Drugs Acting on the Cardiovascular System PDF

DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Women of childbearing age who choose to use one of these  Anti-Hypertensive Drugs drugs should be encouraged to use barrier contraceptive...

DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Women of childbearing age who choose to use one of these  Anti-Hypertensive Drugs drugs should be encouraged to use barrier contraceptives to  Cardiotonic Agents avoid pregnancy while taking the drug  Antiarrythmic Agents  Antianginal Agents Adverse effects  Lipid Lowering Agents Fatigue Airway obstruction Constipation  Drugs Affecting Blood Coagulation Dizziness Reflex tachycardia Liver injury  Drugs Used to Treat Anemia Mood changes Chest pain Renalinsufficiency Headaches Angina Renal failure ANTI-HYPERTENSIVE DRUGS Loss of taste Heart failure Proteinuria Since the underlying cause of hypertension is usually Hyperkalemia Cardiac arrhythmias Rash unknown (essential hypertension), altering the body's regulatory Anemia Gastrointestinal Alopecia mechanisms is the best treatment available. Antihypertensive Neutropenia irritation Dermatitis drugs work by altering the normal reflexes that control blood Pancytopenia Photosensitivity pressure. It does not cure the disease but is aimed at maintaining Unrelenting cough the blood pressure within normal limits to prevent the damage Thrombocytosis Ulcers that hypertension can cause. Subclasses Angiotensin-Converting-Enzyme (ACE) Inhibitors Drug To drug Interactions Angiotensin II Receptor Blockers (ARBs) The risk of hypersensitivity reactions increases if these drugs Calcium-Channel Blockers are Taken with allopurinol. There's a risk of decreased anti Vasodilators hypertensive Effects if taken with nonsteroidal anti- inflammatory drugs. The Combination of drugs used to alter NAME OF DRUG:ANGIOTENSIN-CONVERTING-ENZYME (ACE) the ras is not recommended Due to potentially serious INHIBITOR adverse effects, and should not be Combined with other ace ACE inhibitors act in the lungs to prevent ACE from inhibitors, arbs, or a renin inhibitor converting angiotensin I to angiotensin II, a powerful vasoconstrictor and stimulator of aldosterone release. This action Nursing Consideration leads to a decrease in BP an in aldosterone secretion, with a Assess for the following conditions, which could be resultant slight increase in serum potassium and a loss of serum cautions or contraindications to use of the drug: Any known sodium and fluid allergies to these drugs, impaired kidney function, pregnancy, lactation, salt/volume depletion, and heart failure. Drugs Under Angiotensin-Converting Enzyme (Ace)Inhibitors Assess baseline status before beginning therapy to Benazepril (Lotensin) Moexipril (Univasc) determine any potential adverse effects. Captopril (Capoten) Perindopril (Aceon) Monitor the patient carefully in any situation that might Enalapril (Vasotec) Quinapril (Accupril) lead to a drop in fluid volume (e.g. excessive sweating, Enalaprilat (Vasotec IV) Ramipril (Altace) dehydration) to detect and treat excessive hypotension that Fosinopril (Monopril) Trandolapril (Mavik) may occur Lisinopril (Prinivil, Zestril) Provide comfort measures to help the patient tolerate drug effects. Indication Monitor the patient's response to the drug (maintenance These drugs are indicated for the treatment of hypertension, of BP within normal limits). alone or in Combination with other drugs. They are also used in conjunction with digoxin And diuretics for The treatment of heart NAMEOFDRUG:ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS) failure and left ventricular Dysfunction. They Are also approved ARBs selectively bind with the angiotensin II for the treatment of diabetic Nephropathy receptors in vascular smooth muscle and in the adrenal cortex to block vasoconstriction and the release of Pharmacokinetics aldosterone. These actions block the BP-raising effects of the All of the ace inhibitors are administered orally. Enalapril also has renin-angiotensin system and lower BP the advantage of parenteral use (enalaprilat [vasotec iv]) if oral use is not feasible Or rapid onset is desirable. These drugs are Drugs Under Angiotensin Ii Receptor Blockers (Arbs): well Absorbed, widely distributed, metabolized in the Liver, and Azilsartan (Edarbi) excreted in the urine. They cross the Placenta and enters breast Candesartan (Atacand) milk Eprosartan (Teveten) Irbesartan (Avapro) Contraindication Losartan (Cozaar) presence of allergy - to prevent hypersensitivity Reactions. Olmesartan (Benicar) impaired renal function - which could be exacerbated By the Telmisartan (Micardis) effects of this drug in decreasing renal blood flow. Valsartan (Diovan pregnancy - due to potential for serious adverse effects On the fetus. Indication lactation - because of potential decrease in milk Production These drugs are indicated to be used alone or in combination and effects on the neonate therapy for the treatment of hypertension and for the Caution: treatment of heart failure in patients who are intolerant to Heart failure - because the change in hemodynamics could be ace inhibitors. They also slow the progression of renal disease detrimental in some cases. in patients with hypertension and type 2 diabetes Salt/volume depletion - which could be exacerbated by the drug effects.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Pharmacokinetics relaxes and dilates arteries, causing a fall in BP and a These agents are all given orally. They are well absorbed decrease in venous return. and undergo metabolism in the liver by the cytochrome p450 system. The arbs cross the placenta. They are excreted in the Drugs Under Calcium-Channel Blockers: feces and urine. Amlodipine (Norvasc) Felodipine (Plendil) Contraindication Isradipine (DynaCirc, DynaCirc CR) presence of allergy - to prevent hypersensitivity reactions. Nicardipine (Cardene, Cardene SR) pregnancy - due to association with serious fetal abnormalities Diltiazem (Cardizem, Dilacor CR) and even death. Nifedipine (Procardia XL) lactation - because of the potential for serious adverse effects Nisoldipine (Sular) in the neonate Verapamil (Calan SR) Caution: Clevidipine (Cleviprex) presence of hepatic or renal dysfunction - which could Alter the metabolism and excretion of these drugs. Indication hypovolemia - because of the blocking of potentially These drugs are indicated to be used alone or in combination Life-saving compensatory mechanisms. with other agents for the treatment of hypertension and women of childbearing age should be advised to use angina. Calcium-channel blockers are also sometimes used Barrier contraceptives to avoid pregnancy; if a pregnancy in the treatment of Raynaud's disease and migraine Does occur the arb should be discontinued immediately. headache Adverse Effects Pharmacokinetics Headache, dizziness, syncope, and weakness, which could Calcium-channel blockers are given orally and are generally be associated with drop in BP; well-absorbed, metabolized in the liver, and excreted in the GI complaints including diarrhea, abdominal pain, nausea, urine. These drugs cross the placenta and enter breast milk. dry mouth, and tooth pain Nicardipine and clevidipine are available in IV form for Symptoms of upper respiratory tract infections and cough short-term use when oral administration is not feasible. Rash Dry skin Contraindication Alopecia Presence of allergy to any of these drugs - to prevent Various cancers hypersensitivity reactions. Renal damage Heart block or sick sinus syndrome - which could be Hypotension exacerbated by the conduction-slowing effects of these drugs. Drug To Drug Interactions Renal or hepatic dysfunction - which could alter the The risk of decreased serum levels and loss of effectiveness metabolism and excretion of these drugs increases if the ARB is taken in combination with phenobarbital, Pregnancy because of the potential for adverse effects indomethacin, or rifamycin. on the fetus or neonate. There may be a decrease in anticipated antihypertensive effects Lactation - because of the potential for serious adverse if the drug is combined with ketoconazole, fluconazole, or effects on the baby; if these drugs are required by the diltiazem. mother, another method of feeding the infant should be These drugs should not be used with ACE inhibitors or a renin used. inhibitor because of the potential for serious adverse effects. Adverse Effects Nursing Consideration CNS - dizziness, lightheadedness, headache, and fatigue Assess for the following conditions, which could be cautious or GI - nausea, hepatic injury contraindications to the use of the drug: Any known allergies to CV - hypotension, bradycardia, peripheral edema, and these drug, impaired kidney or liver function, pregnancy and heart block lactation, hypovolemia. Integumentary System - skin flushing, rash Assess baseline status before beginning therapy to determine any potential adverse effects. Drug To Drug Interactions Administer without regard to meals; give