CARDIO DRUGS

trigger points

• low bp

• low blood vessels

• decreased Na

Liver → Angiotensin → Angiotension I

Renin (from Kidney)

Angiotensin I → Angiotensin II

Angiotensin Converting Enzyme (ACE)

Angiotensin II → 2 ways:

• Vasoconstrict → increased BP, increased (constrict) BV

• Na + H2O reabsorption (from aldosterone in adrenal gland)

Stepped Care Approach to Treating HTN

1. Lifestyle Modification 

2. Continue lifestyle modification 

3. Drug modification

4. Additional agents

1. Lifestyle Modification

• weight reduction

• reduction of sodium intake

• smoking cessation

• physical activity

2. Continue lifestyle modification

• initial drug selection

• diuretic or b-blocker

3. Drug Modification

• increase drug dose

• substitute another drug

• add second drug from another class

4. add another

• add second or third agent or diuretic if not already prescribed

Classes of Cardiovascular Drugs (11)

• ACE inhibitors

• Angiotensin II Receptor Blockers

• Calcium Channel Blockers

• Vasodilators

• Cardiac Glycosides

• Phosphodiesterase Inhibitors

• Anti-arrhythmic Agents

• Antianginal Agents

• Antihyperlipidemics

• Drugs affecting Blood Coagulation

• Drugs Used to Treat Anemia

ACE inhibitor action

prevent angiotensin-converting enzyme from converting angiotensin I to Angiotensin II

Indication for ACE inhibitor

• hypertension 

• used in conjunction with digoxin and diuretics for treatment of CHF and left ventricular dysfunction

ACE inhibitors contraindications

• allergy

• impaired renal function

• pregnancy & lactation

ACE inhibitors adverse reactions

• chest pain

• liver injury

• proteinuria

• unrelenting cough

• fatal pancytopenia

ACE inhibitors nsg responsibilities

• implement lifestyle changes 

• empty stomach (1hr b4 or 2 hrs after)

• parenteral forms ONLY IF oral form not feasible

ACE inhibitors sample meds

(-pril) 

• benazepril 

• captopril 

• enalapril 

• ramipril

Angiotensin II Receptor Blockers (ARBs)

angiotensin II receptor blockers selectively bind with angiotensin Il receptor sites in vascular smooth muscles and in the adrenal gland to block vasoconstriction and the release of aldosterone.

ARBs sample medications

(-sartan)

• Losartan

• Valsartan

• Irbesartan

• Cadesartan

• Telmisartan

ARBs indication

• Hypertension

• CHF in patients who are intolerant to ACE inhibitors

• Slow progression of renal disease in patients with hypertension and type 2 diabetes

ARBs contraindication

• allergy

• pregnancy & lactation

ARBs adverse effects

• URTI

• alopecia

ARBs nsg considerations

• monitor bp before and after giving drug

• administer w/o regards to meal

• monitor carefully → may lead to drop in fluid volume

Calcium Channel Blockers action

Inhibit movement of calcium ions across the membranes of myocardial and arterial muscle cells, altering the action potential and blocking muscle cell contraction

Calcium Channel Blockers sample meds

(-dipine)

• amlodipine

• diltiazem

• felodipine

• nicardipine

• nifedipine

• veramipil

calcium channel blockers indications

• HTN

• angina

calcium channel blockers c/i

• Allergy

• Heart block or sick sinus syndrome

• Renal or hepatic dysfunction

• Pregnancy or lactation

calcium channel blokers a/e

• dizziness, lightheadedness, headache and fatigue

• hypotension, bradycardia, peripheral edema, and heart block

• skin flushing and rash

Vasodilators

Act directly on vascular smooth muscles to cause muscle relaxation, leading to vasodilation and a drop in blood pressure

