Drugs Affecting Cardiovascular System PDF

NCMA 216: Pharmacology Drugs Affecting the Cardiovascular System Abigael Comson-De Mesa, RN  Learning Objectives At the end of the discussion, students will be able to: 1 Understand and explain the physiology of the cardiovascular system. 2 Determine common disorder...

NCMA 216: Pharmacology Drugs Affecting the Cardiovascular System Abigael Comson-De Mesa, RN  Learning Objectives At the end of the discussion, students will be able to: 1 Understand and explain the physiology of the cardiovascular system. 2 Determine common disorders affecting the cardiovascular system. Identify the use of various medication for the management and treatment 3 of cardiovascular disorders. Determine appropriate pharmacological treatment and nursing 4 responsibilities during drug therapy for patients with problems in cardiovascular function. 5 Illustrate the use of various medications for cardiovascular disorders. Determine appropriate pharmacological treatment and nursing 6 responsibilities during drug therapy for patients with problems in cardiovascular dysfunction.  01 Review of the Anatomy and Physiology of Cardiovascular System Cardiovascular System ▪ Delivers oxygen and nutrients to all of the cells of the body and for removing waste products for excretion. ▪ Consists of: ▪ Heart ▪ Blood vessels ▪ Blood Heart ▪ Hollow, muscular organ that pumps oxygenated blood to the body’s cells and collects waste products from the tissues. ▪ Divided into four (4) chambers: ▪ Upper – Atrium ▪ Lower – Ventricle ▪ Right Side of the Heart ▪ Deoxygenated Blood from the Body ▪ Veins – Blood vessels carry Blood towards the Heart. ▪ Left Side of the Heart ▪ Oxygenated Blood into the Systemic Circulation ▪ Arteries – Blood vessels carry Blood away from the Heart. Heart ▪ Semilunar Valve ▪ Aortic Valve ▪ Pulmonic Valve ▪ Atrioventricular Valve ▪ Tricuspid Valve ▪ Bicuspid Valve (Mitral Valve) Cardiac Cycle ▪ Period of systole followed by period of diastole. ▪ Systole – Contraction of the Ventricles ▪ Diastole – Relaxation of the Cardiac Muscles ▪ Blood flow: ▪ Deoxygenated blood enters the Right Atrium ⇨ Tricuspid Valve ⇨ Right Ventricle ⇨ Pulmonary Valve ⇨ Pulmonary Arteries ⇨ Lungs ▪ Oxygenated blood from the Lungs ⇨ Pulmonary Veins ⇨ Left Atrium ⇨ Bicuspid Valve (Mitral Valve) ⇨ Left Ventricle ⇨ Aortic Valve ⇨ Aorta ⇨ Systemic Circulation Cardiac Cycle Cardiac Conduction System ▪ Continuous, rhythmic cardiac contractions controlled by the heart. ▪ Brain does not stimulate the heart to beat. ▪ Sinoatrial Node (SA Node) ▪ Constantly generate an action potential. ▪ Normal pacemaker of the heart. ▪ Atrioventricular Node (AV Node) ▪ Slows the impulse and allows the delay needed for atrial contraction and ventricular filling. ▪ Bundle of His ▪ Sends the impulse from the atria to the ventricles. ▪ Purkinje Fibers ▪ Fine network of conducting fibers delivers impulse to ventricular cells and stimulate contraction of ventricles. Cardiac Conduction System  02 Drugs Affecting Blood Pressure Blood Pressure ▪ Blood Flow – Higher Pressure Areas to Lower Pressure Areas. ▪ Left Ventricle – High Pressure (Systole) ▪ Right Atrium – Low Pressure (Diastole) ▪ Brain and Hormones – control maintenance of blood pressure. ▪ Hypertensive – Blood Pressure is too High. ▪ Hypotensive – Blood Pressure is too Low and blood cannot delivered effectively. ▪ Hypertensive Crisis – Severely High Blood Pressure ▪ Shock – Severely Low Blood Pressure Blood Pressure ▪ Mean Arterial Pressure (MAP) ▪ Average pressure in the arteries during ventricular contraction and relaxation. ▪ Three (3) Elements of MAP: ▪ Heart rate ▪ Stroke volume – amount of blood pumped out of the ventricles within each heartbeat. ▪ Total Peripheral Resistance (PVR: Peripheral Vascular Resistance) – resistance of the muscular arteries to the blood being pumped through. ▪ Cardiac Output ▪ Heart rate multiplied by stroke volume. ▪ Formula: ▪ MAP = CO x PVR Blood Pressure ▪ Autonomic Nervous System ▪ Powerful regulator of blood pressure ▪ Stimulate the heart and blood vessels ▪ Parasympathetic – Lowers the Blood Pressure, decreasing the Heart Rate and Heart Contraction. ▪ Sympathetic – Directly on the Heart Muscle, increasing the Heart Rate and Heart Contraction. – Innervate arteries to constrict, decrease blood flow to tissues. – Innervate veins to constrict, decrease blood volume. Blood Pressure ▪ Baroreceptors ▪ Specialized nerve cells in the arch of aorta ▪ Pressure receptors ▪ Sense the blood pressure, keeps the blood pressure balanced. ▪ Cardiovascular Centers ▪ Autonomic control of the cardiac and vascular function. ▪ Vasomotor Control Center – Controls the diameter of blood vessels. ▪ Cardiac Control Center ▪ Cardiac Accelerator – Increases Heart Rate and Cardiac Contractility – Sympathetic Outflow Tract ▪ Cardiac Decelerator – Decreases Heart Rate and Cardiac Contractility – Parasympathetic Outflow Tract Blood Pressure ▪ Renin-Angiotensin-Aldosterone System (RAAS) ▪ Activated when the BP within the kidneys falls. ▪ Kidneys – Constant perfusion. – Help ensure blood flow is maintained. ▪ Renin-Angiotensin-Aldosterone System (RAAS) Hypertension ▪ Blood pressure is above the normal limit for a sustained period. ▪ Primary Hypertension – no known cause ▪ Secondary Hypertension – known cause – body organ damage: heart, kidneys, brain, eyes, blood vessels and other organs ▪ Risk Factors: Increased Age Cigarette Smoking High Salt Diet High Alcohol Intake Low Physical Activity Obesity Chronic Diseases – Diabetes Hypertension Hypotension ▪ Blood pressure becomes too low. ▪ Progress to shock ▪ It occurs in the following situations: ▪ Heart muscle is damaged and unable to pump effectively. ▪ Severe blood or fluid loss – blood volume drops. ▪ Impairment of ANS ▪ Medication-induced ▪ Orthostatic Hypotension – lowering of blood pressure when the person change position (sits up from lying or stands up from lying), resulting to decrease blood flow to the brain tissues. Antihypertensive Drugs  Antihypertensive Drugs Other ACE Inhibitors ARB Calcium-Channel Vasodilators Antihypertensive Drugs Blockers ▪ Captopril ▪ Hydralazine ▪ Losartan ▪ Minoxidil ▪ Benazepril ▪ Candesartan ▪ Amlodipine ▪ Enalapril ▪ Nitroglycerin Renin Inhibitor ▪ Azilsartan ▪ Clevidipine ▪ Nitroprusside ▪ Fosinopril ▪ Irbesartan ▪ Diltiazem ▪ Lisinopril ▪ Olmesartan ▪ Felodipine ▪ Perindopril ▪ Telmisartan Nicardipine ▪ Diuretics ▪ Aliskiren ▪ Quinapril ▪ Valsartan ▪ Nifedipine ▪ Ramipril ▪ Verapamil Sympatholytic Thiazide Drugs Potassium-Sparing Thiazide-like Diuretics Diuretics ▪ Amiloride ▪ Chlorothiazide ▪ Spironolactone ▪ Indapamide ▪ Triamterene  Antihypertensive Drugs Other Antihypertensive Drugs