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Cardiodrugs Cardiodrugs Presentation Transcript

  • Cardiovascular Drugs Ma. Tosca Cybil A. Torres, RN, MAN
  • Learning Objectives
    • Students will be able to:
      • Discuss the major categories of drugs as they relate to the treatment of Cardiac Disease.
      • Describe the major effects of various medications on cardiac function.
      • Discuss major nursing implications when administering above medications.
  • Antihypertensive
  • Hypertension
    • Defined as a consistent elevation of the systolic or diastolic blood pressure above 140/90mm Hg
    • On two elevated readings (sitting and supine) on separate office visits
    • Two types hypertension
      • Primary: no known cause
      • Secondary: consequence of underlying disease or condition
    • CLASSIFICATION OF HYPERTENSION
    • Hypertension is classified as follows:
      • Prehypertension: BP 120 to 139 / 80 to 89 mm Hg
      • Hypertension , Stage 1: BP 140 to 159 / 90 to 99 mm Hg
      • Hypertension , Stage 2: systolic BP greater than or equal to 160 or diastolic BP greater than or equal to 100 mm Hg.
  • Goal with hypertension:
    • Two primary regulatory factors:
      • Blood flow (volume)
      • Peripheral Vascular Resistance (PVR)
    • Goal is to optimise these two in order to get pressure below 140/90 mm Hg
  • o
  • Pharmacotherapy
    • Primary:
    • Diuretics
    • ACE Inhibitors
    • ARBs
    • Beta-blockers
    • Calcium channel blockers
    • Alternate:
    • Alpha 1 -blockers
    • Alpha 2 -blockers
    • Direct-acting vasodilators
    • Peripheral adrenergic antagonist
  •  
  • Diuretics
    • Therapeutic Effects (overall)
    • General site of action is the nephron structure in the kidney (exact area depends on drug)
    • Increases urine formation and output resulting in a net loss of H 2 O from the body and decreased BP
  • Loop Diuretics
    • Mechanism of action:
    • Inhibits Na + and Cl - resorption in the loop of Henle and so H 2 O (water follows sodium)
    • Dilates blood vessels
  • Loop Diuretics
    • Therapeutic effects:
    • Potent diuresis resulting in substantial fluid loss
    • Treats edema associated with CHF and hepatic or renal disease
    • Adverse effects:
    • hypokalemia
    • metabolic alkalosis
    • dehydration (hypovolemia), leading to hypotension
    • dose-related hearing loss (ototoxicity)
  • Loop Diuretics
    • Specific Drugs
    • furosemide
    • Torsemide
    • bumetanide
    • Nursing actions:
    • Monitor I/O and BP
    • Monitor effects of Lanoxin (digoxin)
    • Baseline and close monitoring of K+
    • Assess for:
      • Dehydration
      • Hypotension
      • Hearing loss
  • Thiazide
    • Mechanism of action:
      • inhibit the sodium-chloride transporter in the distal tubule . Because this transporter normally only reabsorbs about 5% of filtered sodium, these diuretics are less efficacious than loop diuretics in producing diuresis and natriuresis.
  • Thiazide
    • Therapeutic effects:
      • Excretion of Na + , Cl - , K + and H 2 O without altering pH
      • Treatment of edema
      • Side effects
      • Hypokalemia
      • Headache, dizziness
  • Thiazide
    • Specific Drug
    • Hydrodiuril (hydrochlorthiazide)
    • Zaroxolyn (Metolazone)
  • NCs: Thiazide
    • Nursing actions:
      • Monitor I/O, BP and K +
      • Monitor effects of Lanoxin (digoxin)
      • Monitor electroytes
      • Adequate dietary K+
      • Monitor uric acid
      • Crosses placenta and into breastmilk
  • Potassium Sparing Diuretics
    • Mechanism of action:
    • antagonize the actions of aldosterone ( aldosterone receptor antagonists ) at the distal segment of the distal tubule. This causes more sodium (and water) to pass into the collecting duct and be excreted in the urine.
