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Cardiac Drugs. Daymar College Lisa H. Young, RN, BSN, MA Ed. How to Use a Drug Book. Classifications and Prototype Drugs ( Pr ) Pregnancy Category Controlled Substances Availability Uses and Unlabeled Uses Action and Therapeutic Effect Contraindications and Cautious Use Route and Dosage

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cardiac drugs

Cardiac Drugs

Daymar College

Lisa H. Young, RN, BSN, MA Ed

how to use a drug book
How to Use a Drug Book
  • Classifications and Prototype Drugs (Pr)
  • Pregnancy Category
  • Controlled Substances
  • Availability
  • Uses and Unlabeled Uses
  • Action and Therapeutic Effect
  • Contraindications and Cautious Use
  • Route and Dosage
  • Administration
  • Intravenous Drug Administration
  • Adverse Effects
  • Diagnostic Test Interference
  • Interactions
  • Pharmacokinetics
  • Clinical Implications
  • Therapeutic Effectiveness

http://www.youtube.com/watch?v=Jh_U8V9-Htw

http://www.youtube.com/watch?v=9mcqPJFB3UE

pharmacologic principles
Pharmacologic Principles
  • Drug Names

Generic name

Brand name/Proprietary name

Chemical name

  • Indications and Usage
  • Contraindications
pharmacologic principles1
Pharmacologic Principles
  • Drug Interactions
    • “Red Flag” Drugs: Warfarin

Aspirin

Cimetinde

Theophylline

  • Drug Reactions

Adverse reaction

Side effects

pharmacologic principles2
Pharmacologic Principles
  • Drug Administration
  • Enteral Routes
  • Parenteral Routes
  • Topicals & Transdermal
pharmacologic principles3
Pharmacologic Principles
  • Pharmacokinetics
  • Absorption
  • Bioavailability
  • Therapeutic range
  • Distribution
pharmacologic priniciples
Pharmacologic Priniciples
  • Metabolism
  • Elimination
  • Pharmacodynamics
  • Tolerance
pharmacologic principles4
Pharmacologic Principles
  • Half-Life
    • Digoxin 30-60 hours
    • Warfarin 0.5 – 3 days
    • Heparin 1 – 2 days
  • Poisonings/Toxicity
legal classifications of drugs
Legal Classifications of Drugs
  • Prescription Drugs
  • Nonprescription Drugs
  • Controlled Substances

Drug Abuse

Drub dependency

pharmacologic principles5
Pharmacologic Principles
  • Prescription Orders
    • Patient Name (superscription)
    • Address
    • Drug name (inscription)
    • Drug dose
    • Route (subscription)
    • Frequency of administration
    • Number to be dispensed
    • Number of refills allowed
    • DEA #
    • MD Name/signature
    • MD address
    • MD Phone number

http://www.youtube.com/watch?v=Mhqe12Aj1dE

reading prescription label
Reading Prescription Label
  • http://www.youtube.com/watch?v=S0oqYJp9t2o
  • http://www.youtube.com/watch?v=hRdGLzylovM
medication administration
Medication Administration
  • Ten Rights
    • Right patient name
    • Right drug
    • Right dosage
    • Right route & technique
    • Right time
    • Right documentation
    • Right client education
    • Right to refuse
    • Right assessment
    • Right evaluation

http://www.youtube.com/watch?v=cm7GexPKNOc&list=PLxdOP8vuQhz9SNJLTWjTGzh3yOTsEsd6l

http://www.youtube.com/watch?v=kdB0PmsX2ng

http://www.youtube.com/watch?v=yhHq-pV6HOw

charting medication administration
Charting Medication Administration

Examples of charting:

A. 9/1/12 9:00 a.m. nitroglycerin, 1 tab, sublingually. Written instructions given to pt. Precautions explained. Told to call office at 1:00p.m. today to report progress of his condition….M. Richards, CMA (AAMA)

B. 1/19/12 11:00 a.m. B 12 vitamin, 10000mcg given IM to left deltoid muscle without complications and band aid applied to injection site. Pt tolerated injection well. Pt. given written instructions for possible side effects and considerations. Pt to return in one monthly to receive monthly B 12 injections as ordered……L.Young, CCT.

