Cardiovascular Drugs: Cardiotonics

Pharmacology: Cardiovascular Drugs

• Cardiovascular drugs include cardiotonics, antianginals, antihypertensives, diuretics, anticoagulants/thrombolytics, and cholesterol agents.

Cardiotonics: Actions and Uses

• These drugs increase cardiac output by increasing the force of myocardial contraction, known as positive inotropic activity
• Additionally slow conduction and decrease heart rate through a negative chronotropic effect.
• Cardiotonics are used for heart failure and atrial fibrillation

Cardiotonics: Adverse Effects, Contraindications, and Interactions

• Adverse effects include headache, weakness, drowsiness, visual disturbances, arrhythmias, and Gl upset and anorexia, which is usually the first sign of toxicity.
• Cardiotonics are contraindicated in cases of digitalis toxicity and disturbances in ventricular rhythm.
• Macrolides increase the risk of digitalis toxicity.
• ACE inhibitors and angiotensin receptor blockers increase the risk of hyperkalemia, reducing the therapeutic effects.
• Thyroid hormones decrease digoxin's effectiveness, and thiazide/loop diuretics lead to hypokalemia, increasing toxicity risk.
• Quinidine and verapamil increase the risk of dig toxicity and serum dig levels, respectively; antacids decrease dig absorption.

Cardiotonics: Examples and Management of Digoxin Toxicity

• An example is Lanoxin (digoxin), that requires a loading dose.
• A therapeutic drug level is 0.5-2.0 ng/ml.
• Signs of dig toxicity include visual changes, green/yellow vision, anorexia, N/V/D, fatigue, weakness, and changes in cardiac function.
• Monitoring potassium levels is essential, as hypokalemia predisposes individuals to dig toxicity.
• The antidote for dig toxicity is digibind (digoxin immune).
• Management includes withholding digoxin and potassium-sparing medications.
• Monitor potassium levels, use phenytoin and lidocaine for digoxin-induced arrhythmias, and administer atropine for bradycardia. Digibind can also be used.

Antianginals: Actions and Uses

• Nitrates relax smooth muscles in vessels to increase blood flow to the myocardium
• Calcium Channel Blockers slow conduction, dilate coronary arteries, and depress contractility of the heart.
• Beta blockers slow conduction.
• Nitrates relieve pain associated with angina, prevent anginal attacks, and treat chronic stable angina.
• Calcium Channel Blockers treat anginal pain and hypertension
• Beta blockers treat angina and hypertension

Antianginals: Adverse Effects, Contraindications, and Interactions

• Nitrates can cause headaches known as a hallmark effect, dizziness, weakness, hypotension, and flushing.
• Calcium Channel Blockers adverse effects include dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, and cough.
• Grapefruit juice use should be avoided as it increases medication effects.
• Beta Blockers can cause heart failure (HF), dizziness, bradycardia, arrhythmias, decreased libido, impotence, and constipation/diarrhea.
• Nitrates are contraindicated in cases of severe anemia, closed-angle glaucoma, postural hypotension, head trauma, and cerebral hemorrhage.
• Calcium Channel Blockers are contraindicated in cases of hypotension, 2nd or 3rd-degree block, dig toxicity, and heart failure.
• Beta Blockers are contraindicated in sinus bradycardia, second or third-degree block, asthma, emphysema, or hypotension.
• Aspirin increases levels of nitrates.
• Antihypertensives and alcohol can cause hypotension and ED meds combined with NTG result in life-threatening hypotension.
• Heparin decreases the effect of Heparin.
• Beta Blockers may cause bradycardia and digoxin increases risk of digoxin toxicity
• Grapefruit juice increases drug levels and effectiveness for Calcium Channel Blockers.
• Calcium channel Blockers increase the effects of Beta blockers and antihypertensive medications that increase the likelihood of hypotension.
• NSAIDs decrease the effect of beta blockers, loop diuretics increase the risk of hypotension, clonidine increases the risk of a paradoxical hypertensive reaction when combined with Beta Blockers.