Sympatholytic Drugs Alpha 2 Alpha 1 Non-selective Non-selective Alpha Beta Blockers Adrenergic Agonists Adrenergic Antagonists Adrenergic Antagonists Adrenergic Antagonists ▪ Acebutolol ▪ Clonidine ▪ Doxazosin ▪ Carvedilol ▪ Phentolamine ▪ Atenolol ▪ Guanfacine ▪ Prazosin ▪ Labetalol ▪ Phenoxybenzamine ▪ Metoprolol ▪ Methyldopa ▪ Terazosin ▪ Bisoprolol ▪ Nadolol ▪ Propranolol ▪ Pindolol ▪ Timolol Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin- Therapeutic Action: Converting Enzyme ▪ Act on the lungs to block the conversion of Angiotensin I to (ACE) Inhibitors Angiotensin II. ▪ Benazepril ▪ Vasoconstrictor ▪ Captopril ▪ Stimulator of Aldosterone release ▪ Enalapril ▪ Perindopril ▪ Ramipril Indication: ▪ Quinapril ▪ Hypertension – decrease BP ▪ Heart failure and Left Ventricular Dysfunction – decrease cardiac workload and decrease PVR and blood volume ▪ Diabetic Nephropathy – decrease stimulation of angiotensin receptors, slowing the damage of renal artery. Pharmacokinetics: ▪ Oral preparations ▪ Parenteral administration - Enalapril ▪ Cross the placenta - NOT BE USE DURING PREGNANCY Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin- Contraindications: Converting Enzyme ▪ Allergic reaction (ACE) Inhibitors ▪ Impaired renal function ▪ Benazepril ▪ Acute heart failure ▪ Captopril ▪ Salt/ Volume depletion ▪ Enalapril ▪ Pregnant/ Lactating Women ▪ Perindopril ▪ Ramipril ▪ Quinapril Adverse Effects: ▪ Hypotension ▪ Angioedema – serious allergic reaction ▪ Cough – increase bradykinin ⇨ bronchoconstriction ▪ Elevated Potassium Levels – blockage of aldosterone Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin- Drug-to-Drug Interactions: Converting Enzyme ▪ Allopurinol – risk of hypersensitivity (ACE) Inhibitors ▪ NSAIDs – decreased antihypertensive effects ▪ Benazepril ▪ Diuretics – increase antihypertensive effects ▪ Captopril ▪ ARB and Renin Inhibitor – serious adverse effects ▪ Enalapril ▪ Perindopril ▪ Ramipril Nursing Considerations: ▪ Quinapril ▪ Administer on empty stomach (1 hr before meals or 2 hrs after meal) – to increase absorption – Captopril and Moexipril ▪ If patient will undergo surgery, alert the surgeon – to prevent hypotension after surgery. ▪ Give parenteral form (Enalapril) if oral form is contraindicated. ▪ Consult doctor to reduce dose for patients with renal disease. ▪ Monitor patient for drop in fluid volume – excessive sweating, diarrhea, vomiting, dehydration. ▪ Encourage patient to implement lifestyle changes. Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin II Therapeutic Action: Receptor Blockers ▪ Selectively bind with the Angiotensin II receptors in the vascular (ARB) smooth muscles of the blood vessels and adrenal cortex to block ▪ Azilsartan vasoconstriction and release of aldosterone. ▪ Candesartan ▪ Irbesartan Indication: ▪ Losartan ▪ Olmesartan ▪ Hypertension ▪ Telmisartan ▪ Heart failure ▪ Valsartan ▪ After Myocardial Infarction ▪ Slow the Progression of Renal Disease ▪ Hypertension among Children Pharmacokinetics: ▪ Oral preparations ▪ Absorbed in GIT ▪ Metabolized in the Liver ▪ Excreted in the urine and feces. Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin II Contraindication: Receptor Blockers ▪ Angioedema – severe hypersensitivity reactions (ARB) ▪ Hepatic/ Renal Dysfunction ▪ Azilsartan ▪ Hypovolemia ▪ Candesartan ▪ Pregnancy ▪ Irbesartan ▪ Lactation ▪ Losartan ▪ Olmesartan ▪ Telmisartan Adverse Effects: ▪ Valsartan ▪ Hypotension – dizziness, headache, weakness, and syncope ▪ GI disturbance – diarrhea, abdominal pain, nausea, dry mouth, tooth pain ▪ URTI symptoms and cough ▪ Rash ▪ Dry skin ▪ Alopecia ▪ Renal Dysfunction Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Angiotensin II Drug-to-drug Interaction: Receptor Blockers ▪ Other antihypertensive drugs – increased hypotension effects (ARB) ▪ Potassium supplements and Potassium-sparing diuretics – ▪ Azilsartan hyperkalemia ▪ Candesartan ▪ Lithium salts – Lithium toxicity ▪ Irbesartan ▪ NSAIDs – increase risk of renal impairment ▪ Losartan ▪ Olmesartan ▪ Telmisartan Nursing Considerations: ▪ Valsartan ▪ If pregnancy occurs, discontinue ARB therapy immediately. ▪ Suggest the use of barrier contraceptives. ▪ Administer without regard to meals. May give with food to decrease GI distress. ▪ Alert surgeon if patient will undergo surgery – to prevent hypotension after surgery. ▪ Monitor renal function regularly. ▪ Check potassium levels. ▪ Monitor for signs and symptoms of drop in fluid volume. Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Renin Inhibitor Therapeutic Action: ▪ Aliskiren ▪ Directly inhibits renin, decreasing plasma renin activity. ▪ Inhibits conversion of angiotensinogen to angiotensin I. ▪ RAAS is inhibited: ▪ Decrease blood pressure ▪ Decrease aldosterone release ▪ Decrease sodium reabsorption. Pharmacokinetics: ▪ Poorly and slowly absorbed in GIT *** high-fat meals decrease absorption. ▪ Steady-state blood levels – 7-8 days ▪ Metabolized in the liver – Half life 24 hrs ▪ Excreted in the urine ▪ Crosses the placenta ▪ Enters the human milk Drugs Affecting the Renin-Angiotensin-Aldosterone System (RAAS) Drug Classification Important Considerations Renin Inhibitor Adverse Effects: ▪ Aliskiren ▪ Hyperkalemia ▪ Angioedema – swelling of face, lips, or tongue ▪ Respiratory symptoms – difficulty of breathing ▪ Renal impairment ▪ Diarrhea – most common side effect. Drug-to-drug Interactions: ▪ Furosemide – loss of diuretic effects ▪ Other antihypertensive agents – increase effects ▪ ACEI, ARB, Potassium-sparing diuretics – increase risk of hyperkalemia Drugs Affecting the Blood Pressure Drug Classification Important Considerations Calcium Channel Therapeutic Action: Blockers ▪ Inhibit the movement of calcium ions across the membranes of ▪ Amlodipine myocardial and arterial muscle cells. ▪ Diltiazem ⇩ ▪ Felodipine ▪ Altering the action potential ▪ Isradipine ▪ Levamlodipine ▪ Blocking muscle cell contraction ▪ Nicardipine ⇩ ▪ Nifedipine ▪ Depresses myocardial contractility ▪ Nisoldipine ▪ Slows cardiac impulse formation in conductive tissues ▪ Verapamil ▪ Relaxes and dilates arteries ▪ Clevidipine ⇩ ▪ Decrease in blood pressure ▪ Decrease cardiac workload ▪ Decrease myocardial oxygen consumption Pharmacokinetics: ▪ Oral preparations ▪ IV preparation (short-term use) – Nicardipine and Clevidipine Drugs Affecting the Blood Pressure Drug Classification Important Considerations Calcium Channel Contraindication: Blockers ▪ Allergy ▪ Amlodipine ▪ Renal dysfunction ▪ Diltiazem ▪ Hepatic dysfunction ▪ Felodipine ▪ Pregnancy ▪ Isradipine ▪ Levamlodipine ***Nifedipine – commonly administered during pregnancy to treat ▪ Nicardipine hypertension ▪ Nifedipine ▪ Nisoldipine Non-dihydropyridine