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1. 2 3 Classification of Ischemic Heart Disease Ischemic Heart Disease Chronic coronary artery disease (stable angina) Acute coronary syndromes -Unstable.

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Presentation on theme: "1. 2 3 Classification of Ischemic Heart Disease Ischemic Heart Disease Chronic coronary artery disease (stable angina) Acute coronary syndromes -Unstable."— Presentation transcript:

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3 3 Classification of Ischemic Heart Disease Ischemic Heart Disease Chronic coronary artery disease (stable angina) Acute coronary syndromes -Unstable Angina -Myocardial infarction

4 4 1) Drugs that Affect Blood Coagulation Used in the prevention and management of thrombotic and thromboembolic disorders Used in the prevention and management of thrombotic and thromboembolic disorders

5 5 XIIa XIa IXa XaX VII THROMBINPROTHROMBIN X IX XII XI FIBRINOGENFIBRIN (monomer) FIBRIN (polymer) VIIa Intrinsic System Extrinsic System (thromboplastin) =Factor affected by oral anticoagulatants (Vitamin K-dependent clotting factor) =Factor affected by heparin (factor that can be inactivated by antithrombin) THE COAGULATION CASCADE

6 6 (i) Anticoagulant drugs (i) Anticoagulant drugs –Drugs that disrupt the coagulation cascade, & thereby suppress production of fibrin –Prevention of thrombosis in veins –Heparin Suppresses coagulation by helping antithrombin III inactivate thrombin, factor Xa and other clotting factors Suppresses coagulation by helping antithrombin III inactivate thrombin, factor Xa and other clotting factors Used in: Used in: –Prevention and treatment of pulmonary embolism, stroke, deep vein thrombosis (DVT) –Prevent coagulation in devices in open heart surgery and renal dialysis –Treatment of disseminated intravascular coagulation –Adjunct to thrombolytic therapy of acute myocardial infarction 1) Drugs that Affect Blood Coagulation (Cont ’ d)

7 7 Dosage Dosage –Based on body weights of the patients & their indications Adverse effects Adverse effects –Hemorrhage –Thrombocytopenia Decrease platelet count Decrease platelet count –Hypersensitivity reactions Since commercial heparin is extracted from animal tissue Since commercial heparin is extracted from animal tissue 1) Drugs that Affect Blood Coagulation (Cont ’ d)

8 8 –Warfarin Suppress coagulation by acting as an antagonist of vitamin K Suppress coagulation by acting as an antagonist of vitamin K 4 clotting factors (VII, IX, X & prothrombin) require vitamin K for their synthesis 4 clotting factors (VII, IX, X & prothrombin) require vitamin K for their synthesis Indications: Indications: –Prevention of venous thrombosis & associated pulmonary embolism –prevention of thromboembolism in patients with prosthetic heart valves –Prevention of thrombosis during atrial fibrillation –Reduce risk of recurrent transient ischemic attacks (TIAs) & recurrent MI 1) Drugs that Affect Blood Coagulation (Cont ’ d)

9 9 Daily dose Daily dose –usually 3 to 9 mg but it should be based on the INR values. –INR targeted values are different in different indications, usually within 2 to 3.5 Adverse effects: Adverse effects: –Hemorrhage –Teratogenic 1) Drugs that Affect Blood Coagulation (Cont ’ d)

10 10 (ii) Antiplatelet drugs (ii) Antiplatelet drugs –Suppress platelet aggregation –Indicated for prevention of thrombosis in arteries 1) Drugs that Affect Blood Coagulation (Cont ’ d)

11 11 Clopidogrel (Plavix) Clopidogrel (Plavix) –Adenosine diphosphate receptor (ADP) antagonist – Irreversible blocking of ADP receptors on the platelet surface –Prevent ADP-stimulated aggregation –Indicated for prevention of stroke, vascular death & MI –The combination of aspirin and clopidogrel appears to be the most effective and safest therapy for secondary prevention of stroke. 11) Drugs that Affect Blood Coagulation (Cont ’ d)

12 12 Clopidogrel (Plavix) Clopidogrel (Plavix) –Dose 75 mg po daily with or without food 75 mg po daily with or without food –Adverse effects: Hemorrhage (GI & Intracranial) Hemorrhage (GI & Intracranial) GI side effects GI side effects 11) Drugs that Affect Blood Coagulation (Cont ’ d)