Antianginals: Examples and Nursing Interventions

• Examples of nitrates include ISMO, and Imdur (isosorbide mononitrate), Isordil (isosorbide dinitrate), and Nitro-Bid, Nitrostat (nitroglycerin).
• Examples of Calcium Channel Blockers include Norvasc (amlodipine), Cardizem (diltiazem HCL), Plendil (felodipine), Cardene (nicardipine HCL), Procardia, Adalat (nifedipine), and Calan, Isoptin (verapamil HCL).
• Examples of Beta Blockers are Tenormin (atenolol), Lopressor (metoprolol), Corgard (nadolol), and Inderal (propanolol, nonselective).
• When administering nitroglycerin, give sublingually, 1 every 5 minutes, up to 3 doses. If chest pain is still present after the first dose, call 911.
• Monitor vital signs, with an apical pulse and protect patient safety; monitor and document chest pain.

Antianginals: Client Teaching

• Get a new bottle of nitroglycerin every 3-6 months and store it in the original brown bottle.
• Rise slowly from lying or sitting and the Nitro should tingle or sting when used.
• Clients should rotate patch sites, remove old patches, and keep Nitro with them at all times.
• Take Nitro prophylactically before any stress-inducing activity.

Antihypertensives: ACE Inhibitors Actions, Uses, and Adverse Reactions

• ACE Inhibitors inhibit the conversion of angiotensin I to angiotensin II, a powerful vasoconstrictor.
• They are used for hypertension, heart failure, preventing and treating MI, and neuropathy.
• The common adverse reactions are the first dose orthostatic hypotension, cough, hyperkalemia, rash, altered taste, and neutropenia, especially with captopril.

Antihypertensives: ACE Inhibitors Contraindications, Interactions, and Nursing Interventions

• A contraindication is pregnancy category D and hypersensitivity
• Interactions are Diuretics increasing the risk of first-dose hypotension, Antihypertensives and Lithium increasing the risk of hypotension and lithium levels respectively
• NSAIDs decrease the effects of ACE inhibitors
• Monitor BP post first dose for at least 2 hours and rise slowly

Antihypertensives: Angiotensin II Receptor Antagonists Actions and Uses

• Angiotensin II Receptor Antagonists block the binding of angiotensin II at receptor sites, which inhibits vasoconstriction to treat HTN.
• These medications also treat HF (valsartan), Stroke prevention (lorsartan) and Nephropathy (irebesartan, losartan) treat and prevent them, Slows diabetic retinopathy (losartan), and Reduce mortality post Ml (valsartan)

Antihypertensives: Angiotensin II Receptor Antagonists Adverse Reactions, Contraindications, and interactions

• Adverse Reactions include Hypersensitivity, Fetal injury , Hypotension and Dizziness and lightheadedness
• These drugs are contraindicated in Pregnancy category D
• Other antihypertensives increase hypotension, increases risk of lithium toxicity

Antihypertensives: Direct Renin Inhibitors Action, Use, and Adverse Reactions

• Actio of Direct Renin Inhibitors is inhibiting the production of angiotensin I
• It treats HTN.
• Adverse Reactions are Hypersensitivity, Rash, Cough, Hyperkalemia , Diarrhea, Hypotension.

Antihypertensives: Direct Renin Inhibitors Contraindications and Interactions

• Drugs are contraindicated in Pregnancy category D, Hyperkalemia and Hypotension
• Interactions inclue Decreased levels of furosemide, Increased effect of other antihypertensives, avoid foods high in fat decrease absorbtion , Increased Hyperkalemia wACE inhibitors, potassium suplements and k sparing diuretics
• and Drug – Aliskiren (Tekturna).

