CARDIOVASCULA

R DRUGS
dr. Dian Nugrahenny,
M.Biomed.
Department of Pharmacology
Faculty of Medicine
Brawijaya University
diannugr2407@gmail.com

BASIC ANATOMY AND

PHYSIOLOGY
Functions of cardiovascular system:
Delivery of oxygen, nutrients, and hormones to
the various parts of the body
Transports waste products to the appropriate
waste removal system

COMPONENT OF
CARDIOVASCULAR SYSTEM
Cardiac
Blood vessels
Blood

Guyton Textbook of Medical Physiology, 11th ed.

BASIC ANATOMY
AND PHYSIOLOGY

Guyton Textbook of Medical Physiology, 11th ed.

CARDIAC SYMPATHETIC AND

PARASYMPATHETIC NERVES

Guyton Textbook of Medical Physiology, 11th ed.

ADRENERGIC SYSTEM
Receptor Subtype Tissue
Alpha 1
Contraction

Effects

Vascular smooth
muscle

Beta 1

Heart

Beta 2
Relaxation

Bronchial smooth

Inc. Heart Rate

Inc. Force of
Contraction

muscle

POSSIBLE MECHANISMS FOR

INFLUENCING HEART FUNCTION

Lllmann et al. 2000. Color Atlas of Pharmacology, 2nd

ed. Thieme.

HYPERTENSION

Primary (essential): 90%

Secondary
Virtually no symptoms
Treatment is usually life-long
Consequences of hypertension:
heart disease, kidney disease, blindness, stroke

INITIAL DRUG THERAPY

CHOICES

DiPiro et al. 2005. Pharmacotherapy: A Pathophysiologic Approach, 6th ed. The McGraw-Hill
Companies, Inc.

COMPELLING
INDICATIONS

DiPiro et al. 2005. Pharmacotherapy: A Pathophysiologic Approach, 6th ed. The McGraw-Hill
Companies, Inc.

DIURETICS
Drugs with a direct renal action.
Augment urine excretion (diuresis) by inhibiting the
reabsorption of NaCl and water.
Indications:
1. Mobilization of edemas: increase renal excretion of Na+
and H2O.
2. Antihypertensive therapy: decrease peripheral
resistance.
3. Therapy of congestive heart failure: decrease
peripheral resistance, cure symptoms of venous
congestion.

ACTION OF
DIURETICS

1.Thiazides (e.g. HCT): act in the

intermediate segment of distal
tubules.
2.Loop diuretics (e.g.
furosemide): act in the thick
portion of the ascending limb of
Henles loop.
3.K+-sparing diuretics (e.g.
spironolactone): an aldosterone
antagonist, act in the distal
portion of the distal tubule and
the proximal part of the collecting
ducts.

Side
effects
Increase
urine
output

SIDE EFFECTS OF DIURETICS

NURSING ALERTS

Nursing actions

Give in the early morning if

ordered daily

Rationale

Peak action will occur

during waking hours & not
interrupt with sleep

Keep a bedpan within reach.

Mainly to avoid fall
Assist to the bathroom anyone
who is elderly, weak, dizzy, or
unsteady in walking.
Postural
hypotensio
n

Assist the patient to get up

slowly

Possibility
Record fluid intake & output
of
regularly
dehydration

Avoid falling

Avoid fluid volume depletion

due to excessive diuresis

Hypo/Hyper Monitor serum potassium level Avoid K depletion due to

-kalemia
(within 3.5-5 mEq)
thiazide & loop diuretics or
avoid K accumulation in
patient taking K-sparing
diuretics

CA2+CHANNEL
BLOCKER
(CCB)

Inhibit the influx of

Ca2+ ions without
affecting inward Na+ or
outward K+ currents to a
significant degree.
Inhibition of cardiac
functions by VERAPAMIL

Nifedipine

Verapamil

used as an antiarrhythmic drug

SIDE EFFECTS OF CCB

Hypotension, dizziness, weakness, peripheral
edema, headache, heart failure, pulmonary
edema, nausea, constipation
Bradycardia (Verapamil, Diltiazem)
Tachycardia (Nifedipine & other
dihydropyridines)

16

CCB NURSING ALERTS

The older may have a greater hypotensive effect after taking
CCBs than younger adults. The nurse must monitor them
closely during dosage adjustments.
Make position changes slowly to minimize hypotensive effects.
Some patients may experience dizziness and lightheadedness, especially during early therapy. The nurse should
assist the patient with all ambulatory activities and instructs
the patients to ask for help when getting out of bed or
ambulating.

