Cardiovascular Drugs James Shockley RN, BSN

Overview: Rules of Engagement

• Review of Learning Objectives• Explanation/Discussion – Anticoagulants– Cardiotonics– Anti-arrhythmics– Anti-anginals– Antihypertensives

• Review and Questions.

Important Vocabulary

• Positive inotropic effect – increased strength of contraction– Clients with PUMP failure

• Positive chronotropic effect – increased cardiac rate– Bradyarrhytmias

• Negative chronotropic – decreased cardiac rate– SVT

• Positive dromotropic effect increased AV conduction– Used in pt with heart block

• Negative dromotropic effect – block conduction of disorders– Afib

Anticoagulantsor there are no such things as blood thinners!

• Prevent extension and formation of clots by inhibiting the factors in the clotting cascade.

• USES – Thrombosis–PE–MI

Anticoagulants

• Side Effects– Hemorage– Hematuria– Ecchymosis– Bleeding gums– THROMBOCYTOPENIA

Anticoagulants

• Heparin– Prevents thrombin from converting fibrinogen to

fibrin– DOES NOT DISOLVE CLOT

• Test for is aPTT ( activated partial thromboplastin time)– Normal 20 – 36 seconds– Maintain a therapeutic level 1.5 to 2 times normal

Anticoagulants

• Heparin uses– Prophylaxis and treatment of DVT– PE– Afib with embolization– Used in DIC

• Low-melecular weight heparins– Prevention of thromboembolic phenomena

including DVT.

Anticoagulants

• Nursing –– Monitor aPTT q 4-6 hours or per MD

discretion.– Observe for S/S of bleeding…bleeding

precautions• Gums• Stool• Urine

• ANTIDOTE = PROTAMIN SULFATE

Anticoagulants

• Warfarin (coumadin)– Decreases PT activity and prevents use of vitamin

K by liver.– For long term anticoagulation• Thrombophlebitis• PE• Embolism formation from AFIB

Anticoagulants

• Warfarin• Test – – PT /INR( prothrombin time and international

normalized ratio)– Normal PT is 9.6 – 11.8 seconds• Goal is 2-3 times normal but may be higher

• ANTIDOTE – VITAMIN K PHYONADIONE (AQUAMEPHYTON)

Antiplatelets

• Inhibits aggregation of platelets in clotting process.– ASA– Plavix ( clopidogrel bisulfate)

• Side effects– GI upset / bleeding– Bruising tarry stools

Cardiotonics:General Information

• Cardiotonics=Cardiac/Digitalis Glycosides

• Glycoside = sugar+ attached to steroid nucleus

Cardiotonics:General Information

• Digitalization-being started on therapy

– Loading dose- series of doses until get full therapeutic effect (variations as per doctor’s orders)

–Maintenance dose-placed on a schedule once therapeutic effect obtained

Cardiotonics:General Information

• Increases cardiac output and efficiency– Slows heart rate– Increases cardiac output (CO)• Blood to kidneys and other organs• H2O, electrolytes and waste removed

– Symptoms of CHF relieved

Cardiotonics:General Information

• Inhibits sodium-potassium pump, increasing intercellular calcium which causes heart muscles to contract more efficiently.

• Produces a POSITIVE INOTROPIC EFFECT• Affects electrical impulses along pathway of cardiac

conduction system via a negative chronotropic action– Depresses SA node and slows conduction of electrical

impulses to AV node– Decreases number of impulses and number of ventricular

contractions per minute

Cardiotonics:General Information

• Examples:• Digoxin (Lanoxin)

-Rapid onset and short a short duration of action.

• Digitoxin -Slowed onset and longer duration of

action.