with food to decrease Drug-drug interactions vary with each of the GI distress if needed. calcium-channel blockers used to treat hypertension. A Find an alternative method of feeding the baby if the patient is potentially serious effect to note is an increase in serum nursing levels and toxicity of cyclosporine if taken with diltiazem Monitor the patient carefully in any situation that might lead to a drop in fluid volume (e.g. excessive sweating, dehydration) to Nursing Consideration detect and treat excessive hypotension that may occur. Assess for contraindications or cautions: known allergies to Provide comfort measures to help the patient tolerate drug any of these drugs, impaired liver or kidney function, heart effects. block, pregnancy or lactation Monitor the patient’s response to the drug (maintenance of BP Perform a physical assessment to establish baseline status within normal limits) before beginning therapy and during therapy to determine effectiveness and evaluate for any potential adverse effects. NAMEOFDRUG:CALCIUM-CHANNEL BLOCKERS Monitor laboratory test results, including liver and renal Calcium-channel blockers inhibit the movement of function tests. calcium ions across the membranes of myocardial and arterial Provide comfort measures to help the patient tolerate drug muscle cells, altering the action potential and blocking muscle effects cell contraction. This effect depresses myocardial contractility, slows cardiac impulse formation in the conductive tissues, and  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM NAMEOFDRUG:VASODILATORS Provide comfort measures to help the patient tolerate drug Vasodilators act directly on vascular smooth muscle to cause effects. muscle relaxation, leading to vasodilation and drop in BP. Monitor for adverse effects. Drugs Under Vasodilators: GLOSSARYOFTERMS Diazoxide (Hyperstat) Antihypertensive drugs - medications used to treat Hydralazine (Apresoline) hypertension. Minoxidil (Loniten) Angiotensin-converting enzyme (ACE) inhibitor - drug that Nitroprusside (Nitropress) blocks ACE, the enzyme responsible for converting angiotensin I to angiotensin II in the lungs; this blocking Indication prevents the vasoconstriction and aldosterone release These drugs are indicated for the treatment of severe related to angiotensin II. angiotensin II receptors - specific hypertension that has not responded to other therapy receptors found in blood vessels and in the adrenal gland that react with angiotensin II to cause vasoconstriction and Pharmacokinetics release of aldosterone. Diazoxide and nitroprusside are intravenously; hydralazine is Hypertension - a common, often asymptomatic disorder in available for used oral, intravenous, and intramuscular use; and which systolic blood pressure persistently exceeds 140 mm minoxidil is available as an oral agent only. These drugs are Hg and/or diastolic pressure exceeds 90 mm Hg rapidly absorbed and widely distributed. They are metabolized in Essential hypertension - sustained blood pressure above the liver and primarily excreted in the urine. They cross the normal limits with no discernible underlying cause. placenta and enters breastmilk. Hypotension - sustained blood pressure that is lower than that required to adequately perfuse all of the body’s tissues. Contraindication Peripheral resistance - force that resists the flow of blood Presence of known allergy to the drug - to prevent through the vessels, mostly determined by the arterioles, hypersensitivity reactions. which contract to increase resistance; important in Conditions that could be exacerbated by a sudden fall determining overall blood pressure in blood pressure such as cerebral insufficiency. Pregnancy - because of the potential for adverse effects on the CARDIOTONIC AGENTS fetus or neonate. Cardiotonic agents are drugs used to increase the Lactation - because of the potential for serious adverse contractility of the heart muscle for patients experiencing effects on the baby; if these drugs are required by the mother, heart failure. another method of feeding the infant should be used Caution: Subclasses Peripheral vascular disease, CAD, heart failure,  Cardiac Glycoside tachycardia - all of which could be exacerbated by the  Phosphodiesterase Inhibitors fall in blood pressure. Diazoxide must be used with extreme caution in NAMEOFDRUG:CARDIAC GLYCOSIDE patients with functional hypoglycemia - because this The cardiac glycosides were originally derived from the drug increases blood glucose levels by blocking insulin foxglove or digitalis plant. These plants were once ground up release. to make digitalis leaf. Adverse Effects Drugs Under Cardiac Glycoside: Dizziness, anxiety, headache  Digoxin- it has a brand name called Lanoxin. Most Reflex tachycardia, heart failure, chest pain frequently it is used for atrial fibrillation, atrial flutter, Edema and heart failure. Digoxin is one of the oldest Skin rash and lesions medications used in the field of cardiology Abnormal hair growth  Digitoxin- is a cardiac glycoside used for the treatment GI upset, nausea, and vomiting of heart failure and certain kinds of heart arrhythmia. It Cyanide toxicity (dyspnea, headache, vomiting, dizziness, ataxia, is a phytosteroid and is similar in structure and effects loss of consciousness, imperceptible pulse, absent reflexes, to digoxin dilated pupils, pink color, distant heart sounds, shallow breathing Hypothyroidism Indication Cardiac glycosideis indicated for treating heart Drug To Drug Interactions failure and irregular heartbeats The incidence of drug interactions is low for the direct-acting vasodilators as a class. Hydralazine can produce additive Pharmacokinetics hypotensive effects when given with adrenergic or other anti- It is available for oral and parenteral administration. hypertensive drugs. It has a rapid onset of action and rapid absorption, 30-120 minutes when taken orally and 5 to 30 minutes when given Nursing Consideration intravenously. Assess for contraindications or cautions: any known allergies to It is widely distributed throughout the body. these drugs, impaired kidney or liver function, pregnancy or lactation, CV dysfunction Contraindication Assess baseline status before beginning therapy to determine Cardiac glycosides are contraindicated in the presence of any potential adverse effects. allergy to any component of the digitalis preparation. Monitor BP closely during administration to evaluate for Should be used cautiously in patients who are preg- nant or effectiveness and to ensure quick response if BP falls rapidly or lactating. too much. It is contraindicated in the following conditions: 1. Ventricular tachycardia or fibrillation  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM 2. Heart block or sick sinus syndrome Acute MI 3. Idiopathic hypertrophic subaortic stenosis (IHSS) Which could be exacerbated by increased oxygen 4. Acute Myocardial Infarction consumption and increased force of contractions. 5. Renal insufficiency Fluid Volume Deficit 6. Electrolyte abnormalities Which could be made worse by increased renal perfusion. Adverse Effects Ventricular Arrhythmias Headache Vision changes Which could be exacerbated by these drugs Weakness Gastrointestinal upset Drowsiness Anorexia Adverse Effects Ventricular arrhythmias (which can progress to fatal Drug To Drug Interactions ventricular fibrillation) There is a risk of increased therapeutic effects and toxic effects Hypotension of cardiac glycosides if it is taken with verapamil, amiodarone, Chest pain quinidine, quinine, erythromycin, tetracycline, or cyclosporine. GI effects Cardiac glycosides drugs may be less effective if it is combined nausea with thyroid hormones, metoclopramide, or penicillamine. vomiting Absorption of oral cardiac glycosides may be decreased if it is anorexia taken with cholestyramine, charcoal, colestipol, antacids, abdominal pain bleomycin, cyclophosphamide, or methotrexate. Thrombocytopenia occurs frequently with inamrinone, and it also can occur with milrinone Nursing Consideration Hypersensitivity reactions associated with these Assess for contraindications or cautions. drugs include: Perform physical assessment to establish baseline status. vasculitis Obtain patient’s weight, noting any recent increases or pericarditis decreases to determine the patient’s fluid status. pleuritis Assess cardiac status closely, including pulse and blood ascites. pressure. Burning at the intravenous injection site is also a Monitor affect, orientation, and reflexes to evaluate central frequent adverse effect nervous system (CNS) effect of the drug. Assess the patient’s respiratory rate and auscultate lungs. Drug To Drug Interactions Examine the abdomen for distention. Precipitates form when these drugs are given in solution Assess voiding patterns and urinary output to provide a gross with furosemide. Avoid this combination in solution. Use indication of renal function. alternate lines if both of these drugs are being given Obtain a baseline electrocardiogram (ECG) to