Pharmacology - Heart Failure & Dysrhythmia PDF

Bullet Point Nursing Pharmacology – Heart failure Disclaimer: These notes are designed to provide the key points of each topic and may not contain all necessary information. Every effort is made to ensure this content is up to date and accurate at the time of writing. No liability is assumed for th...

Bullet Point Nursing Pharmacology – Heart failure Disclaimer: These notes are designed to provide the key points of each topic and may not contain all necessary information. Every effort is made to ensure this content is up to date and accurate at the time of writing. No liability is assumed for the content or its relation to current standards and practices. This should not replace comprehensive nursing educational resources. Pathophysiology review     Heart failure is when output of the heart cannot meet the needs of the cells HR X SV = CO tomancardiacontent HF is divided into HF with reduced ejection fraction and HF with preserved ejection fraction Pharmacotherapeutics often involve a combination of three medications I o Diuretic o RAAS inhibitor o Beta blocker  Patient education is critical to prevent readmission. This includes education on medication IEEE.EE i compliance, reduced sodium diet, self-monitoring and exercise.  S/S of HF include fatigue, orthopnea, cough, rales, exertional dyspnea, and edema Afterload thepressure  BNP is a common lab for HF  Ejection fraction from an echo is the most used imaging for diagnosing heart failure Drug class: Angiotensin Converting Enzyme Inhibitors (ACEI) andbetterbe howto reduce wordood  Drugs: o Lisinopril (Zestril) o Captopril (Capoten)  MOA: Inhibit the conversion of angiotensin one to angiotensin two  Indications: HTN, ACS, chronic kidney disease, stroke prevention, and heart failure EjtinEq'tion  SE/AE: Kidney injury, angioedema, cough, and hyperkalemia o Captopril can cause neutropenia  Black Box warning: Teratogenic Drug class: Angiotensin Receptor Blockers (ARB)  Drugs: o Losartan (Cozaar) o Valsartan (Diovan)  MOA: Inhibits angiotensin two receptors  Indications: HTN and kidney disease  SE/AE: Kidney injury and hyperkalemia  Less likely to have a cough and angioedema versus ACEI  Black Box warning: Teratogenic Drug class: Beta adrenergic antagonists (Beta blockers)  Drugs: Bullet Point Nursing © 2023  Bullet Point Nursing o Carvedilol o Metoprolol  MOA: Blocks beta one receptors  Indications: Angina, HTN, heart failure, AMI, dysrhythmias, migraines prevention, anxiety  SE/AE: Fatigue  Black Box warning: Abrupt discontinuation can cause adverse cardiac effects Drugsthat causing  Assess HR and BP prior to admin Bradycardia bring  Discussed in more depth in the HTN lecture Down HRandmust Drug class: Loop diuretics bewithheld if Pt's haslow HR  Drugs: I o Bumetanide (Bumex) o Furosemide (Lasix)  MOA: Blocks reabsorption of sodium and chloride in the loop of Henle  Indications: Pulmonary edema, congestive heart failure, and alternative for hypertension  SE/AE: Ototoxicity  Black Box warning: can cause fluid and electrolyte imbalances  Most potent class of diuretics Drug class: Potassium sparing diuretics (Aldosterone antagonist)  Drug: o Spironolactone  MOA: Blocks aldosterone (aldosterone increases sodium and water reabsorption)  Indications: Hypertension, edema and heart failure  SE/AE: Hyperkalemia  Caution with drugs that increase your potassium Drug class: Cardiac glycosides DigoxintoxicitySls ED  EE Drug: o Digoxin (Lanoxin) a  MOA: Increased effects of calcium resulting in increased contractility  Indications: Dysrhythmias (atrial fibrillation and flutter) and HF with reduced EF onlynothingelse  SE/AE: Nausea and vomiting, visual disturbances (notably halos), bradycardia, dysrhythmias  Patients should have heart rate and rhythm monitored when initiating treatment  Antidote available for digoxin toxicity called digoxin-immune fab havetochecktheapicalpulseprior Drug class: Phosphodiesterase inhibitors (PDI)  Drugs: o Amrinone o Milrinone  MOA: Inhibiting phosphodiesterase resulting in increased contractility and vasodilation  Indications: Heart failure with reduced EF  SE/AE: Dysrhythmias and hypotension Bullet Point Nursing © 2023 E E.EEEEEE ii  Bullet Point Nursing t.EE i i Drug name: Sacubitril-Valsartan (Entresto)  MOA: Inhibits neprilysin which increases vasodilation plus blocks the RAAS Teratogenic  Indications: Heart failure EE  Also referred to as an ARNI (angiotensin receptor, neprilysin inhibitor)  Not safe in pregnancy Drug name: Isosorbide Dinitrate – Hydralazine (Bidil)  MOA: Dilates veins and arteries  Indications: Heart failure with reduced