CardiotonicsIndications for use

• Congestive Heart Failure• Atrial Fibrillation• Atrial Flutter• SV Tachycardia• Paroxysmal and atrial tachycardia

Adverse Reactions

• Digitalis Toxicity/Intoxication– Toxic drug effects can occur when ANY

cardiotonic is administered.–Hypokalemia plays a role in toxicity

• Normal Serum Levels:– Digoxin: 0.5-2 Ng/ml. Toxic >2.5 Ng/ml– Digitoxin: 14-26 Ng/ml. Toxic > 35 Ng/ml

Dig toxicity

• Signs and symptoms–Cardiac: Brady/tachycardia, PVC’s,

bigeminy, trigeminy, other EKG changes–Neuro: Headaches, drowsiness, apathy,

visual disturbances, confusion, disorientation, delirium

Digitalis Toxicity

–Muscular: fatigue and weakness (asthenia)

–GI: N/V/D

Digitalis Toxicity

• Treatment–Withhold drug immediately–Blood tests. Serum Dig level–KCL IV or PO– {Digibind in presence of life threatening

arrythmias. Throws off serum levels.}–Atropine for severe bradycardia

Nursing Process & Implications

• Physical Assessment–Blood Pressure, Apical Pulse, RR–Auscultation of lungs– Edema of extremities– JVD–Weight– Sputum ( clear, frothy red, etc.)

Nursing Process & Implications

• Lab & diagnostic tests- EKG, renal and hepatic function, enzymes, CBC, B11, Drug levels

Nursing Process & Implications

– Weigh Daily – Monitor I&O– Monitor for Hypokalemia

• Patient becomes more susceptible to Digitalis toxicity.

– Administer the right dose at the right time.– ANY questions about administration, talk to the

charge nurse or the MD.

Please Note

• Dig toxicity can occur even when normal doses are being administered or when patient has been on a maintenance dose for a period of time.

Nursing Process & Implications

• Patient & family teaching usually night– Same time each day– Take pulse prior to taking med– DO NOT discontinue drug unless instructed to

do so by an MD.– Avoid OTC drugs.– Notify MD if S&S of toxicity occurs– Follow diet– Keep all appointments with MD.

Anti-Arrhythmics

• General Information• Indications for Use• Adverse reactions• Nursing Process/Implications

Anti-Arrhythmic:General Information

• Causes of Cardiac Dysrhythmias– Atrial vs Ventricular- abnormal impulses may

generate from the SA node or may be generated from other areas of the myocardium.

• Mechanisms of Action:– Suppresses impulse that triggers the arrhythmia

Examples of Anti-Arrhythmics

• Amiodarone hydrocloride – afib with RVR.– Pulmonary fibrosis– Increases effects of digoxin• Cut dose by half

• Adenosine (Adenocard) –for paroxysmal supraventricular tachycardia (PSVT)

Anti-Arrhythmics:Indications for use

• Used to treat dysrhythmias– (atrial tachycardia/AFib/flutter, PSVT, PVC’s,

VT/VF)

• Control angina pectoris caused by atheroschlerosis and hypertrophic subaortic stenosis

Anti-Arrhythmic:Adverse Reactions

• Cardiac dysrhythmias• Hypotension• Nausea• Dizziness• Headache• Cinchonism: Related to Quinidine

Administration-ringing in ears

Anti-Arrhythmic: Nursing Process & Implications

• Assessment:–NBP, Apical & Radial Pulses, RR–Pt’s general condition is assessed.– Subjective assessment.

• Laboratory and Diagnostic tests.– EKG, Renal and Liver Function tests, CBC,

serum electrolytes and drug levels.

Anti-Arrhythmic: Nursing Process & Implications

• Take BP, P, RR usually every 1-4 hours• If pulse rate >120 or < 60, hold drug and call

MD• If patient is acutely ill or receiving one of these

drugs parentally, the I+O should be measured and recorded

Anti-Arrhythmic: Nursing Process & Implications

• Planning and Implementation:– Instruct in monitoring patient’s pulse rate

and BP prior to taking med. – If pulse >120 or < 60, hold med and call

doctor.– Instruct patient to take BP periodically

Anti-Arrhythmic: Nursing Process & Implications

• Patient Family Teaching:– Teach technique for NBP, pulse

monitoring.–Avoid OTCs–Avoid alcohol or smoking– Follow directions on label–Do now chew tablets or capsules,

swallow the whole

Anti-Arrhythmic: Nursing Process & Implications

• Patient Family Teaching:– Instruct on side effects of medications– Do not drive or perform hazardous tasks if

lightheadedness occurs– Dry mouth: sip water, or ice chips may be used.– Wax matrix; is not absorbed, may be found in

stool.

