Cardiac DrugsDaymar College

Lisa H. Young, RN, BSN, MA Ed

Classifications and Prototype Drugs (Pr) Pregnancy Category Controlled Substances Availability Uses and Unlabeled Uses Action and Therapeutic Effect Contraindications and Cautious Use Route and Dosage Administration Intravenous Drug Administration Adverse Effects Diagnostic Test Interference Interactions Pharmacokinetics Clinical Implications Therapeutic Effectiveness

How to Use a Drug Book

http://www.youtube.com/watch?v=Jh_U8V9-Htw

http://www.youtube.com/watch?v=9mcqPJFB3UE

Drug Names Generic name Brand name/Proprietary name Chemical name

Indications and Usage

Contraindications

Pharmacologic Principles

Drug Interactions◦ “Red Flag” Drugs: Warfarin

Aspirin Cimetinde

Theophylline

Drug Reactions Adverse reaction Side effects

Pharmacologic Principles

Drug Administration

Enteral Routes

Parenteral Routes

Topicals & Transdermal

Pharmacologic Principles

Pharmacokinetics

Absorption

Bioavailability

Therapeutic range

Distribution

Pharmacologic Principles

Metabolism

Elimination

Pharmacodynamics

Tolerance

Pharmacologic Priniciples

Half-Life◦ Digoxin 30-60 hours◦ Warfarin 0.5 – 3 days◦ Heparin 1 – 2 days

Poisonings/Toxicity

Pharmacologic Principles

Prescription Drugs

Nonprescription Drugs

Controlled Substances Drug Abuse Drub dependency

Legal Classifications of Drugs

Prescription Orders◦ Patient Name (superscription)◦ Address◦ Drug name (inscription)◦ Drug dose◦ Route (subscription)◦ Frequency of administration◦ Number to be dispensed◦ Number of refills allowed◦ DEA #◦ MD Name/signature◦ MD address◦ MD Phone number

Pharmacologic Principles

http://www.youtube.com/watch?v=Mhqe12Aj1dE

Reading & Writing a Prescription

http://www.youtube.com/watch?v=S0oqYJp9t2o

http://www.youtube.com/watch?v=hRdGLzylovM

Reading Prescription Label

Ten Rights◦ Right patient name◦ Right drug◦ Right dosage◦ Right route & technique◦ Right time◦ Right documentation◦ Right client education ◦ Right to refuse◦ Right assessment◦ Right evaluation

Medication Administrationhttp://www.youtube.com/watch?v=cm7GexPKNOc&list=PLxdOP8vuQhz9SNJLTWjTGzh3yOTsEsd6l

http://www.youtube.com/watch?v=kdB0PmsX2ng

http://www.youtube.com/watch?v=yhHq-pV6HOw

Abbreviation Meaning Abbreviation MeaningAc before meals qhs every nightBid twice daily Rx takec with s without

DC discontinue SL sublingualdx diagnosis SOA short of air

NPO nothing by mouth

ss half

NS normal saline suppos suppositoryp after tid 3 times daily

PR per rectum top topicalprn as needed ung ointmentq every UT under tongue

Pharmacology Abbreviations

“Do Not Use” Abbreviations

Examples of charting:A. 9/1/12 9:00 a.m. nitroglycerin, 1 tab, sublingually. Written

instructions given to pt. Precautions explained. Told to call office at 1:00p.m. today to report progress of his condition….M. Richards, CMA (AAMA)

B. 1/19/12 11:00 a.m. B 12 vitamin, 10000mcg given IM to left deltoid muscle without complications and band aid applied to injection site. Pt tolerated injection well. Pt. given written instructions for possible side effects and considerations. Pt to return in one monthly to receive monthly B 12 injections as ordered……L.Young, CCT.

C. 10/10/2012 1:00 p.m. Mantoux test, 0.01 ml. Tuberculin Purified Protein Derivative, Left forearm, subcutaneous, small wheal noted. Pt. instructed not to rub or cover the are and to return for reading on 10/12/12…..M. Richards, CMA (AAMA)

Charting Medication Administration

Client’s own words Clarity Completeness Conciseness Chronological Confidentiality