identify rate and intravenously. rhythm and evaluate for possible changes. Monitor the results of laboratory tests, including serum Nursing Consideration electrolyte levels and renal function tests to determine the need ·Assess for contraindications or cautions: any known for possible dose adjustments allergies to these drugs or to bisulfites to avoid hypersensitivity reactions; acute aortic or pulmonic valvular NAMEOFDRUG: PHOSPHODIESTERASE INHIBITORS disease, acute MI or fluid volume deficit, and ventricular The phosphodiesterase inhibitors belong to a second arrhythmias, which could be exacerbated by these drugs; class of drugs that act as cardiotonic (inotropic) agents. These and current status of pregnancy and lactation to prevent include inamrinone (Inocor) and milrinone (Primacor). potential adverse effects to the fetus or baby. Perform a physical assessment to establish baseline status Indication before beginning therapy, determine the effectiveness of Approved only for use in patients with HF who does not have therapy, and evaluate for any potential adverse effects been responsive to digoxin, diuretics, or vasodilators. Assess cardiac status closely, including pulse and blood Short-term management of HF in adults receiving digoxin pressure, to identify changes or the presence of adverse and diuretics. effects; auscultate heart sounds, noting any evidence of Because these drugs have been associated with the abnormal sounds. development of potentially fatal ventricular arrhythmias, their Obtain the patient’s weight, noting any recent increases or use is limited to severe situations decreases, to determine the patient’s fluid status. ·Inspect skin and mucous membranes for color, and check Pharmacokinetics nail beds and capillary refill for evidence of perfusion. Inamrinone and milrinone are available only for intravenous ·Examine the abdomen for distention; auscultate bowel use. These drugs are widely distributed after injection. They are sounds to evaluate GI motility metabolized in the liver and excreted primarily in the urine. Assess voiding patterns and urinary output to provide a Route Onset Peak Duration gross indication of renal function. IV Immediate 10 minutes 2 hours Obtain a baseline ECG to identify rate and rhythm and T 1/2:3/6 to 5.8 hours; metabolized in the live and excreted in urine and evaluate for possible changes. feces Monitor the results of laboratory tests, including serum electrolyte levels, complete blood count, and renal and Contraindication hepatic function tests, to determine the need for possible Phosphodiesterase inhibitors are contraindicated in the dose adjustment. presence of allergy to either of these drugs or to bisulfites. They also are contraindicated in the following conditions: ·Severe Aortic or Pulmonic Valvular Disease Which could be exacerbated by increased contractions.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM GLOSSARY OF TERMS Pharmacokinetics Cardiomegaly: enlargement of the heart, commonly seen with Distributed after injection or after rapid absorption through chronic hypertension, valvular disease, and heart failure the gastrointestinal (GI) tract. Undergo extensive hepatic Cardiomyopathy: a disease of the heart muscle that leads to an metabolism and are excreted in urine. enlarged heart and eventually to complete heart muscle failure Disopyramide is available in oral form. and death Procainamide is available in intramuscular (IM),intravenous Dyspnea: discomfort with respirations, often with a feeling of (IV), and oral forms. anxiety and inability to breathe, seen with left-sided heart failure Quinidine is also available for oral, IM, or IV administration Heart failure (HF): a condition in which the heart muscle fails to and is administered to adults only. adequately pump blood around the cardiovascular system, Lidocaine is administered by the IM or IV route, and can leading to a backup or congestion of blood in the system also be given as a bolus injection in emergencies when Hemoptysis: blood-tinged sputum, seen in left-sided heart monitoring is not available to document the exact arrhythmia. failure when blood backs up into the lungs and fluid leaks out Mexiletine is an oral drug administered to adults only. into the lung tissue Flecainide and propafenone are available in oral form Nocturia: getting up to void at night, reflecting increased renal perfusion with fluid shifts in the supine position when person has Contraindication gravity-dependent edema related to heart failure; other medical Class I antiarrhythmics are contraindicated in the presence of conditions, including urinary tract infection, increase the need to allergy to any of these drugs; with bradycardia or heart block get up and void unless an artificial pacemaker is in place, because changes in Orthopnea: difficulty breathing when lying down, often conduction could lead to complete heart block; with heart referred to by the number of pillows required to allow a person failure (HF), hypotension, or shock, which could be to breath comfortably exacerbated by effects on the action potential; and with Positive inotropic: effect resulting in an increased force of electrolyte disturbances, which could alter the effectiveness contraction of these drugs. Pulmonary edema: severe left-sided heart failure with backup Caution: of blood into the lungs, leading to loss of fluid into the lung Should be used in patients with renal or hepatic dysfunction, tissue which could interfere with the biotransformation and Tachypnea: rapid and shallow respirations, seen with left sided excretion of these drugs heart failure Adverse Effects ANTIARRHYTHMIC AGENTS  CNS: Dizziness, drowsiness, fatigue, twitching, mouth Antiarrhythmic agents, also known as cardiac numbness, slurred speech, vision changes, and tremors dysrhythmia medications, are a group of pharmaceuticals that that can progress to convulsions.* are used to suppress abnormal rhythms of the heart (cardiac  GI: Changes in taste, nausea, and vomiting. arrhythmias), such as atrial fibrillation, atrial flutter, ventricular  CV: Proarrhythmic effects that lead to the development tachycardia, and ventricular fibrillation. of arrhythmias (including heart blocks), hypotension, vasodilation, and the potential for cardiac arrest. CLASSES Respiratory depression progressing to respiratory arrest  CLASS I- Fast Sodium Channel Blockers can also occur.  CLASS II- conventional beta blockers  Other adverse effects include rash, hypersensitivity  CLASS III reactions, loss of hair, and potential bone marrow  CLASS IV depression. NAMEOFDRUG:CLASS I ANTIARRHYTHMICS Drug To Drug Interactions -are fast sodium channel blockers The risk for arrhythmia increases if these agents are combined with other drugs that are known to cause Drugs Under Class I Antiarrhythmics arrhythmias, such as digoxin and the beta-blockers. Class Ia The risk of bleeding effects of these drugs increases if they Disopyramide (Norpace) are combined with oral anticoagulants Procainamide (Pronestyl) quinidine (Generic) Nursing Consideration Check apical radial pulses before each dose during the Class Ib period of adjustment to the oral route. lidocaine (Xylocaine) Patients with severe heart, liver, or kidney disease and mexiletine (Mexitil) hypotension are at particular risk for adverse effects. Monitor the patient’s ECG and BP continuously during IV Class Ic drug administration. Flecainide (Tambocor) Discontinue IV drug temporarily when (1) arrhythmia is Propafenone (Ryhtmol) interrupted, (2) severe toxic effects are present, (3) QRS complex is excessively widened (greater than 50%), (4) PR Indication interval is prolonged, or 5) BP drops 15 mm Hg or more. These drugs preferable in conditions such as tachycardia, in Obtain a rhythm strip and notify the physician. which the sodium gates are open frequently Report promptly complaints of chest pain, dyspnea, and Also for the treatment of potentially life-threatening ventricular anxiety. Digitalization may have preceded procainamide in arrhythmias and should not be used to treat other arrhythmias patients with atrial arrhythmias. Cardiotonic glycosides may because of the risk of a proarrhythmic effect. induce sufficient increase in atrial contraction to dislodge atrial mural emboli, with subsequent pulmonary embolism.