Cardiovascular Agents

1. Cardiac Glycosides:
Action: inhibit Na-K ATPase ---> increase cardiac contraction

Indic: CHF, atrial dysrhythmias

LIZZY DIGGY
digoxin (Lanoxin)
digitoxin

Therapeutic level of Digoxin: 0.5 - 2 ng/ ml

Dig level 2 ng/ml or greater is toxic!!!!

Increases myocardial contractility
GI or CNS signs indicate adverse effects
SE:
• GI- nausea & anorexia, vomiting & diarrhea
• CNS – vertigo , HA, drowsiness, confusion
• bradycardia --> cardiac dysrhythmias, heartblock
• photophobia, yellow-green halos around visual images, flashes of light

2. Nitrates:
ANDY ANGINA
nitroglycerin (Nitro-Bid, Nitrostat, Transderm- Nitro)
isosorbide dinitrate (Isordil)
isosorbide mononitrate (Imdur)

Action
Relaxes vascular smooth muscle
venous return
arterial BP
left ventricular workload
myocardial oxygen consumption

Indic: Angina Pectoris

SE: headache (MC), syncope, weakness, nausea & hypotension
 SL: burning & tingling sensation in mouth

3. Antiarrhythmic : Lidocaine
Action: Decrease cardiac excitability, delayed cardiac conduction
Indic: ventricular dysrhythmias (ie. PVCs, ventricular tachycardia & fibrillation)
SE:
• bradycardia/tachycardia
• hypotension, confusion & drowsiness
• dizziness, NV, seizures
• cardiac arrest

Liddy Lidocaine
lidocaine (Xylocaine)

4. ACE Inhibitors:
Action: supressess renin- angiotensin-aldosterones system (RAAS)
(blocks conversion of angiotensin 1---> angio .2)
Indic: HPN, adjunct in CHF, prevents kidney failurein DM

PRIL Sisters
captopril (Capoten)
enalapril
quinapril

Cough
ontraindicated in renal artery stenosis
Hypotension
yperkalemia
First- dose syncope
SVR PVR
Tx of MI
Relase of aldosterone
Occult diabetic nephropathy
LVD after MI
SVR =systemic vascular resistance
PVR = peripheral vascular resistance
LVD = left ventricular dilation
 5. Angiotensin II Receptor Blockers (ARBS):
Action: blocks angio. II binding to receptor --> blocks VC & aldosterone release --> BP
Indic: HPN
SE: occasional – cough, URTI, dizziness, diarrhea
Overdose – hypotension

SARTAN Sisters
candesartan
telmisartan (Micardis))
valsartan (Diovan)

Cande Telmi Val

Administer without regard to meals

Renal function tests - review
Blocks VC effect of RAS
Salt substitution or potassium supplements – do not use

6. Alpha 1- adrenergic Blockers:

Action: blocks alpha 1 adrenergic receptor --> VD, PVR, relaxes bladder sphincter &
Prostate
Indic: HPN, BPH

MINI’s SINS
prazosin (Minipress)
terazosin
doxazosin

SE:
Syncope, sexual dysfunction
Increased drowsiness, orthostatic hypotension, HR
 Need to be recumbent for 3 -4 hours after initial dose
7. Beta- adrenergic Blockers:
Action: blocks beta 1 & 2 receptors
Indic: HPN, angina, MI

The “LOL” Team

Action: heart contractility, renin, sympathetic act.
metoprolol (Lopressor)
atenolol (Tenormin)
propanolol (Inderal))
carvedilol
labetalol

SE:
Bradycardia
Lipidemia , libido
brOronchospasm difficulty breathing
CHF, conduction abnormailities heart failure
Kinks peripheral vessels
Exhaustion, emotional depression fats in blood
Reduces recognition of hypoglycemia

Low Bld sugar

Little or no
interest in sex

8. Calcium -channel Blockers:

Action: blocks calcium access --> heart contraction, BP
Indic: HPN, vasospastic & classic angina
My rate is
slower and
“DON’T GIVE A SHIT Pills” my
pressure is
amlodipine (Norvasc) down.
felodipine (Plendil)
nifedipine
verapamil
diltiazem

SE: headache (MC), hypotension,

syncope, peripheral edema &
bradycardia, constipation
9. Central Alpha2 adrenergic agonists:
Action: decreases NE from brain --> PVR & blood pressure
Indic: Hypertension (Stepped- care approach, step 2 drug)

CATAPRES
clonidine(Catapres)
guanabenz
guanfacine
methyldopa (Aldomet)

C is at the eyes --.> NE released from the brain.

