Cardiovascular Pharmacology

For a Narrated Version of this Presentation, Go To: http://nursing-pharmacology.pbworks.com/Cardiovasc ular-Medications A Good Resource: http://www.cvpharmacology.com/index.html

Concept Map: Selected Topics in Cardiovascular Nursing

ASSESSMENT
Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring

PATHOPHYSIOLOGY
Myocardial Infarction Acute Coronary Syndrome Valvular Heart Disease Pacemakers CABG Abdominal Aortic Aneurysm Pericarditis Peripheral Vasc Disease (PVD) Fem-Pop Bypass Graft Shock / Fluid Deficit Raynauds Phenomenon Arrhythmias / Dysrhythmias

PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Beta Blockers Antiarrhythmics Catecholamines Anticoagulants

Care Planning
Plan for client adls, Monitoring, med admin., Patient education, more

Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

Cardiovascular Pharmacology
ACE Inhibitors Alpha Blockers Beta Blockers AntiArrhythmics AntiHypertensives

Calcium Channel Blockers

Anti-Anginals Anti-Lipemics

Digitalis Glycosides

Loop Diuretics

Potassium Sparing / Combination Diuretics

Thiazide / Related Diuretics

Platelet Aggregation Inhibitors

-pril------------------------------- ACE Inhibitor -lol or olol ------------------Beta Blocker -pine --------------------- Ca Channel Blocker -statin --------------- anti-lipemic -nitr ------------- nitrates -zosin --------------- alpha blockers

Alpha Blockers Beta Blockers Ca Channel Blockers ACE Inhibitors Anti-Lipemic Nitrates

-olol -pril -pine -statin -nitr-zosin -lol

atenolol (Tenormin ) carvedilol (Coreg ) metoprolol (Toprol XL , LoPressor ) propranolol HCl (Inderal )
benazepril HCl (Lotensin ) captopril (Capoten) enalapril maleate (Vasotec) lisinopril (Prinivil , Zestril)

amlodipine besylate (Norvasc ) diltiazem HCl (Cardizem , Dilacor ) nifedipine (Adalat , Procardia XL ) Verapamil HCl (Calan , Isoptim , Covera ) atorvastatin calcium (Lipitor ) lovastatin ( Mevacor ) pravastatin (Pravachol ) rosuvastatin calcium (Crestor ) simvastatin (Zocor ) isosorbide dinitrate (Isordil ) isosorbide mononitrate (Ismo) Nitroglycerin

doxazosin mesylate (Cardura) prazosin HCl (Minipress)

ACE Inhibitors
hypertension
CHF Diabetic Neuropathy

benazepril HCl (Lotensin ) captopril (Capoten) enalapril maleate (Vasotec) lisinopril (Prinivil , Zestril)

Left Ventricular Dysfunction After MI

ACUTE M.I.

The Multi-Purpose Group !

Prototype: captopril
ACE Inhibitors produce desired effect by blocking production of angiotensin II, resulting in arteriolar vasodilation, excretion of sodium and retention of potassium Indications: Heart failure, HTN, MI (reduce mortality, reduce heart failure), diabetic & non-diabetic nephropathy. Nursing Implications: orthostatic hypotension, cough, potential hyperkalemia

The prils: ACE Inhibitors

Treatment of Hypertension captopril, enalapril, lisinopriltx of HTN, CHF, decreased L ventricular function after MI Always check BP before administeringhold PRN (parameters) Teach patient to change positions slowly to avoid postural hypotension C.O. = HR x SV cough
BP = C.O. x PVR

Alpha Blockers
doxazosin mesylate prazosin HCl (Cardura) (Minipress)

Prototype: prazosin
Alpha blockers cause venous and arterial dilation, smooth muscle relaxation of prostate Indications: HTN Nursing Implications: monitor BP closely after initial dose; orthostatic hypotension

The zosins: Alpha Blockers

sympatholytic

Uses: Treatment of HTN BPH (doxazosin (Cardura)

