Patho Pharm 2 Cardiac

Atherosclerosis

Build-up of fatty plaque, loss of elasticity of walls of arteries, narrow, thrombi

cholesterol

essential for life BUT too much LDL=BAD!

LDL levels

Less than 100 (70 if high risk)

HDL levels

Greater than 40 M 50 F

Triglycerides levels

Less than 150

total levels

Less than 200

LDL

*greatest contribution to ASCVD* (storage) "BAD" delivery

HDL

"H" healthy/good" promote removal!

triglyceride

deliver and store

therapeutic lifestyle changes (TLC)

•THIS IS FIRST LINE THERAPY!

•Diet

•Exercise

•Smoking cessation

•Weight control

•THIS MUST CONTINUE EVEN WITH DRUG THERAPY!

Dyslipidemia Drugs

•HMG-CoA reductase inhibitors (Statins)

•Cholesterol absorption inhibitors

•Bile-acid sequestrants

•Fibrates

HMG-CoA Reductase Inhibitors (Statins) prototype

atorvastatin (Lipitor)

atorvastatin purpose

Reduce LDL, increase HDL, reduce triglycerides

atorvastatin MOA

inhibition of HMG-CoA Reductase & increase LDL receptor sites

atorvastatin therapeutic uses

Lower Events r/t ASCVD:

•Stroke/MI/death

atorvastatin adverse drug reactions

•Hepatotoxicity

•Myopathy

•GI upset

•Memory loss

•Teratogenic do not give during pregnancy or while breastfeeding

atorvastatin nursing interventions/education

•LFT's before and during therapy

•Jaundice

•Avoid ETOH

•Monitor CK levels and for signs of muscle weakness

•Use cautiously in older adults

•Administer at HS (usually dosed once a day)

Cholesterol Absorption Inhibitors prototype

ezetimibe (Zetia)

ezetimibe purpose

reduction of total cholesterol, reduction of LDL

ezetimibe MOA

•inhibits dietary cholesterol abs in SI, inhibits reabsorption of cholesterol in bile

•Monotherapy or combined with a statin

ezetimibe adverse drug reactions

•Hepatotoxicity (especially if also taking statins)

•Muscle pain

ezetimibe nursing interventions/education

•Monitor LFTS/signs of dysfunction (jaundice)

•Monitor creatinine kinase (CK)

•Avoid ETOH

Bile-Acid Sequestrants prototypes

colesevelam (Welchol) and cholestyramine (Questran)

colesevelam and cholestyramin MOA

•Binds to bile salts and prevents their reabsorption

•Decreases LDL cholesterol

colesevelam and cholestyramin adverse drug reactions

constipation

colesevelam and cholestyramin nursing interventions/client education

•dose one hour before or 4 hours after thiazides, digoxin, and warfarin

•cholestyramine decrease uptake of fat-soluble vitamins (ADEK)

•Increase fluids & water

•Take with food and full glass of water

fibrates prototype

gemfibrozil (Lopid)

gemfibrozil (Lopid) adverse drug reactions

•Gallstones

•GI distress

•Myopathy

•Hepatotoxicity

gemfibrozil (Lopid) nursing interventions/education

•Watch for signs of gallbladder disease

•Monitor CK levels and watch for muscle weakness

•Monitor liver function tests

•Increases risk for bleeding when on Coumadin

•Proceed with caution if also dosed w Statins

•Take 30 minutes before breakfast and dinner

angina treatment

•Nitrates

•Beta adrenergic blockers (metoprolol)

•Calcium channel blockers

preload

volume of blood in ventricles at end of diastole (end diastolic pressure)

afterload

resistance left ventricle must overcome to circulate blood

cardiac output equals

heart rate x stroke volume

stroke volume

preload, afterload, and contractility (Starling's Law)

nitroglycerin MOA

•Works directly on vascular smooth muscle (VSM) to promote venous dilation (decrease preload, decrease O2 demand)

•Works to reduce coronary artery spasm

nitroglycerin adverse drug reactions

•headache

•hypotension

•tachycardia

•Tolerance

nitroglycerin nursing interventions/education

•Use acetaminophen/analgesia for pain

•Education about ortho HTN (think safety)

•Monitor vitals/ beta blocker for tachycardia

•Use lowest dose

•Avoid alcohol

•Do not take with sildenafil (VIAGRA) PDE5 inhibitor

nitroglycerin sublingual tablets/powders/sprays

•Rapid onset

•Practice change: if no resolution in pain after 5 minutes call 911 (take more while you wait)

nitroglycerin sustained-release oral capsules

•long term prophylaxis

•Swallow (don't chew/crush)

nitroglycerin transdermal/topical

•Patches

•Ointment

nitroglycerin intravenous

•Used for angina/heart failure

•Titrated

•Monitor BP

•Glass bottle

antihypertensive drug classes

•Thiazide diuretics - hydrochlorothiazide (1st line)

•Angiotensin-converting enzyme (ACE) inhibitors

•Angiotensin II receptor blockers (ARBs)