A is at the nose --.> clear risk factors: hypotension, hepatotoxicity, hemolytic anemia
T is at the chin --> drops with transient drowsiness
A is “body-wide” --> arterial pressure all over body is
P --> paradoxical hypertension with propranolol
R is a her baseline feet --> get baseline VS
E is on her belt---> expand with weight gain
S is on her tapered dress --> must be slowly tapered down

10. Vasodilators:
Action: direct relaxation of bld vessels --> arteriole vasodilation --> decrease afterload

Indic: HPN
DILLY DILATOR
hydralazine (Apresoline), minoxidil

Directly acts on vascular smooth muscle causing VD

Increases blood flow to kidneys & brain
Lupus- like reaction ( fever, facial rash, muscle & jt ache, splenomegaly
Assess peripheral edema of hands & feet
Take with food
 Other SE- headache, dizziness, anorexia, tachycardia, hypotension
Review BP

PRESSURE

Pressure (blood) monitor

Rise slowly
Eat low Na & low fat food
Stay on medications
Skipping or stopping is a no- no
Undesirable responses
Remind to exercise, alcohol
Eliminate smoking; educate

Drugs for CHF Antianginal Drugs

1. Cardiotonic drugs 1. Nitrates
a. Cardiac Glycosides 2. Beta blockers
b. Phosphodiesterase inhibitors 3. Calcium channel blockers
2. Vasodilators
3. ACE inhibitors
4. Diuretics
5. Nonselective adrenergic blockers

Antihypertensive Drugs
1. ACE Inhibitors
2. Angiotensin II Receptor blockers (ARBS)
3. Alpha 1 Adrenergic Blockers
4. Beta Adrenergic Blockers
5. Calcium Channel Blockers
 6. Central Alpha 2 Agonists
7. Vasodilators
8. Diuretics

DIURETICS

Diet - K for all except Aldactone

Intake & output, daily weight
Undesirable effects: fluid & electrolyte imbalance
Review HR, BP, & electrolytes
Elderly – careful
Take with or after meals and in AM
Increase risk or orthostatic hypotension: move slowly
Cancel alcohol

Diuretics:
1. Loop Diuretics
• furosemide (Lasix)
• bumetanide
• torsemide
• ethacrynic acid

2. Thiazides
• hydrochlorothiazide (HydroDiuril)
• chlorothiazide
• chlorthalidone

3. Potassium- Sparing Diuretics

• spironolactone (Aldactone)
• amiloride
• triamterene

4. Osmotic diuretics
• mannitol (Osmitrol)
• urea
• glycerin
 5. Carbonic anhydrase inhibitors
• acetazolamide (Diamox)
• methazolamide

I. Loop Diuretics:
Action: increase UO -->Inhibit Na, Cl & water reabsorption in the proximal portion of ascending
LOH.
Indications:
1. edema in CHF, liver or kidney dses
2. HPN
SE:
• hyponatremia, hypokalemia, hypocalcemia,hypochloremic alkalosis
• hyperglycemia, hyperuricemia
• hypotension, HA, dizziness, lightheadedness
• anorexia, nausea, diarrhea, dehydration
• muscle cramp, ototoxicity
• leucopenia & photosensitivity

Drug interactions:
• digitalis & lithium toxicity
• K with steroids & some penicillins, anticoagulant effect
• Avoid nephrotoxic & ototoxic drugs

Lou La BELL
furosemide (Lasix)
bumetanide
torsemide
ethacrynic acid

2. Thiazides:
Action: increase UO -->inhibit Na, Cl, & water reabsorption in the distal portion of the
ascending LOH.
Indic: same as Loop diuretics

SE:
• same electrolyte imbalance as loop diuretics except
o hypercalcemia
 • same CNS & GI effects as Loop diuretics except no ototoxicity

Drug interactions: same as above

Lou La
hydrochlorothiazide (Hydrodiuril)
chlorothiazide
chlorthalidone

3. Potassium-sparing Diuretics:
Action: promotes excretion of Na & water but retains K in the distal tubule
Indications:
1. same as Loop or thiazide
2. diuretic- induced hypokalemia
3. steroid- induced edema
4. hyperaldosteronism
SE:
• nausea, diarrhea, dry mouth
• dizziness, HA, photosensitivity
• peak T waves on ECG

Drug- interactions: digitalis & lithium toxicity , anticoagulant effects

K levels with ACE inhibitors

Alan Aldactone
spirinolactone (Aldactone)
amiloride
triamterene

Low Na
Elevated T waves from K
Agranulocytosis with triamterene
K level must be monitored

