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Cardiovascular Pharmaceuticals Irene Mueller, EdD, RHIA MHA2010.

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1 Cardiovascular Pharmaceuticals Irene Mueller, EdD, RHIA MHA2010

2 Objectives – First Hour Medications –Heart –Vessels

3 Objectives - 2 nd hour Medications –Vessels, continued Using the ICD-9-CM Table of Drugs Homework Answers Responses to Questions Resources

4 CV System Pharmaceuticals Many can be used for –Multiple Heart AND/OR vessel conditions –Dosage, etc. variations –Therefore, can be grouped many ways Many used in combination Many can interact with –each other –Other types of meds Following lists are most common Many other drugs

5 Actions of Heart Drugs Possible actions of cardiac drugs –change the rate of the heartbeat –change the rhythm of the heartbeat –change the amount of output of blood –change the strength of contraction Inotropic and Cardiotonic Blood vessel/Blood drugs can help heart

6 Classifications of Heart Drugs ACE Inhibitors*Anti-coagulants/Anti-platelets Anti-anginals#Anti-fibinolytics Beta-adrenergic BlockersAnti-hyperlipidemics Calcium channel BlockersCardiac glycosides Nitrites and NitratesDiuretics Anti-arrhythmic (-Dysrhythmic) agents Carbonic Anhydrase Inhibitors Beta-adrenergic Blockers (Class II) Osmotic Calcium channel Blockers (Class IV) Thiazide/Thiazide -like Potassium channel Blockers (Class III)Thrombolytics Sodium Channel Blockers (Class I) *Italics = in vessel section # Bold = in heart section

7 Anti-anginals ContraindicationsInteractionsSide Effects Anemia, severealcoholBlurred vision GI diseaseViagraDry mouth GlaucomaFlushing Intracranial pressureGI - Constipation Low blood pressureHeadache Hypersensitivity reaction Orthostatic hypotension

8 Beta-adrenergic Blockers Reverse the sympathetic system effects –Caused by exercise, mental exertions –Decrease heart rate and force of contractions –Decrease cardiac work & oxygen consumption –Often prevents myocardial ischemia and pain Long-term mgt of angina pectoris Can be combined with nitrates

9 Types of CV Beta receptors Beta-1 (β1) - heart Beta (β2) - blood vessels Beta (β3) - fat cells Block the effect of norepinephrine and epinephrine at receptor sites –reduce heart rate (B1) –reduce blood pressure by dilating blood vessels (B2)

10 NS Beta-adrenergic Blockers Nonselective Blockers (beta 1 and 2) Labetalol (Normodyne) – HTN Nadolol (Corgard) – HTN, angina pectoris Pindolol (Visken) – HTN Propranolol (Inderal) –HTN, angina, arrhythmias, migraine Timolol (Blocadren) – HTN, post MI

11 Selective Beta-1 Blockers acebutolol (Sectral) – HTN, ventricular arrhythmias atenolol (Tenormin) – HTN, angina pectoris bisoprolol (Zebeta) – HTN esmolol (Brevibloc) – SV Tachycardia metoprolol (Lopressor) – HTN, angina pect.

12 Calcium Channel Blockers Can be used to treat –Tachyarrhythmias, angina pectoris, HTN Decrease calcium entry into cells with actions potentials (heart and blood vessels) 2 effects in heart (conduction & muscle) –Decrease rate of SA node, AV conduction –Decrease force of contractions Effect in vessels – relaxation, vasodilation

13 Calcium Channel Blockers verapamil (Calan, Isoptin) – AV node/SV arrhythmias, angina diltiazem (Cardizem) –More effective as anti- hypertensive nifedipine (Procardia) –Vasodilator nicardipine (Cardene) –Vasodilation, relax coronary artery spasm Newer amlodipene (Norvasc) bepridil (Vascor) felodipine (Plendil) Isradipine (DynaCirc)

14 Nitrites and Nitrates Oldest/Most frequently used antianginals General dilation of systemic veins/arteries –Vascular smooth muscle Ions are converted by enzymes to Nitric Oxide Lower doses = more venous dilation

15 Nitrites and Nitrates Decrease preload and afterload of heart –Preload – force of venous return to heart –Afterload – arterial pressure (blood pressure) L ventricle must work against to eject blood Reduce cardiac work/oxygen consumption Used prophylactically and during angina Also to tx CHF Nitrates relieve vasospasm in coronary art.

