DRUGS AFFECTING THE CARDIOVASCULAR and RENAL SYSTEMS Chpts: 22-29

DRUGS AFFECTING THE CARDIOVASCULAR and RENAL SYSTEMS Chpts: 22-29
Kevin Dobi, MS, APRN Winter 2013 9/18/2018

CARDIAC PROBLEM AREAS PUMP CIRCULATION TO MUSCLE ELECTRICAL SYSTEM
Winter 2013 9/18/2018

CARDIAC A&P REVIEW Winter 2013 9/18/2018

CARDIAC A&P REVIEW 9/18/2018 Winter 2013

HEART FAILURE Chapter 22 LEFT SIDED HEART FAILURE (CHRONIC HEART FAILURE) RESTLESS ORTHOPNEA SOB (SHORTNESS OF BREATH) DOE (DYSPNEA ON EXERTION) Winter 2013 9/18/2018

Common Causes for Heart Failure
Inadequate Contractility Myocardial Infarction Inadequate Filling Atrial fibrillation Pressure Overload Hypertension Volume Overload Hypervolemia Complete list on pg. 336 Winter 2013 9/18/2018

DRUG CLASSES FOR HEART FAILURE
ANGIOTENSIN – CONVERTING ENZYME INHIBITORS ANGIOTENSIN II RECEPTOR BLOCKERS BETA-BLOCKERS B-TYPE NATRIURETIC PEPTIDE PHOSPHODIESTERASE INHIBITORS CARDIAC GLYCOSIDES Winter 2013 9/18/2018

ANGIOTENSIN –CONVERTING ENZYME INHIBITORS
ACE Inhibitors Prevents vasoconstriction, sodium and water resorption Lisinopril Indicated for heart failure, hypertension, acute Myocardial Infarction Winter 2013 9/18/2018

ANGIOTENSIN II RECEPTOR BLOCKERS
ARBs valsartan (Diovan) Potent vasodilating effects Decreases systemic vascular resistance Used in combination with diuretics to treat Heart Failure and Hypertension Winter 2013 9/18/2018

BETA-BLOCKERS Block sympathetic nervous system stimulation of the heart Reduce heart rate, delayed AV node conduction, reduced myocardial contractility and decreased myocardial automaticity. metoprolol Decreased workload of the heart Winter 2013 9/18/2018

Synthetic human B-type natriuretic peptide
Nesiritide (Natrecor) Vasodilating effect on both arteries and veins Treatment of patients with acutely decompensated CHF who have dyspnea at rest or with minimal activity. Treatment for severe life-threatening heart failure Causes diuresis, urine sodium loss and vasodilation Winter 2013 9/18/2018

PHOSPHODIESTERASE INHIBITORS
inamrinone and milrinone Positive inotropic and vasodilating effects Decrease cardiac work load Parenteral only Short-term management of CHF Winter 2013 9/18/2018

CARDIAC GLYCOSIDES (aka: digitalis glycosides)
INCREASE THE EFFICIENCY OF THE HEART BY IMPROVING THE CONTRACTION OF THE HEART MUSCLE POSITIVE INOTROPIC ACTION INCREASING THE FORCE OF MYOCARDIAL CONTRACTION Negative chronotropic effect – reduced heart rate Negative dromotropic effect – decreased automaticity at the SA note, AV node and bundle of HIS digoxin (Lanoxin) Not first line drug in Heart Failure Winter 2013 9/18/2018

WHY DO WE WANT TO INCREASE THE MYOCARDIAL CONTRACTILITY??
INADEQUATE CONTRACTILITY MI (MYOCARDIAL INFARCTION) CORONARY ARTERY DISEASE CARDIOMYOPATHY INADEQUATE FILLING ATRIAL FIBRILLATION Winter 2013 9/18/2018

Atrial Fibrillation NORMAL SINUS RHYTHM (NSR) A FIB Winter 2013
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WHY DO WE WANT TO INCREASE THE MYOCARDIAL CONTRACTILITY??
PRESSURE OVERLOAD HYPERTENSION VOLUME OVERLOAD HYPERVOLEMIA Winter 2013 9/18/2018

DIGOXIN (LANOXIN) DIGITALIZATION
The administration of digitalis or one of its glycosides in a dosage schedule designed to produce and then maintain optimal therapeutic concentration CARDIAC GLYCOSIDES HAVE BEEN USED TO TREAT HEART FAILURE FOR OVER 200 YEARS Winter 2013 9/18/2018

DIGOXIN (LANOXIN) WHAT DOES IT DO???
INCREASES CARDIAC CONTRACTILITY BY INHIBITING THE K+/Na+ PUMP AND INFLUENCING CALCIUM MOVEMENT STIMULATES THE VAGUS NERVE = SLOWING THE HEART RATE NEGATIVE CHRONOTROPIC EFFECT POSITIVE INOTROPIC EFFECT – Increases the squeeze! Winter 2013 9/18/2018

ADVERSE EFFECTS OF CARDIAC GLYCOSIDES MEDICATIONS
DYSRYTHMIAS HEADACHE FATIGUE ANOREXIA N, V, D Winter 2013 9/18/2018

NURSING CONSIDERATIONS
APICAL PULSE FOR ONE MINUTE PRIOR TO GIVING DIGOXIN “HOLD” IF <60 ANTACIDS INTERFERE WITH ABSORPTION AVOID GIVING DIGOXIN WITH HIGH-FIBER FOODS (FIBER BINDS WITH DIGITALIS) TEACH S&S OF TOXICITY TRACK BLOOD LEVELS FOR DIG AND ELECTROLYTES DIGOXIN LEVELS MUST BE MONITORED 0.5 TO 2 ng/ml Winter 2013 9/18/2018

