Exam 22 - Drugs for Cardiovascular II

Antihyperlipidemics

• HMG-CoA Reductase Inhibitors (Statins) lower blood LDL levels by blocking the liver enzyme that controls cholesterol production
• Statins reduce the risk of atherosclerosis, hypertension, heart attack, peripheral arterial disease, and stroke
• Abdominal pain, headache, diarrhea, muscle pain, joint discomfort, sore throat, heartburn, and elevated blood glucose levels are side effects of Statins
• Liver dysfunction, pancreatitis, myositis, and rhabdomyolysis are adverse effects of statins
• Examples of statins are: Atorvastatin, simvastatin, lovastatin, pravastatin, and rosuvastatin
• Alcohol and acetaminophen increase liver toxicity when taking statins
• Aspirin and antacids decrease effectiveness of statins
• Grapefruit juice increases statin concentration in the blood.
• Nursing implications for statins include: Monitor liver function and CK levels
• Nursing implications for statins include: Assess for rhabdomyolysis
• Nursing implications for statins include: Determine if patient is pregnant or breastfeeding
• Nursing implications for statins include: Maintain a low-cholesterol diet
• Nursing implications for statins include: Avoid alcohol and grapefruit juice
• Nursing implications for statins include: Report muscle aches, changes in urine color, or decreased urine output
• Non-Statin Antihyperlipidemics lower blood LDL levels to reduce the risk for atherosclerosis, hypertension, heart attack, peripheral arterial disease, and stroke
• Selective Cholesterol Absorption Inhibitors limit cholesterol absorption in the intestinal wall and includes Ezetimibe
• Fibric Acid Derivatives (Fibrates) lower triglyceride levels and increases HDL levels
• Fibrates can cause liver toxicity and cholelithiasis
• Examples of Fibrates are: Gemfibrozil and fenofibrate
• Action of Bile Acid Sequestrants is to increase cholesterol excretion
• Side effects of Bile Acid Sequestrants are GI issues such as constipation, bloating, and nausea
• Bile Acid Sequestrants can interfere with other drug absorption and reduce absorption of fat-soluble vitamins
• Examples of Bile Acid Sequestrants are: Cholestyramine and colestipol
• Niacin or Nicotinic Acid reduces the breakdown of triglycerides
• Flushing, indigestion, hot flashes, and sweating are adverse effects of Niacin
• Example of Niacin is: Niacin
• Nursing implications and patient teaching for all non-statins include: Assess the patient's diet history
• Nursing implications and patient teaching for all non-statins include: Assess the patient's liver function tests and avoid alcohol use
• Nursing implications and patient teaching for all non-statins include: Monitor cholesterol levels
• Nursing implications and patient teaching for all non-statins include: Give supplemental vitamins if needed for those taking bile sequestrants
• Nursing implications and patient teaching for all non-statins include: Administer drugs at appropriate times
• Nursing implications and patient teaching for all non-statins include: Monitor for GI complications
• Nursing implications and patient teaching for all non-statins include: Notify health care providers of cholesterol-lowering drug use