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM NAMEOFDRUG: CLASS II ANTIARRHYTHMICS NAMEOFDRUG: CLASS III ANTIARRHYTHMICS - are conventional beta blockers - act by blocking depolarizing currents and thereby Drug under Class II Antiarrhythmics prolonging the effective refractory period of the Acebutolol myocardium. Esmolol Propranolol Drug under Class III Antiarrhythmics Amiodarone Indication Dofetilide The class II antiarrhythmics competitively block beta-receptor Ibutilide sites in the heart and kidneys. sotalol These drugs are indicated for the treatment of supraventricular tachycardias and PVCs Indication The class III antiarrhythmics block potassium channels and Pharmacokinetics slow the outward movement of potassium during phase 3 of Acebutolol is an oral drug, Esmolol is administered the action potential, prolonging it. All of these drugs are intravenously and Propranolol may be administered orally or proarrhythmic and have the potential of inducing intravenously. These drugs are absorbed from the GI tract or arrhythmias. Amiodarone HCl injection is indicated for have an immediate effect when given intravenously and initiation of treatment and prophylaxis of frequently excreted in the urine recurring ventricular fibrillation and hemodynamically unstable ventricular tachycardia in patients refractory to Contraindication other therapy. The use of these drugs is contraindicated in the presence of sinus bradycardia (rate less than 45 beats/min) and AV block, which Pharmacokinetics could be exacerbated by the effects of these drugs; with Amiodarone is available in an oral or intravenous form. cardiogenic shock, HF, asthma, or respiratory depression Dofetilide and sotalol are administered only in oral form. Caution should be used in patients with diabetes and thyroid Ibutilide is given IV. dysfunction Absorbed after oral administration and are immediately available after IV administration and widely distributed. Adverse Effects Absorption of sotalol is decreased by the presence of food. The adverse effects associated with class II antiarrhythmics are Metabolized in the liver and excreted in urine related to the effects of blocking beta-receptors in the sympathetic nervous system. Contraindication CNS: Dizziness, insomnia, dreams, and fatigue. When these drugs are used to treat life-threatening CV: hypotension, bradycardia, AV block, arrhythmias, and arrhythmias for which no other drug has been effective, alterations in peripheral perfusion. there are no contraindications. Ibutilide and dofetilide Respiratory: Bronchospasm and dyspnea. should not be used in the presence of AV block, which could GI: nausea, vomiting, anorexia, constipation, and diarrhea be exacerbated by the drugs. Because sotalol is known to be Other effects to anticipate include a loss of libido, decreased proarrhythmic, patients should be monitored very closely at exercise tolerance, and alterations in blood glucose levels. the initiation of therapy and periodically during therapy. Caution : Drug To Drug Interactions Should be used with all of these drugs in the presence of The risk of adverse effects increases if these drugs are taken shock, hypotension, or respiratory depression; with a with verapamil; if this combination is used, dose adjustment will prolonged QTc interval, which could worsen due to the be needed. depressive effects on action potentials; and with renal or There is a possibility of increased hypoglycemia if these drugs hepatic disease, which could alter the biotransformation are combined with insulin and excretion of these drugs. Nursing Consideration Adverse Effects Obtain careful medical history to rule out allergies, asthma,  Nausea, vomiting and GI distress; weakness and and obstructive pulmonary disease. Propranolol can cause dizziness; and hypotension, HF, and arrhythmia are bronchiolar constriction even in normal subjects. common. Monitor apical pulse, respiration, BP, and circulation to  Amiodarone has been associated with a potentially fatal extremities closely throughout the period of dosage liver toxicity, ocular abnormalities, and the adjustment. Consult a physician for acceptable parameters. development of very serious cardiac arrhythmias. Evaluate adequate control or dosage interval for patients being treated for hypertension by checking blood pressure near end of Drug To drug Interactions dosage interval or before administration of next dose. These drugs can cause serious toxic effects if they Be aware that adverse reactions occur most frequently are combined with digoxin or quinidine. There is an following IV administration soon after therapy is initiated; increased risk of pro arrhythmias if they are combined with however, incidence is also high following oral use in the older antihistamines, phenothiazines, or tricyclic antidepressants. adult and in patients with impaired kidney function. Reactions There is an increased risk of serious adverse effects if may or may not be dose related. dofetilide is combined with ketoconazole, cimetidine, or Monitor I&O ratio and daily weight as significant indexes for verapamil, and so these combinations should be avoided. detecting fluid retention and developing heart failure. Sotalol may have a loss of effectiveness if it is Consult a physician regarding allowable salt intake. Drug combined with nonsteroidal antiinflammatory drugs, plasma volume may increase with consequent risk of CHF if aspirin, or antacids. Other specific drug–drug interactions dietary sodium is not restricted in patients not receiving have been reported with individual drugs; adrug reference concomitant diuretic therapy. should always be consulted when adding a new drug to a regimen containing any of these agents.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Nursing Consideration additive AV slowing with digoxin; increased serum levels Obtain careful medical history to rule out allergies, asthma, and and toxicity of digoxin, carbamazepine, prazosin, and obstructive pulmonary disease. Propranolol can cause quinidine; increased respiratory depression with bronchiolar constriction even in normal subjects. atracurium,gallamine, pancuronium, tubocurarine, and Monitor apical pulse, respiration, BP, and circulation to vecuronium; and decreased effects if combined with extremities closely throughout the period of dosage adjustment. calcium products or rifampin. There is a risk of severe Consult a physician for acceptable parameters. cardiac effects if these drugs are given IV within 48 hours of Evaluate adequate control or dosage interval for patients being IV beta-adrenergic drugs. The combination should be treated for hypertension by checking blood pressure near the avoided.Diltiazem can increase the serum levels and toxicity end of the dosage interval or before administration of the next of cyclosporine if the drugs are taken concurrently. dose. Be aware that adverse reactions occur most frequently Nursing Consideration following IV administration soon after therapy is initiated; Assess for contraindications or cautions: any known however, incidence is also high following oral use in the older allergies to these drugs to avoid hypersensitivity reactions; adult and in patients with impaired kidney function. Reactions impaired liver or kidney function, which could alter the may or may not be dose related. metabolism and excretion of the drug; any condition that Monitor I&O ratio and daily weight as significant indexes for could be exacerbated by the depressive effects of the drugs detecting fluid retention and developing heart failure. to avoid exacerbation of these conditions; and current Consult a physician regarding allowable salt intake. Drug status of pregnancy and lactation to prevent potential plasma volume may increase with consequent risk of CHF if adverse effects on the fetus or baby. dietary sodium is not restricted in patients not receiving Perform a physical assessment to establish a baseline concomitant diuretic therapy before beginning therapy and during therapy to determine the effectiveness of therapy and evaluate for any potential NAME OF DRUG: CLASS IV ANTIARRHYTHMICS adverse effects. - are slow non-dihydropyridine calcium channel blockers. Assess the patient’s neurological status, including level of Drug under Class IV Antiarrhythmics alertness, speech and vision, and reflexes, to identify Diltiazem possible CNS effects. Verapamil Assess cardiac status closely, including pulse, blood pressure, heart rate, and rhythm, to Indication Identify changes requiring a change in the dosage of the The class IV antiarrhythmics block the movement of calcium ions drug or the presence of adverse effects; auscultate heart across the cell membrane, depressing the generation of action sounds, noting any evidence of abnormal sounds, for early potentials and delaying phases 1and 2 of repolarization, which detection of heart failure. slows automaticity and conduction.Both diltiazem and verapamil are used as antihypertensives and to treat angina. GLOSSARY OF TERMS ○ antiarrhythmics- drugs that affect the action potential of Pharmacokinetics cardiac cells and are used to treat arrhythmias and restore Diltiazem is administered intravenously. normal rate and rhythm. When used as an antiarrhythmic, verapamil is used ○ bradycardia- slower-than-normal heart rate (usually less intravenously. than60 beats/min). Well absorbed after intravenous administration. ○ cardiac output-the amount of blood the heart can pump Protein bound, metabolized in the liver. per beat; influenced by the Excreted in the urine. coordination of cardiac muscle contraction, heart rate, and Cross the placenta and enter breast milk. blood return to the heart. ○ Cardiac Arrhythmia Suppression Test (CAST)-a large Contraindication