RENIN-ANGIOTENSIN-ALDOSTERONE
SYSTEM (RAAS)

ACE
Inhibitor
s

ACTION OF ANGIOTENSIN II
Angiotensin
II receptor
blocker
(ARB)

reabsorption

Adrenal cortex

ACE INHIBITORS
Used to treat hypertension, heart failure, myocardial
infarction, and nephropathy
Enalapril 10-40 mg/day in 1 or 2 doses
Lisinopril 10-40 mg once daily
Perindopril 2-8 mg daily
Ramipril 1.25-10mg once daily

Angiotensin II receptor
blockers (ARBs)
Used for hypertension, may be used as an alternative
to ACE inhibitors in the management of heart failure
and diabetic nephropathy.
Irbesartan 150-300 mg once daily
Losartan 25-100 mg once daily
Valsartan 80-160 mg once daily

ACE INHIBITOR ARB: NURSING

ALERTS
Potential Adverse Effects

Nursing Actions

ACE inhibitors and ARBs may

cause first dose
hypotension

Instruct the patient to lie down

if hypotension develops

ACE inhibitors may produce

dry cough, due to
accumulation of bradykinin

Warn patients about the

possibility of cough.
Consult the doctor if the cough
is bothersome to the patient.

ACE inhibitors may cause

hyperkalemia

Avoid potassium supplements,

potassium containing salt
substitutes and potassiumsparing diuretics

ACE inhibitors and ARBs are

Avoid these drugs in pregnancy
contra-indicated
Note:
The intestinalin
absorption of ACE inhibitors and ARBs may be re
ifpregnancy
taken with food.

BETA-BLOCKER
By blocking cardiac -receptors, -Blockers serve to lower
cardiac rate and lower the elevated blood pressure caused by
high cardiac output.
The mechanism
underlying their
antihypertensive
action via reduction
of peripheral
resistance is unclear.

Agonist

Antagonist

BETA BLOCKERS
Drug

Receptors
Blocked

Maintenance Dosage in
Hypertension

Atenolol

Beta1

50mg daily po

Metoprolol

Beta1

100-200mg daily in one to two doses po

200-400mg daily po (Slow release)

Carvedilol

Beta1 and 2

12.5-50mg bd po

Labetolol

Beta1 and 2

100-200mg bd po with food

Propranolol

Beta1 and 2

160-320mg daily po

24

ADRENERGIC SYSTEM
Receptor Subtype Tissue
Alpha 1
Contraction

Effects

Vascular smooth
muscle

Beta 1

Heart

Beta 2
Relaxation

Bronchial smooth
muscle
Insulin secretion

Stimulation

Inc. Heart Rate

Inc. Force of
Contraction

BETA BLOCKERS
Side Effects:
Bradycardia
Hypotension
Bronchospasms
GI disturbances
Fatigue
Nursing Alerts:
Caution patients not to stop taking them abruptly
because that can precipitate angina and MI
Instruct diabetics to monitor blood glucose levels more
often at vulnerable times
Screen for asthma patients on beta blockers

TREATMENT OF CHRONIC HYPERTENSION

IN PREGNANCY

DiPiro et al. 2005. Pharmacotherapy: A Pathophysiologic Approach, 6th ed. The McGraw-Hill
Companies, Inc.

ANTIANGINAL DRUGS
NITRATES

Drugs: nitroglycerin,
ISDN, ISMN.
As NO donors.
The effect is more
pronounced in
venous than in
arterial beds.