DIGITALIS TOXICITY SIGNS AND SYMPTOMS N, V ANOREXIA
VISUAL DISTURBANCES MAY SEE YELLOW, GREEN, BLUE HALOS CONFUSION BRADYCARDIA EKG CHANGES Winter 2013 9/18/2018

TREATMENT FOR DIG TOXICITY
STOP TAKING THE DRUG DIGOXIN IMMUNE FAB (DIGIBIND) WHAT CAUSED THE PROBLEM? HYPOKALEMIA R/T DIURETIC DRUGS LIVER FAILURE Winter 2013 9/18/2018

ANTIDYSRHYTHMIC DRUGS Chapter 23
DYSRHYTHMIA (ARRHYTHMIA) ANY DEVIATION FROM THE “NORMAL” RHYTHM Winter 2013 9/18/2018

“NORMAL” ELECTRICAL PATTERN OF THE HEART
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Vaughan Williams Classification
System commonly used to classify antidysrhythmic drugs Based on the electrophysiologic effect of particular drugs on the action potential Winter 2013 9/18/2018

Vaughan Williams Classification (cont’d)
Class Ia Class Ib Class Ic Class II Class III Class IV Other Winter 2013 9/18/2018

Vaughan Williams Classification: Mechanism of Action
Membrane-stabilizing drugs Fast sodium channel blockers Divided into Ia, Ib, and Ic drugs, according to effects Winter 2013 9/18/2018

Vaughan Williams Classification: Mechanism of Action and Indications
Class I: moricizine General class I drug Has characteristics of all three subclasses Used for symptomatic ventricular and life-threatening dysrhythmias Winter 2013 9/18/2018

Vaughan Williams Classification: Mechanism of Action and Indications (cont’d)
Class Ia: quinidine, procainamide, disopyramide Block sodium (fast) channels Delay repolarization Increase APD (action potential duration) Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, ventricular tachycardia, Wolff-Parkinson-White syndrome Winter 2013 9/18/2018

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Class Ib: phenytoin, lidocaine Block sodium channels Accelerate repolarization Increase or decrease APD Used for ventricular dysrhythmias only Premature ventricular contractions, ventricular tachycardia, ventricular fibrillation Winter 2013 9/18/2018

Class Ic: flecainide, propafenone Block sodium channels (more pronounced effect) Little effect on APD or repolarization Used for severe ventricular dysrhythmias May be used in atrial fibrillation/flutter, Wolff- Parkinson-White syndrome, supraventricular tachycardia dysrhythmias Winter 2013 9/18/2018

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Class II: beta-blockers: atenolol, esmolol, metaprolol, propranolol Reduce or block sympathetic nervous system stimulation, thus reducing transmission of impulses in the heart’s conduction system Depress phase 4 depolarization General myocardial depressants for both supraventricular and ventricular dysrhythmias Also used as antianginal and antihypertensive drugs Winter 2013 9/18/2018

Class III: amiodarone, sotalol*, ibutilide, others Increase APD Prolong repolarization in phase 3 Used for dysrhythmias that are difficult to treat Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter—resistant to other drugs Sustained ventricular tachycardia *Sotalol also exhibits Class II properties Winter 2013 9/18/2018

Class IV: verapamil, diltiazem Calcium channel blockers Inhibit slow-channel (calcium-dependent) pathways Depress phase 4 depolarization Reduce AV node conduction Used for paroxysmal supraventricular tachycardia (PSVT); rate control for atrial fibrillation and flutter Winter 2013 9/18/2018

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Vaughan Williams Classification: Other Antidysrhythmics
Digoxin, adenosine Have properties of several classes and are not placed into one particular class Winter 2013 9/18/2018

Unclassified Antidysrhythmic
adenosine (Adenocard) Slows conduction through the AV node Used to convert paroxysmal supraventricular tachycardia to sinus rhythm Very short half-life—less than 10 seconds Only administered as fast IV push May cause asystole for a few seconds Other adverse effects minimal Winter 2013 9/18/2018

ADVERSE REACTION TO ANTIDYSRHYTHMICS
N, V, D DIZZINESS HEADACHE BLURRED VISION CAN CAUSE DYSRHYTHMIAS !! Winter 2013 9/18/2018

MONITOR PULSE RATE IF SENDING PT HOME – TEACH THEM HOW TO MONITOR THEIR PULSE ALWAYS CHECK ALL VS BEFORE ADMINISTERING THE MEDICATION Winter 2013 9/18/2018

MONITOR FOR FLUID RETENTION DO NOT STOP DRUGS ABRUPTLY AVOID ALCOHOL Winter 2013 9/18/2018

CHAPTER 24 Antianginal Drugs
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Angina Pectoris (Chest Pain)
When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart, the heart muscle “aches” The heart requires a large supply of oxygen to meet the demands placed on it Winter 2013 9/18/2018

Ischemia Ischemia Ischemic heart disease Myocardial infarction (MI)
Poor blood supply to an organ Ischemic heart disease Poor blood supply to the heart muscle Atherosclerosis Coronary artery disease Myocardial infarction (MI) Necrosis, or death, of cardiac tissue Disabling or fatal Winter 2013 9/18/2018