Vasodilators sample meds

• Nitroprusside

• Diazoxide

• Hydralazine

• Minoxidil

Vasodilators indication

• severe HTN or HTN emergencies

Vasodilators c/i

• Allergy

• Pregnancy and lactation

• Any condition that could be exacerbated by a sudden fall in blood pressure

Vasodilators a/e

• dizziness, anxiety, headache, reflex tachycardia, CHF, chest pain, edema

• Skin rash and lesions (abnormal hair growth with minoxidil

• Gl upset, nausea and vomiting

• Cyanide toxicity (dyspnea, headache, vomiting, dizziness, ataxia, loss of consciousness, imperceptible pulse, to cyanide absent reflexes, dilated pupils, pink color, distant heart sounds, shallow breathing) may occur with nitroprusside

Vasodilators nsg considerations

• Be alert for signs of cyanide toxicity with intake of nitroprusside

• Monitor blood pressure closely during administration

• Minoxidil increases the heart rate, notify the physician if the HR is 20 beats above the normal

• Nitroprusside and diazoxide are used to treat patients a hypertensive emergency.

• Nitroprusside infusion bottles are wrapped in aluminium foil or other opaque material to protect the drug from light. If protected from light, it remains stable for up to 24 hours.

Vasodilators nsg considerations

• Obtain blood pressure and pulse rate on both arms with the patient standing, sitting and lying.

• The blood pressure and pulse rate must be obtained immediately before each drug administration and compared with previous readings.

• Obtain daily weights because of sodium and water retention. Examine the extremities for edema. Report a weight gain of 2 lbs or more per day.

• advises the patient to rise slowly from a sitting or lying position

• Skipping doses of the drug or discontinuation may cause severe, rebound hypertension.

• The nurse educates the patient about lifestyle modifications to manage hypertension.

Cardiac Glycosides

increase intracellular calcium and allow more calcium to enter myocardial cells during depolarization

Cardiac glycosides → cause following effects:

• a positive inotrope effect

• Increased cardiac output and renal perfusion

• a negative chronotropic effect - decrease ype

• Decreased conduction velocity through the AV node

Cardiac glycosides sample meds

• Digoxin 

• Digitoxin

Cardiac glycosides indications

• CHF

• atrial flutter

• atrial fibrillation

• paroxysmal atrial tachycardia

Cardiac glycosides c/i

• Ventricular tachycardia or fibrillation

• Heart block or sick sinus syndrome

• Idiopathic hypertrophic subarotic stenosis

• Acute MI

• Renal Insufficiency

Cardiac glycosides a/e

• headache

• weakness

• drowsiness & vision changes

• bradycardia 

• anorexia & GI upset

Cardiac glycosides nsg responsibilities

• Consult with the prescriber about the need for a loading dose when beginning therapy.

• Monitor apical pulse for 1 full minute before administering the drug. Hold the dose if pulse is less than 60 in adults or less than 90 infants; retake pulse in 1 hour.

• Administer IV doses very slowly over at least 5 minutes.

• Avoid administering the oral drug with food or antacids to avoid delays in absorption.

• Monitor the patient for therapeutic digoxin level 0.5-2 nE/meg

• Severe toxicity with digoxin is treated with digoxin immune fab (Digibind).

• Avoid hypokalemia. Hypokalemia makes the heart muscle more sensitive to digitalis, increasing the possibility of developing digitalis toxicity.

Phosphodiesterase inhibitors

blocking effect → increase in myocardial cell CAMP, which increases calcium levels in the cell → stronger contraction and prolongs the effects of sympathetic stimulation → increased oxygen consumption and arrhythmias

phosphodiesterase inhibitors sample meds

• Amrinone

• Milrinone

phosphodiesterase inhibitors indication

• short-term treatment of CHF

phosphodiesterase inhibitors c/i

• Allergy to bisulfites.

• Severe aortic or pulmonic valvular disease

• Acute MI

• Fluid volume deficit

• Ventricular arrhythmias

phosphodiesterase inhibitors a/e

• hypotension & chest pain

• nausea

• vomiting

• anorexai & abdominal pain

• thrombocytopenia

phosphodiesterase inhibitors nsg responsibilities

• Protect the drug from light

• Monitor pulse and blood pressure periodically during administration.

• Monitor input and output and record daily weights o Monitor platelet counts prior to and regularly during therapy.