Nursing Implications Teach patient to avoid changing positions rapidly (postural hypotension) Check blood pressure prior to administration; hold med PRN (Parameters)
C.O. = HR x BP = C.O. SV x PVR

Anti-Anginals
isosorbide dinitrate (Isordil ) isosorbide mononitrate (Ismo) Nitroglycerin Nitro-dur, Transderm Nitro Nitrol Nitrostat Nitrotab

Prototype: nitroglycerin
Vasodilation of coronary artries increases myocardial oxygen supply; decreases myocardial oxygen demand via vasodilation and reduction of preload Indications: angina treatment and/or prophylaxis; Nursing Implications: hypotension, orthostatic hypotension, cough, potential hyperkalemia

The NITRs Anti-Anginals (effect: vasodilation)

nitroglycerin sl, nitropaste, nitroderm Chest pain regimen: 1 tab NTG sl, q5 min X 3

Isosorbide dinatrate (Isordil) Treatment / Prophylaxis of angina, CHF

C.O. = BP = HR x C.O. x SV PVR

Anti-Arrhythmics
( Anti-Dysrhythmics )

amiodarone HCl (Cordarone , Pacerone ) lidocaine HCl (Xylocaine ) procainamide (Procanbid , Pronestyl ) quinidine (Quinaglute )

Prototype: lidocaine
Class Ib antiarrhythmic; decreases electrical conduction, decreases automaticity, increases rate of repolarization Indications: short-term use for ventricular dysrhythmias; monitor respirationsrespiratory arrest. Cardiac monitorvital signs Nursing Implications: CNS effectsdrowsiness, altered mental status, paresthesias, seizures

A Slight Side-Effect of IV Amiodarone !

 Lidocaine HClthe old reliable; used for PVCs, ventricular ectopy, ventricular tachycardia
Amiodarone Management of life-threatening ventricular arrhythmias unresponsive to less toxic meds; assess for pulmonary toxicity Both of these: Infusion pumps, monitor v.s. frequently, cardiac monitor

Anti-Hypertensives
clonidine (Catapres , Catapres Patch , Catapres TTS ) hydralazine HCl (Apresoline ) hydroclorothiazide / lisinopril (Prinzide , Zestoretic ) minoxidil (Loniten )

Prototype: clonidine
Sympatholyticdecreases HR causes decrease in C.O., peripheral vasodilationdecreases BP Indications: HTN, severe cancer pain Nursing Implications: hypotension, orthostatic hypotension, administer twice daily in divided dose

 Hydralazinetx of essential hypertension HCTZ/Lisinoprilcombination drug essential hypertension Always check BP prior to administrationhold PRN (Parameters) Postural hypotension precautions

Anti-Lipemics
atorvastatin calcium (Lipitor ) colestipol (Colestid ) gemfibrozol (Lopid ) lovastatin ( Mevacor ) Niacin ( Niacor , Niaspan ) nicotinic acid (Slo-Niacin , Vitamin B) pravastatin (Pravachol ) rosuvastatin calcium (Crestor ) simvastatin (Zocor )

Prototype: atorvastatin

Beta Blockers
atenolol (Tenormin ) carvedilol (Coreg ) metoprolol (Toprol XL , LoPressor ) propranolol HCl (Inderal )

Prototype: metoprolol
Remember that there are cardioselective and non-selective Beta blockers; Beta1 adrenergic blockage to reduce heart (- chronotrope) rate, decrease myocardial contractility (-inotrope), decrease rate of conduction through the AV node Indications: angina, HTN, dysrhythmias, MI, Heart failure, Nursing Implications: Apical pulse; monitor VS; Contraindicated in AV Block, SB.

 Used for tx of HTN, MI, angina prophylaxis, CHF Cardioselective vs nonselective B-Blockers and Respiratory Nursing: Apical Pulse
C.O. = HR x SV

BP

C.O.

