CARDIAC GLYCOSIDES, ANTIANGINALS, AND ANTIDYSRHYTHMICS

CARDIAC GLYCOSIDES

DRUGS THAT INHIBIT THE SODIUMPOTASSIUM PUMP THUS INCREASING INTRACELLULAR CALCIUM WITH CAUSES THE CARDIAC MUSCLES TO CONTRACT MORE EFFICIENTLY

CARDIAC GLYCOSIDES

POSITIVE INOTROPIC ACTION NEGATIVE CHRONOTROPIC ACTION NEGATIVE DROMOTROPIC ACTION

CARDIAC GLYCOSIDES
INDICATIONS TREATMENT OF HEART FAILURE CORRECT ATRIAL FIBRILLATION AND FLUTTER

NONPHARMACOLOGIC MEASURES

LIMIT SALT INTAKE TO 2 GRAMS DAILY (1 TSP) EXCESSIVE ALCOHOL CAN CAUSE CARDIOMYOPATHY SMOKING- CAN DEC O2 TO THE HEART OBESITY MILD EXERCISE

Cardiac Glycosides and Inotropic Agents

Cardiac Glycosides and Inotropic Agents

RAPID ACTING DIGITALIS Digoxin (Lanoxin) LONG ACTING DIGITALIS Digitoxin PHOSPHODIESTERASE INHIBITORS Amrinone (Inocor) Milrinone lactate (Primacor) ATRIAL NATRIURETIC PEPTIDE Nesiritide (Natrecor) ANTIDOTE FOR DIGITALIS TOXICITY Digoxin immune Fab (ovine, Digibind)

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

TO TREAT CHF, ATRIAL TACHYCARDIA, FLUTTER, OR FIBRILLATION

DIGITALIS TOXICITY

VERY, VERY, VERY IMPORTANT!

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Assess for signs and symptoms of digitalis toxicity

ANOREXIA DIARRHEA NAUSEA AND VOMITING PVCS DYSRHYTHMIAS BRADYCARDIA HEADACHES YELLOW HALOS AROUND OBJECTS CONFUSION DELIRIUM

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Obtain a baseline pulse rate for future comparisons.

Apical pulse should be taken for a full minute and should be > 60 bpm.

Client checks pulse rate daily before taking digoxin.

Client will repot pulse rate of < 60 bpm or a marked decline in pulse rate. Do not administer if pulse rate is <60 bpm.

DIGOXIN Antidote for Digitalis Toxicity

Digoxin immune Fab (Digibind,Ovine) To correct serious digitalis toxicity. This agent binds with digoxin to form complex molecules. A serum digoxin level >2.0 ng is indicative of digitalis toxicity.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

A low serum potassium level enhances the action of digoxin. Clients taking digoxin and a potassium-wasting diuretic or cortisone drug may cause hypokalemia, causing digitalis toxicity.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Advise client to eat foods rich in potassium to maintain a desired serum potassium level
Foods rich in potassium such as fresh and dried fruits, fruit juices, and vegetables, including potatoes.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Check the serum digoxin level. The normal therapeutic drug range for
digoxin is

0.5 to 2 ng/ml.

A serum digoxin serum potassium level (normal range, 3.5 to 5.3 mEq/L) Report if hypokalemia (< 3.5 mEq/L) is present.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Normal

therapeutic drug range for digoxin

0.5 to 2 ng/ml

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Report

if hypokalemia (< 3.5 mEq/L) is present.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Determine the signs of peripheral and pulmonary edema, which indicate congestive heart failure is present.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Explain to client the importance of compliance with the drug therapy. Advise client not to take OTC drugs without first consulting the health care provider to avoid adverse drug interactions.

Rapid-Acting Digitalis DIGOXIN (Lanoxin)

Keep drugs out of reach of small children. Request childproof bottles.

Instruct client or parent of child to check pulse rate before administering the drug.