•Calcium channel blockers (CCB)

•Alpha adrenergic blockers

•Alpha 2 agonists

•Beta adrenergic blockers

•Vasodilators

Angiotensin-Converting Enzyme (ACE) Inhibitors prototype

captopril (Capoten)

captopril purpose/MOA

Block ACE from converting angiotensin I to angiotensin II

captopril therapeutic uses

•HTN

•Heart failure

•LV dysfunction post MI

•Diabetic Nephropathy

captopril adverse drug reactions

•First-dose orthostatic hypotension

•Angioedema

•Cough

•Elevated potassium

•Neutropenia

•teratogenic

captopril nursing interventions/education

•Monitor blood pressure 2 hours after initial dose

•Monitor potassium levels and WBC count

•Stop medication if sensitivity reaction occurs

•Caution with potassium sparing diuretics

Angiotensin II Receptor Blockers (ARBs) prototype

losartan (Cozaar) "sartans"

losartan purpose/MOA

blocks angiotensin II from working (vasodilation and excretion of sodium and water)

losartan therapeutic uses

•HTN

•Heart failure, prevent MI and stroke

losartan adverse drug reactions

•Angioedema (less than ACE inhib)

•Dizziness

•Hypotension

•Headache

•Insomnia

•Teratogenic

losartan nursing interventions/education

•Monitor BP

•Watch for facial swelling and treat with epinephrine

•Do not give during pregnancy

Calcium Channel Blockers prototype

nifedipine

nifedipine purpose/MOA

•Blocks calcium channels in blood vessels

•Causes vasodilation and prevents vessel spasms

•Decreases heart rate and contractility

nifedipine therapeutic uses

•Hypertension

•Angina

•Tachycardia/dysrhythmias (diltiazem)

nifedipine adverse drug reactions

•Reflex tachycardia

•Peripheral edema

•Acute toxicity

•Hypotension, bradycardia

nifedipine nursing interventions/education

•Monitor vitals BP/HR (EKG)

•Monitor for edema, weight gain and give diuretic

•Do not give with grapefruit juice

Alpha1 Adrenergic Blockers prototype

doxazosin

doxazosin purpose

Blocks alpha 1 receptors causing venous & arterial dilation

doxazosin therapeutic uses

HTN (BPH)

doxazosin adverse drug reactions

First-dose orthostatic hypotension, reflex tachycardia, headache, dizziness

doxazosin client education

•First dose is given at night

•Educate about orthostatic hypotension - safety measures

Centrally Acting Alpha-2 Agonists prototype

clonidine (Catapres)

clonidine purpose/MOA

•Act within the CNS to decrease stimulation of alpha and beta receptors of the heart and vasculature system

•Lowers heart rate and cardiac output, vasodilation

clonidine therapeutic uses

•Hypertension

•Pain (migraines), ADHD

•Off label use: withdrawal and Tourette's

clonidine adverse drug reactions

•Drowsiness and dizziness

•Dry mouth (xerostomia)

•Rebound hypertension if abruptly discontinued

clonidine nursing interventions/client education

•Avoid activities that require mental alertness

•Do not discontinue treatment - wean off

•If given in addition with other antihypertensive - monitor for hypotension

•Do not give with other drugs that cause CNS depression or alcohol

•Given twice a day - larger dose at bedtime

•Chew gum or suck on hard candy

•Transdermal patches change every 7 days

Beta Adrenergic Blockers "olols" prototype

carvedilol (atenolol, propranolol)

carvedilol (atenolol, propranolol) purpose

Blocks beta I and beta 2 receptors causing:

•Beta I - decreased heart rate, contractility, BP, & cardiac output

•Beta 2 - constricts bronchi in the lungs

carvedilol (atenolol, propranolol) therapeutic uses

•hypertension

•Angina, tachycardia, heart failure, MI

carvedilol (atenolol, propranolol) adverse effects

•Bradycardia (may worsen HF)

•Decreased cardiac output

•Orthostatic hypotension

•Mask signs of hypoglycemia

•Beta 2 blockade: bronchoconstriction

carvedilol (atenolol, propranolol) nursing interventions/education

•Monitor HR and hold drug if <60 bpm / monitor BP

•Use cautiously in clients with heart failure and watch for worsening

•Educate on orthostatic hypotension

•Avoid nonselective beta blockers if client has asthma or other lung diseases

•May mask symptoms of hypoglycemia - monitor blood glucose levels in diabetics closely

Direct-Acting Vasodilators prototype

hydralazine

hydralazine purpose

Dilates arteries, decrease BP

hydralazine therapeutic uses

•hypertension

•HF, pulm HTN, and angina

hydralazine adverse effects

•Reflex tachycardia

•Dizziness

•Weakness

•Fatigue

•Headache

•SLE like syndrome

hydralazine nursing interventions/education

•Monitor HR

•Educate on orthostatic hypotension

•Facial rash, joint pain, fatigue (SLE)

•Taper off dosing