Nitrate Preparations and Dosage

Drug and
dosage form

Route

Dosage

Glyceryl Trinitrate
Sublingual tablet
500mcg

Sublingual

1 tablet under the

tongue
immediately as
required

Spray 0.4mg/dose Sublingual

Spray 1-2 doses

under tongue

Capsule 2.5mg
(Retard)

1-2 capsules 2-3

times a day

Oral

Nitrate Preparations and Dosage (Contd)

Drug and dosage

form

Route

Dosage

Glyceryl Trinitrate (Contd)

Transdermal
patches 5mg /
10mg

Transdermal

1 patch every 24
hours

Isosorbide Mononitrate
Tablet 20mg

Oral

20mg bd to tid /
40mg bd

Tablet 60mg
(controlled
release)

Oral

30-120mg in the
morning

Capsule 50mg
Oral
(sustained release)

1-2 capsules in the

morning

Nitrate Preparations and Dosage (Contd)

Drug and
dosage form

Route

Dosage

Isosorbide Dinitrate
Tablet 10mg

Oral

30-240mg in
divided doses

Tablet 40mg
Oral
(sustained release)

20-40mg every 12
hours

Capsule 20mg
Oral
(sustained release)

1 capsule bd or tid

NITRATE-TOLERANCE
Tolerance to nitrate can develop rapidly
This may be due to depletion of sulfhydryl (S-H)
groups in the vascular smooth muscle. These
groups are needed to convert nitrate to NO.

NITRATE: NURSING ALERTS

Potential Adverse
Effects

Nursing Actions

Headache

Inform patients that headache will diminish

with continued drug use. Can be relieved
by mild analgesics.

Orthostatic
hypotension

Slowly change from a sitting or lying

position to an upright position. Advise the
patient to lie or sit down if symptoms of
hypotension (e.g. dizziness,
lightheadedness) occur.

Tolerance

To prevent tolerance, use the minimum

effective dose. For long-acting
preparations, they should be used on an
intermittent schedule to allow at least 8
drug-free hours.

NITRATE: NURSING
IMPLICATIONS
Teach the patients:
NTG needs to absorb from mouth so dont swallow, may
crush tab with teeth to speed absorption if pain is severe
If chest pain continues after taking 3 slow/sustained
release (SL) tablets at 5-minute intervals then seek
emergency care
Carry with you at all times
Keep in dark glass bottle and get new supply every 6
months

NITRATE: NURSING IMPLICATIONS

(CONTD)
Take before any activity that usually precipitates chest
pain
Side effects may include flushing, throbbing headache,
hypotension, and tachycardia
May develop tolerance to NTG, so that many physicians
suggest the patch removed at 10 pm for 6-8 hours without
nitrates in system
Monitor BP and pain closely if IV route used

CONGESTIVE HEART
FAILURE
Inadequate tissue perfusion from a failing pump, volume
overload

Major causes: hypertension, myocardial infarction

Right Heart Failure
Predominant: Sign:
venous congestion
Subcutaneous
edema
Abdominal effusion
(ascites)
Hepatomegaly
Splenomegaly

Left Heart
Failure
Predominant:

Symptom
Dyspnea,

orthopnea,
cough
(pulmonary
edema)

DRUGS FOR HEART

FAILURE
3D:
VasoDilators:
Venodilators
Arteriolar dilators
Diuretics
Digitalis

VASODILATORS
Venodilators: Reduces preload by trapping blood in the
venous circulation
Arteriolar dilators: Reduces afterload by reducing arterial
resistance
Potensial side effect:
hypotension

Lllmann et al. 2000. Color Atlas of

Pharmacology, 2nd ed. Thieme.

OTHER
VASODILATORS
Hydralazine:
Dilate arterioles
Treats hypertension
Less postural hypotension
Minoxidil:
Dilate arterioles
For severe hypertension
Diazoxide:
Given i.v. causes prominent arteriolar dilation
For hypertensive crises
Can be used in the management of insulin-secreting pancreatic
tumors.
Nitroprusside sodium:
Dilate venous and arterioles
Given i.v. for hypertensive crises

DIGITALIS, CARDIAC
GLYCOSIDES
In severe cases of myocardial insufficiency,
digitalis may be added to augment cardiac force
(positive inotrope) and to relieve the symptoms of
insufficiency.
Very narrow therapeutic index.
Very long half-life.
Digoxin has many drug interactions:
diuretics,verapamil, amiodarone, etc.

