Cardiac  Medications:  What’s With the Mixing & Matching? Michele B. Collins MSN RN CCRN September 2009
 
Sodium-Potassium Pump <ul><ul><ul><ul><ul><li>Sodium OUTSIDE cell &  </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li...
<ul><li>With cell stimulation, cell permeability allows sodium INTO cell & potassium OUT of cell </li></ul><ul><li>With so...
Cardiac Repolarization <ul><li>Na+ - K+ pump uses energy (ATP) so SODIUM LEAVES cell and POTASSIUM RETURNS to cell </li></...
Cardiac Repolarization <ul><li>If the S-A node does not generate an impulse, another cardiac site WILL (“reentry phenomeno...
<ul><li>Statistically, if you take six different drugs, you have an 80% percent chance of at least one drug-drug interacti...
Medications Discussed <ul><li>Antiarrhythmics </li></ul><ul><li>Beta Blockers   Ace Inhibitors   </li></ul><ul><li>Calcium...
Why so Many? <ul><li>In atrial fibrillation, used to suppress arrhythmias </li></ul><ul><li>Often done to relieve the symp...
<ul><li>In individuals with ventricular arrhythmias, used to suppress arrhythmias. Antiarrhythmic agents may be considered...
 
Automaticity <ul><li>Refers to a  cardiac muscle  cell firing off an impulse on its own </li></ul><ul><li>All cardiac cell...
Re-entry <ul><li>Occurs when an electrical impulse recurrently travels in a tight circle within the heart, rather than mov...
<ul><li>Can produce a sustained abnormal circuit rhythm. Re-entry circuits are responsible for  atrial flutter , most paro...
<ul><li>Conditions that increase automaticity include  sympathetic nervous system  stimulation and  hypoxia </li></ul>
<ul><li>Resulting heart rhythm depends on where the first signal begins </li></ul><ul><ul><li>if in sinoatrial node, the r...
Positive Inotropes <ul><li>THE EFFECTS OF STIMULATING ADRENERGIC RECEPTORS </li></ul><ul><li>RECEPTOR  SITE  ACTION </li><...
 
ANTIARRHYTMICS  (Vaughan Williams classification) <ul><li>Class I  – Membrane-stabilizing agents </li></ul><ul><li>Class I...
<ul><li>Class I agents interfere with the  sodium  (Na+) channel.  </li></ul><ul><li>Class II agents are anti- sympathetic...
Class I Antidysrhythmics:   <ul><li>slow rate of spontaneous depolarization of cardiac cells, thus decreasing automaticity...
Class 1c <ul><li>Increases blockage of sodium channel  </li></ul><ul><li>Encainide, Tombocor, Rythmol </li></ul><ul><li>se...
Class I: Sodium  channel blockers <ul><li>Disopyramide (Norpace) Flecainide  Procainamide  Propafenone (Rythmol) Quinidine...
Beta blockers <ul><li>Decrease mortality in patients with myocardial infarction </li></ul><ul><ul><li>Decrease infarct siz...
Class II Agents: Beta Blockers <ul><li>Blockage of beta-1 receptors causes </li></ul><ul><ul><li>Decreased force of contra...
Side Effects <ul><li>Angina </li></ul><ul><li>Fatigue, nightmares, & slow HR </li></ul><ul><li>Males may experience impote...
Cardioselectivity <ul><li>Acebutolol  Sectrol </li></ul><ul><li>Atenolol Tenormin </li></ul><ul><li>Esmolol Brevibloc </li...
Non Cardioselectivity <ul><li>Propranolol Inderal </li></ul><ul><li>Labetalol normodyne, Trandate (alpha  properties as we...
Beta Blockers  <ul><li>Atenolol  </li></ul><ul><li>Metoprolol  </li></ul><ul><li>Propranolol  </li></ul><ul><li>Sotalol  <...
Calcium Channel Blockers <ul><li>Block movement of calcium into smooth muscle cells in vessel walls </li></ul><ul><ul><li>...
<ul><li>R educe cardiac contractility, PVR, & myocardial O2 needs.  Effective on reentrant dysrhythmias that require AV no...
Uses <ul><li>Paroxysmal SVT, rate control for a-fib and flutter  </li></ul><ul><li>Dilate coronary arteries/decreases BP  ...
Side Effects <ul><li>Usually go away within a few hours to a day or so and are not said to be permanent once the medicatio...
Diltiazem (Cardizem) <ul><li>Less negative inotropic activity than verapamil </li></ul><ul><li>D ilates the coronary arter...
<ul><li>A dverse Effects : fewest  adverse effects  of this category of drugs </li></ul><ul><li>  Hypotension </li></ul><u...
Calcium Channel Blockers  <ul><li>Drugs in this class include:   </li></ul><ul><li>Nifedipine  </li></ul><ul><li>Diltiazem...
ACE Inhibitors (“pril”) <ul><li>Used to treat both hypertension and Acute Coronary Syndrome </li></ul><ul><li>Inhibit conv...
ACE Inhibitors <ul><li>Act to lower the blood pressure </li></ul><ul><ul><li>Dilate blood vessels </li></ul></ul><ul><ul><...
 
 
Indications <ul><li>Mild to severe hypertension </li></ul><ul><li>Treatment of heart failure </li></ul><ul><li>Given withi...
 
Side Effects <ul><li>Hypotension </li></ul><ul><ul><li>have person lie down for 3 hrs after first dose  </li></ul></ul><ul...
