Download CB064-4.15

Cardiovascular Diseases and Related
Medications
NSG 106
Pharmacotherapeutics
Six Cardinal Signs of Heart
Failure
Dyspnea
Chest Pain
Fatigue
Edema
Syncope or near-syncope
Palpitations
Treatment of Heart Failure
Combination of vasodilator, inotropic, and diuretic
therapies
Vasodilators reduce Left Ventricular strain = reduced
peripheral resistance against which the LV must pump (I.e.,
reduces “afterload”)
Vasodilators also reduce “preload”.
• the volume of blood returning to the right side of heart is
decreased. This decreases pulmonary congestion and decreases
SOB.
• Example – IV Nitro gtt (critical pt)
• Example – ACE Inhibitors, possibly Beta blockers if no severe
respiratory compromise
Treatment of Heart Failure
Inotropic agents stimulate the heart to increase the
force of contraction, making cardiac output more
efficient, which improves overall tissue and organ
perfusion
Example: Digoxin
Diuretics are administered after renal perfusion is
improved, to further enhance sodium and water
excretion.
Example: Loop diuretics – Lasix, Bumex
Digitalis Glycosides
Definition
These drugs (Prototype-digoxin) have 2 primary actions in the
treatment of heart failure/arrhythmias
• Positive Inotrope
 Increases force of heart’s contraction
• Negative chronotrope
 Slows the heart rate
Purpose
These actions allow the “pump” to work more effectively by filling
and emptying more completely w/each beat
Treatment
CHF, afib/flutter, other atrial arrhythmias
Digoxin (Lanoxin)
Loading dose to “digitalize” the patient over
24-48 hrs, then –
Maintenance dose, usu. QD
To achieve optimum Cardiac Output, heart rate,
and relief of CHF symptoms
• Usu. will take med the rest of their life
Digoxin most commonly used, IV or p.o.
Not the same as digitoxin
Digoxin
Implementation
Take apical pulse one full minute before administration
• Adult: DO NOT administer if apical pulse is < 60
• Peds: DO NOT administer if apical pulse is < 90
 Consult w/MD before administering drug
Monitor for S/S of dig. toxicity
• Lab results for digoxin levels
• N/V, bradycardia, visual/psych disturbances
• If toxic, expect orders to stop digoxin and any K+-depleting
diuretics
 Digibind IV (antidote if severely toxic)
Therapeutic Outcomes
Improved Cardiac Output, resulting in improved tissue
perfusion and tolerance to activity
Antiarrhythmics
•Classified according to their
effects on the electrical
conduction system of the
heart.
• Therapeutic Outcome:
Normal Sinus Rhythm
Antiarrhythmics
Myocardial depressants inhibit NA+ ion movement in
cardiac muscle (“anesthetize” the muscle in an effort to stop
the arrhythmia)
Example: Lidocaine
Treat ventricular arrhythmias which can be life-threatening, e.g., vtach, v-fib
Make sure you have lidocaine WITHOUT PRESERVATIVES OR
EPINEPHRINE! Lidocaine with preservatives and/or epi are used to
inject locally for an anesthetic.
S.E.’s: restlessness, muscle twitching, seizures
Antiarrhythmics
Slow the rate of electrical conduction
Prolongs time between contractions
Example: Amiodarone (Cordarone) IV/p.o.
Treats ventricular, supraventricular arrhythmias,
afib/flutter
Many side effects
• Fatigue, tremors, sleep disturbance, ataxia, dizziness, exertional
dyspnea, cough, blurred vision, N/V, constipation, anorexia,
photosensitivity, hepatotoxicity
• Increases serum levels of digitalis glycosides, coumadin,
dilantin, theophylline – MONITOR!
Anti-Anginals
Definition
Angina pectoris is chest discomfort resulting from the heart muscle’s
lack of adequate 02 perfusion, typically due to coronary artery disease
(CAD) of the vessels which perfuse the heart muscle.