16 Nitrites and Nitrates amyl nitrite (Vaporole) erythrityl Tetranitrate (Cardilate) isosorbie Dinitrate (Isordil) nitroglycerin (Nitrol, Notrostat, Nitrong, Nitro-Bid, Transderm-Nitro pentaerythritol Tetranitrate (Peritrate)

17 Nitroglycerin Sublingual –Almost immediate onset, but short duration –Acute anginal attacks Ointment (2%) Extended release tablets/capsules Transdermal patches IV – Emergencies/surgeries in hospital

18 Anti-arrhythmics 4 classes Class 1 – Sodium channel blockers Class 2 – Beta-adrenergic blockers –Described in anti-anginals Class 3 – Potassium channel blockers Class 4 – Calcium channel blockers –Described in anti-anginals

19 Anti-arrhythmics Dromotrophics – irregular rhythms Chronotropics – too fast or too slow Several ions regulate electrical system –Sodium, Potassium, Calcium Arrhythmias disturb movement of ions –Drugs can help restore normal movement Anti-arrhythmics do NOT cure causes

20 Sodium Channel Blockers (Class 1) Interfere with movement of sodium ions Slow conduction velocity Tx –Supraventricular tachycardias –Ventricular arrhythmias Side effects/Contraindications –Specific to each drug

21 Sodium Channel Blockers quinidine (chinchona bark) procainamide (Procanbid) disopyramide (Norpace) lidocaine (Xylocaine) phenytoin (Dilantin) Newer –flecainide (Tambocor), moricizine (Ethmozine), propafenone (Rythmol)

22 Potassium Channel Blockers Decrease frequency of arrhythmias bretylium (Bretylol) –Adrenergic neuronal blocker amiodarone (Cordarone) –Blocks alpha, beta, calcium receptors sotalol (Betapace) –Non-selective beta blocker

23 Other Anti-arrhythmics quinidine sulfate (Class 1) –decreases the # of atrial muscle contractions –used to treat Afib Pronestyl –ventricular arrhythmias w/premature contractions –Afib Lidocaine (Xylocaine) (Class 1) –IV - prevents & controls Vfib, pt w/recent severe MI –(SE) drowsiness, disorientation, confusion, convulsions, coma

24 Cardiac Glycosides Derived from Digitalis plants –Oleander, Lily of valley, Cane toads Increase force of contractions (Inotropic) –Lowers ventricular rate w/o increasing oxygen consumption Kidney function improves, reducing edema Decrease heart rate and AV conduction Increase kidney function, reduces edema

25 Cardiac Glycosides ContraindicationsInteractionsSide Effects HypothyroidismAdrenergicsArrhythmias Lactation, PregnancyAntacidsDizziness MIAnti-arrhythmicsElectrolyte imbalance Impaired kidneysDiureticsGI upset MonitorNeomycinHeadache High/low potassiumPhenobarbitalIrritability Irregular rhythmRifampinLethargy Slow heart rateSulfa drugsMuscle weakness Discontinue if notedSeizures Tremors

26 Cardiac Glycosides Digitalization, then maintenance Low potassium increases toxic effects High potassium antagonizes tx effects High calcium enhances action Tx CHF

27 Cardiac Glycosides deslanoside (Cedilanid-D) IM, IV digitoxin (Purodigin) PO, IV digoxin (Lanoxin) PO, IV side effects (overdose of digoxin) - nausea, vomiting, objects appear brighter, bradycardia