Six Cs of Charting

http://www.youtube.com/watch?v=mYGf0AdhhI4

http://www.youtube.com/watch?v=SDcmXqSvP7A

Date/time of entry Legible handwriting Permanent black ink Proper terminology, correct spelling and

correct grammar Document in sequence Be concise Correct errors Sign every entry

Guidelines for Charting

http://www.youtube.com/watch?v=pe2TQJKXZIs

http://www.youtube.com/watch?v=GMVwoR0YU-I

http://www.youtube.com/watch?v=Bkoic2dLFmY

gr = grain gal = gallon dr = dram qt iii = 3 quarts oz = ounce ix = 9 lb = pound qt i = 1 quart m = minims gr ½ = ½ grain fl dr = fluid drams pt iiiss = 3 ½

pints fl oz = fluid ounce 1 grain = 60 mg pt = pint qt - quart

Apothecary System

Metric Conversion Value Chart

Kilo – Hecto-Deka-Base-Deci-Centi-Milli-X-X-Micro Gram Liter Meter

45.2 grams = 45200.0 milligrams

1cubic centimeter (cc) = 1 milliliters (ml)

Metric System

http://www.youtube.com/watch?v=2QR9yCkAEpE

Dosage unit

Dosage strength

Dosage ordered

Desired dose

Dose on hand Amount to administer

Dosage Definitions

Drug Calculation: Formula Method

Ordered Dose X Available Amount

Available Dose Amount to give

Ordered dose: 500 mgAvailable dose: 1000 mgAvailable amount: 1 ml

Drug Dosage Calculations

http://www.youtube.com/watch?v=b69Wr008dzM

http://www.youtube.com/watch?v=BMDOk3RAHC4

http://www.youtube.com/watch?v=Wa9Zi64_HJk

Rules of ConversionApothecary Metric

1 fluid oz 30 mL or cc1 quart 1000 mL or cc1 grain 0.065 gram

15 grains 1 gram2.2 pounds 1 kilogram

Household Metric1 drop 0.06 mL1 tsp 4-5 mL1 T 15-16 mL

1 cup 250 mL2 cups 500 mL

Clark’s Rule

Fried’s Rule

Young’s Law

West’s nomogram

Body Weight method

Calculating Pediatric Dosages

http://www.youtube.com/watch?v=AQaeAON4GUM

Assessment Plan Implementing Document Evaluate Special Needs Noncompliance

Patient Education

http://www.youtube.com/watch?v=1HQHdpAov-I

Cultural Considerations

The Life Span

Understanding and knowledgeable about medication

In the Workplace

The Law

Professionalism

http://www.youtube.com/watch?v=eboZYnTF6vs

Inotropic, Chronotropic and Dromotropic Drugs

http://www.youtube.com/watch?v=mQirK5RxhFo

Sympathetic Nervous System

Adrenergic Response_ Catecholamines_ Adrenaline_ Beta 1-Adrenergic Receptors

_ Alpha 1-Adrenergic Receptors

Neurological Control of the Heart and Blood Pressure

http://www.youtube.com/watch?v=lw1Ag86SvlY

Baroreceptors_ Pressure receptors

_Mechanoreceptors

_Efferent pathways

Neurological Control of the Heart and Blood Pressure

Chemoreceptors_ carotid artery

_ Elevated arterial carbon dioxide level

_ Heart rate increases

_ Vasoconstriction

Neurological Control of the Heart and Blood Pressure

Parasympathetic Nervous System

Vagal Response _ Cholinergic Response _ Acetylcholine _ Nicotinic Cholinergic Receptors _ Muscarinic Cholinergic Receptors

Neurological Control of the Heart and Blood Pressure

Renin-Angiotensin-Aldosterone System_ Release of Renin_ Angiotensin I → Angiotensin II_ Angiotensin-converting enzyme (ACE)

Neurological Control of the Heart and Blood Pressure

http://www.youtube.com/watch?v=M0vpn6YVwiI

Preload The stretching of the ventricle at the end of diastole.

_ Increasing Preload Administer extracellular fluid expander Decrease dose of stop drugs that cause venous vasodilation

_ Decreasing Preload Stop or decrease fluid Diuretics ACE inhibitors Aldosterone antagonists Venous vasodilators

Cardiovascular Pharmacology

http://www.youtube.com/watch?v=lPK017oR3bw

http://www.youtube.com/watch?v=mQirK5RxhFo

http://www.youtube.com/watch?v=FjdJdoZcbyA

Afterload The resistance that the ventricle must overcome to eject

its contents.

