D116 Unit 4 Study Guide

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Western Governors University

D116 Advanced Pharmacology for the Advanced Practice Nurse

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Unit 4 Study Guide

Explain the classification of heart failure severity per the NYHA system and the ACC/AHA system

Heart failure (HF) severity is commonly classified using two complementary frameworks: the New York Heart Association (NYHA) functional classification and the American College of Cardiology/American Heart Association (ACC/AHA) staging system. While the NYHA system emphasizes symptom burden and functional capacity, the ACC/AHA system focuses on disease progression and structural changes.

NYHA Functional Classification

The NYHA classification stratifies patients based on the degree to which heart failure symptoms limit physical activity.

NYHA Class	Clinical Description
Class I	No limitation of physical activity; ordinary activity does not produce symptoms
Class II	Mild limitation of physical activity; symptoms such as fatigue or dyspnea occur with normal exertion
Class III	Marked limitation of physical activity; symptoms occur with minimal activity
Class IV	Inability to perform any physical activity without discomfort; symptoms present at rest

This system is widely used in clinical practice to guide treatment intensity and assess prognosis.

ACC/AHA Heart Failure Stages

The ACC/AHA staging system categorizes heart failure as a progressive condition, even before symptoms develop.

ACC/AHA Stage	Description
Stage A	High risk for heart failure without structural disease or symptoms
Stage B	Structural heart disease present but no signs or symptoms of HF
Stage C	Structural heart disease with current or prior HF symptoms
Stage D	Advanced, refractory HF requiring specialized interventions

Unlike NYHA classes, ACC/AHA stages are unidirectional and emphasize prevention and early intervention.

What is the first line treatment for hypertension?

Lifestyle modification is considered the first-line intervention for the management of hypertension. These measures target modifiable risk factors and may delay or reduce the need for pharmacologic therapy. Recommended strategies include dietary sodium restriction, weight reduction, regular aerobic exercise, moderation of alcohol intake, smoking cessation, and adherence to heart-healthy dietary patterns such as the DASH diet. These interventions have demonstrated effectiveness in lowering blood pressure and improving overall cardiovascular risk profiles.

In patients with asthma and hypertension, what would the recommended plan for treatment be?

In patients with coexisting asthma and hypertension, angiotensin-converting enzyme (ACE) inhibitors—commonly identified by the suffix “-pril”—are often considered appropriate therapeutic agents. Unlike nonselective beta-blockers, ACE inhibitors do not exacerbate bronchoconstriction and therefore present a safer option for patients with reactive airway disease. However, patients should be monitored for the development of cough, which may necessitate a switch to an angiotensin II receptor blocker (ARB).

Why are ACE inhibitors contraindicated in pregnant women?

ACE inhibitors are contraindicated during pregnancy due to their association with significant fetal toxicity, particularly during the second and third trimesters. In utero exposure can result in fetal hypotension, renal dysgenesis, oligohydramnios, skull hypoplasia, pulmonary hypoplasia, hyperkalemia, and even fetal death. Women who become pregnant while taking ACE inhibitors should discontinue the medication immediately and transition to a safer alternative under medical supervision.

Review the mechanism of action, adverse effects and contraindications of HMG-CoA Reductase inhibitors

HMG-CoA reductase inhibitors, commonly referred to as statins, reduce low-density lipoprotein (LDL) cholesterol by inhibiting the rate-limiting step in hepatic cholesterol synthesis. This inhibition leads to upregulation of LDL receptors on hepatocytes, enhancing clearance of circulating LDL cholesterol.

Common adverse effects include headache, gastrointestinal disturbances (such as dyspepsia, constipation, or abdominal discomfort), and dermatologic reactions. Rare but serious adverse effects include myopathy and rhabdomyolysis. Statins are contraindicated during pregnancy and lactation and should be used cautiously in patients taking other lipid-lowering agents or medications that inhibit CYP3A4, due to increased risk of toxicity.

What types of patients shouldn’t receive ACE inhibitors?

ACE inhibitors are contraindicated in patients with a history of angioedema related to previous ACE inhibitor use, pregnant patients, and individuals with known neutropenia. Additional caution is warranted in patients with bilateral renal artery stenosis or severe renal impairment due to the risk of acute kidney injury.

What types of adverse reactions can come from aspirin and warfarin?

The most significant adverse reaction associated with both aspirin and warfarin is bleeding. This risk may manifest as gastrointestinal hemorrhage, intracranial bleeding, or excessive bruising. The risk is heightened when these agents are used concurrently or in patients with underlying bleeding disorders or uncontrolled hypertension.