28 Diuretics Used to tx CV conditions –HTN, Edema (CHF) Diuretic actions –Stimulate urine production inc glomerular filtration –Decrease sodium reabsorption (diuresis) Five major classes of Diuretics

29 Diuretics ContraindicationsInteractionsSide Effects AnuriaCardiac glycosidesAnorexia BreastfeedingCorticosteroidsHypersensitivity reactions (skin rash) Known hypersensitivity LithiumHyperuricemia PregnancyNSAIDsHypokalemia Oral hypoglycemicsHyponatremia Hypotension Nausea Ototoxicity (loop)

30 Classes of Diuretics Carbonic anhydrase inhibitors Organic acids (Loop) Osmotic (Lumenal) (no  uses) Potassium-sparing Thiazide/Thiazide-like OTC (Xanthine derivatives)

31 Carbonic Anhydrase Inhibitors Increase sodium and water excretion Not used as often today Still adjunct tx in CHF (Acetazolamide) Also used to tx –Glaucoma –Petit mal seizures dichlorphennamide, mathazolamide –Acute mountain sickness (Acetazolamide)

32 Organic Acid (Loop) Diuretics Inhibit sodium and chloride ion transport in loop of Henle Great loss of sodium, chloride, and water –Usu. Hypochloremic alkalosis Tx –Edema inpts resistant to thiazides –Severe peripheral and pulmonary edema –Edema of CHF

33 Organic Acid (Loop) Diuretics bumetanite (Bumex) – CHF edema, ascites ethacrynic acid (Ederin) – CHF edema furosemide (Lasix) – CHF edema, HTN torsemide (Demadex) – CHF edema

34 Potassium-Sparing Diuretics Mild diuresis Inhibit potassium secretion in the distal convoluted tubules Primarily adjuncts to thiazide/loop diuretics –Inhibit hypokalemia Hyperkalemia promoted in –Impaired renal function/diabetic pts

35 Potassium-Sparing Diuretics amiloride (Midamor) – HTN spironolactone (Aldactone) – HTN, Edema spironolactone –w/thiazide (Aldactazide) – HTN, Edema triamterene (Dyrenium) - Edema, HTN

36 Thiazide/Thiazide-like Diuretics Largest group Inhibit sodium transport in the distal portion of the nephron Intense diuresis of sodium and water Increase excretion of chloride and potassium Produce alkalosis and hypokalemia –Hyponatremia in elderly reported

37 Uses of Thiazide Diuretics Edema of any cause –immediate Mild/moderate HTN –4-6 weeks –Decrease blood volume –Relax smooth muscles in vessel walls

38 Side Effects of Thiazides Drop in blood pressure Orthostatic hypotension Dizziness, faint Hypokalemia Hyperuricemia Hyperglycemia Muscle spasms/cramps Glucose changes in DM Nausea Diarrhea Constipation Anorexia Headache Impotence Elevation –BUN –Creatinine

39 Thiazide Diuretics bendroflumethiazide (Naturetin) benzthiazide (ExNa) chlorothiazide (Diuril, Diurgen) hydrochlorothiazide (Exidrix, Ezide, HydroDIURIL, Oretic) methyclothiazide (Enduron, Aquatensin) polythiazide (Renese) trichlormethizade (Diurese, Metahydrin, Naqua)

40 Thiazide-like Diruetics chlorthalidone (Hygroton) indapamide (Lozol) metalazone (Zaraxolyn) qinethazone (Hydromox)

41 Classification of Vessel Drugs Anti-coagulants/Antiplatelets*Diuretics Aspirin (Prostaglandin Inhibitor) Carbonic Anhydrase Inhibitors Coumarins Osmotic Heparin Thiazide/Thiazide -like Thrombolytics AntifibrinolyticsVasoconstrictors Anti-hyperlipidemicsOther Vasodilators Anti-hypertensives Nitrites and Nitrates ACE Inhibitors Calcium channel Blockers # Vasodilators*Bold = in vessel section Alpha-adrenergic Blockers # Italics = in heart sections Angiotensin II receptor blockers (ARBs)