<ul><li>Give one hour before meals </li></ul><ul><li>Hold enalapril or lisinopril until after hemodialysis (both are remov...
Ace Inhibitors   <ul><li>Enalapril  Vasotec </li></ul><ul><li>Lisinopril  Zestril </li></ul><ul><li>Captopril  Capoten </l...
ARBs <ul><li>Related to ACE inhibitors </li></ul><ul><li>Used to treat hypertension </li></ul><ul><li>Block the action of ...
 
Angiotensin II Receptor Blockers (ARBs)  <ul><li>Losartan  </li></ul><ul><li>Valsartan  </li></ul><ul><li>Candesartan  </l...
     Digitalis   <ul><li>First medication useful in treating disorders of the heartbeat (1800s) </li></ul><ul><li>Digitali...
Actions <ul><li>Direct: increases myocardial contractility and CO </li></ul><ul><ul><li>Vagal effect on SA & AV nodes so d...
<ul><li>Slows HR so used in treatment of atrial fibrillation and atrial flutter </li></ul><ul><ul><li>does not suppress or...
Digitalis Toxicity <ul><ul><li>anorexia, n & v, visual disturbances </li></ul></ul><ul><ul><li>lethargy, bradycardia, hear...
Drug Interactions <ul><li>Decreased digoxin absorption with antacids & laxatives </li></ul><ul><li>Decreased digoxin effec...
Digoxin Fab (Digibind) <ul><li>Used for life-threatening digoxin toxicity </li></ul><ul><li>Mechanism:  antibody  complex ...
Nitrates <ul><li>Vasodilator: increases coronary blood flow by dilating coronary  arteries  and improving blood flow to is...
 
<ul><li>Used for angina, hypertension, MI </li></ul><ul><li>Used in heart failure to diminish symptoms of shortness of bre...
Short-acting: Nitroglycerin <ul><li>For acute anginal attacks. SL dosage (0.4mg): · Instruct patient to lie down · Repeat ...
Long-acting Nitrates:  Isordil, nitroglycerin ointment, nitroglycerin transdermal patch <ul><li>Ointment: use appropriate ...
Side Effects <ul><li>Hypotension, diaphoresis, nausea </li></ul><ul><li>Tachy- and bradydysrhythmias </li></ul><ul><li>Hea...
Drug Interactions <ul><li>Sympathomimetics, thyroid hormones, nicotine </li></ul><ul><li>All increase cardiac workload so ...
Nitrates  <ul><li>Drugs in this class include:   </li></ul><ul><li>Isosorbide Dinitrate  </li></ul><ul><li>Isosorbide Mono...
Amiodarone <ul><li>Principal effect on cardiac tissue to  </li></ul><ul><li>increase time for cell to repolarize  </li></u...
Side Effects <ul><li>Pulmonary fibrosis </li></ul><ul><li>Abnormal thyroid function </li></ul><ul><li>Photophobia, </li></...
<ul><li>May take over 3 weeks to work; half-life about 50 days </li></ul><ul><li>Monitor with patients in HF and elderly f...
<ul><li>Have patient swallow whole </li></ul><ul><li>Do not stop abruptly </li></ul><ul><li>Take one hour before meals or ...
Drug Interactions <ul><li>Anticoagulants increase anticoagulation </li></ul><ul><li>Increased digoxin effects </li></ul><u...
Class III — Potassium Channel Blockers <ul><li>Amiodarone (Cordarone) </li></ul><ul><li>Dofetilide (Tikosyn) </li></ul><ul...
So How Does This  Relate to My Patients? HTN <ul><li>Goal  </li></ul><ul><ul><li>Two primary regulatory factors </li></ul>...
Pharmacologic Treatment <ul><li>For patients with systolic dysfunction (ejection fraction <40%)  </li></ul><ul><ul><li>Ang...
<ul><ul><li>Aldosterone antagonist (ACE inhibitor or ARB) for those with </li></ul></ul><ul><ul><ul><li>dyspnea at rest or...
<ul><li>Digoxin only for patients who remain symptomatic despite treatment with </li></ul><ul><ul><li>Diuretics, ACE inhib...
<ul><li>HF patients on multiple medications are at a risk of potential drug interactions and side effects </li></ul><ul><u...
Goals for Mgt of Heart Disease <ul><li>Maximize blood flow to heart muscle  </li></ul><ul><li>Maximize preload & minimize ...
<ul><li>Reduce chances of clot formation  </li></ul><ul><li>Reduce overall blood volume if overload  </li></ul><ul><li>Mai...
What Drugs Help to  Meet these Goals?  <ul><ul><li>Maximize preload I.V. fluids, volume expanders  </li></ul></ul><ul><ul>...
What Drugs Help to  Meet these Goals (cont’d)? <ul><ul><li>Reduce chances of ASA or other anti-platelet </li></ul></ul><ul...
Treatment Goals for HF <ul><ul><li>Relieve symptoms & improve quality of life  </li></ul></ul><ul><ul><li>Prevent readmiss...
ACE Inhibitors <ul><li>Increase lifespan of patients with heart failure </li></ul><ul><li>Effects on blood vessels that se...
Beta-Blockers <ul><li>Lower blood pressure & slow heart rate (including protection against arrhythmias) </li></ul><ul><li>...
Nitrates <ul><li>Used to treat angina  </li></ul><ul><li>Vasodilates and  </li></ul><ul><li>stops chest pain by increasing...