4. Osmotic Diuretics:
Action: increase in osmotic pressure, preventing reabsorption of water --> increase UO

Buster Brain Man

mannitol (Osmitrol)
glycerin
urea
 Oliguria, edema, ICP & IOP, drug toxicities. – indic.
Stops reabsorption of water
Mannitol
Output of urine, electrolytes – monitor
Tissue dehydration – SE
Increased freq & vol of urination
Circulatory overload –SE
ANTIPLATELETS, ANTICOAGULANTS, THROMBOLYTICS

 Process of blood coagulation & thrombus formation:

Blood vessel injury

Vasoconstriction Blood loss into tissues Intrinsic pathway Extrinsic pathway

to clot formation to clot formation

Platelet adhesion
to injured wall of bv &
platelet aggregation

decrease blood flow compression of platelet plug blood clot

at site of injury injured bv

thrombus

Decrease blood loss at site of injury

 Final step of clot formation:

Prothrombin thrombin

Fibrinogen Fibrin clot

 Clot dissolution:
Plasminogen plasmin (fibrinolysin)

Fibrin clot dissolution of clot

Drugs for Coagulation Disorders:

I. Anticoagulants:
1. warfarin (Coumadin)
2. heparin
a. heparin sodium
b. Low- Molecular-Weight Heparins (LMWH)
• enoxaparin
 • dalteparin
II. Antiplatelets:
1. aspirin
2. clopidrogel
3. ticlopidine
4. dipyridamole

III. Thrombolytics:
1. altepase (tPA)
2. streptokinase
3. urokinase

I. ANTICOAGULANTS: prevent clot formation

1. warfarin (Coumadin)
Action: interferes with liver synthesis of vitamin K –clotting factors (II, VII,IX,& X)
Indic: prevents or slows down clot formation
SE:
• GI – anorexia, nausea, diarrhea
• bleeding, thrombocytopenia

Drug interactions: effects with Vit k –rich foods, &

with rifampin. OCP, phenytoin, estrogen (ROPE)
risk of bleeding – chamomile, garlic, ginger, ginkgo, & ginseng tx
with glucocorticoids, alcohol, salicylate (GAS)

CORA Coumadin
warfarin (Coumadin)

PT/INR

PT
therapeutic
range
1.5- 2.5 X control
INR = 2- 3
3- 4.5 = prosthetic valves

Coumadin -------------> vitamin K

Check VS, platelet count, PT

Observe for bleeding

 Review bleeding protocol

Avoid ASA

2. Heparin Sodium:
Action: combines with antithrombin III --> to stop thrombin activity.
LMWH --> blocks factor Xa & IIa

Indic:
1. thrombosis
2. reduces risk of MI, CVA
3. clots associated with atrial fibrillation & pulmonary embolism

SE: bleeding tendencies

Drug interactions: effects with digoxin, antihistamine, nitroglycerin (DAN)

risk of bleeding (same with warfarin)

effects with aspirin, alcohol & antibiotics (3A)

Harry HEPARIN
heparin sodium (Heparin)
enoxaparin , dalteparin

--------------->

PTT
Therapeutic range
1.5 – 2.5 x control

Heparin Protamine
sulfate
 ------------------------------->

II. ANTIPLATELETS: Aspirin, ticlodipine (Ticlid), dipyridamole,clopidogrel (Plavix)

Action: inhibit platelet aggregation
Indic:
1. Transient ischemic attacks (TIA)
2. CVA with hx of embolic TIA
3. reduces risk of death from MI

SE: GI discomfort, bleeding, dizziness, tinnitus

Drug interactions: risk of bleeding with anticoagulants, thrombolytics

risk of GI ulcers with alcohol, NSAIDS

Annie ASPIRIN

Fever

Inflammation

Reduces TIAs due to fibrin platelet embolus

Eliminates (reduces) death with hx of MI

III. THROMBOLYTICS:
Action: bind with plasminogen causing conversion to plasmin which dissolves clots.

Indic: dissolves existing clots in pxs with CAD, CVA, DVT, pulmonary embolism

SE: HA, nausea, rash, bleeding, fever, allergic rxn, hypotension, cardiac dysrhythmias

ADAM “ASE”
urokinase, streptokinase, altepase (tPA)
 CBC, hgb, hct, - monitor

Look for dysrhythmias

Observe for bleeding, antidote: aminocaproic

acid

The vital signs must be monitored.