C. 10/10/2012 1:00 p.m. Mantoux test, 0.01 ml. Tuberculin Purified Protein Derivative, Left forearm, subcutaneous, small wheal noted. Pt. instructed not to rub or cover the are and to return for reading on 10/12/12…..M. Richards, CMA (AAMA)

six cs of charting
Six Cs of Charting
  • Client’s own words
  • Clarity
  • Completeness
  • Conciseness
  • Chronological
  • Confidentiality

http://www.youtube.com/watch?v=mYGf0AdhhI4

http://www.youtube.com/watch?v=SDcmXqSvP7A

guidelines for charting
Guidelines for Charting
  • Date/time of entry
  • Legible handwriting
  • Permanent black ink
  • Proper terminology, correct spelling and correct grammar
  • Document in sequence
  • Be concise
  • Correct errors
  • Sign every entry

http://www.youtube.com/watch?v=pe2TQJKXZIs

http://www.youtube.com/watch?v=GMVwoR0YU-I

http://www.youtube.com/watch?v=Bkoic2dLFmY

apothecary system
Apothecary System
  • gr = grain gal = gallon
  • dr = dram qt iii = 3 quarts
  • oz = ounce ix = 9
  • lb = pound qt i = 1 quart
  • m = minims gr ½ = ½ grain
  • fl dr = fluid drams pt iiiss = 3 ½ pints
  • fl oz = fluid ounce 1 grain = 60 mg
  • pt = pint
  • qt - quart
metric system
Metric System

Metric Conversion Value Chart

Kilo – Hecto-Deka-Base-Deci-Centi-Milli-X-X-Micro

Gram

Liter

Meter

45.2 grams = 45200.0 milligrams

1cubic centimeter (cc) = 1 milliliters (ml)

http://www.youtube.com/watch?v=2QR9yCkAEpE

dosage definitions
Dosage Definitions
  • Dosage unit
  • Dosage strength
  • Dosage ordered
  • Desired dose
  • Dose on hand
  • Amount to administer
drug dosage calculations
Drug Dosage Calculations

Drug Calculation: Formula Method

Ordered Dose X Available Amount

Available Dose Amount to give

Ordered dose: 500 mg

Available dose: 1000 mg

Available amount: 1 ml

http://www.youtube.com/watch?v=b69Wr008dzM

http://www.youtube.com/watch?v=BMDOk3RAHC4

http://www.youtube.com/watch?v=Wa9Zi64_HJk

calculating pediatric dosages
Calculating Pediatric Dosages
  • Clark’s Rule
  • Fried’s Rule
  • Young’s Law
  • West’s nomogram
  • Body Weight method

http://www.youtube.com/watch?v=AQaeAON4GUM

patient education
Patient Education
  • Assessment
  • Plan
  • Implementing
  • Document
  • Evaluate
  • Special Needs
  • Noncompliance

http://www.youtube.com/watch?v=1HQHdpAov-I

professionalism
Professionalism
  • Cultural Considerations
  • The Life Span
  • Understanding and knowledgeable about medication
  • In the Workplace
  • The Law
inotropic chronotropic and dromotropic drugs
Inotropic, Chronotropic and Dromotropic Drugs
  • http://www.youtube.com/watch?v=eboZYnTF6vs
neurological control of the heart and blood pressure
Neurological Control of the Heart and Blood Pressure
  • Sympathetic Nervous System
  • Adrenergic Response

_ Catecholamines

_ Adrenaline

_ Beta 1-Adrenergic Receptors

_ Alpha 1-Adrenergic Receptors

http://www.youtube.com/watch?v=lw1Ag86SvlY

neurological control of the heart and blood pressure1
Neurological Control of the Heart and Blood Pressure
  • Baroreceptors

_ Pressure receptors

_Mechanoreceptors

_Efferent pathways

neurological control of the heart and blood pressure2
Neurological Control of the Heart and Blood Pressure
  • Chemoreceptors

