Cardiovascular Drugs PDF

# Pharmacology Study Guide ## Cardiovascular Drugs ### A. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors) - Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Lisinopril (Prinivil), Ramipril (Altace) #### 1. Indications: - Treatment of hypertension, either alone or in co...

# Pharmacology Study Guide ## Cardiovascular Drugs ### A. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors) - Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Lisinopril (Prinivil), Ramipril (Altace) #### 1. Indications: - Treatment of hypertension, either alone or in combination with other antihypertensive agents - Adjunctive therapy in treatment of CHF - Treatment of left ventricular dysfunction after myocardial infarction #### 2. Serious Adverse Reactions: - Angioedema - Severe hypotension - Acute renal failure - Severe hyperkalemia #### 3. Nursing Considerations: - Monitor for angioedema (swelling of lips, tongue, or glottis) - If patient has any of these symptoms, hold the dose and notify the physician immediately. - Monitor for hypotension within one to three hours of first dose or new increased dose - Patients placed on ACE inhibitors will have a lowering of the blood pressure. - If the patient remains warm and dry and can "read a newspaper", he or she is fine regardless of what his or her blood pressure is. - However, if the patient becomes restless, cool, ashen and/or clammy, these findings need to be reported to the provider and the ACE inhibitor may be temporarily stopped or the dose reduced. - If the patient on an ACE inhibitor is complaining of feeling dizzy or lightheaded when standing from a sitting or lying position, orthostatic blood pressures should be done to assess for orthostatic hypotension - Monitor renal function (BUN, creatinine) and potassium levels - Discuss the development of a dry, tickly, and often bothersome cough #### 4. Patient Teaching: - Take directly as ordered and do not discontinue without consulting physician - Take first dose at bedtime - Do not use with NSAIDS such as Motrin, Indocin, or Naproxen - Avoid potassium supplements and foods high in potassium - May cause dizziness when rising from lying or sitting position or climbing stairs - May experience dry mouth or transient loss of appetite - Report chest pain, palpitations, mouth sores, fever, or unusual cough - Avoid salt substitutes which are high in potassium ### B. Angiotensin II Receptor Blockers (ARBs) - Losartan (Cozaar) Valsartan (Diovan) Candesartan (Atacand) #### 1. Indications: - The ARBs are especially useful in providing an alternative therapy in those patients who have intractable cough in response to ACE Inhibitors or who have angioedema from ACE Inhibitors. - Losartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. #### 2. Serious Adverse Reactions: - Angioedema - Severe hypotension - Hepatotoxicity - Leukopenia - Neutropenia - Hyperkalemia #### 3. Nursing Considerations: - Observe for symptomatic hypotension and tachycardia, especially in patients with CHF - Assess for hyponatremia or severe volume depletion - Assess orthostatic blood pressures for complaints of dizziness when going from a lying or sitting to a standing position - Monitor creatinine and BUN #### 4. Patient Education: - Take exactly as directed and do not discontinue without consulting physician - Take first dose at bedtime - Consult physician before using NSAIDS - May cause dizziness, fainting, and/or lightheadedness - Report chest pain or palpitations, unrelenting headache, swelling of extremities, face or tongue, difficulty in breathing, or unusual cough ### C. Cardiac Glycosides (digitalis preparations) - Digoxin (Lanoxin) #### 1. Indications: - Digoxin is used for the treatment of CHF and to slow the ventricular rate in a tachyarrhythmia such as atrial fibrillation, atrial flutter, and supraventricular tachycardia. #### 2. Serious Adverse Reactions: - AV block - Bradycardia - Ventricular arrhythmia - Thrombocytopenia (rare) - Delirium - Hallucinations #### 3. Nursing Considerations: - Observe patients for non-cardiac signs of toxicity such as anorexia, vision changes (blurred, yellow halos), confusion, depression, anorexia, and fatigue - Monitor for changes in pulse rate, or rhythm, or BP. Take apical pulse before administering. Usual parameters: Pulse under 60 or greater than 120 - hold dose & notify physician. - Narrow therapeutic window; monitor levels accordingly - Monitor patient's potassium levels as hypokalemia may potentiate the risk of digoxin toxicity - The antidote for digoxin toxicity is Digibind - Elderly patients are at greater risk for developing digoxin toxicity #### 4. Patient Education: - Take as directed - do not discontinue without consulting physician - Maintain adequate dietary intake of potassium to reduce toxicity - Take pulse