PVR

Calcium Channel Blockers

amlodipine besylate (Norvasc ) diltiazem HCl (Cardizem , Dilacor , Tiamate , Cardizem SR , Cardizem CD ) nifedipine (Adalat , Procardia XL ) Verapamil HCl (Calan , Isoptim , Covera )

Prototype: nifedipine
Vasodilation of peripheral arterioles; clocking of CA+ channels in heart causes decreased force of contraction, decreased heart rate, decreased pulse. (-inotrope, -chronotrope) Indications: HTN, angina, selected dysrhythmias Nursing Implications: hypotension, orthostatic hypotension, cardiac monitor, monitor pulse rate
Contraindications: AV blocks, hypotension, bradycardia, aortic stenosis, severe heart failure

 Treatment of HTN, vasospastic angina, angina prophylaxis, Atrial Fibrillation (sometimes) , rapid atrial dysrhythmias Nursing: Check BP, hold PRN (Parameters) Postural Hypotension Precautions C.O. = HR x SV
BP = C.O. x PVR

Digitalis Glycosides
digoxin (Lanoxin )
(+) Inotrope, (-) Chronotrope CHF, Atrial Tachy-arrhythmias (A-Fib, AFlutter), Cardiogenic Shock Assess Apical Pulse
Dig Toxicityanorexia, fatigue, weakness, yellow-green halos around lights Role of K+ ! (Can be Dig Toxic with therapeutic Dig levels if K+ is low!) Therapeutic Level = 0.5-2.0 ng/ml Low K+: Possible U Waves on EKG

Prototype: digoxin
(+) inotropic effect; (-) chronotropic effect; improves stroke volume and C.O. Indications: treatment of heart failure; treatment of atrial fibrillation Nursing Implications: AP, monitor dig levels, monitor K+ Contraindicated: Ventricular rhythm disturbances: VF, VT, 2nd -3rd degree AV block

Loop Diuretics
bumetanide (Bumex ) furosemide (Lasix )

Monitor serum K+ 3.5 5.0 mEq/L Potassium rich foods

Prototype: furosemide
Block reabsorption of NA and Cl, prevent reabsorption of H2O, causing extensive diuresis; Indications: Pulmonary edema d/t Heart failure Nursing Implications: I&O, daily weights, hypotension, diuresis (foley?), orthostatic hypotension, monitor K+, RELATE THIS MED IN RELATION TO OTHER MEDS. Dietary counseling.

Platelet Aggregation Inhibitors

clopidogrel bisulfate (Plavix ) dipyridamole (Persantine ) ticlopidine HCl (Ticlid ) Prevention of TIAs, CVA; combined with warfarin or ASA for heart valves, MI, bypass grafts, stents.

Prototype: aspirin
Prevent platelets from clumping or aggregating; Indications: Primary prevention of MI; prevention of CVA (stroke); Nursing Implications: bleeding , GI Upset ; use cautiously in those with anticoagulants and NSAIDs (potentiates).

Potassium Sparing / Combination Diuretics

hydrochlorothizide / triamterene (Dyazide , Maxzide )

spironolactone (Aldactone ) Treatment of edema and hypertension

Avoid high K= foods (oranges, bananas, salt substitute, dried apricots, dates, Weigh Daily

Prototype: spironolactone
Spironolactone is classified as a potassiumsparing diuretic. Indications:congestive heart failure, cirrhosis of the liver, and kidney disease. It can also be used in combination with other drugs to treat elevated blood pressure. Nursing Implications: Used with other diuretics; Give with meals; Avoid salt substitutes containing potassium; Monitor I and O

Thiazides / Related Diuretics

chlorthalidone (Hygroton , Hylidone , Thalitone

hydrochlorothiazide [hctz] (Hydrodiuril ) indapamide (Lozol ) metolazone (Zaroxylyn )

 NOTE THAT MORE THAN ONE HYPERTENSIVE SOMETIMES SEVERAL--MAY BE NEEDED TO CONTROL HTN; USED IN COMBINATION WITH DIURETICS; Tx edema, HTN Monitor for hypokalemia