LIPID LOWERING DRUGS

I. HMG- CoA reductase inhibitors / Statins:

Action: inhibits HMG- CoA reductase  inhib. Cholesterol synthesis LDL

Indic: hypercholesterolemia
SE:
1. GI distress
2. HA, BOV with lovastatin
3. rare: liver dysfunction, myalgia, myositis

L.L. STATIN
atorvastatin (Lipitor)
simvastatin (Zocor)
lovastatin

II. Bile Acid sequestrants:

Action: binds bile acids in SI & promote increase disposal of cholesterol
Indic: hypercholesterolemia if diet does not work
SE:
1. GI effects: constipation, indigestion, NV, GI bleeding
2. CNS: HA, syncope
3. increased bleeding tendencies
4. rash, muscle pains

BILE - ACiD SEQUESTRANT

cholestyramine
colestipol +
 LDL is 15 -30%
Increase fluids & fiber

PT monitoring
Increase GI distress – constipation
Decrease absorption of many meds

III. Fibrates/ Fibric Acid:

Action: increase activity of lipase --> breakdown of VLDL & TG ---> TG & HDL

Indic: hyperlipidemia

SE:
1. same GI effects + cholelithiasis
2. HA, muscle pains

FIBRATES
gemfibrozil
clofibrate

Liver or renal dse – WARNING

Increases effect of warfarin & sulfonylureas

VLDL, LDL, TG & cholesterol –monitor

Encourage diet in fat, cholesterol & sugars

Restrict alcohol

IV. Nicotinic Acid / Vitamin B3 / Niacin

Action:
1. inhib. release of fatty acids from adipose tissue
2. increase TG removal from plasma  TG & LDL, HDL
Indic: hyperlipidemia
SE:
1. intense flushing & itching with raised rash
2. dizziness, fainting
3. GI : nausea, abdominal pain
4. hyperglycemia, hyperuricemia, cardiac dysrhythmias in CAD

NIACIN
 Note liver function tests – regular intervals
Itching & flushing – SE
Aspirin before Niacin may SE of VD
CI: liver dse, pregnancy
Instruct to take with food & at hs
No high cholesterol foods
DIABETES
Diet , weight loss, exercise
Identification – medic-alert bracelet
Avoid alcohol & other meds
Blood sugar, urine sugar, HbA1c
Educ. - antidiabetic agents

Therapy decrease signs, not a cure

Educ. - foot care, no smoking, stressors

S/sxs of hyper/hypoglycemia
show to do self-monitoring
skin care

ANTIDIABETIC DRUGS:
I. Oral Hypoglycemic Agents (OHA)
A. Sulfonylureas
1. 1st generation: B. Nonsulfonylureas:
• chlorpropramide 1. Biguanides
• metformin (Glucophage)
• tolbutamide (Orinase)
• acetohexamide 2. Alpha-glucosidase inhibitor
• tolazamide • acarbose
2. 2nd generation: 3. Thiazolenidiones (Insulin sensitizer)
• glipizide • rosiglitazone (Avandia)
• glyburide
• glimepiride 4. Meglitinides:
• repaglinide (Prandin)

II. Insulin:
A. Rapid –acting insulin:
• Lispro (Humalog)
• Insulin aspart (Novolog)
B. Short-acting insulin:
• Regular (Humulin R, Novolin R)
 C. Intermediate-Acting insulin:
• NPH (Humulin N, Novolin N)
• Lente (Humulin L, Novolin L)
D. Long-acting insulin:
• Ultralente (Humulin U)
• Insulin glargine (Lantus)
E. Premixed insulin:
• 70% NPH/ 30% regular (Humulin 70/30)
• 50% NPH/ 50% regular (HUmulin 50/50)
• 75% LIspro protamine/ 25%lispro

Glucose Elevating Drugs:

1. glucagon (IV)
2. diazoxide (oral)

Alpha- glucosidase
Inhibitor works here

Sulfonylureas
& Meglitinides
work here

Biguanides, Diazoxide & Insulin replacement works here

glucagons work here

Thiazolinediones work here

ANTIDIABETIC AGENTS:

I. A. OHA - Sulfonylureas:
Action:
• stimulates insulin release from pancreas
• reduce glucose output by liver
• increase peripheral sensitivity to insulin
Indic: NIDDM -Type 2
SE: GI: NV, diarrhea
rash, pruritus, HA
hypoglycemia

Drug interactions: hypoglycemic effect with:

• aspirin, alcohol, anticoagulant, anticonvulsants,beta-blockers
• MAOIs, TCA, sulfonamides,
• celery, coriander, dandelion roots, garlic, ginseng

hypoglycemic effect with:

