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Pharmacology II Cardiac & Vascular Kathy Plitnick RN PhD CCRN Georgia Baptist College of Nursing Physiology of Circulation Return of deoxygenated blood to the heart Enters the lungs to reoxygenated Ejected out of the left ventricle Cardiac Glycosides Positive Inotropes Increase contractility & CO Improved renal perfusion Increased GFR Increased urine output Slow onset of action Digoxin – Prototype Inhibits Na/K+ pump Calcium remains intracellular longer Improves contractility Lowers heart rate Treatment for At. Fib/Flutter, PSVT Digitalization Digoxin – Prototype Side Effects Bradycardia Heart block Toxic Effects CNS & GI Visual disturbances Precipitated by low K+, Mg, & Ca+ levels Antidote: Digibind Therapeutic Level: 0.5-2.0 ng/ml Digoxin – Prototype Nursing Assess apical pulse for 60 seconds Hold if HR < 60, Call MD Draw blood levels 6-8 hours after dose Monitor drug levels, electrolytes Teach patient to take own pulse Monitor K+, Mag & Calcium Cardiotonics Inocor – Inamrinone Primacor – Milrinone Both given by continuous IV infusion Dosages adjusted to maintain a CI > 2.0 Heart Transplant candidates Coronary Vasodilators Nitrates: Nitroglycerin, Isordil Relax arterial & venous smooth muscle Primary effect on veins Decrease myocardial work, O2 requirements Improves perfusion during ischemia Arterial dilatation Nitrates Routes Sublingual Oral Ointment Transdermal Parenteral Nitrates Side Effects Headache Hypotension Dizziness Palpitations Difficulty breathing Chest pain Nitrates Nursing IV infusion – frequent VS Continuous cardiac monitoring Maintain systolic BP > 90 mmHg Sublingual 3 tablets q 5 minutes Call 911 if no relief Continuous cardiac monitoring Antidysrhythmic Agents Terminate/prevent abnormal cardiac rhythms Classified according to primary effect on action potential Class I – Sodium Channel Blockers Decrease influx of Na+ ions through fast channels during phase 0 Prolongs absolute refractory period Slow rate of spontaneous depolarization during phase 4 Negative inotrope, chronotrope Decrease myocardial O2 demand Class IA – Quinidine Also slows phase 3 repolarization Prolong AP duration Increases QRS & QT Depress contractility Give with food Cardiac monitoring Class IB – Lidocaine Continuous IV for ventricular dysrhythmias Weakens phase 4 Decreases automaticity, AP duration Raises V. Fib threshold Biphasic half-life Topical & local anesthetic Lidocaine “crazies” Class IC – Encainide, Flecainide, Propafenone Slow conduction through His-Purkinje Increase both PR & QRS Increased mortality with Encainide & Flecainide Class II – Beta Blockers Cardioselective Metoprolol Atenolol Acebutolol Non-cardioselective Propranolol Nadolol Esmolol – Prototype Class III - Amiodarone Slow rate of phase 3 repolarization Increase effective refractory period Treat atrial & ventricular dysrhythmias Has characteristics of all 4 classes Blocks potassium channels Vasodilatory action Amiodarone Major Adverse Effects Hypotension, bradycardia, AV block Elevation of LFT’s Proarrhythmic effect Torsades ARDS Pulmonary fibrosis Amiodarone Nursing Baseline pulmonary, LFT’s, CXR Monitor VS, EKG Assess pulse for strength, rate, regularity Monitor for side effects Nausea, fever, decreased appetite Blue-gray discoloration of skin Blurred vision Amiodarone Correct electrolyte imbalances Check SaO2/ABG’s Continuous cardiac monitoring Central line for infusion Class IV – Calcium Channel Blockers Inhibit influx of calcium during phase 2 Primarily in sinus & AV nodes, atrial tissue Negative inotropic, chronotropic, dromotropic effects Increases angina threshold Verapamil (Calan) Depresses sinus & AV node Terminates SVT caused by AV nodal reentry Controls ventricular rate in AFib/Flutter Contraindicated in Sick Sinus Syndrome, advanced block, cardiogenic shock Verapamil Nursing Administer slow > 2 minutes Continuous EKG monitoring Frequency VS Avoid concomitant use of Beta Blockers Diltiazem (Cardizem) Fewer hypotensive side effects Control of ventricular rate in atrial dysrhythmias Rapid conversion of PSVT to NSR Treatment of Angina Initial bolus followed by continuous IV Adenosine Treatment of PSVT & diagnostic aid Slows impulse formation in SA node & through AV node Depresses LV function Half-life less than 10 seconds ! Monitor patient very closely Given IV bolus Monitor EKG, apical pulse, BP, respirations Antihyperlipidemics Definition of Hyperlipidemia Can lipids be bad? 3 Types of Agents Used HMG CoA reductase inhibitors - Statins Zocor, Mevacor, Pravachol Block the synthesis of cholesterol in the liver Decrease LDL, increase HDL Fibric Acids Lopid, Tricor Decrease concentration of VLDL Increase lipase – promotes VLDL catabolism Antihyperlipidemics Bile Acid Sequestrants Questran, Welchol, Colestid Lower LDL levels Bind bile acids in intestine Major Interaction Increase effects of anticoagulants Do not give with grapefruit juice Antihyperlipidemics Dietary corrections Reduce fats, sugars & cholesterol High fiber foods Obtain baseline levels Monitor GI effects Increase water intake Administer dose in evenings