_ carotid artery

_ Elevated arterial carbon dioxide level

_ Heart rate increases

_ Vasoconstriction

neurological control of the heart and blood pressure3
Neurological Control of the Heart and Blood Pressure
  • Parasympathetic Nervous System
  • Vagal Response

_ Cholinergic Response

_ Acetylcholine

_ Nicotinic Cholinergic Receptors

_ Muscarinic Cholinergic Receptors

neurological control of the heart and blood pressure4
Neurological Control of the Heart and Blood Pressure
  • Renin-Angiotensin-Aldosterone System

_ Release of Renin

_ Angiotensin I → Angiotensin II

_ Angiotensin-converting enzyme (ACE)

http://www.youtube.com/watch?v=M0vpn6YVwiI

cardiovascular pharmacology
Cardiovascular Pharmacology
  • Preload

The stretching of the ventricle at the end of diastole.

_ Increasing Preload

Administer extracellular fluid expander

Decrease dose of stop drugs that cause venous

vasodilation

_ Decreasing Preload

Stop or decrease fluid

Diuretics

ACE inhibitors

Aldosterone antagonists

Venous vasodilators

http://www.youtube.com/watch?v=FjdJdoZcbyA

http://www.youtube.com/watch?v=lPK017oR3bw

http://www.youtube.com/watch?v=mQirK5RxhFo

cardiovascular pharmacology1
Cardiovascular Pharmacology
  • Afterload

The resistance that the ventricle must overcome to eject its contents.

_ Increasing Afterload

Sympathomimetics (stimulate alpha receptors)

ADH

_ Decreasing Afterload

Smooth muscle relaxants

Calcium channel blockers

Alpha receptor blockers

ACE inhibitors

ARBs & PDE

http://www.youtube.com/watch?v=NFcg62I54w8

cardiovascular pharmacology2
Cardiovascular Pharmacology
  • Contractility

_Increasing Contractility

Sympathomimetics (stimulate B1 receptors)

PDE inhibitors

Cardiac glycosides

_Decreasing Contractility

Beta-blockers

Calcium channel blockers

http://www.youtube.com/watch?v=_sxiloNshfE

cardiovascular pharmacology3
Cardiovascular Pharmacology
  • Heart Rate

Cardiac output = heart rate X stroke volume

Increasing heart rate

Parasympatholytics

Sympathomimetics (stimulate B1 receptors)

Decreasing heart rate

Beta-blockers (block B1 receptors)

Calcium channel blockers

Cardiac glycosides

Other antiarrhythmics

http://www.youtube.com/watch?v=PJ8WsZOywgo

http://www.youtube.com/watch?v=OVVwyCCyH8E

sympathomimetics adrenergics
Sympathomimetics/Adrenergics
  • Stimulate the sympathetic nervous system
  • Increase heart rate
  • Increase contractility
  • Increase afterload

http://www.youtube.com/watch?v=HklZH5QdOeE

epinephrine
Epinephrine
  • Stimulates: B1 & B2 (low dose) & Alpha receptors (high doses)
  • Results: increased contractility, automaticity, bronchodilation and selective vasoconstriction
  • Uses: advanced cardiac life support, anaphylactic shock, hypotension/profound bradycardia
  • Considerations: instant onset, peak 20 minutes and given IV every 3 – 5 minutes for cardiac standstill

http://www.youtube.com/watch?v=9cpD8lG6DvY

dobutamine
Dobutamine
  • Stimulates: primarily B1, some alpha receptors and modest B2
  • Results: increased contractility, increased AV node conduction, modest vasoconstriction
  • Uses: as an inotrope with modest afterload reduction
  • Considerations: onset 1 – 2 minutes, peak 10 minutes, blood pressure is variable: B2 causes vasodilation, increased cardiac output increases blood pressure
dopamine
Dopamine
  • Stimulates: dopaminergic and some B1 at low doses, B1 at moderate doses, pure alpha stimulation at high doses (>10 mcg/kg/min)
  • Results: increased contractility at small and moderate doses, increased conduction, vasoconstriction at high doses, does not treat or prevent renal failure at low doses
  • Uses: refractory hypotension and shock
  • Considerations: IV onset 1 – 2 minutes & peak 10 minutes