    • Therapeutics effects:
    • Diuresis
    • Decreased K + excretion
  • Potassium Sparing Diuretics cont
    • Adverse effects:
    • Electrolyte imbalance with potential elevation in K +
    • Headache, dizziness
    • Prototype:
    • Aldactone (spironolactone)
  • NCs: Potassium Sparing Diuretics
    • Nursing actions:
      • Monitor I/O, BP and K +
      • Monitor effects of Lanoxin (digoxin)
      • No salt substitutes or K+ rich foods
      • Contraindicated:
        • Pregnancy, lactation
    • Initial and follow-up uric acid levels
    • Monitor CBC
    • Watch for s/s of infection
    • Spironalactone
      • Gynecomastia
      • Testicular atrophy
      • Hirsutism
  • Calcium Channel Blockers
    • Mechanism of action:
    • Inhibits transport of calcium into myocardial and smooth muscle cells
    • Dilates peripheral arterioles, decreasing afterload
    • Decreases heart contractility (negative ionotrope)
    • Decreases SA node firing rate and conductivity of AV node (negative chronotrope)
  • Calcium Channel Blockers cont.
    • Therapeutic Effects:
    • Lowers HR and BP- Depending on drug in class
    • Decreases myocardial O 2 demand
    • Decreases coronary artery spasm
    • Decreases angina and rhythm disturbances
  • Calcium Channel Blockers cont.
    • Side effects:
    • Bradycardia, reflex tachycardia
    • Peripheral edema
    • Interactions:
    • Other antihypertensives and diuretics (increased hypotensive effects)
  • Calcium Channel Blockers cont.
    • Prototypes:
    • Calan (verapamil), Cardiazem (diltiazem) and Norvasc (amlodipine)
    • Nursing considerations:
    • Monitor BP, HR, I/O, daily weight, side effects
    • Focus assessment-cardiac and pulmonary
  • NCs: Calcium Channel Blockers
    • Baseline ECG, HR, BP
    • Frequent assessment of VS
    • Contraindicated:
      • complete heart block
    • Pregnancy Category C
    • No grapefruit juice
    • May worsen Heart Failure
    • Evaluate any c/o chest pain
  • e
  • RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS) Angiotensinogen in plasma Juxtaglomerular cells-kidney ↓ Serum Sodium ↓Blood volume Angiotensin I Kidney tubules Angiotensin II Adrenal Cortex ↑ Sodium resorption (H2O resorbed with sodium); ↑ Blood volume RENIN Angiotensin-converting enzyme ALDOSTERONE Intestine, sweat glands, Salivary glands Via vasoconstriction of arterial smooth muscle
  • Angiotensin Converting Enzyme Inhibitors (ACE-I)- “prils”
    • Mechanism: Blocks interaction between Angiotensin I and Renin, preventing production of Angiotensin II
    • Angiotensin II not produce resulting in decreased vasoconstriction and decreased afterload
    • Decreased aldosterone production results in decreased Na and H 2 O reabsorption so decreased BP
  • Angiotensin Converting Enzyme Inhibitors (ACE-I)- “prils” cont.
    • Adverse Effects
      • Most common: dry, nonproductive cough
      • Dizziness, increased potassium levels
    • Interactions: Other antihypertensives and diuretics (increased hypotensive effects)
    • Prototypes:
    • Vasotec (enalapril) and Zestril (lisinopril)
  •  
  • te
  • NCs: ACE Inhibitors
    • Baseline VS
    • Captopril- oral dose 1 hour pc
    • First dose phenomenon
    • IV: monitor BP carefully
    • Monitor for Angioedema
    • Monitor K+, CBC
    • Assess for S/S infection
    • Pregnancy Category D
    • Assess for minor side effects
  • Angiotensin II Receptor Blockers (ARB’s)- “sartans”
    • Mechanism of action: Blocks binding of Angiotensin II to its receptor sites
    • Therapeutic effects
      • Decreased BP: Decreased vasoconstriction, decreased vascular resistance, decreased afterload
      • Major use is afterload reduction in CHF and MI
      • Frequently a second line treatment for patients who do not tolerate ACE-I
  • Angiotensin II Receptor Blockers (ARB’s)- “sartans” cont.