• Electrolyte disturbances, decreases in the oxygen delivered to the cells, structural damage in the conduction pathway, drug effects, acidosis or the accumulation of waste products can trigger arrhythmias

• cardiac conduction system determines the heart's rate and rhythm. Landmarks of the system include the SA node → directs electrical impulses through the atria → AV node → through the bundle of His into the ventricles and down bundle branches → the Purkinji fibers

Anti-arrhythmic Agents (4)

• Class I Antiarrhythmics

• Class II Antiarrhythmics

• Class III Antiarrhythmics

• Class IV Antiarrhythmics

Class I Antiarrhythmics subclass (2)

• Class Ia

• Class Ib

Class I Antiarrhythmics Class Ia sample meds

• procainamide

• quinidine

Class I Antiarrhythmics Class Ib sample meds

• lidocaine

Class I Antiarrhythmics

Stabilize the cell membrane of cardiac muscles by binding to sodium channels, depressing phase 0 of the action potential; have a local anesthetic effect

Class I Antiarrhythmics indications

• Ventricular arrhythmias

Class I Antiarrhythmics c/i

• Allergy

• Bradycardia or heart block unless artificial pacemaker is in place

• Congestive heart failure, hypotension or shock

• Lactation

• Electrolyte imbalances

class I antiarrhythmics a/e

• dizziness, drowsiness, twitching, mouth numbness, slurred speech and tremors

• change in taste, hypotension and vasodilation, respiratory arrest

class I antiarrhythmics nsg responsibilities

• Continually monitor cardiac rhythm when initiating or changing dose. Maintain life support on standby.

• Give parenteral forms only if the oral form is not feasible

• Titrate the dose to the smallest amount needed to achieve control of the arrhythmia.

Class II antiarrhythmics

Block beta receptor (Beta → 2nd letter) sites in the heart and kidneys → decreasing heart rate, cardiac excitability, and cardiac output and slowing conduction through the AV node → decreasing the release of renin.

Class II antiarrhythmics sample meds

(-olol)

• Acetabutolol

• Esmolol 

• Propanolol 

Class II antiarrhythmics indication

• supraventricular tachycardia (SVT)

• Premature Ventricular Contractions (PVC)

class II antiarrhythmics c/i

• Sinus bradycardia and AV block

• Cardiogenic shock, CHF, asthma or respiratory depression

• Pregnancy and lactation

class II antiarrythmics a/e

• dizziness, insomnia, hypotension, BRADYCARDIA, bronchospasm and dyspnea, alterations in blood glucose level

• Nausea, vomiting, anorexia

Class III antiarrhythmics

Block potassium channels and slow the outward movement of potassium during phase 3 of the action potential

Class III antiarrhythmics sample meds

• Amiodarone

• Bretylium

Class III Antiarrhythmics

• life threatening ventricular arrhythmias

• atrial fibrillation 

• atrial flutter

class III antiarrhythmics a/e

• nausea, vomiting, Gl distress, weakness and dizziness, hypotension

• Amiodarone: liver toxicity, ocular abnormalities and cardiac arrhythmias

class IV antiarrhythmics

Block the movement of calcium ions across the cell membrane, depressing depolarization and prolonging repolarization

class IV antiarrhythmics indication

• HTN

• angina 

• supraventricular tachycardia

class IV antiarrhythmics c/i

• Allergy

• Sick sinus svndrome or heart block

• Pregnancy or lactation

class IV antiarrhythmics a/e

• vasodilation

• dizziness

• weakness

• fatigue

• headache

• hypotension

• edema

class IV antiarrhythmics nsg cons

• Take and record the BP, apical and radial pulses and respiratory rate before giving the drug.

• Notify physician if the pulse rate is above 120 bpm or below 60 bpm.

• Continual cardiac monitoring assists the nurse in assessing the patient for adverse drug reactions.

• Lidocaine is an emergency drug for ventricular arrhythmias. Constant cardiac monitoring is needed. Observe closely for signs of respiratory depression, bradycardia, change in mental status, and hypotension. Airway and suction equipment are kept at bedside. Atropine is given IV for pronounced bradycardia.

