Diuretics, Inotropes, and Antihypertensives

• This is a list of drugs based on their common uses and mechanism of action
• An asterisk (*) next a drug name denotes that it is specifically called out in the text

Diuretics and Inotropes

• CCB stands for Calcium Channel Blocker
• BB stands for Beta Blocker

Loop Diuretics

• Furosemide* is included, Bumetanide and Torsemide are also included

Thiazide Diuretics

• Hydrochlorothiazide*, Chlorthalidone, Metolazone are thiazide diuretics

Potassium-Sparing Diuretics

• Spironolactone* and Triamterene are diuretics that conserve potassium

Inotropes

• Digoxin*, Dobutamine*, Milrinone*, and Dopamine are inotropic medications
• Oral and IV potassium replacements are available
• Magnesium replacements can be given

Antihypertensives

ACE Inhibitors (-pril)

• Enalapril* and Lisinopril* are examples of ACE inhibitors

ARBs (-sartan)

• Losartan* and Valsartan* belong to the ARB class

Beta Blockers (-lol)

• Beta blockers include Metoprolol*, Propranolol*, Carvedilol*, and Atenolol*

Calcium Channel Blockers

• Verapamil*, Nifedipine*, and Diltiazem are calcium channel blockers

Centrally Acting Alpha 2 Agonist

• Clonidine* acts as a centrally acting alpha 2 agonist

Vasodilators

• Hydralazine* is classified as a vasodilator

CAD, Cholesterol-Lowering Drugs, Antiarrhythmics, ED, & BPH

Nitrates (Drugs for Angina)

• Isosorbide dinitrate and Nitroglycerin are nitrate medications used for angina

Antiarrhythmics

• Procainamide, Lidocaine, Flecainide are antiarrhythmics
• Metoprolol (BB), Amiodarone (K+ blocker), Verapamil (CCB), Diltiazem, and Adenosine are further examples

Cholesterol-Lowering Drugs (-statins)

• Atorvastatin, Rosuvastatin, Simvastatin are in this category
• Gemfibrozil, and Fenofibrate are other cholesterol-lowering agents

Erectile Dysfunction (-fil) & BPH Drugs (-osin, alpha 1 blocker)

• Sildenafil (Viagra), Vardenafil, Tadalafil (treats both) - for erectile dysfunction
• Finasteride, Tamsulosin, Doxazosin, Prazosin, and Terazosin focus on BPH

Question Types

• Assess body system, lab test, or physical assessment for a drug's side effects.
• Question drug usage with a history of heart block, asthma, glaucoma, etc.
• Determine a drug's purpose when it has been ordered
• Clarify client statements about a drug that suggest incorrect understanding

Types of Questions for the Nurse

• Essential points for a teaching plan
• How to evaluate the drug's effectiveness
• What adverse effects to monitor
• Expected actions of the drug
• Side effects that require close monitoring
• Contraindications for the drug
• Assessments to perform prior to administration
• Relevant underlying health problems
• Statements indicating a need for further clarification

Antihypertensives: Arterial Pressure Factors

• Arterial Pressure = CO x peripheral resistance
• CO = HR x SV
  • Tachycardia reduces SV.
  • SV depends on preload, afterload, and contractility

Definitions

Preload

• Force stretching heart muscle during ventricular filling.
• Dependent on venous return.
• Diuretics reduce preload by targeting fluid overload

Afterload

• Resistance the heart must overcome to eject blood.
• Influenced by arterial BP, systemic vascular resistance.
  • Beta blockers reduce afterload

Contractility

• Force of ventricular contraction, needing calcium.
• Inotropic effect influences contractility: positive effect increases, negative decreases
  • Digoxin improves contractility.
• Force of contraction is also reduced by Beta blockers and Calcium channel blockers

HR (Chronotropic)

• HR is how many beats per minute the heart makes
• Chronotropic effect: positive increases HR, negative decreases HR
  • Beta blockers reduce HR
  • Calcium channel blockers reduce HR

Effects of Angiotensin II

• Angiotensin II leads to cardiac hypertrophy, ventricular remodeling and thickening blood vessel walls

First Dose Effect

• First dose effect is when the initial dose causes a sudden drop in BP.
  • ACE inhibitors, ARBs, vasodilators, and Doxazosin (A1 blocker) cause it.
  • Take a low dose, monitor BP for 2 hours, and take the first dose at bedtime

Reflex Tachycardia

• Calcium channel blockers (Nifedipine) and A1 receptor blockers (Doxazosin)

Fluid Retention

• Calcium channel blockers like Nifedipine & Verapamil cause fluid retention
• Fluid retention can occur because they decrease arterial pressure from vasodilation
  • Hydralazine causes fluid retention

Diuretics

• Diuretics are used to treat fluid buildup.