Anti-Arrhythmic: Nursing Process & Implications

• Patient Family Teaching:–Keep all appt’s: MD, lab etc.–Adhere to diet restrictions–Report any problems to MD

immediately.

Anti Anginals

• General Information• Indications for Use• Adverse reactions• Nursing Process/Implications• Examples of Anti-anginals:– Nitrates: Nitroglycerin, Isosorbide dinitrate– Calcium Channel Blockers: Cardizem

General Information:Anti Anginals

• Used to treat Angina• Consists of Nitrates, Calcium Channel

Blockers, beta blockers• Increases blood supply and decreases

myocardial O2 demand.

Examples:Anti Anginals

• Nitrates: produce vasodilation–Decreases preload and afterload:reduces

myocardial O2 consumption - Nitroglycerine

1 tablet q5-10min x 3store in a cool dark place

- Isosorbide ( Isordil)

Anti Anginals• Beta-blockers– Interrupt adrenergic stimulation– Inhibit B2 receptors cause vasodilation in skelatal

muscle arterioles• Used to control angina by lowering BP

– Mainstay treatment of CHRONIC STABLE ANGINA– DO NOT STOP ABRUPTLY – Titrate down– Propanolol, Atenolol

• Beta blockers mask the S/S of hypoglycemia

Anti Anginals• Calcium Channel Blockers– Decreases cardiac contractility and work load of heart thus

decreasing O2 consumption• Relaxes coronary vascular smooth muscle• Dilates coronary arteries and peripheral arteries causing

vasodilation.- Verapamil ( Canan, Isoptin)

- Diltiazem (Cardizem) - Nifedipine (Procardia, Adalat)

- Amlodipine ( Norvasc)

Indications for use:

• Prophylaxis and long term treatment of Angina Pectoris.

• Acute attacks of Angina Pectoris• Treatment of Prinzmetal Angina• Treatment of coronary artery spasm

Adverse Reactions:• Nitrates:– Headaches common in early therapy– Dizziness, vertigo, weakness, hypotension,

flushing.– Reactions lessen/disappear with prolonged use– Doses are adjusted to avoid or decrease

adverse reactions and treatment of symptoms. – Goal: alleviate Anginal pain.

Adverse Reactions:

• Calcium Channel Blockers–Hypotension, pulmonary edema, CHF,

dizziness, nausea, skin rash, dermatitis, fever, and chills

• Usually not serious and rarely requires discontinuing drug

Nursing Process• Assessment–Record thorough description of Anginal

pain (type, radiates, events)– Thorough physical assessment (rest)

• Vital signs (AP)• Weight, extremity inspection,

auscultate lungs

Nursing Process

• Planning and implementation:–Monitor Blood pressure and pulse q 3-4

hours.–Record patient’s response to treatment.

• EX: Chest pain relieved? Monitor Chest pain

Nursing Process

Sublingual nitroglycerine:• Placement tablet in mouth under the tongue• May be ordered to be left at the bedside

Nursing Considerations.

• Nitrogylcerine Topical ointment:–Measured in inches or millimeters–Ambulatory patient should rest for 10-15

minutes and have BP and P checked before applying.–Rotate sites–Remove paper from previous application

Nitro “paste”– May use chest (front/back), abdomen, upper

or lower arms and legs – Ointment IS NOT rubbed into patient’s skin – Do not get ointment on YOUR fingers!!!– Assist with ambulation – Administer while pt is sitting or lying down

Transdermal: Nitro patch

• Skin must be free of hair, dry and not subject to excessive rubbing or movement.

• Apply at same time once a day in morning.• Keep patch on 12 hr Off 12 hr.• Remove previous pad and cleanse area. Be

sure to rotate sites.• Oral Tablets:

- Give on an empty stomach

Nursing Process:Planning & Implementation

• Calcium Channel Blockers:–Monitor I&Os & Daily Weights. S&S CHF.–Assess Chest Pain.–Monitor renal and liver function Tests–May administer with meals.

Patient & Family Teaching-Nitrates

• Avoid Alcohol• Notify MD: Headaches, flushing, dizziness• Follow MD instructions, Notify MD if med does

not relieve pain• Take capsules on empty stomach• Adequate supply on hand• If acute attack, sit or lie down• DO NOT mix with other drugs, keep in original

container• Always replace cap.