Calcium Channel Blockers – not safe to ▪ Verapamil administer: ▪ Clevidipine ▪ Heart block ▪ Sick sinus syndrome ▪ Heart failure ▪ Acute Myocardial Infarction with Pulmonary Edema Adverse Effects: ▪ CNS effects – dizziness, lightheadedness, headache, and fatigue ▪ GI problems – nausea, constipation, hepatic injury Drugs Affecting the Blood Pressure Drug Classification Important Considerations Calcium Channel Adverse Effects: Blockers ▪ CVS effects – hypotension, bradycardia, peripheral edema, heart ▪ Amlodipine block ▪ Diltiazem ▪ Skin flushing and rash ▪ Felodipine ▪ Isradipine ▪ Levamlodipine Drug-to-drug Interactions: ▪ Nicardipine ▪ Cyclosporine – Diltiazem ▪ Nifedipine ▪ Increase serum levels and toxicity ▪ Nisoldipine ▪ Grapefruit juice ▪ Verapamil ▪ Increase concentration of calcium-channel blockers ▪ Clevidipine ▪ Toxicity Nursing Considerations: ▪ Do not cut, crush, or chew tablet. ▪ Administer with food if GI upset is present. ▪ Avoid drinking grapefruit juice. ▪ Reduce dosage if renal failure occurs. ▪ Monitor patient for any situation lead to drop in blood pressure. Drugs Affecting the Blood Pressure Drug Classification Important Considerations Vasodilators Therapeutic Action: ▪ Hydralazine ▪ Use directly on vascular smooth muscles to cause muscle ▪ Minoxidil relaxation. ▪ Nitroglycerin ⇩ ▪ Nitroprusside ▪ Vasodilation ⇩ ▪ Decrease in blood pressure ▪ Reserved for use in severe hypertension and hypertensive emergencies. Indication: ▪ Severe hypertension ▪ Angina and Hypertension - Nitroglycerin Pharmacokinetics: ▪ IV preparation – Nitroprusside ▪ Oral, IV, IM preparation – Hydralazine ▪ Variety of forms – Nitroglycerin Drugs Affecting the Blood Pressure Drug Classification Important Considerations Vasodilators Contraindications: ▪ Hydralazine ▪ Allergy ▪ Minoxidil ▪ Conditions leading to Hypotension ▪ Nitroglycerin ▪ Peripheral Vascular Disease ▪ Nitroprusside ▪ Coronary Artery Disease ▪ Heart Failure ▪ Tachycardia ▪ Pregnancy ▪ Lactation Adverse Effects: ▪ Dizziness ▪ Anxiety ▪ Headache ▪ Heart failure ▪ Chest pain ▪ Cyanide Toxicity – Nitroprusside Drugs Affecting the Blood Pressure Drug Classification Important Considerations Diuretic Drugs ▪ First-line agents used to treat mild hypertension. ▪ Thiazide and Thiazide- ▪ Affect blood sodium levels and blood volume. like Diuretics ▪ Chlorothiazide ▪ Increases excretion of sodium and water from the kidney. ▪ Hydrochlorothiazide ▪ Methylclothiazide ▪ Increase urination. ▪ Chlorthalidone ▪ Disturb electrolyte and acid-base balance. ▪ Indapamide ▪ Metolazone ▪ Potassium-sparing Diuretics ▪ Amiloride ▪ Spironolactone ▪ Triamterene Drugs Affecting the Blood Pressure – Sympathetic Nervous System Block the compensatory effects of the SNS. Drug Classification Important Considerations Beta Blockers Block vasoconstriction, decrease heart rate, decrease cardiac muscle ▪ Acebutolol contraction, and increase blood flow to kidneys, leading to decrease ▪ Atenolol in release of renin. ▪ Bisoprolol ▪ Metoprolol ▪ Nadolol Often used as monotherapy, controlling BP adequately. ▪ Pindolol ▪ Propranolol *Not recommended for COPD patients ▪ Timolol Alpha and Beta Blockers Useful in conjunction with other agents. ▪ Carvedilol ▪ Labetalol Block all receptors in the sympathetic nervous system. Alpha Adrenergic Inhibit post-synaptic alpha 1 adrenergic receptors Blockers Vasodilation ▪ Phenoxybenzamine Decrease in blood pressure ▪ Phentolamine Block pre-synaptic alpha 2 adrenergic receptors Decrease norepinephrine levels Drugs Affecting the Blood Pressure – Sympathetic Nervous System Block the compensatory effects of the SNS. Drug Classification Important Considerations Alpha 1 Blockers Block the post-synaptic alpha 1 receptor ▪ Doxazosin Decrease vascular tone ▪ Prazosin Vasodilation ▪ Terazosin Decrease blood pressure *do not block alpha 2 pre-synaptic receptor, no reflex tachycardia. Alpha 2 Agonists Stimulate the alpha 2 receptors in the CNS and inhibit the CV centers ▪ Clonidine Decrease in sympathetic outflow from the CNS ▪ Guanfacine Decrease in blood pressure ▪ Methyldopa Antihypotensive Drugs  Antihypotensive Drugs Sympathetic Blood-Pressure Adrenergic Agonists Raising Agents (Vasopressors) ▪ Dobutamine Midodrine Droxidopa ▪ Dopamine ▪ Epinephrine ▪ Ephedrine ▪ Isoproterenol ▪ Norepinephrine ▪ Phenylephrine Sympathetic Adrenergic Agonists Drug Classification Important Considerations Sympathetic Adrenergic ▪ React with the sympathetic adrenergic receptors – sympathetic Agonists stress response: (Vasopresssors) ▪ Increase blood pressure ▪ Dobutamine ▪ Increase blood volume ▪ Dopamine ▪ Increase strength of cardiac muscle contraction ▪ Ephedrine ▪ Epinephrine ▪ Norepinephrine ▪ Restore balance in cardiovascular system ▪ Isoproterenol ▪ Treating underlying cause of shock – volume depletion, blood loss ▪ Phenylephrine Adverse Effects: ▪ Decrease GI activity ▪ Increased respiratory rate ▪ Changes in blood pressure ▪ Changes in peripheral blood flow Contraindications: ▪ Patients with disease that limit the blood flow, hypertension, tachycardia. Blood Pressure-Raising Agents Drug Classification Important Considerations Midodrine ▪ Treatment: Orthostatic Hypotension ▪ Alpha-specific adrenergic agonists. ▪ Activates alpha-receptors in arteries and veins – produce increase in vascular tone ▪ Increases blood pressure. Pharmacokinetics: ▪ Rapidly absorbed in GIT ▪ Peak levels: 1-2 hrs ▪ Metabolized in the liver ▪ Excreted in the urine ▪ Half-life: 3-4 hrs Contraindication: ▪ Supine hypertension ▪ Pheochromocytoma ▪ Severe heart disease ▪ Acute renal disease Blood Pressure-Raising Agents Drug Classification Important Considerations Midodrine Contraindication: ▪ Urinary retention ▪ Thyrotoxicosis – further increases blood pressure ▪ Pregnancy ▪ Lactation ▪ Visual problems – exacerbated vasoconstriction ▪ Renal dysfunction ▪ Hepatic impairment Adverse Effects: Related to the stimulation of alpha-receptors ▪ Piloerection ▪ Chills and rash ▪ Hypertension ▪ Bradycardia ▪ Dizziness and vertigo ▪ Vision change Blood Pressure-Raising Agents Drug Classification Important Considerations Midodrine Drug-to-drug interactions: ▪ Cardiac glycoslides ▪ Beta blockers ▪ Alpha adrenergic agents ▪ Corticosteroids * Increase risk of effects and toxicity. Blood Pressure-Raising Agents Drug Classification Important Considerations Droxidopa ▪ Treatment: Neurogenic Orthostatic Hypotension ▪ Blood pressure-raising agent ▪ Amino acid analog that is metabolized to norepinephrine by dopa decarboxylase. ▪ Related to norepinephrine effects - VASOCONSTRICTION Pharmacokinetics: ▪ Rapidly absorbed in GIT ▪ Peak levels: 1-4 hrs ▪ Metabolized by normal catecholamines ▪ Excreted in the urine ▪ Half-life: 2.5 hrs Contraindication: ▪ Allergy ▪ Cardiovascular conditions ▪ Renal impairment ▪ Breastfeeding Blood Pressure-Raising Agents Nursing Considerations: ▪ Monitor blood pressure carefully to monitor effectiveness and changes in blood pressure. ▪ Do not administer the drug to patients who are bedridden, but only to patients who are up and mobile – to ensure therapeutic effects and decrease risk of severe supine hypertension. ▪ Monitor heart rate regularly when beginning of therapy – to monitor bradycardia. ▪ Monitor patients with known visual problems – to ensure drug discontinuation if there are changes in the visual field. ▪ Provide comfort measures. ▪ Provide patient teaching. ▪ Offer support and encouragement. 