Classification of Medications Cardiology

8/6/2019 Classification of Medications Cardiology

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conditions

II. Classification of Medications by Body SystemA. Managing cardiac disease

1. Antianginal agent

2. Anticoagulant

3. Antidysrhythmia agent

4. Antihypertensive

5. Antilipid agent

6. Antiplatelet agent

7. Diuretic

8. Positive inotropic agent

9. Thrombolytic agent

10. Vasodilator

11. Vasopressors

1. Therapeutic class: antianginal agents



1. Therapeutic class: antianginal agentsa. type: nitrates

i. actiony arterial, venous, and capillary vasodilation by

relaxing vascular smooth muscleo decreases myocardial oxygen

consumptiono decreases preload with venous poolingo decreases afterload by decreasing

peripheral vascular resistance ii. example

y nitroglycerino Nitro-bid IV 10-20 mcg/min, titrate to BP

dose should be 5-20 mcg/mino Nitro-Dur 1 transdermal patch daily,

remove for 6 to 8 hours dailyo Nitrostat 0.2-0.6 mg tab sublingual (SL),

may repeat every 5 minutes up to 3tabs

iii. uses: prophylaxis, treatment, and management of angina, acute myocardial infarction (MI)

iv. adverse effects



y life-threatening: sudden, severe refractoryhypotension when taken with sildenafilcitrate (Viagra), tadanafil (Cialis),orvardenafil (Levitra); methoglobinemia,contact dermatitis

y

most common: o headac he, nausea, vomiting , d izziness o r eflex t ac hy c ar d i a, post ur al hypot ension

y other o clinical indicators of alcohol intoxication

(without the alcohol)o may decrease effectiveness of heparin

v. contraindicationsy severe anemia, cardiac tamponade y cerebral hemorrhage or right ventricular failurey hypovolemia, hypotension, shock

vi.

nursing carey assist health care team to establish baseline

data and observe during acute angina or IVadministration blood pressure, heart rate,EKG, chest pain

y clarify data to report and frequency of reporty withdraw treatment gradually to avoid anginay toxicity: CNS changes, hypotension, flushing,

nauseay buccal area must be moist for SL absorptiony maintain a 6 to 8 hour nitrate-free period every

24 hours after acute episode to avoidtolerance

y assist health care team to implement clientteaching plano apply spray under tongue; do not chew

tabletso sit down when taking, change positions

slowlyo report blurred vision or dry mouth, avoid

alcoholo keep tablets away from light, moisture,

and body heat; change tablets every 6months

o use spray or sublingual tablets for immediate relief; combine medicationwith rest for acute attack

o for acute angina: take 1 tablet (or 1 spray under the tongue) SL every 5





2. Anticoagulantsa.Type: oral

i. action: interferes with vitamin K dependent clottingfactors in the liver resulting in prolonged bleedingtime

ii. example: warfarin (Coumadin) 2.5-10 mg by mouth

daily for 2 to 5 days; then, titrate according to INRiii. usesy atrial fibrillation (A fib) and atrial flutter (A

flutter)y heart failure, DVT, and pulmonary embolism

(PE)y mechanical heart valve surgery (postoperative)y maintenance therapy and prophylaxis to

suppress formation of dangerous clots after MI

iv. adverse effectsy

hemorrhage, peripheral skin necrosis y bone marrow depression, liver dysfunctiony anorexia, many drug-drug interactionsy high-risk drug with older or incompetent clients

v. contraindicationsy clients at risk for falls, malabsorption

syndromes y severe hepatic or renal disease



y bleeding disorders and active bleedingy recent invasive procedure to spinal cord

vi. nursing carey assist health care team to establish baseline

data and check prior to each dose prothrombin

time (PT) and international normalized ratio (INR), bleeding, bruising, liver function tests(LFTs), headache, decreased level of consciousness, and risk of falls

1. check and report daily INR, PT andperiodic LFTs

y high risk therapy for older clients in thecommunity

1. check for bleeding, bruising, and fallsy apply prolonged pressure to any puncture

wounds to stop bleedingy

antidote: vitamin K1. suppresses warfarin activity for 1-3weeks

2. may need alternate form of anticoagulation

y assist HCT to implement client teaching plan1. avoid alcohol, NSAIDs2. use electric razor for shaving3. seek emergency treatment for falls4. wear MedicAlert identification, check for

bleeding and bruising5. take at same time daily, need for follow-

up care and testing6. avoid herbal remedies including

echinacea, licorice, and ginseng7. avoid foods containing vitamin K

(decreases effect of warfarin) especiallygreen leafy vegetables, broccoli, andliver

b. type: low-molecular weight (LMW) heparin (parenteral)

(i llust r ation )i. action: blocks action of Factors Xa and IIa without

appreciably affecting thrombin or prothrombin ii. examplesy dalteparin (Fragmin) 2500 international units by

subcutaneous injection dailyy enoxaparin (Lovenox) 1-1.5 mg/kg by

subcutaneous injection dailyiii. uses: prophylaxis against thromboembolic disorders

associated with surgery and bedrest



iv. adverse effectsy hemorrhage, thrombocytopenia, angioedema y increased bleeding times and bruisingy inflammation at injection site, dypsnea, rash

v. contraindicationsy

recent GI bleed or invasive spinal cordprocedurey active bleeding, thrombocytopenia,

uncontrolled HTNvi. nursing care (See also: II. A. anticoagulants: oral,

nursing care)y assist HCT to establish baseline data; check

CBC and plateletsy does not affect PT, INR, or activated partial

thromboplastin time (aPTT) with therapeuticdoses

y

lower risk of heparin-inducedthrombocytopenia (HIT) than unfractionatedheparin

y give subcutaneously according tomanufacturer's direction; do not eject bubble

y assist health care team to implement clientteaching plan

1. subcutaneous injection technique2. rotate injection sites3. expect small hematomas4. report falls