    • Adverse effects
      • Most common is headache
    • Interactions: Other antihypertensives and diuretics (increased hypotensive effects)
    • Prototype:
    • Cozaar (losartan) and Diovan (valsartan)
  • Angiotensin II Receptor Blockers (ARB’s)- “sartans” cont
    • Nursing considerations
    • Monitor BP, I/O, daily weight, side effects
    • Monitor Potassium levels and renal function
    • Reinforce patient education
    • Contraindicated to pregnant women
    • Can be taken without regard to food
    • First Dose Phenomenon
    • Orthostatic BP checks
    • Monitor renal, hepatic, and electrolyte level
  • Beta Blockers- “olols
    • Mechanism of action:
    • Cardioselective: Bind to and block B 1 receptors on the hearts conduction system and throughout the myocardium
    • Nonselective: bind to, and block, B 1 and B 2 receptors (heart and lungs)
    • Decreases heart contractility (Negative ionotrope) reducing O 2 requirements of myocardial cells
    • Decrease SA node firing rate (negative chronotrope)
  • Beta Blockers- “olols cont.
    • Therapeutic Effects
      • Decreased heart rate and decreased myocardial oxygen demand
      • Decreased angina
      • Fewer rhythm disturbances
      • Decreased renin release
  • Beta Blockers- “olols cont.
    • Adverse effects:
      • Dysrhythmias (bradycardia), heart failure
      • Bronchospasm / bronchoconstriction
      • Fatigue, depression, impotence
    • Interactions:
      • Other antihypertensives and diuretics (increased hypotensive effects)
  • Beta Blockers- “olols cont.
    • Prototypes:
      • Inderal (propranolol), Lopressor (metoprolol) and Tenormin (atenolol)
    • Nursing Actions:
      • Monitor BP, HR, I/O, daily weight, side effects
      • Focus assessment-cardiac and pulmonary
      • Contrindicated with some dysrhythmias, CHF and some lung diseases
  • NCs: Beta-adrenergic Blockers
    • May take two weeks for optimal therapeutic response
    • Check BP and pulse prior to dose
    • Monitor cardiac function
    • Assess for:
      • Respiratory distress
      • Bradycardia, heart block, fatigue, activity intolerance
    • DO NOT STOP SUDDENLY
  •  
  • y
  • Alpha 1 -adrenergic Antagonists
    • Mechanism of action
    • -selectively inhibits alpha-1 adrenergic receptors. Blockages of the alpha-1 adrenergic action on the vascular smooth muscles lead to a decrease in vascular resistance and antihypertensive activity.
  • NCs: Alpha 1 -adrenergic Blockers
    • First dose phenomenon
    • Assess BP prior to and during RX
    • Persistent orthostatic hypotension
    • Assess for:
      • Weakness, dizziness, headache, GI complaints
    • Closely monitor elderly
  •  
  • Direct Vasodilators
    • Relaxes smooth muscle in arterioles  < PVR
    • Highly effective but many side effects (some serious)
      • Reflex tachycardia
      • Sodium/water retention
    • Not a first choice drug
    • Primary use: emergency situations where immediate ↓ in BP is needed
  • NCs: Direct Vasodilators
    • Monitor: VS, ECG, SpO 2 during RX
    • Assess for increased HR
    • BP q 5 min if not continuous monitor
    • Contraindicated: hypersensitivity, CAD, rheumatic mitral valve disease, CVA, renal insufficiency, SLE
    • Priapism- medical emergency
  • Direct Vasodilators
    • IV Nitroprusside (Nitropress):
      • Continuously monitored
      • Only dilute in D 5 W
      • Brown color; protect from light
    • Minoxidil (Loniten):
      • BP & pulse both arms, three positions
      • Assess for orthostatic hypotension
    • Diazoxide (Hyperstat):
      • For hypetensive crisis in L&D
    • Cardiac Glycosides, Antianginals, Antidysrhythmics
  • Cardiac Glycosides
    • AKA digitalis glycosides
    • Group of drugs that inhibit the sodium-potassium pump, thus increasing intracellular calcium which causes cardiac muscle fibers to contract more efficiently
  • Action Potential
  • Cardiac Glycosides
    • Therapeutic Effects
    • Positive Inotropic action
    • Negative Chronotropic action
    • Negative Dromotropic effect
  • Inotropes
  • Inotropes
    • Agents that affect myocardial contraction
    • Positive Inotropes
      • Cardiac glycosides
      • Catecholamines
    • Negative Inotropes
      • BB
      • CCB
      • Class IA & IC anti-arrhythmics
  • Class Participation
    • Which of the following is an example of a positive inotrope?
    • Docusate
    • Digoxin
    • HCTZ
    • Propranolol
    • Nitroglycerin
  • Class Participation
    • Which of the following is an example of a positive inotrope?