Anti-Coagulants
Heparin Enoxaparin Warfarin Antidotes: Heparin = protamine sulfate Coumadin = vitamin K Digoxin = Digibind, Digifab,

Prototype: heparin
Inactivation of thrombin formation vis inhibition of fibrin formation, Indications: DIC, stroke, prophylaxis agains post-op DVT, Nursing Implications: bleeding (remember: internal & external bleeding) Heparin Induced Throbocytopenia (HIT)stop if platelets <100,000; monitor aPTT (< 2 x baseline) Antidote: Protamine sulfate

Thrombolytic Medications

Prototype: streptokinase
Act by dissolving clots. Indications: Acute MI; DVT; Pulmonary emboli, ischemic stroke (alteplase) Nursing Implications: MONITOR FOR BLEEDING; monitor VS; (see p. 310, ATI Pharm) Contraindications: prior intracranial hemorrhage, active internal bleeding, significant trauma within 3 months, acute pericarditis, brain tumors.

EMERGENCY CARDIAC PHARMACOLOGY

Oxygen Epinephrine Atropine Adenosine Lidocaine (or amiodarone)

Oxygen
100 % ! (during resuscitation, for all clients, including those with chronic respiratory conditions, e.g., COPD)

Epinephrine
(Adrenaline)

Pharmacologic action: vasoconstriction; increased heart rate (+ chronotrope); increased rate of conduction; increased BP; increased myocardial contractility. Indication: Cardiac arrest; ventricular fibrillation Administration: IV, IV push Dose: 1 mg IV push q3-5min Nursing Implications: Monitor blood pressure,
peripheral pulses, urinary output Use infusion pump

catecholamine

Atropine
sympathomimetics

Pharmacologic Action: Indication: SYMPTOMATIC BRADYCARDIA Administration: IV Nursing Considerations: weigh the risks to increased myocardial oxygen demand in CV patient 1 mg rapid IV. Repeat q3-5 minutes up to maximum total dose of 0.04 mg/kg.

Adenosine
class V antiarrhythmic

Pharmacologic Action: Class V antiarrhythmic; causes transient heart block in the AV node Indication: SVT & WPW Administration: IV Bolus Nursing Considerations: after IV bolus, causes a transient asystole
6 mg rapid IV, followed by saline flush. If no response in 1-2 minutes give 12 mg rapid IV. May repeat in 1-2 minutes if needed.

Lidocaine
anti-arrhythmic

Indications: ventricular fibrillation, ventricular tachycardia Pharmacologic Actions: anti-arrhythmic Administration: IV Nursing Considerations: monitor the patient! If received bolus, needs to receive a continuous infusion afterwards; CNS effects drowsiness, altered mental status, seizures 1 to 1.5 mg/kg q3-5min. Maximum total: 3 mg/kg.

Amiodarone
anti-arrhythmic

Indications: Pharmacologic Actions: Administration: Nursing Considerations:

Matching
Column A
Alpha Blocker

Column B
A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Y. Z. isosorbide dinitrate (Isordil ) digoxin (Lanoxin ) prazosin HCl (Minipres ) amiodarone HCl (Cordarone, Pacerone ) hydralazine HCl (Apresoline ) dipyridamole (Persantine ) nitroglycerin (Nitrostat ) lidocaine HCl (Xylocaine ) simvastatin (Zocor ) doxazosin mesylate (Cardura) quinidine (Quinaglute ) clonidine (Catapres ) atorvastatin calcium (Lipitor ) gemfibrozol (Lopid ) lovastatin ( Mevacor ) spironolactone (Aldactone ) hydrochlorothiazide [hctz] (Hydrodiuril ) clopidogrel bisulfate (Plavix ) carvedilol (Coreg ) furosemide (Lasix ) colestipol (Colestid ) propranolol HCl (Inderal ) nifedipine (Adalat , Procardia XL ) ticlopidine HCl (Ticlid) verapamil HCl (Calan ) bumetanide (Bumex )