13 13 Aspirin Aspirin –Suppress platelet aggregation by causing irreversible inhibition of cyclooxygenase, an enzyme required by platelets to synthesize thromboxane A 2 (TXA 2 ) 1) Drugs that Affect Blood Coagulation (Cont ’ d)

14 14 Aspirin Aspirin –Indicated in : Primary prophylaxsis of MI Primary prophylaxsis of MI Prevention of reinfarction patients who have experienced an acute MI Prevention of reinfarction patients who have experienced an acute MI Prevention of stroke in patients with a history of TIAs Prevention of stroke in patients with a history of TIAs –Dose Maintenance treatment mg daily po Maintenance treatment mg daily po –Adverse effects GI hemorrhage & also other hemorrhage GI hemorrhage & also other hemorrhage Bronchospasm Bronchospasm 1) Drugs that Affect Blood Coagulation (Cont ’ d)

15 15 (iii) Thrombolytic drugs (iii) Thrombolytic drugs –Promote lysis of fibrin, thereby cause dissolution of thrombi Streptokinase Streptokinase –First bind to plasminogen to form an active complex –The streptokinase-plasminogen complex then catalyzes the conversion of other plasminogen molecules into plasmin, an enzyme that digests the fibrin meshwork of clots 1) Drugs that Affect Blood Coagulation (Cont ’ d)

16 16 Alteplase (tPA) Alteplase (tPA) –Also known as tissue plasminogen activator (tPA) –Is produced commercially by recombinant DNA technology –Human tPA is an enzyme that promotes conversion of plasminogen to plasmin, an enzyme that digests the fibrin matrix of clots Adverse effects: Adverse effects: –Nausea & vomiting –Bleeding 1) Drugs that Affect Blood Coagulation (Cont ’ d)

17 17 Nursing Alerts: Nursing Alerts: –Monitor signs of hemorrhage Lowering of blood pressure, elevation of heart rate, discoloration of urine or stools, bruises, petechiae, etc. Lowering of blood pressure, elevation of heart rate, discoloration of urine or stools, bruises, petechiae, etc. –Monitor INR, APTT, PT regularly –Warfarin is contraindicated in pregnancy & breast-feeding 1) Drugs that Affect Blood Coagulation (Cont ’ d)

18 18 2) Cardiotonics & other Inotropic Drugs The cardiotonics are drugs used to increase the efficiency & improve the contraction of the heart muscle, which leads to improved blood flow to all tissues of the body The cardiotonics are drugs used to increase the efficiency & improve the contraction of the heart muscle, which leads to improved blood flow to all tissues of the body

19 19 Digoxin Digoxin –Inhibits the enzyme Na, K-adenosine triphosphatase (Na, K-ATPase), increases the movement of Na out of myocardial cells after contraction –As a result, Ca enters the cell in exchange for Na, causing additional Ca to be released from intracellular binding sites –With the increase in intracellular concentration of free Ca ions, more Ca is available to activate the contractile proteins, actin & myosin, & increase myocardial contractility 2) Cardiotonics & other Inotropic Drugs (Cont ’ d)

20 20 Side effects: Side effects: –Usually associated with excessive dose –Digoxin toxicity: anorexia, nausea, vomiting, diarrhoea, visual disturbance, confusion & mental disturbance, arrthythmia, heart block anorexia, nausea, vomiting, diarrhoea, visual disturbance, confusion & mental disturbance, arrthythmia, heart block Dosage: Dosage: –Maintenance: mcg daily 2) Cardiotonics & other Inotropic Drugs (Cont ’ d)

21 21 Milrinone (Primacor) Milrinone (Primacor) –Increase levels of cyclic adenosine monophosphate (cAMP) in myocardial cells by inhibiting phosphodiesterase (PDE) –Relax vascular smooth muscle to produce vasodilation & decrease preload & afterload –Used in short term management of acute severe heart failure that is not controlled by digoxin, diuretics & vasodilators 2) Cardiotonics & other Inotropic Drugs (Cont ’ d)