    • Docusate
    • Digoxin
    • HCTZ
    • Propranolol
    • Nitroglycerin
  • Cardiac Glycosides
    • Prototype: Digoxin (Lanoxin ® , Digitek ® , Lanoxicaps ® )
  • Digoxin MOA
  • Digoxin (cont’d)
      • Nursing Responsibilities
      • Assess heart rate before administration; if below 60 bpm withhold the drug.
      • Monitor serum potassium
      • Assess for signs of Digitalis toxicity
        • Bradycardia
        • GI manifestations (anorexia, nausea, vomiting and diarrhea)
        • Dysrhythmias
        • Altered visual perceptions
        • In males: gynecomastia, decreased libido and impotence
  • Chronotropes
  • Chronotropes
    • Agents that change heart rate
      • affects the nerves controlling the heart
      • changes the rhythm produced by the SA node
  • Chronotropes (cont’d)
    • Positive Chronotropes
      • Atropine
      • Quinidine
      • Dopamine
      • Dobutamine
      • Epinephrine
      • Isuprel
    • Negative Chronotropes
      • Beta-blockers
      • Acetylcholine
      • Digoxin
      • Diltiazem
      • Verapamil
      • Ivabradine
      • Metoprolol
  • Positive Chronotrope
    • Prototype: Atropine
    • belladonna alkaloid
    • d,l -hyoscyamine
    • Anticholinergic
    • Uses
      • Symptomatic bradycardia
      • Aspiration prophylaxis
      • Produces mydriasis
      • Organophosphate toxicity
      • Adjunct nerve agent & insecticide poisoning
  • Atropine (cont’d)
    • MOA
      • competitive inhibitor at autonomic postganglionic cholinergic receptors
    • Clinical effects
      • “ anti-SLUD” S alivation, L acrimation, U rination, D igestion, D efecation
      • ↓ in salivary bronchial, & sweat gland secretions; mydriasis; changes in heart rate; contraction of the bladder detrusor muscle and of the GI smooth muscle; ↓ gastric secretion; and ↓ GI motility
  • Nursing Responsibilities
    • Monitor HR---note rhythm, quality, and rate
    • Monitor I&O
    • Assess for dryness or mucus membranes
    • Monitor GI function
  • Anti-anginal Drugs
  • Antianginal Drugs
    • Prototype: Nitrites & Nitrates
    • BB
    • Calcium Channel Blockers (CCBs)
  • Angina Pectoris
    • Definition:
    • Angina: Choking or suffocation.
    • Pectoris: Chest.
    • Angina pectoris, is the medical term used to describe acute chest pain or discomfort.
    • Angina occurs when the heart’s need for oxygen increases beyond the level of oxygen available from the blood nourishing the heart.
    • It has 3 types
    • Stable Angina
    • Un stable angina &
    • Variant Angina (Prinzmetal’s or resting angina) :
    • Types of Angina
    • Stable angina :
      • People with stable angina have episodes of chest discomfort that are usually predictable. That occur on exertion or under mental or emotional stress.
      • Normally the chest discomfort is relieved with rest,
      •   nitroglycerin (GTN) or both.
      • It has a stable pattern of onset, duration and intensity of symptoms.
    • Unstable angina:
      • It is triggered by an un predictable degree of exertion or emotion.
      • (progressive), more severe than stable. Characterized by increasing frequency & severity. Provoked by less than usual effort, occurring at rest &
      • interferes with pt lifestyle.
    • Variant Angina (Prinzmetal’s or resting angina) :
    • occur spontaneously with no relationship to activity. Occurs at rest due to spasm. Pt discomfort that occurs rest usually of longer duration. Appears to by cyclic & often occurs at about the same time each day (usually at night). Thought to be caused by coronary artery spasm
  • Symptoms of Angina
  • Nitrites/Nitrates
    • Previously known as “coronary dilators”
    • Main effect: to produce general vasodilation of systemic vein & arteries
      • ↓ preload & ↓afterload
      • ↓ cardiac work & oxygen consumption
    • 2 main uses
      • Angina attacks
      • Angina prophylaxis
  • Class Participation
    • Which is the PREFERRED route for nitroglycerin during angina attacks?
      • Topical (ointment 2%)
      • IV infusion
      • Transdermal
      • SL
      • Extended release tablets/capsules
  • Class Participation
    • Which is the PREFFERED route for nitroglycerin during angina attacks?