_ Increasing Afterload Sympathomimetics (stimulate alpha receptors) ADH

_ Decreasing Afterload Smooth muscle relaxants Calcium channel blockers Alpha receptor blockers ACE inhibitors ARBs & PDE

Cardiovascular Pharmacology

http://www.youtube.com/watch?v=NFcg62I54w8

Contractility

_Increasing Contractility Sympathomimetics (stimulate B1 receptors) PDE inhibitors Cardiac glycosides

_Decreasing Contractility Beta-blockers Calcium channel blockers

Cardiovascular Pharmacology

http://www.youtube.com/watch?v=_sxiloNshfE

Heart Rate Cardiac output = heart rate X stroke volume

Increasing heart rate Parasympatholytics Sympathomimetics (stimulate B1 receptors)

Decreasing heart rate Beta-blockers (block B1 receptors) Calcium channel blockers Cardiac glycosides Other antiarrhythmics

Cardiovascular Pharmacology

http://www.youtube.com/watch?v=PJ8WsZOywgo

http://www.youtube.com/watch?v=OVVwyCCyH8E

Stimulate the sympathetic nervous system

Increase heart rate

Increase contractility

Increase afterload

Sympathomimetics/Adrenergics

http://www.youtube.com/watch?v=HklZH5QdOeE

Stimulates: B1 & B2 (low dose) & Alpha receptors (high doses)

Results: increased contractility, automaticity, bronchodilation and selective vasoconstriction

Uses: advanced cardiac life support, anaphylactic shock, hypotension/profound bradycardia

Considerations: instant onset, peak 20 minutes and given IV every 3 – 5 minutes for cardiac standstill

Epinephrine

http://www.youtube.com/watch?v=9cpD8lG6DvY

Stimulates: primarily B1, some alpha receptors and modest B2

Results: increased contractility, increased AV node conduction, modest vasoconstriction

Uses: as an inotrope with modest afterload reduction

Considerations: onset 1 – 2 minutes, peak 10 minutes, blood pressure is variable: B2 causes vasodilation, increased cardiac output increases blood pressure

Dobutamine

Stimulates: dopaminergic and some B1 at low doses, B1 at moderate doses, pure alpha stimulation at high doses (>10 mcg/kg/min)

Results: increased contractility at small and moderate doses, increased conduction, vasoconstriction at high doses, does not treat or prevent renal failure at low doses

Uses: refractory hypotension and shock Considerations: IV onset 1 – 2 minutes & peak

10 minutes

Dopamine

http://www.youtube.com/watch?v=YrEn_1FBBsw

Stimulates: primarily alpha stimulation, some B1

Results: potent vasoconstriction (vasopressor) and some increased contractility (positive inotrope)

Uses: refractory hypotension, shock, used as vsopressor but with inotrope properties

Considerations: Rapid IV onset, duration 1-2 minutes

Norepinephrine

Stimulates: direct effect is dominant alpha stimulation, no substantial B1 effect at therapeutic doses, indirect effect; causes release of norepinephrine

Results: potent vasoconstriction (vasopressor)

Uses: refractory hypotension Considerations: rapid IV onset, duration of

action 10 – 15 minutes

Phenylephrine (synthetic compound)

Arginine vasopressin used as vasopressor

Milrinone (phosphodiesterase inhibitor) used as an inotrope◦ Side effects: ventricular dysrhythmias exacerbation of accelerated

ventricular rate with atrial dysrhythmias

Non-Sympathomimetic Medications

Angiotensin-Converting Enzymes (ACE) Inhibitors

prevent conversion of angiotensin I to angiotensin II

inhibits angiotensin-converting enzyme promotes arterial vasodilation reduces afterload

Benazepril Captopril Enalapril FosinoprilLisinopril Quinapril Ramipril

Medications Affect Renin-Angiotensin-Aldosterone System

Blocks angiotensin II Similar hemodynamic effects as ACE

inhibitors Used in place of ACE inhibitors if they are

not tolerated due to intractable cough or angioedema

ARBs end with “sartan” Candesartan, first drug approved by FDA for

heart failure Candesartan Irbesartan Telmisartan Eprosartan Losartan Valsartan

Angiotensin II Receptor Blockers

mineralocorticoid hormone hold sodium and water and excrete potassium potassium-sparing diuretics decrease in preload minimized release of catecholamines improved endothelial function antithrombotic effects decreased vascular inflammation and

myocardial fibrosis Spironolactone Eplerenone

Aldosterone Antagonists

http://www.youtube.com/watch?v=OAkbKN6AuWE

block B1 or B2 receptors decrease heart rate and contractility bronchial and peripheral vasoconstriction management of heart failure management of stable angina management of acute coronary syndromes decrease myocardial oxygen demand increase coronary perfusion management of hypertensionAtenolol Metoprolol Propranolol Esmolol

