Cardiovascular

Pharmacology
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Concept Map: Selected Topics in Cardiovascular Nursing

ASSESSMENT PHARMACOLOGY
Physical Assessment Cardiac Glycosides
Inspection PATHOPHYSIOLOGY
Myocardial Infarction
ACE Inhibitors
Palpation Beta Blockers
Acute Coronary Syndrome
Percussion
Auscultation
Valvular Heart Disease Antiarrhythmics
Pacemakers
Cardiac Monitoring CABG
Catecholamines
Lab Monitoring Abdominal Aortic Aneurysm Anticoagulants
Pericarditis
Peripheral Vasc Disease (PVD)
Fem-Pop Bypass Graft
Shock / Fluid Deficit
Raynauds Phenomenon
Arrhythmias / Dysrhythmias

Care Planning Nursing Interventions & Evaluation

Plan for client adls, Execute the care plan, evaluate for
Monitoring, med admin., Efficacy, revise as necessary
Patient education, more
 Cardiovascular Pharmacology
Alpha Anti-
Beta Blockers
ACE Blockers Arrhythmics
Anti-
Inhibitors
Hypertensives

Calcium Anti-Anginals Digitalis

Channel Glycosides
Anti-Lipemics
Blockers

Potassium Platelet
Loop Diuretics Sparing /
Combination Thiazide / Aggregation
Diuretics Related Inhibitors
Diuretics
 -pril------------------------------- ACE Inhibitor
-lol or olol ------------------Beta Blocker
-pine --------------------- Ca Channel Blocker
-statin --------------- anti-lipemic
-nitr ------------- nitrates
-zosin --------------- alpha blockers
 atenolol (Tenormin )
carvedilol (Coreg )
metoprolol (Toprol XL , LoPressor )

Alpha Blockers -olol propranolol HCl (Inderal )

benazepril HCl (Lotensin )
captopril (Capoten)

Beta Blockers -pril enalapril maleate (Vasotec)

lisinopril (Prinivil , Zestril)
amlodipine besylate (Norvasc )
Ca Channel Blockers -pine diltiazem HCl (Cardizem , Dilacor )
nifedipine (Adalat , Procardia XL )
Verapamil HCl (Calan , Isoptim , Covera )

ACE Inhibitors -statin atorvastatin calcium (Lipitor )

lovastatin ( Mevacor )
pravastatin (Pravachol )

Anti-Lipemic -nitr- rosuvastatin calcium (Crestor )

simvastatin (Zocor )
isosorbide dinitrate (Isordil )

Nitrates -zosin isosorbide mononitrate (Ismo)

Nitroglycerin

-lol doxazosin mesylate (Cardura)

prazosin HCl (Minipress)
 ACE Inhibitors
hypertension
CHF
Diabetic
benazepril HCl (Lotensin ) Neuropathy

captopril (Capoten) Left

Ventricular
enalapril maleate (Vasotec) Dysfunction
After
lisinopril (Prinivil , Zestril) 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
cough C.O. = HR x SV

BP = C.O. x PVR
 Alpha Blockers
doxazosin mesylate (Cardura)
prazosin HCl (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: Nursing Implications

Treatment of HTN
BPH (doxazosin (Cardura)
Teach patient to avoid
changing positions rapidly
(postural hypotension)
Check blood pressure prior
to administration; hold med
PRN (Parameters)

C.O. = HR x SV

BP = C.O. 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. = HR x SV

BP = C.O. x 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. x 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, A-
Flutter), 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 potassium-
sparing 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)
catecholamine
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
 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 anti-

arrhythmic; 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 Column B
Alpha Blocker A. isosorbide dinitrate (Isordil )
C J

B.
C.
digoxin (Lanoxin )
prazosin HCl (Minipres )
Beta Blocker D. amiodarone HCl (Cordarone, Pacerone )
E. hydralazine HCl (Apresoline )
S V

F.
G.
dipyridamole (Persantine )
nitroglycerin (Nitrostat )
Calcium Channel Blocker H. lidocaine HCl (Xylocaine )
I. simvastatin (Zocor )
J. doxazosin mesylate (Cardura)
K. quinidine (Quinaglute )
Anti-Anginal
L. clonidine (Catapres )
A G

M.
N.
atorvastatin calcium (Lipitor )
gemfibrozol (Lopid )
Anti-Arrhythmic O. lovastatin ( Mevacor )
P. spironolactone (Aldactone )
DH K Y Q. hydrochlorothiazide [hctz] (Hydrodiuril )
R. clopidogrel bisulfate (Plavix )
Anti-Hypertensive S. carvedilol (Coreg )
E L

T.
U.
furosemide (Lasix )
colestipol (Colestid )
Anti-Lipemic V. propranolol HCl (Inderal )
W. nifedipine (Adalat , Procardia XL )
I M N O U X. ticlopidine HCl (Ticlid)
Y. verapamil HCl (Calan )
Digitalis Glycosides Z. bumetanide (Bumex )

B
Loop Diuretics

T
Platelet Aggregation Inhibitors

F R X
Potassium Sparing / Combination Diuretics
ACE Inhibitors
P Z
W
Thiazide Diuretics Q
 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
 Effects
>Decreased
Calcium (Ca++) Frequent hives, chronic fatigue, canker
and cold sores, muscle cramps (Charlie
Normal level = Horses), and itchy skin dementia,
8.5 to 10 mg/dL depression, psychosis, tetany (Chvostek's
and Trousseau's signs), laryngospasm, or
Involved in bone and tooth generalized convulsions, cardiac
arrhythmias with lengthened QT
formation, blood segments
coagulation, nerve function,
<Increased
muscle contraction. 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 Hypomagnesemia: prolonged QT, flat T waves,
QRS, sine wave prolonged PR, aFib, torsade
Hypocalcemia: prolonged QT, flat or Hypermagnesemia: short PR, heart block,
inverted T waves peaked T waves, widened QRS0
Hypercalcemia: short or absent ST, Digitalis toxicity: ST depression (scoop), flat T
decreased QTc interval waves
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
 Appendix:
A Med-Surg Nurses description of cardiac carethings to think
about with patient care

Monitor your patient's If the physician prescribes a

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.
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 If he's also receiving a
therapy by administering a thiazide or loop diuretic,
loading dose (AS ORDERED) monitor his serum
to achieve a therapeutic potassium level; a low
level more quickly. Monitor potassium level can lead to
your patient's serum digitalis toxicity.
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.

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 If your patient is taking
may need potassium
supplements with diuretic
and digitalis glycoside
therapy.
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 The home health nurse will
benefit from a home care also instruct him and his
referral. If your patient will have
a home care nurse, tell him that
family about using home
the nurse will perform a oxygen therapy, if
complete assessment of his prescribed.
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.