Cardiac Drugs and Cholesterol Synthesis

• Drugs can impact the Hematopoietic System

Major Classes of Cardiac Drugs

• Some major classes of cardiac drugs include inotropic drugs, anti-adrenergic drugs, vasodilator drugs, anti-arrhythmic drugs, diuretics, antiplatelets, anticoagulants, thrombolytics, and antilipemic drugs.

Inotropic Drugs

• Adrenergic drugs or sympathomimetics amines are a type of inotropic drug
• Anticholinergics or antimuscarinics or cholinergic blockers are a type of inotropic drug
• Digitalis glycosides (Digoxin) are a type of inotropic drug

Anti-adrenergic Drugs

• Alpha1-adrenergic blockers (antagonists) are a type of anti-adrenergic drug
• Beta-adrenergic receptor antagonists are a type of anti-adrenergic drug

Vasodilator Drugs

• Angiotensin-converting enzyme inhibitors are vasodilator drugs
• Angiotensin II type 1 receptor antagonists are vasodilator drugs
• Calcium channel blockers are vasodilator drugs
• Direct vasodilators are vasodilator drugs
• Organic nitrates are vasodilator drugs

Anti-arrhythmic Drugs

• There are four classes; Class I, Class II, Class III, and Class IV anti-arrhythmics
• Amiodarone, Digoxin, and adenosine are anti-arrhythmic drugs

HMG-CoA Reductase Inhibitors (Statins)

• These are antilipemic drugs, which reduce cholesterol
• These are used in cholesterol biosynthesis, a pathway that converts acetic acid into squalene and then cholesterol
• In early stages, HMG-CoA is reduced to mevalonate by HMG-CoA reductase. Statins inhibit this enzyme
• They inhibit the HMG-CoA reductase enzyme to convert HMG-CoA to mevalonate and decrease Cholesterol production
• Statins treat hypercholesterolemia, reduce the risk of CAD, and prevent MI or stroke
• Examples include Atorvastatin (Lipitor), Simvastatin (Zocor), fluvastatin, lovastatin, pravastatin, and rosuvastatin

Side Effects of Statins

• Statins have gastrointestinal symptoms as a side effect
• Most cholesterol-lowering drugs damage liver function and increase alkaline phosphatase (ALP), alanine transminase (ALT), and bilirubin levels
• Other hepatic effects may include pancreatitis, drug-induced hepatitis, cirrhosis, and easy bleeding
• Lovastatin, rosuvastatin, and simvastatin may increase the risk of bleeding when administered with warfarin
• A severe, rare side effect is muscle pain, myopathy, or rhabdomyolysis, which is the breakdown of muscle tissue
• Statins damage muscle cell's gatekeeper proteins called ryanodine receptors, which control Calcium release

Nursing Considerations for Statins

• Monitor liver function regularly through liver function tests (LFT)
• Monitor creatine kinase (CK) levels regularly
• Creatine kinase (CK) in muscle, heart, and brain tissue; elevated CK levels may indicate muscle injury or disease
• Avoid grapefruit, as it reduces the breakdown of statins, and increases risk of side effects

Cholesterol-Lowering Medications

• Statins, Fibrates, Cholesterol absorption inhibitors Bile acid sequestrants, PCSK9 inhibitors and Small interfering RNA-based therapy are several different classes of cholesterol-lowering drugs

Statins

• Common side effects of statins are headache, stomach upset, and muscle pain
• . Atorvastatin, Rosuvastatin, Simvastatin are all statins
• Statins should not be taken at the same time with rosuvastatin or with antacids
• Simvastatin should be taken in the evening
• Pregnancy and breastfeeding should be avoided
• A doctor should be contacted immediately if unexplained muscle pain or weakness, loss of appetite, nausea, vomiting, dark urine, and yellow skin or eyes occurs
• Avoid grapefruit or grapefruit juice while taking simvastatin