Beta-Blockers

decrease the flux of calcium decrease heart rate, contractility and

afterload degree of negative inotropic effect reduce coronary and systemic vascular

resistance decreasing myocardial oxygen demand not indicated in the treatment of heart

failure adverse effects: peripheral edema,

worsening heart failure, hypotension and constipation

Verapamil Dihydropyridine CCB Diltiazem

Calcium Channel Blockers

Action Verapamil Dihydropyridine calcium channel blockers

Diltiazem

Heart rate ⇓ ⇑ ⇓

AV nodal conduction

⇓ Neutral ⇓

Contractility ⇓ ⇓ ⇓

Arterial vasodilation

⇑ ⇑ ⇑

Calcium Channel Blockers

Nitroglycerin and Nitrates IV a primary venous vasodilator sublingual produces both venous and

arterial vasodilation decreases preload reducing myocardial oxygen demand higher doses = coronary artery dilation exhibits antithrombotic and antiplatelet

effects

Arterial and Venous Vasodilators

mixed venous and arterial vasodilative arterial vasodilator indicated in hypertensive crisis cardiac emergencies hypotension side effect possible thiocyanate toxicity

Nitroprusside

synthetic brain natriuretic peptide (BNP) counteract the effects of RAAS venous and arterial vasodilative effects management of acute decompensated

heart failure decrease preload and afterload lowers blood pressure

Nesiritide

cardiac glycoside weak inotropic properties parpasympathetic properties used in treatment of heart failure narrow therapeutic range easy to develop toxicity electrolyte increase effect of digoxin

Digoxin

reduce preload ascending loop of Henle promote venous vasodilation reduce preload rapid onset and short duration of action high-ceiling diuretics effective for renal dysfunction Bumex Lasix Demadex

Loop Diuretics

Inhibit reabsorption of sodium & chloride Less potent than loop diuretics Decreased effectiveness with renal dysfunction Low-ceiling diuretics

Bendrofluazide Cyclothiazide Hydrochlorothiazide Chlorothiazide Indapamide Polythiazide Metolazone Trichlormethiazide

Thiazide Diuretics

Direct renin inhibitors – Aliskiren _ treatment of hypertension _ impact RAAS

Vasopressin 2 Antagonists – Tolvaptan _ oral medication _ renal collecting ducts _ treatment of heart failure with volume overload

Emergency Medications

Low-Density Lipoprotein Cholesterolo primary goal in the management of

coronary heart diseaseo HMG-CoA reductase inhibitors (statins)o Bile acid resinso Nicotine acido Dose dependent effect on LDL-C

Lipid-Lowering Medications

Nicotinic acid (Niacin)

Fibrates

Statins

Bile acid resins

Bile acid sequestrants

Triglycerides and High-Density Lipoprotein Cholesterol

Combine with bile acids Hepatic circulation More production of cholesterol Breaks cholesterol to make bile acids Increases LDL-C receptors Net decrease in total cholesterol Net decrease in LDL-C Constipation Questran Colestid WelChol

Bile Acid Sequestrants (Resins)

B complex vitamin Dilates the cutaneous blood vessels Increases blood flow to face, neck and chest Vasodilation – “flush” Increase gastric acid secretion Decrease mortality in MI Decrease VLDL-C production Decreases lipolysis of triglycerides Decreases hepatic triglyceride synthesis Niacor Slo-Niacin Niaspan

Nicotinic Acid (Niacin)

Fibric acid agents Not fully understood Stimulate lipoprotein lipase activity Decrease hepatic triglyceride production Decrease cholesterol synthesis Increase mobilization of cholesterol Enhance the removal of cholesterol Increase cholesterol excretion Raise HDL-C levels Atromid-S Tricor Lopid

Fibrates

Statins Reduced lipid levels Reduced future coronary events Reduce the risk of coronary mortality &

morbidity Inhibition of HMG-CoA reductase Reduce the quantity of mevalonic acid

Mevacor Zocor Lescol Lipitor Crestor

HMG-CoA Reductase Inhibitors

Newest class of lipid-lowering medications

May be combined with HMG-CoA reductase inhibitor

Ezetimibe

Blocks the absorption of cholesterol in the small intestine

Intestinal Absorption of Inhibitors

To protect the integrity of the vessels and prevent harmful bleeding

To maintain the fluid state of the blood

These two goals must be achieved simultaneously to maintain health

Coagulation Overview

Clotting CascadePlatelet Aggregation

Release Thromoboplastin

Prothrombin

Thrombin

Fibrinogenhttp://www.youtube.com/watch?v=IEuFUSuGcxE&list=PL2UREUiTlHRn3iW9DhoeLjxNDM7Ly5vrA