2.Coagulation Cascade





y other 1. bronchospasm, increased bleeding time2. rebound hyperlipidemia, fever, chills,

rash3. impairment of endocrine system

4.

drug-drug interaction with nitroglycerin,nicotinev. contraindications

y extensive burns, trauma; severe HTNy recent surgery or invasive spinal cord

procedurey thrombocytopenia, active bleeding, bleeding

disorders

vi. nursing care (See also: II. A. anticoagulants: oral,nursing care)

y assist health care team to establish baseline

data and check aPTT, CBC, and plateletsbefore administration and during therapyy adjust dosage when given with nitroglycerin

(NTG): check PTT frequentlyy high-risk therapy for women, older clients, and

with renal or hepatic insufficiencyy antidote: protamine sulfate (Protamine Sulfate)

1.0% 0.5-1 mg IV/100 units of heparin giveny client teaching (See also: II. A. client teaching)y need for regular PTT levels

3. Antidysrhythmia agents (aka antiarrhythmia)

a.

information common to antidysrhythmia agentsi. use (i llust r ation )y eradication of frequent premature ventricular

contractions that cause hemodynamicinstability or loss of consciousness

y emergency eradication of ventricular dysrhythmias

y cardiopulmonary resuscitationy chemical cardioversion of atrial and ventricular

dysrhythmiasii. adverse effects

y

heart blocky most are have dysrhythmogenic potential

(capable of causing dysrhythmias)y prolongation of QTc interval or QRS complexy increased risk of torsades des pointes

iii. assist health care provider to implement clientteaching plan



y count heart rate and pattern of rhythm, i.e.,regularity

y provide acceptable range for heart ratey report

1. new onset of irregular rhythm

2.

findings outside of acceptableparameters3. worsening heart rate, dizziness,

lightheadedness, loss of consciousness,and edema

b. type: sodium channel blocking agents (Class Iantidysrhythmia agents)

i. action: suppresses various phases in myocardial cellaction potential by blocking sodium channels;stabilizes myocardial cell membrane

ii. exampley

lidocaine (Xylocaine) 2 mg/min IV infusion:titrate according to frequency of ventricular ectopy

y quinidine gluconate (Quinalan) 325-650 mg bymouth every 6 hours, 324-972 mg by mouthevery 8 to 12 hours as extended-release tabs

y procainamide (Pronestyl) 500-1000 mg bymouth every 4-6 hours, 1 gram every 12 hoursas sustained-release form

iii. uses: ventricular dysrhythmias, chemicalcardioversion with A fib and A flutter (exceptlidocaine)

iv. adverse effectsy life-threatening:

1. dysrhythmias, heart block, torsades

de pointes (i llust r ation )2. respiratory depression, bone marrow

depression y other:

1. nausea, vomiting, rash2. increases risk of digoxin toxicity and risk

of bleeding with anticoagulants

3.

CNS effects including sedation,confusion, and seizures (especiallylidocaine)

Conduction System of the Heart





Torsades de Pointe

Copyright Elsevier B.V. (used with permission)

v. Haugh, K. H. and Keeling, A. (2003). Coronary artery

disease and dysrhythmias. In W. J. Phipps, F. D. Monahan,J. K. Sands, J. F. Marek, and M. Neighbors (Eds.),

Medical-surgical nursing: health and illness perspectives (figure 23-36. Torsades de Pointe, p. 688). St. Louis:

Mosby, Inc. contraindicationsy prolonged QTc intervaly hypotension and shocky heart block without pacemaker y prolonged therapy, use with cimetadine


data and monitor vital signs, EKG, QTc interval, neurological status, drug levels

y prevent client injury: associated with manyadverse effects

y quinidine and procainamide reserved for useafter many other therapies have failed

y assist health care team to implement clientteaching

o avoid citrus juices, antacids, and milkproducts when taking oral forms

o take heart rate daily: report change inrhythm

d.type: beta-adrenergic blocking agents (Class II

antidysrhythmia agents, aka beta-blockers) (See also: II. A. beta-adrenergic antagonists)

e. type: potassium channel blocking agents (Class IIIantidysrhythmia agents)

v. action: slows the outward movement of potassiumthrough myocardial cell membranes and prolongs theaction potential

vi. examples



y amiodarone (Cardarone) 400 mg by mouthdaily

y sotalol (Betapace) 160-320 mg by mouth dailyin 2 to 3 doses

vii. uses: ventricular and supraventricular dysrhythmias,

chemical cardioversion with a fib and a flutter viii. adverse effectsy life-threatening: heart failure, heart block,

sinus arrest, liver damage y most common: nausea, vomiting , d izziness,

w eak ness, photosensitivit y y other: pulmonary fibrosis, hypotension

ix. contraindicationsy prolonged QTc intervaly concomitant use with quinidine or

procainamidey

severe liver disease, heart block, cardiogenicshockx. nursing care

y assist health care team to establish baselinedata and check vital signs, EKG; hepatic,pulmonary, endocrine, neurological, and GIfunction

y follow oral and IV administration guidelines:timing and rates of infusion are very important


o avoid taking with echinaceao need for follow-up care and testingo protect skin and eyes from UV rays,

e.g., wear sunscreen, protectiveclothing, and sunglasses

o count pulse and report changes inrhythm

o may take with meals but must beconsistent

4. Therapeutic class: antihypertensive agents

a. agents antihypertensive tocommon

b. angiotensin converting



enzyme (ACE) inhibitors

c. angiotensin II receptor blockers

d. calcium channel blockers

e. beta-adrenergic blockers

f. combined alpha- and beta-adrenergic receptor

blockers

g. alpha-adrenergic receptor blockers

h. alpha1 -receptor blockers

i. alpha2 -receptor blockers

j. centrally actingvasodilator

k. diuretics

4. Antihypertensive agents

a.information common to antihypertensive agentsi. uses: heart failure, primary and secondary HTN

ii. adverse effectsy orthostatic hypotension, reflex tachycardia,

bradycardia y dizziness, weakness, sexual dysfunctiony nausea, vomiting, diarrhea, anorexia, and

constipationiii. contraindications

y severe deficiencies in serum electrolytesy heart block, pediatrics, hypovolemia

iv.