research study run by the National Heart and Lung Institute These drugs are contraindicated with known allergy to any that found that long-term treatment of arrhythmias may calcium channel blocker to avoid hypersensitivity reactions; have a questionable effect on mortality, and in some cases with sick sinus syndrome or heart block (unless an artificial actually lead to increased cardiac death; basis for the pacemaker is in place) because the block could be exacerbated current indication for antiarrhythmics (short-term use to by these drugs; with pregnancy or lactation because of the treat life-threatening ventricular arrhythmias). potential for adverse effects on the fetus or neonate; and with heart blocks- blocks to conduction of an impulse through HF or hypotension because of the hypotensive effects of these the cardiac conduction system; can occur at the drugs. atrioventricular node, interrupting conduction from the Caution: atria into the ventricles, or in the bundle branches within Should be used in cases of idiopathic hypertrophic subaortic the ventricles,preventing the normal conduction of the stenosis (IHSS), which could be exacerbated, or impaired renal or impulse. liver function, which could affect the metabolism or excretion of ○ hemodynamics-the study of the forces moving blood these drugs. throughout the cardiovascular. Adverse Effects ANTIANGINAL AGENTS  CNS effects include dizziness, weakness, fatigue, depression, In patients with coronary artery disease, clinical and headache. GI upset, nausea, and vomiting can occur. symptoms result from a lack of or inadequate delivery of  Hypotension, HF, shock, arrhythmias, and edema have also blood carrying oxygen and nutrients to the heart, which been reported. results in ischemic heart disease. Antianginal drugs are used to reduce ischemia by increasing the delivery of oxygen-rich Drug To drug Interactions blood to cardiac tissues or by reducing oxygen consumption Verapamil has been associated with many drug–drug interactions, by the coronary vessels. Either of these mechanisms can including increased risk of cardiac depression with beta blockers; reduce ischemia and lead to a decrease in anginal pain.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Subclasses Nitroglycerin should not be used in pregnant women or  Nitrates and Nitrites those who are breastfeeding.  Betal Blockers Nitroglycerin is contraindicated in patients who have  Calcium Channel Blockers severe anemia, increased intracranial pressure, hypersensitivity, or circulatory failure. NAMEOFDRUG:NITRATES AND NITRITES Instruct patients to avoid eating or smoking during Nitrates and nitrites work mainly by decreasing venous administration as this may alter absorption. return to the heart (preload) and decreasing systemic vascular Patients should sit during administration to decrease the resistance (afterload). risk for injury due to the possibility of hypotension, dizziness, The following are the rapid- and long-acting nitrates and weakness. available for clinical use: Amyl nitrite (rapid acting),Nitroglycerin Nitroglycerin decomposes when exposed to heat or light, (both rapid and long acting,Isosorbide dinitrate (both rapid and so it should be stored in the original, airtight glass container. long acting) and Isosorbide mononitrate (primarily long acting) ·Seek emergency help (call 911) if pain persists after the first dose if symptoms are not improved or become Indication worse.While waiting emergency care to arrive, may take a The nitrates are used to treat stable, unstable, and vasospasti second or third dose five minutes apart if needed (Prinzmetal) angina. Long-acting dosage forms are used more for prevention of anginal episodes. Rapid-acting dosage forms, most NAMEOFDRUG:BETA BLOCKERS often sublingual nitroglycerin tablets, or an intravenous drip in Beta blockers help by slowing the heart rate and decreasing the hospital setting, are used to treat acute anginal attacks contractility, thereby decreasing oxygen demands. Pharmacokinetics Those beta blockers approved as antianginal drugs are Route Onset Duration atenolol, metoprolol, nadolol, and propranolol IV 1-2 min 3-5 min Sublingual Tablet 1-3 min 30-60 min Indication Translingual Tablet 2 min 30-60 min The beta blockers are most effective in the treatment of Transmucosal Tablet 1-2 min 3-5 min exertional angina (i.e., that caused by exercise). This is Oral SR Tablet 20-45 min 8-12 hr because the usual physiologic effects of an increase in the Topical Ointment 30-60 min 4- 8 hr heart rate and systolic blood pressure that occurs during Transdermal 30-60 min 24 hr exercise or stress are blunted by the beta blockers, thereby T1/2; 1-4 minutes decreasing the myocardial oxygen demand. For an individual (often elderly) with significant angina, “exercise” may simply Metabolism: Liver be carrying out the activities of daily living, such as bathing, dressing, cooking, or housekeeping. Performing such Excretion: Kidney Urine activities with significant angina can become a major stressor for these patients. The beta blockers are also approved for the treatment of MI, hypertension,cardiac dysrhythmias, and Contraindication essential tremor. Allergy to nitrates – prevent hypersensitivity reactions Severe anemia – decreased cardiac output (CO) caused by Pharmacokinetics nitrates is dangerous for blood with low-oxygen binding capacity Head trauma and cerebral hemorrhage – relaxation of cerebral Route Onset Peak Duration vessels can lead to intracranial bleeding Oral 15 min 90 min 15-19 hr Pregnancy and lactation – potential harm to fetus IV Immediate 60-90 min 15-19 hr Hepatic and renal disease – alteration in drug metabolism and T1/2; 3-4 hr excretion Conditions that can limit CO (e.g. hypovolemia, hypotension, Metabolism: Liver etc. Excretion: Kidney (Urine) Adverse Effects CNS: throbbing headache, dizziness, weakness  ·Food increases bioavailability of propranolol. GI: nausea, vomiting, incontinence  · Propranolol is the only drug under this class that can CV: hypotension, reflex tachycardia, syncope cross the blood-brain barrier. EENT: pallor, flushing, sweating Large dose leads to methemoglobinemia and cyanosis. Contraindication There are a number of contraindications to the use of beta Drug To Drug Interactions blockers, including systolic heart failure and serious Nitrate antianginal drugs can produce additive hypotensive conduction disturbances, because of the effects of beta effects when taken in combination with alcohol, beta blockers, blockade on heart rate and myocardial contractility. These calcium channel blockers, phenothiazines, and erectile drugs should be used with caution in patients with bronchial dysfunction drugs such as sildenafil, tadalafil, and vardenafil. In asthma, because any level of blockade of beta2 receptors can fact, numerous deaths have been reported due to interactions promote bronchoconstriction. These contraindications are with erectile-dysfunction drugs. relative rather than absolute and depend on patient-specific risks and expected benefits of this drug therapy. Other Nursing Consideration relative contraindications include diabetes mellitus (due to Patients taking sildenafil (Viagra) or similar medications for masking of hypoglycemia-induced tachycardia) and erectile dysfunction in the previous 24 hours may not take peripheral vascular disease (the drug may further nitroglycerin as this may result in a dangerous drop in blood compromise cerebral or peripheral blood flow). pressure.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Adverse Effects Pharmacokinetics  CV - Bradycardia, Hypotension, Atrioventricular Block Route Onset Peak Duration  CNS- Dizziness, Faatigue, Depression, Lethargy Oral 30-60 min 2-3 hr 2-4 hr  Metabolic- Hyperglycemia, and/or Hypoglycemia, SR, ER 30-60 min 6-11 hr varies Hyperlipidemia IV Immediate 2-3 min varies  Other- Wheezing, Dyspnea, Impotence T1/2: SR (3.5-6 hr) ; ER (6-7 hr) Drug to Drug Interactions Metabolism: Liver There are many important drug interactions that involve the beta blockers. Excretion: Kidney (Urine) BETA BLOCKERS: COMMON DRUG INTERACTIONS Contraindication Interacting Drugs Mechanism Result Contraindications include known drug allergy, acute MI, Diuretics and Anti- Additive Effects Hypotension second or third-degree AV block (unless the patient has a Hypertensives pacemaker), and hypotension Calcium Channel Additive Hypotension, Blockers Atrioventricular Bradycardia, Heart Adverse Effects (DItiazem, Node Suppression Block  CV- Hypotension, Papitations, Tachycardia or Verapamil) Bradycardia Insulin and Oral Masking of Unrecognized  GI- Constipation, Nausea Antidiabetic Drugs Hypoglycemic Hypoglycemia  Other- Dyspnea, Rush, Flushing, Peripheral Edema Effects Nursing Consideration Drug to Drug Interactions Teach patients that they shouldn’t suddenly stop therapy. A particular food interaction of note is the interaction with Because of the risk of rebound tachycardia and hypertension, a grapefruit juice, which can reduce the metabolism