at the same time each day and follow physician's orders of when to call - Notify physician if there is a loss of appetite, nausea and vomiting, persistent diarrhea, swelling of extremities, palpitation, yellowing or blurred vision, mental confusion, depression, or fatigue ### D. Coronary Vasodilators (Antianginal agents) - Nitrites, Nitrates: Nitroglycerin [NTG] (Nitrobid, Nitrostat, Nitro-Dur) - Isosorbide dinitrate (Isordil), Isosorbide Mononitrate (Imdur), Nitropaste, Nitro spray #### 1. Indications: - Treatment of angina pectoris, CHF, pulmonary hypertension, hypertensive emergencies #### 2. Serious Adverse Reactions: - Thrombocytopenia - Orthostatic hypotension #### 3. Common Reactions - Hypotension - Migraine headache #### 4. Nursing Indications: - IV must be prepared in glass bottles; special IV tubing may be used due to absorption of the drug by plastic materials - Transdermal patch labeled as mg/hour - Transdermal patches may be ordered to be removed at night to allow for a nitrate-free period - Do not crush sublingual drug product - Infusion should be administered only via pump and titrated as ordered - Isorbide mononitrate is a sustained released nitrate - Viagra and other vasodilators used to treat ED potentiates the hypotensive effects of nitrates; concurrent use is contraindicated - Beta and calcium channel blockers, antihypertensives, and antidepressants may enhance hypotensive effects #### 5. Patient Education: - Patient teaching related to nitroglycerin sublingual: - Tell patient to always carry bottle with them. Keep them in original dark glass bottle and replace 6 months after opening - Tell patient to put 1 tablet under tongue at first sign of anginal attack - Advise patient to sit or lie down for 10-15 minutes after taking drug to decrease side effects - Instruct patient to take additional SL tablets (up to 3) at 5-minute intervals if pain is not relieved. If pain is still present after 15 minutes, call 911. - Use caution with elderly patients - risk of hypotension - Do not chew or swallow sublingual tablets - Do not chew extended-release capsules - Nitro spray is sprayed directly on mucous membranes - do not inhale - Transdermal patches are placed on hair-free area of skin; rotate sites - May cause dizziness; use caution when changing position ### E. Calcium channel blockers: - Diltiazem (Cardizem) Amlopidine (Norvasc) Nifedipine (Procardia), Verapamil (Calan, Calan SR, Isoptin) #### 1. Indications: - Used in the treatment of angina, hypertension, and pulmonary hypertension #### 2. Serious Adverse Reactions: - Bradycardia/AV Block - Arrhythmias - Hypotension; Severe/Syncope - CHF #### 3. Nursing Considerations: - Monitor heart rate, blood pressure, signs and symptoms of CHF, peripheral edema - Increased therapeutic and vasodilator side effects, including severe hypotension and myocardial ischemia, may occur if taken with grapefruit juice - Serum levels may be decreased if taken with food - Elderly may experience greater hypotensive response; constipation may be more of a problem in elderly as well - Grapefruit juice increases bioavailability - monitor for altered effects #### 4. Patient Education: - Take as directed and do not alter dosage regimen or stop without consulting provider - Do not crush or chew tablets/capsules - Change position slowly to prevent orthostatic events - Maintain good oral care and inspect gums for swelling or redness - May cause frequent urination at night - Report irregular heartbeat, swelling, difficulty breathing, or new cough ### F. Other Antihypertensive Drugs - **Beta-Adrenergic Blocking Agents:** Metoprolol tartate (Lopressor), Carvedilol (Coreg), Nadolol (Corgard), Propranolol hydrochloride (Inderal), Sotalol (Betapace), Labetolol (Normodyne), Esmolol (Brevibloc), Atenolol (Tenormin) - **Alpha 1 Adrenergic Blocking Agents:** Doxazosin mesylate (Cardura), Prazosin hydrochloride (Minipress) - **Alpha 2 Adrenergic Agonist Agents:** Clonidine hydrochloride (Catapres) **Classification of Blood Pressure based on the JNC7 report** | Category | SPB MM Hg | DPB MM Hg | |---|---|---| | Normal | Less than 120 | Less than 80 | | Prehypertension | 120-139 | 80-89 | | Hypertension, Stage 1 | 140-159 | 90-99 | | Hypertension, Stage 2 | Greater than 160 | Greater than 100 | **Principles of Hypertension Treatment** - Treat to BP less then 140/90 or BP less then 130/80 in patients with diabetes or chronic kidney disease. - Majority of patients will require two medications to reach goal. **Compelling Indications for Individual Drug Classes** | Compelling Indication | Initial Therapy Options | |---|---| | Heart failure | Thiazide diuretic, Beta blocker, ACE Inhibitor, Angiotensin Receptor Blocker, Aldosterone antagonist | | Post Myocardial Infarction | Beta blocker, ACE Inhibitor, Aldosterone antagonist | | High