http://www.youtube.com/watch?v=YrEn_1FBBsw

norepinephrine
Norepinephrine
  • Stimulates: primarily alpha stimulation, some B1
  • Results: potent vasoconstriction (vasopressor) and some increased contractility (positive inotrope)
  • Uses: refractory hypotension, shock, used as vsopressor but with inotrope properties
  • Considerations: Rapid IV onset, duration 1-2 minutes
phenylephrine synthetic compound
Phenylephrine(synthetic compound)
  • Stimulates: direct effect is dominant alpha stimulation, no substantial B1 effect at therapeutic doses, indirect effect; causes release of norepinephrine
  • Results: potent vasoconstriction (vasopressor)
  • Uses: refractory hypotension
  • Considerations: rapid IV onset, duration of action 10 – 15 minutes
non sympathomimetic medications
Non-Sympathomimetic Medications
  • Arginine vasopressin used as vasopressor
  • Milrinone (phosphodiesterase inhibitor) used as an inotrope
    • Side effects: ventricular dysrhythmias

exacerbation of accelerated ventricular

rate with atrial dysrhythmias

medications affect renin angiotensin aldosterone system
Medications Affect Renin-Angiotensin-Aldosterone System

Angiotensin-Converting Enzymes (ACE) Inhibitors

  • prevent conversion of angiotensin I to angiotensin II
  • inhibits angiotensin-converting enzyme
  • promotes arterial vasodilation
  • reduces afterload

Benazepril Captopril Enalapril Fosinopril

Lisinopril QuinaprilRamipril

angiotensin ii receptor blockers
Angiotensin II Receptor Blockers
  • Blocks angiotensin II
  • Similar hemodynamic effects as ACE inhibitors
  • Used in place of ACE inhibitors if they are not tolerated due to intractable cough or angioedema
  • ARBs end with “sartan”
  • Candesartan, first drug approved by FDA for heart failure

CandesartanIrbesartanTelmisartan

EprosartanLosartanValsartan

aldosterone antagonists
Aldosterone Antagonists
  • mineralocorticoid hormone
  • hold sodium and water and excrete potassium
  • potassium-sparing diuretics
  • decrease in preload
  • minimized release of catecholamines
  • improved endothelial function
  • antithrombotic effects
  • decreased vascular inflammation and myocardial fibrosis

SpironolactoneEplerenone

http://www.youtube.com/watch?v=OAkbKN6AuWE

beta blockers
Beta-Blockers
  • block B1 or B2 receptors
  • decrease heart rate and contractility
  • bronchial and peripheral vasoconstriction
  • management of heart failure
  • management of stable angina
  • management of acute coronary syndromes
  • decrease myocardial oxygen demand
  • increase coronary perfusion
  • management of hypertension

Atenolol Metoprolol Propranolol Esmolol

calcium channel blockers
Calcium Channel Blockers
  • decrease the flux of calcium
  • decrease heart rate, contractility and afterload
  • degree of negative inotropic effect
  • reduce coronary and systemic vascular resistance
  • decreasing myocardial oxygen demand
  • not indicated in the treatment of heart failure
  • adverse effects: peripheral edema, worsening heart failure, hypotension and constipation

Verapamil Dihydropyridine CCB Diltiazem

arterial and venous vasodilators
Arterial and Venous Vasodilators

Nitroglycerin and Nitrates

  • IV a primary venous vasodilator
  • sublingual produces both venous and arterial vasodilation
  • decreases preload
  • reducing myocardial oxygen demand
  • higher doses = coronary artery dilation
  • exhibits antithrombotic and antiplatelet effects
nitroprusside
Nitroprusside
  • mixed venous and arterial vasodilative
  • arterial vasodilator
  • indicated in hypertensive crisis
  • cardiac emergencies
  • hypotension side effect
  • possible thiocyanate toxicity
nesiritide
Nesiritide
  • synthetic brain natriuretic peptide (BNP)
  • counteract the effects of RAAS
  • venous and arterial vasodilative effects
  • management of acute decompensated heart failure
  • decrease preload and afterload
  • lowers blood pressure
digoxin
Digoxin
  • cardiac glycoside
  • weak inotropic properties
  • parpasympathetic properties
  • used in treatment of heart failure
  • narrow therapeutic range
  • easy to develop toxicity
  • electrolyte increase effect of digoxin
loop diuretics
Loop Diuretics
  • reduce preload
  • ascending loop of Henle
  • promote venous vasodilation
  • reduce preload
  • rapid onset and short duration of action
  • high-ceiling diuretics
  • effective for renal dysfunction