Antidysrhythmic Drugs <ul><li>Used to bring under control abnormal rhythms of the heart (including atrial fibrillation), s...
Antihypertensives <ul><li>Used to control BP & risk of stroke & MI </li></ul><ul><li>Categories </li></ul><ul><ul><li>ACE ...
Managing the Cost <ul><li>Patients may be taking two to four drugs to </li></ul><ul><li>manage  cardiac condition  </li></...
<ul><li>Even with worsening condition some people try to limit costs </li></ul><ul><ul><li>May or may not ask which can be...
Refill Red Tape <ul><li>Patients and HCPs often face red tape when it comes to refills and preapproved status.  </li></ul>...
<ul><li>Patients receiving non-formulary drugs often pay more </li></ul><ul><ul><li>May only be able to get partially fill...
 
Simple Steps:  Lifestyle Changes <ul><li>Decrease sodium intake </li></ul><ul><li>Exercise & weight loss </li></ul>
Preload or Afterload? <ul><li>Arterial vasoconstriction  </li></ul><ul><li>BP 190/124  </li></ul><ul><li>Administration of...
<ul><li>List some positive and negative aspects to the administration of beta  blockers </li></ul>
<ul><li>The desired effect from the use of diuretics in the patient with acute left ventricular failure is to … </li></ul>
<ul><li>List some medications that decrease myocardial contractility </li></ul>
<ul><li>What are some of the signs & symptoms of left sided heart failure? </li></ul>
<ul><li>Your patient on digoxin has a morning heart rate of 56 BPM and is supposed to be discharged today. Your first prio...
<ul><li>What are some positive and negative aspects related to Nitroglycerin administration? </li></ul>
<ul><li>A patient with a dysrhythmia is placed on digoxin and metoprolol (Lopressor). Because of the combined effects of t...
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Cardiac Medications Review 2011

  1. 1. Cardiac Medications: What’s With the Mixing & Matching? Michele B. Collins MSN RN CCRN September 2009
  2. 3. Sodium-Potassium Pump <ul><ul><ul><ul><ul><li>Sodium OUTSIDE cell & </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Potassium INSIDE cell before depolarization </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cell has NEGATIVE charge & must CONTRACT to become POSITIVE </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>SA node has less negativity so it serves as pacemaker </li></ul></ul></ul></ul></ul>
  3. 4. <ul><li>With cell stimulation, cell permeability allows sodium INTO cell & potassium OUT of cell </li></ul><ul><li>With sodium, can only have STAT (“fast channel”) contraction </li></ul><ul><li>Calcium (“fast channel”) also enters cell, </li></ul><ul><li>leading to total controlled contraction </li></ul>
  4. 5. Cardiac Repolarization <ul><li>Na+ - K+ pump uses energy (ATP) so SODIUM LEAVES cell and POTASSIUM RETURNS to cell </li></ul><ul><li>Calcium also leaves cell at this time </li></ul>
  5. 6. Cardiac Repolarization <ul><li>If the S-A node does not generate an impulse, another cardiac site WILL (“reentry phenomenon”) </li></ul>
  6. 7. <ul><li>Statistically, if you take six different drugs, you have an 80% percent chance of at least one drug-drug interaction. </li></ul>Wayne K. Anderson, Dean, State University of New York School of Pharmacy
  7. 8. Medications Discussed <ul><li>Antiarrhythmics </li></ul><ul><li>Beta Blockers Ace Inhibitors </li></ul><ul><li>Calcium Channel Blockers </li></ul><ul><li>ACE Inhibitors </li></ul><ul><li>Angiotensin II Receptor Blockers (ARB) </li></ul><ul><li>Diuretics </li></ul><ul><li>Digitalis </li></ul><ul><li>Nitrates </li></ul><ul><li>Amiodarone </li></ul>
  8. 9. Why so Many? <ul><li>In atrial fibrillation, used to suppress arrhythmias </li></ul><ul><li>Often done to relieve the symptoms associated with loss of the atrial component to ventricular filling ( atrial kick ) due to atrial fibrillation or flutter . </li></ul>
  9. 10. <ul><li>In individuals with ventricular arrhythmias, used to suppress arrhythmias. Antiarrhythmic agents may be considered the first-line therapy in the prevention of sudden death in certain forms of structural heart disease </li></ul>
  10. 12. Automaticity <ul><li>Refers to a cardiac muscle cell firing off an impulse on its own </li></ul><ul><li>All cardiac cells can initiate an action potential , however, only some of these cells are designed to routinely trigger heart beats </li></ul><ul><li>Found in the 'conduction system' of the heart and include the SA node, AV node, Bundle of HIS and Purkinje fibers </li></ul><ul><li>S inoatrial node is a single specialized location in the atrium which has a higher automaticity (a faster pacemaker) than the rest of the heart, and therefore is usually responsible for setting the heart rate, and initiating each heart beat. </li></ul>