nursing carey assist health care team to establish baseline

data and check before initiating therapy andperiodically thereafter: blood pressure, K+,fluid and electrolyte balance, renal function

y older clients more susceptible to toxicity, labile hypotension, and orthostatic hypotension

y see C ont r ol of bl ood pr essur e (illustration )




o avoid OTC drugs, change positionsslowly

o recognition of findingso

take medication only as directed, whenfeeling well, and if blood pressure (BP)is controlled (indicates that the therapyis effective)

o combine with weight loss, smokingcessation, and an active lifestyle for the most effective therapy

o instruct about BP technique for self-monitoring

rest for 15-30 minutes beforetaking BP

relax arms at side place cuff correctly take BP with same device

consistently; may purchasedevice for home use

In 2003, the National Heart, Lung, and Blood Institute tightened the guidelines that define hypertension.

A systolic blood pressure >120-139 and/or a diastolic blood pressure >80-89 is prehypertension and

requires lifestyle modification for treatment. These guidelines are more restrictive for clients with

diabetes mellitus or hyperlipidemia.

Control of Blood Pressure





In, Karch, A. M. (2003). F ocus on nursing pharmacology (2nd Ed., figure 43-1.Control of blood

pressure, p. 641). Philadelphia, PA: Lippincott, Williams and Wilkins.

b.type: angiotensin-converting enzyme (ACE) inhibitorsi. action: inhibits conversion of angiotensin I to

angiotensin II in the lungs preventingvasoconstriction from angiotensin II and the releaseof aldosterone

ii. examplesy enalapril (Vasotec) 10-40 mg twice daily by

mouth, initiate therapy at 2.5-5 mgy lisinopril (Zestril) 20-40 mg daily by mouth,

initiate therapy at 2.5-5 mgiii. uses: HTN and heart failure

iv. adverse effectsy orthostatic hypotension, especially when

initiating therapy and with dosage changesy refractory cough, hyperkalemia y rash, renal and hepatic injury

v. contraindications: hyperkalemia and renalinsufficiency

vi. nursing care (See also: II. A. information common toantihypertensive agents)

y administer on empty stomachy assist health care team to implement client

teaching plano take 1 hour before and 2 hours after

eatingo may need periodic renal function tests

(RFT)o avoid salt substitutes containing

potassium without provider approvalo increased risk of hypersensitivity

reaction if given with allopurinolc.type: angiotensin II-receptor blocker (ARB)

i. action: binds to angiotensin II receptors to block

vasoconstriction and release of aldosteroneii. examples

y losartan (Cozaar) 25-100 mg in 1 to 2 dosesy valsartan (Diovan) 80-320 mg daily

iii. uses: HTN and heart failureiv. adverse effects: hyperkalemiav. nursing care (See also: II. A. information common to

antihypertensive agents)



y relatively few drug-drug interactionsy assist health care team to implement client

teaching plan: may take with food, avoid saltsubstitutes containing potassium withoutprovider approval

d.

type: calcium channel blocker (CCB)i. action: block movement of calcium into muscle cell;negative inotropic action (decreases myocardialcontractility)

ii. examplesy amlodipine (Norvasc) 5-10 mg by mouth dailyy diltiazem (Cardizem) 30-120 mg by mouth 3 to

4 times daily; Cardizem SR 240- 360 mg bymouth daily

y verapamil (Calan) XR 240-480 mg by mouthdaily; IV 2.5-5 mg/kg, may repeat with 5-10 mg

after 30

minutesiii. uses: HTN, angina, and dysrhythmiasiv. adverse effects

y precipitous hypotensiony heart block and heart failurey venous pooling, peripheral edema y hypotensive effect of diltiazem potentiated with

cyclosporine v. contraindications: heart block, heart failure and sick

sinus syndrome vi. nursing care (See also: II. A. information common to

antihypertensive agents)y client teaching: do not take with grapefruit juice

Notice that the adverse effects of anticholinergic agents are classic anticholinergic effects. They are

similar to the effects of anticholinergic agents like atropine or scopolamine. Learn anticholinergic agents

and apply the findings to all anticholinergic effects.

e.type: beta-adrenergic blocking agents (antagonists) (akabeta blockers)

i. action: cardioselective (beta1 -adrenergic receptors)and non-selective (beta1 - and beta2 -adrenergic)

blockers of the sympathetic nervous system (SNS)resulting in

y slower heart ratey decreased vasoconstriction, decreased BPy decreased myocardial oxygen consumption

ii. examplesy selective blockers



o atenolol (Tenormin) 50-100 mg bymouth daily; 5 mg IV and may repeat 2times

o metoprolol (Toprol) 100-450 mg bymouth 1 to 2 times daily; 5 mg IV every

2 minutes for 3 dosesy non-selective blocker

o propranolol (Inderal) 80-240 mg bymouth in 2 to 4 divided doses daily; 1-3 mg IV and may repeat in 2 minutes

iii. uses: heart failure, hypertension, heart rate control,angina, and migraine headache prophylaxis

iv. adverse effectsy life-threatening: bradycardia, heart block,

heart failure, hypotension y most common: y

depr ession, dec

r eased exe

r cise tole

r anc e

y suppr esses c l inic al ind ic ator s of hypog ly c emi a, inc lud ing t ac hy c ar d i a and daphor esis

y other: bronchospasm (not as common withcardioselective forms)

v. contraindicationsy thyrotoxicosis, diabetes mellitus (DM)y peripheral vascular disease (PVD), cardiogenic

shocky chronic obstructive pulmonary disease (COPD)

vi. nursing care (See also: II. A. information common toantihypertensive agents)

y assist health care team to establish baselinedata and monitor breath sounds andperipheral perfusion before initiating therapyand periodically thereafter

y avoid concomitant use of clonidine andnonsteroidal anti-inflammatory drugs (NSAID)

y do not abruptly discontinue therapyo taper dose before discontinuingo do not discontinue before surgery

y check with provider for administration limits for heart rate and blood pressure


o take pulse or blood pressure beforeadministration

o do not abruptly discontinue therapy



Therapeutic and adverse effects may be potentiated by alternative and complementary therapies

including ginseng, sage, nightshade, celery, coriander, and saw palmetto. In addition, alcohol and OTC

medications (especially NSAIDs) affect drug actions and potentiate adverse effects.