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Types of Angina Chronic stable angina (also called classic or effort angina) Unstable angina (also called preinfarction or crescendo angina) Vasospastic angina (also called Prinzmetal’s or variant angina) Winter 2013 9/18/2018

Drug Classifications for Angina
Nitrates/nitrites Beta-blockers Calcium channel blockers Winter 2013 9/18/2018

Therapeutic Objectives
Increase blood flow to ischemic heart muscle and/or Decrease myocardial oxygen demand Winter 2013 9/18/2018

Therapeutic Objectives (cont’d)
Minimize the frequency of attacks and decrease the duration and intensity of anginal pain Improve the patient’s functional capacity with as few adverse effects as possible Prevent or delay the worst possible outcome: MI Winter 2013 9/18/2018

Nitrates/Nitrites Available forms Sublingual* Buccal* Chewable tablets
Oral capsules/tablets Intravenous solutions* *Bypass the liver and the first-pass effect Transdermal patches* Ointments* Translingual sprays* Winter 2013 9/18/2018

Nitrates/Nitrites (cont’d)
Cause vasodilation because of relaxation of smooth muscles Potent dilating effect on coronary arteries Used for prevention and treatment of angina Winter 2013 9/18/2018

Vasodilation results in reduced myocardial oxygen demand Nitrates cause dilation of both large and small coronary vessels Result: oxygen to ischemic myocardial tissue Nitrates alleviate coronary artery spasms Winter 2013 9/18/2018

Rapid-acting forms Used to treat acute anginal attacks Sublingual tablets Intravenous infusion Long-acting forms Used to PREVENT anginal episodes Winter 2013 9/18/2018

Nitroglycerin Prototypical nitrate Large first-pass effect with oral forms Used for symptomatic treatment of ischemic heart conditions (angina) IV form used for BP control in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies Winter 2013 9/18/2018

Nitrates Isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate SR)
Isosorbide mononitrate (Imdur, Monoket, ISMO) Used for: Acute relief of angina Prophylaxis in situations that may provoke angina Long-term prophylaxis of angina Winter 2013 9/18/2018

Nitrates (cont’d) Adverse effects Headaches
Usually diminish in intensity and frequency with continued use Tachycardia, postural hypotension Tolerance may develop Winter 2013 9/18/2018

Tolerance Occurs in patients taking nitrates around the clock or with long-acting forms Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning Winter 2013 9/18/2018

Beta-Blockers atenolol (Tenormin) metoprolol (Lopressor)
propranolol (Inderal) nadolol (Corgard) Winter 2013 9/18/2018

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Beta Adrenergic Blockers: Mechanism of Action
Block beta1 Adrenergic -receptors on the heart Decrease HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart Decrease myocardial contractility, helping to conserve energy or decrease demand Winter 2013 9/18/2018

Beta Adrenergic Blockers: Mechanism of Action (cont’d)
After an MI, a high level of circulating catecholamines irritate the heart, causing an imbalance in supply and demand ratio and even leading to life-threatening dysrhythmias Beta Adrenergic Blockers block the harmful effects of catecholamines, thus improving survival after an MI Winter 2013 9/18/2018

Beta Adrenergic Blockers (cont’d)
Indications Angina Antihypertensive Cardiac dysrhythmias Cardioprotective effects, especially after MI Some used for migraine headaches, essential tremors, and stage fright Winter 2013 9/18/2018

Adverse effects Body System Adverse Effects Cardiovascular Bradycardia, hypotension, second- or third-degree heart block; heart failure Metabolic Altered glucose and lipid metabolism Winter 2013 9/18/2018

Adverse effects (cont’d) Body System Adverse Effects CNS Dizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams Other Impotence, wheezing, dyspnea, constipation Winter 2013 9/18/2018

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Calcium Channel Blockers
verapamil (Calan, Isoptin) diltiazem (Cardizem) nifedipine (Procardia) amlodipine (Norvasc) Others Winter 2013 9/18/2018

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Calcium Channel Blockers (cont’d)
Mechanism of action Cause coronary artery vasodilation Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance Reduce the workload of the heart Result: decreased myocardial oxygen demand Winter 2013 9/18/2018

Indications First-line drugs for treatment of angina, hypertension, and supraventricular tachycardia Coronary artery spasms (Prinzmetal’s angina) Short-term management of atrial fibrillation and flutter Several other uses Winter 2013 9/18/2018

Adverse effects Very acceptable adverse effect and safety profile May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea, other adverse effects Winter 2013 9/18/2018

Nursing Implications – All Antidysrhythmic Drugs
Before administering, perform a complete health history to determine presence of conditions that may be contraindications for use or those that may call for cautious use Obtain baseline VS, including respiratory patterns and rate Assess for drug interactions Winter 2013 9/18/2018

Patients should not take any medications, including over-the-counter medications, without checking with their physician Patients should be encouraged to limit caffeine intake Winter 2013 9/18/2018

Patients should report blurred vision, persistent headache, dry mouth, dizziness, edema, fainting episodes, weight gain of 2 pounds in 1 day or 5 pounds in 1 week, pulse rates less than 60, and dyspnea Winter 2013 9/18/2018

Alcohol consumption and spending time in hot baths or whirlpools, hot tubs, or saunas will result in vasodilation, hypotension, and the possibility of fainting Teach patients to change positions slowly to avoid postural BP changes Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of pills taken, and therapeutic effects Winter 2013 9/18/2018