Purpose
To decrease the oxygen demand of the heart muscle by decreasing
heart rate, myocardial contractility, and ventricular volume.
Platelet aggregation, blood flow turbulence, and blood viscosity also
play a role in coronary circulation. Therefore, platelet-active agents are
included in the discussion.
Anti-Anginals
Nitrates
Calcium Channel Blockers
Beta Blockers
Platelet-Active Agents
Therapeutic Outcome:
Relief of chest discomfort and improved ability
to tolerate physical activity
Nitrates
Nitroglycerin (Nitrostat)
Produces potent peripheral vasodilatation and coronary
artery dilatation, enhancing 02 supply to ischemic heart
muscle.
Delivery: sublingual (tab), topical (paste), translingual
(spray), transdermal (patch), or IV
For chest pain (CP)
• SL tab or spray dose q 5 minutes x 3 to relief of CP,
• monitoring BP and pulse before each successive dose. Have pt sit
or lie down; assist to trendelenberg if lightheaded or low BP.
• IV site in place before hand, in case fluid administration is needed
to raise BP.
If unrelieved, alert MD.
Nitrates
Side Effects:
Headache (usu. transient, ~5 - 20 mins)
Excessive hypotension
• May need to place in Trendelenberg and/or IV fluids if nearsyncope.
Dizziness, flushing, nausea (usu. transient)
Interactions
Avoid alcohol, other CNS depressants unless
prescribed; do NOT use concurrently w/Viagra
Platelet-Active Agents
Hemorrheologic Agents
Definition
• Increases erythrocyte flexibility, decreases
fibrinogen, and prevents aggregation of RBC’s and
platelets.
Purpose
• Decreases viscosity of blood and improves flow
properties, resulting in increased blood flow to
affected areas, thereby enhancing tissue oxygenation
Platelet-Active Agents
Pentoxifylline (Trental)
• Treatment
 Peripheral vascular disease
 Intermittent claudication
• Side Effects:
 GI upset (dyspepsia)
 Give w/ food
 HA, dizziness
 Monitor for pt. safety with initial doses
Therapeutic Outcome
• Improved tissue perfusion and peripheral pulses; improved
activity tolerance
Platelet-Active Agents
Platelet Aggregation Inhibitors
Definition
• Increases levels of cAMP, resulting in vasodilatation
and inhibition of platelet aggregation (tendency of
platelets to clump together).
Purpose
• By improving vasodilatation and decreasing platelet
aggregation, symptoms of peripheral vascular
disease should improve.
Platelet-Active Agents
Cilostazol (Pletal)
Treatment
• PVD, e.g., intermittent claudication
 Tx should also include smoking cessation, weight loss, surgical
intervention if necessary
Side Effects
• Dyspepsia, diarrhea
• HA, dizziness
Adverse Effect
• NOT to be given to CHF patients
• Anti-fungals, diltiazem, and grapefruit juice can inhibit the
metabolism of this drug - dose should be halved if taking any of
these concurrently.
Hypertension
High blood pressure puts a strain
on the heart and the arteries.
People with high blood pressure
are also at higher risk for MI and
CVA. Controlling high blood
pressure makes these problems
less likely.
Hypertension and the JNC-7
Guidelines
Ten years ago, the therapeutic goal in
patients with high blood pressure was a BP of
less than 140/90 mm Hg.
In 2003, the seventh report of the Joint
Committee on the Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure (JNC VII) appropriately
assigned patients with pressures of 120139 systolic, and 80-89 diastolic as
prehypertensive, and requiring treatment
with life style modifications. See pg 642
Hypertension and the JNC-7
Guidelines
According to the JNC-VII evidence-based
guidelines:
Note that lifestyle modification is #1 step, then on to
a thiazide diuretic as the initial treatment.
Begin with once daily, low dosing.
• If control not controlled in 3 months, dose can be
increased, or a different BP med may be prescribed, or
a second drug from a different class may be added.