f . type: combined alpha- and beta-adrenergic blocking agents

i. action: blocks all SNS receptors and inhibits releaseof epinephrine (Epi) and norepinephrine (NE)resulting in decreased vasoconstriction, slower heartrate, and increased renal perfusion

ii. examplesy carvedilol (Coreg) 6.25-25 mg twice daily by

mouth, increase dose in 2 week intervalsy labetalol (Normodyne) 400-800 mg 2 to 3 times

daily by mouthiii. uses: heart failure, HTN secondary to renal failure,

refractory HTN

iv. adverse effectsy cerebrovascular accident (CVA),

bronchospasm, pulmonary edema y serious dysrhythmias when combined with

CCBsy masks signs of hypoglycemiay impaired peristalsis, decreased exercise

tolerancev. contraindications: heart block, acute asthma, DM, and

shock vi. nursing care (See also: II. A. information common to

antihypertensive agents)y assist health care team to establish baseline

data and check for heart block on EKG,bronchospasm, pulmonary edema, and liver failure

y taper dose before discontinuingy assist health care team to implement client

teaching plan: do not abruptly discontinuetherapy

g. type: alpha-adrenergic blocking agentsi. action: non-selective blocker of alpha-adrenergic

receptors (of SNS)ii. example: phentolamine (Regitine) 5 mg IV bolus, then

0.5-1 mg/min; 5-10 mg subcutaneouslyiii. uses: HTN associated with pheochromocytoma,

extravasation of epinephrine and dopamine(vasoconstricting agents)

iv. adverse effects



y life-threatening: angina and myocardialinfarction (MI), CVA, profoundhypoglycemia

y other: nausea, vomiting, and diarrheav. contraindications: coronary artery disease (CAD) and

MIvi. nursing carey potentiated by alcoholy suppressed with epinephrine and ephedrine

h. type: alpha 1 -blocking agentsi. action: blocks alpha1-receptors of SNSii. examples

y prazosin (Minipress) 6-15 mg by mouth daily individed doses, not to exceed 40 mg in divideddoses

y terazosin (Hytrin) 1-5 mg by mouth daily in 2

doses, not to exceed 20

mg daily in 2 dosesy tamsulosin (Flomax) 0.4-0.8 mg by mouth daily

after mealsiii. uses: hypertension, benign prostatic hypertrophy

(BPH)iv. adverse effects: angina, priapism, headache,

peripheral edemav. contraindications: hepatic and renal failure; do not

take with agents for erectile dysfunctionvi. nursing care (See also: II. A. information common to

antihypertensive agents): provide small frequentmeals to manage GI discomfort

i. type: alpha2 - agonistsi. action: displaces NE and stimulates alpha2 -receptors

of SNS resulting in decreased release of norepinephrine in the periphery

ii. example: clonidine (Catapres) 0.1-0.6 mg by mouth(twice daily); daily over 1 week transdermal

iii. uses: HTN, chronic pain related to cancer iv. adverse effects

y life-threatening: bradycardia y other:y dry mouth, sedationy nausea, vomiting, anorexia, headache, urinary

retention v. contraindications

y narrow-angle glaucoma y vasospastic disease including Prinzmetal's

angina and vasospastic peripheral vascular disease



y thyroidtoxicosis or DMvi. nursing care (See also: II. A. information common to

antihypertensive agents)y taper dose before discontinuingy do not discontinue before surgeryy

do not administer with tricyclic antidepressants or propranololy assist health care team to implement client

teaching plan: do not abruptly discontinuetherapy

j. type: centrally acting vasodilatorsi. action: directly relaxes arteriolar vascular smooth

muscle resulting in lowered peripheral vascular resistance and reflex tachycardia

ii. example: hydRALAZINE (Apresloine) 200-300 mg bymouth daily divided in 4 doses; do not confuse with

hydrOXYzineiii. uses: acute hypertension associated with pregnancy,essential hypertension and renal dysfunction

iv. adverse effectsy life-threatening: shock, myelosuppression,

reflex tachycardia, angina y most common: headac he, t r emor s, d izziness,

per i pher al neur itis y other: anorexia, paralytic ileus, rash, nasal

congestion, flushingv. contraindications: maternal bleeding, CAD, mitral

valve diseasevi. nursing care

y assist health care team to establish baselinedata and check prior to initiating therapy and atregular intervals during therapy

1. blood pressure, heart rate, EKG2. breath sounds, CBC, weight, edema3. pregnancy: fetal heart tones (FHTs)

y administration1. give orally with food2. hypertension in pregnancy: given IV

bolus, monitor vital signs every 15minutes

y assist heath care team to implement clientteaching plan

1. report chest pain, severe fatigue,muscle or joint pain

2. report decreased fetal activity3. avoid OTC drugs



4. change positions slowlyvii. type: diuretics (See also: II.H. diuretics)

2. Antilipid agentsf . information common to antilipid agents

i. most effect liver function and require regular LFTs

ii.