22 22 2) Cardiotonics & other Inotropic Drugs (Cont ’ d) Side effects: Side effects: –Arrhythmias, headache, hypotension Dosage: Dosage: –Maximum dose: 1.13mg/kg daily

23 23 Nursing Alerts: Nursing Alerts: –Withhold the drug & contact the physician if there are any signs of digoxin toxicity or marked changes in the pulse rate/rhythm –Monitor digoxin levels closely: should be smaller than 2 ng/ml –Older adults are particularly prone to digoxin toxicity –Hypokalemia makes the heart muscle more sensitive to digoxin, thereby increasing the possibility of developing digoxin toxicity 2) Cardiotonics & other Inotropic Drugs (Cont ’ d)

24 24 3) Antihypertensive Drugs –(i) Diuretics Diuretics are drugs that increase renal excretion of water, sodium & other electrolytes, thereby increasing urine formation & output Diuretics are drugs that increase renal excretion of water, sodium & other electrolytes, thereby increasing urine formation & output Used in the management of heart failure, renal & hepatic disease, hypertension, ophthalmic surgery Used in the management of heart failure, renal & hepatic disease, hypertension, ophthalmic surgery

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26 26 3) Antihypertensive Drugs (Cont ’ d) –Thiazide diuretics: Decrease reabsorption of Na, water, Cl & bicarbonate in the distal convoluted tubule Decrease reabsorption of Na, water, Cl & bicarbonate in the distal convoluted tubule Hydrocholorothiazide Hydrocholorothiazide – mg daily or BD po Indapamide (Natrilix) Indapamide (Natrilix) –2.5 mg/1.5mg(S.R.) daily po

27 27 –Loop Diuretics: Inhibit Na & Cl reabsorption in the ascending loop of Henle Inhibit Na & Cl reabsorption in the ascending loop of Henle Frusemide Frusemide –20-80 mg daily po Bumetanide (Burinex) Bumetanide (Burinex) –0.5-2 mg daily po 3) Antihypertensive Drugs (Cont ’ d)

28 28 –Potassium-Sparing Diuretics: Act directly on the distal tubule to decrease the exchange of Na for K Act directly on the distal tubule to decrease the exchange of Na for K –Amiloride : 5-20 mg daily po –Triamterene: mg daily in divided dose po Spironolactone Spironolactone –Block the Na-retaining effects of aldosterone in the distal tubule – mg daily po 3) Antihypertensive Drugs (Cont ’ d)

29 29 –Combination Products Thiazide & related diuretics are available in numerous fixed-dose combination with non- diuretic antihypertensive agents & with K- sparing diuretics. This can increase patient compliance & prevent K imbalances: Thiazide & related diuretics are available in numerous fixed-dose combination with non- diuretic antihypertensive agents & with K- sparing diuretics. This can increase patient compliance & prevent K imbalances: –Dyazide (Hydrochlorothiazide 25mg+Triamterene 50mg) –Moduretic (Hydrochlorothiazide 50mg+Amiloride 5mg) –Hyzaar (Losartan 50mg+Hydrochlorothiazide 12.5mg) 3) Antihypertensive Drugs (Cont ’ d)

30 30 Side effects Nursing actions Rationale Increase urine output Give in the early morning if ordered daily Peak action will occur during waking hours & not interrupt with sleep Keep a bedpan within reach. Assist to the bathroom anyone who is elderly, weak, dizzy, or unsteady in walking Mainly to avoid fall Postural hypotension Assist the patient to get up slowly Avoid falling Possibility of dehydration Record fluid intake & output regularly Avoid fluid volume depletion due to excessive diuresis Hypo/Hyper- kalemia Monitor serum potassium level (within mEq) Avoid K depletion due to thiazide & loop diuretics or avoid K accumulation in patient taking K- sparing diuretics Electrolytes imbalance Monitor K, Na, Cl, Mg & bicarbonate levels Avoid electrolyte imbalance 3) Antihypertensive Drugs (Cont ’ d)

31 31 (ii) Beta Blockers (ii) Beta Blockers –Block beta-1 receptors in the heart –Hence: Reduce heart rate Reduce heart rate Reduce force of contraction Reduce force of contraction Reduced velocity impulse conduction through the AV node Reduced velocity impulse conduction through the AV node 3) Antihypertensive Drugs (Cont ’ d)