  11. 13. Re-entry <ul><li>Occurs when an electrical impulse recurrently travels in a tight circle within the heart, rather than moving from one end of the heart to the other and then stopping </li></ul><ul><li>If conduction is abnormally slow in some areas, part of the impulse will arrive late and potentially be treated as a new impulse </li></ul>
  12. 14. <ul><li>Can produce a sustained abnormal circuit rhythm. Re-entry circuits are responsible for atrial flutter , most paroxysmal supraventricular tachycardia , and dangerous ventricular tachycardia . </li></ul>
  13. 15. <ul><li>Conditions that increase automaticity include sympathetic nervous system stimulation and hypoxia </li></ul>
  14. 16. <ul><li>Resulting heart rhythm depends on where the first signal begins </li></ul><ul><ul><li>if in sinoatrial node, the rhythm remains normal but rapid </li></ul></ul><ul><ul><li>if an ectopic focus, many types of dysrhythmia may ensue. </li></ul></ul>
  15. 17. Positive Inotropes <ul><li>THE EFFECTS OF STIMULATING ADRENERGIC RECEPTORS </li></ul><ul><li>RECEPTOR SITE ACTION </li></ul><ul><li>alpha peripheral blood vessels vasoconstriction of peripheral arterioles </li></ul><ul><li>beta 1 myocardium increased heart rate (chronotropic) </li></ul><ul><li>increased contraction force (inotropic) inc. conduction </li></ul><ul><li>(dromotropic) </li></ul><ul><li>beta 2 peripheral blood vessels vasodilation of peripheral arterioles & veins </li></ul><ul><li> bronchioles bronchodilation </li></ul>
  16. 19. ANTIARRHYTMICS (Vaughan Williams classification) <ul><li>Class I – Membrane-stabilizing agents </li></ul><ul><li>Class II – Beta-blocking agents </li></ul><ul><li>Class III – Increase time for cell to repolarize </li></ul><ul><li>Class IV – Calcium Channel blockers </li></ul>
  17. 20. <ul><li>Class I agents interfere with the sodium (Na+) channel. </li></ul><ul><li>Class II agents are anti- sympathetic nervous system agents. Most agents in this class are beta blockers . </li></ul><ul><li>Class III agents affect potassium (K+) efflux. </li></ul><ul><li>Class IV agents affect calcium channels and the AV node . </li></ul><ul><li>Class V agents work by other or unknown mechanisms. </li></ul>
  18. 21. Class I Antidysrhythmics: <ul><li>slow rate of spontaneous depolarization of cardiac cells, thus decreasing automaticity, increasing refractory period, & decreasing susceptibility to escape beats </li></ul><ul><li>Prolong QT interval. </li></ul><ul><li>Widen QRS interval : decreased Na+ influx into the cell decreases conduction velocity and lengthens the QRS interval) </li></ul><ul><li>CLASS I-A (quinidine, procainamide, </li></ul><ul><li>disopyramide) </li></ul><ul><li>Not often used today </li></ul>
  19. 22. Class 1c <ul><li>Increases blockage of sodium channel </li></ul><ul><li>Encainide, Tombocor, Rythmol </li></ul><ul><li>severe ventricular dysrhythmias </li></ul>
  20. 23. Class I: Sodium channel blockers <ul><li>Disopyramide (Norpace) Flecainide Procainamide Propafenone (Rythmol) Quinidine Tocainide </li></ul>
  21. 24. Beta blockers <ul><li>Decrease mortality in patients with myocardial infarction </li></ul><ul><ul><li>Decrease infarct size </li></ul></ul><ul><ul><li>Decrease ventricular dysrhytmias </li></ul></ul><ul><li>Slow progression of heart failure (HF) and prolong lifespan in patients with HF </li></ul><ul><li>Used in treatment of coronary artery disease, heart failure (HF), & dysrhythmia </li></ul>
  22. 25. Class II Agents: Beta Blockers <ul><li>Blockage of beta-1 receptors causes </li></ul><ul><ul><li>Decreased force of contraction (- inotrope) </li></ul></ul><ul><ul><li>Decreased heart rate (-chronotrope) </li></ul></ul><ul><ul><li>Slowed conduction (-dromotrope) </li></ul></ul><ul><li>These 3 mechanisms of action combine to decrease myocardial oxygen demand </li></ul><ul><li>decrease cardiac workload & myocardial oxygen needs </li></ul><ul><li>Tr eatment of supraventricular tachycardias . They decrease conduction through the AV node . </li></ul>
  23. 26. Side Effects <ul><li>Angina </li></ul><ul><li>Fatigue, nightmares, & slow HR </li></ul><ul><li>Males may experience impotence </li></ul><ul><li>Patients with asthma or emphysema </li></ul><ul><li>may not be able to tolerate beta </li></ul><ul><li>blockers because of an increase in symptoms of shortness of breath and wheezing </li></ul><ul><li>Depression </li></ul><ul><li>Weight gain </li></ul><ul><li>Assess for cough, fatigue, edema, and other symptoms of HF </li></ul><ul><li>may mask hypoglycemia in diabetics; check blood glucose frequently </li></ul><ul><li>Removed from blood during hemodialysis; hold dose until treatment finished </li></ul>
  24. 27. Cardioselectivity <ul><li>Acebutolol Sectrol </li></ul><ul><li>Atenolol Tenormin </li></ul><ul><li>Esmolol Brevibloc </li></ul><ul><li>Metoprolol Lopressor </li></ul>