Thrombolytics & Fibrinolytics

Type Actions/ Physiologic Effect

Agents

Fibrin specific Plasminogen activationRapid clot lysisClot specific

Tissue plasminogen activators (t-PAs)Alteplase Reteplase Tenecteplase

Nonfibrin specific Systemic lysisSlow clot lysisMore prolonged, systemic effect

StreptokinaseAnistreplase (APSAC)

Earliest “clot busting” medication

Dissolves clots during an acute MI

Produce antistreptokinase antibodies Contraindicated to use streptokinase in

these patients

Streptokinase

Anisoylated plasminogen streptokinase activator complex

Altered form of streptokinase Converts circulating plasminogen into

plasmin May be given as an IV bolus over 2 – 5

minutes Particular affinity for fibrin Activates the plasminogen that is bound to

fibrin

Anistreplase (APSAC)

Unfractionated Heparin (UFH)◦ Antithrombotic agent◦ Prevents the conversion of prothrombin to thrombin◦ Binds to plasma proteins, blood cells, and

endothelial cells◦ Administered intravenously◦ Weight-based protocol◦ Administrated subcutaneoulsy◦ aPTT , PT, INR, platelet count, hemoglobin level and

hematocrit◦ Bleeding potential complication◦ Thrombocytopenia

Anticoagulants

Low-molecular-weight Heparin (LMWH)◦ Accelerating the activity of antithrombin III◦ Longer half-life than UFH◦ No clotting times need to be monitored◦ Lower incidence of HIT◦ Higher rate of minor bleeding◦ Special dosing required for patients with chronic renal

insufficiency◦ Protamine used for reversing effects◦ Administered subcutaneously◦ Enoxaparin

Anticoagulants

Direct Thrombin Inhibitors◦ Treatment of thrombosis in patients with HIT◦ Ability to inactivate fibrin-bound thrombin◦ Lepirudin and desirudin◦ Argatroban◦ Bivalirudin◦ Pradaxa

Anticoagulants

Factor Xa Inhibitors◦ New class of anticoagulants◦ Fondaparinux◦ DVT and PE prophylaxis treatment◦ Antithrombotic action by neutralizing factor Xa◦ Subcutaneous injection ◦ No need for laboratory monitoring◦ No reports of HIT◦ Contraindicated in severe renal dysfunction

Anticoagulants

Warfarin (Coumadin)◦ Oral anticoagulant◦ Inhibition of the synthesis of factor II

(prothrombin)◦ Altering the synthesis of other vitamin K-

dependent factors ◦ Primarily bound to albumin in the blood◦ Monitor PT and INR levels◦ Lifelong therapy for atrial fibrillation◦ Many drugs interact with warfarin ◦ No aspirin, ibuprofen or naprosyn

Anticoagulants

Glycoprotein Iib/IIIa Inhibitors◦ Interfere with the final pathway of platelet

aggregation◦ Prevent fibrinogen binding◦ Administrated intravenously◦ May be given with aspirin, clopidogrel & heparin◦ Abciximab (ReoPro)◦ Monitor platelet count and hemoglobin level◦ Treatment of unstable angina and non-STEMI

Antiplatelet Therapy

Adenosine Diphosphate Inhibitors◦ Clopidogrel (Plavix)◦ Prevents adenosine diphosphate (ADP) activation

of platelets◦ Treatment of unstable angina & non-STEMI◦ Avoid use of omeprazole (Prilosec)◦ Warning for patients who are poor metabolizers◦ Prasugrel

Antiplatelet Therapy

Aspirin◦ Anti-inflammatory, analgesic, antipyretic &

antithrombotic◦ Treatment of acute or chronic ischemic heart

disease◦ Inhibiting cyclooxygenase and inhibiting the

synthesis of thromboxane A2.◦ Inhibits endothelial production of prostabladin I2◦ Chewing aspirin accelerates absorption◦ GI side effects

Antiplatelet Therapy

Oxygen Aspirin Sublingual or Intravenous Nitroglycerin Intravenous Beta Blocker Unfractionated Heparin Glycoprotein IIb/IIIa Receptor Blocker

Treatment for Myocardial Infarction

Antiarrhythmics

Antiarrhythmics Continued