Antihypertensive Drugs

• Diuretics reduce blood pressure by increasing sodium and water loss
• Thiazides and Thiazide-like diuretics increase urine output and dilate arterioles
• Loop diuretics increase urine output by blocking active transport of chloride, sodium, and potassium in the loop of Henle
• Potassium-sparing diuretics increase water and sodium excretion without potassium loss
• Uses for diuretics is to treat hypertension, heart failure, and cirrhosis of the liver.
• Side effects of diuretics: Urinary urgency and frequency, dehydration, and electrolyte imbalances
• Adverse effects of diuretics are: Dehydration, hypokalemia, hyperkalemia (with potassium-sparing diuretics), and loss of sodium
• Examples of diuretics: Hydrochlorothiazide (HCTZ), indapamide, furosemide, and spironolactone
• Drug interactions with diuretics are: Antibiotics, lithium, and other medications can cause potassium imbalances
• Nursing implications and patient teaching for diuretics include: Assess vital signs and for signs of dehydration
• Nursing implications and patient teaching for diuretics include: Hold if BP is less than 90/60 mmHg
• Nursing implications and patient teaching for diuretics include: Monitor daily weight, potassium, and BUN/Cr levels
• Nursing implications and patient teaching for diuretics include: Administer in the morning
• Nursing implications and patient teaching for diuretics include: Monitor peripheral edema and intake/output
• Nursing implications and patient teaching for diuretics include: Teach patients to stand up slowly
• Nursing implications and patient teaching for diuretics include: Monitor for symptoms of low and high potassium
• Nursing implications and patient teaching for diuretics include: Monitor for tinnitus with loop diuretics
• Nursing implications and patient teaching for diuretics include: Teach about dietary changes
• Nursing implications and patient teaching for diuretics include: Monitor glucose levels in patients with diabetes
• Renin-Angiotensin-Aldosterone System (RAAS) Drugs interfere with angiotensin II and aldosterone to decrease vasoconstriction and fluid volume
• ACE-Inhibitors stop the conversion of angiotensin I to angiotensin II
• ARBs block angiotensin II receptor sites
• RAAS Drugs are used to treat hypertension and heart failure
• Side effects of RAAS Drugs are: Hyperkalemia, dry cough (with ACE-Is), and angioedema and are contraindicated during pregnancy
• Examples of ACE-Inhibitors: captoPRIL, enalaPRIL, lisinoPRIL, and quinoPRIL
• Examples of ARBs: loSARTAN, valSARTAN, irbeSARTAN, and candeSARTAN
• Calcium Channel Blockers reduce the effect of calcium in the heart muscle and smooth muscles of arteries
• Calcium Channel Blockers inhibit calcium influx causing relaxation of coronary smooth muscle and dilation of coronary arteries and peripheral veins
• Calcium Channel Blockers inhibit calcium entry into heart muscle cells, slowing electrical impulses
• Calcium Channel Blockers treat chronic stable angina, hypertension, and dysrhythmias
• Dysrhythmias, fatigue, dizziness, headache, flushing, and Steven Johnson Syndrome are side effects of Calcium Channel Blockers
• Contraindications for Calcium Channel Blockers are: Cardiogenic shock, heart block, and hypotension
• Examples of Calcium Channel Blockers: Verapamil, Nifedipine, Nicardipine, Diltiazem, and amlodipine
• Avoid grapefruit and grapefruit juice when taking Calcium Channel Blockers
• Beta Blockers block beta 1 receptors, lowering blood pressure and heart rate
• Beta Blockers treat coronary artery disease, hypertension, angina pectoris, heart failure, dysrhythmias, myocardial infarction, and premature ventricular contractions
• Bradycardia, hypotension, masked signs of hypoglycemia, decreased sexual ability, dizziness, drowsiness, difficulty sleeping, weakness, and cold hands or feet are side effects of Beta Blockers
• Contraindications for Beta Blockers are: Cardiogenic shock, heart blocks, and bradycardia
• Do not stop taking Beta Blockers suddenly
• Alpha1-adrenergic antagonists (alpha blockers) block alpha1-adrenergic receptor sites, leading to decreased peripheral vascular resistance and decreased blood pressure
• Alpha1-adrenergic antagonists are used to treat hypertension
• First-dose effect and fluid retention are the side effects of Alpha1-adrenergic antagonists
• Examples of Alpha1-adrenergic antagonists: doxAZOSIN, prAZOSIN, and terAZOSIN
• Alpha-2 agonists decrease vasoconstriction, vasodilation, and blood pressure in the brain
• Alpha-2 agonists are used to treat hypertension that is difficult to manage
• Dry mouth and nasal congestion are side effects of Alpha-2 agonists
• Examples of Alpha-2 agonists: clonidine, clonidine transdermal patch, and methyldopa
• Do not stop taking Alpha-2 agonists suddenly
• Vasodilators dilate the arterial and/or venous system to decrease peripheral resistance
• Vasodilators are used for treating hypertension
• A significant drop in blood pressure is a side effect of of Vasodilators Examples of Vasodilators - hydralazine, minoxidil
• Do not miss doses of Vasodilators
• Nursing implications and patient teaching for all antihypertensive drugs: Avoid sudden changes in position
• Nursing implications and patient teaching for all antihypertensive drugs: Keep taking drugs as prescribed
• Nursing implications and patient teaching for all antihypertensive drugs: Avoid alcohol and OTC drugs
• Nursing implications and patient teaching for all antihypertensive drugs: Withhold drug and contact provider if heart rate is slower than 60 beats/min or systolic blood pressure is less than 90 mm Hg
• Nursing implications and patient teaching for all antihypertensive drugs: Monitor blood pressure carefully at the beginning of therapy
• Nursing implications and patient teaching for all antihypertensive drugs: Weigh themselves every day and to report swelling of the hands or feet to their healthcare provider
• Nursing implications and patient teaching for all antihypertensive drugs: Take the drug at the same time every day
• Nursing implications and patient teaching for all antihypertensive drugs: Teach proper techniques for home monitoring of blood pressure and heart rate