of the healthcare provider should monitor the cessation of beta-blocker CCBs, especially nifedipin therapy. CALCIUM CHANNEL BLOCKERS: COMMON DRUG Beta blockers can cause transient increases in serum lipid and INTERACTIONS glucose levels. INTERACTING MECHANISM RESULT Because beta blockers inhibit the sympathetic nervous system DRUG response, they also hide the symptoms of hypoglycemia and can Beta- BLockers Adverse Effects Bradycardia, be dangerous in patients with diabetes who use insulin. atrioventricular Some older beta blockers such as propranolol and high doses of block beta 1blockers can block the beta2 receptors in the pulmonary Digoxin Goxin Interference Possible increased vasculature, resulting in broncho constriction and asthma with drug digoxin levels symptoms. elimination Carefully assess patients with asthma or chronic lung disease Amiodarone Decreased Bradycardia and for an exacerbation of their symptoms during beta-blocker metabolism decreased cardiac therapy. output Check for common adverse effects of beta blockers, such as Azole antifungals, Decreased Elevated levels dizziness, slowing of the pulse, fatigue, and hypotension. clarithomycin, metabolism and effects of erythromycin, HIV calcium channel NAMEOFDRUG:CALCIUM CHANNEL BLOCKERS Drugs blockers Calcium channel blockers decrease calcium influx into the smooth Statins Inhibited statin Increased risk muscle, causing vascular relaxation. This either reverses or metabolism statin toxicity prevents the spasms of coronary vessels that cause the anginal Cyclosporine Decreased Possible toxicity of pain associated with Prinzmetal or chronic angina. metabolism of either drugs either drug There are three chemical classes of calcium channel blockers (CCBs): phenylalkylamines, benzothiazepines, and Nursing Consideration dihydropyridines, commonly represented by verapamil, diltiazem, Tell patients to report dizziness and symptoms of an and amlodipine, respectively. irregular heart rate. Teach your patients to avoid grapefruit juice because it Indication inhibits the hepatic metabolism of calcium channel blockers The therapeutic benefits of the CCBs are numerous. Because of and may lead to increased blood drug levels and increased their very acceptable adverse effect and safety profiles, they are pharmacologic effects. considered first-line drugs for the treatment of such conditions as All calcium channel blockers should be used cautiously in angina, hypertension, and supraventricular tachycardia. They are patients with heart failure. often effective for the treatment of coronary artery spasms Drugs that inhibit cytochrome P450 isoenzymes, such as (vasospastic or Prinzmetal angina). However, they may not be as erythromycin, inhibit the metabolism of amlodipine and may effective as the beta blockers in blunting exercise-induced result in a stronger antihypertensive effect. elevations in heart rate and blood pressure. CCBs are also used for the short-term management of atrial fibrillation and flutter, GLOSSARYOFTERMS migraine headaches, and Raynaud’s disease (a type of peripheral Angina pectoris Chest pain that occurs when the heart’s vascular disease). The supply of blood carrying oxygen is insufficient to meet the dihydropyridine CCB nimodipine is indicated solely for cerebral demands of the heart. (p. 369) artery spasms associated with aneurysm rupture  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Atherosclerosis A common form of arteriosclerosis involving act while in the intestine and are excreted directly in the deposits of fatty, cholesterol-containing material (plaques) feces. Their action is limited to their effects while they are within arterial walls. (p. 369) present in the intestine. Chronic stable angina Chest pain that is primarily caused by Cholestyramine is a power that must be mixed with liquids atherosclerosis, which results in a long-term but relatively stable and taken up to six times a day. level of obstruction in one or more coronary arteries. (p. 369) Colestipol is available in both powder and tablet form and Coronary arteries Arteries that deliver oxygen to the heart is taken only four times a day. muscle. (p. 369) Colesevelam is available in tablet form and is taken once or Coronary artery disease (CAD) Any one of the abnormal twice a day. conditions that can affect the arteries of the heart and produce various pathological effects, especially a reduced supply of Contraindication oxygen and nutrients to the myocardium. (p. 369) Bile Acid sequestrants are contraindicated in the presence of Ischemia Poor blood supply to an organ. (p. 369) allergy to any bile acid sequestrant. These drugs also are Ischemic heart disease Poor blood supply to the heart via the contraindicated in the following conditions: complete biliary coronary arteries. (p. 369) obstruction, abnormal intestinal function, and pregnancy or Myocardial infarction (MI) Necrosis of the myocardium lactation. If a lipid-lowering drug is needed, however, a bile following interruption of blood supply; it is almost always caused acid sequestrants is the drug of choice. by atherosclerosis of the coronary arteries and is commonly called a heart attack.(p.369) Adverse Effects Reflex tachycardia A rapid heartbeat caused by a variety of CNS: headaches, anxiety, fatigue and drowsiness, which autonomic nervous system effects, such as blood pressure could be related to changes in serum cholesterol levels. changes, fever, or emotional stress. (p. 371) Direct gastrointestinal (GI) irritation, including nausea, Unstable angina Early stage of progressive coronary artery constipation that may progress to fecal impaction, and disease. (p. 369) aggravation of hemorrhoids, may occur. Vasospastic angina Ischemia-induced myocardial chest pain Other effects include increased bleeding times related to a caused by spasms of the coronary arteries; also referred to as decreased absorption of vitamin K and consequent Prinzmetal or variant angina. (p. 369) decreased production of clotting factors; vitamin A and D deficiencies related to decreased absorption of fat-soluble LIPID LOWERING AGENTS vitamins; rash; and muscle aches and pains. Lipid-lowering agents lower serum levels of cholesterol and various lipids. These include bile acid sequestrants, HMG-CoA Drug to Drug Interactions reductase inhibitors, and a cholesterol absorption inhibitor. Other Malabsorption of fat-soluble vitamins occurs when they are drugs that are used to affect lipid levels do not fall into any of the combined with these drugs. These drugs decrease or delay classes but are approved for use in combination with changes in the absorption of thiazide diuretics, digoxin, warfarin, diet and exercise thyroid hormones, and corticosteroids. Consequently, any of these drugs should be taken 1hour before or 4 to 6 hours Subclasses: after the bile acid sequestrant.  Bile- Acid Sequestrants  HMG-COA Reducatase INhibitors/ Statins Nursing Consideration  Cholesterol Absorption Inhibitor Assess for contraindications or cautions: known allergies to these drugs; impaired intestinal function, biliary obstruction, NAMEOFDRUG:BILE ACIDSEQUESTRANTS and current status related to pregnancy and lactation. · Bile acid sequestrants prevent the reabsorption of bile salts, Perform a physical assessment. which are very high in cholesterol. Consequently, the liver will Weigh the patient. pull cholesterol from the blood to make new bile acids, lowering Inspect the patient’s skin for color, bruising, and rash the serum cholesterol level. Assess neurological status, including level of orientation and alertness Drug under Bile Acid Sequestrants Monitor pulse and blood pressure Cholestyramine (Questran) Inspect the abdomen for distention and auscultate bowel Colestipol (Colestid) Assess bowel elimination patterns, including frequency of Colesevelam (WelChol) stool passage and stool characteristics Monitor the results of laboratory tests Indication · Bile Acid sequestrants bind with bile acids in the intestine to NAME OF DRUG:HMG-COAREDUCTASE INHIBITORS/ form an insoluble complex that is then excreted in the feces. Bile STATINS acids contain high levels of cholesterol. As a result, the liver must HMG-CoA reductase inhibitors, or statins, block the enzyme use cholesterol to make more bile acids. The hepatic intracellular HMG-CoA reductase, resulting in lower serum cholesterol cholesterol level falls, leading to an increased absorption of levels, a resultant breakdown of LDLs, and a slight increase in cholesterol-containing LDL segments from circulation to replenish HDLs. the cell’s cholesterol. The serum levels of cholesterol and LDL decrease as the circulating · Patients receiving HMG-CoA reductase inhibitors should cholesterol is used to provide the cholesterol that the liver needs avoid pregnancy because of serious fetal adverse effects; to make bile acids. These drugs are used to reduce serum should take the drug in the evening to mimic the normal cholesterol in patients with primary hypercholesterolemia. patterns of lipid