Cardiac Glycosides and Inotropic Agents

RAPID ACTING DIGITALIS Digoxin (Lanoxin) LONG ACTING DIGITALIS Digitoxin PHOSPHODIESTERASE INHIBITORS Amrinone (Inocor) Milrinone lactate (Primacor) ATRIAL NATRIURETIC PEPTIDE Nesiritide (Natrecor) ANTIDOTE FOR DIGITALIS TOXICITY Digoxin immune Fab (ovine, Digibind)

Long-Acting Digitalis Digitoxin

For CHF. Serum therapeutic level is 15-30 mg/ml. Because of its long half-life, this drug is seldom given.

Cardiac Glycosides and Inotropic Agents

RAPID ACTING DIGITALIS Digoxin (Lanoxin) LONG ACTING DIGITALIS Digitoxin PHOSPHODIESTERASE INHIBITORS Amrinone (Inocor) Milrinone lactate (Primacor) ATRIAL NATRIURETIC PEPTIDE Nesiritide (Natrecor) ANTIDOTE FOR DIGITALIS TOXICITY Digoxin immune Fab (ovine, Digibind)

Phosphodiesterase Inhibitors (Positive Inotropic Bipyridines)

INHIBITS ENZYME PHOSHODIESTERASE THUS PROMOTING A POSITIVE INOTROPIC RESPONSE AND VASODILATATION

Phosphodiesterase Inhibitors (Positive Inotropic Bipyridines)

Phosphodiesterase Inhibitors (Positive Inotropic Bipyridines)

Amrinone lactate For CHF, amrinone may be prescribed when digoxin and diuretics have not been effective. It may be used in conjunction with diuretic it is incompatible with furosemide Drug is for short-term use.

Phosphodiesterase Inhibitors (Positive Inotropic Bipyridines)

Milrinone lactate For short-term treatment of CHF May be given before heart transplantation. Heart rate and blood pressure should be monitored.

Cardiac Glycosides and Inotropic Agents

RAPID ACTING DIGITALIS Digoxin (Lanoxin) LONG ACTING DIGITALIS Digitoxin PHOSPHODIESTERASE INHIBITORS Amrinone (Inocor) Milrinone lactate (Primacor) ATRIAL NATRIURETIC PEPTIDE Nesiritide (Natrecor) ANTIDOTE FOR DIGITALIS TOXICITY Digoxin immune Fab (ovine, Digibind)

Atrial Natriuretic Peptide Hormone

Nesiritide
To treat acute CHF by increasing sodium loss. It is useful in managing dyspnea at rest. It causes vasodilation. Contraindication includes clients with a systolic BP less than 90 mm Hg.

OTHER DRUGS CHF

VASODILATORS
Decrease venous return

ACE INHIBITORS DIURETICS

First line for reducing fluid volume

ANTIANGINALS

FINISHED WITH CARDIAC GLYCOSIDES

ANTIANGINALS

ANGINA PECTORIS

ACUTE CARDIAC PAIN CAUSED BY INADEQUATE BLOOD FLOW TO THE MYOCARDIUM RESULTING FROM EITHER:
PLAQUE OCCLUSIONS WITHIN SPASMS OF THE CORONARY ARTERIES

NONPHARMACOLOGIC MEASURES

AVOID:
HEAVY MEALS SMOKING EXTREMES IN WEATHER CHANGES STRENEOUS EXERCISE EMOTIONAL UPSET

PROPER NUTRITION EXERCISE REST RELAXATION MEASURES

ANTIANGINALS
NITRATES BETA-ADRENERGIC BLOCKERS CALCIUM CHANNEL BLOCKERS

ANTIANGINALS
NITRATES Short Acting Nitroglycerin(Nitrostat, Nitro-Bid, Transderm-Nitro) Long Acting Isosorbide dinitrate (Isordil, Sorbitrate) Isosorbide mononitrate (Imdur)

Nitrates

CAUSE GENERALIZED VASCULAR AND CORONARY VASODILATATION

Nitrates
Short-Acting Nitroglycerin (nitrostat, transderm)
TO CONTROL ANGINAL PAIN DECRESE MYOCARDIAL DEMAND FOR O2

DECRESE PRELOAD BY DILATING VEINS THUS DECREASING AFTERLOAD

Nitrates
Long Acting Isosorbide dinitrate (isoket,isordil)
To prevent anginal attacks. Drug can lower blood pressure. Tolerance builds up over time. Headaches, dizziness, light-headedness, and flush may occur.

