Cardiovascular Drugs: Cardiotonics

Pharmacology: Cardiovascular Drugs

Cardiotonics

• Actions include increasing cardiac output by increasing the force of myocardial contraction, known as positive inotropic activity.
• Slow conduction and decrease heart rate through the negative chronotropic effect.
• Used for the treatment of heart failure and atrial fibrillation
• Hold Digoxin medication if Heart rate is less than 60 for adults; less than 70 for children; less than 90 for infants
• Adverse effects include headache, weakness, drowsiness, visual disturbances (diplopia blurred vision yellow/green vision and white halo around objects) and arrhythmias.
• GI upset and anorexia are usually the first manifestation of toxicity.
• Contraindications include 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, which can reduce therapeutic effects of dig.
• Thyroid hormones decrease the effectiveness of digoxin.
• Thiazide and loop diuretics can lead to hypokalemia, which increases the risk of toxicity.
• Quinidine increases the risk of dig toxicity.
• Verapamil increases serum dig
• Antacids decrease absorption of dig.
• Lanoxin is an example of digoxin and requires a loading dose.
• A therapeutic drug level is 0.5-2.0 ng/ml.
• Dig toxicity can cause visual changes, including green/yellow vision, anorexia, N/V/D, fatigue, and weakness.
• Changes in cardiac function can occur.
• Monitor potassium levels, as hypokalemia predisposes one to dig toxicity.
• The antidote is digibind (digoxin immune).
• If dose is missed DO NOT double dose
• Manage digoxin toxicity by withholding dig and potassium-sparing medications and notifying the provider immediately.
• Monitor potassium levels.
• Phenytoin and lidocaine treat digoxin-induced arrhythmias.
• Atropine treats bradycardia
• Digibind can also be used.

Antianginals

• Actions of nitrates relax smooth muscles (vessels), increasing 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.
• Nitrates can also be used for the prevention of anginal attacks and treatment of chronic stable angina.
• Calcium Channel Blockers are used for anginal pain and hypertension.
• Beta blockers are used for angina and hypertension.
• Adverse effects of nitrates include headache (hallmark effect), dizziness, weakness, hypotension, and flushing.
• Calcium Channel Blockers can cause dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, and cough.
• Avoid grapefruit juice as it increases meds effects
• Beta Blockers possible adverse effects are HF, dizziness, bradycardia, arrhythmias, decreased libido, impotence, constipation/diarrhea.
• Nitrates are contraindicated in severe anemia, closed-angle glaucoma, postural hypotension, head trauma, and cerebral hemorrhage.
• Calcium Channel Blockers are contraindicated in 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 can cause hypotension when taking Nitrates
• ED meds and NTG can result in life-threatening hypotension.
• Heparin decreases the effect of heparin.
• Alcohol can cause severe hypotension.
• Beta Blockers may cause bradycardia when taking Calcium Channel Blockers
• Digoxin increases the risk of digoxin toxicity.
• Grapefruit juice increases drug levels and effectiveness.
• Calcium channel Blockers increase the effects of Beta blockers.
• Antihypertensive medications increase the risk of hypotension.
• NSAIDs decrease the effect of beta blockers.
• Loop diuretics increase the risk of hypotension.
• Clonidine has a risk of paradoxical hypertensive reaction
• ISMO and Imdur are examples of isosorbide mononitrate.
• Isordil is an example of isosorbide dinitrate.
• Nitro-Bid and Nitrostat is nitroglycerin
• Norvasc is amlodipine. Cardizem is diltiazem HCL. Plendil is felodipine. Cardene is nicardipine HCL. Procardia and Adalat are nifedipine. Calan and Isoptin are verapamil HCL.
• Tenormin is atenolol. Lopressor is metoprolol. Corgard is nadolol. Interal is propanolol (nonselective).
• One should give SL nitroglycerin 1 every 5 minutes x 3; if pain is still present after the first dose, call 911, then take the second one.
• Monitor vital signs, taking an apical pulse, protecting safety and one should monitor and document chest pain.
• The client should get a new bottle every 3-6 months.
• Nitro should be kept in a brown bottle.
• One should rise slowly from lying or sitting position.
• Nitro should tingle or sting when used.
• Rotate patch sites, remove old patch.
• Keep nitro with you at all times.
• Take prophylactically before any stress-inducing activity.