• cortisone, thiazide diuretics, CCB
• estrogen, OCPs, phenytoin, thyroid drugs

Glimepride are better for Grandmother

Glipizide
Sulfonylureas
1. 1st generation:
 • chlorpropramide
• tolbutamide (Orinase)
• acetohexamide
• tolazamide

2. 2nd generation:
• glipizide
• glyburide
• glimepiride

 VS, BUN, Crea, liver function test

 Bld & urine glucose
 HbA1c

B. OHA- Nonsulfonylureas:

1. Metformin (Glucophage)
Action:
• decreases hepatic glucose production
• decreases intestinal glucose absorption
• increases peripheral insulin uptake

Indic: Type 2- NIDDM

SE: GI: VAN, abdominal gas or pain, metallic taste, hypoglycemia

Toxic: lactic acidosis (unexplained hyperventilation, muscle aches, & fatigue)

METFORMIN HOME VISITORS

(N-range) High
HbA1c HbA1c
6% 12%
 2 . sensitizer: Rosiglitazone (Avandia)
Insulin
Action: decrease insulin resisitance

Indic: monotherapy for type 2 DM

combination with metformin

AVANDIA

Signs of anemia, hepatotoxicity, HA, hypoglycemia- SE

Use barrier contraceptives --> lessen OCP effect
Glucose urine & blood- monitor
Administer with meals
Rosiglitazone (Avandia)

II. Insulin:
Action:
• increase glucose transport across muscle & fat cell decrease blood glucose
• promote conversion of glucose to glycogen

Indic: type 1 & 2 DM, DKA,

SE:
1. local allergic reaction
2. insulin lipodystrophy
3. insulin resistance
4. Dawn Phenomenon
5. Somogyi phenomenon
6. Insulin waning

Hypoglycemic Reaction:

Tremors & tachycardia

Irritability

Restlessness
 Excessive hunger

Diaphoresis & depression

Hyperglycemic Reaction: DKA

• polyuria, polydipsia,
• VAN, abdo. pain
• headache, hypotension, weak & rapid pulse
• acetone breath, kussmaul’s respirations
• weakness, mental status changes

PEAK TIMES FOR INSULIN

SHORT COMBINATION INTERMEDIATE LONG

Humalog Regular Reg/NPH NPH Lente Ultralente

Hoppy
Humalog
Reggie
Regular
Nanny
NPH
Lazy
Lente
THE Contestants

A. Rapid –acting insulin:

• Lispro (Humalog) <15min 1hr 4- 5
• Insulin aspart (Novolog) 5-10 min 30- 60 min 3- 5

B. Short-acting insulin:
• Regular (Humulin R, Novolin R) 30-60 min 2- 4 hr 6- 8

C. Intermediate-Acting insulin:
• NPH (Humulin N, Novolin N) 1-2 hrs 6-12hr 18- 24
• Lente (Humulin L, Novolin L) 1- 2.5 hrs 6-12 hr 18-24

D. Long-acting insulin:
• Ultralente (Humulin U) 6 hrs 18-24hr >36
• Insulin glargine (Lantus) 30- 60 min 24

E, Premixed insulin:
• 70% NPH/ 30% regular (Humulin 70/30) ½-1 hr 2-12 18-24
• 50% NPH/ 50% regular (Humulin 50/50) ½ hr 3- 5 24
• 75% LIspro protamine/ 25%lispro 10-15 min 1- 6 24
Mixing insulin
FOOD- DRUG interactions
 Antacids
calcium carbonate (TUMS)
Bran & whole grain breads

Antibiotics
erythromycin, penicillin
citrus fruits, cola & any food

tetracycline

dairy products

Anticoagulants
Warfarin (Coumadin)

Vitamin K

MAO inhibitors

tyramine

Drugs that can cause NEPHROTOXICITY

acetaminophen
acyclovir
aminoglycosides
amphotericin B
ciprofloxaxin
cisplatin
methotrexate
NSAIDs
rifampin
sulfonamides
tetracyclines
vancomycin
 Drugs that can cause HEPATOTOXICITY

ACE inhibitors
acetaminophen
alcohol
iron overdose
erythromycin
estrogens
fluconazole
isoniazid
itraconazole
NSAIDs
phenothiazines
phenytoin
rifampin
sulfamethoxazole & trimethoprin

Drugs that can cause OTOTOXICTY

aminoglycosides
bumetanide
cisplatin
erythromycin
ethacrynic acid
furosemide
hydroxychloroquine
NSAIDs
salicylates (chronic high dose)
vancomycin

Patient: Well, doc, what does the X-ray of my head show?

Doctor: Nothing.