42 Anti-coagulants (Veins) 4 stages in coagulation and clot resolution Anti-coagulant mechanisms –Inhibit the function of preformed clotting factors (heparin - IV/SQ) –Prevent synthesis of normal clotting factors Coumarin derivatives (PO) Mechanisms determines onset/duration of drug effects Used to prevent MIs

43 Anti-coagulants ContraindicationsInteractionsSide Effects Uncontrolled bleedingAcetaminophen, NSAIDsBleeding (increased) Pregancy (use with caution)AlcoholBlood irregularities Anti-infectivesGI disease BarbituratesKidney disease Chloral hydrateLiver disease Estrogen Steroids anabolic and cortico- Thyroid drugs Tricyclic antidepressants

44 Coumarin Derivatives Can be PO Warfarin sodium (Coumadin) Vitamin K antagonist Side effects –Hematuria, petechiae –Nausea, Diarrha, urticaria, alopecia

45 Heparin (IV,SQ) Used to Prevent –Venous thrombosis, esp. Pulmonary embolism –Clots prior to blood transfusion, during open heart surgery Treat –MI –Thrombophlebitis –Stroke Preferred anti-coagulant during pregnancy

46 Antiplatelets (Arteries) Suppress aggregation of platelets –Core of arterial thrombus Low-dose aspirin - Preventative Clopidgrogrel (Plavix) –Previous MI Ticlopidine (Ticlid) –More expensive than aspirin, same level of tx Dipyridamole (Persantin)

47 Aspirin acetylsalicylic acid Hippocrates (460 B.C and 377 B.C) –historical records of pain relief tx –use of powder made from willow bark and leaves for headaches, pains and fevers 1829, scientists discovered called salicin in willow plants which provide pain relief Aspirin was patented on February 27, 1900 by Bayer

48 Thrombolytics Dissolve existing clots Tx MI w/in 6 hours of symptoms onset 5 drugs –streptokinase (streptase) –alteplase (Activase) –urokinase (Abbokinase) –reteplase (Retavase) –anistreplase (Eminase)

49 Anti-fibrinolytics Help form blood clots Provide hemostasis Vitamin K = antidote for anticoagulant overdose

50 Anti-hyperlipidemics (Hypolipidemics) Atherosclerotic plaques usually in large/medium arteries –Lifestyle changes first –Diet changes needed even with meds Prophylactic tx, lifelong once begun –Reduce cholesterol and LDL

51 Anti-hyperlipidemics ContraindicationsInteractionsSide Effects Biliary obstructionantacidsabdominal pain Elevated liver enzymesanticoagulantsarrhythmias Gallbladder diseasecardiac glycosidesasthenia Lactationcimetidineconstipation Liver diseasecorticosteroidsdizziness Peptic ulcerscyclosporineheadache Pregnancyerythromycinmyalgia Renal dysfunctionironN&V sulfonylureasrash

52 Anti-hyperlipidemics Bile Acid sequestrants HMG CoA Reductase Inhibitors (statins) Nicotinic Acid Fibric Acid Derivatives Estrogens

53 Anti-hyperlipidemics cholestyramine (Questran, Prevalite) (BAS) colestipol (Colestid) (BAS) atorvastin (Lipitor) fluvastatin (Lescal) lovastatin (Mevacor) pravastatin (Pravachol) simvastatin (Zocor)

54 Break Time

55 Anti-hypertensives Treatment usually begins with –lifestyle changes, then add –diuretic or beta blocker, then –add another med, etc. Compliance big problem, HTN asymptomatic ACE Inhibitors Vasodilators –Alpha-adrenergic Blockers –Angiotensin II receptor blockers (ARBs)

56 ACE Inhibitors Angiotensin Converting Enzyme (ACE) –Angiotensin is a vasoconstrictor Slow formation of angiotensin II Decrease blood volume/pressure Increase renal blood flow Interfere Less with mental/physical performance = better Quality of Life = better compliance SE – nonprod cough, loss of taste, joint pain