C J
Beta Blocker

S V
Calcium Channel Blocker

Anti-Anginal

Anti-Arrhythmic

DH K Y
Anti-Hypertensive

E L
Anti-Lipemic

I M N O U
Digitalis Glycosides

B
Loop Diuretics

T
Platelet Aggregation Inhibitors

F R X
Potassium Sparing / Combination Diuretics

P Z
Thiazide Diuretics

ACE Inhibitors

Appendix: Electrolytes & Imbalances

related to: Cardiac Effects

Sodium (Na+) Normal level = 135 to 145 mEq/L (adult) Required in acid-base and osmotic pressure balance, nerve function and water equilibrium.

Effects:
>Decreased Hypotension, headache, nausea, vomiting, abdominal cramps, muscle tremors, twitching, fatigue, headache, nausea, vomiting, diarrhea, abdominal cramps, muscle tremors, twitching, weakness, confusion, seizures, and coma <Increased Lethargy, irritability, muscle twitching, tremors, dry skin and mucous membranes, fever, hypotension, disorientation, delirium,

cerebral hemorrhage, coma

Potassium (K+) Normal level = 3.5 to 5 mEq/L (adult) Major factor in carbohydrate metabolism, osmotic pressure balance, acid-base balance and normal muscle contraction.

Effects:
> Decreased Cardiac arrhythmia, depressed S-T segment, flattened/inverted T wave, U wave, confusion, lethargy, muscle weakness, paralysis, abdominal distention, constipation, paralytic ileus, thirst, frequent voiding < Increased Muscle weakness, paralysis, numbness and tingling, ventricular fibrillation, cardiac arrest, tall tented T waves

Calcium (Ca++) Normal level = 8.5 to 10 mg/dL Involved in bone and tooth formation, blood coagulation, nerve function, muscle contraction.

Effects

>Decreased
Frequent hives, chronic fatigue, canker and cold sores, muscle cramps (Charlie Horses), and itchy skin dementia, depression, psychosis, tetany (Chvostek's and Trousseau's signs), laryngospasm, or generalized convulsions, cardiac arrhythmias with lengthened QT segments

<Increased
Muscle weakness, bone fragility, kidney stones, loss of appetite, thirst, frequent urination, lethargy, fatigue, joint pains, memory loss, depression, constipation, anorexia, nausea and vomiting, abdominal pain, ileus, polyuria, nocturia, and polydipsia, emotional lability, confusion, delirium, psychosis, stupor, coma, cardiac arrhythmias with shortened QT segment

Magnesium (Mg2+) Normal level = 1.3 to 2.1 mEq/L Required for activation of an enzyme necessary for energy metabolism and bone formation.

>Decreased
Muscle weakness, fatigue, confusion, restlessness, hyperexcitability, vertigo, seizures, muscle tremors, nystagmus, tachycardia, hypotension, PAC, PVC, Toursades de Pointes arrhythmia, anorexia, nausea, vomiting, personality change, tetany (eg, positive Trousseau's or Chvostek's sign or spontaneous carpopedal spasm), and tremor and muscle fasciculations

<Increased
Muscle weakness, drowsiness, lethargy, hypotension, paralysis, coma, cardiac and respiratory problems

Blood Glucose
Hypoglycemia
Restlessness Irritability Confusion Trembling Slurred speech Headache Tingling lips Paresthesia Diaphoresis (cool skin) Pallor Tachycardia Shallow respirations Hypertension Weakness Hunger Coma Tremors

Hyperglycemia
Diabetic Ketoacidosis Fatigue Flushed, dry skin Dry mouth Increased thirst Increased urination Blurry vision Headache Nausea and Vomiting Dehydration Weak, rapid pulse Hypotension High blood glucose levels (>240 mg/dL). Ketones in urine Increased thirst and urination Nausea, vomiting, and/or stomach pain Changes in or difficulty breathing (Kussmauls respirations) Acid or fruity smell on breath (Acetone breath) Flushing Dehydration Fatigue Stupor and coma