      • Topical (ointment 2%)
      • IV infusion
      • Transdermal
      • SL
      • Extended release tablets/capsules
  • Drug (Trade Name) Common Dosage Onset Duration Amyl nitrate (Vaporole ® ) 0.3 ml inhalation 30-60 sec 10 min ISDN (Isordil ® ) 2.5 - 10 mg SL 5 - 30 mg po qid 2-5 min 2 - 4 hr Nitroglycerin ( Nitro-bid ® ) 2% ointment 15 min 4 - 8 hr ( Nitrostat ® ) 0.3 - 0.6 mg SL 1-3 min 10 - 45 min ( Nitrogard ® ) 1,2,3 mg XR tab 30 min 8 - 12 hr ( Transderm-Nitro ® ) 2.5 - 15 mg/day Transdermal patch 30-60 min 24 hr
  • MOA
    • Direct relaxation of arterial and venous smooth muscle
      • Venodilation predominates at therapeutic doses which reduces preload
      • Arteriodilation at high doses (high therapeutic/toxic) which produces hypotension compensated by sympathetics (heart/vascular)to produce tachycardia
  • Nitroglycerin (NG)
    • Indications
      • Angina
      • Acute MI
      • HF
      • HTN
      • Hypertensive emergency
      • Hypotension induction
      • Peri/postoperative HTN
      • Pulmonary edema
      • Pulmonary HTN
  • NG (cont’d)
    • Dosing
      • 1 tablet (0.3 mg, 0.4 mg, or 0.6 mg strength) SL, dissolved under the tongue or in buccal pouch immediately following indication of anginal attack
      • During drug administration, the patient should rest, preferably in the sitting position
      • Symptoms typically improve within 5 minutes. If needed for immediate relief of stable angina symptoms, SL nitroglycerin may be repeated every 5 minutes as needed, up to 3 doses
  • NG (cont’d)
    • Adverse Effects
      • dizziness or fainting
      • flushing of the face or neck
      • headache, this is common after a dose, but usually only lasts for a short time
      • irregular heartbeat, palpitations
      • nausea, vomiting
    • Contraindication:
      • sildenafil (Viagra®)
      • tadalafil (Cialis®)
      • vardenafil (Levitra ®)
    • Lab monitoring not necessary
  • Antidysrhythmics Antiarrhythmics
  • What are Arrhythmias?
    • Cardiac disorder of
      • Rate
      • Rhythm
      • Impulse generation
      • Conduction of electrical impulses in the heart
    • Causes
      • May develop from a diseased heart
      • Consequence of chronic drug therapy
    • Symptoms
      • Mild palpitations  cardiac arrest
    • Treatment goal
      • Covert arrhythmia to a normal rhythm
  • Antidysrhythmics/Antiarrhythmics
    • Uses
      • restore normal cardiac rhythm
      • Successful conversion of an arrhythmia depends on the type of arrhythmia present
  • Antidysrhythmics/Antiarrhythmics
    • 4 major classes
      • Class I
        • Class IA
        • Class IB
        • Class IC
      • Class II
      • Class III
      • Class IV
  • Cardiac Action Potential
    • 4: resting membrane potential; steady K+ flux
    • 0: Na+ influx into cell
    • 1: K+ efflux
    • 2: K+ efflux & Ca+ influx
    • 3: K+ efflux
  • Antiarrthymics: Class I
    • Na channel blockers
    • Common features
      • Local anesthetic activity
      • Interferes with movement of Na ions
      • Slow conduction velocity
      • Prolong refractory period
      • Decreases automaticity of the heart
  • Class I A
    • Quinidine (Quinidine sulfate ® , Quinaglute ® , Quinidex ® , Cardioquin ® )
    • Disopyramide (Norpace ® )
    • Procainimide (Procainimide HCI ® , Procan ® , Procanabid ® , Pronestyl ® )
  • Class 1A – Quinidine
    • Derived from cinchona tree
    • Depresses both the myocardium & conduction system
    • Overall effect: slows heart rate
    • Pharmacokinetics
      • Well absorbed in GI tract after po administration
      • Metabolized to several active metabolites
      • Primarily excreted by urinary tract
      • Cardiac poison when large amounts are present in blood
