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Drugs affecting the circulatory system
 

Drugs affecting the circulatory system

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  • The heart is divided by partitions into four chambers. What are they? (Answer: right and left atria, and right and left ventricles)
  • Review the remainder of blood circulation. Venous capillaries merge to form larger veins. Blood returns to the heart via vena cava; enters the right atrium. Right atrium contracts; forces blood into right ventricle. Right ventricle contracts, forces blood to lungs. Blood is oxygenated and returned again to left atrium. What are differences between arteries and veins?
  • Review the exception: The pulmonary artery carries unoxygenated blood. Review the exception: The pulmonary vein carries oxygenated blood. Discuss the components of the heart that are affected by cardiac medications. Consider muscle contraction, chamber filling, electrical conduction, and rhythm.
  • Why do these conditions require medication? Explain the effect position and rate of flow of blood has on the client with heart failure.
  • What types of patients are vulnerable to heart failure?
  • Review the rationale for various drug classes that affect the heart.
  • Weight should be obtained daily, early in morning before eating or drinking; the bladder should be empty.
  • An inotropic drug such as digoxin may be combined with an ACE inhibitor, a beta-blocking agent, and/or a diuretic.
  • When would a prescription for digoxin immune Fab be used? With digitalis therapy, the rate of heart contraction is slowed. Normal heart rate is 60 to 80 beats per minute.
  • These medications assist in the treatment of hypertension by suppressing the formation of angiotensin II. The first dose may induce a severe hypotensive reaction. The patient should be closely monitored. The physician may discontinue diuretic agents 2 to 3 days before beginning ACE inhibitor therapy.
  • ACE inhibitors are excreted through the kidney. These medications may cause a severe decrease in blood pressure and an increase in serum potassium level. These medications should be used with caution for patients with renal compromise or pregnancy-induced hypertension.
  • Beta-blocking agents can be used alone or in combination with other agents to treat hypertension.
  • A low incidence of side effects exists with angiotensin II receptor–blocking agents. What are some side effects? (Answer: skin rash, facial edema, insomnia, and myalgia)
  • These medications are also useful in treating diabetic nephropathy and are usually well tolerated. Valsartan (Diovan) is the only one of the listed medications approved to treat heart failure. The remainder are used to treat hypertension and diabetic nephropathy. If the patient is receiving other drugs for hypertension or heart failure, the physician may decrease the dose or eliminate those drugs.
  • Aldosterone inhibitor agents include spironolactone, a potassium-sparing diuretic agent. Aldosterone inhibitor agents should not be used for patients with elevated serum potassium levels or decreased renal function. Aldosterone is suspected of causing myocardial remodeling after myocardial infarction. This limits the efficient function of the heart. By inhibiting aldosterone, the heart responds more efficiently and the risk for heart failure is decreased.
  • Discuss normal sinus rhythm and its rate. Rate for bradycardia: 100
  • What disorders or conditions require the use of vasoconstricting agents? (Answer: shock, rhinorrhea, allergic reaction)
  • Epinephrine is available as an EpiPen.
  • Vasodilating agents are common medication for home management of angina. Vasodilating agents are often first-line treatment for chest pain in the emergency department. What are the routes of administration? (Answer: sublingual, sustained-release oral tablets and capsules, transdermal, spray, intravenous)
  • Some medications target the dilation of arteries, increasing cardiac output and tissue perfusion. Some medications target the dilation of veins, easing the work of the ventricles. Some medications target both. Common side effects include postural hypotension, reflex tachycardia, and fluid retention. Nearly one third of patients do not take antihypertensive agents properly.
  • Most patients have “essential” hypertension (no cause is identified). Other lifestyle issues include the following: obesity, diabetes, arthritis (may affect likelihood of exercise), time constraints Review with students the current American Heart Association blood pressure guidelines (available on the organization’s website). If diet and exercise are not effective, single-drug therapy is begun. If this is not effective, combination therapy is begun with several drugs.
  • Through vessel dilation, these medications reduce the blood flow and workload of the vessels and the heart. Why is orthostatic hypotension a common side effect for this class of drugs?
  • Clonidine also may be used to control impulsivity in the hyperactive child or the child with attention deficit disorder. It does not increase school performance. Side effects of Aldomet are drowsiness, impotence, and gynecomastia.