EF  SE/AE: Hypotension and headache Nitroglycerine is another vasodilator that is used for heart failure. It is discussed in the angina lecture Drug name: Dobutamine  MOA: Beta one agonist  Indications: Acute decompensated heart failure  IV only  Considered a vasopressor but not a vasoconstrictor. Has minimal impact on increasing BP Pathophysiology review:  Dysrhythmias refer to the electrical activity of the heart Eiin Faith miiattntiini  Any rhythm other than normal sinus rhythm is considered an arrhythmia  These can be of expected physiology such as tachycardia during exercise or bradycardia in an athlete  These can be of pathologic origin (disease) such as atrial fibrillation  Diagnosed based upon ECG monitoring such as a 12 lead or Holter monitor  Symptoms of a dysrhythmia can include palpitations, near-syncope, dizziness  In dysrhythmias that impair perfusion, like atrial fibrillation, an anticoagulation may be needed Drug class: Class 1a antiarrhythmics – Sodium channel blockers  Antirrhythmics Drug: o Procainamide 4 98not  MOA: Slows cardiac conduction  Indications: Arrhythmias  Black Box warning: Lupus like syndrome (+ANA titer), blood dyscrasias, proarrhythmic effects Drug class: Class 1b antiarrhythmics – Sodium channel blockers  Drug: AllAntiarrhythmichas o Lidocaine commonMOA Bradycardia  MOA: Slows cardiac conduction orslowdownheartrateand  Indications: Arrhythmias allthemshouldwitheld if  SE/AE: CNS effects patienthas slowrate Bullet Point Nursing © 2023  Bullet Point Nursing  Contraindicated in patients with WPW and certain heart blocks  Also used as an anesthetic Drug class: Class 1c antiarrhythmics – Sodium channel blockers  Drug: o Flecainide o Propafenone  MOA: Slows cardiac conduction  Indications: Arrhythmias  Black Box warning: Proarrhythmic effects, consideration for increased mortality Drug class: Class 2 antiarrhythmics – Beta adrenergic blockers Betablockers   Drug: o Labatolol MOA: Beta one adrenergic antagonist results in decreased sympathetic stimulation on the heart g  Indications: Angina, HTN, heart failure, AMI, arrhythmias, migraine prevention, anxiety, and more 2Drugclassrequire  SE/AE: Fatigue and bradycardia   Black Box warning: Abrupt discontinuation can cause adverse cardiac effects Assess HR and BP prior to admin IE ii E Drug class: Class 3 antiarrhythmics – Potassium blockers  Drug: o Amiodarone  MOA: Prolongs repolarization  Indications: Arrhythmias  SE/AE: Bradycardia, hypotension, arrhythmias, hepatoxicity, pulmonary toxicity, adverse thyroid effects, skin sensitivity to light  Black Box warning: Proarrhythmic effects, pulmonary toxicity, hepatotoxicity pancreatitis  Not safe in pregnancy  Patient education: Avoid grapefruit juice, can cause toxicity  Assess HR and BP prior to admin  Duration can last for months class2 Class4 Drug class: Class 4 antiarrhythmics – Calcium channel blockers   Drug: o Verapamil o Diltiazem EE MOA: Relaxation of vascular smooth muscle and vasodilation also decreases cardiac cellular ii i excitability and contractility  Indications: Arrhythmias, HTN, angina  SE/AE: Dysrhythmias  Non-dihydropyridines only Bullet Point Nursing © 2023  Bullet Point Nursing  Assess HR and BP prior to admin Drug name: Adenosine (Adenocard) ATP  MOA: Decreases automaticity and slows conduction  Indications: Tachydysrhythmia treatment and diagnostics SVT SuperVentricularTachycardia  Patients must be on a cardiac monitor and should have a running ECG strip printing  Serves a diagnostic purpose even if arrhythmia returns  Onset is a few seconds and duration is under 10 seconds  Should be administered as centrally as possible  The ECG may flatline briefly upon administration  Also referred to as chemical conversion Certain life threatening arrythmias require cardioversion or defibrillation for immediate treatment Magnesium and other electrolytes may be the cause and/or treatment for dysrhythmias Any patient with a dysrhythmia and/or starting an antiarrhythmic should be on a cardiac monitor when in the acute care setting 2Disease contraindication avoidfluid overload 1 kidneyFailure 7 heart failure Nasopharyngitis Adverseeffectsof Ezetimide 180120 threshold for a hypertensive emergency Clopidogrel causes flu like symptoms Bullet Point Nursing © 2023  Bullet Point Nursing Pharmacology – Hyperlipidemia Disclaimer: These notes are designed to provide the key points of each topic and may not contain all necessary information. Every effort is made to ensure this content is up to date and accurate at the time of writing. No liability is assumed for the content or its relation to current standards and practices. This