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Cardiac Medications By Theresa Till RN, Ed.D, CCRN The Intima Controls the Destiny of the Cardiovascular System Atherosclerosis Atherosclerosis results from the interaction between the intimal surface (endothelium), WBCs (macrophages), and fat (lipoprotein). http://www.youtube.com/watch?v=n8P3n6GKBSY http://www.youtube.com/watch?v=q RK7-DCDKEA&NR=1 Macrophage on Intima The macrophage determines that the fat on the intima is foreign and sends WBCs to the surface to destroy the fat. However, the intima is frequently also damaged. Blood Vessel Layers http://www.youtube.com/watch?v= zeS-0au8ij4&NR=1&feature=fvwp Antiplatelets Decrease afterload because they cause the cells to be less sticky. http://www.youtube.com/watch? v=YcNYxegDXa8 Platelet Activation Clotting Cycle Heparin Route: IV or SQ Onset: Immediate Duration: hours (about 4) Monitor: APTT, anti-Xa Antidote: Protamine Sulfate Heparin-Induced Thrombocytopenia (HIT) 12 million patients exposed to heparin each year. Consider HIT whenever a hospitalized patient exposed to heparin experiences a drop in platelet count or develops new thrombi. HIT results in thrombosis despite anticoagulation due to immune complex aggregation in blood despite low or reduced platelet counts. Patients lose unaffected extremity due to thrombosis (fractured ankle, lose hand). Definition of HIT Thrombocytopenia: ≤ 150,000 50% drop in platelet count from baseline (can still be within normal range and have HIT) Platelet recovery once UFH/LMWH stopped Patient with or without thrombosis Treatment for HIT Stop heparin product Give direct thrombin inhibitor bivalirudin (Angiomax) lepirudin (Refludan) Argatroban (Acova) Fondaparinux (Arixtra) Once platelet count recovers, put patient on Coumadin. Coumadin Route: Oral Onset: Slow (hours) Duration: Days Monitor: PT, INR Antidote: Vitamin K Keep dietary intake of Vitamin K consistent. Properties of the Heart Inotropic (strength of cardiac contraction) Chronotropic (rate of cardiac contraction) Dromotropic (electrical excitability of the heart) Hemodynamics of the Heart Preload –amount of fluid in ventricles immediately before contraction. Afterload- amount of resistance the heart has to overcome to eject blood into the circulatory system. Contractility- amount of heart stretch Preload Patients in HF have an increased preload. This increased fluid in the chambers of the heart result in increased stretching of the muscle. Degree of stretching can be measured by the BNP (Brain Naturetic Peptide). Blood test BNP > 100 suggestive of HF http://www.youtube.com/watch?v=GnpL m9fzYxU Hypertension Guidelines Category Normal Pre-HTN HTN (1) HTN (2) SBP <120 120-139 140-159 >160 DBP <80 80-89 90-99 >100 HTN 2X risk of CVA, MI if patient 20/10 over goal. 4X risk of CVA, MI if patient 30/20 over goal. Using combination therapy much sooner. “Dipper v. Non-Dipper” Important to take BP different times during day----even at night. Normally, BP reduces when a person sleeps. However, some people have a BP that remains high throughout the day, which increases the risk of coronary artery disease. Diuretics and Renal Absorption Nitrates Tolerance is a “big” issue Safety is a big issue since they are powerful preload and afterload reducers (dilate blood vessels and drop BP) Renin Angiotensin Aldosterone System (RAA) Renin/Angiotensin System Renin Angiotensin I Angiotensin II (vasoconstriction) Aldosterone release from adrenals (sodium retention, potassium excretion and fluid retention). Opposite occurs with ACEI because block Angiotensin II so loose sodium/fluid and retain potassium. Renin/Angiotensin/Aldosterone (RAA) System Angiotensin I converts to Angiotensin II which causes VASOCONSTRICTION Next, aldosterone is released that results in sodium retention and potassium excretion. When ACE inhibitors block the renin/angiotensin system, sodium is released and potassium is absorbed. Check for hyperkalemia. Ace Inhibitors Preload reducer (decreases venous volume) Afterload reducer (decreases arterial volume) Diuretic ACE Inhibitors Renin-angiotensin-aldosterone system (RAAS): http://pearsonium.com/RAASystem/ind ex.html Calcium Channel Blockers Block the calcium influx into the blood vessel thus preventing actin and myosin from sliding over each other. Net vasodilation Also, great for Prinzmetal angina (spasm). Some are powerful dysrhythmics Calcium Channel Blockers Actin/Myosin Beta Blockers Decreases Heart Rate (Blunts HR) Decreases Heart Contraction Decreases Excitability of Heart CARE WITH DIABETICS AND ASTHMATICS Cholesterol Remember that cholesterol can be elevated if a person is hypothyroid. Physicians should do a thyroid panel (T3,T4, TSH) before starting a patient on hypolipemics. Many times once the thyroid problem is corrected, the cholesterol returns to normal. New Statin Guidelines ACC/AHA Individuals who need statins are Diabetics History of Heart Disease LDL >1 90 •Patients with an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75 years of age (the report provides formulas for calculating 10year risk). New Statin Guidelines Websites http://circ.ahajournals.org/content/early/2013/11/11/01.cir.00004377 38.63853.7a.full.pdf Research article explaining new guidelines http://my.americanheart.org/professional/StatementsGuidelines/Pr evention-Guidelines_UCM_457698_SubHomePage.jsp Calculator http://newsroom.heart.org/news/acc-aha-publish-new-guidelinefor-management-of-blood-cholesterol Guidelines Controversy Regarding “Statin” Guidelines http://www.doctoroz.com/episode/controversial-new- statin-guidelines Part 1 http://www.doctoroz.com/episode/controversial-newstatin-guidelines?video_id=2859817307001 Part 2 Cholesterol HDL/LDL Ratio Hyperlipidemia Total Cholesterol HDL “Good Fat” LDL “Bad Fat” Triglycerides Hypothyroidism can lead to increased cholesterol. TC/HDL Ratio Want < 200 Want >40 M >50 F Want < 130 if healthy Want < 100 if high risk (some MD want ≤ 70) Want < 150 Want < 4.5 TC/HDL Ratio Examples: Patient A: Total cholesterol 240, HDL 80 240/80 =3 (Low Risk for CAD) Patient B: Total Cholesterol 240, HDL 30 240/30= 8 (High Risk for CAD) Metabolic Syndrome Clustering of obesity, dyslipidemia, hypertension, and insulin resistance exponentially increase the risk of CAD. http://www.oprah.com/oprahshow/ Dr-Oz-Explains-What-DiabetesDoes-to-Your-Body-Video Metabolic Syndrome (continued) Three of five = increased risk of CAD Waist circumference M >40” and F >35” TG > 150 HDL Men <40 Women <50 BP > 130/85 Fasting blood sugar >110 Dysrhythmics http://www.youtube.com/watch?v=xL zRFAT9uFA http://www.youtube.com/watch?v= XV11kplLoxw&feature=related Normal Electrical Conduction System through the Heart When impulses do not travel normal electrical pathway, dysrhythmias occur. Electrical System 1) P Wave = atrial contraction 2) PR Interval = 0.12-0.20 (SA Node → AV Node) 3) QRS complex =ventricular contraction (≤ 0.12) 4) ST segment (should be flat or isoelectric) 5) T wave = ventricular relaxation 6) QT Interval = ventricular contraction and relaxation (≤ 0. 40) Smoking Disconnect remains between trial evidence and clinical practice. 25% of Americans smoke yet people have known since the 1960s that smoking causes cancer. Cardiologists are writing “no smoking” prescriptions to reinforce importance of abstinence.