Antihypertensives: Beta Blockers, Slow, and Calcium Channel Blockers

• They Slow heart rate and dilate blood vessels treat HTN, Angina, HF, MI, Hyperthyroidism, migraine headaches, glaucoma, pheochromocytoma . Also, see PP above for more
• Calcium-Channel Blockers: Action Slows heart rate and decreases contractility of the heart- Treats Angina, HTN, cardiac dysrhythmias (verapamil, diltiazem) See above in PP for adverse reactions etc

Antihypertensives: Alpha Adrenergic Blocking Drugs Actions, Uses, Adverse Reactions, Contraindications, and Interactions

• Action: Relax the smooth muscle of vessels by blocking the stimulation of a-alpha adrenergic nerves as well as treat treat HTN, Benign prostatic hyperplasia (BPH)
• They have show First dose orthostatic hypotension Contraindication: hypotension Interactions: other antihypertensives

Antihypertensives: Centrally Acting, Actions, Uses, Adverse Reactions, Contraindications, and Interactions

• Action: Act in the CNS to block activity of the sympathetic nervous system (vasoconstriction) treat HTN
• Cause Drowsiness, Dry mouth
• Rebound hypertension (must taper to prevent over 2-4 days) Contraindications: bleeding disorders and anticoagulant therapy Interactions are Other antihypertensives to treat the condition as well as Prazosin, MAOls and tricyclic antidepressan counteracting clonidine effect as well as CNS depression with other CNS depressants Apply to a hairless area to the torso or upper arm

Antihypertensives: Examples

• Beta Blockers (olol drugs) examples are Atenolol, Metoprolol, Nadolol, Propanolol, timolol maleate, bisprolol, carvedilol
• Calcium Channel Blockers examples are Amlodipine, Nifedipine, Diltiazem HCL
• Antiasrenergic Drugs-Centrally aciting: Clonidine HCL, Guanabenz acetate, Methyldopa Alpha-Adrenergic Blockers are Prazosin
• ACE Inhibitors end with pril drug: Benazepril HCL, captopril, enalapril, trandolapril, lisinopril Angiotensin II Receptor Antagonists end with sartan drugs like Candesartan Cilexetil , Irbesartan , Losartan potassium , Telmisartan and Valsartan

Antihypertensives: Nursing Interventions

• Take blood pressure before giving meds
• Monitor for adverse effects
• Monitor the patients I & O
• Have patient Dangle before getting out of bed

Antihypertensives: Client Teaching

• Do not stop your drug(s) abruptly
• Report adverse effects to physician
• Take as directed
• Keep all F/U care appointments
• eport signs/symptoms of HF (sudden weight gain, swelling, SOB)
• Do not use OTC decongestants without clearing with physician

Diuretics: Actions, Uses, Adverse Effects, and Contraindications

• Loop: Increases the reabsorption of water in the Loop of Henle

• Thiazide: inhibit reabsorption of sodium and water

• Potassium sparring : depress reabsorption of sodium therefore water

• Treat Edema, HTN and Renal disease.

• Adverse Reaction causes Orthostatic hypotension; weakness; fatigue For Loop it Hypokalemia; dig toxicity

• Thiazide: Hyperglycemia; decreased libido

• And Potassium sparing causes Hyperkalemia; hyponatremia, gynecomastia; erectile dysfunction, flu like signs and symptoms Dizziness, fatigue Contraindications

• Severe kidney or liver disease; anuria

• Potassium sparing causes Hyperkalemia

Diuretics: Interventions and Examples

• Monitor I & O Weigh daily for fluid balance.

• Monitor blood pressure for hypotension

• Dangle before getting up

• Monitor for dehydration And for electrolytes imbalance Give during day and early afternoon

• Loop examples include Furosemide, Bumetanide, Torsemide

• Thiazide examples include Hydrochlorothiazide, Metolazone Potassium sparing examples include Amiloride, spironolactone ,eplerenone

Anticoagulants and Thrombolytics: Anticoagulants

• Prevent the formation and extension of a thrombus.
• Oral anticoagulant: Coumadin (warfarin)
• Parenteral: Heparin
• Low-molecular-weight heparins (LMWH): Produce stable response, Bleeding less likely to happen such as Enoxaparin and dalteparin, Arixtra - fondaparinux sodium: Activated factor Xa inhibitor

Anticoagulants and Thrombolytics: Actions and Uses

• Actions of Heparin include the Inhibition Inhibits formation of fibrin and Inactivates factors necessary for clotting of blood.
• Uses are CVA, PE, DVT ,MI to treat them and Prophylaxis post op thrombosis and a fib and DIC , to treat these factors.
• Action of LMWH prevent post of DVT and helps with DVT and PE as well as preventing the complications of angina and MI

Anticoagulants and Thrombolytics: Activated Factor Xa Inhibitor

• Uses: Prevent DVT and PE post-op.
• Treat acute DVT or PE in conjunction with warfarin.