CVD risk | Thiazide diuretic, Beta blocker, ACE Inhibitor, Calcium Channel Blocker | | Diabetes | Thiazide diuretic, Beta blocker, ACE Inhibitor, Angiotensin Receptor Blocker, Calcium Channel Blocker | | Chronic kidney disease | ACE Inhibitor, Angiotensin Receptor Blocker | | Recurrent stroke prevention | Thiazide diuretic, ACE Inhibitor | #### 1. Indications: - Beta-blockers are indicated for treatment of hypertension, post myocardial infarction, improving cardiovascular outcomes with patients who have underlying cardiovascular disease and are undergoing noncardiac surgery, treatment of atrial fibrillation, unstable angina, and heart failure (cardiac selective) - Alpha 1-blockers are indicated for treatment of hypertension #### 2. Adverse Reactions: - **Beta Blockers:** - **Serious Reactions**: - Bronchospasm - Hypotension, Severe - Cardiac failure - **Common Reactions**: - Hypotension - Dizziness - Nausea - Somnolence - Confusion - **Alpha Adrenergic Agents:** - **Serious Reactions:** - Arrythmia - **Common Reactions:** - Dizziness - Headache - Orthostatic hypotension - Fatigue #### 3. Nursing Indications: - Minimize risk of bradycardia with initiation of treatment with a low dose and slow upward titration - Administer medication with food - Monitor blood pressure and heart rate - Does not work well in elderly patients. Response rates only 20% to 50% - Beta-blockers may mask symptoms of hypoglycemia #### 4. Patient Education: - Instruct patient to report lightheadedness/dizziness associated with therapy - Inform patients not to abruptly stop taking antihypertensive medications - Encourage increased fluid intake. Increase dietary bulk for patients as constipation is common - Do not take with antacids and avoid alcohol or over the counter medications before consulting physician - If diabetic, monitor serum glucose closely - May cause fatigue, dizziness, or postural hypotension; use caution when changing position from lying or sitting to standing - May cause alteration in sexual performance - Report unresolved swelling of extremities, difficulty breathing, or new cough ### G. Antiarrhythmics - Amiodarone, Procainamide (Pronestyl) - Lidocaine hydrochloride (Xylocaine) - IV only #### 1. Indications: - Lidocaine IV is used for acute treatment of ventricular arrhythmias due to myocardial infarction, cardiac manipulation, and digitalis intoxication - Amiodarone and Procainamide are used for the treatment of both atrial and ventricular arrhythmias #### 2. Adverse Reactions: - **a. Amiodarone:** - **Serious Reactions**: - Ventricular arrhythmia - Prolonged QT - Bradycardia, Severe - Hypotension, Severe - CHF - **Common Reactions**: - Photosensitivity; may result in a bluish coloring of the skin - Fatigue - **b. Procainamide** - **Serious Reactions**: - Ventricular Fibrillation - Asystole - Seizures - Thrombocytopenia - **Common Reactions**: - Hypotension - Bradycardia - **c. Lidocaine** - **Serious Reactions**: - Seizures - Respiratory arrest - Worsened arrhythmia - Status asthmaticus - Heart block - Bradycardia - Coma - **Common Reactions**: - Tremor - Confusion - Hypotension - Blurred Vision ### H. Anticoagulants - Heparin - Antagonist is protamine sulfate. An overdose of heparin will be reported immediately upon discovery. Drug withdrawal may be sufficient to manage the overdose. If not, the administration of protamine sulfate is done by the physician - Heparin is never administered IM due to pain, irritation, and hematoma formation - Do not massage the site after injection - Lovenox - Administer by deep subcutaneous injection to the left or right anterolateral and left or right posterolateral abdominal wall - Do not expel air bubble from the syringe prior to injection - Do not massage injection site - Direct Oral Anticoagulants - Do not require routine laboratory level monitoring - Dosing may be once daily or twice daily - Avoid in liver or renal dysfunction - Reversal process is dependent on agent used; idarucizumab (Praxbind) is used to reverse Dabigatron, and Andexanet alfa (Andexxa®) [coagulation factor Xa (recombinant) inactivated-zhzo] is used to reverse Rivaroxaban and Apixaban - Henry Ford Health has a Tier1 anticoagulation reversal guideline in place #### 4. Patient Education: - Do not take any medication that your physician is not aware of and follow diet and activity as recommended by your physician - You may tend to bleed easily while taking this drug - Brush teeth with soft brush, floss with waxed floss, use electric razor, and avoid scissors or sharp knives and potentially harmful activities - Report chest pain, persistent constipation, unusual bleeding or bruising, pain in joints or back, or numbness/tingling/swelling/pain at injection site - Increased risk of bleeding if combined with chamomile, garlic, ginger, ginkgo, or ginseng therapy