and prolongs the effects of
sympathetic stimulation, which can lead to
vasodilation, increased oxygen
consumption, and arrhythmias.
✔ Because these drugs have
been associated with the
development of potentially fatal
ventricular arrhythmias, their
use is limited to severe
situations.
 PHARMACOKINETICS
✔ Inamrinone and milrinone are
available only for intravenous use.
✔ These drugs are widely
distributed after injection.
✔ They are metabolized in the liver
and excreted primarily in the urine.
 CONTRAINDICATIONS
✔ They also are contraindicated in the
following conditions: severe aortic or
pulmonic valvular disease.
✔ Acute myocardial infarction, fluid
volume deficit, and ventricular
arrhythmias.
✔ Caution in giving to elderlies.
 ADVERSE EFFECTS
✔ Ventricular arrhythmias, ventricular fibrillation,
hypotension, and chest pain.
✔ Nausea, vomiting, anorexia, and abdominal
pain.
✔ Thrombocytopenia and burning in the IV site.
✔ Hypersensitivity reactions associated with
these drugs include vasculitis, pericarditis,
pleuritis, and ascites.
 DRUG- DRUG
INTERACTIONS
✔ Precipitates form when these
drugs are given in solution with
furosemide.
✔ Avoid this combination in solution.
✔ Use alternate lines if both of these
drugs are being given intravenously.
 NURSING ACTIONS
✔ Protect the drug from light to prevent
drug degradation.
✔ Assess skin for signs of
thrombocytopenia.
✔ Check platelets regularly to check dose
adequacy.
✔ Watch closely BP and HR for toxicity.
✔ Check IV site for burning or irritation.