most effective when combined with low-fat diet,exercise and weight lossiii. instruct clients to avoid alcohol during therapy

g. type: bile acid sequestrantsi. action: bind with bile acid in small intestine leading to

decreased absorption and increased excretion of fatin stool

ii. example: cholestyramine (Questran) 4-20 grams bymouth once or twice daily

iii. uses: in combination with low fat diet to lower serum lipids, primary hypercholesterolemia, and

elevated low-density lipoproteins (LDL)iv. adverse effectsy steatorrhea y increased bleeding times y headache, nausea, constipationy decreased absorption of fat-soluble vitamins

v. contraindicationsy bleeding disorders, biliary obstruction y post cholecystectomy, abnormal bowel function


data and to check prior to initiating therapy andat regular intervals thereafter 1. establish baseline data and monitor

bowel sounds before administering,serum lipids, bowel pattern, bleeding

2. prevent constipation, monitor: vitamindeficiency and increased bleeding times

3. administration1. do not crush or chew tablets2. give with food; do not administer

in dry form

3.

administer 1

hour before or 4 to 6hours after thiazide, diuretics,digoxin, warfarin, thyroidhormone, or glucocorticoids

y assist client to schedule medications at home2.



3.


o must take with foodo report bleeding, muscle paino do not crush or chew tablets or take in

dry formo prevent constipation with increased

fluids, fiber, and physical activityd.type: HMG-CoA reductase inhibitors (statins)

i. action: controls final step in cholesterol formation byblocking formation of cellular cholesterol leading todecreased serum cholesterol and slightly increasedhigh density lipoproteins (HDL)

ii. examplesy atorvastatin (Lipitor) 10-80 mg/day for

hyperlipidemia; 10-20 mg/day for familialhypercholesterolemia

y simvastatin (Zocor) 5-80 mg/day for hypercholesterolemia

y rosuvastatin (Crestor) 5-40 mg/day for hyperlipidemia, atherosclerosis, familialhypercholesteromia and hypertriglyceridemia

iii. use in combination with low-fat diet and exerciseiv. adverse effects

y life-threatening: cataracts, liver and renaldysfunction





i. example: niacin (Niaspan) 1.5-6 grams daily in 2 to 4 divided dosesii. uses: hyperlipidemia not responding to diet and weight lossiii. adverse effects

y increases serum uric acid levely intense cutaneous flushing, nausea, and

abdominal painiv. nursing carey assist health care team to establish baseline

data and ehcek prior to beginning therapy andat regular intervals thereafter serum lipids, uricacid, joint pain

y give at bedtimey often combined with bile acid sequestrants, but

administer 4 to 6 hours after the bile acidsequestrants

y assist health care team to implement client

teaching plano take at bedtime to minimize GI upseto take four to six hours after

cholestryramine (Questran)o report joint pain

type: LDL absorption inhibitors. action: inhibits absorption of lipids from small intestinesi. example: ezetimibe (Zetia) 10 mg by mouth dailyii. uses: to decrease serum levels of cholesterol, LDLs, and triglycerides, and to

increase HDLs in hypercholesterolemiaiii. adverse effects

y sinusitis, muscle and back painy abdominal pain, diarrheay effect greatly increased when given with

cycloSPORINE (immunosuppressant)iv. contraindications: liver disease or unexplained increase in LFTsv. nursing care

y assist health care team to establish baselinedata before initiating therapy and check duringtreatment: LFTs, lipid levels, muscle pain,bowel pattern

y do not give with fibratesy assist health care team to implement client

teaching plano take with or without foodo most effective when combined with low-

fat diet and weight lossomega-3 fatty acids (from fish oil)

Antiplatelet agentsinformation common to antiplatelet agents



. action: prevent platelet aggregationi. adverse effect: prolonged bleeding times, bleeding and bruisingii. nursing care

y assist health care team to establish baselinedata and check before initiating therapy and at

regular intervals during therapyo bleedingo Hgb and Hct

y effect potentiated with simultaneousadministration of

o other antiplatelet agents andanticoagulants

o feverfew, gingko, garlic, and ginger y assist health care team to implement client

teaching plano avoid NSAIDs, additional antiplatelet

medication, and anticoagulants withoutprovider approvalo avoid herbal remedieso avoid alcohol and OTC medicationso report tinnitus and buzzing in the ear,

bleedingtype: aspirin

. action: inhibits prostaglandin formationi. examples: acetylsalicylic acid (Bayer) 81-325 mg by mouth dailyii. uses: prophylaxis against ischemic attacks in brain and heart, to decrease risk of

death or MI in clients with angina; also classified as antipyretic, non-steroidal anti-inflammatory drug (NSAID), and analgesic (in therapeutic doses)

iii. adverse effectsy most common: bleed ing and br uising , tinnit us,

GI upset and er osion y other:

o hemolytic anemia, triggers asthmao Reye's syndrome (clients under 14

years of age)iv. contraindications

y asthma, sensitivity to other NSAIDsy history of GI bleeding, bleeding disordersy within 10 days of invasive procedure or surgeryy children less than 14 years-old due to risk of

Reye's syndromev. nursing care

y may take with food to decrease GI complaintsy assist health care team to establish baseline

data and check before initiating therapy:



muffled hearing and bleeding times; history of bleeding

y check periodically for toxicity: muffled hearingand tinnitus

y increased risk of toxicity in clients with asthma,

nasal polyps, and allergic rhinitis y assist health care team to implement client

teaching plano avoid use with feverfew, garlic, ginger,

and ginkgo due to increased bleedingtimes

o report to provider and discontinue usewith persistent ringing or buzzing in theears, impaired hearing, dizziness, or bleeding

o take with a full glass of water o

if taking aspirin 81

mg by mouth: maychew tablet

type: adenosine diphosphate inhibitor (i llust r ation ). action: inhibits platelet aggregation by preventing adenosine diphosphate bindingto platelet receptor

i. exampley clopidogrel (Plavik) 75 mg by mouth dailyy ticlopidine (Ticlid) 250 mg by mouth twice daily

with foodii. uses: secondary prevention of MI, CVA, and unstable angina; established PVDiii. adverse and side effects

y

myelotoxicity, thrombotic thrombocytopenicpurpura chest pain, edema, HTNy flu-like findings, headache, dizziness, rash,y epistaxis

iv. contraindicationsy closed head bleeding or injuryy history of bleeding or bleeding disorder

v. nursing carey assist health care team to establish baseline

data and check before initiating therapy andperiodically during therapy platelet count, lipids

y discontinue 7 to

10days before surgery

y protect medication from lighty assist health care team to implement client

teaching plano avoid taking anticoagulants, NSAIDs,

feverfew, garlic, ginger, and ginkgo:increases bleeding times



type: non-nitrate vasodilator (See also: II. A. vasodilators); example:dipyradidamole (Persantine)