32 32 3) Antihypertensive Drugs (Cont ’ d) –Used in: Hypertension Hypertension Angina pectoris Angina pectoris Arrhythmias Arrhythmias Myocardial Infarction Myocardial Infarction Heart Failure Heart Failure

33 33 3) Antihypertensive Drugs (Cont ’ d) –Differ in: Receptor selectivity Receptor selectivity Intrinsic sympathomimetic activity (partial agonist Intrinsic sympathomimetic activity (partial agonist activity), e.g. Oxprenolol. Pindolol, acebutolol Lipid solubility Lipid solubility (Atenolol, nadolol, Sotalol are the most water- soluble) Duration of action, e.g. Esmolol Duration of action, e.g. Esmolol

34 34 3) Antihypertensive Drugs (Cont ’ d) Drug Receptors Blocked Maintenence Dosage in Hypertension AtenololBeta1 50mg daily po MetoprololBeta mg daily in one to two doses po mg daily po (Slow release) Carvedilol Beta1 and mg bd po Labetolol Beta1 and mg bd po with food Propranolol Beta1 and mg daily po

35 35 3) Antihypertensive Drugs (Cont ’ d) Receptor SubtypeTissueEffects Alpha 1,2Vascular smoothContraction muscle Beta 1HeartInc. Heart Rate Inc. Force of Contraction Beta 2Smooth muscleRelaxation

36 36 3) Antihypertensive Drugs (Cont ’ d) –Adverse Effects Bradycardia Bradycardia Hypotension Hypotension Brochospasms Brochospasms GI disturbances GI disturbances Heart failure Heart failure Fatigue Fatigue Nursing Alert Nursing Alert –Check blood pressure & pulse frequently, especially when dosage is being increased

37 37 (iii) Calcium Channel Blockers (CCB) (iii) Calcium Channel Blockers (CCB) –Drugs that prevent calcium ions from entering cells. –Have the greatest effect on the heart and blood vessels. –Widely used to treat hypertension, angina pectoris and cardiac dysrhythmias 3) Antihypertensive Drugs (Cont ’ d)

38 38 Classification Sites of action DosageIndications HypertensionAnginaArrhythmiasOthers Dihydropyridine AmlodipineArterioles 5-10 mg daily po YY Felodipine S.R. Arterioles mg daily po Y NifedipineArterioles mg tid po 10 mg bd po (Adalat Retard) mg daily po (Adalat GITS) YY NimodipineArterioles 60 mg q4h for 21 days IND Key: Y-Yes; IND-Ischaemic neurological deficits 3) Antihypertensive Drugs (Cont ’ d)

39 39 Classification Sites of action Normal dosage Indications HypertensionAnginaArrhythmias Phenylakylamines Verapamil Arterioles/ heart mg daily in 2-3 divided dose, depending on indications YYY Benzothiazepines Diltiazem Arterioles/ heart 30 mg tid; 90 mg bd (SR) mg daily (SR) YYY 3) Antihypertensive Drugs (Cont ’ d)

40 40 –Side effects: Hypotension, dizziness, weakness, peripheral edema, headache, heart failure, pulmonary edema, nausea, constipation Hypotension, dizziness, weakness, peripheral edema, headache, heart failure, pulmonary edema, nausea, constipation Bradycardia (Verpamil, Diltiazem) Bradycardia (Verpamil, Diltiazem) Tachycardia (Nifedipdine & other dihydropyridines) Tachycardia (Nifedipdine & other dihydropyridines) 3) Antihypertensive Drugs (Cont ’ d)

41 41 Nursing Alerts: Nursing Alerts: –The older may have a greater hypotensive effect after taking CCB’s than younger adults. The nurse must monitor them closely during dosage adjustments –Make position changes slowly to minimize hypotensive effects –Some patients may experience dizziness and light-headedness, especially during early therapy. The nurse should assist the patient with all ambulatory activities and instructs the patients to ask for help when getting out of bed or ambulating 3) Antihypertensive Drugs (Cont ’ d)