Anticoagulants and Thrombolytics: Heparin Adverse Reaction

• Adverse Reactions to Heparin include Hemorrhage as well as Thrombocytopenia including hypersensitivity and Toxicity

Anticoagulants and Thrombolytics: LMWH Adverse Reactions

• Hemorrhage
• Neurologic damage (hematoma formation during spinal anesthesia)
• Thrombocytopenia
• Toxicity/overdose

Anticoagulants and Thrombolytics: Fondaparinux

• Adverse Reactions are Hemorrhage , Neurologic damage and thrombocytopenia

Anticoagulants and Thrombolytics: Contraindications and Interactions

• Contraindications : Thrombocytopenia, active bleeding (except DIC), hemorrhagic disease, uncontrolled hypertension; recent surgery of eye or CNS, hemophilia, severe HTN
• Interactions include Aspirin, NSAIDS, anticoagulants as they increased risk for bleeding Oral contraceptives, vitamin K as they decreased effectiveness of anticoagulant (Coumadin)

Anticoagulants and Thrombolytics: Nursing Interventions

• Obtain drug history and vital signs
• Examine extremity for color and skin temperature
• Check for pedal pulses, noting rate and strength of pulses
• Note areas of redness or tenderness and ask patient to describe current symptoms
• Monitor CBC as ordered
• Assess patient for signs of bleeding and hemorrhage
• Monitor for intracranial bleeding by assessing level of consciousness
• Know current PT/INR results before administering Coumadin
• PT 1.2-1.5 times the control INR 2-3.
• Know current PTT results before giving Heparin 1.5-2.5 times the control

Anticoagulants and Thrombolytics: Nursing Interventions Cont.

• Parenteral administration Heparin Administration of heparin: Intermittent IV, continuous IV infusion, or SC route
• Inspect needle site for signs of inflammation, pain, and tenderness along pathway of vein- Know current aPTT before administering Parenteral administration of Lovenox SC only
• Do not dispel air bubble
• Do not aspirate or massage with either
• Give SC in abdomen rotating sites, 2 inches away from umbilicus

Anticoagulants and Thrombolytics: Coumadin

• Uses: Prevention of DVT, PE, a fib, prosthetic heart values and Prevent recurrent MI, TIA, PE, DVT
• Adverse Reactions include Hemorrhage, Hepatitis and Toxicity/overdose
• Contraindications are Preg category X,
• Breastfeeding, thrombocytopenia, bleeding, Surgeries of eye and CNS and Vitamin K deficiencies, liver disorders and ETOH use

Anticoagulants and Thrombolytics: Coumadin Interactions and Nursing Adminsitrations

Interactions Increases Coumadin effects include anticoagulant and antiplatlelet drug as well as ASA etc and parenternal chepalosporins Decreases effets of Coumadin are Phenobarbital, carbamazepine, Rifampin, phenytoin etc as well Vit K.

• Nursing administration include Same time of day, Baseline vitals , PT levels, INR , CBC, platelet, Hct and Hgb, Avoid alcohol, Medic alert bracelet, Vit K, For surgery will need to stop several days prior, Use of an Electric razor and soft toothbrush

Anticoagulants and Thrombolytics: Other Anticoagulants

Direct Thrombin Inhibitors Drugs: Pradaxa (dabigatran), Angiomax (bivalirudin), Iprivask (desirudin), argatroban Direct Inhibitor of Factor Xa drug incluedes: Xarelto (rivaroxaban), Eliquis (apixaban)

Antiplatelet Meds: Salicylate, ADP Inhibitors, and Arterial Vasodilators

• Salicylate: Aspirin prevents the formation of clots.
• Antiplatelet/ADP inhibitors: Clopidogrel, Ticlopidine, Prasugrel, Ticagrelor
• Antiplatelet/arterial dilators include dipyridamole and cilostazole.