Fibrates

• Taking fibrates could result in stomach pain, abdominal pain, and Shin rash as common side effects.
• Fenofibrate should be swallowed, not chewed and taken with water
• Gemfibrozil should be taken 30 minutes before a meal
• Fenofibrate, Gemfibrozil are both fibrates
• Contact your doctor if you experience unexplained muscle pain or weakness, loss of appetite, nausea, vomiting, dark urine, yellow skin or eyes

Cholesterol Absorption Inhibitors

• Taking Cholesterol absorption inhibitors could result in headache, tiredness, abdominal pain, stomach upset, flatulence and nausea
• Ezetimibe is a cholesterol absorption inhibitor
• A doctor should be contacted if you experience unexplained muscle pain or weakness, loss of appetite, nausea, vomiting, dark urine, yellow skin or eyes

Bile Acid Sequestrants

• Cholestyramine is a bile acid sequestrant
• Constipation, gas or bloating, and stomach upset are possible after taking Bile Acid Sequestrants
• Don’t take the medication in its dry powder form: mix with fluids
• Reduce side effects by eating more high fibre food (like vegetable) and drinking more fluids
• Other medications should be taken 1 hour before or 4 hours after as it may prevent other medications from being absorbed
• Store the drug in the refridgerator

PCSK9 Inhibitors

• Injections can cause reaction (redness, bruising), influenza, inflammation of the nose and throat. upper respiratory tract infection, nausea.
• Alirocumab, Evolocumab are PCSK9 inhibitors drugs
• Take the medication through subcutaneous use only
• Don’t shake or discard unused portions

Small Interfering RNA-based

• Injection site reaction (redness, pain, rash), bronchitis, joint pain are common side effects
• Inclisiran is a component of the RNA-Based
• An professional should administer for subcutaneous use

General points for Cholesterol-lowering drugs

• If you experience sleepiness, dizziness or blurred vision after taking the medications, avoid driving or activities requiring mental alertness or coordination.
• Avoid alcohol as it may increase the side effects.
• If you notice any allergic reactions like skin itchiness, face or hand swelling, breathing difficulty, etc., consult your doctor immediately.

Coagulation Disorders

• Many common diseases affect hemostasis

Hypercoagulability

• This condition can occur, where blood clots more easily than is normal.
• This is the increased tendency of blood to thrombose and emboli
• Thromboembolic disorders, Venous or arterial thrombosis and myocardial infarction can occur

Hypo-coagulable

• This condition can occur, also known as Bleeding
• This is because of abnormal hemostasis and an increased bleeding risk
• Thrombocytopenia and hemophilia can occur

Stroke

• Strokes can be haemorrhagic or ischaemic

Coagulation Modifiers

Prevention of clot formation

• Anticoagulants like Heparin, Low-molecular-weight heparins, Direct thrombin inhibitors, factor Xa inhibitors, and Warfarin can prevent Clot formation
• Antiplatelets, such as Aspirin, ADP receptor blockers, and Glycoprotein IIB/IIIA receptor antagonists, inhibit Clot formation and prevent platelet aggregation.
• Thrombolytics, such as Alteplase, Reteplase and Streptokinase, attack and dissolove blood clots that have already formed

Heparin Action

• It combines with antithrombin III, accelerating reactions that prevent thrombosis
• It blocks fibrinogen to fibrin conversion and prevents the formation of new fibrin clot

Warfarin

• Warfarin is a drug in the Anticoagulants class, inhibits vitamin K epoxide reductase, thus inhibiting the production of vitamin K, which is dependent on clotting factors
• It prevents thromboembolism and arterial embolism in patients with atrial fibrillation

Warfarin Side Effects/Considerations

• A side effect of Warfarin is bleeding
• International Normalized Ratio (INR) levels need to be monitored.
• Intake of vitamin K foods should also be monitored

Warfarin Dosing/Considerations

• Take antiplatelet drugs with food
• Avoid injury and the consumption of alcohol and self-medication
• Make sure to consult a doctor if you are taking any other medication

Warfarin Monitoring

• Unusual bleeding, prolonged nosebleed, blood in urine or coughing blood
• Seek medical attention if there are signs of bleeding or head injury
• Inform healthcare provider if invasive medical and dental prodecures must be taken.
• Medicine must be stopped days before invasive procedure.

