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Cardiovascular Diseases and Related Medications

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Cardiovascular Diseases and Related Medications Powered By Docstoc
					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., v-
   tach, 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 near-
      syncope.
  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 120-
 139 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 anti-
 hypertensives
 Increases serum levels of digitalis, some anti-
 seizure 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

				
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