Cardiovascular Pharmacology

1. CardiovascularPharmacology A Good Resource: http://www.cvpharmacology.com/index.html

3. Concept Map: Selected Topics in Cardiovascular Nursing ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Beta Blockers Antiarrhythmics Catecholamines Anticoagulants 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 Raynaud’s Phenomenon Arrhythmias / Dysrhythmias Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more… Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

4. Cardiovascular Pharmacology Alpha Blockers Beta Blockers Anti-Arrhythmics ACE Inhibitors Anti-Hypertensives Anti-Anginals Digitalis Glycosides Calcium Channel Blockers Anti-Lipemics Loop Diuretics Potassium – Sparing / Combination Diuretics Platelet Aggregation Inhibitors Thiazide / Related Diuretics

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

6. atenolol (Tenormin ®) carvedilol (Coreg ®) metoprolol (Toprol XL ®, LoPressor ®) propranolol HCl (Inderal ®) • Alpha Blockers • Beta Blockers • Ca Channel Blockers • ACE Inhibitors • Anti-Lipemic • Nitrates • -olol • -pril • -pine • -statin • -nitr- • -zosin • -lol 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®)

7. ACE Inhibitors -pril • benazepril HCl (Lotensin ®) • captopril (Capoten®) • enalapril maleate (Vasotec®) • lisinopril (Prinivil ®, Zestril®) hypertension CHF Diabetic Neuropathy Left Ventricular Dysfunction After MI ACUTE M.I. “The Multi-Purpose Group !”

8. 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

9. The –pril’s: ACE Inhibitors • Treatment of Hypertension • captopril, enalapril, lisinopril—tx of HTN, CHF, decreased L ventricular function after MI • Always check BP before administering—hold PRN (parameters) • Teach patient to change positions slowly to avoid postural hypotension • “cough” C.O. = HR x SV BP = C.O. x PVR

10. -zosin Alpha Blockers • doxazosin mesylate (Cardura®) • prazosin HCl (Minipress®)

11. 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

12. The –zosin’s: Alpha Blockerssympatholytic Uses: Nursing Implications Teach patient to avoid changing positions rapidly (postural hypotension) Check blood pressure prior to administration; hold med PRN (Parameters) • Treatment of HTN • BPH (doxazosin (Cardura®) C.O. = HR x SV BP = C.O. x PVR

13. -nitr- Anti-Anginals • isosorbidedinitrate(Isordil ®) • isosorbidemononitrate(Ismo®) • Nitroglycerin • Nitro-dur®, • Transderm Nitro ® • Nitrol ® • Nitrostat ® • Nitrotab ®

14. 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

15. The –”NITR’s” 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

16. Anti-Arrhythmics( Anti-Dysrhythmics ) • amiodarone HCl (Cordarone ®, Pacerone® ) • lidocaine HCl (Xylocaine ®) • procainamide (Procanbid ®, Pronestyl ®) • quinidine (Quinaglute ®)

17. Prototype: lidocaine • Class Ibantiarrhythmic; decreases electrical conduction, decreases automaticity, increases rate of repolarization • Indications: short-term use for ventricular dysrhythmias; monitor respirations—respiratory arrest. Cardiac monitor—vital signs • Nursing Implications: CNS effects—drowsiness, altered mental status, paresthesias, seizures

18. A “Slight” Side-Effect of IV Amiodarone !

19. Lidocaine HCl—the old reliable; used for PVC’s, 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

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

21. Prototype: clonidine • Sympatholytic—decreases HR causes decrease in C.O., peripheral vasodilation—decreases BP • Indications: HTN, severe cancer pain • Nursing Implications: hypotension, orthostatic hypotension, administer twice daily in divided dose

22. Hydralazine—tx of essential hypertension • HCTZ/Lisinopril—combination drug –essential hypertension • Always check BP prior to administration—hold PRN (Parameters) • Postural hypotension precautions

23. -statin 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 ®)

24. Prototype: atorvastatin

25. -lol Beta Blockers -olol • atenolol (Tenormin ®) • carvedilol (Coreg ®) • metoprolol (Toprol XL ®, LoPressor ®) • propranolol HCl (Inderal ®)

26. 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.

27. 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

28. -pine Calcium Channel Blockers • amlodipine besylate (Norvasc ®) • diltiazem HCl (Cardizem ®, Dilacor ®, Tiamate ®, Cardizem SR ®, Cardizem CD ® ) • nifedipine (Adalat ®, Procardia XL ®) • Verapamil HCl (Calan ®, Isoptim ®, Covera ®)

29. 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

30. 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

31. Digitalis Glycosides • digoxin (Lanoxin ®) • (+) Inotrope, (-) Chronotrope • CHF, Atrial Tachy-arrhythmias (A-Fib, A-Flutter), Cardiogenic Shock • Assess Apical Pulse • Dig Toxicity—anorexia, fatigue, weakness, yellow-green halo’s 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

32. 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

33. Loop Diuretics • bumetanide (Bumex ®) • furosemide (Lasix ®) • Monitor serum K+ 3.5 – 5.0 mEq/L • Potassium rich foods

34. 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.

35. Platelet Aggregation Inhibitors • clopidogrel bisulfate (Plavix ®) • dipyridamole (Persantine ®) • ticlopidine HCl (Ticlid ®) • Prevention of TIA’s, CVA; combined with warfarin or ASA for heart valves, MI, bypass grafts, stents.

36. 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 NSAID’s (potentiates).

37. 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

38. Prototype: spironolactone • Spironolactoneis classified as a potassium-sparing diuretic. • Indications:congestiveheart 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

39. Thiazides / Related Diuretics • chlorthalidone • (Hygroton ®, Hylidone ®, Thalitone ® • hydrochlorothiazide [hctz] (Hydrodiuril ®) • indapamide (Lozol ®) • metolazone (Zaroxylyn ®)

40. NOTE THAT MORE THAN ONE HYPERTENSIVE –SOMETIMES SEVERAL--MAY BE NEEDED TO CONTROL HTN; USED IN COMBINATION WITH DIURETICS; Txedema, HTN • Monitor for hypokalemia

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

42. 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

43. Thrombolytic Medications

44. 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.

45. EMERGENCY CARDIAC PHARMACOLOGY

46. Oxygen • Epinephrine • Atropine • Adenosine • Lidocaine (or amiodarone)

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

49. 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 pushq3-5min • Nursing Implications: Monitor blood pressure, peripheral pulses, urinary outputUse infusion pump

50. 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.