Bumex Lasix Demadex

thiazide diuretics
Thiazide Diuretics
  • Inhibit reabsorption of sodium & chloride
  • Less potent than loop diuretics
  • Decreased effectiveness with renal dysfunction
  • Low-ceiling diuretics

BendrofluazideCyclothiazide

Hydrochlorothiazide Chlorothiazide

IndapamidePolythiazide

MetolazoneTrichlormethiazide

emergency medications
Emergency Medications
  • Direct renin inhibitors – Aliskiren

_ treatment of hypertension

_ impact RAAS

  • Vasopressin 2 Antagonists – Tolvaptan

_ oral medication

_ renal collecting ducts

_ treatment of heart failure with volume

overload

lipid lowering medications
Lipid-Lowering Medications
  • Low-Density Lipoprotein Cholesterol
  • primary goal in the management of coronary heart disease
  • HMG-CoAreductase inhibitors (statins)
  • Bile acid resins
  • Nicotine acid
  • Dose dependent effect on LDL-C
triglycerides and high density lipoprotein cholesterol
Triglycerides and High-Density Lipoprotein Cholesterol
  • Nicotinic acid (Niacin)
  • Fibrates
  • Statins
  • Bile acid resins
  • Bile acid sequestrants
bile acid sequestrants resins
Bile Acid Sequestrants (Resins)
  • Combine with bile acids
  • Hepatic circulation
  • More production of cholesterol
  • Breaks cholesterol to make bile acids
  • Increases LDL-C receptors
  • Net decrease in total cholesterol
  • Net decrease in LDL-C
  • Constipation

QuestranColestidWelChol

nicotinic acid niacin
Nicotinic Acid (Niacin)
  • B complex vitamin
  • Dilates the cutaneous blood vessels
  • Increases blood flow to face, neck and chest
  • Vasodilation – “flush”
  • Increase gastric acid secretion
  • Decrease mortality in MI
  • Decrease VLDL-C production
  • Decreases lipolysis of triglycerides
  • Decreases hepatic triglyceride synthesis

NiacorSlo-Niacin Niaspan

fibrates
Fibrates
  • Fibric acid agents
  • Not fully understood
  • Stimulate lipoprotein lipase activity
  • Decrease hepatic triglyceride production
  • Decrease cholesterol synthesis
  • Increase mobilization of cholesterol
  • Enhance the removal of cholesterol
  • Increase cholesterol excretion
  • Raise HDL-C levels

Atromid-S TricorLopid

hmg coa reductase inhibitors
HMG-CoAReductase Inhibitors
  • Statins
  • Reduced lipid levels
  • Reduced future coronary events
  • Reduce the risk of coronary mortality & morbidity
  • Inhibition of HMG-CoAreductase
  • Reduce the quantity of mevalonic acid

Mevacor ZocorLescol Lipitor Crestor

intestinal absorption of inhibitors
Intestinal Absorption of Inhibitors
  • Newest class of lipid-lowering medications
  • May be combined with HMG-CoAreductase inhibitor
  • Ezetimibe
  • Blocks the absorption of cholesterol in the small intestine
coagulation overview
Coagulation Overview
  • To protect the integrity of the vessels and prevent harmful bleeding
  • To maintain the fluid state of the blood
  • These two goals must be achieved simultaneously to maintain health
clotting cascade
Clotting Cascade

Platelet Aggregation

Release Thromoboplastin

Prothrombin

Thrombin

Fibrinogen

http://www.youtube.com/watch?v=IEuFUSuGcxE&list=PL2UREUiTlHRn3iW9DhoeLjxNDM7Ly5vrA

streptokinase
Streptokinase
  • Earliest “clot busting” medication
  • Dissolves clots during an acute MI
  • Produce antistreptokinase antibodies