formation; should have liver function Cholestyramine is also used to treat pruritus associated with monitored regularly; and should be instructed to report any partial biliary obstruction. sudden muscle pain, especially if accompanied by fever. Pharmacokinetics Bile Acid sequestrants are not absorbed systemically. They  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Drug under HMG-COAREDuCtaSe InHIBItOrS/ StatInS Artovastatin (Lipitor) Drug to Drug Interactions Fluvastatin (Lescol) The risk of rhabdomyolysis increases if any of these drugs is Lovastatin (Mevacor) combined with erythromycin, cyclosporine, gemfibrozil, Pravastatin (Pravachol) niacin, or antifungal drugs; such combinations should be Rosuvastatin (Crestor) avoided. Simvastatin (Zocor) Increased serum levels and resultant toxicity can occur if these drugs are combined with digoxin or warfarin; if this Indication combination is used, serum digoxin levels and/or clotting The early rate-limiting step in the synthesis of cellular times should be monitored carefully and the prescriber cholesterol involves the enzyme HMG-CoA reductase. If this consulted for appropriate dose changes. enzyme is blocked, serum cholesterol and LDL levels decrease Increased estrogen levels can occur if these drugs are taken because more LDLs are absorbed by the cells for processing into with oral contraceptives; the patient should be monitored cholesterol. In contrast, HDL levels increase slightly with this carefully if this combination is used. alteration in fat metabolism. HMG-CoA reductase inhibitors block Serum levels and the risk of toxicity increase if these drugs HMG-CoA reductase from completing the synthesis of cholesterol. are combined with grapefruit juice. Most of these drugs are chemical modifications of compounds produced by fungi. As a group, they are frequently referred to as Nursing Consideration “statins.” Because these drugs undergo a marked first-pass effect Assess for contraindications and cautions: any known in the liver, most of their effects are seen in the liver. allergies to these drugs or to fungal by products to avoid These drugs may also have some effects on the process hypersensitivity reactions; active liver disease or history of that generates atheromas in vessel walls. That exact mechanism alcoholic liver disease which could be exacerbated by the of action is not understood. These drugs are indicated as adjuncts effects of these drugs; current status of pregnancy or with diet and exercise for the treatment of increased cholesterol lactation. and LDL levels that are unresponsive to dietary restrictions alone. Perform a physical assessment. Pravastatin, lovastatin (one of the oldest HMG-CoA Weigh the patient to establish a baseline and evaluate. drugs available), and simvastatin are indicated for patients with Assess for contraindications and cautions: any documented CAD to slow progression of the disease. These three Assess the patient’s neurological status, including level of agents and atorvastatin are used to prevent a first myocardial orientation, affect, and reflexes, which show early changes infarction (MI) in patients who have multiple risk factors for related to CNS function, developing CAD. Several of the statin drugs have been · Obtain vital signs, including pulse and blood pressure. formulated as combination therapy. · Inspect the abdomen for distention and auscultate bowel sounds. Pharmacokinetics Assess bowel elimination patterns, including frequency of The statins are all absorbed from the GI tract and undergo stool passage and stool characteristics. first-pass metabolism in the liver. They are excreted through Monitor the results of laboratory tests, including renal and feces and urine. The peak effect of these drugs is usually seen liver function tests. within 2 to 4 weeks. These drugs are most effective when taken at night when the liver is processing the most lipids. These drugs NAMEOFDRUG:CHOLESTEROLABSORPTION INHIBITOR cross the placenta, and most have been found in breast milk. The cholesterol absorption inhibitor ezetimibe works in the brush border of the small intestine to prevent Contraindication · the absorption of dietary cholesterol, which leads to  These drugs are contraindicated in the presence of allergy increased clearance of cholesterol by the liver and a resultant to any of the statins or to fungal by products or compounds. fall in serum cholesterol.  Statins also are contraindicated in patients with active liver Change in diet and increased exercise are very disease or a history of alcoholic liver disease, and with important parts of the overall treatment of a patient pregnancy or lactation. These drugs are labeled as receiving a cholesterol absorption inhibitor. pregnancy category X.  Atorvastatin levels are not affected by renal disease, but patients with renal impairment who are taking other statins Drug Under Cholesterol Absorption Inhibitor require close monitoring. Caution should be used in patients Ezetimibe (Zetia) with impaired endocrine function. Indications Adverse Effects Ezetimibe works in the brush border of the small GI system: flatulence, abdominal pain, cramps, nausea, intestine to decrease the absorption of dietary cholesterol vomiting, and constipation. from the small intestine. CNS effects can include headache, dizziness, blurred vision As a result, less dietary cholesterol is delivered to insomnia, fatigue, and cataract development and may reflect the liver, and the liver increases the clearance of cholesterol changes in the cell membrane and synthesis of cholesterol. from the serum to make up for the drop in dietary cholesterol, causing the total serum cholesterol level to drop. Adverse Effects Increased concentrations of liver enzymes commonly occur, Pharmacokinetics and acute liver failure has been reported with the use of Ezetimibe is absorbed well after oral administration, atorvastatin and fluvastatin. Lovastatin, pravastatin, and reaching peak levels in 4 to 6 hours. It is metabolized in the simvastatin are not associated with some of the severe liver liver and the small intestine, with a half-life of 22 hours. toxicity that is seen with the other agents. Excretion is through feces and urine. It is not known · Rhabdomyolysis, a breakdown of muscles whose waste whether the drug crosses the placenta or enters breast milk. products can injure the glomerulus and cause acute renal failure, has also occurred with the use of all of these drugs.  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Contraindication hyperlipidemia: increased levels of lipids in the serum,  Ezetimibe is contraindicated in patients with: ·An allergy to associated with increased risk of coronary artery disease any component of the drug. development.  If it is used in combination with a statin, it should not be low-density lipoprotein (LDL): tightly packed fats that are used during pregnancy or lactation or with severe liver thought to contribute to the development of coronary artery disease. disease when remnants left over from the LDL are processed in the arterial lining. Adverse Effects metabolic syndrome: a collection of factors, including GI: Mild abdominal pain and diarrhea insulin resistance, abdominal obesity, low high-density CNS: Headache, dizziness, back pain, and muscle aches and lipoprotein and high triglyceride levels, hypertension, and pains proinflammatory and prothrombotic states, that increase the Upper Respiratory Tract Infection (URI) incidence of coronary artery disease. risk factors: factors that have been identified as increasing Drug To drug Interactions the risk of the development of a disease; for coronary artery  · The risk of elevated serum levels of ezetimibe increases if it disease, risk factors include genetic predisposition, gender, is given with cholestyramine, fenofibrate, gemfibrozil, or age, high-fat diet, sedentary lifestyle, gout, hypertension, antacids. diabetes, and estrogen deficiency  ·If these drugs are used in combination, ezetimibe should be taken at least 2 hours before or 4 hours after the other DRUGS AFFECTING BLOOD COAGULATIONS drugs. Drugs that affect coagulation are some of the most  · The risk of toxicity also increases if ezetimibe is combined dangerous drugs used today, and numerous factors can with cyclosporine. affect their action. These drugs are among the most  · If this combination cannot be avoided, the patient should commonly associated with adverse drug reactions. be monitored very closely.  If ezetimibe is combined with any fibrate, the risk of Subclasses: cholethiasis increases.  