Warfarin Dosage

• Warfarin Dosage may be prescribed differently in Odds & Evens Days
• If patients need to take an alternating dose of warfarin to be taken on EVEN and ODD days
• EVEN day doses on even-numbered days of the month
• ODD day doses on odd-numbered days of the month
• Pharmacies will standardize the dispensing combination of warfarin tablets against each prescribed dose using only 1mg (brown) and 3mg (light blue) warfarin tablets.
• Medicine must be taken as soon as possible it is the same day.
• You must not skip/double dose.
• The crossing of placental barrier is detrimental to fetal health

Warfarin: Lifestyle and Side Effects

• Be sure you are getting the suitable amount if vitamin K, as a change will affect warfarain’s effect
• There may be abnormal bruising, bloody/red urine or stool, or an upset stomach
• Speak to a doctor if you feel anything is wrong

Warfarin: Dietary Guidelines

• Some things to avoid alongside Warfarin are fish oil, medications, vitamin pills, or alcohol
• Take Vitamin K

Aspirin

• Aspirin gives thromboxane, causing vasoconstriction and platelet aggregation, boosting clot formation
• Cox2 yielded prostaglandin, facilitating inflammation to trigger pain and fever at the release site.
• Aspirin blocks cyclooxygenase, hindering thromboxane A2 generation; it also inhibits platelet function
• This is used for acute Coronary Syndrome at 160-300 mg, maintenance dose is 80mg with P2Y12
• Bleeding an be a side effect

Clopidogrel (Plavix)

• Clopidogrel (Plavix) is a prodrug that undergoes first-pass metabolism and active metabolite formation in the liver
• The active version binds to P2Y12 ADP receptors on platelets, preventing adenosine diphosphate (ADP) binding for reduced platlet formation
• This is used for acute Coronary Syndrome, Clopidogrel(Plavix), 300 mg, 75 mg daily for 14 days or 12 months with aspirin.
• Bleeding is a side effect

DOACs (Direct Oral Anticoagulants)

• These medicines prevent clots, and consist of Direct Thrombin Inhibitors and Factor XA Inhibitors
• They help reduce blood clots stemming from irregular heartbeats or conditions of clots in vital areas such as clots in the legs or the lungs
• DOACs help reduce blood clots stemming from irregular heartbeats or conditions of clots in vital areas such as clots in the legs or the lungs

DOACs (Direct Oral Anticoagulants: Precautions)

• Seek medical help during symptoms of severe headaches with blurred vison and or difficulties breathing and problems or chest pains.
• If you have any allergies seek help
• Read the drug lable, especially on the dosage and frequency, consult doctor
• Avoid other medications, and if preganant tell others

DOACs: Daily Activity Tips

• Remind your dentist or doctor that you are on medication
• If you have a fall or a bump monitor for signs of internal bleeding

Coagulation Modifiers (Clot Promotion)

• Hemostatics such as Aminocaproic acid and Tranexamic Acid help with in vitro use Vitamin K is a substance to help clot and prevent bleeding
• Fresh frozen plasma is one of the ingredients that helps with clotting along with Cryoprecipitate that concentrates clotting factors in bleeding
• You must not freeze platelets and use it to prevent with functional bleeding diseases

Tranexamic Acid (Transamin)

• Tranexamic acid binds to the lysine binding site of fibrin, hinders Plasmin Binding to fibrin, decreasing destruction
• It is a hemostatic effect

Anaemia-related drugs

• Vitamin supplements, like cyanocobalamin, treat the effects along with iron salts and ferrous sulfate
• Hematopoiesis in the body is related to a protein molecule (erythropoetin) which help with red blood cell production
• Erythropoietin alfa is used for treating anemia.