7.Diuretics (See also: II.H.)8.Positive inotropes: improve myocardial contractility and cardiac

output

a.type: cardiac glycosidei. action: slows A-V conduction, improves cardiac

output, improves myocardial contractility (increasesstrength of contractions) and slows heart rate

ii. example: digoxin (Lanxoin) 0.125-0.25 mg by mouthdaily

iii. uses: heart failure, ventricular rate control in atrialfibrillation (A fib) and atrial flutter (A flutter)

iv. adverse effectsy bradycardia, heart block, dysrhythmias y xanthopsia, muscle weaknessy nausea, vomiting, diarrhea, and anorexia

v. contraindications

y ventricular fibrillation (i llust r ation )y heart blocky hypokalemia


data and check before first dose and at regular intervals during therapy heart rate, intake andoutput, serum potassium

y check if heart rate is within range establishedby provider, usually greater than 50 bpm

y antidote: Digibindy monitor for toxicity

1. therapeutic range 0.8 to 2 mg/mL2. pediatrics: dysrhythmias3. adults: visual disturbances, nausea and

vomiting, anorexia



4. older clients: higher risk of toxicityy assist health care team to implement client

teaching plan1. taking pulse and evaluating regular

rhythm

2.

take medication as prescribed3. take heart rate daily beforeadministration

4. perform daily weight: report weight gainof more than 2 pounds in 24 hours

5. finding recognition: irregular pulse or change in rhythm, heart rate < 60 bpm(or outside range established byprovider)

6. avoid1. St. John's Wort, licorice, ginseng

2.

dehydration7. if taking diuretic, discuss potassium losswith provider

Ventricular Fibrillation

b.type: phosphodiesterase inhibitorsi. action: blocks action of phosphodiesterase

leading to increased myocardial contractilityand vasodilation, increased myocardialoxygen consumption, and dysrhythmias

ii. examples: inamrinone (Inocor) and milrinone(Primacor)

iii. usesy bridge to transplantation



y end-stage heart failure: titrated to clientresponse

y heart failure unresponsive to digoxin,diuretics, and vasodilators

iv. adverse effectsy

lethal ventricular dysrhythmiasy chest pain, hypotension y increased myocardial oxygen

consumptiony nausea, vomiting, anorexia

v. contraindicationsy acute MI, hypovolemia, severe heart

valve diseasey allergy to bisulfites

vi. nursing carey assist health care team to establish

baseline data and check beforeinitiating therapy and at regular intervals thereafter

o vital signs and EKGo report hypotension, ventricular

dysrhythmias, hypoxia,hypokalemia, oliguria, andvomiting

o platelet and beta-natriureticpeptide (BNP) levels, fluidbalance

o clarify frequency of checking withprovider; clarify ranges for data

y administrationo protect drug from light, administer

in large bore IV catheter o maintain O2 saturation, and

serum K+, Ca++, and Mg++within normal limits

y client may be maintained on therapy athome

y assist health care team to implementclient teaching plan

o establish reliable emergencyresponse for cardiac arrest,unstable angina, syncope, or change in level of consciousness

o keep emergency numbers andcontacts immediately available



o long-term IV therapy care of catheter insertion

site identify and enhance

coping skillso

need for follow-up care andtestingo report

worsening chest pain,palpitations, dypsnea,weight, lightheadedness

hypotension, low urineoutput

c.digoxin antidotei. action: fragments of antibodies bind to digoxin

and reverse the effects of toxicity by inhibiting

the binding of digoxin to sites of actionii. example: digoxin immune Fab (ovine) or (Digibind)

iii. use: reverse digoxin toxicityiv. adverse effects

y life-threatening: impaired respiratoryfunction, tachypnea, atrial fib

y other: increased ventricular rate, lowcardiac output, hypokalemia,hypersensitivity

v. contraindications: mild digoxin toxicity;hypersensitivity to Digibind or sheep

vi. nursing carey observe RN establish baseline data and

monitor prior to initiating therapy andat regular intervals during therapy

o check BP, heart rate, andrespiratory rate every 10 to 15minutes during the infusion

o potassium level, breath sounds,oxygen saturation, bloodpressure, and level of consciousness

o EKG for ventricular rate andhypokalemia (ST depressionand flat T waves)

o RFTs and urine outputo check previous allergic reactions

before administering



y test dose: reserve for clients withprevious hypersensitivity to or previousadministration of Digibind

y administrationo dilute in sterile water for injection,

mix gentlyo 2-microgram filter if cardiac arrest

is imminenty observe RN implement client teaching

plan; report fever, chills, itching,dypsnea

2. Thrombolytics1. action: binds with plasminogen to dissolve thrombi (clots)

within 4 to 6 hours of occlusion: activates conversion of plasminogen to plasmin; plasmin breaks down clots (fibrin)

2. examples

b.

streptokinase (Streptase)c. urokinase (Abbokinase)3. uses

b. myocardial infarctionc. deep venous thrombosis d. pulmonary embolism e. thrombosed intravenous cathetersf . in combination with unfractionated heparin