  25. 28. Non Cardioselectivity <ul><li>Propranolol Inderal </li></ul><ul><li>Labetalol normodyne, Trandate (alpha properties as well) </li></ul><ul><li>Carteolol Cartrol </li></ul><ul><li>Nadolol Corgard </li></ul><ul><li>Pindolol Visken </li></ul><ul><li>Timolol Blocadren </li></ul>
  26. 29. Beta Blockers <ul><li>Atenolol </li></ul><ul><li>Metoprolol </li></ul><ul><li>Propranolol </li></ul><ul><li>Sotalol </li></ul><ul><li>Bisoprolol </li></ul><ul><li>Nadolol </li></ul>Carvedilol Timolol Nadolol Betaxolol Pindolol Labetolol
  27. 30. Calcium Channel Blockers <ul><li>Block movement of calcium into smooth muscle cells in vessel walls </li></ul><ul><ul><li>Calcium required for muscle contraction; calcium channel blockers cause relaxation and dilatation of arteries </li></ul></ul><ul><ul><li>By this mechanism, lower BP </li></ul></ul><ul><ul><li>Dilate the coronary arteries so also used in treatment of </li></ul></ul><ul><ul><li>angina </li></ul></ul>
  28. 31. <ul><li>R educe cardiac contractility, PVR, & myocardial O2 needs. Effective on reentrant dysrhythmias that require AV nodal conduction for their continuation </li></ul><ul><li>In contrast to beta blockers, they allow the body to retain adrenergic control of heart rate and contractility. </li></ul><ul><li>Some have a slowing effect on the heart rate and are used in the treatment of arrhythmia </li></ul><ul><li>Used in treatment of hypertension, arrhythmia, and angina </li></ul>
  29. 32. Uses <ul><li>Paroxysmal SVT, rate control for a-fib and flutter </li></ul><ul><li>Dilate coronary arteries/decreases BP </li></ul><ul><li>Potentiates effects of digoxin </li></ul><ul><li>Change position slowly. </li></ul>
  30. 33. Side Effects <ul><li>Usually go away within a few hours to a day or so and are not said to be permanent once the medication has &quot;washed out&quot; of the system </li></ul><ul><li>Common side effects of these drugs include constipation, dizziness, and weakness </li></ul><ul><li>Swelling of the feet and ankles </li></ul><ul><li>Excessive lowering of the blood pressure </li></ul><ul><ul><li>Most common with first dose </li></ul></ul><ul><ul><li>Change position slowly </li></ul></ul><ul><li>Rarely an excessively slow heart beat </li></ul><ul><li>Worsening of HF </li></ul><ul><li>Many calcium channel blockers come in an extended release or sustained release preparation ( XL, SR) that is convenient for once a day dosing. These tablets should not be cut in half or crushed, as this would affect the rate of drug release into the bloodstream. </li></ul>
  31. 34. Diltiazem (Cardizem) <ul><li>Less negative inotropic activity than verapamil </li></ul><ul><li>D ilates the coronary arteries </li></ul><ul><li>Treatment of supraventricular arrhythmias </li></ul><ul><li>Oral diltiazem is effective in treatment of reentry tachycardia </li></ul>
  32. 35. <ul><li>A dverse Effects : fewest adverse effects of this category of drugs </li></ul><ul><li> Hypotension </li></ul><ul><li>- AV Block if patient is on Beta Blocker therapy </li></ul><ul><li>Verapamil (Calan, Isoptin): severe hypotension & bradycardia </li></ul>
  33. 36. Calcium Channel Blockers <ul><li>Drugs in this class include: </li></ul><ul><li>Nifedipine </li></ul><ul><li>Diltiazem </li></ul><ul><li>Verapamil </li></ul><ul><li>Amlodipine </li></ul>Felodipine Isradapine Nicardipene Nimodipine Bepridil
  34. 37. ACE Inhibitors (“pril”) <ul><li>Used to treat both hypertension and Acute Coronary Syndrome </li></ul><ul><li>Inhibit conversion of angiotension I to angiotension II >>> block release of aldosterone >>> reducing sodium & water retention </li></ul>
  35. 38. ACE Inhibitors <ul><li>Act to lower the blood pressure </li></ul><ul><ul><li>Dilate blood vessels </li></ul></ul><ul><ul><li>Help with cardiac emptying in HF </li></ul></ul><ul><li>Good for patients with heart failure by lowering the net resistance in the vascular bed, thereby facilitating the heart’s task of pumping blood. </li></ul>
  36. 41. Indications <ul><li>Mild to severe hypertension </li></ul><ul><li>Treatment of heart failure </li></ul><ul><li>Given within 48 hours of MI to prevent ventricular remodeling & development of HF </li></ul><ul><li>Increase survival rate after MI </li></ul>
  37. 43. Side Effects <ul><li>Hypotension </li></ul><ul><ul><li>have person lie down for 3 hrs after first dose </li></ul></ul><ul><ul><li>temporarily D/C diuretics when starting therapya </li></ul></ul><ul><ul><li>avoid potassium supplements/salt substitutes, diuretics (may cause severe hypotension) </li></ul></ul><ul><li>Hyperkalemia, renal tubular damage </li></ul><ul><li>Cough </li></ul><ul><li>Angioedema </li></ul>
  38. 44. <ul><li>Give one hour before meals </li></ul><ul><li>Hold enalapril or lisinopril until after hemodialysis (both are removed by dialysis) </li></ul>