should not replace comprehensive nursing educational resources. Lipid Panel:  Total cholesterol should be under 200  Triglycerides should be under 150  LDL should be under 100  HDL should be over 50 in females and over 40 in males First line treatment: Lifestyle modifications  Decrease saturated fats and cholesterol  Fitting Increase dietary fiber monitoring  Increase exercise  Quit smoking  Reduce weight Decision to start pharmacotherapeutics is based on LDL and sometimes on ASCVD Drug class: HMG-CoA reductase inhibitors (statins)  Drugs: o Atorvastatin (Lipitor) o Rosuvastatin (Crestor) hyperlipidemia 1stlinedrugfor o Simvastatin (Zocor)  MOA: Inhibiting HMG-CoA reductase results in reduced LDL  Indications: Hyperlipidemia and prevention of cardiovascular disease  Not recommended in pregnancy  First line agent for hyperlipidemia  Preferred to be taken in the evening due to this is the time of cholesterol synthesis  SE/AE: Hepatotoxicity, muscle aches which can progress to rhabdomyolysis bloodinurine theresign 1 1191959  Dose is categorized by low, medium, and high o High dose statin reduces LDL by around 50% o Medium dose statin reduces LDL by around 30%-50% o Low dose statin reduces LDL by around 30% Drug class: Bile acid sequestrants  Drug: o Cholestyramine o Colesevelam  MOA: Increases loss of LDL through the feces  Indications: Hyperlipidemia Bullet Point Nursing © 2023  Bullet Point Nursing  SE/AE: GI effects  Patient education: Take an hour before or several hours after other medications Drug class: Cholesterol absorption inhibitors  Drug: Nasopharyngitis Adverseeffectsof Ezetimide o Ezetemibe (Zetia)  MOA: Inhibits absorption of cholesterol  Indications: Hyperlipidemia and off-label for prevention of cardiovascular disease  Mostly used as an add on to statin therapy Drug class: Fibrates  Drug: o Fenofibrate o Gemfibrozil (Lopid)  MOA: lowers VLDL (triglycerides)  Indications: Hypertriglyceridemia  SE/AE: Increased risk of gallstones  Not a first line agent  Primarily lowers VLDL Drug class: PCSK9 Inhibitors  Drugs: o Alirocumab (Praluent) o Evolocumab (Repatha)  MOA: Prevent the breakdown of LDL receptors for more LDL receptors to be working to reduce LDL  Indications: Hyperlipidemia, prevention of cardiovascular disease  Used as an alternative agent for monotherapy in patients that cannot tolerate statins  Given by subcutaneous injection. Dosed every two or more weeks Goal of therapy is to reduce the low density lipoproteins (LDL) Niacin is no longer recommended for hyperlipidemia Patienteducation for usingHyperlipidemia meds i II atte modificationtoimprovehearthealth 3 labcheckregularly than 1 at atime classesdrugsafetobeonmore medsthatyairenterallo I.fi I Bullet Point Nursing © 2023 In  Bullet Point Nursing Pharmacology – Anticoagulation Disclaimer: These notes are designed to provide the key points of each topic and may not contain all necessary information. Every effort is made to ensure this content is up to date and accurate at the time of writing. No liability is assumed for the content or its relation to current standards and practices. This should not replace comprehensive nursing educational resources. Pathophysiology review:  Platelets provide the first aspect of inhibiting bleeding i  Platelets are then reinforced with fibrin resulting from the coagulation pathway  The intrinsic mechanism for destroying clots is plasmin, an enzyme that breaks down fibrin Anticoagulant / antiplatelet therapy notes:  Clotting factors are found in plasma and may be an alternative option to treating bleeding  All anticoagulants increase risk of bleeding t.ciiiiii  Some of these drugs may be prescribed with a PPI to reduce risk of GI bleeding  Almost all anticoagulants and antiplatelets should be stopped prior to surgery  Patients on anticoagulation should be placed on bleeding precautions (shaving with an electric razor, using soft toothbrush, etc)  Many CAMs interact with anticoagulants including garlic, ginger, ginkgo biloba, and feverfew  Many patients with arrhythmias such as atrial fibrillation will also be prescribed an anticoagulant Drug name: Heparin (anticoagulant) further  MOA: Inactivates thrombin and prevents conversion of fibrinogen to fibrin prevent  Indications: Treatment and prevention of thromboembolic events clots o Examples include atrial fibrillation, DVT, pulmonary embolism, AMI, and more  Parenterally only  SE/AE: Hemorrhage, heparin induced thrombocytopenia (HIT)  Reversed with protamine sulfate  Monitored via the lab aPTT o Normal value is 40 seconds. With heparin therapy value should be 60-80 seconds.  