Differences in Types

• Furosemide is preferred for emergencies.
• Spironolactone prevents K+ loss when used with loop & thiazide diuretics.
• Hydrochlorothiazide (HCTZ) is a first-line drug for HTN

Differences in Effectiveness & Action

• Furosemide is the most effective diuretic, acting in the ascending loop of Henle
• Hydrochlorothiazide (HCTZ) acts in the distal tubule, less effective
• Spironolactone is a weak diuretic used with loop & thiazide diuretics, acting in the distal tubule & collecting ducts

Monitoring Electrolytes

• Spironolactone causes hyperkalemia
• Furosemide & HTZ cause hypokalemia

Dietary Considerations per Diuretic type

• Furosemide needs K+ rich foods, monitor K supplements, avoid grapefruit, avoid taking dose before sleep
• Thiazide diuretics also need K+ rich foods, monitor K supplements. Take w/ meals, avoid taking dose before sleep
• Spironolactone needs restricted K+ intake, avoid K supplements and salt substitutes

Furosemide (Ototoxicity and Hypokalemia Unique Side Effects)

• Furosemide can cause ototoxicity and hypokalemia.
• Hydrochlorothiazide can cause hypokalemia. Take with food if GI upset.
• Spironolactone can cause hyperkalemia and endocrine effects.

How to Monitor Effects

• Monitor serum K+, electrolytes, BUN, glucose levels, and endocrine effects with Spironolactone

How to Prevent Effects

• Avoid ototoxic drugs with furosemide.
• Eat K+ rich foods with furosemide & HCTZ, avoid grapefruit juice.
• Dose furosemide/HCTZ in the morning, take HCTZ with meals, and avoid drug interactions
• Monitor for hyperkalemia
• Restrict intake of K+ foods and salt substitutes with spironolactone

Drug Interactions

• Furosemide and grapefruit, other ototoxic drugs
• HCTZ can intensify digoxin effects and is toxic with hyponatremia
• Avoid digoxin and lithium in combination with HCTZ

Patient Education Notes

• Eat foods rich in K+ to avoid hypokalemia, and monitor glucose levels
• Restrict intake of K+ rich foods and avoid salt supplements

Desired Outcomes

• Assess for reduced fluid overload, improved lung sounds
• Decreased peripheral edema, decreased JVD, decreased BP
• Improved exercise tolerance, stable electrolytes (esp. K+), and increased urine output

Potassium Replacements (IV and Oral)

• Both IV and PO
• IV potassium is ALWAYS diluted and administered slowly via infusion pump. NEVER give IV push.
• Do NOT crush oral K+ supplements; take with food/water to avoid Gl distress

Adverse Effects

• Avoid high doses of potassium as it is dangerous

ACE-Inhibitors (-pril)

Action

• Blocks angiotensin II, leading to vasodilation, excretion of Na and water, and K+ retention.
• Prevents aldosterone release to lower BP.
• It inhibits kinase II increasing bradykinin
• It stops the breakdown of bradykinin

Uses

• HTN, heart failure, post-MI, prevent CV events

Side Effects

• ACE cough, angioedema, hyperkalemia, metallic taste
  • Caution use due to first dose effect (BP drop)

Nursing Considerations with ACE Inhibitors

• Nursing Considerations: Monitor BP, start with low doses, avoid in renal artery stenosis

ACE Inhibitor Specifics

ACE Cough

• Kinase II inhibition causes the cough.

Cautions

• Caution: pregnancy (teratogenic)
• Drug Interactions: diuretics, antiHTN drugs, NSAIDs

Drugs that Alter K+ (ACE Inhibitors)

• Lithium can become toxic or cause hyponatremia
• Avoid drugs that increase, potassium will cause hyperkalemia

ARBs (-sartan)

Action

• Blocks angiotensin II receptors in BV and adrenals
  • Does NOT inhibit kinase II à less bradykinin à no cough

Uses

• See ACE: HTN, HF, and post MI

Side Effects

• See ACE: first dose and hyperkalemia
  • Less frequent: No cough/angioedema

ARB Use

• Why? Can give to a person who has side effects with ACE.