  39. 45. Ace Inhibitors <ul><li>Enalapril Vasotec </li></ul><ul><li>Lisinopril Zestril </li></ul><ul><li>Captopril Capoten </li></ul><ul><li>Quinapril Accupril </li></ul><ul><li>Benazopril </li></ul><ul><li>Fosinopril </li></ul>
  40. 46. ARBs <ul><li>Related to ACE inhibitors </li></ul><ul><li>Used to treat hypertension </li></ul><ul><li>Block the action of angiotensin II to constrict blood vessels </li></ul><ul><ul><li>lower blood pressure </li></ul></ul><ul><ul><li>function in a similar way as the ACE inhibitors, but do not cause the dry, hacking cough that is sometimes associated with ACE inhibitor use. </li></ul></ul>
  41. 48. Angiotensin II Receptor Blockers (ARBs) <ul><li>Losartan </li></ul><ul><li>Valsartan </li></ul><ul><li>Candesartan </li></ul><ul><li>Irbesartan </li></ul>
  42. 49.     Digitalis <ul><li>First medication useful in treating disorders of the heartbeat (1800s) </li></ul><ul><li>Digitalis leaf from the foxglove plant </li></ul><ul><li>Used to treat atrial fibrillation and heart failure </li></ul>
  43. 50. Actions <ul><li>Direct: increases myocardial contractility and CO </li></ul><ul><ul><li>Vagal effect on SA & AV nodes so decreases heart rate </li></ul></ul><ul><ul><li>Slows conduction through AV node (positive inotrope, negative chronotrope and negative dromotrope) </li></ul></ul><ul><li>Indirect </li></ul><ul><ul><li>decreases diastolic cardiac size </li></ul></ul><ul><ul><li>reduces cardiac wall tension </li></ul></ul><ul><ul><li>increases renal Na+ & H2O excretion </li></ul></ul><ul><ul><li>decreases peripheral vasoconstriction </li></ul></ul>
  44. 51. <ul><li>Slows HR so used in treatment of atrial fibrillation and atrial flutter </li></ul><ul><ul><li>does not suppress or prevent arrhythmias but only works to slow them down and relieve symptoms </li></ul></ul><ul><ul><li>of palpitations </li></ul></ul><ul><li>Frequently used in heart failure (HF) </li></ul><ul><ul><li>Reduces frequency of HF exacerbations </li></ul></ul><ul><ul><li>Does not reduce mortality from HF </li></ul></ul>
  45. 52. Digitalis Toxicity <ul><ul><li>anorexia, n & v, visual disturbances </li></ul></ul><ul><ul><li>lethargy, bradycardia, heart block, tachydysrhythmias </li></ul></ul><ul><ul><li>Take apical heart rate for one full minute before administering </li></ul></ul><ul><ul><li>Monitor digoxin levels: narrow therapeutic window: 0.8-2.0 ng/ml </li></ul></ul><ul><ul><li>Monitor potassium levels: hypokalemia more likely to become digtoxic </li></ul></ul>
  46. 53. Drug Interactions <ul><li>Decreased digoxin absorption with antacids & laxatives </li></ul><ul><li>Decreased digoxin effect: metoclopramide, aminoglycosides, thyroid supplements </li></ul><ul><li>Increased digoxin effect Amphotericin B, corticosteroids, non-potassium-sparing diuretics, amiodarone </li></ul>
  47. 54. Digoxin Fab (Digibind) <ul><li>Used for life-threatening digoxin toxicity </li></ul><ul><li>Mechanism: antibody complex formation to digoxin </li></ul><ul><li>Adverse Events </li></ul><ul><ul><li>exacerbation of heart failure or a-fib due to withdrawal of digoxin </li></ul></ul><ul><ul><li>potential for complex dissociation with repeat toxicity in end-stage renal disease </li></ul></ul><ul><ul><li>digoxin levels meaningless for 7 days post Digibind use. </li></ul></ul>
  48. 55. Nitrates <ul><li>Vasodilator: increases coronary blood flow by dilating coronary arteries and improving blood flow to ischemic regions of the heart </li></ul><ul><ul><li>Decreases preload by dilating peripheral veins </li></ul></ul><ul><ul><li>Decreases afterload </li></ul></ul><ul><ul><li>Decreases myocardial oxygen demand to decrease angina </li></ul></ul>
  49. 57. <ul><li>Used for angina, hypertension, MI </li></ul><ul><li>Used in heart failure to diminish symptoms of shortness of breath </li></ul><ul><li>Do not reduce mortality in coronary artery disease or heart failure. Their use is principally for symptom relief. </li></ul>
  50. 58. Short-acting: Nitroglycerin <ul><li>For acute anginal attacks. SL dosage (0.4mg): · Instruct patient to lie down · Repeat at 5 minute intervals; if pain not </li></ul><ul><li>relieved, up to 3 tablets · If anginal pain persists after 3 doses, go to ED · Stay with patient and monitor VS (esp. BP) · Headache & hypotension are major side effects </li></ul>
  51. 59. Long-acting Nitrates: Isordil, nitroglycerin ointment, nitroglycerin transdermal patch <ul><li>Ointment: use appropriate application paper; don’t “rub in” </li></ul><ul><li>Rotate sites (remove old patch, ointments) </li></ul><ul><li>Avoid contact with skin </li></ul>Nitrate-free periods (6 – 10 hrs/ 24 hr period) to prevent tolerance Remove patch before defibrillating as patch may explode
  52. 60. Side Effects <ul><li>Hypotension, diaphoresis, nausea </li></ul><ul><li>Tachy- and bradydysrhythmias </li></ul><ul><li>Headache; reflex tachycardia </li></ul>