Anticoagulanta  The patient should be monitored closely. Warfarin levels  Antiplatelet Drugs increase in a patient who is also taking ezetimibe; if this  Thrombocylytic Drugs combination is used, the patient should be monitored very closely. NAMEOFDRUGS: ANTICOAGULANTS Anticoagulants are drugs that interfere with the normal Nursing Consideration coagulation process by interfering with the clotting cascade Assess for contraindications or cautions: any known allergies to and thrombin formation. any component of the drug; liver dysfunction or advanced age; current status of pregnancy or lactation. Drug under Anticoagulants Perform a physical assessment to establish a baseline  ·antithrombin III (Thrombate III) Monitor orientation and reflexes  ·argatroban (Acova) Monitor respirations and auscultate lungs  ·bivalirudin (Angiomax) Inspect the abdomen for distention and auscultate bowel  ·desirudin (Iprivask) sounds  ·fondaparinux (Arixtra) Assess bowel elimination patterns, including frequency of stool  ·heparin (generic) passage and stool characteristics  · warfarin (Coumadin) Monitor the results of laboratory tests, including serum cholesterol and lipid levels, and liver function studies Indication The anticoagulants interfere with the normal GLOSSARY OF TERMS cascade of events involved in the clotting process. Heparin, Antihyperlipidemic agents: general term used for drugs used argatroban, and bivalirudin block the formation of thrombin to lower lipid levels in the blood. from prothrombin. Patients may be started on heparin in the Bile acids: cholesterol-containing acids found in the bile that acute situation and then switched to the oral drug warfarin. act like detergents to break up fats in the small intestine. Cholesterol: necessary component of human cells that is Pharmacokinetics produced and processed in the liver, then stored in the bile until ANTI- ROU ONSET PEAK DURATI EXCRETI METABOLI stimulus causes the gallbladder to contract and send the bile into COAGULA TE ON ON SM NTS the duodenum via the common bile duct; a fat that is essential Heparin IV or Imme 5min 2-6 hr Urine Kidney for the formation of steroid hormones and cell membranes; it is SQ diate (IV) (IV) and liver produced in cells and taken in by dietary sources. (IV) Chylomicron: carrier for lipids in the bloodstream, consisting of 2-4 8-12 hr 20-60 hr (SQ) proteins, lipids, cholesterol, and so forth. min (SQ) Endocannabinoids: endogenous substances that activate (SQ) nervous system receptors that are important in the regulation of Warfarin Oral 3 days 1 4-5 days Urine or liver appetite, food intake, and metabolism. 1/2- feces 4 high-density lipoprotein (HDL): loosely packed chylomicron days containing fats, able to absorb fats and fat remnants in the periphery; thought to have a protective effect, decreasing the Contraindication development of coronary artery disease. The anticoagulants are contraindicated in the hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase: presence of known allergy to the drugs to avoid enzyme that regulates the last step in cellular cholesterol hypersensitivity reactions. They also should not be used with synthesis. any conditions that could be compromised by increased bleeding tendencies, including hemorrhagic disorders, recent  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM trauma, spinal puncture, GI ulcers, recent surgery, intrauterine Indication device placement, tuberculosis, presence of indwelling catheters, Antiplatelet agents inhibit platelet adhesion and aggregation and threatened abortion. by blocking receptor sites on the platelet membrane, Warfarin is contraindicated in pregnancy because fetal preventing platelet–platelet interaction or the interaction of injury and death have occurred; in lactation, because of the platelets with other clotting chemicals. One drug, anagrelide, potential risk to the baby; and in renal or hepatic disease, which blocks the production of platelets in the bone marrow. These could interfere with the metabolism and effectiveness of these agents are used effectively to treat cardiovascular diseases drugs. Although some adverse fetal effects have been reported that are prone to produce occluded vessels; for the with its use during pregnancy, heparin does not enter breast milk, maintenance of venous and arterial grafts; to prevent and so it is the anticoagulant of choice if one is needed during cerebrovascular occlusion; and as adjuncts to thrombolytic lactation. therapy in the treatment of myocardial infarction (MI) and the prevention of reinfarction after MI. The prescriber’s Adverse Effects choice of drug depends on the intended use and the Adverse effects of anticoagulants can range from bleeding gums patient’s tolerance of the associated adverse effects. with tooth brushing to severe internal hemorrhage. Periodic blood tests will be needed to assess the effects of the drug on Pharmacokinetics the body. Warfarin has been associated with alopecia, dermatitis ANTI- ROU ONSET PEAK DURATI EXCRETI METABOLI and bone marrow depression. PLATELET TE ON ON SM Aspirin Oral 5-30 0.25- 3-6 hr Urine Liver min 2 hr Drug To Drug Interactions Increased bleeding can occur if heparin is combined with oral Contraindication anticoagulants, salicylates, penicillins, or cephalosporins. Antiplatelet agents are contraindicated in the Decreased anticoagulation can occur if heparin is combined presence of allergy to the specific drug to avoid with nitroglycerin. Warfarin has documented drug–drug hypersensitivity reactions. Although there are no adequate interactions with a vast number of other drugs. It is a wise studies of these drugs in pregnancy, they are contraindicated practice never to add or take away a drug from the regimen of a with pregnancy because of the potential for increased patient receiving warfarin without careful patient monitoring bleeding; they should be used during pregnancy only if the and adjustment of the warfarin dose to prevent serious adverse benefits to the mother clearly outweigh the potential risks to effects. Because of the many factors that can affect the the fetus. These drugs are also contraindicated during therapeutic levels of warfarin, it is often very difficult to reach a lactation because of the potential adverse effects on the stable level and maintain that level. fetus or neonate; if they are needed by a breastfeeding mother, she should find another method of should be Nursing Consideration checked regularly to monitor for thrombocytopenia if a  Assess for the mentioned contraindications to this drug (e.g. patient is on this drug. hypersensitivity, acute liver disease, pregnancy etc.) to prevent potential adverse effects. Adverse Effects  Conduct thorough physical assessment before beginning The most common adverse effect seen with these drugs is drug therapy to establish baseline status, determine bleeding, which often occurs as increased bruising and effectivity of therapy, and evaluate potential adverse effects. bleeding while brushing the teeth. Other weakness; the  Educate patient on drug therapy including drug name, its cause of these reactions is common problems include indication, and adverse effects to watch out for to enhance headache, dizziness, and not understood. Nausea and patient understanding on drug therapy and thereby gastrointestinal (GI) distress may occur because of direct promote adherence to drug regimen. irritating effects of the oral drug on the GI tract. Skin rash,  Maintain antidotes on bedside (e.g. protamine sulfate for another common effect, may be related to direct drug effects heparin, Vitamin K for warfarin) to promptly treat drug on the dermis. overdose.  Assess for signs signifying blood loss (e.g. petechiae, bruises, Drug To drug Interactions dark-colored stools, etc.) to determine therapy effectiveness The risk of excessive bleeding increases if any of these drugs and promote prompt intervention for bleeding episodes. is combined with another drug that affects blood clotting. NAMEOFDRUGS: ANTIPLATELET Nursing Consideration Antiplatelet agents decrease the formation of the platelet plug by  Administer drug with meals to relieve GI upset. decreasing the responsiveness of the platelets to stimuli that  Provide comfort measures for headache because pain would cause them to stick and aggregate on a vessel wall. due to headache may decrease patient compliance to treatment regimen. Drug under Anticoagulants  Educate patient on ways to promote safety like using ·abciximab (ReoPro) electric razor, soft-bristled toothbrush, and cautious ·anagrelide (Agrylin) movement because any injury at this point can ·aspirin precipitate bleeding. ·cilostazol (Pletal) ·clopidogrel (Plavix) NAME OF DRUG: THROMBOLYTIC AGENTS ·dipyridamole (Persantine) Thrombolytic agents break down the thrombus that ·eptifibatide (Integrilin) has been formed by stimulating the plasmin system. ·sulfinpyrazone (Anturane) Drug under Thrombolytic Agents: ·ticlopidine (Ticlid) ·alteplase (Activase) ·tirofiban (Aggrastat). ·reteplase (Retavase) ·streptokinase (Streptase) ·tenecteplase (TNKase) ·urokinase (Abbokinase).  DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Indication  Monitor cardiac rhythm continuously if the drug is being If a thrombus has already formed in a vessel (e.g., during an given for acute MI because of the risk of alteration in acute MI), it may be necessary to dissolve that clot to open the cardiac function; have life support equipment on vessel and restore blood