4. contraindicationsb. CNS neoplasms or recent closed head injuryc. active bleeding or severe hypertensiond. cerebral embolism, thrombosis, hemorrhagee. recent arterial diagnostic procedure or surgeryf . recent major surgery, trauma, invasive spinal

procedures5. adverse side effects

b. bleedingc. reperfusion injury, dysrhythmiasd. allergic reactions: urticaria, itching, flushing

headache, antibody formation6. nursing care

b. assist health care team to establish baseline data andcheck before beginning treatment

i. EKG for ischemic changes, peripheral pulses,and skin color and temperature

ii. bleeding (overt and occult, abdominal girth)iii. CBC, PT, PTT, INR, allergies or previous

therapyc. keep available: aminocaproic acid (fibrinolysis

inhibitor: inhibits breakdown of clots)



d. avoid IM injections prior to administratione. monitor neurological status, reperfusion injury, and

dysrythmias3. Vasodilators

1. type: non-nitrate

b.

action: coronary artery vasodilation with action similar to papaverine; antiplatelet properties and mild positiveinotrope

c. example: dipyridamole (Persantine) 225-400 mg bymouth in 3 to 4 doses daily

d. usesi. reduce need for nitratesii. peripheral vascular disease (PVD)iii. adjunct for thallium stress test to mimic

impaired blood flow to coronary arteriesiv. prevention of postoperative thromboembolic

complications (thromboembolism)e. adverse effects: usually dose related; headache,dizziness, peripheral vasodilation, nausea, andvomiting

f . nursing carei. assist health care team to establish baseline

therapy and check prior to beginning therapyand at regular, predetermined intervals bloodpressure and heart rate: chest pain on 0 to 10 scale

ii. therapeutic effect may take 2 to 3 months toappear

iii. assist health care team to implement clientteaching plan: change positions slowly

2. type: peptide hormone, syntheticb. action: inhibits anti-diuretic hormone (ADH) to

increase urine output and relax vascular smoothmuscle

c. example: beta-natriuretic hormone, neseritide(Natrecor) 0.1 mcg/kg/min titrate to cardiac output

iii. uses: severe, acute heart failure; critical care settingsfor profound heart failure

iv. adverse effectsy life-threatening: hypotension, dysrhythmias y other:

o insomnia, dizziness, confusiono fever, abdominal pain, pruritus, rash

v. contraindications



y cardiogenic shock; increased pulmonary arterypressure or pulmonary capillary wedgepressure; pulmonary hypertension

y cardiac tamponade or constrictive pericarditis vi. nursing care

y

observe RN establish baseline data andmonitor continuously during therapyo vital signs, pulmonary capillary wedge

pressure (PCWP), cardiac outputo fluid and electrolyte balanceo urine output

y monitor serum creatininey extremely expensive, made from recombinant

DNA

c.type: nitrate (See also: II. A. antianginal agents)

d.type: calcium channel blockers (See also: antihypertensivesII. A.)

2. Vasopressorsc. type: alpha- and beta-adrenergic agonists, sympathomimetic

agents (mimics action of sympathetic nervous system)1. action: increases heart rate, vasoconstricts peripheral

vessels to increase blood pressure, and dilates renaland splanchnic vessels to improve perfusion viastimulation of sympathetic nervous system; oppositeaction of alpha- or beta-blockers

2. examples1. dopamine hydrochloride (Intropin) 0.5-10

mg/kg/min IV, titrated to blood pressure



+- = no effect ; - = dec r eased effect; + = mi ld inc r ease; ++ = moder at e inc r ease; +++= st r ong inc r ease

y norepinephrine bitartrate (Levophed) 2-30

mcg/min IV titrated according to bloodpressure and vasoconstriction

y epINEPHrine (Adrenalin) 1 mg IV bolus every 3to 5 minutes in cardiac arrest; see also:bronchodilators: epINEPHrine II.B.

iv. uses: improve cardiac output and perfusion to vitalorgans in shock and profound hypotension

v. adverse effectsy life-threatening: angina, dysrhythmias,

vasoconstriction, necrosis (verydestructive to soft tissue)

y most common: im pai r s g lucose met abol ism( epi)

y other:o nausea, vomiting, headacheo disproportionate increase in diastolic

blood pressureo shunts blood to vital organs at the

expense of extremities



vi. contraindications: pheochromocytoma, PVD,hypovolemia, tachydysrhythmias

vii. nursing carey observe RN establish baseline data and

monitor o

blood pressure, chest pain, heart rate,and rhythm every 15 minuteso peripheral perfusion, urine output, chest

pain every hour y infuse in central venous catheter with infusion

pump, protect infusion from lighty solution is very dilute with dosage based on

mcg/kg of body weight/minutey antidote for extravasation

o stop infusion and remove IV tubingo phentolamine mesylate 10-15 mL

subcutaneously into affected tissuec.type: beta-agonist, sympathomimetic agentiii. action: selectively stimulates cardiac beta1 -

adrenergic receptors; primarily increases cardiacoutput; increases blood pressure withoutconcomitant increase in heart rate

iv. examplesy dobutamine (Dobutrex) 2.5-15 mcg/kg/min IV

titrated to blood pressure, cardiac output andEKG rhythm

y isoproterenol (Isuprel) 2-6 mcg/kg/min IVtitrated to blood pressure, heart rate and EKGrhythm

v. uses: cardiogenic shock, preparation for pediatriccardiac catheterization

vi. adverse effectsy life-threatening: HTN, tachydysrhythmias,

vasoconstriction

y most common: angina, nausea, vomiting vii. contraindications: tachydysrhythmias, idiopathic

subaortic stenosisviii. nursing care

y observe RN establish baseline data andmonitor cardiac output, peripheral perfusion,urine output, chest pain

y monitor and record blood pressure, heart rate,and rhythm every 15 minutes

y control with infusion pumpy infuse in central venous catheter



y antidote for extravasation: stop infusion,remove IV tubing

y increased risk of peripheral vasoconstrictionwhen given with beta-adrenergic blockers

type: alpha-agonist.