Nitrates
Long Acting Isosobide mononitrate (indur)
To prevent anginal attacks. Sustained release form provides controlled delivery and a 6 hour drug-free period.

By allowing a drug-free period, tolerance to nitrates is reduced; effectiveness is increased.

ANTIANGINALS
NITRATES BETA-ADRENERGIC BLOCKERS CALCIUM CHANNEL BLOCKERS

ANTIANGINALS BETA-ADRENERGIC BLOCKERS

Atenolol (Tenormin), B1 Metoprolol tratrate (Lopressor), B1 Nadolol (Cogard) B1, B2 Propanolol (Inderal) B1, B2

Beta-Adrenergic Blockers

Atenolol (tenorminm,therabloc)
To control angina pectoris. Also effective in managing hypertension. Dec blood pressure and heart rate by blocking beta1. Can be used by clients with asthma.

Beta-Adrenergic Blockers

Metoprolol tartrate (betaloc, neobloc, cardiostat)

Similar to atenolol by blocking beta1. High doses of metoprolol can effect beta2 and could cause broncoconstriction. It can reduce cardiac oxygen demand, which decreases heart rate and contractility.

Beta-Adrenergic Blockers

Nedolol (Corgard) B1, B2

To treat angina pectoris and hypertension.

Beta-Adrenergic Blockers

Propranolol HCL (inderal)

First beta-blocker, blocking beta1 and beta2. it is no longer the drug of choice to prevent angina because of the risk of bronchospasm. Heart rate, blood pressure, and respiratory status should be monitored.

ANTIANGINALS
NITRATES BETA-ADRENERGIC BLOCKERS CALCIUM CHANNEL BLOCKERS

Calcium Channel Blockers

Amlodipine (envacar, norvasc)

Management of angina pectoris and hypertension.

Calcium Channel Blockers

Bepridil HCL (Vascor)

Treatment of angina pectoris. May be used as single drug or in combination with nitrates. Given as a single dose.

Calcium Channel Blockers

Diltiazem HCL (dilzem)

For angina pectoris. Hypotensive effect is not as severe as with nifedipine. Kidney function should be monitored.

Calcium Channel Blockers

Felodipine (plendil)
To chronic angina pectoris and manage hypertension. Reduces O2 demand by the heart. A potent peripheral vasodilator thus increasing heart rate and myocardial contractility.

Calcium Channel Blockers

Nifedipine (adalat,calcibloc)
Potent calcium channel blocker. For Angina pectoris Blood pressure should be monitored, esp if taken with nitrates or beta-blockers

Calcium Channel Blockers

Isradipine (DynaCirc)
Primary use is to treat hypertension. Also can be given for angina pectoris.

Calcium Channel Blockers

Nicardipine HCL (cardepine)

Used for angina pectoris. May be used alone or incombination with other antianginals. Used also for hypertension. Peripheral edema, headache, dizziness, and light-headedness may occur.

Calcium Channel Blockers

Nisoldipine (Nisocor)
To treat angina pectoris and hypertension. Suppresses contraction of cardiac and vascular smooth muscle. Increases heart rate and cardiac output. Decreases blood pressure. Caution: clients with heart disease are prone to MI and CHF.

Calcium Channel Blockers

Verapamil HCL (isoptin)

Treatment of angina pectoris, cardiac dysrhythmias and hypertension. Peripheral edema, constipation, dizziness, headache, and hypotension may occur.

NURSING PROCESS
Antianginals

Assessment

Obtain baseline vital signs for future comparisons Obtain health and drug histories. Nitroglycerin is contraindicated for marked hypotension or acute myocardial infarction.

Nursing Diagnoses

Decreased cardiac output Anxiety related to cardiac problems Acute pain Activity intolerance

Planning

Client takes nitroglycerine or other antianginals and angina pain is controlled.

Nursing Interventions

Monitor vital signs.

Hypotension is associated with most antianginal drugs.

Have client sit or lie down when taking a nitrate for the first time.
After administration, check the vital signs while client is lying down and then sitting up. Have client rise slowly to a standing position.