  • Alpha-blocking agents include prazosin hydrochloride (Minipress), terazosin hydrochloride (Hytrin), and doxazosin mesylate (Cardura). Alpha-blocking agents are also used to treat benign prostatic hypertrophy (BPH) or hyperplasia.
  • These medications affect peripheral arterioles, arteries and arterioles of the heart, and cardiac muscle. They have no effect on the veins. These medications also affect the sites of the electrical conduction of the heart: the SA and AV nodes.
  • These medications must be used carefully with digoxin. How does the action of beta-blocking agents differ from calcium channel–blocking agents? Common side effects include bradycardia, AV block, exacerbation of heart failure, reflex tachycardia, dizziness, and peripheral edema.
  • Calcium salts include calcium gluconate, calcium chloride, and calcium lactate.
  • Drugs include the following: Phytonadione (vitamin K 1 oxide), (Mephyton) Phytonadione injection (AquaMEPHYTON) Administered by the oral or intravenous route. Intravenous administration may cause a severe adverse reaction. Vitamin K injection is administered at birth because infants are bone deficient in vitamin K and are at risk for neonatal hemorrhage.
  • Prothrombin time (PT) is used to evaluate the effectiveness of warfarin and guard against overdose. International normalized ratio (INR) is a system of standardizing the PT values. What is meant when patients say they take a “blood thinner”? How does an anticoagulant agent “thin” the blood?
  • Subcutaneous administration is seldom used because of the risk for bruising and bleeding. Heparin is used for prevention and treatment of pulmonary embolism, arterial emboli, and treatment of consumption coagulopathies (like disseminated intravascular coagulation [DIC]). Heparin encourages the antithrombin activity by altering the thrombin part of the clotting cascade.
  • The lab value activated partial thromboplastin time (aPTT) is used to monitor response to therapy and coagulation. Normal aPTT is approximately 40 seconds. Treatment range for aPTT is usually between 60 and 80 seconds (depends on the patient situation). Review the patient situations that would require heparin treatment. What are the signs and symptoms of the side effects of heparin?
  • Advantages over unfractionated heparin agents: May be given by subcutaneous injection Have a longer half-life, and thus may be administered less frequently Lower incidence of antiplatelet formation and HIT May be given on a fixed schedule. No need to monitor aPTT because of the low molecular weight. Low–molecular-weight heparin is more expensive than heparin, but many patients can remain at home and self-administer this treatment.
  • The dose is based on body weight. This medication may be given as prophylaxis to prevent deep vein thrombosis. It may be used to treat an active deep vein thrombosis. Review with students the patient teaching regarding subcutaneous administration, home care, and use of this medication.
  • Lepirudin directly inhibits thrombin formation. It is used to reverse HIT while maintaining the anticoagulation in the patient. Common side effects include back pain, nausea, hypotension, and hemorrhage.
  • Heparin must be given for initial treatment while coumarin is being started. Neither large loading doses nor administration using the intramuscular or intravenous route hastens antithrombotic action.
  • Dose may be adjusted by using the PT or INR.
  • This therapy is used for acute myocardial infarction, deep vein thrombosis, and massive pulmonary emboli. For myocardial infarction treatment, therapy must be administered within 4 to 6 hours of symptom presentation. Common side effects include hemorrhage, antibody production, fever, and hypotension.
  • These medications prevent thrombus formation in the arteries. An anticoagulant agent is used to prevent thrombus formation in the veins. They are useful for the prevention of a myocardial infarction (either initial or recurring). They are useful for decreasing the risk for stroke for patients with history of transient ischemic attacks (TIAs).
  • These medications increase the risk of gastrointestinal bleeding and also increase the risk of hemorrhage and hemorrhagic stroke.
  • Present guidelines recommend obtaining a complete lipoprotein and triglyceride profile every 5 years beginning at age 20. A low blood cholesterol level is unattainable for many patients using diet alone. Atherosclerosis is the fatty streak in the arterial wall. Atherosclerosis encourages fibrin formation and subsequent thrombi.
  • Many lipid-lowering drugs must be taken later in the day, with the evening meal. Some drugs decrease production of cholesterol. Others increase the removal of cholesterol from the bloodstream.