  • Class 1A – Quinidine (cont’d)
    • Adverse Effects
      • N/V, diarrhea, weakness, fatigue, cinchonism
    • Drug Interactions
      • Hyperkalemia
      • Digitalis
      • propranolol
    • Monitoring
      • CBC
      • ECG
      • serum quinidine concentrations (target range 2-6 µg/ml or higher)
    • CI: AV block
  • Class I B
    • prototype: Lidocaine (Xylocaine®)
    • Tocainide (Tonocard®)
    • Mexiletene (Mexitel®)
    • Phenytoin (Dilantin®)
  • Lidocaine – Class IB
    • MOA: blocks influx of Na fast channel
    • Indication: ventricular arrhythmias
  • Lidocaine – Class IB (cont’d)
    • Common Adverse Effects
      • anxiety, nervousness
      • dizziness, drowsiness
      • feelings of coldness, heat, or numbness; or pain at the site of the injection
      • N/V
    • Monitoring
      • serum lidocaine concentrations (target range 2-6 µg/ml): parenteral use
  • Class I C
    • prototype: Flecainide (Tambocor®)
    • Propafenone (Rhythmol®)
  • Flecainide – Class IC
    • MOA
      • Blocks fast Na channels depresses the upstroke of the action potential, which is manifested as a decrease in the maximal rate of phase 0 depolarization.
      • significantly slow His-Purkinje conduction and cause QRS widening
      • shorten the action potential of Purkinje fibers without affecting the surrounding myocardial tissue.
    • Indications
      • Afib
      • Atrial flutter
      • Ventricular tachycardia prophylaxis
  • Flecainide – Class IC
    • Adverse Reactions
      • visual impairment, dizziness, asthenia, edema, abdominal pain, constipation, headache, fatigue, and tremor, N/V, arrhea, dyspepsia, anorexia, rash, diplopia, hypoesthesia, paresthesia, paresis, ataxia, flushing, increased sweating, vertigo, syncope, somnolence, tinnitus, anxiety, insomnia, and depression.
    • Avoid in
      • CHF
      • Acute MI
      • Hx of MI (LVEF < 30%)
    • Monitoring
      • ECG
      • serum creatinine/BUN: baseline
  • Class II – Beta Blockers
    • Propranolol (Inderal®)
    • Acebutolol (Sectral®)
    • Atenolol (Tenormin®)
    • Betaxolol (Kerlone®)
    • Bisoprolol (Zebeta®)
    • Carvedilol (Coreg®)
    • Esmolol ( Brevibloc®)
    • Metoprolol(Toprol®, Lopressor®)
    • Nadolol (Corgard®)
    • Timolol (Blocadron®)
  • Propranolol Warning
    • 2 situations in which propranolol requires extreme caution
      • AV block
      • CHF
      • Asthma or emphysema
  • Class III
    • K+ channel blockers
    • Drugs:
      • Prototype: Amiodarone (Cordarone)
      • Bretylium (Bretylol)
      • Sotalol (Betapace)
  • Amiodarone – Class III
    • MOA
      • noncompetitively inhibits alpha- and beta-receptors,
      • possesses both vagolytic and calcium-channel blocking properties
      • relaxes both smooth and cardiac muscle
    • Indications
      • Vfib
      • Vtach
  • Amiodarone – Class III (cont’d)
    • Monitoring
      • CBC
      • chest x-ray
      • ECG
      • ophthalmologic exam
      • thyroid function tests (TFTs)
  • Class IV
    • Ca channel blockers
    • Drugs
      • Adenosine (Adenocard ® )
      • Diltiazim (Cardizem®, Tiazac®)
      • Verapamil (Dovera®, Isoptin®, Calan®)
    • Clinical Effects
      • widen the blood vessels
      • may decrease the heart’s pumping strength
  • Sympathomimetics
  • Sympathomimetics
    • 2 classes:
      • α - agonist
        • Phenylephrine
        • Clonidine
        • Oxymetazoline
        • Tetrahydralazine
        • Xylometazoline
      • β -agonist
        • Prototype: Epinephrine
        • Norepinephrine
        • Dopamine
        • Dobutamine
        • Isoproterenol
    • SE:
      • hypertension,
      • excessive cardiac stimulation
      • cardiac arrhythmias
      • Long-term use increases mortality in heart failure patients.