Drugs for Angina and Myocardial Infarction

• Nitrates dilate blood vessels by relaxing vascular smooth muscle, reducing resistance to blood flow
• Nitrates are used for chronic stable angina pectoris and prophylaxis for angina pain
• Throbbing headaches and a slight drop in BP are side effects of Nitrates
• Severe postural hypotension, reflex tachycardia, paradoxical bradycardia, vertigo, and severe weakness are adverse effects of Nitrates
• Examples of Nitrates are: Nitroglycerin and Isosorbide mononitrate
• Drug interactions with Nitrates: Alcohol, antihypertensive drugs, opioids, and diuretics can increase the effect of nitrate drugs, causing tachycardia and severe hypotension
• Drug interactions with Nitrates: Caffeine, pseudoephedrine, methylphenidate, and certain antidiabetic drugs can decrease the effectiveness of nitrates and drugs given for erectile dysfunction can cause severe hypotension
• Nursing implication for Nitrates: Assess BP and pulse before and during treatment and hold if BP is less than 90/60
• Nursing implication for Nitrates: For acute attacks, give nitroglycerin sublingually every 5 minutes x3 doses
• If pain if not resolved when taking Nitrates, call for immediate help from a health care provider
• Wear gloves when applying NTG ointment or paste
• Store NTG tablets in dark container
• Assess for lightheadedness, dizziness, or headache
• Always carry nitroglycerin on their person
• Place the buccal tablet between their cheek and gum or under the tongue
• Place nitroglycerin patches on skin in the morning and REMOVE at bedtime
• If chest pain is not improving when taking Nitrates, contact health care professional immediately (Call 911) if chest pain does not improve, worsens after therapy, is accompanied by diaphoresis or shortness of breath; or if severe, persistent headache occurs
• Do not drink alcohol while taking Nitrates
• Caution patient to change positions slowly to minimize orthostatic hypotension
• Use Nitrates with caution when taking medication for erectile dysfunction