57 ACE Inhibitors (PO) benazepril (Lotensin) enalapril (Vasotec) fosinopril (Monopril) quinapril (Accupril) ramipril (Altace) Tx - CHF

58 Alpha-adrenergic Blockers Alpha-adrenergics action similar to norepinephrine (smooth muscle contraction) Major alpha organ is blood vessels Alpha blockers effects –Vasodilation, lower blood pressure SE – nasal congestion, orthstatic hypotension, fainting

59 Alpha-adrenergic Blockers - PO doxazosin (Cardura) phentolamine (Regitine HCl) prazosin (Minipress) terazosin (Hytrin) Prescribed for Adults

60 Angiotensin II receptor blockers (ARBs) Angiotensin II receptor blockers (ARBs) Angiotensin II is a vasoconstrictor ARBs have effects that are similar to angiotensin converting enzyme (ACE) inhibitors ACE inhibitors act by preventing the formation of angiotensin II ARBS block the binding of angiotensin II to muscles on blood vessels

61 Angiotensin II receptor blockers (ARBs) candesartan (Atacand) eprosartan (Teveten) irbesartan (Avapro) telmisartan (Micardis) valsartan (Diovan) losartan (Cozaar) olmesartan (Benicar)

62 Vasoconstrictors Constrict the muscle fibers in blood vessel walls by direct action on vessels OR stimulate the vasomotor center in medulla –stop superficial hemorrhage –relieve nasal congestion –Raise blood pressure –Increase force of heart

63 Vasoconstrictors norepinephrine (Levophed) –tx hypotension metaraminol (Aramine) –prolonged duration, raises bl pressure epinephrine (Adrenalin)

64 Vasodilators Vasodilators Increase size of bl vessels Used to tx peripheral vascular disease, heart conditions (CHF), & HTN Papaverine – opium alkaloid, but NOT narcotic Alcohol - dilates blood vessels by depressing the vasomotor center of medulla –can tx angina pectoris?


66 Using the Table of Drugs Coder must determine –Adverse Effect vs Poisoning –Decision Flow chart Taking less/stopping drug is – NOT poisoning OR adverse effect 980 – 989 - Toxic effects of NON-medicinal substances = follow Poisoning steps

67 Table of Drugs Rows = Drugs, medicinal substances Columns = Poisoning code, E codes ALWAYS VERIFY in TL –Instructional Notes Ex: 960 Poisoning by antibiotics –Exclusion Note: 976.x should be used for local (topical) applications

68 Adverse Effect Correct substance administered as prescribed Adverse effect (manifestation) sequenced 1st E code from Therapeutic use column 2 nd CANNOT use E code from any other column Adverse Effect E codes MUST BE REPORTED

69 Adverse Effect Documentation Dx statements of –Toxic effect, toxicity, intoxication due to prescription drug (digitalis, lithium) –w/o any further info –Indicates Adverse Effect Other terms for AE –Allergic reaction –Cumulative effect (toxicity) –Hypersensitivity –Idiosyncratic reaction –Paradoxical reaction –Synergistic reaction

70 Adverse Effects Toxicity Synergistic reaction Side effect Idiosyncratic reaction Because of Pt differences –Age, sex, disease –Genetic factors Drug-related –Type –Administration route –Duration of tx –Dosage –Bioavailability

71 AE Drug E codes AE Drug E codes When agent causes multiple adverse reactions, code the E code ONCE When 2+ drugs are responsible, code individually unless there is a combo E code

72 Unspec AE 995.2 Unspec AE effect of drug, … –CAN be used in OUTpatient setting –Inappropriate for Inpatient setting Code S&S or 796.0 w/ Ecode

73 Late Effects of AE of Drugs Code residual condition 909.5 E code (E930-E949) Chronic effects of drug taken for long time and still being taken = current AE If delayed effects AFTER stopping = LE