03 Drugs for Heart Failure Heart Failure ▪ A condition in which the heart fails to pump blood around the body effectively. ▪ Syndrome due to structural and/or functional irregularities in the heart. Low cardiac output – volume of blood being pumped by the heart ⇩ Pulmonary and/ or Systemic Congestion of the Heart ▪ Involves dysfunction of the cardiac muscle.  Drugs treating Heart Failure Cardiotonic Agents Hyperpolarization Angiotensin -Activated Cyclic Receptor Nucleotide-Gated Neprilysin Channel Blocker Inhibitor Cardiac Glycoside Phosphodiesterase (HCN Blocker) (ARNI) Inhibitor Digoxin Ivabradine ▪ Valsartan Milrinone ▪ Sacubitril Cardiotonic (Inotropic) Agents ▪ Drugs that affect intracellular calcium levels in the heart muscles. ▪ Increased contractility. ▪ Increased cardiac output. ▪ Increased renal blood flow – decrease renin release – interfere RAAS ▪ Increased urine production – decrease blood volume Drug Classification Important Considerations Cardiac Glycosides ▪ Derived from foxglove or digitalis plant. ▪ Digoxin ▪ Used to treat heart failure symptoms. Therapeutic Effects: ▪ Increases intracellular calcium and allows more calcium to enter myocardial cells during depolarization. ▪ Increased force of myocardial contraction – positive inotropic effect. ▪ Increased cardiac output and renal perfusion – diuretic effect ▪ Slowed heart rate – slow rate of cellular repolarization. ▪ Decreased conduction velocity AV node. Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Therapeutic Effects: ▪ Digoxin ▪ Increase cardiac output – relieve symptoms of HF. Indication: ▪ Heart failure ▪ Atrial flutter ▪ Atrial fibrillation ▪ Paroxysmal Atrial Tachycardia ***Narrow therapeutic index drug. Pharmacokinetics: ▪ Oral and parenteral preparations ▪ Rapid onset of action ▪ Rapid absorption – Oral: 30-120 mins | IV: 5-30 mins ▪ Widely distributed ▪ Excreted unchanged in the urine *** renal impairment – drug accumulate lead to toxicity. Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Contraindications: ▪ Digoxin ▪ Allergy ▪ Ventricular tachycardia/ Ventricular Fibrillation ▪ Heart block – Sick Sinus Syndrome ▪ Idiopathic hypertrophic subaortic stenosis – increase force in contraction, obstruct outflow tract ▪ Acute Myocardial Infarction ▪ Renal insufficiency ▪ Electrolyte abnormality ▪ Pregnancy ▪ Lactation Adverse Effects: ▪ Headache ▪ Weakness ▪ Drowsiness ▪ Vision changes – yellow halo around objects ▪ GI upset and anorexia Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Adverse Effects: ▪ Digoxin ▪ Arrhythmias – glycoside affect action potential and conduction system ▪ Digoxin toxicity – too high digoxin levels ▪ Anorexia ▪ Nausea and vomiting ▪ Malaise ▪ Depression ▪ Irregular heart rhythm – atrial arrhythmias, ventricular tachycardia *** Digoxin Immune Fab (Digifab) – antidote for Digoxin Toxicity Drug-to-drug Interaction: ▪ Verapamil Increases therapeutic effects and toxicity ▪ Amiodarone ▪ Quinidine ▪ Quinine ▪ Erythromycin ▪ Tetracycline/ Cyclosporine Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Drug-to-drug Interaction: ▪ Digoxin ▪ Potassium-sparing diuretics Increases risk of arrhythmia ***checked potassium levels regularly. ▪ Thyroid hormone Decreases therapeutic effect ▪ Metoclopramide ▪ Penicillamine *** increase dosage may be needed. ▪ Cholestyramine Decreases absorption of oral digoxin ▪ Charcoal ▪ Colestipol ▪ Antacids ▪ Methotrexate ▪ Cyclophosphamide ▪ Bleomycin *** administered 2 to 4 hrs apart, drugs should not be taken at the same time. Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Nursing Considerations: ▪ Digoxin ▪ Administer a loading dose to provide rapid therapeutic effects. ▪ Monitor apical pulse rate and rhythm, and notify the doctor if the patient’s heartrate is less than 60bpm. Hold the dose. Re-check the pulse after 1 hour. *** Adult – less than 60 bpm. Child – less than 70bpm. Infant – less than 90bpm. *** Low pulse rate – sign of digoxin toxicity ▪ Check dose carefully – Digoxin is small margin of safety (NTID) ▪ Administer medications daily at the same time of the day. ▪ IV administration – infuse over at least 5 mins and monitor for dysrhythmias. ▪ Check pediatric dose with extreme care. Double-check by another nurse. *** Children more likely to develop Digoxin Toxicity. ▪ Provide support and reassurance to deal with drug effects. ▪ Provide patient teaching. Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Cardiac Glycosides Nursing Considerations: ▪ Digoxin ▪ Avoid IM administration – painful. ▪ Monitor fluid retention and heart failure – weigh the patient regularly. Assess dependent areas for edema and evaluate degree of pitting. ▪ Avoid administering oral drugs with food or antacids – to avoid delays in absorption. ▪ Maintain emergency equipment standby: ▪ Potassium Salts, Lidocaine - treatment for arrhythmias ▪ Phenytoin – treatment for seizure ▪ Atropine – to increase heart rate ▪ Cardiac monitor – for severe toxicity ▪ Obtain digoxin level as ordered: ▪ Therapeutic levels – 0.5 to 2 ng/mL Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Phosphodiesterase Therapeutic Effects: Inhibitor ▪ Second class cardiotonic agent ▪ Milrinone ▪ Block the enzyme – phosphodiesterase ▪ Increase in myocardial cell cyclic adenosine monophosphate. ▪ Increases calcium levels ▪ Stronger contractions ▪ Prolong effects of sympathetic stimulation ▪ Vasodilation ▪ Increase oxygen consumption ▪ Arrhythmias Indication: ▪ Short-term treatment of Heart Failure *** not responded to Digoxin, Diuretics, and Vasodilators Pharmacokinetics: ▪ IV preparation only ▪ Widely distributed after injection. Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Phosphodiesterase Contraindication: Inhibitor ▪ Allergy ▪ Milrinone ▪ Severe aortic or pulmonary valvular disease ▪ Acute Myocardial Infarction ▪ Fluid Volume Deficit – increase renal perfusion ▪ Ventricular Arrhythmia ▪ Older adult ▪ Pregnancy Adverse effects: ▪ Ventricular arrhythmias – progress to fatal ventricular fibrillation ▪ Hypotension ▪ Chest pain ▪ GI effects – nausea, vomiting, anorexia, and abdominal pain ▪ Thrombocytopenia ▪ Hypersensitivity reactions ▪ Burning sensation at the IV site Cardiotonic (Inotropic) Agents Drug Classification Important Considerations Phosphodiesterase Drug-to-drug Interaction: Inhibitor ▪ Furosemide – precipitate formation ▪ Milrinone *** avoid combination in a solution. *** use alternate lines, if given IV. Nursing Considerations: ▪ Protect the drug from light – to prevent drug degradation. ▪ Ensure patent IV access site available – to allow for IV administration of the drug. ▪ Monitor pulse and blood pressure frequently during administration – to monitor adverse effects. ▪ Monitor input and output and record daily weight to evaluate the resolution of heart failure. ▪ Monitor platelet counts before and regularly during therapy. ▪ Monitor IV injection sites and provide comfort measures if infusion is causing irritation. ▪ Provide comfort measures to help patient tolerate drug effects. ▪ Offer support and encouragement. 04 Drugs for Arrhythmia Conductivity Automaticity ▪ Normal heart function – cycle ▪ Action potential of the cardiac of cardiac contraction and muscles cell. relaxation. ▪ Sinoatrial (SA) Node – conduct ▪ Depolarization the impulse spontaneously and ▪ Repolarization transmitted to the Cardiac Conduction System. ▪ Oxygen and Nutrients - help and allow the heart to continuous rhythmic contractions on its own.  Phases of Action Potential of Cardiac Muscle Cells ▪ Short period. ▪ Calcium influx ▪ Fast sodium stops. ion channels ▪ Increase close. permeability of ▪ Decrease potassium. permeability of ▪ Potassium Phase 0 sodium. Phase 2 rapidly moves out of the cell. Phase 4 ▪ Potassium ions begin to leave ▪ K and Na Sodium-Potassium Depolarization Plateau Stage the cell distribution. Pump Slight ▪ Cell membrane Rapid ▪ Cell is at resting ▪ Point of Repolarization Repolarization membrane stimulation. becomes less permeable to potential. ▪ Sodium gates open. Phase 1 potassium. Phase 3 ▪ Sodium out of ▪ Calcium slowly the cell, ▪ Sodium exchange of rushes into enters the cell. ▪ Potassium potassium. the cell. efflux very slow. ▪ Action potential of the cardiac muscles cell. ▪ SA node impulse – 60 to 100x/ min ▪ AV node impulse – 40 to 50x/ min ▪ Complex ventricular muscle cells – 10 to 20x/ min Hemodynamics ▪ Forces the move blood throughout the cardiovascular system. ▪ Effective pumping of blood – coordinated contraction of atrial and ventricular muscles. ▪ Atrial stimulation followed by Total Atrial Contraction. ▪ Ventricular stimulation followed by Total Ventricular Contraction. Dysrhythmia ▪ Disruption in impulse formation and in the conduction of impulses through the myocardium. Arrhythmia ▪ Irregular heart beat ▪ Interfere with the myocardial contractions. ▪ Affect the stroke volume – the amount of blood pumped with each beat.  Types of Arrhythmias ▪ Changes in Rate: ▪ Tachycardia – faster than normal heart rate, >100bpm ▪ Bradycardia – slower than normal heart rate, < 60bpm ▪ Stimulation from Ectopic Focus: ▪ Premature Atrial Contraction (PAC) – early contraction (atria) – stimulates atrial response ▪ Premature Ventricular Contraction (PVC) – early contraction (ventricles) – stimulates cells ▪ Atrial flutter ▪ Atrial fibrillation ▪ Ventricular fibrillation ▪ Alteration in Conduction through the Muscle: ▪ Heart block – disruption in conduction of an impulse (Cardiac Conduction System) ▪ Bundle-branch block  Drugs treating Arrhythmias Class 0 Class I Class II Class III Class IV ▪ Acebutolol Ivabradine ▪ Adenosine ▪ Amiodarone ▪ Diltiazem ▪ Dofetilide ▪ Verapamil ▪ Digoxin ▪ Dronedarone ▪ Esmolol ▪ Ibutilide ▪ Propranolol ▪ Sotalol Class I-A Class I-B Class I-C Class I-D ▪ Disopyramide ▪ Lidocaine ▪ Flecainide ▪ Ranolazine ▪ Procainamide ▪ Mexiletine ▪ Propafenone ▪ Quinidine ▪ Gluconate Antiarrhythmic Agents Drug Classification Important Considerations Class 0 ▪ Treatment for heart failure. ▪ Ivabradine ▪ Reduced left ventricular ejection fraction. Class I ▪ Block the sodium channels in the cell membrane during an action ▪ I-A potential. ▪ Disopyramide ▪ Class I –A ▪ Procainamide ▪ Quinidine ▪ Depress phase 0 and prolong the duration of action potential. ▪ Gluconate ▪ Class I – B ▪ I-B ▪ Depress phase 0 and shorten the duration of action potential. ▪ Lidocaine ▪ Class I – C ▪ Mexiletine ▪ Depress phase 0, extreme slowing of conduction, little effect on ▪ I-C action potential. ▪ Flecainide ▪ Propafenone ▪ Class I – D ▪ I-D ▪ Inhibit late sodium current after rapid influx of sodium during an ▪ Ranolazine action potential. ▪ Local anesthetic ▪ Membrane-stabilizing agents Antiarrhythmic Agents Drug Classification Important Considerations Class I ▪ Tachycardia – preferable condition. ▪ I-A Indication: ▪ Disopyramide ▪ Ventricular arrhythmias – life-threatening ▪ Procainamide ▪ Quinidine ▪ Symptomatic paroxysmal atrial arrhythmias ▪ Gluconate ▪ Atrial fibrillation ▪ I-B ▪ Atrial flutter ▪ Lidocaine ▪ Mexiletine Pharmacokinetics: ▪ I-C ▪ Widely distributed after injections. ▪ Flecainide ▪ Propafenone ▪ Rapid absorption GIT. ▪ I-D ▪ Extensive hepatic metabolism. ▪ Ranolazine ▪ Excreted in the urine. ▪ Disopyramide – Oral form. ▪ Procainamide – IM/ IV form. ▪ Quinidine – Oral/ IM/ IV form and ADULTS only. ▪ Lidocaine – IM/ IV form and Bolus injection – emergency. Topical – analgesia Antiarrhythmic Agents Drug Classification Important Considerations Class I Pharmacokinetics: ▪ I-A ▪ Mexiletine – Oral and ADULTS only. ▪ Disopyramide ▪ Flecainide/ Propafenone – Oral forms. ▪ Procainamide ▪ Quinidine Patients without structural heart disease. ▪ Gluconate ▪ I-B Contraindications: ▪ Lidocaine ▪ Allergy ▪ Mexiletine ▪ Bradycardia/ Heart block ▪ I-C ▪ Heart failure/ Hypotension/ Shock ▪ Flecainide ▪ Propafenone ▪ Electrolyte disturbance ▪ I-D ▪ Renal and Hepatic dysfunction ▪ Ranolazine ▪ Pregnancy ▪ Lactation Adverse Effects: ▪ CNS effects ▪ GIT symptoms ▪ CV effects Antiarrhythmic Agents Drug Classification Important Considerations Class I Adverse Effects: ▪ I-A ▪ Respiratory arrest ▪ Disopyramide ▪ Rash/ Hypersensitivity reactions ▪ Procainamide ▪ Quinidine ▪ Loss of hair ▪ Gluconate ▪ Bone marrow depression ▪ I-B ▪ Systemic lupus syndrome – Procainamide ▪ Lidocaine ▪ Neutropenia ▪ Mexiletine ▪ Thrombocytopenia ▪ I-C ▪ Hemolytic anemia ▪ Flecainide ▪ Propafenone ▪ Liver failure ▪ I-D ▪ Ranolazine Drug-to-drug interactions: ▪ Digoxin and Beta blockers – increase risk for arrhythmia ▪ Digoxin and Cimetidine – toxicity with Quinidine ▪ Warfarin – Increase risk for bleeding Drug-to-Food interactions: ▪ Quinidine to Alkalinize Foods – citrus juices, vegetables, antacid, milk Antiarrhythmic Agents Drug