Antidysrhythmics

• Class I antidysrhythmics are Sodium channel blockers (e.g., quinidine, procainamide, disopyramide)
• Sodium channel blockers lengthen the period during which the cells cannot release or discharge their electrical activity
• Sodium channel blockers make the heart less excitable, slowing the impulse conduction through the heart
• Class II antidysrhythmics are Beta blockers (e.g., propranolol, esmolol, acebutolol)
• Beta blockers reduce sympathetic stimulation to the heart, decreasing the heart rate
• Beta blockers decrease contractility of the heart muscle
• Class III antidysrhythmics are Potassium channel blockers (e.g., amiodarone)
• Potassium channel blockers make the cells less excitable
• Potassium channel blockers can slow the heart rate
• Class IV antidysrhythmics are Calcium channel blockers (e.g., diltiazem, verapamil)
• Calcium channel blockers selectively block the ability of calcium to enter the heart muscle cells
• Calcium channel blockers slow conduction through the sinoatrial and/or atrioventricular node
• Other drugs used as antidysrhythmics include digoxin and magnesium sulfate
• Sodium channel blockers increase the length of time during which the cells cannot discharge their electrical activity, slowing conduction of impulses through the heart and making it less excitable
• Sodium channel blockers are used to treat supraventricular and ventricular dysrhythmias and life-threatening dysrhythmias such as atrial or fibrillation and ventricular fibrillation
• Potassium channel blockers make cardiac cells less excitable and reduce the heart rate
• Potassium channel blockers are often used to help convert atrial fibrillation and/or atrial flutter to a normal sinus rhythm and can be used to treat dangerous ventricular dysrhythmias
• Calcium channel blockers impede the ability of calcium to enter heart muscle cells, which slows conduction of electrical impulses through the sinoatrial and atrioventricular nodes
• Calcium channel blockers are used primarily to treat supraventricular tachycardia
• The cause of the dysrhythmia dictates which drug class will be most effective for treatment, goal is to restore the rhythm to normal and maintain adequate cardiac output
• Side Effects of antidysrhythmics are: hypotension and other dysrhythmias
• Examples of Sodium channel blockers include quinidine, disopyramide, and propafenone
• Examples of Potassium channel blockers include amiodarone
• Examples of Calcium channel blockers include Very Nice Drugs + amlodipine
• For Sodium channel blockers, carefully monitor the heart rate and blood pressure because these drugs can cause hypotension and dysrhythmias
• Teach patients to avoid all OTC drugs to prevent dangerous interactions
• Quinidine can cause significant GI side effects, remind patients to take the drug with food to ease these symptoms
• Give the drug exactly as scheduled to avoid irregular blood levels, patients may need to use timers to remember to take the drug on schedule
• Monitor patient weight and intake and output because some of these drugs can cause urinary retention
• Older adult patients are more likely to experience dizziness and confusion and therefore are at greater risk for falls
• Teach family members to assess the patients for any confusion and report to the healthcare provider
• For Potassium channel blockers, monitor for common side effects such as photosensitivity, nausea, vomiting, dizziness, fatigue, and hypotension
• Be sure to monitor the respiratory status of patients who are taking amiodarone because this drug may cause pulmonary complications
• Teach patients who are taking amiodarone that the drug causes sensitivity to light and that they may need to wear dark glasses when going outside, protective clothing, and a sunscreen barrier
• It may take several days or weeks for patients to feel side effects when taking amiodarone
• Long-term use of amiodarone may cause a bluish discoloration of the face, neck, or arms which is a reversible reaction
• Patients need to schedule eye examinations every 6–12 months because amiodarone can cause corneal microdeposits or other eye changes
• Remind male patients to report pain or swelling in the scrotum to the healthcare provider
• Assessing the apical heart rate using your stethoscope is best practice before giving the drug
• Obtain an ECG before giving antidysrhythmics
• Ensure telemetry (24-hour-a-day cardiac monitoring) is ordered for antidysrhythmics

Inotropic drugs: Digoxin

• Digoxin activates contractile proteins in the heart muscle, increasing their ability to contract
• Digoxin can lead to an improvement in cardiac output
• Digoxin is used for symptom management in patients with advanced heart failure and in critical care areas to increase contractility of the heart muscle and improve cardiac output and also treat atrial fibrillation
• Adverse effects of Digoxin include: Symptoms of digoxin toxicity include anorexia, nausea, vomiting, diarrhea, visual disturbances such as blurred or yellow vision, and irregular heart rate (at times with palpitations), anxiety, depression, or confusion
• Examples of Inotropic drugs: Digoxin
• Drug Interactions with Digoxin: Beta-adrenergic blocking agents, calcium gluconate, calcium chloride, succinylcholine, and verapamil increase the therapeutic and the toxic effects of inotropic drugs and any drug that changes the electrolyte balance may also lead to digoxin toxicity
• Calcium channel blockers such as verapamil and diltiazem are replacing digoxin for treatment of atrial dysrhythmias, so monitor patients very carefully for symptoms of digoxin toxicity, such as lack of appetite, nausea, vomiting, and vision changes if they are taking digoxin
• Monitor potassium levels carefully because a low potassium level can cause dangerous dysrhythmias, which may be worsened in patients on diuretics or other potassium lowering drugs
• If the patient experiences any symptoms of digoxin toxicity, contact the healthcare provider, optimal blood levels range between 0.5 and 0.8 ng/mL
• Take the apical pulse before giving digoxin and do not give the drug if the pulse is less than 60 beats/min
• Give digoxin at the same time every day to prevent irregular drug blood levels
• Teach patients that a missed dose may be taken within 12 hours of the scheduled time and to never take double doses because of the high risk of drug toxicity
• Let the healthcare provider know if you have any loss of appetite, nausea, vomiting, diarrhea, or vision changes that can be an indication of digoxin toxicity
• Notify the healthcare provider of any chest pain, shortness of breath, or peripheral edema that may indicate worsening heart failure
• Include foods rich in potassium in the diet (unless contraindicated by the healthcare provider) when taking digoxin