1. Diuretics
   1. Loop Diuretics
      1. Drug of choice for severe HF
      2. Monitor closely for digoxin toxicity if patient taking
      3. Effective even with < GFR
   2. Thiazide Diuretic
      1. Produce modest diuresis
      2. Not effective if low GFR
   3. Potassium Sparing Diuretic
      1. Produces little diuresis
      2. If patient also taking ACEs or ARBs
         1. Monitor potassium levels for hyperkalemia risk
2. RAAS
   1. ACEs (-prils)
      1. Often in combo with BB and diuretics
      2. If patient develops intractable cough, switch to ARBs
   2. ARBs (-sartans)
      1. Does not increase bradykinin release
      2. Increase left ventricular ejection fraction (LVEF)
   3. Aldosterone Antagonist
      1. Decrease symptoms and prolongs life but added for patients with persistent symptoms despite other treatments
3. Beta Blockers (BB)
   1. (-olols)
      1. MOA:
         1. Decreases contractility which allows ventricles to fill by decreasing/blocking SNS to reduce electrical transmission in heart’s conduction system -->
            1. Result: Decrease HR and BP
      2. Nursing Considerations:
         1. Assess before administration
            1. BP
            2. HR
         2. Start with low dose. Full benefits seen between 1-3 months
4. Vasodilators
   1. isorbide dinatrate + hydralazine
      1. Improves survival and HF symptoms
   2. nitroglycerin
      1. Decreases pulmonary edema and angina
      2. AE
         1. hypotension
         2. reflex tachycardia
         3. HA- most common
   3. sodium nitroprusside
      1. Fast acting, short term use in treating severe HF
      2. Remember, AE
         1. Severe hypotension
            1. continuous monitoring BP
      3. Therapeutic agent for hypertensive crisis
   4. nesiritide
      1. Synthetic form of BNP
      2. Short term use for very severe/acute decompensated HF
      3. AE: v-tach, HA, hypotension
5. Cardiac Glycoside
   1. digoxin
      1. MOA:
         1. Inhibition of Na+, K+, ATPase leads to increased inotropic action (increase myocardial contraction), which then leads to increased CO
            1. Improves circulation
            2. Promotes diuresis - increases stroke volume, decreases HR
         2. (+ inotrope) increases force of contractions (CO) (- chronotrope) decreases HR allowing fill time (- dromotrope) decreases conduction
      2. Indications:
         1. 2nd line therapy for Heart Failure patients due to its toxicity
            1. Multiple drug Interactions
         2. Treats symptomatic Heart Failure & A. fib
         3. Does not prolong life
      3. Adverse Effects:
         1. GI effects
            1. Anorexia
            2. N/V
            3. Abdominal pain
            4. Vision Blurred/ Yellow tinged, halos around objects
         2. CNS effects
            1. Fatigue
            2. HA
         3. Dysrhythmias (Most serious)
            1. Common cause: hypokalemia secondary to diuretic use (particularly loop diuretics)
      4. Nursing Considerations:
         1. Potassium supplements
         2. Monitor EKG, K+ levels, establish baseline vitals
         3. Monitor digoxin level
            1. NARROW Therapeutic range (0.5-2 ng/mL) -reference used by many hospitals
            2. Current evidence for best practice: (0.5-0.8ng/mL) to decrease risk of toxicity
         4. Apical pulse, hold for < 60 bpm
         5. Reinforce lifestyle modifications
         6. Watch for signs of toxicity
            1. The Antidote for Severe Digoxin Toxicity
            2. Digoxin immune Fab - (Digibind/Digifab)
            3. Activated charcoal & cholestyramine (Questran)
6. Medical Acronyms