Classification Important Considerations Class I Drug-to-Food interactions: ▪ I-A ▪ Quinidine and Alkalinize Foods ▪ Disopyramide – citrus juices, vegetables, antacid, milk ▪ Procainamide ▪ Quinidine – Toxicity ▪ Gluconate ▪ Quinidine and Grapefruit juice ▪ I-B – Increase serum levels and toxicity ▪ Lidocaine ▪ Mexiletine ▪ I-C ▪ Flecainide ▪ Propafenone ▪ I-D ▪ Ranolazine Class II ▪ Beta-adrenergic blockers ▪ Acebutolol ▪ Block beta-receptors – depression of Phase 4 Action Potential ▪ Adenosine ▪ Atropine – anticholinergic ▪ Digoxin ▪ Digoxin – muscarinic receptor activator ▪ Esmolol ▪ Propranolol ▪ Adenosine – activates adenosine receptors in supraventricular heart tissues. Antiarrhythmic Agents Drug Classification Important Considerations Class II ▪ Beta-adrenergic blockers ▪ Acebutolol ▪ Block beta-receptors – depression of Phase 4 Action Potential ▪ Adenosine ▪ Atropine – anticholinergic ▪ Digoxin ▪ Digoxin – muscarinic receptor activator ▪ Esmolol ▪ Propranolol – treatment of atrial arrhythmia – slowing conduction of AV node, decrease automaticity SA node – positive inotropic = increase CO ▪ Adenosine – activates adenosine receptors in supraventricular heart tissues. ▪ Decrease heart rate, cardiac excitability, and cardiac output. ▪ Slowing conduction of AV node ▪ Decrease release of renin ▪ Stabilizes excitable cardiac tissues ▪ Decrease blood pressure ▪ Decrease heart’s workload Antiarrhythmic Agents Drug Classification Important Considerations Class II Indication: ▪ Acebutolol ▪ Rapid Atrial Fibrillation ▪ Adenosine ▪ Atrial Flutter ▪ Digoxin ▪ Supraventricular Tachycardia ▪ Esmolol ▪ Propranolol ▪ Hypertension ▪ Angina ▪ Premature Ventricular Copntractions ▪ Ventricular Tachycardia Pharmacokinetics: ▪ Acebutolol – Oral form ▪ Esmolol – IV form ▪ Propranolol – Oral/ IV form – Food increases bioavailability ▪ Adenosine – IV push, continuous telemetry monitoring. – Extreme short half-life ▪ Digoxin – Oral/ IV form Antiarrhythmic Agents Drug Classification Important Considerations Class II Contraindication: ▪ Acebutolol ▪ Sinus bradycardia ▪ Adenosine ▪ AV block ▪ Digoxin ▪ Cardiogenic shock ▪ Esmolol ▪ Propranolol ▪ Respiratory depression ▪ Diabetes and Thyroid dysfunction ▪ Asthma/ COPD patients ▪ Pregnancy ▪ Lactation ▪ Renal and Hepatic Dysfunction Adenosine ▪ Second-degree/ Third-degree AV Block ▪ Sinus Node Disease ▪ Hypersensitivity Adverse Effects: ▪ CNS effects Antiarrhythmic Agents Drug Classification Important Considerations Class II Adverse Effects: ▪ Acebutolol ▪ CVS symptoms ▪ Adenosine ▪ GI problems ▪ Digoxin ▪ Respiratory effects ▪ Esmolol ▪ Propranolol ▪ Loss of libido ▪ Decrease exercise tolerance ▪ Alteration in blood glucose levels Adenosine ▪ Flushing ***Side effects are SHORT-TERM only. ▪ Headache ▪ Shortness of breath Drug-to-drug Interaction: ▪ Verapamil and Diltiazem – Increase risk of CV effects ▪ Antidiabetic medications – Risk of masking hypoglycemic effects ▪ Methylxanthines (Theophylline and Caffeine) – block the adenosine receptors and decrease therapeutic effects. Antiarrhythmic Agents Drug Classification Important Considerations Class III ▪ Block the potassium channels and slow the outward movement of ▪ Amiodarone potassium during Phase 3 of Action Potential – prolonging. ▪ Dofetilide ▪ Dronedarone Indication: ▪ Ibutilide ▪ Sotalol ▪ Ventricular arrhythmias – life-threatening ▪ Maintenance of sinus rhythm in patients with symptomatic Atrial Fibrillation or Atrial Flutter. Pharmacokinetics: ▪ Amiodarone – Oral/ IV ▪ Dofetilide, Dronedarone, and Sotalol – Oral only *** Sotalol decrease absorption with food. ▪ Ibutilide – IV only ▪ Well-absorbed after Oral administration ▪ Immediately available after IV administration ▪ Widely distributed ▪ Metabolized in the liver ▪ Excreted in the urine Antiarrhythmic Agents Drug Classification Important Considerations Class III Contraindications: ▪ Amiodarone ▪ Presence of AV block ▪ Dofetilide ▪ Shock ▪ Dronedarone ▪ Hypotension ▪ Ibutilide ▪ Sotalol ▪ Respiratory distress ▪ Thyroid and Pulmonary disease Adverse Effects: ▪ GI distress ▪ Bradycardia ▪ AV block ▪ QT prolongation ▪ Hepatic toxicity ▪ Lung fibrosis ▪ Cardiac Arrhythmias Drug-to-drug Interactions: ▪ Digoxin and Quinidine – increase risk of serious toxic effects Antiarrhythmic Agents Drug Classification Important Considerations Class III Drug-to-drug Interactions: ▪ Amiodarone ▪ Antihistamine, Phenothiazines, TCA – increase risk of proarrhythmia ▪ Dofetilide ▪ Ketoconazole, Cimetidine, Verapamil - increase risk of serious adverse ▪ Dronedarone effects ▪ Ibutilide ▪ Sotalol ▪ Sotalol and NSAIDs, Aspirin, Antacids – decrease therapeutic effects ▪ Beta Blockers, Verapamil, Diltiazem – increase risk of bradycardia and heart block. Class IV ▪ Two non-dihydropyridine calcium channel blockers ▪ Verapamil ▪ More direct negative inotropic effects ▪ Diltiazem ▪ Better antiarrhythmics ▪ Avoided in heart failure – decrease heart muscle function ▪ Block the movement of calcium ions across the cell membrane and vascular smooth muscle cells ▪ Delaying Phase 1 and 2 ▪ Slows automaticity and conductivity ▪ Slow AV conduction and ventricular rate ▪ Antihypertensive and Anti-anginal agents Antiarrhythmic Agents Drug Classification Important Considerations Class IV Indication: ▪ Verapamil ▪ Rapid Supraventricular Dysrhythmias ▪ Diltiazem Pharmacokinetics: ▪ Administered Oral/ IV forms ▪ Well absorbed ▪ Highly protein bound ▪ Metabolized in the liver ▪ Excreted in the urine ▪ Cross the placenta and enters the human milk Contraindication: ▪ Allergy ▪ Sick sinus syndrome/ Heart Block ▪ Severe heart failure ▪ Hypotension ▪ Pregnancy ▪ Lactation Antiarrhythmic Agents Drug Classification Important Considerations Class IV Contraindication: ▪ Verapamil ▪ Idiopathic Hypertrophic Subaortic Stenosis ▪ Diltiazem ▪ Impaired renal or liver functions Adverse Effects: ▪ CNS effects – dizziness, weakness, fatigue, depression, headache ▪ GI upset ▪ Hypotension ▪ Heart failure ▪ Shock ▪ Arrhythmia ▪ AV block ▪ Edema Drug-to-drug Interaction: ▪ Beta blockers – increase risk of cardiac depression ▪ Digoxin – increase AV slowing and increase toxicity levels ▪ Carbamazepine, Prazosin, Quinidine – increase serum levels and toxicity Antiarrhythmic Agents Drug Classification Important Considerations Class IV Drug-to-drug Interaction: ▪ Verapamil ▪ Atracurium, Pancuronium, Vecuronium – increase respiratory ▪ Diltiazem depression ▪ Rifampin and Calcium products – decrease therapeutic effects ▪ Beta-adrenergic – increase risk of severe cardiac effects *** administered IV within 48hrs ▪ Cyclosporine – increase serum levels and toxicity ▪ Other antihypertensive drugs – increase risk of hypertension, bradycardia, and heart