    • CI
      • CAD  
  • Epinephrine
    • “ fight or flight “hormone
    • Aka “adrenaline”
    • increases heart rate and stroke volume
    • dilates the pupils
    • constricts arterioles in the skin and gastrointestinal tract while dilating arterioles in skeletal muscles
  • Epinephrine MOA
  • Epinephrine (cont’d)
    • Indications
      • Vfib
      • Ventricular asystole
      • Cardiac arrest
      • Pulseless electrical activity
    • IV Dosage
      • IV: 1 mg (10 ml of a 1:10,000 solution) IV; may repeat every 3-5 minutes
      • Each dose may be given by peripheral injection followed by a 20 ml flush of IV fluid.
  • Epinephrine
    • Common Adverse Effects
      • anxiety or nervousness
      • dry mouth
      • drowsiness or dizziness
      • headache
      • increased sweating
      • nausea
      • weakness or tiredness
    • Monitoring
      • ECG: in patients receiving IV therapy
  • Vasopressors
  • Vasopressors
    • Vasoconstrictors vs. Vasodilators
    • 2 Vasoconstrictor Classes
      • Sympathomimetics
      • Vasopressin Analogs
    • Vasodilators
        • Alpha-adrenoceptor antagonists (alpha-blockers)
        • Angiotensin converting enzyme (ACE) inhibitors
        • Angiotensin receptor blockers (ARBs)
        • Beta2-adrenoceptor agonists (b2-agonists)
        • Calcium-channel blockers (CCBs)
        • Centrally acting sympatholytics
        • Direct acting vasodilators
        • Endothelin receptor antagonists
        • Ganglionic blockers
        • Nitrodilators
        • Phosphodiesterase inhibitors
        • Potassium-channel openers
        • Renin inhibitors
  • Vasoconstrictor
    • any agent that produces vasoconstriction and a rise in blood pressure (usually understood as increased arterial pressure)
    • Drugs
      • Prototype: Vasopressin
      • Epinephrine
      • Dobutamine
      • Dopamine
      • Norepinephrine
  • Vasopressin
    • aka : “ADH”
    • MOA
      • ↑ the resorption of water at the renal collecting ducts
      • Vasoconstrictive property: stimulates the contraction of vascular smooth muscle in coronary, splanchnic, GI, pancreatic, skin, and muscular vascular beds
  • Vasopressin (cont’d)
    • Indications:
      • Cardiac arrest
      • Cardiogenic shock
      • Cardiopulmonary resuscitation
      • Hypotension
      • Septic shock
      • Diabetes Insipidus
  • Vasopressin (cont’d)
    • Dosage for cardiac arrest including ventricular asystole and pulseless electrical activity (PEA) during cardiopulmonary resuscitation (CPR)
      • IV or intraosseous dosage:
        • Adults: A single dose of 40 units IV (or intraosseous) may be given one time to replace the first or second dose of epinephrine during cardiac arrest
        • Do not interrupt cardiopulmonary resuscitation to administer drug therapy.
  • Vasopressin (cont’d)
    • Adverse Effects
      • Cardiovascular: Cardiac arrest; circumoral pallor; arrhythmias; decreased cardiac output; angina; myocardial ischemia; peripheral vasoconstriction; and gangrene
      • CNS: Tremor; vertigo; “pounding” in head
      • Dermatologic: Sweating; urticaria; cutaneous gangrene
      • GI: Abdominal cramps; nausea; vomiting; passage of gas
      • Hypersensitivity: Anaphylaxis (cardiac arrest and/or shock) has been observed shortly after injection
      • Respiratory: Bronchial constriction.