Nursing Implications Nitroglycerin
Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain Instruct patients never to chew or swallow the sublingual form Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent Winter 2013 9/18/2018

Nursing Implications Nitroglycerin (cont’d)
Instruct patients to keep a fresh supply of sublingual medication on hand; potency is lost in about 3 months after the bottle has been opened To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler Winter 2013 9/18/2018

Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication To reduce tolerance, the patient may be instructed to remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period Winter 2013 9/18/2018

Instruct patients to take prn nitrates at the first hint of anginal pain Monitor vital signs frequently during acute exacerbations of angina and during IV administration If experiencing chest pain, the patient taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension Winter 2013 9/18/2018

Nursing Implications Nitroglycerin (cont’d) If anginal pain occurs: Stop activity and sit or lie down Take a sublingual tablet, if no relief, call 911/Emergency Services immediately! If no relief in 5 minutes, take a second sublingual tablet If no relief in 5 minutes, take a third sublingual tablet Do not try to drive to the hospital Winter 2013 9/18/2018

IV forms of nitroglycerin must be given with special non-PVC tubing and bags Discard parenteral solution that is blue, green, or dark red Follow specific manufacturer’s instructions for IV administration Winter 2013 9/18/2018

Nursing Implications Calcium channel blockers
Constipation is a common problem; instruct patients to take in adequate fluids and eat high- fiber foods Winter 2013 9/18/2018

Nursing Implications Beta-blockers
Patients taking beta-blockers should monitor pulse rate daily and report any rate lower than 60 beats per minute Instruct patients to report dizziness or fainting Constipation is a common problem; instruct patients to take in adequate fluids and eat high- fiber foods Winter 2013 9/18/2018

Nursing Implications Beta-blockers (cont’d)
Inform patients that these medications should never be abruptly discontinued because of risk of rebound hypertensive crisis Inform patients that these medications are for long-term prevention of angina, not for immediate relief Winter 2013 9/18/2018

Nursing Implications Antianginal drugs Monitor for adverse reactions
Allergic reactions, headache, lightheadedness, hypotension, dizziness Monitor for therapeutic effects Relief of angina, decreased BP, or both Winter 2013 9/18/2018

CHAPTER 25 Antihypertensive Drugs
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ATHEROSCLEROSIS DEPOSITS OF ON THE WALLS OF THE ARTERIES CALCIUM
LIPIDS CHOLESTROL ON THE WALLS OF THE ARTERIES Winter 2013 9/18/2018

Winter 2013 9/18/2018

The plaque deposited in your arteries is hard on the outside and soft and mushy on the inside. Sometimes the hard outer shell cracks. When this happens, a blood clot forms around the plaque. If the clot completely blocks the artery, it cuts off the blood supply to a portion of the heart. Without immediate treatment, that part of the heart muscle could be damaged or destroyed. Winter 2013 9/18/2018

Blood Pressure Blood pressure = CO × SVR
CO = cardiac output SVR = systemic vascular resistance Hypertension = high blood pressure Winter 2013 9/18/2018

Winter 2013 9/18/2018

Four stages, based on BP measurements
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)* Four stages, based on BP measurements Normal Pre-hypertension Stage 1 hypertension Stage 2 hypertension *New guidelines pending Winter 2013 9/18/2018

Compelling Indications
Post-MI High cardiovascular risk Heart failure Diabetes mellitus Chronic kidney disease Previous stroke Winter 2013 9/18/2018

JNC-7: Significant Changes
High diastolic BP (DBP) is no longer considered to be more dangerous than high systolic BP (SBP) Studies have shown that elevated SBP is strongly associated with heart failure, stroke, and renal failure Winter 2013 9/18/2018

JNC-7: Significant Changes (cont’d)
For those older than age 50, SBP is a more important risk factor for cardiovascular disease (CVD) than DBP “Prehypertensive” BPs are no longer considered “high normal” and require lifestyle modifications to prevent CVD Winter 2013 9/18/2018

JNC-7: Significant Changes (cont’d)
Thiazide-type diuretics should be the initial drug therapy for most patients with hypertension (alone or with other drug classes) The previous labels of “mild,” “moderate,” and “severe” have been dropped Winter 2013 9/18/2018

Cultural Considerations
Beta-blockers and ACE inhibitors have been found to be more effective in white patients than in African American patients CCBs and diuretics have been shown to be more effective in African American patients than in white patients Winter 2013 9/18/2018

Primary Hypertension Hypertension can also be defined by its cause
Unknown cause Essential, idiopathic, or primary hypertension 90% of cases Genetic (hereditary) – 30% African-American Obesity Renal failure Advanced age Any of the above factors complicated by lifestyle Winter 2013 9/18/2018

Secondary Hypertension
Known cause Secondary hypertension 10% of cases Causes such as Pheochromocytoma, pre- eclampsia, renal artery disease Winter 2013 9/18/2018

Take the Salt quiz http://www.medicinenet.com/salt_quiz/quiz.htm
Winter 2013 9/18/2018

Antihypertensive Drugs
Medications used to treat hypertension Categories Adrenergic drugs Angiotensin converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Winter 2013 9/18/2018

Adrenergic Drugs: Centrally Acting Alpha2-Receptor Agonists
clonidine (Catapres) methyldopa (Aldomet) Can be used for hypertension in pregnancy Winter 2013 9/18/2018