block ▪ Other negative inotropic medications- increase risk of Heart Failure Antiarrhythmic Agents Nursing Considerations: ▪ Titrate the dose to the smallest amount needed to achieve control of the arrhythmia to decrease the risk of severe adverse effects. ▪ Continually monitor cardiac rhythm when initiating or changing dose to detect potentially serious adverse effects and to evaluate drug effectiveness. ▪ Ensure that emergency life support equipment is readily available to treat severe adverse reactions that might occur. ▪ Administer parenteral forms as ordered only if the oral form is not feasible, expect to switch to the oral form as soon as possible. ▪ Consult with the prescriber to reduce the dose in patients with renal or hepatic dysfunction, to ensure therapeutic effects without increased risk of toxic effects. ▪ Establish safety precautions ▪ Arrange periodic monitoring of cardiac rhythm when patient is receiving a long-term therapy. ▪ Provide comfort measures. ▪ Offer support and encouragement. ▪ Provide thorough patient teaching.  05 Drugs for Angina Atherosclerotic Cardiovascular Disease (ASCVD) ▪ Accumulation of cholesterol plaque in the arteries and can lead to: ▪ Peripheral arterial disease ▪ Myocardial infarction ▪ Ischemic stroke. Coronary Artery Disease (CAD) ▪ Type of ASCVD ▪ Characterized by progressive narrowing of the coronary arteries ▪ Decrease delivery of oxygen to the cardiac muscle cells. ▪ Frequently diagnosed cause of heart disease ▪ Chronic illness – manageable but not curable  CAD Risk Factors Dyslipidemia Obesity Diabetes Mellitus Inactive Hypertension Smoking Family Lifestyle History  Coronary Artery Disease (CAD) ▪ Blood vessel lumen – narrowed ▪ Blood is no longer able to flow freely. Atheroma (Fatty tumors) ▪ Fats, blood cells, lipids, inflammatory agents, platelets. Atherosclerosis ▪ Process of atheroma development in the endothelial lining of the arteries. Angina ▪ Pain from imbalance between oxygen supply and demand. ▪ Angina Pectoris – suffocation of the chest. ▪ Body’s response to a lack of oxygen in the heart muscle. ▪ Substance P is released from ischemic myocardial cells. ▪ Reacts with pain receptors ▪ Basic response: *** STOP whatever one is doing and wait for the pain to go away.  Types of Angina Pronounced narrowing of the No damage to the heart muscle and coronary arteries. basic reflexes. Heart may experience ischemia Restore blood flow to the heart. even at rest. Can go on for long time. No resultant to Increase risk of complete blockage MI of blood supply to the heart muscle. STABLE ANGINA CHRONIC ANGINA UNSTABLE ANGINA PRINZMETAL ANGINA Minor limitations to the blood Drop in blood flow through coronary flow through the vessels. arteries. Stopping activity – bring blood Vasospasm in the artery. supply and demand back into balance. Acute Myocardial Infarction ▪ Unable to deliver blood to the cardiac muscle ▪ Ischemic ▪ Necrotic Manifestations: ▪ Excruciating pain ▪ Nausea ▪ Severe sympathetic stress reactions Complications: ▪ Arrhythmia Antianginal Drugs ▪ Help restore appropriate supply-and-demand ration in oxygen delivery to the myocardium. ▪ These drugs work to improve blood delivery to the heart muscle: ▪ By dilating blood vessels – increasing supply of oxygen ▪ By decreasing the work of the heart – decreasing the demand of oxygen ▪ Heart muscle demand for oxygen is influenced by: ▪ Heart rate – faster heart rate requires more energy ▪ Preload – more blood returned to the heart, the more pumping will be done to empty it, requiring more energy. ▪ Afterload – more pressure the heart has to pump against the more energy is required. ▪ Contractility of the Heart Muscle Cells  Drugs treating Angina Nitrates Beta Blockers Calcium Channel Piperazine Blockers Acetamide ▪Isosorbide Dinitrate ▪ Atenolol ▪Isosorbide Mononitrate ▪ Metoprolol ▪ Ranolazine ▪ Nadolol ▪ Amlodipine ▪Nitroglycerin ▪ Propranolol ▪ Diltiazem ▪ Nicardipine ▪ Nifedipine ▪ Verapamil *** Treatment for Prinzmetal Angina Antianginal Drugs Drug Classification Important Considerations Nitrates ▪ Act directly on smooth muscles to cause relaxation and depress muscle ▪ Isosorbide tone. Dinitrate ▪ Vasodilation – decrease in blood pressure ▪ Isosorbide ▪ Do not influence any nerve or other activity. Mononitrate ▪ Nitroglycerin ▪ Response is fast. Therapeutic Action: ▪ Relax and dilate blood vessels. ▪ Allowing increased blood flow. ▪ Lowering systemic blood pressure. ▪ Increase blood flow – healthy coronary arteries ▪ Help decrease vasospasm of arteries Indications: ▪ Angina pectoris Antianginal Drugs Drug Classification Important Considerations Nitrates Pharmacokinetics: ▪ Isosorbide ▪ Nitroglycerin – available in variety forms Dinitrate ▪ Sublingual tablet ▪ Isosorbide ▪ Translingual spray Mononitrate ▪ Nitroglycerin ▪ Intravenous solution ▪ Transdermal patch ▪ Topical ointment ▪ Transmucosal agent ▪ Slow-releasing tablet form ▪ Isosorbide dinitrate/ Isosorbide mononitrate ▪ Oral form ▪ onset of action – 14 to 45 mins Contraindications: ▪ Allergy ▪ Severe anemia – decreased ability of oxygen delivery ▪ Head trauma/ Cerebral hemorrhage Antianginal Drugs Drug Classification Important Considerations Nitrates Contraindications: ▪ Isosorbide ▪ Hepatic or Renal disease Dinitrate ▪ Pregnancy ▪ Isosorbide ▪ Lactation Mononitrate ▪ Nitroglycerin ▪ Hypotension ▪ Hypovolemia ▪ Condition limits the cardiac output Adverse Effects: ▪ CNS effects – dizziness, weakness, headache ▪ GI side effects – nausea and vomiting ▪ CV problems ▪ Skin-related effects Drug-to-drug interactions: ▪ Ergot derivatives – increase risk of hypertension and decrease antianginal effects Antianginal Drugs Drug Classification Important Considerations Nitrates Drug-to-drug interactions: ▪ Isosorbide ▪ Phosphodiesterase Inhibitors and drugs to treat erectile dysfunction Dinitrate – serious hypotension and CV problems ▪ Isosorbide ▪ Other antihypertensive drugs Mononitrate ▪ Nitroglycerin – increase antihypertensive effect. Nursing Considerations: ▪ Have the patient lay down or sit down prior to administration – to prevent the risk of low blood pressure and avoid dizziness and light- headedness. ▪ Give sublingual forms under the tongue or in the buccal pouch and inform the patient not to swallow the tablet – to ensure therapeutic effects. ▪ Ask the patient if the tablet fizzles or burns – indicate potency. ▪ Always check expiration date, protect the medication from direct light and heat – to prevent drug inactivation. ▪ Sublingual doses can be repeated – 5 mins, total of 3 doses. Antianginal Drugs Drug Classification Important Considerations Nitrates Nursing Considerations: ▪ Isosorbide ▪ Give SR forms with water and caution the patient