    • Monitoring
      • serum osmolality
      • serum Na
  • Anticoagulants
  • Antiplatelets/Anticoagulants
    • Prevents/interferes with coagulation
    • Uses
      • deep vein thrombosis (DVTs), pulmonary embolism, myocardial infarctions & strokes in those who are predisposed
  • Types of Antiplatelets/Anticoagulants
    • Antiplatelets
      • Aspirin
      • Dipyridamole
      • Thienopyridines
        • Clopidogrel (Plavix)
        • Ticlopidine (Ticlid)
      • Glycoprotein IIb/IIIa antagonists
        • Abciximab (ReoPro)
        • Eptifibatide (Integrelin)
        • Tirofiban (Aggrastat )
  • Antiplatelets/Anticoagulants
    • Anticoagulants
      • Heparin
      • LMWH
        • Enoxaparin (Lovenox ® )
        • Dalteparin (Fragmin ® )
        • Tinzaarin (Innohep ® )
      • Factor Xa inhibitors
        • Fondaparinux (Arixtra ® )
      • Direct Thrombin Inhibitors
        • Argatroban
        • Lepirudin (Refludan ® )
      • Oral Anticoagulants
        • Prototype: Warfarin
  • Coagulation Cascade
  • Warfarin – Oral Anticoagulant
    • MOA: Warfarin inhibits the synthesis of vitamin K-dependent coagulation factors II, VII, IX, and X and anticoagulant proteins C and S
  • Warfarin (cont’d)
    • Indications
      • Stroke
      • DVT
      • Post MI
      • Afib
      • Cardiomyopathy
  • Warfarin Warnings
    • Bleeding Risk!
    • Warfarin can cause major or fatal bleeding
    • Risk factors for bleeding
      • 65 years of age and older
      • history of GI bleeding
      • Hypertension
      • cerebrovascular disease
      • anemia, malignancy
      • Trauma
      • renal function impairment
      • long duration of warfarin therapy.
    • Pregnancy Category X
  • Warfarin (cont’d)
    • SE
      • Hemorrhage: Signs of severe bleeding resulting in the loss of large amounts of blood depend upon the location and extent of bleeding. Symptoms include: chest, abdomen, joint, muscle, or other pain; difficult breathing or swallowing; dizziness; headache; low blood pressure; numbness and tingling; paralysis; shortness of breath; unexplained shock; unexplained swelling; weakness
      • Nursing responsibilities
      • Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to health care provider signs and symptoms of bleeding
      • prothrombin time (PT)
      • stool guaiac
      • bleeding
      • DDIs
        • NSAIDs
        • 3 G’s
          • Garlic
          • Ginger
          • Ginsing
      • Vitamin K intake
    • Class Participation Question #5:
    • Which foods are high in vitamin K?
    • Class Participation Question #5:
    • Which foods are high in vitamin K?
  • Fibrinolytic Enzymes
  • Fibrinolytic Enzymes
    • “ clotbusters”
    • MOA: stimulate the synthesis of fibrinolysin which breaks the clot into soluble products
    • Drugs
      • Urokinase (Abbokinase ® )
      • Anistreplase (Eminase ® )
      • Alteplase (Activase ® )
      • Reteplase (Retevase ® )
      • Prototype: Streptokinase (Strepase ® )
  • Streptokinase (cont’d)
    • Indications
      • Acute MI
      • Acute ischemic stroke
      • Pulmonary embolism
      • Lysis of DVT
    • Dose Administration
      • Parental infusion (usually IV)
      • Deep vein or arterial thrombosis
        • IV: 250,000 IU over 30 min followed by 100,000 IU per hour up to 72 hours
  • Streptokinase (cont’d)
    • Adverse Effects
      • Hemorrhage
      • Concomitant use of heparin, oral anticoagulants, NSAIDs is NOT recommended because of the increased risk of bleeding
      • Allergic reactions
  • Streptokinase (cont’d)
  • Antilipidemics
  • Antilipidemics
    • Drugs that lower down abnormal blood lipid levels.
  • Types of antilipidemics
      • Statin drugs work by inhibiting the synthesis of cholesterol in the liver. Liver enzymes must be regularly monitored. (ex. Simvastatin)
      • Niacin , a water-soluble B vitamin, is highly effective in lowering LDL and triglyceride levels by interfering with their synthesis. Niacin also increases HDL levels better than many other lipid-lowering drugs.(Ex. Niacin SR)
      • Fibric acid derivatives work by accelerating the elimination of VLDLs and increasing the production of apoproteins A-I and A-II. (ex. Lipofen, Tricor)
      • Bile-acid sequestrants increase conversion of cholesterol to bile acids and decrease hepatic cholesterol content. The primary effect is a decrease in total cholesterol and LDLs. (ex. Questran)
  • Side effects
    • Constipation
    • Peptic ulcer
    • Flushing
    • Headache
  • Nursing responsibilities
    • Monitor client’s lipid levels
    • Observe for signs of GI upset
    • Instruct to take with sufficient fluids or meals
    • Low fat diet
    • Instruct not to abruptly stop intake
    • Questions?