  • Lab testing of lipid levels and liver enzymes is necessary.

Drugs affecting the circulatory system Drugs affecting the circulatory system Presentation Transcript

  • Drugs That Affect the Circulatory System
  • Learning Objectives
    • Discuss the ways drugs may affect the heart.
    • Identify drugs used to treat heart failure.
    • Identify drugs used to treat hypertension.
    • Explain the action of antiarrhythmic agents.
  • Components and Function of the Circulatory System
    • Circulatory system includes the heart and blood vessels
    • Heart is a hollow, muscular organ
      • Situated near the center of thoracic cavity
      • Divided into four chambers
      • Muscular chambers pump blood
      • Left ventricle more muscular
  • Normal Blood Circulation
    • Oxygenated blood comes into left atrium from lungs; passes into the left ventricle
    • Ventricle contracts; blood is forced into aorta
    • Blood is carried to gastrointestinal tract, liver, capillary beds
    • Oxygen (O 2 ) and nutritive materials carried to tissue
    • Carbon dioxide (CO 2 ) and waste carried away to lungs and kidneys for excretion
  • Components and Function of the Circulatory System
  • Drugs That Affect the Heart
    • Cardiac drugs can affect the following:
      • Heart rate
      • Rhythm of the heartbeat
      • Amount of output of blood
      • Strength of the contraction
      • Intracellular energy production
  • Uses for Cardiac Drugs
    • Three main conditions
      • Heart failure—heart is not circulating blood at a satisfactory rate, fluid collects in lungs or extremities
      • Myocardial infarction—blood supply to heart muscle is blocked
      • Arrhythmias—abnormal electric conduction affects pumping action of heart
  • Heart Failure
    • During heart failure the following occurs:
      • Capillaries and veins contain more blood
      • Hydrostatic pressure is greater
      • Blood in the periphery retains more CO 2 and wastes
      • Blood has less O 2 with hemoglobin
      • Respiration in lungs is reduced
      • Cyanosis
      • Edema
  • Drugs That Affect the Heart
    • Heart failure is treated with several classes of drugs:
      • Diuretic agents
      • Inotropic drugs
      • Angiotensin-converting enzyme (ACE) inhibitor agents
      • Beta blockers
  • Diuretic Agents
    • Promote the formation and excretion of urine
    • Reduce fluid overload
    • Used in treatment of heart failure and hypertension
    • Reduce orthopnea and dyspnea
    • Most helpful in combination with other drugs
    • Examples:
      • Furosemide (Lasix)
      • Metolazone (Zaroxolyn)
      • Hydrochlorothiazide (HydroDIURIL)
  • Inotropic Drugs
    • Inotropic drugs increase the contractibility of the myocardium.
    • Digitalis was the first inotropic drug.
      • Crude digitalis leaf no longer used because of problems with standardization.
  • Inotropic Drugs
    • Digitalis
      • Strengthens heart musculature
      • Increases blood flow and allows heart to empty more efficiently
      • Side effects indicating toxicity include nausea, vomiting, and visual disturbances (objects may appear brighter than they actually are)
      • Synthetic form is exclusively used.