Patient & Family Teaching- Nitrates

• Keep record of anginal attacks Check expiration dates of SL meds.

• Handle SL tablets as little as possible • Once open SL tablets are good only for 90

days. • SL: Burning should occur under tongue• DO NOT chew or swallow

Patient & Family Teaching- Nitrates

• Teach how to apply ointment• Rotate sites of topical ointment or

transdermal patch • Cleanse old application sites • Wash hand before and after application• Cleanse area before application• Apply at the same time each day

Patient & Family Teaching

• Calcium Channel Blockers:– Notify MD of worsening S&S.

*Chest pain, SOB, irregular heart rate*Edema, dizziness, nausea

– Take Cardizem AC & HS as directed.– Check pulse prior to taking medications.– No OTC or ETOH unless cleared by MD.– Caution patient about photosensitivity.– Nitro SL can be used concurrently.

Antihypertensives

• Facts about Antihypertensives:– No one set therapy for treatment of hypertension.

Step approach– Thorough patient assessment required– MD orders medications based on history and physical

assessment. – Weight loss, NACL restriction, life style changes may be

ordered.

Antihypertensives

• Indications: Treatment of hypertension• Adverse Reactions: – Postural hypotension , especially early in therapy

• Antihypertensives act in the following ways– Kidneys – increase NA and water loss and lower blood

volume– Arterioles – decrease peripheral resistance– Veins – decrease return and lower cardiac output– Heart – reduce CO

Examples

• Combined alpha/beta adrenergic blocking agent • (adrenergic = activated by epi or epi like substance)– Normodyne (Labetalol)

• Peripherally acting Alpha-adrenergic blockers– MINIPRESS– Cardura

HTN

• Centrally acting Alpha-adrenergic blockers– Stimulate alpha receptors in CNS to inhibit

vasoconstriction• Clonidine

HTN

• Angiotensen Converting Enzyme (Ace Inhibitors)– Prevent peripheral vasoconstriction by blocking

conversion of angiotensin 1 to angiiotensin 2– Zestril (Lisinopril)– Capoten (Captopril)– Lotensin (Benazepril)– Vasotec ( Enalapril)• AVOID USE OF K+ supplements

HTN

• Beta Adrenergic blocking agents– Inhibit response to beta-adrenergic stimulation

decreasing cardiac output– Block release of epi and norepi thus decreasing HR and

BP• Beta blockers may mask the s/s of hypoglycemia

– Lopressor (metoprolol)– Tenormin (atenonol)– Carvedilol (Coreg)

Adverse Reactions

• Alpha/beta adrenergic blocking agents:– Fatigue– H/A– Drowsiness– N/V– Dyspnea– Dizziness– Bronchospasm– Postural hypotension

Adverse Reactions• ACE inhibitors– Hypotension– N/V– GI irritation– Dizziness, renal insufficiency– Angioadema– Cough– Headache– Fatigue– Constipation

Beta-adrenergic blocking agents

• Bradycardia, Hypotension• CHF• Dizziness, • Rash• Bronchospasm• Hyperglycemia• Sexual dysfunction• Eye irritaion• Joint pain

Nursing Process• Assessment– Orthostatic blood pressure checks.– Document blood pressure– Obtain patient weight

• Planning and implementation:– Take NBP (same arm/position) & pulse prior to

administration.– Hold meds if NBP is significantly low– Observe for adverse drug reactions

Nursing Process

• Planning and implementation:–Assist with ambulation to prevent postural

hypertension.–Rise slowly–Obtain daily to weekly weights.

Antihypertensives: Nursing Process

• Patient and Family Teaching– Teach family to take pulse and NBP– Teach adverse reactions– Instruct patients to continue to take

medications even if they are feeling better.

Patient and Family Teaching

–Avoid alcohol, OTC medications– Avoid other prescriptions medications –Avoid hazardous tasks if drowsy or light

headed– To avoid lightheadedness and dizziness,

instruct patient to rise slowly from sitting or lying position.

Questions

Review of Main Points

• Cardiotonics• Anti-arrhythmics (anti-dysrhythmics)• Anti-anginals• Anti-hypertensives