Nursing Interventions

Offer sips of water before giving sublingual nitrates; dryness may inhibit drug absorption. Monitor effects of IV nitroglycerin. Report angina that persists.

Nursing Interventions
Apply Nitro-Bid ointment to the designated mark on paper. Do not use fingers because the drug can be absorbed; use a tongue blade or gloves.

Nursing Interventions

Nito-Bid ointment or the Transderm-Nitro patch Do not apply in any area on the chest in the vicinity of defibrillator-cardioverter paddle placement.
Explosion and skin burns may result.

IMPORTANT Client Teaching

General A SL nitroglycerin tablet is used if chest pain occurs. Repeat in 5 minutes if the pain has not subsided and again in another 5 minutes if it persists. Do not give more than three tablets. If the chest pain persists >15 minutes, immediate medical help is necessary.

Client Teaching
General Instruct client not to ingest alcohol while taking nitroglycerin to avoid hypotension, weakness, and faintness. Tolerance to nitroglycerin can occur. If clients chest pain is not completely alleviated, client should notify the health care provider.

Client Teaching
Beta-Blockers and Calcium Blockers Inform client not to discontinue these drugs without the health care providers approval. Withdrawal symptoms, such as reflex tachycardia and pain, may be severe.

Client Teaching
Self Administration Demonstrate to client how nitroglycerin tablets are taken.

The tablet is placed under the tongue for quick absorption. A stinging or biting sensation may indicate the tablet is fresh. With the newer SL nitroglycerin, the biting sensation may not be present.

Client Teaching
Self Administration The bottle is stored away from light and kept dry. Keep in original screw-cap, amber glass bottle.

The amber color of the glass provides light protection and the screw-cap closure protects from moisture in the air, which can easily reduce the potency of the tablets.

Self Administration Instruct client about the Transderm-Nitro patch.

Apply once a day, usually in the morning. Rotation of skin sites is necessary. Usually the patch is applied to the chest wall; however, the thighs and arms are used. Avoid hairy areas.

Client Teaching

Side Effects

Headaches commonly occur when first taking nitroglycein products and last about 30 minutes. Acetaminophen is suggested for relief.

Side Effects

If hypotension results from SL nitroglycerin, place client is supine position with legs elevated.

Beta-Blockers and Calcium Blockers Instruct client how to take a pulse rate. Advise that client to call the health care provider if dizziness or faintness occurs; this may indicate hypotension

Evaluation Evaluate clients response to nitrate product for relieving anginal pain. Note headache, dizziness or faintness.

Antidysrhythmics

CARDIAC DYSRHYTHMIAS

ANY DEVIATION FROM THE NORMAL RATE OR PATTERN OF HEARTBEAT

Antidysrhythmics

DESIRED ACTION IS TO RESTORE CARDIAC RHYTHM

CARDIAC ACTION POTENTIAL

MECH OF ACTION

BLOCK ADRENERGIC STIMULATION OF THE HEART DEPRESS MYOCARDIAL CONTRACTILITY AND EXCITABILITY DECREASE CONDUCTION VELOCITY IN CARDIAC TISSUE INCREASE RECOVERY TIME (REPOLARIZATION) OF THE MYOCARDIUM SUPRESS AUTOMATICITY

CLASS 1 FAST NA CHANNEL BLOCKERS IA SLOWS CONDUCTION AND PROLONGS REPOLARIZATION IB SLOWS CONDUCTION AND SHORTENS REPOLARIZATION 1C PROLONGS CONDUCTION WITH LITTLE EFFECT ON REPOLARIZATION

CLASS 11 BETA-BLOCKERS REDUCES CA ENTRY, DEC CONDUCTIONVELOCITY, AUTOMATICITY AND RECOVERY TIME (REFRACTORY PERIOD)
CLASS 111 PROLONG REPOL PROLONG REPOL DURING VENTRICULAR DYSRHYTMIAS, PROLONGS ACTION POTENTIAL DURATION CLASS IV CALCIUM CHANNEL BLOCKERS BLOCKS CALCIUM INFLUX, SLOWS CONDUCTION VELOCITY, DEFCREASES MYOCARDIAL CONTRACTILITY AND INC REFRACTION IN AV NODE

Antidysrhythmics
Class I Fast (Sodium) Channel Blockers IA Disopyramide phosphate (Norpace)

Prevention and suppression of unifocal and multifocal premature ventricular contractions (PVCs). For ventricular dysrhythmias. May cause anticholinergic symptoms. Serum therapeutic level 3-8 mcg/ml.