Antiplatelets: Actions and Uses

• Action is Prohibits Aggregation
• Uses: treats Acute coronary syndrome, myocardial infarction tx and prevention, prevent Stroke/TIA, and intermittent claudication

Antiplatelets: Asprin (Adverse Reaction, Contraindications, Interactions)

• Causes Hemorrhagic stroke as well Bleeding and thrombocytopenia as well as Tinnitus, hearing loss and Nausea, vomiting and dyspepsia. As well patients are contraindicated it in Pregnancy Category D, bleeding disorders and thrombocytopenia
• Also, Children who have influenza or chickenpox due to the potential risk of Reyes syndrome.
• Interactions with other medications are medications that enhance bleeding, Decrease action of beta blockers and Corticosteroids decrease aspirin effects, caffeine can increase risk for toxicity

Antiplatelets: ADP Inhibitors (Adverse Reaction, Contraindications, Interactions, Other)

• Adverse reactions Bleeding as well as GI: diarrhea, dyspepsia and pain. It is contraindicated in patients with Bleeding disorders and thrombocytopenia.
• Interactions Increase the risk of bleeding with other meds that enhance bleeding and proton pump inhibitors decrease effectiveness. Grapefruit juice use may increase Cilostazol levels.
• For prevention of MI an intake of 81 mg. Greater levels increase risk for bleeding. 325 mg for initial MI Stop meds before surgery Watch for bleeding

Thrombolytic Drugs: Actions, Uses, and Reactions

• Actions:
  • Breaks down fibrin clots by converting plasminogen to plasmin.
  • Plasmin:An enzyme that breaks down fibrin of a blood clot.
• Uses:
  • Treats Acute myocardial infarction by lysis of blood clots in coronary arteries.
  • Blood clots causing pulmonary emboli, ischemic stroke, and DVT.
  • Bleeding .
  • Internal bleeding: Gl tract, genitourinary tract, brain
  • External bleeding: : External bleeding: Broken skin, such as venipuncture sites and recent surgical wounds
• Allergic reactions

Thrombolytics: Contraindications and Interactions

• Contraindications
  • Active bleeding.
  • History of stroke, aneurysm ady recent intracranial surgery, closed head trauma or spinal trauma within 2 months
• Interactions
  • Aspirin, dipyridamole, anticoagulants increase risk for bleeding.

Thrombolytics: Nursing Interventions

• Check that thrombolytics are given IV and they are outside the LPNs scope of practice
  • Avoid any unnecessary needle sticks
• If administering -assess the patient for bleeding until therapy is completed, and also monitor vital signs.
• For best results administer medication within 2 to 4 hours of onset
• Evaluate lab levels and vitals. Thrombolytic examples
  • Ateplase recombinant
  • Tenecteplase Urokinase

Nursing interventions Anticoagulants:

• Obtain drug history and vital signs.
• Examine extremity for color and skin temperature.
• Check for pedal pulses, noting rate and strength of pulses.
• Note areas of redness or tenderness and ask patient to describe current symptoms.
• Monitor CBC as ordered.
• Assess patient for signs of bleeding and hemorrhage.
• Monitor for intracranial bleeding by assessing level of consciousness.
• Know current PT/INR results before administering Coumadin PT 1.2-1.5 times the control INR2-3. Know current PTT results before giving Heparin 1.5-2.5 times the control.

Nursing Interventions

• Parenteral administration Heparin Administration of heparin: Intermittent IV, continuous IV infusion, & SC route
• Inspect needle ste for signs of inflammation, pain, & tenderness along pathway of vein Know current aPTT before administering
• Parantertal Admninistration of Lovenox Only Adminster SC and Do not dispel air bubble
• Do not aspirate or massage with either
  Give SC in abdomen—rotating sites, 2 inches away from umbilicus

Nursing Interventions Cont:

• Anticoagulant Antagonist are used to reverse the effects of anticoagulantes
• Includes phytonadione - Aqua-Mephyton that counteracts the affects of Coumadin and protamine sulfate which counteracts the affects of Heparin