74 Late Effects AE Examples Brain damage caused by penicillin allergy (while taking med) –348.9, E930.0 Brain damage caused by penicillin allergy (stopped using 6 months ago) –348.9, 909.5, E930.0

75 Poisoning Substance used incorrectly –Error in prescription –Drug overdose (Intentional/Accidental) –Non-prescribed drug taken with correctly prescribed/taken drug –Wrong administration method –Wrong dosage given/taken –Wrong medication given/taken

76 Poisoning Code from Poisoning column first Manifestation E code for how substance used –Accident, Assault, Suicide, etc. CANNOT use E code from Tx Use column

77 Poisoning by Interaction Tx drug and non- prescription drug or alcohol –Poisoning code for EACH substance –Manifestation, if documented –E code for EACH substance Ex: Coma due to Adverse reaction to Valium taken correctly, but with 2 martinis 980.0 969.4 780.01 E860.0 E853.2

78 Poisoning E codes Cause not stated = undetermined E code

79 Substance Abuse/Dependence Acute condition due to alcohol/drug abuse/dependence = Poisoning code –Code acute manifestation –Code abuse/dependence –E code Ex: Acute pulmonary edema due to accidental heroin overdose/pt dependent –965.01, 518.4, 304.00, E850.0 Chronic conditions are NOT poisoning

80 Late Effects of Poisoning Same LE rules Residual coded first 909.0 E929.2

81 Specific Drug NOT in Table American Hospital Formulary Service (AHFS) Index from brand names, etc to # –Hospital Pharmacist is valuable resource ICD-9-CM Appendix 3 has list of AHFS # by drug functions (no brand names) May have to research drug name to find type and then find type in Appx 3

82 Drug Resources Mayo Clinic – information/DrugHerbIndex information/DrugHerbIndex – le.htm le.htm MedlinePlus – mation.html mation.html

83 Drug Resources NLM. NIH. Drug Information Portal. – al.jsp al.jsp PDRHealth. Drugs and Supplements. –

84 Adverse Effects vs Poisoning Condition due to Drug, Med. Bio?NO Code Condition Yes Med used exactly as prescribed?NOCode as Poisoning Add code for condition Add E code (Optional) Yes Alcohol/non-prescr. drug also taken? NOCode condition Add Tx use E code (E930-E949) Yes Code as Poisoning Add code for condition Add E code (Optional)

85 Drug Coding Hypokalemia resulting from reaction to Diuril given by mistake in Dr’s office Electrolyte imbalance due to interaction between lithium carbonate and Diruil, both taken as prescribed Toxic encephalopathy due to excessive use of aspirin

86 Drug coding Coumandin intoxication due to accumulative effect resulting in gross hematuria Severe bradycardia due to accidental double dose of digoxin Lightheadedness due to interaction between Aldomet and peripheral vasodilating agent (both taken as presc.)

87 Drug Coding Bradycardia due to eating oleander leaves Systemic hypocalcemia and hypodalemia due to using lye in housecleaning Extrapyramidal disease due to attempted suicide by overdose of Thorazine six months ago


89 Resources Beaman, N. Pharmacology Clear and Simple. 2008. Philadelphia:F. A. Davis. Fulcher, E. M., Soto, C. D., and Fulcher, R. M. Pharmacology: Principles and applications. Saunders, 2003. Hitner & Nagle. Basic Pharmacology. 4 th ed. Glencoe,1999.

90 Resources ICD-9-CM Official Guidelines for Coding and Reporting, October 1, 2009 – Inotropic and Cardiotonic Drugs. Heart Rhythm Society. – Drugs/ Drugs/ Kapitanyan, Su, & Landry. 2009. Plant Poisoning, Glycosides – Cardiac. –

91 Resources Klabunde, R. Cardiovascular pharmacology concepts. – Medicinenet. Angiotensin II Receptor Blockers (ARBs). 2010. – WebMD. Heart Disease Medications. – disease-medications-index disease-medications-index

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