42 42 (iv) Drug Acting on Renin-Angiotensin System (iv) Drug Acting on Renin-Angiotensin System –There are 2 families of drugs: Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme (ACE) inhibitors –Block the enzyme (ACE) that normally converts angiotensin I to the potent vasoconstrictor angiotensin II –Decrease vasoconstriction & decrease aldosterone production, reducing retention of Na and water 3) Antihypertensive Drugs (Cont ’ d)

43 43 *A-II is the major stimulator of aldosterone secretion

44 44 (iv) Drug Acting on Renin-Angiotensin System (iv) Drug Acting on Renin-Angiotensin System –There are 2 families of drugs: Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme (ACE) inhibitors –Block the enzyme (ACE) that normally converts angiotensin I to the potent vasoconstrictor angiotensin II –Decrease vasoconstriction & decrease aldosterone production, reducing retention of Na and water 3) Antihypertensive Drugs (Cont ’ d)

45 45 Used to treat hypertension, heart failure, myocardial infarction, and nephropathy Used to treat hypertension, heart failure, myocardial infarction, and nephropathy –Enalapril 10-40mg/day in 1 or 2 doses –Lisinopril 10-40mg once daily –Perindopril 2-8mg daily –Ramipril mg once daily Side Effects: Side Effects: –Can produce serious first-dose hypotension –Cough, due to accumulation of bradykinin –Hyperkalaemia, due to inhibition of aldosterone release 3) Antihypertensive Drugs (Cont ’ d)

46 46 Angiotensin II receptor blockers (ARBs) Angiotensin II receptor blockers (ARBs) –Compete with angiotensin II for tissue binding sites & prevent angiotensin II from combining with its receptors in body tissues –Used for hypertension, may be used as an alternative to ACE inhibitors in the management of heart failure and diabetic nephropathy. Irbesartan mg once daily Irbesartan mg once daily Losartan mg once daily Losartan mg once daily Valsartan mg once daily Valsartan mg once daily 3) Antihypertensive Drugs (Cont ’ d)

47 47 3) Antihypertensive Drugs (Cont ’ d) Side-effects Side-effects –Hypotension –Less likely to cause cough and hyperkalaemia than ACE inhibitors

48 48 Nursing Alerts Nursing Alerts Potential Adverse Effects Nursing Actions ACE inhbitors and Angiotensin II receptor antagonists may cause first dose hypotension Instruct the patient to lie down if hypotension develops ACE inhibitors may produce ACE inhibitors may produce cough cough Warn patients about the possibility of cough. Consult the doctor if the cough is bothersome to the patient 3) Antihypertensive Drugs (Cont ’ d)

49 49 Potential Adverse Effects Nursing Actions ACE inhibitors may cause hyperkalaemia Avoid potassium supplements, potassium containing salt substitutes and potassium- sparing diuretics ACE inhibitors and Angiotensin II receptor antagonists are contra-indicated in pregnancy Avoid these dugs in pregnancy Nursing Alerts (cont’d) Nursing Alerts (cont’d) 3) Antihypertensive Drugs (Cont ’ d)

50 50 4) Antianginal Drugs Organic Nitrates Organic Nitrates –Used to treat or prevent angina –Mechanism:  Nitrates are converted to NO in vascular smooth muscle  NO activates guanylate cyclase  Increase formation of cGMP so that the intracellular calcium levels decrease  Vasodilation

51 51 4) Antianginal Drugs(Cont ’ d) 4) Antianginal Drugs(Cont ’ d) –Relieves anginal pain by relaxing smooth muscles in the blood vessels (vasodilation) by several mechanisms Dilate veins Dilate veins Dilate coronary arteries Dilate coronary arteries Dilate arterioles Dilate arterioles

52 52 –Most widely used nitrate is nitroglycerin (Glyceryl trinitrate) Since it is highly lipid soluble, it can be administered by sublingual and transdermal route, as well as oral and intravenous routes Since it is highly lipid soluble, it can be administered by sublingual and transdermal route, as well as oral and intravenous routes 4) Antianginal Drugs (Cont ’ d)