Adrenergic Drugs: Peripherally Acting Mechanism of Action
Peripheral alpha1-blockers/antagonists Block alpha1-adrenergic receptors doxazosin (Cardura) terazosin (Hytrin) Results in decreased blood pressure Winter 2013 9/18/2018

Adrenergic Drugs: Mechanism of Action (cont’d)
Beta-blockers Reduce BP by reducing heart rate through beta1-blockade Cause reduced secretion of renin Long-term use causes reduced peripheral vascular resistance Propranolol, atenolol, others Newest: nebivolol (Bystolic)—beta1-selective Result: decreased blood pressure Winter 2013 9/18/2018

Adrenergic Drugs: Mechanism of Action (cont’d)
Dual-action alpha1- and beta1-receptor blockers Block alpha1-adrenergic receptors Reduction of heart rate (beta1-receptor blockade) Vasodilation (alpha1-receptor blockade) carvedilol (Coreg) and labetalol Result in decreased blood pressure Winter 2013 9/18/2018

Adrenergic Drugs: Adverse Effects
High incidence of orthostatic hypotension Most common Dry mouth Drowsiness, sedation Constipation Other Headaches Sleep disturbances Nausea Rash Cardiac disturbances (palpitations), others Winter 2013 9/18/2018

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Adrenergic Drugs (cont’d)
Beta1 Adrenergic blockers Act in the periphery Reduce heart rate owing to b1-blockade Examples: nebivolol (bystolic), propranolol (Inderal), atenolol (Tenormin), others Winter 2013 9/18/2018

Angiotensin Converting Enzyme (ACE) Inhibitors
Large group of safe and effective drugs Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic or calcium channel blocker Winter 2013 9/18/2018

ACE Inhibitors: Mechanism of Action
Renin-Angiotensin-Aldosterone System Inhibit angiotensin-converting enzyme, which is responsible for converting angiotensin I (through the action of renin) to angiotensin II Angiotensin II is a potent vasoconstrictor and causes aldosterone secretion from the adrenal glands Winter 2013 9/18/2018

ACE Inhibitors: Mechanism of Action (cont’d)
Aldosterone stimulates water and sodium resorption Result: increased blood volume, increased preload, and increased BP Winter 2013 9/18/2018

ACE Inhibitors: Mechanism of Action (cont’d)
Block angiotensin-converting enzyme, thus preventing the formation of angiotensin II Prevent the breakdown of the vasodilating substance, bradykinin Result in decreased systemic vascular resistance (afterload), vasodilation, and therefore decreased blood pressure Winter 2013 9/18/2018

ACE Inhibitors: Indications
Hypertension HF (either alone or in combination with diuretics or other drugs) Slow progression of left ventricular hypertrophy after MI (cardioprotective) Renal protective effects in patients with diabetes Winter 2013 9/18/2018

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ACE Inhibitors: Indications (cont’d)
Drugs of choice in hypertensive patients with HF Drugs of choice for diabetic patients Winter 2013 9/18/2018

ACE Inhibitors (cont’d)
captopril (Capoten) Very short half-life enalapril (Vasotec) Available in oral and parenteral forms lisinopril (Prinivil and Zestril) and quinapril (Accupril), others Newer drugs, long half-lives, once-a-day dosing Several other drugs available Winter 2013 9/18/2018

ACE Inhibitors (cont’d)
Captopril and lisinopril are NOT prodrugs Prodrugs are inactive in their administered form and must be metabolized in the liver to an active form so as to be effective Captopril and lisinopril can be used if a patient has liver dysfunction, unlike other ACE inhibitors that are prodrugs Winter 2013 9/18/2018

ACE Inhibitors: Adverse Effects
Fatigue Dizziness Headache Mood changes Impaired taste Possible hyperkalemia Dry, nonproductive cough, which reverses when therapy is stopped Angioedema: rare but potentially fatal NOTE: First-dose hypotensive effect may occur! Winter 2013 9/18/2018

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Angiotensin II Receptor Blockers
(A-II blockers, or ARBs) Newer class Well tolerated Do not cause a dry cough Winter 2013 9/18/2018

Angiotensin II Receptor Blockers: Mechanism of Action
Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II Block vasoconstriction and release of aldosterone Winter 2013 9/18/2018

Angiotensin II Receptor Blockers
losartan (Cozaar, Hyzaar) valsartan (Diovan) eprosartan (Teveten) irbesartan (Avapro) Others Winter 2013 9/18/2018

Angiotensin II Receptor Blockers: Indications
Hypertension Adjunctive drugs for the treatment of HF May be used alone or with other drugs such as diuretics Used primarily in patients who cannot tolerate ACE inhibitors Winter 2013 9/18/2018

Angiotensin II Receptor Blockers: Adverse Effects
Upper respiratory infections Headache May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue Hyperkalemia much less likely to occur Winter 2013 9/18/2018

Calcium Channel Blockers: Mechanism of Action
Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in Decreased peripheral smooth muscle tone Decreased systemic vascular resistance Decreased blood pressure Winter 2013 9/18/2018

Calcium Channel Blockers
Benzothiazepines diltiazem (Cardizem, Dilacor) Phenylalkamines verapamil (Calan, Isoptin) Dihydropyridines amlodipine (Norvasc), bepridil (Vascor), nicardipine (Cardene) nifedipine (Procardia), nimodipine (Nimotop) Winter 2013 9/18/2018