Cholesterol Agents: Bile Sequestrants

• Actions: Binds bile acids, preventing their use by the liver to emulsify fats, causing the liver to use cholesterol to make more bile.
• Uses: treat Hyperlipidemia that does not respond to exercise and diet
• Adverse effects include Constipation, abdominal cramps, flatulence, nausea for adverse effects complete biliary obstructions and pancreatitis will cause a potential risk of patients

Cholesterol Agents: Bile Sequestrants Interactions, HMG-COA Reudctase Inhibitors (Statins) Actions and Uses

• Interactions with Sulfonylureas, Thyroid hormones will result in decreased thyroid hormone levels, Fat soluble vitamins and folic acid will decrease its absorption and it well also intect with taking Oral contraceptives. HMG-CoA Reductase Inhibitors (statins) Actions
• They inhibit the production of cholesterol in the body as well promote the breakdown of cholesterol which are LDL & VLDL also Raise HDLs
• It is Used as an Adjunct to therapy for hyperlipidemia , and as an tool to Reduce the risk of coronary death in those with evident heart disease

Cholesterol Agents: Interactions (Statins), Fibric Acid Derivatives (Actions and Uses)

• Adverse Effects Hepatotoxicity, myopathy Significant hepatic and renal disease, gallstones Interactions Sulfonylureas—will increase antiglycemic effects
• With Ezetimibe increased risk of myopathy . Grapefruit juice will Increased level of statins
• Fibric Acid Derivatives: Decrease in triglyceride levels, Increase in HDL level
• Used for Reduction of lipids

Cholesterol Agents: Miscellaneous Agents, Niacia And Zetia-exetimibe

• Actions:
  • Breaks down fibrin clots by converting plasminogen to plasmin.
  • Plasmin: An enzyme that breaks down fibrin of a blood clot.
• Action of Niacn:
  • Adjunct therapy for those art risk o pancreatitis and lowered cholesterol
• Uses:
• For patients which have acute myocardial infarction and blood clotts Zetia-exetimibe:
  • Treats primey Hypercholestermia

Drug therapy: Blood disorders

• Hematopoietic factors- Neupogen
• Action. Stimulates production of neutrophils
• Uses: netropenia
• Advrse ffcts — Bone pain, leukcytosis, elations in uric acid, splenomegaly (risk of rupture) Contraindications: — Caution in hypothyroidism Interactions: —. Lithium- Increases neutrophil

Drug therapy blood disorders

• Drug: Nuupogen(fillgastrim) —Hematotietic Factors — epogen —Action stimuliâtes production of -Red blood cells USES: — Anemia associated with. Chronie reneal failure , chemotherapy, HN treatment Adverse effects: Hy pertension cardiac arrest, risk for thrombolic event, out, headache, body aches

Drug Therapy: Contrandications

• contraindications: un controlled Hypertension Those needing emergency blood trantusion, allergies it human albumin Drug: epogen and avanesp -Nursing Intentions: Monitor BP Dont agitate vals of epogen or fillgrim
• Iron preperations Action -Elentes serum iron Lene's & replendshed hemoglobin Uses: Iron deficiency anemia Adverse effets: GI iritation NV, comtipation , dark tarry stools, teeth statig. (lqnd form), skin statin) (1M inpectiors) Contraindions: hemolvtic andmā. Interactions: Anibiotics— decreased absorption of antibiotic . Vitamin C—increase absorption of iron. mill/antacids, tea, coffee—decreased absorption of iron. Drugs = ferrous sulfate-Feosol—mmmost common least expensive ferous gluconate Fergon Parenteral form- 1mferon
• Nusing intentom: Oral. - gue with meals 4 couves G! uput Encourage foods high in iron (her, eaq yolks, mosde meats, yeast grains, green leafy wegetable)) Que th utamin C source Parenteral: 32 track + IV watch & anaphylaxis
• 2 *cyanocalbalamin Actons: pomotes the production, growth, and health of RBCS Uses: peicious anemia. Megeloblastic Imacrocytic anemia to vitamin BIZ deficiency
• Advise effets: - diarrhea and iching - hypokalcunia Contrainditions none BI2: parentend given IM. + Pecions anaemia reques be long treatment

• Evaluate B12 level