Class IV antiarrhythmic sample meds

• Diltiazem 

• Verapamil

Antianginal Agents

dilate bv and decrease work of heart

Antianginal Agents (3)

1. Nitrates

2. Beta adrenergic blockers

3. Calcium channel blockers

Nitrates

Relax and dilate veins, arteries and capillaries

Nitrates sample meds

• Nitroglycerin

• Amy nitrate

• Isoborbide dinitrate

• Isoborbide mononitrate

Nitrates indications

• angina pectoris

Nitrates c/i

• allergy

• severe anemia 

• head trauma or cerebral hemorrhage 

• pregnancy and lactation

Nitrates a/e

• Headache, dizziness and weakness

• Nausea, vomiting and incontinence

• Hypotension, reflex tachycardia; syncope

• Flushing, pallor, increased perspiration

• Contact dermatitis and local hypersensitivity reactions

Nitrates nsg consideration

• Proper use of each medication (SL, buccally, chewable tablets, topical, lingual aerosols, inhalation, transdermal nitrates)

• Record characteristics of anginal attacks

• Avoid activities that will cause vasodilation

• Change positions slowly

• Provide life support equipment on a standby basis

• Taper dosage over 4 to 6 weeks

Beta blockers

Block beta-adrenergic receptors in the heart and juxtaglomerular apparatus

Beta blockers sample meds

• metoprolol

• nadolol

• propanolol

*same as class II antiarrhythmic

beta blockers indication

• Long-term management of angina pectoris

• prevent reinfarction in stable patients (propanolol)

beta blockers c/i

• Bradycardia, heart block, cardiogenic shock, asthma or COPD

• Pregnancy and lactation

beta blockers nsg cons

• Have a supply of immediate-acting nitrate - a need

• EOF, high fiber diet

• Do not discontinue abruptly

• Avoid activities that result in vasodilation

• Report unusualities

Calcium channel blockers

Inhibit the movement of calcium ions across the membranes

calcium channel blockers indications

• Prinzmetal's angina

• chronic angina

• effort associated angina

• hypertension

calcium channel blockers sample meds

• amlodipine besylate

• diltiazem hydrochloride

• nicardipine hydrochloride

calcium channel blockers c/i

• Allergy

• Heart block or sick sinus syndrome

• Renal and hepatic dysfunction

calcium channel blockers a/e

• Dizzines, light headedness, headache and fatigue

• Nausea, hepatic injury

• Hypotension, bradycardia, peripheral edema and heart block

• Flushing and rash

calcium channel blockers nsg cons

• Monitor the patient carefully

• Take as prescribed

• Monitor pulse rates and anginal pain

• Limit caffeine intake

• NO OTC drugs

Antihyperlipidemics (3)

1. bile acid sequestrants

2. HMG-CoA reductase inhibitors

3. cholesterol absorption inhibitors

bile acid sequestrants (antihyperlipidemics)

Bind with bile acids in the intestine to form a complex that is excreted in the feces

bile acid sequestrants indication

• Primary hypercholesterolemia

bile acid sequestrants sample meds

• cholestyramine

• colestipol (Colestid)

• colesevelam (Welchol)

bile acid sequestrants c/i and cautions

• Allergy to bile acid sequestrant

• Complete biliary obstruction

• Abnormal intestinal function

• Pregnancy and lactation

bile acid sequestrants a/e

• Headache, anxiety, fatigue and drowsiness

• nausea, constipation that may progress to fecal impaction, and aggravation of hemorrhoids

• Increased bleeding times

• Vitamin A and D deficiencies

• Muscle aches and pains

bile acid sequestrants nsg cons

• Do not administer powdered agents in dry form; Colestipol may be mixed with carbonated beverages and swallow all of the dose.

• Swallow the tablets whole

• Give the drug before meals

• Administer other oral medications 1 hour before or 4 to 6 hours after the bile sequestrant

• Arrange bowel program

• Provide comfort measures

HMG-CoA Reductase Inhibitors

Block HMG-CoA reductase from completing the formation of cellular cholesterol

3-hydroxy-3-methylglutaryl coenzyme A

HMG-CoA

HMG-CoA Reductase Inhibitors indications

• increased cholesterol and LDL levels

• To slow progression of CAD in patients

• To prevent first MI in patients