PROCESSE
S IN
MYOCARDI
AL
CONTRACT
ION AND
RELAXATIO
N

Lllmann et al. 2000. Color

Atlas of Pharmacology, 2nd
ed. Thieme.

SIDE EFFECTS OF
DIGITALIS
Dysrhythmias
Bradycardia
Toxicity very narrow therapeutic index
hypokalemia makes it easier for toxicity to
occur
Anorexia, nausea, vomiting
Disturbances of color vision
Fatigue

DIGITALIS: NURSING
ALERTS
Withhold the drug & contact the physician if there are any
signs of digoxin toxicity or marked changes in the pulse
rate/rhythm (bradycardia)
Monitor digoxin levels closely: should be smaller than 2
ng/mL
Older adults are particularly prone to digoxin toxicity
Screen for factors that potentiate digitalis toxicity:
hypokalemia, impaired renal function, oral antibiotics,
quinidine, amiodarone, Ca++ channel blockers

CARDIAC
ARRHYTHMIAS
Autonomic nervous system disorders
Altered ionic permeability of cardiac membranes
Factors: trauma; hypoxia; infection; metabolic
disease; drugs and toxins
Intrinsic cardiovascular disease

CARDIAC IMPULSE
GENERATION AND
CONDUCTION

ANTI-ARRHYTHMIA DRUGS
(AARD): GENERAL
MECHANISMS OF ACTION
Change gating properties of
cardiac ion channels (Na+, Ca2+,
K+) directly
Change neuromodulatory control
of cardiac ion channel
opening/closing

CLASSIFICATION OF
AARDS

a) Variables for normal tissue models in ventricular tissue. b) Variables for SA and AV nodal tissue only.
c) Also has type II -blocking actions. d) Classification controversial. e) Not clinically manifest. f) Also
has sodium, calcium, and -blocking actions.

AARDS: NURSING ALERTS

Antiarrhythmic drugs are capable of causing new
arrhythmias, as well as an exacerbation of existing
arrhythmias.
Older adults taking antiarrhythmic drugs are at greater
risk for adverse reactions such as development of
additional arrhythmias or aggravating of existing
arrhythmias, hypotension, and congestive heart
failure.
Careful monitoring (HR, BP, ECG) is necessary for early
identification and management of adverse effects.

HEMOSTASIS AND
THROMBOSIS
C. SECONDARY HEMOSTASIS

latelets
adhesio
n

ADP, adenosine diphosphate; t-PA, tissue type plasminogen

activator

PARENTERAL
ANTICOAGULANTS
Heparin
Administered by injection
Helps inactivate thrombin, factor Xa and others
Half-life is short
Therapeutic Uses:
Open heart surgery
Deep Vein Thrombosis
Acute MI

PARENTERAL
ANTICOAGULANTS
Side Effects
Bleeding
Thrombocytopenia heparin induced
Hypersensitivity
Therapeutic effect is monitored by PTT (partial
thromboplastin time) every 6 hours and dose adjusted to
achieve PTT 1.5-2.0 times normal level

Nursing Alerts:
Monitor for signs and symptoms of bleeding: low HR,
hypotension, tachycardia, epistaxis
Avoid injuries
Hold injection sites longer than usual

ORAL
ANTICOAGULANTS
Warfarin
Act as false vitamin K and prevent regeneration of active
vitamin K from vitamin K epoxide, hence the synthesis of
vitamin K-dependent clotting factors.
Vitamin K promotes activation of factors II, VII, IX, and X.
Peak effects take several days.
Therapeutic Uses: Long-term prophylaxis of thrombosis, e.g.
in patients with prosthetic heart valves/atrial fibrillation.

ORAL
ANTICOAGULANTS

Warfarin has MANY drug and herb interactions

Hemorrhage
Warfarin is contraindicated in pregnancy
Must monitor PT (prothrombin time)/INR
(international normalized ratio, contains a
correction factor for PT)
Vitamin K can be given in case of overdose

DRUGS INTERACT WITH

WARFARIN

Abciximab
Acetaminophen
Alcohol
(acute and chronic)
Allopurinol
Aminodarone
Aminoglutethimide
Amobarbital
Anabolic steroids
Aspirin
Azathioprine
Butabarbital
Butalbital
Carbamazepine
Cefoperazone
Cefotetan
Cefoxitin
Ceftriaxone
Chenodiol
Chloral hydrate
Chloramphenicol
Chlorpropamide
Chlorthalidone
Cholestyramine
Cimetidine
Ciprofloxacin
Clarithromycin
Clofibrate