Calcium Channel Blockers: Indications
Angina Hypertension Dysrhythmias Migraine headaches Raynaud’s disease Winter 2013 9/18/2018

Calcium Channel Blockers: Adverse Effects
Cardiovascular Hypotension, palpitations, tachycardia Gastrointestinal Constipation, nausea Other Rash, flushing, peripheral edema, dermatitis Winter 2013 9/18/2018

DIURETICS AND DRUGS THAT EFFECT THE RENAL SYSTEM
Winter 2013 9/18/2018

Diuretics Decrease plasma and extracellular fluid volumes Results
Decreased preload Decreased cardiac output Decreased total peripheral resistance Overall effect Decreased workload of the heart, and decreased blood pressure Winter 2013 9/18/2018

CARBONIC ANHYDRASE INHIBITORS (CAIs)
INHIBIT THE ENZYME ACTIVITY OF CARBONIC ANHYDRASE CA RECEPTORS ARE LOCATED IN THE PROXIMAL RENAL TUBULE CAIs PREVENT THE RESORPTION OF SODIUM = ELIMINATION OF WATER AND SODIUM 9/18/2018 Winter 2013

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WHEN TO USE CAIs? GLAUCOMA EDEMA EPILEPSY ACETOZOLAMIDE (DIAMOX)
USED IN THE TREATMENT OF: GLAUCOMA EDEMA EPILEPSY HIGH ALTITUDE SICKNESS (PULMONARY EDEMA) Winter 2013 9/18/2018

LOOP DIURETICS Have renal, cardiovascular, and metabolic effects
Act along the ascending limb of the loop of Henle. Blocks chloride and sodium resorption Chemically related to sulfonamides antibiotics 9/18/2018 Winter 2013

WHEN DO WE USE LOOP DIURETICS?
Heart Failure Liver failure Hypertension Renal failure Increase renal excretion of calcium 9/18/2018 Winter 2013

FUROSEMIDE (LASIX) BLOCK SODIUM AND CHLORIDE RESORPTION
USEFUL FOR RAPID DIURESIS HYPOKALEMIA IS OFTEN A SIDE EFFECT Winter 2013 9/18/2018

OSMOTIC DIURETICS PRODUCES OSMOTIC PRESSURE IN THE GLOMERULUS
PULLS WATER INTO THE RENAL TUBULES FROM THE SURROUNDING TISSUE  DECREASING CELLULAR EDEMA! 9/18/2018 Winter 2013

WHEN TO USE AN OSMOTIC DIURETIC?
CEREBRAL EDEMA INCREASED INTRAOCULAR PRESSURE NOT USED FOR PERIPHERAL EDEMA – NOT ENOUGH SODIUM LOSS 9/18/2018 Winter 2013

MANNITOL (OSMITROL) PRODUCES OSMOTIC PRESSURE IN THE GLOMULAR FILTRATE
PULLS WATER FROM THE RENAL TUBULES AND SURRONDING TISSUE USED IN ACUTE RENAL FAILURE AND CEREBRAL EDEMA Winter 2013 9/18/2018

POTASSIUM SPARING DIURETICS
WORK IN COLLECTING DUCTS AND DISTAL CONVOLUTED TUBLES INTERFERE WITH SODIUM + POTASSIUM EXCHANGE RELEASE Na+ AND H2O –> RETAIN K+ 9/18/2018 Winter 2013

WHEN TO USE POTASSIUM SPARING DIURETICS?
HYPERTENSION CHF (CHRONIC HEART FAILURE) 9/18/2018 Winter 2013

SPIRONOLACTONE (ALDACTONE)
INTERFERES WITH SODIUM AND POTASSIUM EXCHANGE NURSE MUST BE AWARE OF THE DANGER OF HYPERKALEMIA Winter 2013 9/18/2018

THIAZIDE AND RELATED DIURETICS
RELATED TO SULFONAMIDE ANTIBIOTICS (ALSO CAIs) PREVENT RESORPTION OF SODIUM (Na) POTASSIUM (K) AND CHLORIDE (Cl) IN THE DISTAL CONVOLUTED TUBULE 9/18/2018 Winter 2013

WHEN TO USE THIAZIDE DIURETICS?
CAN BE USED ALONE OR IN COMBINATION WITH OTHER DIURETICS TO TREAT: EDEMA HYPERTENSION CRONIC HEART FAILURE RENAL FAILURE 9/18/2018 Winter 2013

HYDROCHLORTHIAZIDE (HCTZ) (ESIDRIX)
INHIBIT RESORPTION OF SODIUM, POTASSIUM AND CHLORIDE COMMONLY USED WITH OTHER ANTIHYPERTENSIVES MAJOR SIDE EFFECTS ARE RELATED TO ELECTROLYTE BALANCE Winter 2013 9/18/2018

Diuretics (cont’d) Thiazide diuretics are the most commonly used diuretics for hypertension Listed as first-line antihypertensives in the JNC- 7 guidelines Winter 2013 9/18/2018

Vasodilators: Mechanism of Action
Directly relax arteriolar and/or venous smooth muscle Results in: Decreased systemic vascular response Decreased afterload (PVR) Peripheral vasodilation Winter 2013 9/18/2018

Vasodilators diazoxide (Hyperstat) hydralazine HCl (Apresoline)
minoxidil (Loniten) sodium nitroprusside (Nipride, Nitropress) Winter 2013 9/18/2018