Therapy with antihypertensive agents from a
multiplicity of drug classes with diverse
pharmacologic effects (diuretics, beta blockers,
calcium antagonists and angiotensin-converting
enzyme inhibitors) reduces blood pressure-related
disease and death.
Alpha1-adrenergic
blockers
Definition
Alpha1-adrenergic blockers are drugs that
work by producing arteriolar and venous
vasodilatation, thus reducing peripheral
vascular resistance.
Purpose
These drugs, called alpha blockers for short,
are used for two main purposes: to treat
high blood pressure (hypertension) and
to treat benign prostatic hyperplasia
(BPH), a condition in men in which the
prostate gland enlarges, impeding urine
flow.
Alpha1-adrenergic
blockers
doxazosin mesylate (Cardura) and terazosin
HCl (Hytrin)
May make blood pressure drop too low =
dizziness, lightheadedness, palpitations, and
fainting.
Additive effect with diuretics and beta blockers
Pt. Teaching
Do not abruptly stop taking this medication.
Should begin with a low dose and take w/food.
Watch for additive effects: Teach safety - Lie down if
above symptoms occur.
Therapeutic Outcomes
Reduction of BP and/or
Angiotensin-Converting Enzyme
Inhibitors (ACE)
Definition
ACE inhibitors are medicines that block the
conversion of the chemical angiotensin I to
angiotensin II, a reaction that would increase
salt and water retention in the body.
• Therefore, there is a diuretic effect with use of ACE
inhibitors.
Purpose
ACE inhibitors may be used alone or in
combination with other BP meds.
Promising approach to slowing nephropathy
in patients with type 2 diabetes
ACE Inhibitors
Captopril (Capoten), enalapril maleate
(Vasotec), lisinopril (Prinivil, Zestril)
“First dose faint” potential w/initial dose, esp.
if concurrent use of diuretics (not an indicator
to stop therapy)
Fetotoxic during pregnancy!
Other Side Effects
Potential for hyperkalemia (aldosterone is inhibited);
chronic cough; nephrotoxicity; neutropenia
Pt Teaching
Postural hypotension measures
Importance of lab work for at risk re: kidney
function, low WBC counts, hyperkalemia
Beta blockers
Definition
Beta blockers inhibit the cardiac response to
sympathetic nerve impulses. This, in turn, decreases
the force and rate of the heart's contractions, which
lowers blood pressure and reduces the heart's
demand for oxygen.
Purpose
Used to treat high blood pressure, angina, cardiac
arrhythmias, and acute MI
Reduction of morbidity and mortality from MI
and HTN has been shown.
• They may also be prescribed for migraines, tremors,
and “stage fright”.
• In eye drop form, they are used to treat certain kinds of
glaucoma.
Beta Blockers
Atenolol (Tenormin), metoprolol
(Lopressor), labetolol (Normodyne)
Side effects: (lungs)
Beta 1=heart; Beta 2=bronchi (lungs)
Bradycardia
Bronchospasm (esp. if nonselective beta drug, e.g.,
labetolol)
CardioSelective Bblockers (block Beta 1 only) include
atenolol, metoprolol – better for pts with respiratory
conditions, CHF
• However, any of these in larger doses impact beta2
receptors, and thus use w/caution in pts who have
respiratory compromise or CHF hx.
Hypoglycemia - S/S can be masked
Heart failure - monitor for increase in edema, dyspnea
Beta Blockers
Side Effects, continued
Additive effect with other anti-HTN’s
Prostaglandin inhibitors such as NSAIDS can inhibit
Bblocker activity
Pt. Teaching
• Do not discontinue drug abruptly
 Side Effects usually just need dosage adjustment
• If drug dc’d, must do so gradually, per MD order
 Pt.s have experienced angina and subsequent MI after an abrupt d/c
Therapeutic Outcome
Reduction in BP, angina, cardiac arrhythmias
Reduction in ocular pressure re: eye gtts
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Calcium Channel Blockers
Definition
Calcium channel blockers are medicines
that slow the movement of calcium into the
cells of the heart and blood vessels. This, in
turn, relaxes blood vessels, increases the
supply of oxygen-rich blood to the heart,
and reduces the heart's workload.