  53. 61. Drug Interactions <ul><li>Sympathomimetics, thyroid hormones, nicotine </li></ul><ul><li>All increase cardiac workload so counteract NTG effects </li></ul>
  54. 62. Nitrates <ul><li>Drugs in this class include: </li></ul><ul><li>Isosorbide Dinitrate </li></ul><ul><li>Isosorbide Mononitrate </li></ul>
  55. 63. Amiodarone <ul><li>Principal effect on cardiac tissue to </li></ul><ul><li>increase time for cell to repolarize </li></ul><ul><li>Mainly block potassium channels , thereby prolonging repolarization. </li></ul><ul><li>Do not affect the sodium channel so conduction velocity is not decreased </li></ul><ul><li>Used to treat atrial arrhythmias (atrial fibrillation and atrial flutter) as well as ventricular arrhythmias (ventricular fibrillation </li></ul><ul><li>Prevent re-entrant arrhythmias </li></ul><ul><li>results in &quot;chemical antifibrillatory&quot; action </li></ul>
  56. 64. Side Effects <ul><li>Pulmonary fibrosis </li></ul><ul><li>Abnormal thyroid function </li></ul><ul><li>Photophobia, </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Blue-gray skin color </li></ul><ul><li>Seeing halos around objects </li></ul>
  57. 65. <ul><li>May take over 3 weeks to work; half-life about 50 days </li></ul><ul><li>Monitor with patients in HF and elderly for decreased BP and pulse </li></ul><ul><li>Assess for fluid retention </li></ul>
  58. 66. <ul><li>Have patient swallow whole </li></ul><ul><li>Do not stop abruptly </li></ul><ul><li>Take one hour before meals or 2 hours after meals </li></ul><ul><li>High fat meals elevate levels </li></ul><ul><li>Use sunscreens and sunglasses when outside </li></ul>
  59. 67. Drug Interactions <ul><li>Anticoagulants increase anticoagulation </li></ul><ul><li>Increased digoxin effects </li></ul><ul><li>Avoid grapefruit juice as it will increase serum levels causing hypotension </li></ul>
  60. 68. Class III — Potassium Channel Blockers <ul><li>Amiodarone (Cordarone) </li></ul><ul><li>Dofetilide (Tikosyn) </li></ul><ul><li>Ibutilide (Corvert) </li></ul>
  61. 69. So How Does This Relate to My Patients? HTN <ul><li>Goal </li></ul><ul><ul><li>Two primary regulatory factors </li></ul></ul><ul><ul><ul><li>Blood flow (volume) </li></ul></ul></ul><ul><ul><ul><li>Peripheral Vascular Resistance (PVR) </li></ul></ul></ul><ul><ul><li>Primary groups of drugs are used: </li></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Adrenergic inhibitors (Beta-blockers) </li></ul></ul></ul><ul><ul><ul><li>Vasodilators </li></ul></ul></ul><ul><ul><ul><li>ACE inhibitors </li></ul></ul></ul><ul><ul><ul><li>Calcium antagonists </li></ul></ul></ul>
  62. 70. Pharmacologic Treatment <ul><li>For patients with systolic dysfunction (ejection fraction <40%) </li></ul><ul><ul><li>Angiotensin-converting enzyme (ACE) inhibitors for all patients </li></ul></ul><ul><ul><li>Beta blockers for all patients except </li></ul></ul><ul><ul><ul><li>Hemodynamic instability or </li></ul></ul></ul><ul><ul><ul><li>Dyspnea at rest with signs of </li></ul></ul></ul><ul><ul><ul><li>congestion </li></ul></ul></ul>
  63. 71. <ul><ul><li>Aldosterone antagonist (ACE inhibitor or ARB) for those with </li></ul></ul><ul><ul><ul><li>dyspnea at rest or </li></ul></ul></ul><ul><ul><ul><li>symptomatic patients who have suffered a recent myocardial infarction </li></ul></ul></ul><ul><ul><ul><li>ARB as a substitute for patients intolerant of ACE inhibitors </li></ul></ul></ul>
  64. 72. <ul><li>Digoxin only for patients who remain symptomatic despite treatment with </li></ul><ul><ul><li>Diuretics, ACE inhibitors, and beta blockers </li></ul></ul><ul><ul><li>or for those in atrial fibrillation </li></ul></ul><ul><ul><li>Diuretics for symptomatic patients to maintain appropriate fluid balance . </li></ul></ul>
  65. 73. <ul><li>HF patients on multiple medications are at a risk of potential drug interactions and side effects </li></ul><ul><ul><li>risk of hyperkalemia is increased with renal insufficiency treated with an aldosterone antagonist and an ACE inhibitor. </li></ul></ul>
  66. 74. Goals for Mgt of Heart Disease <ul><li>Maximize blood flow to heart muscle </li></ul><ul><li>Maximize preload & minimize afterload </li></ul><ul><li>Maximize cardiac contractility (inotropic effect) </li></ul>
  67. 75. <ul><li>Reduce chances of clot formation </li></ul><ul><li>Reduce overall blood volume if overload </li></ul><ul><li>Maintain heart rate between 60-80 beats/min to maximize cardiac output and filling pressures </li></ul>
  68. 76. What Drugs Help to Meet these Goals? <ul><ul><li>Maximize preload I.V. fluids, volume expanders </li></ul></ul><ul><ul><li>Minimize afterload ACE inhibitors </li></ul></ul><ul><ul><li>Maximize cardiac </li></ul></ul><ul><ul><li>contractility Digoxin, Dopamine </li></ul></ul><ul><ul><li>Decrease preload, </li></ul></ul><ul><ul><li>inc coronary circulation </li></ul></ul><ul><ul><li>& reduce pulmonary </li></ul></ul><ul><ul><li>congestion Nitrates </li></ul></ul>