Vasodilators: Indications
Treatment of hypertension May be used in combination with other drugs Sodium nitroprusside and intravenous diazoxide are reserved for the management of hypertensive emergencies Winter 2013 9/18/2018

Vasodilators: Adverse Effects
hydralazine Dizziness, headache, anxiety, tachycardia, nausea and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion, others sodium nitroprusside Bradycardia, hypotension, possible cyanide toxicity (rare) Winter 2013 9/18/2018

Vasodilators: Adverse Effects (cont’d)
diazoxide Dizziness, headache, anxiety, orthostatic hypotension, dysrhythmias, sodium and water retention, nausea, vomiting, hyperglycemia in diabetic patients, others Winter 2013 9/18/2018

Nursing Implications Remind patients that medication is only part of therapy. Encourage patients to watch their diet, stress level, weight, and alcohol intake Instruct patients to avoid smoking and eating foods high in sodium Encourage supervised exercise Winter 2013 9/18/2018

Nursing Implications (cont’d)
Teach patients to change positions slowly to avoid syncope from postural hypotension Instruct patients to report unusual shortness of breath; difficulty breathing; swelling of the feet, ankles, face, or around the eyes; weight gain or loss; chest pain; palpitations; or excessive fatigue Winter 2013 9/18/2018

Male patients who take these drugs may not be aware that impotence is an expected effect, and this may influence compliance with drug therapy If patients are experiencing serious adverse effects, or if they believe the dose or medication needs to be changed, they should contact their physician immediately Winter 2013 9/18/2018

Hot tubs, showers, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low blood pressure, leading to fainting and injury; patients should sit or lie down until symptoms subside Winter 2013 9/18/2018

CHAPTER 28 Coagulation Modifier Drugs
Winter 2013 9/18/2018

Hemostasis The process that halts bleeding after injury to a blood vessel Complex relationship between substances that promote clot formation and either inhibit coagulation or dissolve a formed clot Winter 2013 9/18/2018

Coagulation System “Cascade”
Each activated factor serves as a catalyst that amplifies the next reaction Result is fibrin, a clot-forming substance Intrinsic pathway and extrinsic pathway Winter 2013 9/18/2018

Winter 2013 9/18/2018

Coagulation Modifier Drugs
Anticoagulants Inhibit the action or formation of clotting factors Prevent clot formation Antiplatelet drugs Inhibit platelet aggregation Prevent platelet plugs Winter 2013 9/18/2018

Coagulation Modifier Drugs (cont’d)
Hemorheologic drugs Pentoxifylline(Trental) changes the shape of red blood cells in your blood. This makes it easier for these blood cells to fit into small arteries (blood vessels). Pentoxifylline is used to improve blood flow. Improved blood flow helps to reduce leg cramps and other symptoms of vascular disease Thrombolytic drugs Lyse (break down) existing clots Hemostatic or antifibrinolytic drugs Promote blood coagulation Winter 2013 9/18/2018

Anticoagulants Also known as antithrombotic drugs
Have no direct effect on a blood clot that is already formed Used prophylactically to prevent Clot formation (thrombus) An embolus (dislodged clot) Winter 2013 9/18/2018

Anticoagulants: Mechanism of Action
Vary depending on drug Work on different points of the clotting cascade Do not lyse existing clots Heparin and low–molecular-weight heparins Turn off coagulation pathway and prevent clot formation Winter 2013 9/18/2018

Anticoagulants: Mechanism of Action (cont’d)
All ultimately prevent clot formation Heparin Low–molecular-weight heparins warfarin (Coumadin) Anti-Thrombin (Inhibit thrombin molecule) fondaparinux (Arixtra) dabigatran (Pradaxa) Winter 2013 9/18/2018

Pradaxa channel 7 and FDA
Winter 2013 9/18/2018

Anticoagulants (cont’d)
Prevention of clot formation also prevents: Stroke Myocardial infarction (MI) Deep vein thrombosis (DVT) Pulmonary embolism (PE) Winter 2013 9/18/2018

Anticoagulants: Indications
Used to prevent clot formation in certain settings where clot formation is likely Myocardial infarction Unstable angina Atrial fibrillation Indwelling devices, such as mechanical heart valves Major orthopedic surgery Winter 2013 9/18/2018

Anticoagulants: Adverse Effects
Bleeding Risk increases with increased dosages May be localized or systemic Heparin-induced thrombocytopenia (HIT) May also cause: Nausea, vomiting, abdominal cramps, thrombocytopenia, others Winter 2013 9/18/2018

Heparin Monitored by activated partial thromboplastin times (aPTTs) Parenteral (IV or SC) Short half-life (1 to 2 hours) Effects reversed by protamine sulfate Winter 2013 9/18/2018

Low–molecular-weight heparins enoxaparin (Lovenox) and dalteparin (Fragmin) More predictable anticoagulant response Do not require laboratory monitoring Given subcutaneously Winter 2013 9/18/2018

warfarin sodium (Coumadin) Given orally only Monitored by prothrombin time (PT) and International Normalized Ratio (INR) (PT-INR) Vitamin K can be given if toxicity occurs Winter 2013 9/18/2018

Antiplatelet Drugs Prevent platelet adhesion aspirin
dipyridamole (Persantine) clopidogrel (Plavix) and ticlopidine (Ticlid) ADP inhibitors tirofiban (Aggrastat), eptifibatide (Integrilin), abciximab (ReoPro) New class, GP IIb/IIIa inhibitors Winter 2013 9/18/2018