Purpose
Used to treat high blood pressure, abnormal
heart rhythms (e.g., Cardizem gtt for afib),
and angina pectoris. They may also be
prescribed to treat panic attacks, bipolar
disorder, and migraine headache.
Calcium Channel Blockers
Amlopidine (Norvasc), diltiazem HCl
(Cardizem), and verapamil (Calan SR,
Isoptin SR).
Side Effects:
Hypotension and syncope possible in first
week.
• Dizziness, lightheadedness, flushing, headache, and
nausea, usually go away as the body adjusts to the
drug and do not require medical treatment unless
symptoms persist or they are bothersome.
Edema
• Is the heart being slowed too much? – CHF
Constipation
Calcium Channel Blockers
Additive effect with diuretics and other antihypertensives
Increases serum levels of digitalis, some antiseizure meds, and blood glucose – monitor
labs accordingly
Pt. Teaching
Do not abruptly stop taking this medication.
Should begin with a lower dose and take w/food.
Watch for additive effects: Teach safety – sit or lie
down if orthostatic hypotension occurs.
Therapeutic Outcomes
Reduction of BP and/or irregular heart rhythm, angina pectoris
Centrally-acting Alpha-2
Agonists
Definition
The action of centrally acting alpha-2
agonists reduces sympathetic nerve outflow
from the brain and CNS, thus decreasing
peripheral vascular resistance and slowing
the heart rate, thereby reducing BP.
Investigational use for ADHD
Purpose
Reduction in blood pressure.
Reduction in attention deficit and
hyperactivity
Centrally-acting Alpha-2
Agonists
Clonidine HCl (Catapres)
Side Effects:
Sedation, dry mouth, dizziness, constipation
• Usually self-limiting
• Do NOT d/c drug abruptly
 Rebound effect may occur with rapid increase in BP, agitation, tremors,
HA, nausea
Depression
• Assess affect and overall cognitive behavior before beginning this
medication, and continue to monitor for behavioral
changes/complaints.
Transdermal application
• Contact dermatitis in 10-15%; consider p.o./SL
Centrally-acting Alpha-2
Agonists
Cumulative effects with other anti-HTN’s and digitalis
Monitor closely for cumulative effects
• Blood levels, medication regimen, OTC’s, alcohol, sedative use
Pt. Teaching
Do NOT d/c abruptly: D/C over 2-4 days per order
Do not drink alcohol while on this medication
Do not use other sedatives without MD prescription
Be alert for signs of depression, esp. if previous hx
Direct Vasodilators
Definition
Vasodilators act directly on muscles in blood
vessel walls to make blood vessels dilate.
Purpose
Through arterial and/or venous
vasodilation, these drugs reduce blood
pressure. Vasodilators usually are
prescribed with other types of blood
pressure drugs and rarely are used alone.
Direct Vasodilators
hydralazine HCl (Apresoline)
Causes arterial vasodilatation (reduces after load)
• However, this action causes a reflex INCREASE in HR, cardiac
output, and renin (Kidneys) release, causing sodium and H20
retention.
• Therefore, this pt should also be taking a sympathetic inhibitor
like a Beta blocker and a diuretic to counter these effects.
Used to treat Stage 2 & 3 HTN, and HTN assoc. with
renal disease and toxemia of pregnancy
sodium nitroprusside (Nipride)(IV only)
Arterial and venous vasodilatation
• Reduces preload and after load
• Used in hypertensive crisis, severe CHF in ICU
Direct Vasodilators
Side Effects:
Headache
Tachycardia, palpitations (hydralazine if used alone)
Nausea or vomiting
Diarrhea
Loss of appetite
Orthostatic hypotension
Additive effects with other anti-HTN’s
and diuretics-monitor closely