What are the adverse effects associated with digoxin toxicity? What lab values are considered therapeutic? What lab values would indicate toxicity?

Digoxin has a narrow therapeutic index. Therapeutic serum digoxin levels typically range from 0.5 to 0.8 ng/mL. Levels exceeding this range increase the risk of toxicity.

Clinical manifestations of digoxin toxicity include anorexia, nausea, vomiting, fatigue, visual disturbances (such as blurred or yellow vision), and potentially life-threatening cardiac arrhythmias. Any alteration in heart rate or rhythm in a patient taking digoxin warrants immediate evaluation of serum drug levels.

What precautions should be taken when a patient is prescribed theophylline? Which medications interact with theophylline?

Oral theophylline is used for maintenance therapy in chronic stable asthma. Patients should be instructed not to double doses if a dose is missed. Because theophylline metabolism is affected by caffeine, patients should limit intake of caffeine-containing beverages, as caffeine can increase adverse effects and reduce drug clearance.

Several medications interact with theophylline. Enzyme inducers such as phenobarbital, phenytoin, and rifampin decrease theophylline levels, while inhibitors such as cimetidine and fluoroquinolone antibiotics (e.g., ciprofloxacin) increase the risk of toxicity.

Discuss the link between thiazides and calcium excretion

Thiazide diuretics decrease urinary calcium excretion by increasing calcium reabsorption in the distal convoluted tubule. As a result, serum calcium levels may be mildly elevated, while urinary calcium levels are reduced. This effect can be beneficial in patients with recurrent calcium-based kidney stones but requires monitoring in patients at risk for hypercalcemia.

Describe side effects of mucolytics

Mucolytics act by reducing the viscosity of respiratory secretions, thereby improving cough productivity. While generally well tolerated, mucolytics can trigger bronchospasm in susceptible individuals, particularly those with asthma, necessitating cautious use and close monitoring.

Discuss the mechanism of action of sympathomimetics

Sympathomimetics alleviate nasal congestion by stimulating alpha-1 adrenergic receptors in nasal blood vessels. This activation causes vasoconstriction, leading to reduced mucosal edema, decreased nasal obstruction, and improved drainage. Overuse, however, can result in rebound congestion.

What are the side effects and interactions with glucocorticoids? Identify specific assessments for side effects

Glucocorticoids are associated with numerous adverse effects, particularly with long-term use. These include osteoporosis, increased susceptibility to infection, impaired wound healing, hyperglycemia, myopathy, fluid and electrolyte disturbances, growth suppression in children, and psychological effects such as mood changes or psychosis.

Additional complications include cataracts, glaucoma, peptic ulcer disease, iatrogenic Cushing syndrome, and adrenal suppression. Clinicians should monitor bone density, blood glucose levels, electrolyte balance, ocular health, and signs of infection. Drug interactions include potassium-depleting agents, NSAIDs, insulin and oral hypoglycemics, and vaccines.

Discuss the step-wise approach to asthma management. Which medications/classes are included in each step? Differentiate between short-acting and long-acting treatments

Asthma management follows a step-wise approach, escalating therapy based on symptom severity and control. Short-acting beta-agonists (SABAs) are used for rapid symptom relief, while long-acting agents such as inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs) provide maintenance control. Higher steps incorporate leukotriene modifiers, biologics, or systemic corticosteroids for severe disease.

Discuss the antitussives and decongestants that are acceptable for women who are pregnant. Which are contraindicated in pregnancy?

Acceptable Medications

Several medications and non-pharmacologic options are considered relatively safe during pregnancy.

Acceptable Options
Diphenhydramine (Benadryl®)
Dextromethorphan (Robitussin®)
Guaifenesin (Mucinex®)
Pseudoephedrine (only after first trimester)
Saline nasal sprays, nasal strips, Neti pots

Contraindicated Medications

Certain agents should be avoided due to potential fetal risks.

Contraindicated Options
Pseudoephedrine (first trimester)
Phenylephrine
Benzonatate
Dextromethorphan (use with caution depending on trimester)

References

American College of Cardiology/American Heart Association. (2022). Guideline for the management of heart failure. Journal of the American College of Cardiology, 79(17), e263–e421. https://doi.org/10.1016/j.jacc.2021.12.012

Brunton, L. L., Hilal-Dandan, R., & Knollmann, B. C. (2023). Goodman & Gilman’s: The pharmacological basis of therapeutics (14th ed.). McGraw-Hill Education.

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, and outcomes (10th ed.). Elsevier.