Antiplatelet Drugs: Indications
Antithrombotic effects Reduce risk of fatal and nonfatal strokes Acute unstable angina and MI Adverse effects Vary according to drug Winter 2013 9/18/2018

Antifibrinolytic Drugs
Prevent the lysis of fibrin Result in promoting clot formation Winter 2013 9/18/2018

Antifibrinolytic Drugs (cont’d)
Enhance blood clotting aminocaproic acid (Amicar) desmopressin (DDAVP) Similar to ADH Also used in the treatment of diabetes insipidus Winter 2013 9/18/2018

Antifibrinolytic Drugs: Indications
Prevention and treatment of excessive bleeding Hyperfibrinolysis Surgical complications Excessive oozing from surgical sites such as chest tubes Reducing total blood loss and duration of bleeding in the postoperative period Treatment of hemophilia or von Willebrand’s disease Winter 2013 9/18/2018

Antifibrinolytic Drugs: Adverse Effects
Uncommon and mild Rare reports of thrombotic events Others include: Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, nausea, vomiting, abdominal cramps, diarrhea, others Winter 2013 9/18/2018

Thrombolytic Drugs Drugs that break down, or lyse, preformed clots
Older drugs streptokinase and urokinase Newer drugs Tissue plasminogen activator (t-PA) Anisoylated plasminogen-streptokinase activator complex (APSAC) Winter 2013 9/18/2018

Thrombolytic Drugs (cont’d)
anistreplase (Eminase) alteplase (t-PA, Activase) reteplase (Retavase) tenecteplase (TNKase) Winter 2013 9/18/2018

Thrombolytic Drugs: Mechanism of Action
Activate the fibrinolytic system to break down the clot in the blood vessel quickly Activate plasminogen and convert it to plasmin, which can digest fibrin Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction Winter 2013 9/18/2018

Thrombolytic Drugs: Indications
Acute MI Arterial thrombolysis DVT Occlusion of shunts or catheters Pulmonary embolus Acute ischemic stroke Winter 2013 9/18/2018

Thrombolytic Drugs: Adverse Effects
Bleeding Internal Intracranial Superficial Other effects Nausea, vomiting, hypotension, anaphylactic reactions Cardiac dysrhythmias; can be dangerous Winter 2013 9/18/2018

Nursing Implications Assess:
Patient history, medication history, allergies Contraindications Baseline vital signs, laboratory values Potential drug interactions—there are MANY! History of abnormal bleeding conditions Winter 2013 9/18/2018

Heparin: Nursing Implications
Intravenous doses are usually double-checked with another nurse Ensure that SC doses are given SC, not IM SC doses should be given in areas of deep subcutaneous fat, and sites rotated Winter 2013 9/18/2018

Heparin: Nursing Implications (cont’d)
Do not give SC doses within 2 inches of: The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas Do not aspirate SC injections or massage injection site May cause hematoma formation Winter 2013 9/18/2018

Heparin: Nursing Implications (cont’d)
IV doses may be given by bolus or IV infusions Anticoagulant effects seen immediately Laboratory values done daily to monitor coagulation effects (aPTT) Protamine sulfate can be given as an antidote in case of excessive anticoagulation Winter 2013 9/18/2018

LWMHs: Nursing Implications
Given subcutaneously in the abdomen Rotate injection sites Protamine sulfate can be given as an antidote in case of excessive anticoagulation Winter 2013 9/18/2018

Warfarin Sodium: Nursing Implications
May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulation Full therapeutic effect takes several days Monitor PT-INR regularly—keep follow-up appointments Antidote is vitamin K Winter 2013 9/18/2018

Warfarin: Nursing Implications
Many herbal products have potential interactions— increased bleeding may occur Capsicum pepper Garlic Ginger Gingko Ginseng Feverfew Winter 2013 9/18/2018

Anticoagulants: Patient Education
Education should include: Importance of regular lab testing Signs of abnormal bleeding Measures to prevent bruising, bleeding, or tissue injury Winter 2013 9/18/2018

Anticoagulants: Patient Education (cont’d)
Education should include (cont’d): Wearing a medical alert bracelet Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables) Consulting physician before taking other meds or over-the-counter products, including herbals Winter 2013 9/18/2018

Antiplatelet Drugs: Nursing Implications
Concerns and teaching tips same as for Anticoagulants Dipyridamole should be taken on an empty stomach Drug-drug interactions Adverse reactions to report Monitoring for abnormal bleeding Winter 2013 9/18/2018

Thrombolytic Drugs: Nursing Implications
Follow strict manufacturer’s guidelines for preparation and administration Monitor IV sites for bleeding, redness, pain Monitor for bleeding from gums, mucous membranes, nose, injection sites Observe for signs of internal bleeding (decreased BP, restlessness, increased pulse) Winter 2013 9/18/2018

Coagulation Modifier Drugs: Nursing Implications
Monitor for therapeutic effects Monitor for signs of excessive bleeding Bleeding of gums while brushing teeth, unexplained nosebleeds, heavier menstrual bleeding, bloody or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood Winter 2013 9/18/2018

Coagulation Modifier Drugs: Nursing Implications (cont’d)
Monitor for adverse effects Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills, fever Winter 2013 9/18/2018

DRUGS AFFECTING THE CARDIOVASCULAR and RENAL SYSTEMS Chpts: 22-29

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DRUGS AFFECTING THE CARDIOVASCULAR and RENAL SYSTEMS Chpts: 22-29

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