not to chew or crush Dinitrate the tablet – it needs to reach GIT intact. ▪ Isosorbide ▪ Long-acting preparation should be administered with plans for nitrate- Mononitrate ▪ Nitroglycerin free intervals because there is a risk of tolerance decreasing effectiveness if given continuously. ▪ Rotate sites of topical forms – to decrease risk of skin abrasion and breakdown. ▪ Make sure translingual spray is used under the tongue and not inhaled – to ensure therapeutic effect. ▪ Keep a record of number of sprays used. ▪ Have emergency life support readily available. ▪ Taper the dose gradually after long-term therapy – to avoid severe reaction and Myocardial Infarction. ▪ Provide comfort measures. ▪ Offer support and encouragement. ▪ Provide patient teaching. Antianginal Drugs Drug Classification Important Considerations Piperazine ▪ Effective in treating angina: Acetamide Agent ▪ decreasing blood glucose levels – diabetic patients ▪ Ranolazine ▪ decreasing incidence of ventricular fibrillation, atrial fibrillation, bradycardia. ▪ First-line treatment for angina. Pharmacokinetics: ▪ Rapidly absorbed ▪ Peak levels: 2 to 5 hrs ▪ Metabolized in the liver ▪ Half-life: 7 hrs ▪ Excreted in the urine and feces Contraindications: ▪ Sensitivity ▪ Prolonged QT interval ▪ Hepatic impairment Antianginal Drugs Drug Classification Important Considerations Piperazine Contraindications: Acetamide Agent ▪ Lactation ▪ Ranolazine ▪ Pregnancy ▪ Renal dysfunction Drug-to-drug interaction: ▪ Diltiazem - increase exposure to Ranolazine ▪ Verapamil ▪ Erythromycin ▪ Digoxin - increase serum levels ▪ TCA - increase serum levels ▪ Antipsychotic drugs ▪ Grapefruit  06 Drugs affecting Blood Coagulation Blood ▪ Fluid state in cardiovascular system. ▪ It moves from areas of higher pressure to lower pressure. Injury – cut, puncture, capillary destruction ⇩ Fluid blood leak out ⇩ System lose pressure Changing the flow Harming tissues and organs Blood Mechanisms to Prevent Blood Loss: Hemostasis ▪ Vascular constriction ▪ Stoppage of blood flow. ▪ Formation of platelet plug ▪ Coagulation – balance ▪ Activation of coagulation cascade between the tendency to ▪ Formation of a blood clot clot or form a solid state. Two (2) Categories of Dysfunction of Hemostasis ▪ Thrombosis – inappropriate clotting. ▪ Bleeding – inability to clot. Disorders Affecting Blood Coagulation Thromboembolic Disorders ▪ Medical conditions involve formation of thrombi due to overproduction of clots. ▪ Decrease blood flow through a blood vessel. ▪ Total occlusion of a blood vessel. Signs and Symptoms: ▪ Hypoxia ▪ Anoxia ▪ Necrosis – affected areas by decrease blood flow Emboli – break off and travel through system until they become lodged in tiny vessels. Disorders Affecting Blood Coagulation Thromboembolic Disorders ▪ Atherosclerotic cardiovascular disease ▪ Infection ▪ Trauma ▪ Inherited disorders: ▪ Factor V Leiden condition ▪ Antiphospholipid syndrome Disorders Affecting Blood Coagulation Hemorrhagic Disorders ▪ Excess bleeding occurs. ▪ Less common than thromboembolic disorders. ▪ Hemophilia – genetic lack of clotting factor ▪ Liver diseases ▪ Thrombocytopenia ▪ Blood transfusion – medical treatment  Drugs Affecting Clot Formation and Resolution Antiplatelet Agents Anticoagulants Thrombolytic Agents ▪ Aspirin ▪ Heparin ▪ Alteplase ▪ Clopidogrel ▪ Warfarin ▪ Reteplase ▪ Tenecteplase Alter platelet interfere with the clotting ▪ Streptokinase aggregation and the cascade and thrombin formation of the formation. break down the platelet plug thrombus or clot by stimulating the plasmin system. Drugs Affecting Blood Coagulation Antiplatelet Agents Nursing Considerations: ▪ Provide small, frequent meals – to relieve GI discomfort. ▪ Provide comfort measures and analgesia for headache – to relieve pain and improve patient adherence to the drug regimen. ▪ Suggest safety measures – use of an electric razor, avoidance of contact sports – to decrease risk of bleeding. ▪ Monitor platelet count – to detect thrombocytopenia and increased risk of bleeding. ▪ Provide increased precautions against bleeding during invasive procedures, use pressure dressing, and ice to decrease excessive blood loss caused by anticoagulation. ▪ Mark the chart of any patient receiving drugs – to alert medical staff for potential risk of bleeding. ▪ Provide thorough patient teaching. ▪ Offer support and encouragement. Drugs Affecting Blood Coagulation Anticoagulants Nursing Considerations: ▪ Evaluate therapeutic effects of warfarin: INR - 2 to 3 ▪ Evaluate therapeutic effects of heparin: WBCT – 2.5 to 3x control value of activated partial thromboplastin time (APTT) ▪ Evaluate the patients regularly for any signs of blood loss – petechiae, bleeding gums, bruises, dark-colored stools, dark-colored urine – to determine safety of the drug dose and to determine the need to consult with the prescriber if bleeding becomes apparent. ▪ Establish safety precautions to protect the patient from injury. ▪ Provide increased precautions against bleeding during invasive procedures – use of pressure dressings, avoid IM injections if possible, and do not rub Subcutaneous injection sites because of the state of anticoagulation increases risk of blood loss. ▪ Maintain antidotes on standby. ▪ Heparin – Protamine Sulfate ▪ Warfarin – Vitamin K/ Prothrombin Complex Concentrate Drugs Affecting Blood Coagulation Anticoagulants Nursing Considerations: ▪ Monitor for clotting if drug is stopped suddenly – to avoid risk of thromboembolic events. ▪ Monitor patient carefully when any drugs or herb taking warfarin because of risk of drug-to-drug interaction that would change effectiveness of anticoagulant. ▪ Make sure patient receives regular follow-up and monitoring – measurement of clotting time, to ensure therapeutic effects. ▪ Provide through patient teaching. ▪ Offer support and encouragement. Drugs Affecting Blood Coagulation Thrombolytic Agents Nursing Considerations: ▪ Arrange to administer tissue-plasminogen activators – to reduce mortality associated with MI or Ischemic Stroke. ▪ Discontinue heparin if it is being given before the administration of a thrombolytic agent unless specifically ordered for coronary artery infusion – to prevent excessive blood loss. ▪ Evaluate patient regularly for any signs of blood loss ▪ Monitor coagulation studies regularly. ▪ Arrange to type and crossmatch blood in case of serious blood loss requiring transfusion. ▪ Monitor cardiac rhythm continuously and ensure life support are readily available. ▪ Provide increased precautions against bleeding during invasive procedures. ▪ Provide thorough patient teaching. ▪ Offer support and encouragement.  Thanks! 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