N402 1

Angina is caused by insufficient O2 to part of the myocardium Therefore, angina is relieved by decreasing O2 to the myocardium! Accomplished by: Decrease the heart rate… Dilate the veins (decrease preload)… Decrease contractility… or, Decrease BP (decrease afterload) 2

3 ProceduresLifestyle Changes Atherotomy Limit ETOH Limit fat, cholesterol Eliminate smoking AngioplastyMaintain normal BP (Balloon)Exercise Maintain normal BG Decrease salt

β- B lockers Organic Nitrates Ca Channel Blockers 4

Requires drugs from 2 classes because each class relieves angina from a different approach… β-B lockers slow heart rate and decrease contractility… Ca Channel Blockers decrease afterload…, and Organic Nitrates decrease preload 5

Slow the heart rate and decrease contractility Therefore, afterload is decreased Used to treat both hypertension and angina Not effective on Prinzmetal’s angina 6

Relax arteriolar smooth muscle to decrease BP Therefore, decrease afterload Also dilate coronary smooth muscle Useful in treating Prinzmetal’s angina 7

Dilation of veins decreases amount of blood returning to heart Therefore decreases preload Also dilates coronary arteries Useful in treating Prinzmetal’s angina May be short acting (NTG) or long acting (isosorbide) 8

Sudden blockage of coronary artery by dislodged plaque Causes coagulation cascade Results in: UNSTABLE ANGINAINFARCTION Incomplete occlusionComplete occlusionby thrombus Causes chest painCauses ischemia and necrosis 9

Goals of treatment: 10 Unstable angina Relief of painPrevent clot enlargement Myocardial infarction Restore blood supply Prevent thrombus enlargement Decrease O2 demandPrevent dysrhythmiasManage pain

Should be given within first 20 minutes to 12 hours Risk is excessive bleeding Not everyone is a candidate Use with caution in the elderly 11

Anticoag. ASA/clopidogrel Antianginal Nitrates ACEI Pain Mgt MS ↓ O2 demand Β- Blockers 12

Occurs when there is insufficient blood supply to vital organs by cardiovascular system Major types of shock: Hypovolemic Excessive blood loss CardiogenicSeptic Pump failureToxins in blood Neurogenic Sudden loss of sympathetic activity 13

Used when fluids alone are ineffective Rapid onset, short duration Given by continuous IV until patient is stabilized Dopamine (Dopastat, Intropin 2-5 mcg/kg/min; up to mcg/kg/min Norepinepherine (Levophed) 0.5 mcg/min up to 8-30 mcg/min Phenyephrine (Neo-Synepherine) Epinephrine Watch closely for adverse effects: BP changes, dysrhythmias, necrosis at infusion/injection site (Regitine) 14

Commonly associated drugs: Antibiotics—especially PCNs, cephalosporins, sulfonamides NSAIDS—ASA, ibuprofen, naproxen ACEIs Opioids Iodine based contrast media 15

Epinephrine 1:1000 subcu or IM initial drug of choice Antihistamines e.g., diphenhydramine Bronchodilator by inhalation, e.g., albuterol High flow oxygen (some exceptions) Systemic cortico- steroids 16

Major categories 17 Atrial Ventric- ular Blocks

Supraventricular Originate in the atria Atrial fibrillation is most common SV dysrhythmia Ventricular More serious than atrial dysrhythmias Complete disorganization of contractions Heart block Blockage of electrical conduction system 18

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Cardioversion Disrupts cardiac rhythm to “reset” Patient may be awake Defibrillation Uses more joules of shock Patient should not be awake! Implantable cardioverter defibrillators Respond to sensing of dysrhythmias 22

Block flow throughChange autonomic ion channelsactivity (conduction)(automaticity) I Sodium channel blockersII β -blockers III Potassium channel blockers IV Calcium channel blockers 23

Prevent depolarization Action potential slows Ectopic pacemaker activity suppressed Procainamide May produce new dysrhythmias Hypotension 24

Decrease conduction through the AV node Automaticity is reduced Dysrhythmias can be stabilized Propanolol (Inderal) Watch for laryngospasm Bradycardia Serious dysrhythmias Myocardial ischemia 25

Delay repolarization of the myocardial cells Lengthen refractory period Used for serious dysrhythmias Used for atrial and ventricular dysrhythmias Amiodarone May cause new dysrhythmias Hypotension Bradycardia 26

Slow conduction velocity through AV node Reduced automaticity in the heart Slows heart rate Prolongs refractory period Verapamil Myocardial infarction Heart failure May be given continuous IV for up to 24 hours 27

Remember? COPD includes: Chronic bronchitis Emphysema And asthma is off in its own category…. 28

Ventilation is the process of moving air in and out of the lungs Respiration is the exchange of gases due to diffusion Perfusion is the flow of blood through the lungs 29

Broncho- spasm Inflam- mation Asthma 30

Bronchodilators address muscle spasm of the respiratory tree: 31 β- adrenergic agonists Methly- xanthines Anti- cholinergics

Activate the sympathetic nervous system (sympathetic = dilation; parasympathetic = constriction) Cause vasodilation Drugs in this category classified as long-acting or short- acting Short-acting referred to as rescue-drugs Long-acting cannot relieve acute bronchospasm! Albuterol (Proventil) Tachycardia Dysrhythmias Hypokalemia Paradoxical bronchospasm 32

Alternative for patients who cannot tolerate β- adrenergic agonists Block the parasympathetic nervous system Prevent vasoconstriction Ipratropium (Atrovent) Headache Cough Dry mouth Paradoxical bronchospasm Pharyngitis 33

Older drugs Long term management of persistent asthma Narrow margin of safety Related to caffeine Theophylline (Theo-Dur) Tremors Tachycardia Dysrhythmias Headache Respiratory arrest 34

Cortico- steroids Mast cell stabilizers Lelukotriene modifiers 35

Potent, naturally occurring Allow smooth muscle to become more sensitive to bronchodilation Reduce responsiveness to allergens Used for preventing asthma attacks Beclomethasone (Qvar) Hoarseness Cough, sore throat Oropharyngeal candidiasis 36

Alternative drugs Inhibit release of leukotrienes Edema Inflammation bronchoconstriction Zafirkulast (Acolate) Headache, nausea Throat pain Increased suicidal ideation 37

Inhibit release of histamine from mast cells Taken daily Not effective for acute events Cromolyn (Intal) Sneezing, nasal stinging Throat irritation Angioedema Bronchospasm 38

Many of the same drugs are used with the COPD patient Medications are based on COPD symptoms 39 Broncho- dilators MucolyticsOxygenAntibiotics Cortico- steroids

β -blockers which cause bronchoconstriction Respiratory depressants (MS, barbiturates) Most importantly…smoking cessation! 40