Antihypertensives

• ACE Inhibitors inhibit the conversion of angiotensin I to angiotensin II (powerful vasoconstrictor).
• ACE Inhibitors are used for HTN, heart failure, to prevent and treat MI, and neuropathy
• Adverse reactions of ACE Inhibitors are first-dose orthostatic hypotension, cough, hyperkalemia, rash, altered taste, neutropenia (captopril).
• ACE Inhibitors are contraindicated in pregnancy cat D and hypersensitivity
• Diuretics increase first-dose hypotension.
• Antihypertensive causes hypotension when taken in connection with ACE drugs
• Lithium increases the risk of lithium levels.
• NSAIDs decrease the effects of ACE inhibitors.
• One should Monitor BP post first dose for at least 2 hours and rise slowly
• Angiotensin II Receptor Antagonists action: Block binding of angiotensin II at receptor sites—this blocks vasoconstriction.
• Angiotensin II Receptor Antagonists Treats HTN, HF (valsartan).
• Stroke prevention (lorsartan), neuropathy (irebesartan, losartan), slow development of diabetic retinopathy (losartan), and reduce mortality post MI (valsartan)
• Adverse Reactions includes Hypersensitivity, fetal injury, hypotension, dizziness, and lightheadedness.
• Drug is contraindicated in Pregnancy, therefore Preg D.
• Other antihypertensives increase hypotension as well as increased risk of lithium toxicity.
• Direct Renin Inhibitors action is to inhibit production of angiotensin I and is for Hypertension
• Direct Renin Inhibitors Adverse Reactions: Hypersensitivity, rash, cough, hyperkalemia, diarrhea, and hypotension
• Preg cat D, hyperkalemia, and Hypotension are all contraindications.
• Decreases levels of furosemide.
• Increases the effect of other antihypertensives.
• Avoid high-fat foods that reduces absorption.
• Increased hyperkalemia with ACE inhibitors, potassium supplements, and potassium-sparing diuretics.
• Beta Blockers slow heart rate and dilate blood vessels.
• Beta Blockers treats HTN, Angina, HF, MI, Hyperthyroidism, migraine headaches, glaucoma, pheochromocytoma
• Calcium Channel Blockers Slows heart rate and decreases contractility of the heart for conditions like angina, HTN, cardiac dysrhythmias (verapamil, diltiazem)
• Alpha Adrenergic Blocking Drugs (sympatholytics) Action: relaxes the smooth muscle of vessels by blocking the stimulation of alpha-adrenergic nerves.
• Alpha Adrenergic Blocking Drugs (sympatholytics) treats HTN and Benign prostatic hyperplasia (BPH),
• Alpha Adrenergic Blocking Drugs (sympatholytics) Adverse Reactions: First-dose orthostatic hypotension
• Alpha Adrenergic Blocking Drugs (sympatholytics) is contraindicated in hypotension.
• Alpha Adrenergic Blocking Drugs (sympatholytics) interacts with other antihypertensives.
• Anti-adrenergic centally acting drugs Action: Act in the central nervous system (CNS) to block the activity of the sympathetic nervous system (vasoconstriction) for ailments such as HTN
• Anti-adrenergic centrally acting drugs has Adverse Reactions such as Drowsiness and dry mouth.
• Rebound hypertension (must taper to prevent over 2-4 days) Contraindications: bleeding disorders and anticoagulant therapy.
• Anti-adrenergic centrally acting drugs interacts with Other antihypertensives
• Prazosin, MAOIs, and tricyclic antidepressants counteract the clonidine effect.
• CNS depression with other CNS depressants, if a patch, apply it to hairless, intact skin on the torso or upper arm