        • Digoxin (Lanoxin, Digitek) in oral, intravenous, and intramuscular forms
      • Antidote
        • Digoxin immune Fab (Digibind)
  • ACE Inhibitors
    • Inhibit angiotensin-converting enzyme
    • Used to treat congestive heart failure
    • Appear to minimize or prevent the left ventricular dilation or dysfunction after myocardial infarction
    • Also used to treat hypertension
    • Used in combination with other agents
    • May cause chronic cough, rarely angioedema
  • ACE Inhibitors
    • Examples:
      • Benazepril (Lotensin)
      • Captopril (Capoten)
      • Enalapril (Vasotec)
      • Fosinopril sodium (Monopril)
      • Lisinopril (Prinivil, Zestril)
      • Moexipril hydrochloride (Univasc)
      • Quinapril (Accupril)
      • Ramipril (Altace)
  • Beta-Blocking Agents
    • Block beta-adrenergic receptors in the sympathetic nervous system
    • Very beneficial in people who have had myocardial infarctions, especially those with low ejection fraction
    • Reduce workload of heart
    • Increase survival rates, decrease hospitalizations
  • Beta-Blocking Agents
    • Examples:
      • Acebutolol hydrochloride (Sectral)
      • Atenolol (Tenormin)
      • Betaxolol (Kerlone)
      • Bisoprolol fumarate (Zebeta)
      • Carvedilol (Coreg)
      • Labetalol (Normodyne, Trandate)
      • Metoprolol (Toprol, Toprol-XL)
      • Nadolol (Corgard)
      • Propranoalol hydrochloride (Inderal)
  • Angiotensin II Receptor–Blocking Agents
    • Used for patients after myocardial infarction or heart failure who cannot tolerate ACE inhibitors
    • Reduce left ventricular dilation or dysfunction after myocardial infarction
    • Less effective than ACE inhibitors
  • Angiotensin II Receptor–Blocking Agents
    • Examples:
      • Candesartan cilexetil (Atacand)
      • Eprosartan mesylate (Teveten)
      • Irbesartan (Avapro)
      • Losartan (Cozaar)
      • Olmesartan (Benicar)
      • Telmisartan (Micardis)
      • Valsartan (Diovan)
  • Aldosterone Inhibitor Agents
    • Used to treat congestive heart failure if ACE inhibitor agents and angiotensin II receptor–blocking agents are not tolerated
    • Cannot be used if patient has hyperkalemia or reduced renal function
    • Also used to treat hypertension
    • Examples:
      • Eplerenone (Inspra)
      • Spironolactone (Aldactone)
  • Cardiac Arrhythmias
    • Sinoatrial (SA) node in right atrium controls rate and rhythm of heart
    • Electrical conduction of heart
      • SA node generates electrical impulses
      • Impulses received by atrioventricular (AV) node
      • Impulses travel down to bundle of His and are transported to ventricular muscles
      • Causes contraction
    • Any deviation from normal called an arrhythmia
    • Rate may be increased or decreased
  • Drug Used to Treat Arrhythmias
    • Examples:
      • Amiodarone HCl (Cordarone, Pacerone)
        • Treats supraventricular and ventricular arrhythmias
        • Can be used during cardiopulmonary resuscitation (CPR)
        • Side effects: bradycardia, heart block, hypothyroidism
      • Disopyramide phosphate (Norpace)
        • Slows atrial contractions
      • Dofetilide (Tikosyn)
      • Ibutilide fumarate (Corvert)
      • Lidocaine hydrochloride (Xylocaine)
  • Drug Used to Treat Arrhythmias
    • Examples:
      • Nadolol (Corgard)
      • Procainamide hydrochloride (Pronestyl)
      • Propranolol hydrochloride (Inderal)
        • Beta blocker that decreases the irritability of the AV node and decreases myocardial contractility
      • Quinidine sulfate
      • Sotalol hydrochloride (Betapace)
    • Chapter 20
    • Lesson 20.2
  • Learning Objectives
    • Explain the action of vasoconstricting agents.
    • Explain the action of vasodilating agents.
    • Identify the classes of antihypertensive drugs and the general mechanism of action.
    • Become familiar with side effects of antihypertensive drugs.
  • Vasoconstricting Agents
    • Constrict the muscle fibers in the walls of the blood vessels by doing the following:
      • Direct action on the vessels
      • Stimulation of vasomotor center in medulla
    • May be used to do the following:
      • Stop superficial hemorrhage
      • Relieve nasal congestion
      • Raise blood pressure
      • Increase force of heart action
  • Vasoconstricting Agents
    • Drugs
      • Epinephrine injection, epinephrine solution (Adrenalin)
        • Frequently used in eyes to constrict blood vessels
        • Marked increase in blood pressure
      • Midodrine hydrochloride (ProAmatine)
        • Treats symptomatic orthostatic hypotension
  • Vasodilating Agents
    • Cause the blood vessels to relax or increase in diameter
    • Used to treat peripheral vascular diseases, heart conditions, hypertension
    • Nitrates and nitrites
      • Chief use is to treat angina pectoris
      • Examples:
        • Glyceryl trinitrate (nitroglycerin) (Nitrostat)
        • Topical nitroglycerin (Transderm-Nitro)
        • Amyl Nitrite
  • Antihypertensive Agents
    • In the United States, about 58 million people are diagnosed with hypertension.