53 53 Nitrate preparations and dosage Nitrate preparations and dosage Drug and dosage form RouteDosage Glyceryl Trinitrate Sublingual tablet 500mcg Sublingual 1 tablet under the tongue immediately as required Spray 0.4mg/dose Sublingual Spray 1-2 doses under tongue Capsule 2.5mg (Retard) Oral 1-2 capsules 2-3 times a day 4) Antianginal Drugs (Cont ’ d)

54 54 Drug and dosage form RouteDosage Glyceryl Trinitrate (Cont’d) Transdermal patches 5mg / 10mg Transdermal 1 patch every 24 hours Isosorbide Mononitrate Tablet 20mg Oral 20mg bd to tid / 40mg bd Tablet 60mg (controlled release) Oral mg in the morning Capsule 50mg (sustained release) Oral 1-2 capsules in the morning 4) Antianginal Drugs (Cont ’ d)

55 55 Drug and dosage form RouteDosage Isosorbide Dinitrate Tablet 10mg Oral mg in divided doses Tablet 40mg (sustained release) Oral 20-40mg every 12 hours Capsule 20mg (sustained release) Oral 1 capsule bd or tid 4) Antianginal Drugs (Cont ’ d)

56 56 –Tolerance Tolerance to nitrate induced vasodilation can develop rapidly Tolerance to nitrate induced vasodilation can develop rapidly This may be due to depletion of sulfhydryl (S-H) groups in the vascular smooth muscle. These groups are needed to convert nitrate to NO This may be due to depletion of sulfhydryl (S-H) groups in the vascular smooth muscle. These groups are needed to convert nitrate to NO 4) Antianginal Drugs (Cont ’ d)

57 57 4) Antianginal Drugs (Cont ’ d) –Adverse Effects Headache Headache Orthostatic hypotension Orthostatic hypotension –Symptoms include light headedness and dizziness Reflex tachycardia Reflex tachycardia

58 58 Nursing Alerts: Nursing Alerts: Potential Adverse Effects Nursing Actions Headache Inform patients that headache will diminish with continued drug use. Can be relieved by mild analgesics Orthostatic hypotension Slowly change from a sitting or lying position to an upright position. Advise the patient to lie or sit down if symptoms of hypotension (eg. dizziness, lightheadedness) occur Tolerance To prevent tolerance, use the minimum effective dose. For long- acting preparations, they should be used on an intermittent schedule to allow at least 8 drug-free hours 4) Antianginal Drugs (Cont ’ d)

59 59 5) Antiarrhythmic Drugs Antiarrhythmic drugs are primary used to treat cardiac arrhythmias, which is a disturbance or irregularity in the heart rate, rhythm, or both Antiarrhythmic drugs are primary used to treat cardiac arrhythmias, which is a disturbance or irregularity in the heart rate, rhythm, or both Antiarrhythmic drugs are divided into 4 classes Antiarrhythmic drugs are divided into 4 classes

60 60 (i) Class I (i) Class I –Sodium channel blockers –Have a membrance-stablizing or anaesthetic effect on the cell of the myocardium –Are subdivided into I-A, I-B, I-C I-A: I-A: Quinidine Quinidine – mg tid or qid po Procainamide Procainamide –25-50 mg/min slow iv injection; max:1g daily 5) Antiarrhythmic Drugs (Cont ’ d)

61 61 I-B: I-B: Lidocaine Lidocaine – mg single bolus injection; followed by 1- 4 mg/min infusion I-C: I-C: Flecainide Flecainide –100 mg bd po; max: 400 mg daily Propafenone Propafenone – mg tid po 5) Antiarrhythmic Drugs (Cont ’ d)

62 62 –Side effects of Class I: Nausea, vomiting Nausea, vomiting Dizziness Dizziness Visual disturbances Visual disturbances Pro-arrhythmic effect Pro-arrhythmic effect Heart block Heart block 5) Antiarrhythmic Drugs (Cont ’ d)

63 63 (II) Class II (II) Class II –Beta Blockers –Block sympathetic stimulation of beta receptors in the heart & decrease the heart rate Propranolol Propranolol –10-40 mg tid or qid po Acebutolol Acebutolol – mg daily po in 2 to 3 divided dose Esmolol Esmolol – mcg/kg/min IV infusion 5) Antiarrhythmic Drugs (Cont ’ d)