action: direct stimulation of SNS resulting in vasoconstrictioni. example: phenylephrine (Neo-Synephrine) 100-180 mcg IV, may repeat initialdose every 10 to 15 minutes

ii. use: profound hypotensioniii. adverse effects

y life-threatening: dysrhythmias, tachycardia,gangrene, anaphylaxis

y most common: insomni a, nausea, vomiting y other: headache, dizziness, weakness, anxiety,

tremor iv. contraindications

y

narrow-angle glaucoma, pheochromocytomay ventricular fibrillation, tachydysrhythmias, HTN,

peripheral vascular diseasev. nursing care - observe RN establish baseline data and monitor

y BP, heart rate, EKG, and pulmonary arterialpressure (PAP) every 15 minutes

y urine output and fluid status every hour y pulmonary capillary wedge pressure (PCWP)

1.Bronchodilators

a.information common to bronchodilatorsi. action: direct relaxation of bronchial smooth

muscle resulting in increased diameter of airway, eases the work of breathing

ii. nursing carey encourage smoking cessation therapy



y assist health care team to establishbaseline data and check beforebeginning and throughout therapy

o breath sounds, oxygen saturation(SaO2 ), respiratory rate

o

vital signs and EKG iii. assist health care team to implement clientteaching plan

y report worsening findingsy avoid caffeine and OTC drugsy eat small, frequent meals to ameliorate

GI upsety take medication only as directed; do not

take extra dosesy client teaching: use of delivery method:

oral, meter-dose inhaler (MDI),

nebulizer , or aerosolized powder (Seealso: I.D. matered-dose inhalers andI.D.5.b.iii nebulizers)

2. type: adrenergic agonist (sympathomimetic) a. action

i. mimics (stimulates and enhances) SNS torelax bronchial smooth muscle

ii. may increase rate and depth of respirationsiii. inhibits release of inflammatory mediators

(cytokines; short-term effect)b. examples:

i.

short-actingy type: alpha1 - and beta2 -adrenergic

agonists, non-selective adrenomimetic o epinephrine (Adrenalin,

Primatene Mist) (See also: II. A. vasopressors: alpha- and beta-adrenergic agonists,sympathomimetic)

o isoproterenol (Isuprel) (See also:II. A. vasopressors: beta-agonist,sympathomimetic agents)

o terbutaline (Brethine)

o ritodrine (Yutopar) (See also:III.C. tocolytic agents)

y type: beta2 -adrenergic agonists,selective adrenomimetic

o albuterol (Proventil 2 inhalationsvia metered-dose inhaler every 4





ii. diabetes mellitus, hyperthyroidism iii. unstable angina, hypertension, cardiac disease

d. nursing carei. assist health care team to establish baseline

data and check before and during therapy

breath sounds, SaO2 and vital signsii. available in oral therapyiii. avoid additional stimulants such as caffeineiv. small frequent meals to ameliorate nausea,

vomiting, anorexiav. assist health care team to implement client

teaching plany take before other inhaled medications

and 30 to 60 minutes before exercisey report chest pain or palpitations y avoid OTC drugs, stimulants including

caffeinated beverages and darkchocolate, Primatene Mist (may result indeath)

2. type: xanthines (i llust r ation )a. actions

i. stimulates the SNS: acts directly on bronchialsmooth muscle to dilate airways and onmedulla in brainstem to increase rate anddepth of respirations

ii. inhibits release of inflammatory mediators inanaphylaxis

b.

examplesi. caffeineii. aminophylline (Truphylline) up to 13 mg/kg or

900 mg/day given in 3 dosesiii. theophylline (Slo-bid Gyrocaps) 100-200 mg by

mouth every 6 hours; individualize dosingc. uses: bronchospasm, asthma, COPD, chronic

bronchitis, anaphylaxisd. adverse effects

i. respiratory arrest ii. dizziness in older clients

iii.

palpitations, dysrhythmiasiv. nausea, anorexia, vomiting, insomnia,nervousness, headache

v. toxicity: hypotension and seizurese. contraindications

i. CAD and heart failureii. ischemic cardiomyopathy iii. severe liver or kidney disease



f . nursing carei. assist health care team to establish baseline

data (See also: II.B. nursing care)ii. monitor drug levels: aminophylline has narrow

therapeutic range at 10-20 mcg/mL; check

drug levels frequently while titrating doseiii. do not exceed administration rate of 20 mg/miniv. dilute in 5% dextrose in water v. avoid combining with other stimulantsvi. less effective with smoking and St. John's Wortvii. assist health care team to implement client

teaching plany maintain consistent diety avoid charcoal-broiled food, stimulantsy take at the same time everydayy drink plenty of caffeine-free beverages

NEBULIZER

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d.type: anticholinergic i. action

y blocks muscarinic receptors, acetylcholinerelease, and stimulation of vagus nerve

y results in bronchodilation, diminishedsecretions, low CNS effect (less effect onheart rate)

y effects mucociliary clearance minimallyy parasympatholytic (reverses effects of), acts

like atropine sulfate



ii. examplesy ipratropium bromide (Atrovent) inhaler 1 to 4

inhalations, 3 to 4 times daily, not to exceed24 inhalations in 24 hours

y tiotroprium bromide, long duration of action

(Spiriva) inhaler 18 mcg dailyiii. uses

y COPDy prophylaxis for bronchospasm; maintenance

therapy for chronic bronchitis; allergic rhinitis y not rescue therapy, less effective for asthma

iv. adverse effectsy worsening of narrow-angle glaucoma y dry mouth, blurred vision, constipation, urinary

retention, coughv. contraindications

y

narrow-angle glaucomay acute bronchospasm


data and check before initiating and at regular intervals during therapy urine output andbreath sounds


o not for use in acute bronchospasm or asrescue therapy

o wait 5 minutes before administeringother inhaled medications or asdirected by provider

o wait 30 to 60 seconds between puffs,rinse mouth after each treatment

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Classification of Medications Cardiology

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