    • Effective treatment of hypertension can reduce incidents of the following:
      • Stroke
      • Myocardial infarction
      • Heart failure
      • Kidney failure
      • Overall cardiovascular disease
  • Treatment of Hypertension
    • Effective treatment reduces the risk of heart attack, stroke, and heart and kidney failure.
    • Lifestyle changes are usually the first treatment option (i.e., diet, exercise).
    • Organic causes include renal artery stenosis, pregnancy, oral contraceptives, and estrogen replacement therapy.
    • Target blood pressure is usually no higher than 120/80 mm Hg.
  • Antihypertensive Drug Classes
    • Diuretic agents
    • ACE inhibitor agents
    • Beta-blocking agents
    • Angiotensin II antagonist agents (also called angiotensin II receptor blockers )
    • Aldosterone inhibitor agents
    • Central alpha agonists
    • Alpha-blocking agents
    • Calcium channel–blocking agents
  • Antihypertensive Agents
    • Central alpha agonists
      • Stimulate central alpha-adrenergic receptors in the brain
      • Result in a decreased sympathetic outflow from the brain to the peripheral circulatory system
      • Reduce vasoconstriction
  • Antihypertensive Agents
    • Central alpha agonists
      • Clonidine (Catapres)
        • Rapid onset, dry mouth
      • Clonidine (Catapres TTS)
        • Transdermal patch
        • Lasts 1 week
      • Guanabenz acetate (Wytensin)
        • Also used for opiate withdrawal and chronic pain management
      • Methyldopa (Aldomet)
        • Acts on CNS to decrease peripheral vascular resistance, little heart rate change
  • Antihypertensive Agents
    • Alpha-blocking agents
      • Believed to work through the blockade of the postsynaptic alpha-adrenergic receptors
      • Cause a vasodilator effect, decrease peripheral resistance
      • Not usually accompanied by increased heart rate
      • Used for adults only, no children
  • Antihypertensive Agents
    • Calcium channel–blocking agents
      • Block the entry of extracellular calcium ions into the myocardial and vascular smooth muscle cells
      • Lead to reduced cardiac output and reduced total peripheral resistance
      • Effective for angina pectoris, supraventricular arrhythmias, and cardiomyopathy
      • Should not be taken with grapefruit juice because of increased effects of medications
  • Antihypertensive Agents
    • Calcium channel–blocking agents
      • Amlodipine besylate (Norvasc, Lotrel)
      • Diltiazem hydrochloride (Cardizem)
      • Isradipine (DynaCirc)
      • Nicardipine (Cardene)
      • Nifedipine (Procardia, Adalat)
      • Nimodipine (Nimotop)
      • Nisoldipine (Sular)
      • Verapamil hydrochloride (Calan, Isoptin)
    • Chapter 20
    • Lesson 20.3
  • Learning Objectives
    • Identify drugs used to hasten the process of coagulation.
    • Discuss the uses of anticoagulant agents.
    • Identify the specific antidote for an overdose of sodium heparin.
    • Identify the specific antidote for an overdose of warfarin sodium.
    • Identify drugs used as thrombolytic agents.
  • Coagulant Agents
    • Hasten the process of blood clotting
    • Calcium salts
      • Needed for the reactions in blood coagulation
      • May be given orally before surgery to prevent excessive bleeding
  • Coagulant Agents
    • Vitamin K
      • Fat-soluble vitamin needed for normal blood coagulation
      • Bile salts must be present in gastrointestinal tract for absorption of natural vitamin K
      • In event of bile obstruction, an oral preparation would be of no use
      • Antidote drug to warfarin (Coumadin) overdose
  • Anticoagulant Agents
    • Increase the time it takes for blood to clot or coagulate
    • Interfere with thrombin production and subsequent formation of fibrin from fibrinogen
    • Used to treat thromboembolic (blood clot) disorders
  • Heparin
    • Available as sodium heparin injection
      • Not active orally; must be given parenterally (intravenously or subcutaneously)
    • Used for the prevention and treatment of venous thrombosis
    • Recommended when immediate effect is desired
  • Heparin
    • Heparin-induced thrombocytopenia (HIT) is a significant side effect.