64 64 –Side effects of Class II: Nausea Nausea Headache Headache Hypotension Hypotension Dizziness Dizziness 5) Antiarrhythmic Drugs (Cont ’ d)

65 65 (III) Class III (III) Class III –Potassium channel blocker –Prolong duration of action potential, slow repolarization, and prolong the refractory period in both atria and ventricles Amiodarone Amiodarone –200 mg one to three times daily po Bretylium Bretylium –5-10 mg/kg IV infusion over min q6-8h 5) Antiarrhythmic Drugs (Cont ’ d)

66 66 Sotalol Sotalol –Has combined Class II & Class III effects –A beta blocker that also delays repolarization – mg po daily in 2 divided dose –Side effects of Class III: Proarrhythmias (Amiodarone & Sotalol) Proarrhythmias (Amiodarone & Sotalol) Hypotension (Bretylium & Sotalol) Hypotension (Bretylium & Sotalol) Malaise, fatigue & tremor (Amiodarone) Malaise, fatigue & tremor (Amiodarone) 5) Antiarrhythmic Drugs (Cont ’ d)

67 67 Class IV: Class IV: –Calcium Channel Blockers (CCB) –Block the movement of Ca into conductile & contractile myocardial cells –Verapamil & Diltiazem are the only approved CCB in arrhythmias Verapamil Verapamil – mg tid po 5) Antiarrhythmic Drugs (Cont ’ d)

68 68 Diltiazem Diltiazem –0.25 mg/kg IV injection over 2 min, second bolus of 0.35 mg/kg if needed; followed by 5-15 mg/hr continuous IV infusion if necessary –Side effects of Class IV: Proarrhythmias (Verapamil) Proarrhythmias (Verapamil) Heart block Heart block Hypotension, headache, dizziness, constipation Hypotension, headache, dizziness, constipation 5) Antiarrhythmic Drugs (Cont ’ d)

69 69 Nursing Alerts Nursing Alerts –Antiarrhythmic drugs are capable of causing new arrhythmias, as well as an exacerbation of existing arrhythmias –Older adults taking antiarrhythmic drugs are at greater risk for adverse reactions such as development of additional arrhythmias or aggravating of existing arrhythmias, hypotension, and congestive heart failure. Careful monitoring is necessary for early identification and management of adverse effects 5) Antiarrhythmic Drugs (Cont ’ d)

70 70 6) Drugs used for Dyslipidemia 6) Drugs used for Dyslipidemia Used in the management of elevated blood lipids, which is a major risk factor for atherosclerosis and vascular disorders such as coronary artery disease and strokes Used in the management of elevated blood lipids, which is a major risk factor for atherosclerosis and vascular disorders such as coronary artery disease and strokes

71 71 (i) HMG CoA reductase inhibitors (Statins) (i) HMG CoA reductase inhibitors (Statins) –Inhibits HMG CoA reductase, the rate- limiting enzyme in cholesterol synthesis –Increase LDL receptors in hepatocytes This enables hepatocytes to remove more LDLs from the blood This enables hepatocytes to remove more LDLs from the blood –Also decrease VLDL levels and increase HDL levels 6) Drugs used for Dyslipidemia (Cont ’ d)

72 72 Drug Usual Dosage Comments Atorvastatin 10-80mg taken at anytime Take with or without food Fluvastatin 20-40mg daily in the evening, up to 40mg twice daily Take with or without food Pravastatin 10-40mg at night Take with food to reduce dyspepsia Simvastatin 5-80mg at night Take with food to reduce dyspepsia 6) Drugs used for Dyslipidemia (Cont ’ d)

73 73 6) Drugs used for Dyslipidemia (Cont ’ d) –Adverse Effects Headache, GI side effects (e.g. abdominal pain, flatulence, diarrhoea, nausea and vomiting) Headache, GI side effects (e.g. abdominal pain, flatulence, diarrhoea, nausea and vomiting) Hepatoxicity Hepatoxicity Myopathy Myopathy

74 74 (ii) Fibric acid derivatives (Fibrates) (ii) Fibric acid derivatives (Fibrates) –Increase oxidation of fatty acids in liver and muscle tissue, decrease hepatic production of triglycerides, decrease VLDL cholesterol and increase HDL cholesterol –Main indication is hypertriglceridemia (high plasma triglycerides) 6) Drugs used for Dyslipidemia (Cont ’ d)