Other labs for monitoring heparin are factor Xa levels and PTT  Dosage is in units  Onset is 20-30 minutes  Does not cross fetal-placenta barrier, generally considered safe in pregnancy  Also referred to as unfractionated heparin (UFH)  Another drug in this class is Enoxaparin (Lovonox) o Also referred to low molecular weight heparin (LMWH) o Onset is several hours Drug class: Vitamin K antagonist  Drug: Warfarin Vitamin k o Warfarin (Coumadin) Herapin Protaminesulfate Bullet Point Nursing © 2023 Easttian Antiplatelet it its eat Anticoagulant  Bullet Point Nursing  MOA: Decreasing production of vitamin K dependent clotting factors (VII, IX, X, and prothrombin)  Indications: Treatment and prevention of thromboembolic events o Examples include Atrial fibrillation, DVT, pulmonary embolism, AMI, and more  Onset is around 1-3 days  Transition from heparin (acute setting) to warfarin (long term) requires overlapping dosing  Oral anticoagulant  Monitored via labs PT and INR o Normal INR is 1.1 or below. With therapy the goal would usually be around 2-3 o Labs are assessed regularly at the start of therapy `  Contraindicated in pregnancy  Reversed with vitamin K  Interacts with many medications  Nursing education: Patients cannot increase their dietary vitamin K intake Drug class: Direct thrombin inhibitors  Drugs: o Dabigatran (Pradaxa)  MOA: Direct inhibition of thrombin  Indications: Treatment of DVT and PE and prevention of clots in patients with atrial fibrillation  SE/AE: GI upset  Black Box warning: Abrupt discontinuation carries increased risk of thromboembolic events  Reversed with idarucizumab (Praxbind)  Also referred to as direct oral anticoagulants (DOAC)  Another drug in this class is argatroban that is commonly used in patients that develop HIT o Argatroban is IV only Drug class: Factor Xa inhibitors  Drug: o Rivaroxaban (Xarelto) o Apixaban (Eliquis)  MOA: Inhibits factor Xa  Indications: Treatment of DVT and PE and prevention of clots in patients with atrial fibrillation  Black Box warning: Abrupt discontinuation carries increased of thromboembolic events  Also referred to as direct oral anticoagulants (DOAC)  Reversed with factor Xa Drug name: Aspirin OTC  MOA: COX inhibition causes suppression of platelet aggregation  Indications: Prevention of thrombotic events in patients having an AMI, prevention of CVA and ACS, and more  SE/AE: Increased risk of GI bleeding  Use as an NSAID discussed separately Bullet Point Nursing © 2023  Bullet Point Nursing  Also considered an antiplatelet Drug class: Glycoprotein IIb/IIIa inhibitors  Drug: o Tirofiban (Aggrastat)  MOA: Inhibits glycoprotein IIb/IIIa resulting in inhibition of platelet aggregation  Indications: Prevention of thrombotic events in patients having an AMI  IV only  Also considered an antiplatelet Drug class: ADP receptor antagonists  Drugs: o Clopidogrel (Plavix) o Ticagrelor (Brilinta)  MOA: Blocking ADP receptors resulting in reduced platelet aggregation  Indications: Prevention of thrombotic events in patients having an AMI and risk reduction for patients with a history of MI, CVA, atherosclerosis  Often given with aspirin  Rarely can cause thrombotic thrombocytopenic purpura (TTP)  Also considered an antiplatelet Drug name: Cilostazol  MOA: Induces reversable platelet aggregation and vasodilation  Indication: Intermittent claudication  Black box warning: contraindicated in patients with heart failure Drug class: Thrombolytics  Drugs: o Alteplase o Reteplase o Tenecteplase  MOA: Initiates fibrinolysis (breakdown of clots)  Indications: AMI, CVA, PE Etiate He  IV only  Usually given with a loading dose followed by one hour infusion  SE/AE: Intracranial hemorrhage (Referred to as conversion in the case of a stroke)  Only drugs that can breakdown an existing clot  Often requires a checklist to assess for high-risk complications and contraindications  Avoid extraneous cannulation of arteries or veins when administering thrombolytics  Reversed with Cryoprecipitate Drug class: Hemostatic / antifibrinolytic  Drug: Bullet Point Nursing © 2023 vitamink foodsupplement greenleafywagesuchas spinach Brocom  injection location Abdomen ismost subcutaneous Inotropic harderstronger faster harder and strongeronly enchangetably contractility Antidepressantclassdrugs SSRI SHIZI TCA MAOI Drugsthattreat PepticulcerDisease ERA Antacids Patienteducationaboutglucocorticoids causeHTN BPmonitoring cause hyperglycemia watchyousugar Diabetes medication increase requireteaching TPAsafetyadministere t.fmIsuseIndometnacin BUHcreatinine reprototoxity education must assess prior to providing patient theyready to learn highestprioritytaking Benzo y