drugs affecting circulation

NITRATES

Drug class used for acute termination and prophylaxis of angina pectoris

NITROGLYCERIN

Prototype drug of nitrates

ISOSORBIDE DINITRATE

Example of a nitrate

ISOSORBIDE MONONITRATE

Example of a nitrate

NITRATES INDICATIONS

Acute termination and prophylaxis of angina pectoris, acute MI chest pain, and IV management of persistent pain, heart failure, or severe hypertension after MI

NITRATES MODE OF ACTION

Vasodilation, preload reduction, afterload reduction, and coronary dilation

NITRATES COMMON SIDE EFFECT

Headache

NITRATES HEADACHE

Caused by cerebral vessel dilation

NITRATES HYPOTENSION

Postural or orthostatic hypotension

NITRATES OTHER SIDE EFFECTS

Dizziness, facial flushing, and reflex tachycardia

REFLEX TACHYCARDIA

Increase in heart rate in response to a rapid drop in blood pressure

PDE-5 INHIBITORS

Drugs contraindicated with nitrates because of life-threatening hypotension

SILDENAFIL

Example of a PDE-5 inhibitor contraindicated with nitrates

NITRATES AND ALCOHOL

Cause additive vasodilating effects

NITRATES AND ANTIHYPERTENSIVES

May cause additive vasodilation and hypotension

NITROGLYCERIN OINTMENT PRECAUTION

Always wear gloves when applying

NITROGLYCERIN SUBLINGUAL

Place 1 tablet under the tongue at the first sign of chest pain

NITROGLYCERIN POSITION

Sit or lie down immediately after taking sublingual nitroglycerin

NITROGLYCERIN PERSISTENT CHEST PAIN

Proceed to the ER if chest pain continues after the first dose

NITRATES PDE-5 SCREENING

Screen for PDE-5 inhibitor use within the previous 24–48 hours

NITRATES MONITORING

Monitor ECG and heart rate for resolving ischemia or reflex tachycardia

ACE INHIBITORS

Angiotensin-converting enzyme inhibitors

ACE INHIBITOR PROTOTYPE

Lisinopril

ACE INHIBITOR SUFFIX

-pril

ACE INHIBITOR INDICATIONS

Hypertension, heart failure, post-MI, and migraines

ACE INHIBITOR EXAMPLES

Lisinopril, ramipril, trandolapril, benazepril, and captopril

ACE INHIBITOR MECHANISM

Blocks ACE and prevents conversion of angiotensin I into angiotensin II

ANGIOTENSIN II

Potent vasoconstrictor normally produced from angiotensin I

ACE INHIBITOR ALDOSTERONE EFFECT

Decreases aldosterone secretion

ACE INHIBITOR PRELOAD EFFECT

Decreases sodium and water reabsorption, reducing blood volume and preload

ACE INHIBITOR COMMON SIDE EFFECT

Persistent dry cough

ACE INHIBITOR SERIOUS SIDE EFFECT

Angioedema

ANGIOEDEMA

Sudden swelling of the face, lips, tongue, throat, or GI tract that can cause fatal airway closure