Antidysrhythmics
Class I Fast (Sodium) Channel Blockers IA Procainamide HCL (Procan)

It controls dysrhythmias (PVC), ventricular tachycardia. It depresses myocardial excitability by slowing down conduction of cardiac tissue.

Antidysrhythmics
Class I Fast (Sodium) Channel Blockers IA Quinidine sulfate, polygalacturonate, gluconate (kinidin)

For atrial, ventricular, and supraventricular dysrhythmias. Nausea, vomiting, diarrhea, abdominal pain or cramps are common side effects. It can increase digoxin concentration Serum therapeutic level: 2-6 mcg/ml.

Antidysrhythmics
Fast (Sodium) Channel Blockers IB Lidocaine (xylocaine)
For acute ventricular dysrhythmias following MI and cardiac surgery. Serum therapeutic range: 1.5-6 mcg/ml.

Antidysrhythmics
Fast (Sodium) Channel Blockers IB Mexiletine HCL [Mexitil]
Analogue of lidocaine. Treatment for acute and chronic ventricular dysrhythmias. Take with food to decrease GI distress. Common side effects include nausea, vomiting, heartburn, tremor, dizziness, nervousness, lightheadedness. Serum therapeutic range: 0.5-2 mcg/ml.

Antidysrhythmics
Fast (Sodium) Channel Blockers IB Tocainide HCL [Tonocard]
For ventricular dysrhythmias, especially PVC. Similar to lidocaine except in oral form. Serum therapeutic level: 4-10mcg/ml.

Antidysrhythmics
Fast (Sodium) Channel Blockers IC Flecainide (Tambocor)
For life-threatening ventricular dysrhythmias; prevention of paroxysmal supraventricular tachycardia (PSVT) and paroxysmal atrial fibrillation or flutter (PAF). Avoid use in cardiogenic shock, second-or third-degree heart block, or right bundle branch block.

Antidysrhythmics
Fast (Sodium) Channel Blockers IC Propafenone HCL
Treatment of life-threatening ventricular dysrhythmias. Avoid use if cardiogenic shock, uncontrolled CHF, heart block, severe hypotension, bradycardia, and bronchospasms occur.

Antidysrhythmics
Other Class I Moricizine
To treat life-threatening ventricular dysrhythmias. Blocks sodium channels, decreases conduction velocity in atria and ventricles, and prolongs refractory period in the AV node. May cause bradycardia, heart block, and CHF in high doses.

Antidysrhythmics
Class II Beta-Adrenergic Blockers Acebutolol HCL (Sectral) B1
Management of ventricular dysrhythmias. Also used for angina pectoris and hypertension. Primarily for PVC. New beta-blocker that affects the beta1 receptor in the heart. Can cause bradycardia and decrease cardiac output.

Antidysrhythmics
Class II Beta-Adrenergic Blockers Esmolol (Brevibloc) B1
To control atrial flutter and fibrillation. For short-term use only. Mainly for clients having dysrhythmias during surgery. May cause bradycardia and decrease cardiac output.

Antidysrhythmics
Class II Beta-Adrenergic Blockers Propranolol HCL (inderal) B1,B2
For ventricular dysrhythmias, PAT,and atrial and ventricular ectopic beats. Clidnts with asthma should not use drug.

Antidysrhythmics
Class II Beta-Adrenergic Blockers

Sotalol HCL (sotalex) B1,B2

For ventricular dysrhythmias. Avoid if bronchial asthma or heart block is present.

Antidysrhythmics
Class III Prolong Repolarization Adenosine (Cardiovert)
Treatment of PSVT, Wolff-Parkinson-White syndrome. Avoid if second- or third-degree AV block or atrial flutter or fibrillation is present.