Examples of Drugs

• Beta Blockers-olol drugs -Tenormin-atenolol -Lopressor, Toprol-metoprolol -Corgard-nadolol -Inderal-propanolol (non-selective) -Blocadren-timolol maleate -Zebeta-bisoprolol (non-Selective) -Coreg-carvedilol
• Calcium Channel Blockers -Norvasc-amlodipine -Procardia and Adalat—nifedipine -Cardizem—diltiazem HCL
• Antiadrenergic Drugs-Centrally acting -Catapres—clonidine HCL -Tenex—guanabenz acetate -Aldomet—methyldopa
• Alpha-Adrenergic Blockers
• Minipress-prazosin
• ACE inhibitors—pril drugs -Lotensin-benazepril HCL -Capoten-captopril -Vasotec-enalapril -Mavik-trandolapril -Zestril-lisinopril
• Angiotensin II Receptor Antagonists—sartan drugs -Atacand—candesartan cilexetil -Avapro-irbesartan -Cozaar-losartan potassium -Micardis—telmisartan -Diovan—valsartan
• Nursing Interventions
• Take blood pressure before giving meds, monitor for adverse effects, I & O and dangle before getting out of bed
• Client Teaching -Do not stop your drug(s) abruptly, report adverse effects to physician, take as directed
• Report signs/symptoms of HF (sudden weight gain, swelling, SOB) and do not use OTC cold preparations (decongestants) without clearing with the physician

Diuretics

• Loop increases the reabsorption of water in the loop of Henle.
• Thiazide inhibits the reabsorption of sodium and water.
• Potassium-sparing depresses reabsorption of sodium, therefore water reabsorption.
• Uses include edema, HTN, and renal disease.
• Adverse reactions include Orthostatic hypotension, weakness, and fatigue
• Loop causes hypokalemia and dig toxicity
• Thiazide causes hyperglycemia and decreased libido
• Potassium sparing causes hyperkalemia, hyponatremia, gynecomastia, erectile dysfunction, and flu-like symptoms and s/s, dizziness, and fatigue.
• Contraindications includes Severe kidney or liver disease and anuria.
• Potassium sparing is contraindicated in hyperkalemia.
• Nursing Interventions
• 1 & 0
• Weigh daily
• Monitor blood pressure
• Dangle before getting up
• Monitor for dehydration
• Monitor electrolytes
• Give during the day and early afternoon

Examples

• Loop -Lasix-furosemide -Bumex-bumetanide -Demadex-toresmide
• Thiazide -Microzide-hydrochlorothiazide (HCTZ) -Zaroxolyn-metolazone
• Potassium-sparing -Midamor-amiloride -Aldactone-spironolactone -Inspra - eplerenone

Anticoagulant/Thrombolytics

• Anticoagulants prevent the formation and extension of a thrombus.
• Coumadin is an oral anticoagulant.
• Heparin is a parenteral anticoagulant.
• Parenteral anticoagulants include low-molecular-weight heparins (LMWH).
  • They can be given stable responses when administered at the recommended dosages and cause bleeding less likely to occur.
  • Examples of LMWH are Lovenox – enoxaparin, Fragmin - dalteparin.
• Activated factor Xa inhibitors: Arixtra - fondaparinux sodium.
• Actions of heparin include inhibits formation of fibrin and inactivates factors necessary for clotting of blood.
• Heparin is used for CVA, PE, DVT, MI, Prophylaxis post op thrombosis and a fib, and DIC.
• LMWH is used to prevent post-op DVT, DVT and PE, and prevent complications of angina and MI.
• Activated factor Xa helps prevent DVT and PE post op and treat acute DVT or PE in conjunction with warfarin.
• Adverse reactions of Heparin include hemorrhage, thrombocytopenia, hypersensitivity, and toxicity/overdose.
• Adverse reactions of LMWH include hemorrhage, neurologic damage (hematoma formation during spinal anesthesia), thrombocytopenia, and toxicity/overdose.
• Fondaparinux's adverse reactions include the risk of hemorrhage, neurologic damage, and thrombocytopenia.
• Anticoagulants are contraindicated in thrombocytopenia, active bleeding (except DIC), hemorrhagic disease, uncontrolled hypertension, recent surgery of the eye or CNS, hemophilia, and severe HTN.
• Aspirin, NSAIDs, and anticoagulants increase the risk of bleeding.
• Oral contraceptives and vitamin K decrease the effectiveness of anticoagulant (Coumadin).
• To nurse drug properly you should check the patient's baseline VS, aPTT, CBC, platelet count, Hematocrit, and Hgb. Check the dose with another nurse prior to its administration and remember that Heparin can be given IV by RN but requires a pump.
• SQ injection includes Draw up with 20-22 g, then replace it with 2526 g ½ - 5/8" needle to inject. Note that you should not aspirate, Use gentle pressure 1-2 min post injection and Rotate sites. Also to monitor for bleeding, instruct to avoid OTC NSAIDs and ASA .One should use an electric razor and a soft toothbrush
• LMWH and fondaparinux has the same procedure as administering heparin but you don't do any lab work. Do not rub post injection, if not prefilled, then same as heparin.
• Coumadin Uses: Prevention of DVT, PE, a fib, and prosthetic heart valves, along with Preventing recurrent MI, TIA, PE, and DVT
• Adverse Reactions that can occur are Hemorrhage, Hepatitis, and Toxicity/overdose
• Contraindications when using Anti-Coagulants are Preg X, Breastfeeding, thrombocytopenia, bleeding, Surgies of eye and CNS and Vitamin K deficiencies, liver d/o and ETOH use
• It Increases Coumadin effects Anti-Coagulants, antiplatelet, ASA, and glucocorticoids and Decreases Coumadin effects are Phenobarbital, carbamazepine, rifampin, phenytoin, oral contraceptives, and vitamin K
• Vitamin K foods includes Lettuce, cooked spinach, cabbage, broccoli, brussel sprouts, mayo, canola, and soybean oil