Contraindicated to use streptokinase in these patients

anistreplase apsac
Anistreplase (APSAC)
  • Anisoylated plasminogen streptokinase activator complex
  • Altered form of streptokinase
  • Converts circulating plasminogen into plasmin
  • May be given as an IV bolus over 2 – 5 minutes
  • Particular affinity for fibrin
  • Activates the plasminogen that is bound to fibrin
anticoagulants
Anticoagulants
  • Unfractionated Heparin (UFH)
    • Antithrombotic agent
    • Prevents the conversion of prothrombin to thrombin
    • Binds to plasma proteins, blood cells, and endothelial cells
    • Administered intravenously
    • Weight-based protocol
    • Administrated subcutaneoulsy
    • aPTT , PT, INR, platelet count, hemoglobin level and hematocrit
    • Bleeding potential complication
    • Thrombocytopenia
anticoagulants1
Anticoagulants
  • Low-molecular-weight Heparin (LMWH)
    • Accelerating the activity of antithrombin III
    • Longer half-life than UFH
    • No clotting times need to be monitored
    • Lower incidence of HIT
    • Higher rate of minor bleeding
    • Special dosing required for patients with chronic renal insufficiency
    • Protamine used for reversing effects
    • Administered subcutaneously
    • Enoxaparin
anticoagulants2
Anticoagulants
  • Direct Thrombin Inhibitors
    • Treatment of thrombosis in patients with HIT
    • Ability to inactivate fibrin-bound thrombin
    • Lepirudin and desirudin
    • Argatroban
    • Bivalirudin
    • Pradaxa
anticoagulants3
Anticoagulants
  • Factor Xa Inhibitors
    • New class of anticoagulants
    • Fondaparinux
    • DVT and PE prophylaxis treatment
    • Antithrombotic action by neutralizing factor Xa
    • Subcutaneous injection
    • No need for laboratory monitoring
    • No reports of HIT
    • Contraindicated in severe renal dysfunction
anticoagulants4
Anticoagulants
  • Warfarin (Coumadin)
    • Oral anticoagulant
    • Inhibition of the synthesis of factor II (prothrombin)
    • Altering the synthesis of other vitamin K-dependent factors
    • Primarily bound to albumin in the blood
    • Monitor PT and INR levels
    • Lifelong therapy for atrial fibrillation
    • Many drugs interact with warfarin
    • No aspirin, ibuprofen or naprosyn
antiplatelet therapy
Antiplatelet Therapy
  • Glycoprotein Iib/IIIa Inhibitors
    • Interfere with the final pathway of platelet aggregation
    • Prevent fibrinogen binding
    • Administrated intravenously
    • May be given with aspirin, clopidogrel & heparin
    • Abciximab (ReoPro)
    • Monitor platelet count and hemoglobin level
    • Treatment of unstable angina and non-STEMI
antiplatelet therapy1
Antiplatelet Therapy
  • Adenosine Diphosphate Inhibitors
    • Clopidogrel (Plavix)
    • Prevents adenosine diphosphate (ADP) activation of platelets
    • Treatment of unstable angina & non-STEMI
    • Avoid use of omeprazole (Prilosec)
    • Warning for patients who are poor metabolizers
    • Prasugrel
antiplatelet therapy2
Antiplatelet Therapy
  • Aspirin
    • Anti-inflammatory, analgesic, antipyretic & antithrombotic
    • Treatment of acute or chronic ischemic heart disease
    • Inhibiting cyclooxygenase and inhibiting the synthesis of thromboxane A2.
    • Inhibits endothelial production of prostabladin I2
    • Chewing aspirin accelerates absorption
    • GI side effects
treatment for myocardial infarction
Treatment for Myocardial Infarction
  • Oxygen
  • Aspirin
  • Sublingual or Intravenous Nitroglycerin
  • Intravenous Beta Blocker
  • Unfractionated Heparin
  • Glycoprotein IIb/IIIa Receptor Blocker