Antidysrhythmics
Class III Prolong Repolarization Amiodarone HCL (Cordarone)
For life-threatening ventricular dysrhythmias. Initially dosage is greater and then decreases over time. Therapeutic serum level; 1-2.5 mcg/ml.

Antidysrhythmics
Class III Prolong Repolarization Bretylium tosylate
For ventricular tachycardia and fibrillation (to convert to a normal sinus rhythm). Used when lidocaine and procainamide are ineffective.

Antidysrhythmics
Class III Prolong Repolarization Sotalol (Sotalex)
Beta-blocker. Can be classified as Class II or III. To treat life-threatening ventricular dysrhythmias (ventricular tachycardia). Slows heart rate, decreases AV conduction, increases AV refractory period, and decreases systolic and diastolic BP. Caution: second- and third-degree heart block.

Antidysrhythmics
Class III Prolong Repolarization Dofetilide
A selective potassium-channel blocker that prolongs repolarization. Prescribed for atrial flutter and fibrillation. Renal function should be monitored.

Antidysrhythmics
Class IV Calcium Channel Blockers Verapamil HCL (isoptin)

For supraventricular tachydysrhythmias, prevention of PSVT. Also used for angina pectoris and hypertension. Avoid use if cardiogenic shock, second- or thirddegree AV block, severe hypotension, severe CHF occur. Serum therapeutic level 80-300 ng/ml or 0.080.3 mcg/ml.

Antidysrhythmics
Class IV Calcium Channel Blockers Diltiazem

For PSVT and atrial flutter or fibrillation. Avoid use if second- or third-degree AV block or hypotension occurs.

Antidysrhythmics
Others Phenytoin (Dilantin)
Treatment of digitalis-induced dysrhythmias. Not approved as dysrhythmic drug by FDA. Serum level <20 mcg/ml.

Digoxin (Lanoxin)
For atrial flutter of fibrillation; to prevent recurrence of paroxysmal atrial tachycardia.

Ibutilide fumarate [Corvert]

To treat atrial flutter and fibrillation. Prolong cardiac action potential and increases atrial and ventricular refractories.

NURSING PROCESS Antidysrhythmics

Antidysrhythmics Assessment

Obtain health and drug histories.

The history may include shortness of breath (SOB) heart palpitations Coughing chest pain (type, duration, and severity) previous angina or cardiac dysrhythmias drugs that client currently takes.

Antidysrhythmics Assessment

Obtain baseline vital signs and electrocardiogram (ECG) for future comparisons Check early cardiac enzyme results (aspartate aminotrasferase, lactate dehydrogenase, creatine phosphokinase) to compare with future laboratory results.

Antidysrhythmics Nursing Diagnoses

Decreased cardiac output Anxiety related to irregular heartbeat Risk for activity intolerance

Antidysrhythmics Planning

Client will no longer experience abnormal sinus rhythm. Client will comply with the antidysrhythmic drug regimen.

Antidysrhythmics Nursing Interventions

Monitor vital signs.

Hypotension can occur.

Administer drug by IV push or bolus over a period of 2 to 3 minutes or as prescribed.

Antidysrhythmics Nursing Interventions

Monitor ECG for abnormal patterns and report findings, such as prematue ventricular contractions (PVCs), increased PR and QT intervals, and /or widening of the QRS complex.

Antidysrhythmics Nursing Interventions

Client Teaching General Instruct client to take the prescribed drug as ordered. Drug compliance is essential Provide specific instructions for each drug (e.g., photosensitivity for amiodarone

Antidysrhythmics Nursing Interventions

Side Effects Instruct client to report side effects and adverse reactions to the health care provider.
These can include dizziness, faintness, nausea, and vomiting.

Antidysrhythmics Nursing Interventions

Side Effects Advise client to avoid alcohol, caffeine, and tobacco.
Alcohol can intensify the hypotensive reaction caffeine increases the catecholamine level tobacco promotes vasoconstriction.

Antidysrhythmics Nursing Interventions

Evaluation Evaluate the effectiveness of the prescribed antidysrhythmic by comparing heart rates with the baseline heart rate and assessing clients response to the drug. Report side effects and adverse reactions. The drug regimen may need to be adjusted. A proarrhythmic effect may occur, which may require discontinuation of the drug.