75 75 Drug and dosage form Usual Dosage Clofibrate capsule 500mg 2g daily in 2-4 divided doses Fenofibrate Capsule 100mg 3 capsules daily in the course of main meals Capsule (Micronized fenofibrate) 200mg 1 capsule daily 6) Drugs used for Dyslipidemia (Cont ’ d)

76 76 Drug and dosage form Usual Dosage Gemfibrozil Capsule 300mg 1.2g daily in 2 divided doses Usual range g daily Tablet 600mg 6) Drugs used for Dyslipidemia (Cont ’ d)

77 77 –Adverse Effects Nausea, vomiting and GI upset Nausea, vomiting and GI upset Cholelithiasis (stones in the gall bladder) and cholecystitis (inflammation of the gallbladder) Cholelithiasis (stones in the gall bladder) and cholecystitis (inflammation of the gallbladder) Myopathy Myopathy 6) Drugs used for Dyslipidemia (Cont ’ d)

78 78 (iii) Bile acid sequestrants (iii) Bile acid sequestrants –Bind bile acids in the intestinal lumen. This causes the bile acids to be excreted in faeces and prevents them being re-circulated to the liver –Mainly used as an adjunct to Statins to decrease LDL cholesterol levels 6) Drugs used for Dyslipidemia (Cont ’ d)

79 79 –Cholestyramine Usual dosage Usual dosage –12-24g daily in water in one to four divided doses; Max: 36g daily Adverse effects Adverse effects –Constipation, diarrhoea, nausea, vomiting, gastro-intestinal discomfort –Decreased absorption of fat-soluble vitamins 6) Drugs used for Dyslipidemia (Cont ’ d)

80 80 (iv) Nicotinic acid (iv) Nicotinic acid –Inhibits mobilization of free fatty acids from peripheral tissues, thereby reducing hepatic synthesis of triglycerides and secretion of VLDL, which leads to decreased production of of LDL cholesterol –Besides reducing LDL and VLDL levels, also effective in increasing HDL levels 6) Drugs used for Dyslipidemia (Cont ’ d)

81 81 –Normal dose 1-2g three times daily 1-2g three times daily –Adverse effects Flushing, itching, nausea, vomiting, diarrhoea Flushing, itching, nausea, vomiting, diarrhoea Hepatotoxic Hepatotoxic Hyperglycaemia and hyperuricaemia Hyperglycaemia and hyperuricaemia 6) Drugs used for Dyslipidemia (Cont ’ d)

82 82 Nursing alerts: Nursing alerts: Potential Adverse Effects Nursing Actions Statins Hepatotoxicity Liver function should be monitored during therapy Myopathy Inform patient about the risk of myopathy. Instruct them to notify physician if unexplained muscle pain or tenderness occurs 6) Drugs used for Dyslipidemia (Cont ’ d)

83 83 Potential Adverse Effects Nursing Actions Fibrates Gallstones Inform patients about symptoms of gallbladder disease (e.g. upper abdominal discomfort, intolerance of fried foods, bloating) and instruct them to notify the physician if these develop Myopathy Warn patient to report any signs of muscle injury, such as tenderness, weakness, or unusual muscle pain Liver Disease Obtain periodic tests of liver function 6) Drugs used for Dyslipidemia (Cont ’ d)

84 84 Potential Adverse Effects Nursing Actions Bile acid sequestrants Constipation Inform patients that constipation can be minimized by increasing dietary fiber and fluids. A mild laxative may be used if needed. Vitamin deficiency Absorption of fat-soluble vitamins (A, D, E, K) may be impaired. Vitamin supplements may be required 6) Drugs used for Dyslipidemia (Cont ’ d)

85 85 Potential Adverse Effects Nursing Actions Nicotinic acid Flushing Contact physician if the patient experiences flushing (face, neck, ears) Hepatotoxicity Monitor liver function during treatment Hyperglycaemia Blood glucose should be monitored frequently Hyperuricaemia Exercise caution in patients with gout 6) Drugs used for Dyslipidemia (Cont ’ d)

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