Chapter 44

Cardiotonic Agents

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 Congestive Heart Failure (CHF)

• Definition

– Condition in which the heart fails to effectively

pump blood around the body

• Primary treatment

– Helping the heart muscle to contract more

efficiently to restore system balance

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 Underlying Problems in CHF
Involving Muscle Function

• The muscle could be damaged

– Atherosclerosis or cardiomyopathy
• The muscle could be forced to work too hard to
maintain an efficient output
– Hypertension or valvular disease
• The structure of the heart could be abnormal
– Congenital cardiac defects
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The Sliding Filament of
Myocardial Muscles

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Composition of the Sarcomere

• Protein fibers

– Thin actin fibers

– Thick myosin fibers

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Causes of Congestive Heart Failure (CHF)

• Coronary artery disease (CAD)

• Cardiomyopathy

• Hypertension

• Valvular heart disease

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Compensatory Mechanisms in CHF

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Signs and Symptoms of CHF

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Treatments for Congestive Heart Failure

• Vasodilators (ACE inhibitors and nitrates)

– Decrease workload of overworked cardiac muscle
• Diuretics
– Decrease blood volume, which decreases venous
return and blood pressure
• Beta-adrenergic agonists
– Stimulate the beta-receptors in the sympathetic
nervous system, increasing calcium flow into the
myocardial cells and causing increased contraction
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Sites of Actions of Drugs
Used to Treat CHF

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 Effects of Cardiac Glycosides

• Increased force of myocardial contraction

• Increased cardiac output and renal perfusion

• Increased urine output and decreased blood volume

• Slowed heart rate

• Decreased conduction velocity through the AV node

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 Cardiac Glycosides
• Actions
– Increase intracellular calcium, allowing more calcium
to enter the myocardial cell during depolarization;
cause positive inotropic effect, increasing renal
perfusion with a diuretic effect and decreasing renin
release; and slow conduction through the AV node
• Indications
– Treatment of CHF and atrial fibrillation
• Pharmacokinetics
– Rapidly absorbed and widely distributed throughout
the body
– Primarily excreted unchanged in the urine
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 Cardiac Glycosides (cont.)
• Contraindications
– Allergy
– Ventricular tachycardia or fibrillation, heart block,
and sick sinus syndrome
– Idiopathic hypertrophic subaortic stenosis
– Acute MI, renal insufficiency, and electrolyte
abnormalities
• Cautions
– Pregnancy and lactation
– In pediatric and geriatric patients
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 Cardiac Glycosides (cont.)
• Adverse effects
– Headache, weakness, drowsiness, and vision changes
– GI upset and anorexia
– Arrhythmia development
• Drug-to-drug interactions
– Verapamil, amiodarone, quinidine, quinine,
erythromycin, tetracycline, and cyclosporine
– Potassium-losing diuretics
– Cholestyramine, charcoal, colestipol, bleomycin,
cyclophosphamide, and methotrexate
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 Phosphodiesterase Inhibitors
• Classification
– Second class of drugs that act as cardiotonic
(inotropic) agents
• Types
– Inamrinone (Inocor): approved for use only in
patients with CHF that has not responded to
digoxin, diuretics, and vasodilators
– Milrinone (Primacor): short-term management of
CHF in patients who are receiving digoxin and
diuretics
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 Phosphodiesterase Inhibitors (cont.)
• Actions
– Block the enzyme phosphodiesterase, leading to an
increase in myocardial cell cyclic adenosine
monophosphate (cAMP), which increases calcium
levels in the cell, causing a stronger contraction and
prolonged response to sympathetic stimulation;
directly relax vascular smooth muscle
• Indication
– Short-term treatment of CHF in patients
unresponsive to digitalis, diuretics, and vasodilators

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 Phosphodiesterase Inhibitors (cont.)
• Pharmacokinetics
– Widely distributed after injection
– Metabolized in the liver and excreted in the urine
• Contraindications
– Allergy
– Severe aortic or pulmonic disease, MI, fluid volume
deficit, and ventricular arrhythmias
• Cautions
– Pregnancy and lactation
– In the elderly
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 Phosphodiesterase Inhibitors (cont.)

• Adverse effects
– Arrhythmia – Pleuritis
– Hypotension – Fever
– Nausea, vomiting
– Chest pain
– Thrombocytopenia
– Burning at injection site
– Pericarditis
• Drug-to-drug interaction
– Furosemide

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Use of Cardiotonic Agents
Across the Lifespan

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Prototype Cardiac Glycosides

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Prototype Phosphodiesterase Inhibitors

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 Nursing Considerations for
Cardiac Glycosides

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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 Nursing Considerations for
Phosphodiesterase Inhibitors

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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