    • Heparin induces formation of platelet antibodies.
    • It should be discontinued if the platelets drop to 100,000/mm 3 .
  • Low–Molecular-Weight Heparin Agents
    • Made by peroxide fragmentation of the heparin molecule
    • Molecular weight is approximately one half of heparin
    • Used for the prevention and treatment of thromboembolic disorders
    • Administered by deep subcutaneous injection
  • Low–Molecular-Weight Heparin Agents
    • Tinzaparin sodium injection (Innohep)
    • Ardeparin sodium injection (Normiflo)
    • Dalteparin sodium injection (Fragmin)
    • Enoxaparin sodium injection (Lovenox)
  • Direct Inhibitors of Thrombin
    • Lepirudin (Refludan)
      • Structurally and chemically unrelated to heparin
      • Produces a similar pharmacologic effect to heparin through direct interaction to thrombin
      • Used for anticoagulation in patients with HIT to prevent further embolic complications
  • Coumarin Anticoagulant Agents
    • Used in the prevention and treatment of thromboembolic disorders
    • Alter the synthesis of blood coagulation factors
    • Main advantage: May be taken orally
    • Main disadvantage: Do not take effect for 2 to 7 days
  • Coumarin Anticoagulant Agents
    • Sodium warfarin (Coumadin)
      • Agent commonly used for long-term prophylaxis of deep vein thrombosis in patients with mechanical heart valves, atrial fibrillation.
      • Its use decreases the risk for stroke, myocardial infarction, or recurrence of myocardial infarction.
      • Common side effects include hemorrhage, alopecia, gastrointestinal upset, red-orange urine, and calcium loss leading to bone loss.
  • Thrombolytic Therapy for Myocardial Infarction
    • A therapy used to dissolve blood clots.
    • It has been shown to do the following:
      • Rescue the myocardium
      • Reduce mortality with acute myocardial infarction
      • Improve left ventricular function
    • Examples:
      • Streptokinase (Streptase)
      • Urokinase (Abbokinase)
      • Alteplase (Activase, rt-PA, t-PA)
    • Chapter 20
    • Lesson 20.4
  • Learning Objectives
    • Understand the role of platelets in blood clotting and cardiovascular disease.
    • Identify drugs used in antiplatelet therapy.
    • Identify drugs used in antilipidemic therapy.
  • Antiplatelet Therapy in Cardiovascular Disease
    • Blood platelets number about 250,000 to 350,000 per cubic millimeter of blood
    • Three functions are as follows:
      • Stick to inner surfaces of damaged blood vessels and plug leaks
      • When ruptured, release thromboplastin to form a blood clot
      • Once a clot is formed, platelets change the clot to a firm mass to stop bleeding
  • Antiplatelet Therapy in Cardiovascular Disease
    • Interfere with platelet aggregation on the surface of atherosclerotic plaques
    • Prevent the formation of thrombi and emboli
    • Drugs
      • Aspirin
        • If myocardial infarction is suspected, 325 mg; otherwise 81 mg daily
      • Dipyridamole (Persantine)
        • Approved only for postoperative heart valve surgery
      • Ticlopidine hydrochloride (Ticlid)
        • Used if aspirin is ineffective
  • Antilipidemic Drugs
    • A cholesterol level of 160 mg/dl is optimal for vessel health.
    • Individuals are classified as high , medium , or low risk for death by coronary artery disease within 6 years.
    • Antilipidemic drugs are contraindicated for pregnant and nursing women.
    • They may cause skeletal muscle or liver damage.
  • Antilipidemic Drugs
    • Examples:
      • Atorvastatin calcium (Lipitor)
      • Cholestyramine (Questran)
      • Colestipol granules (Colestid)
      • Ezetimibe (Zetia)
      • Fenofibrate (Tricor)
  • Antilipidemic Drugs
    • Examples:
      • Gemfibrozil (Lopid)
      • Lovastatin (Mevacor)
      • Niacin (Niacor, Advicor)
      • Pravastatin (Pravachol)
      • Rosuvastatin (Crestor)
      • Simvastatin (Zocor)