Hypokalemia: ST depression, decreased or inverted T waves, U waves Hyperkalemia: peaked T waves, decreased P waves, short QT, widened QRS, sine wave Hypocalcemia: prolonged QT, flat or inverted T waves Hypercalcemia: short or absent ST, decreased QTc interval Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS0 Digitalis toxicity: ST depression (scoop), flat T waves Quinidine: prolonged QT, widened QRS Pericarditis: diffuse ST elevation with PR interval depression

Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS0 Digitalis toxicity: ST depression (scoop), flat T waves

Appendix:
A Med-Surg Nurses description of cardiac carethings to think about with patient care Monitor your patient's response to drug therapy by assessing his blood pressure, heart rate, heart sounds, ECG results, breath sounds, urine output, and weight. Also, assess him for peripheral edema. If the physician prescribes a digitalis glycoside, take your patient's apical pulse for a full minute before administering the drug. Withhold the drug if his apical pulse is less than 60 beats per minute.

 Begin digitalis glycoside therapy by administering a loading dose (AS ORDERED) to achieve a therapeutic level more quickly. Monitor your patient's serum digoxin level to ensure that it remains in the therapeutic range of 1 to 2 ng/ml. Also, assess him for signs and symptoms of digitalis toxicity.

If he's also receiving a thiazide or loop diuretic, monitor his serum potassium level; a low potassium level can lead to digitalis toxicity.

 Other drugs that increase the risk of digitalis toxicity include beta-blockers, anticholinergics, quinidine, verapamil, nifedipine, amiodarone, and propafenone.

If your patient is receiving one of these drugs during digitalis glycoside therapy, monitor his heart rate and rhythm and assess for signs of digitalis toxicity, such as gastrointestinal, neurologic, or vision disturbances. If he shows evidence of toxicity, HOLD THE MEDICATION & NOTIFY THE PYSICIAN--the digitalis glycoside will most likely be on hold until his level returns to the therapeutic range.

 During therapy, reduce your patient's cardiac workload by restricting his activity. Provide oxygen through a face mask or nasal cannula, as prescribed, to support his heart's oxygen demands

After therapy, your patient may be referred to an occupational therapist to learn how to conserve oxygen and energy while performing daily activities. The therapist also may help your patient modify his environment to reduce cardiac workload. For example, the therapist may suggest moving bedroom furniture to the first floor and obtaining a bedside commode.

 Teach your patient and his family about his prescribed drug therapy. If a digitalis glycoside has been prescribed, instruct him to take his pulse before taking the drug. Tell your patient that he may need potassium supplements with diuretic and digitalis glycoside therapy.

Tell him to withhold the dose and call the physician if his pulse is lower than 60 beats per minute. Also, teach him the signs and symptoms of digitalis toxicity, such as nausea, vomiting, diarrhea, fatigue, vision changes, and an abnormally slow pulse rate; hypokalemia, such as weakness, fatigue, nausea, abdominal cramps, and diarrhea; and hyperkalemia, such as muscle tenderness, fatigue, and constipation.

 Tell your patient that he may need potassium supplements with diuretic and digitalis glycoside therapy.

If your patient is taking more than one drug, help him devise a dosage schedule that accommodates his lifestyle. For example, advise him to take twice-daily drugs before breakfast and dinner (if not contraindicated) to avoid forgetting to take them during a busy workday.

 Instruct the patient to follow a low-sodium diet. If necessary, refer him to a dietitian. Tell him to record his daily weights in a log and to report a weight gain greater than 3 pounds over 2 days or less.

Tell him to conserve his energy by resting frequently. Explain how to obtain and use supplemental oxygen, if prescribed.

 Most patients with heart failure benefit from a home care referral. If your patient will have a home care nurse, tell him that the nurse will perform a complete assessment of his cardiac and respiratory status. And the nurse will answer questions about his drug regimen and monitor his compliance with the drug regimen and dietary restrictions.

The home health nurse will also instruct him and his family about using home oxygen therapy, if prescribed.