ACE INHIBITOR ELECTROLYTE EFFECT

Hyperkalemia

ACE INHIBITOR HYPERKALEMIA CAUSE

Potassium retention caused by aldosterone blockade

ACE INHIBITOR PREGNANCY WARNING

Can cause major fetal injury and death

ACE INHIBITOR NSAID INTERACTION

NSAIDs decrease antihypertensive efficacy

ACE INHIBITOR NURSING CONSIDERATION

Screen for history of angioedema

ACE INHIBITOR PREGNANCY SCREENING

Verify that the patient is not pregnant

ACE INHIBITOR ORTHOSTATIC PRECAUTION

Instruct the patient to rise slowly

ARBs

Angiotensin-receptor blockers

ARB PROTOTYPE

Losartan

ARB SUFFIX

-sartan

ARB INDICATION

Hypertension

ARB EXAMPLES

Irbesartan, valsartan, azilsartan, eprosartan, and losartan

ARB MECHANISM

Blocks angiotensin II from binding to its receptors

ARB EFFECT ON VASOCONSTRICTION

Prevents angiotensin II-induced vasoconstriction

ARB EFFECT ON ALDOSTERONE

Blocks aldosterone release

ARB EFFECT ON SODIUM AND WATER

Decreases renal sodium and water reabsorption

ARB SIDE EFFECTS

Dizziness, fatigue, headache, and angioedema

ARB PREGNANCY WARNING

Major fetal injury and death

ARB NSAID INTERACTION

NSAIDs decrease antihypertensive efficacy

ARB ANTIHYPERTENSIVE INTERACTION

Other antihypertensives and diuretics can cause additive hypotension

ARB ANGIOEDEMA TEACHING

Stop the drug and seek emergency medical attention

SELECTIVE CALCIUM CHANNEL BLOCKERS

Dihydropyridine calcium channel blockers

DIHYDROPYRIDINES

Selective calcium channel blockers

DIHYDROPYRIDINE PROTOTYPE

Nifedipine

DIHYDROPYRIDINE SUFFIX

-dipine

DIHYDROPYRIDINE EXAMPLES

Amlodipine, felodipine, nifedipine, nicardipine, and isradipine

DIHYDROPYRIDINE INDICATIONS

Hypertension, stable angina, variant angina, and Raynaud's phenomenon

RAYNAUD'S PHENOMENON

Spasm of small arteries causing reduced blood flow to the fingers and sometimes toes

DIHYDROPYRIDINE MECHANISM

Selectively blocks calcium channels in vascular smooth muscle

DIHYDROPYRIDINE MAIN EFFECT

Arteriolar vasodilation

DIHYDROPYRIDINE AFTERLOAD EFFECT

Decreases afterload

DIHYDROPYRIDINE COMMON SIDE EFFECT

Peripheral edema

PERIPHERAL EDEMA

Swelling of the ankles and feet

DIHYDROPYRIDINE OTHER SIDE EFFECTS

Headache, dizziness, flushing, lightheadedness, nausea, heartburn, constipation, and fatigue

DIHYDROPYRIDINE SERIOUS SIDE EFFECT

Hepatotoxicity

DIHYDROPYRIDINE REBOUND EFFECT

Abrupt discontinuation can cause severe rebound hypotension

DIHYDROPYRIDINE DIGOXIN INTERACTION

May increase serum digoxin levels

DIHYDROPYRIDINE GRAPEFRUIT INTERACTION

Grapefruit juice can increase levels of some dihydropyridines, especially nifedipine

NIFEDIPINE MI PRECAUTION

Avoid immediate-release nifedipine when impending MI is suspected

LOOP DIURETICS

Diuretics that act on the ascending limb of the loop of Henle

LOOP DIURETIC PROTOTYPE

Furosemide

LOOP DIURETIC EXAMPLES

Bumetanide, furosemide, torsemide, and ethacrynic acid

LOOP DIURETIC INDICATIONS

Acute heart failure, pulmonary edema, peripheral edema, and hypertension

LOOP DIURETIC MECHANISM

Blocks sodium, chloride, and water reabsorption in the ascending loop of Henle

LOOP DIURETIC MAJOR SIDE EFFECT

Significant hypokalemia

LOOP DIURETIC OTHER SIDE EFFECTS

Orthostatic hypotension, hypotension, and circulatory collapse

FUROSEMIDE WARNING

Profound diuresis can cause severe water and electrolyte depletion

LOOP DIURETIC DIGOXIN INTERACTION

Hypokalemia increases the risk of digoxin toxicity

LOOP DIURETIC AMINOGLYCOSIDE INTERACTION

Increases risk of nephrotoxicity and ototoxicity

LOOP DIURETIC CORTICOSTEROID INTERACTION

Can cause severe additive hypokalemia

LOOP DIURETIC AMPHOTERICIN B INTERACTION

Can cause severe additive hypokalemia

FUROSEMIDE NURSING CONSIDERATION

Recheck serum potassium before administration

LOOP DIURETIC ADMINISTRATION TIME

Give early in the day to prevent nocturia

FUROSEMIDE HOLD PARAMETERS

Hold if SBP is below 90 mmHg or DBP is below 60 mmHg

THIAZIDE DIURETICS

Diuretics that act on the early distal convoluted tubule

THIAZIDE PROTOTYPE

Hydrochlorothiazide

THIAZIDE INDICATIONS

Hypertension and edema

THIAZIDE MECHANISM

Blocks sodium, chloride, and water reabsorption in the early DCT

SHORT-ACTING THIAZIDE

Chlorothiazide

INTERMEDIATE-ACTING THIAZIDES

Bendroflumethiazide and metolazone

LONG-ACTING THIAZIDES

Chlorthalidone, indapamide, and methyclothiazide

THIAZIDE SIDE EFFECTS

Hypokalemia, hypotension, and orthostatic hypotension

THIAZIDE ANTIHYPERTENSIVE INTERACTION

Causes additive or synergistic BP lowering

THIAZIDE DIGOXIN INTERACTION

Hypokalemia increases digoxin toxicity risk

THIAZIDE NSAID INTERACTION

Increases risk of NSAID-induced nephrotoxicity

THIAZIDE CHOLESTYRAMINE INTERACTION

Decreases thiazide absorption and effectiveness

THIAZIDE COLESTIPOL INTERACTION

Decreases thiazide absorption and effectiveness