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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




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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)


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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.