ACE inhibitors, beta-blockers, diuretics, digoxin, and anticoagulants in heart failure
Heart failure clients typically take multiple cardiac medications with narrow therapeutic windows, significant side effect profiles, and hold parameters that home health clinicians must apply correctly at every visit. Understanding the action, monitoring parameters, and danger signs for each major cardiac medication class is a non-negotiable clinical competency.
ACE inhibitors (lisinopril, enalapril, ramipril) and ARBs (losartan, valsartan) reduce cardiac workload by blocking the renin-angiotensin-aldosterone system. They are first-line therapy for HF with reduced ejection fraction. Monitor: blood pressure (hypotension risk, especially with first dose), kidney function (potassium and creatinine), and — for ACE inhibitors — dry cough. ACE inhibitor-induced cough occurs in up to 20% of patients and requires switching to an ARB. Angioedema (facial/throat swelling) is rare but life-threatening — stop the medication and call 911.
Carvedilol, metoprolol succinate, and bisoprolol reduce mortality in HF with reduced ejection fraction. They slow heart rate and reduce cardiac workload. Hold parameters: HR below 60 bpm (typical), systolic BP below 90 mmHg (per protocol). Monitor for: fatigue (common early — usually improves), dizziness (orthostatic hypotension), bronchospasm in COPD clients, and masking of hypoglycemia symptoms in diabetics. Never abruptly discontinue — rebound hypertension and arrhythmia risk. Always document held doses and notify the clinician.
Furosemide (Lasix), torsemide, and bumetanide remove excess fluid by blocking sodium and water reabsorption in the kidney. Give in the morning (and noon for BID) to time diuresis during waking hours and prevent nocturia-related fall risk. Monitor: weight (response to diuresis), electrolytes (potassium and magnesium loss), signs of dehydration (dizziness, dry mucous membranes, decreased urine output), and renal function. Teach clients to report muscle cramps — often a sign of hypokalemia.
Digoxin increases myocardial contractility and slows heart rate. It has a narrow therapeutic window — toxicity can occur even at levels within the "normal" range. Hold for HR below 60 bpm. Signs of toxicity: bradycardia, nausea, vomiting, visual disturbances (yellow-green halos, blurred vision), fatigue, and confusion. Toxicity risk is dramatically increased by hypokalemia, hypomagnesemia, and renal impairment. Any suspected digoxin toxicity is a clinical emergency.
Many cardiac clients (particularly those with atrial fibrillation or mechanical valves) take warfarin or direct oral anticoagulants (DOACs). Monitor for bleeding at every visit — unusual bruising, blood in urine or stool, gum bleeding, prolonged bleeding from minor cuts. For warfarin clients, current INR values must be tracked. Any fall in an anticoagulated cardiac client requires clinical notification and assessment.
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