Contraindications

• Drugs that alter K+: Lithium

Calcium Channel Blockers

• Both Verapamil & Nifedipine

Action

• Nifedipine blocks Ca channels in vascular smooth muscle (arterioles): vasodilation and decreased BP
• Verapamil blocks Ca influx in peripheral arterioles: vasodilation and decreased BP, slows HR, and decreases contraction

Uses

• All for HTN & vasodilation to lower BP
• Angina: improve coronary flow

Considerations With Use

• Verapamil treats arrhythmias
  • Nifedipine does NOT treat dysrhythmias (ppl can still take)
• Don't give Nifedipine with grapefruit, combine with beta blockers for prevention of reflex tachycardia

Side Effects

• All cause vasodilation hypotension, edema, HA
• Nifedipine reflex tachycardia (increased HR)
• Verapamil causes bradycardia and constipation

Nursing Intervention

• Monitor HR and SBP and hold dose w/ bradycardia

Patient Education

• Do not crush or chew open

Verapamil vs. Nifedipine

• Verapamil has actions from the heart, making it the best drug choice for dysrhymias

Vasodilators Hydralazine

Action

• Dilates arterioles only

Uses

• HTN, HF, and hypertensive emergencies

Special Considerations

AntiHTN drugs can trigger RAAS, caution w/ other antiHTN drugs

Side Effects

• Orthostatic Hypotension
• Reflex tachycardia
• Edema
• Lupus like symptoms
• HA and fatigue
• Teach weight gain and edema
  • Give diuretic w fluid retention
  • Monitor HR and give BB for tachycardia

Beta Blockers (end in -olol)

• Atenolol (selective) and Carvedilol (nonselective)

Action

• Atenolol blocks 1 on heart, reducing HR
  • Beta 1 receptors inc: HR, contractility, conduction
• Carvedilol is nonselective, blocking both alpha and beta
  • Decreases HR, vasodilation, and broncho constriction
  • Can cause dizziness
  • Beta 2 receptors bronchodile
• Alpha 1 receptors on BV vasoconstrict

Beta Blocker Uses

• HTN, Angina, MI, HF, Dysrhythmias

Contraindications

• Allergic reactions, severe allergies, diabetics, and asthma

Special Care With Use

• Masks signs of hypoglycemia and BB Will cause bronchoconstriction
  • Rebound excitation: don't stop suddenly
  • Check BP and take pulse before

Alpha 2 Agonist (Clonidine)

• Selectively activates alpha 2 receptors in the CNS

Action

• Decreases synthesis of NE, which causes vasodilation

Uses

• Add it to other drugs

Contraindications

• Caution in elderly for falls

Side Effects

Low heart, bradycardia, CNS, and dry mouth

More Considerations:

• Applied patch to hairless w tape
• Given at bedtime
• Danger of Abrupt W/D
• Taper patient off slowly

Adrenergic neuro blocker

• Depleted NE for SNS
• Caution in depression: severe depression and at risk for suicide

Alpha 1 Blockers doxazosin

Alpha 1 receptors on BV vasoconstrict selective alpha 1 causes venous and arterial vasodialstion- Used of the medication includes hypertension Side effects Relief to Tachycardia dizziness

• causes hypotention

Nitroglycerin

Vasodialtes veins Dilates arteries Low o2 and angina in both Sublingual

To Help Prevent with TOLERANCE

• Use how to minimize it
• Provide for time off at night

Drug therapy for heart failure

Lowers Renal Failure Dysrhythmias diuretics

Inotropic agents

• Digoxon* Used it increase o2 an renal system

Dobutamine

Is the only drugs to treat hypertension it needs to have be serve and given IV ICU Increase heart contact Causes a low heart contraction Causes chest pain Adverse Hyptotension hypokalemia

Amiodarone (K+ channel blocker)

• Toxic
• Causes multiple
• Pulmonary toxicity
• Prolonged QT interval --> notify doc
• Bradycardia and Heart Failure
• Thyroid
• Hepatototic Ophthalmic and RARE

More Considerations

• EKG check and cardiac monotoring
• Toxic with pregnancy

Antilipemic Drugs: gem-fibrozil statin

Used to lower cholesterol GI stress Muscle issues Used with triglycerides

• Muscle acnes test to look for is elevate

Contraictes live disease monitor function

• Stop using that pain Watch for museacle

Diuretics

Liver Fuction test Serum CK LEVESLS

FINasteride

• Teratogenic Affect Man
• Soothens the Bladder
• Prostate ED In males