Corticotropin
Cortisone
Coumadin
Cyclophosphamide
Danazol
Dextran
Dextrothyroxine
Diazoxide
Diclofenac
Dicloxaxillin
Diflunsial
Disulfram
Doxycycline
Erythromycin
Ethacrynic acid
Ethchlorvynol
Fenoprofen
Fluconazole
Fluorouracil
Gemfibrozil
Glucagon
Glutethimide
Griseofulvin
Haloperidol
Halothane
Heparin

Ibuprofen
Ifosamide
Indomethacin
Influenza virus vaccine
Itraconazole
Ketoprofen
Ketorolac
Levamisol
Levothyroxine
Liothyronine
Lovastatin
Mefenamic
Meprobamate
Methimazole
Methyldopa
Methylphenidate
Methylsalicylate
Miconzale
Metronidazole
Miconazole
Moricizine HCl
Nafcillin
Nalidixic acid
Naproxen
Neomycin
Norfloxacin

Ofloxacin
Olsalazine
Omeprazole
Oxaprozin
Oxymetholone
Paraldehyde
Paroxetine
Penicillin G
Pentobarbital
Pentoxifylline
Phenobarbital
Phenylbutazone
Phenytoin
Piperacillin
Piroxicam
Prednisone
Primidone
Propafenone
Propoxyphene
Propranolol
Propylthiouracil
Phytonadione
Quinidine
Quinine
Ranitidine
Rifampin

Secobarbital
Sertaline
Simvastatin
Spironolactone
Stanozolol
Streptokinase
Sucralfate
Sulfamethizole
Sulfamethoxazole
Sulfinpyrazone
Sulfinpyrazone
Sulfisoxazole
Sulindac
Tamoxifen
Tetracycline
Thyroid hormone
Ticacillin
Ticlopidine
t-PA
Tolbutamide
Trazodone
Trimethoprimsulfamethoxazole
Urokinase
Valproate
Vitamin C
Vitamin E

WARFARIN AND G
HERBS
Garlic (Allium sativum) 2 case reports. Continuing ingestion
of high levels of garlic or garlic oil can decrease platelet
aggregation.
Ginger (Zingiber officinalis) Inconclusive results in studies in
healthy volunteers but case reports exist.
Ginkgo (Ginkgo biloba) The extract inhibits thromboxane and
prostacyclin in diabetics. A case report suggests interaction.
Green tea (Camellia sinensis) Inhibits platelet synthesis of
thromboxane.
Chavez, Life Sci 2006; 78:2146-57

ORAL
ANTICOAGULANTS
Nursing Implications:
Teach the patients:
Observe for signs of bleeding and report
bleeding from gums/nose or in stool/urine
Use soft toothbrush
Avoid using aspirin or NSAIDS or any meds that
may potentiate bleeding
Frequent lab tests are necessary to monitor

ANTIPLATELET
DRUGS
Aspirin
Prevention of thrombosis in arteries
Suppresses platelet aggregation due to inhibition
of thromboxan (TXA2) synthesis
Therapeutic Uses: prophylaxis of MI, prevent
reinfarction in patients with acute MI, prevent
stroke
Low dose - not greater than 325 mg/day
Side Effects: GI bleeding, bronchospasm

ANTIPLATELET
DRUGS
Clopidogrel (Plavix)
Adenosine diphosphate receptor (ADP) antagonist
Irreversible blocking of ADP receptors on the
platelet surface
Prevent ADP-stimulated aggregation
Therapeutic Uses: prevention of stroke,
vascular death & MI
Side Effects:
Hemorrhage (GI & Intracranial)
GI side effects

ANTIPLATELET
DRUGS
Nursing Implications:
Screen for asthma patients on aspirin
Teach the patients:
Drugs should be taken after meal due to GI irritation
Observe for signs of bleeding and report bleeding from
gums/nose or in stool/urine
Use soft toothbrush

SEMANGAT
BELAJAR!!!