Drugs for Thrombolysis

• Direct Thrombin Inhibitors Drugs: Pradaxa (dabigatran), Angiomax (bivalirudin), Iprivask (desirudin) and argatroban and Direct Inhibitor of Factor Xa Xarelto (rivaroxaban), and Eliquis (apixaban)
• Use Salicylate -Aspirin, Antiplatelet/ADP inhibitors
• Plavix-clopidogrel
• Ticlid-ticlopidine
• Effient-prasugrel
• Brillinta-ticagrelor

Actions For Antiplatlets

• prohibits aggregation
• Use it to Treat acute coronary syndrome, myocardial infarction treatment and prevention, prevent stroke/TIA, and intermittent claudication
• Aspirin side effect includes Hemorrhagic stroke, Bleeding/thrombocytopenia, Tinnitus, hearing loss and Nausea, vomiting, dyspepsia,
• Contraindications to the drug Aspirin are as followsPreg D, Bleeding disorders along with thrombocytopenia ,Children who have influenza or chickenpox r/t Reyes syndrome
• Interactions to Drug,Other medications that enhance bleeding,decrease action of bets blockers and Corticosteroids decrease aspirin effects
• Caffeine can increase risk for toxicity"
• ADP inhibitors Adverse reactions Include Bleeding GI: diarrhea, dyspepsia, and pain
• Contraindications with this is Bleeding disorders/thrombocytopenia and Interactions include Increased bleeding with other meds that enhance bleeding and proton pump inhibitors decrease effectiveness

Notes about antiplattlet treatment regimes

Grapefruit juice can increase cilostazol levels 81 mg the recommended dose of ASA to prevent MI, CVA, and reinfarction. The Greater the levels, increase risk for bleeding 325 mg for initial MI episode and the patient should Stop meds before surgery, Watch for bleeding and Nursing Interventions, Assess labs: cholesterol, HDL, LDL, VLDL, triglycerides, liver and kidney

• Use only if patient breaks down fibrin clots by converting plasminogen to plasmin.
• Plasmin: Enymes that breaks down fibrin of blood clot
• You can use the drug from the coronary arteries, but only if the patient has-Acute myocardial infarction by lysis of blood clots found in coronary arteries,
• Blood clots causing pulmonary emboli, ischemic stroke, and DVT-Bleeding, -There is a risk of an allergic reaction with this drug therefore the patient needs to state if is having Internal bleeding: Gl tract, genitourinary tract, or in the brain.
• The patient should state any External bleeding from sites likeBroken skin, such as venipuncture sites and recent surgical wounds
• You should never use this drug if the patient has - Active bleeding, History of stroke or aneurysm.
• You should never use this drug if the patient had recent intracranial surgery, the patient has closed head trauma or spinal trauma within 2 months.
• Drugs that interact with this is: Aspirin, dipyridamole