  69. 77. What Drugs Help to Meet these Goals (cont’d)? <ul><ul><li>Reduce chances of ASA or other anti-platelet </li></ul></ul><ul><ul><li>clot formation agents </li></ul></ul><ul><ul><li>Reduce fluid </li></ul></ul><ul><ul><li>volume overload Diuretics </li></ul></ul><ul><ul><li>Keep heart rate btw Beta blockers & </li></ul></ul><ul><ul><li>60-80/min Calcium-channel blockers </li></ul></ul><ul><ul><li>Dysrhythmias Antidysrhytmics </li></ul></ul>
  70. 78. Treatment Goals for HF <ul><ul><li>Relieve symptoms & improve quality of life </li></ul></ul><ul><ul><li>Prevent readmission to hospital, and/or recurrent ischemic events </li></ul></ul><ul><ul><li>Reduce mortality </li></ul></ul><ul><ul><li>Medications used: </li></ul></ul><ul><ul><ul><li>ACE Inhibitors </li></ul></ul></ul><ul><ul><ul><li>Beta Blockers </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Vasodilators </li></ul></ul></ul><ul><ul><ul><li>Digitalis </li></ul></ul></ul>
  71. 79. ACE Inhibitors <ul><li>Increase lifespan of patients with heart failure </li></ul><ul><li>Effects on blood vessels that seem to counteract the process of atherosclerosis and have been shown to reduce heart attack, stroke, and mortality in CAD </li></ul>
  72. 80. Beta-Blockers <ul><li>Lower blood pressure & slow heart rate (including protection against arrhythmias) </li></ul><ul><li>Helps lower risk of stroke and heart attacks </li></ul>
  73. 81. Nitrates <ul><li>Used to treat angina </li></ul><ul><li>Vasodilates and </li></ul><ul><li>stops chest pain by increasing myocardial oxygen supply & decreasing demand </li></ul>
  74. 82. Antidysrhythmic Drugs <ul><li>Used to bring under control abnormal rhythms of the heart (including atrial fibrillation), so the heart can pump more effectively </li></ul>
  75. 83. Antihypertensives <ul><li>Used to control BP & risk of stroke & MI </li></ul><ul><li>Categories </li></ul><ul><ul><li>ACE Inhibitors </li></ul></ul><ul><ul><li>Beta-Blockers </li></ul></ul><ul><ul><li>Calcium-Channel Blockers </li></ul></ul>
  76. 84. Managing the Cost <ul><li>Patients may be taking two to four drugs to </li></ul><ul><li>manage cardiac condition </li></ul><ul><ul><li>in addition to meds for other health issues such </li></ul></ul><ul><ul><li>as diabetes </li></ul></ul><ul><ul><li>Med treatment for a chronic condition becomes expensive with each drug added   </li></ul></ul>
  77. 85. <ul><li>Even with worsening condition some people try to limit costs </li></ul><ul><ul><li>May or may not ask which can be decreased or stopped </li></ul></ul><ul><li>Best if medication regimen is kept simple so patients without insurance can purchase generic versions without rationing their doses. </li></ul>
  78. 86. Refill Red Tape <ul><li>Patients and HCPs often face red tape when it comes to refills and preapproved status. </li></ul><ul><li>If desired med is not on insurance company's preferred list </li></ul><ul><ul><li>Must complete preauthorization form </li></ul></ul><ul><ul><li>Also must talk with insurance company about why that particular medication is needed </li></ul></ul>
  79. 87. <ul><li>Patients receiving non-formulary drugs often pay more </li></ul><ul><ul><li>May only be able to get partially filled prescriptions </li></ul></ul><ul><ul><li>Providers should seek generic or less expensive alternatives whenever possible </li></ul></ul>
  80. 89. Simple Steps: Lifestyle Changes <ul><li>Decrease sodium intake </li></ul><ul><li>Exercise & weight loss </li></ul>
  81. 90. Preload or Afterload? <ul><li>Arterial vasoconstriction </li></ul><ul><li>BP 190/124 </li></ul><ul><li>Administration of hydralazine or nitroprusside </li></ul><ul><li>Administration of Nitroglycerin </li></ul><ul><li>Diuretic therapy </li></ul><ul><li>Arterial vasodilation </li></ul>
  82. 91. <ul><li>List some positive and negative aspects to the administration of beta blockers </li></ul>
  83. 92. <ul><li>The desired effect from the use of diuretics in the patient with acute left ventricular failure is to … </li></ul>
  84. 93. <ul><li>List some medications that decrease myocardial contractility </li></ul>
  85. 94. <ul><li>What are some of the signs & symptoms of left sided heart failure? </li></ul>
  86. 95. <ul><li>Your patient on digoxin has a morning heart rate of 56 BPM and is supposed to be discharged today. Your first priority is to… </li></ul>
  87. 96. <ul><li>What are some positive and negative aspects related to Nitroglycerin administration? </li></ul>
  88. 97. <ul><li>A patient with a dysrhythmia is placed on digoxin and metoprolol (Lopressor). Because of the combined effects of these drugs, what area(s) need to be the most closely monitored? </li></ul>
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