11cardiac glycosides, antianginals, and antidysrhythmics

CARDIAC GLYCOSIDES, CARDIAC GLYCOSIDES, ANTIANGINALS, AND ANTIANGINALS, AND ANTIDYSRHYTHMICSANTIDYSRHYTHMICS

CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES

DRUGS THAT INHIBIT THE DRUGS THAT INHIBIT THE SODIUM-POTASSIUM PUMP THUS SODIUM-POTASSIUM PUMP THUS INCREASING INTRACELLULAR INCREASING INTRACELLULAR CALCIUM WITH CAUSES THE CALCIUM WITH CAUSES THE CARDIAC MUSCLES TO CONTRACT CARDIAC MUSCLES TO CONTRACT MORE EFFICIENTLYMORE EFFICIENTLY


POSITIVE INOTROPIC ACTIONPOSITIVE INOTROPIC ACTION NEGATIVE CHRONOTROPIC NEGATIVE CHRONOTROPIC

ACTIONACTION NEGATIVE DROMOTROPIC ACTIONNEGATIVE DROMOTROPIC ACTION


INDICATIONSINDICATIONS TREATMENT OF HEART FAILURETREATMENT OF HEART FAILURE CORRECT ATRIAL FIBRILLATION CORRECT ATRIAL FIBRILLATION

AND FLUTTERAND FLUTTER

NONPHARMACOLOGIC NONPHARMACOLOGIC MEASURESMEASURES

LIMIT SALT INTAKE TO 2 GRAMS LIMIT SALT INTAKE TO 2 GRAMS DAILY (1 TSP)DAILY (1 TSP)

EXCESSIVE ALCOHOL CAN CAUSE EXCESSIVE ALCOHOL CAN CAUSE CARDIOMYOPATHYCARDIOMYOPATHY

SMOKING- CAN DEC O2 TO THE SMOKING- CAN DEC O2 TO THE HEARTHEART

OBESITYOBESITY MILD EXERCISEMILD EXERCISE

Cardiac Glycosides Cardiac Glycosides and Inotropic Agentsand Inotropic Agents

Cardiac Glycosides and Cardiac Glycosides and Inotropic AgentsInotropic AgentsRAPID ACTING DIGITALISRAPID ACTING DIGITALIS Digoxin (Lanoxin)Digoxin (Lanoxin)LONG ACTING DIGITALISLONG ACTING DIGITALIS DigitoxinDigitoxinPHOSPHODIESTERASE INHIBITORSPHOSPHODIESTERASE INHIBITORS Amrinone (Inocor)Amrinone (Inocor) Milrinone lactate (Primacor)Milrinone lactate (Primacor)ATRIAL NATRIURETIC PEPTIDEATRIAL NATRIURETIC PEPTIDE Nesiritide (Natrecor)Nesiritide (Natrecor)ANTIDOTE FOR DIGITALIS TOXICITYANTIDOTE FOR DIGITALIS TOXICITY Digoxin immune Fab (ovine, Digibind)Digoxin immune Fab (ovine, Digibind)

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) TO TREAT CHF, ATRIAL TO TREAT CHF, ATRIAL

TACHYCARDIA, FLUTTER, OR TACHYCARDIA, FLUTTER, OR FIBRILLATIONFIBRILLATION

DIGITALIDIGITALIS S TOXICITYTOXICITY

VERY, VERY, VERY, VERY, VERY VERY

IMPORTANT!IMPORTANT!

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin)

Assess for signs and symptoms of digitalis Assess for signs and symptoms of digitalis toxicity toxicity – ANOREXIAANOREXIA– DIARRHEADIARRHEA– NAUSEA AND VOMITINGNAUSEA AND VOMITING– PVC’SPVC’S– DYSRHYTHMIASDYSRHYTHMIAS– BRADYCARDIABRADYCARDIA– HEADACHESHEADACHES– YELLOW HALOS AROUND OBJECTSYELLOW HALOS AROUND OBJECTS– CONFUSION CONFUSION – DELIRIUMDELIRIUM

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) Obtain a baseline pulse rate for future Obtain a baseline pulse rate for future

comparisons. comparisons. Apical pulse should be taken for a full Apical pulse should be taken for a full

minute and should be > 60 bpm.minute and should be > 60 bpm. Client checks pulse rate daily before Client checks pulse rate daily before

taking digoxin. taking digoxin. Client will repot pulse rate of < 60 bpm or a Client will repot pulse rate of < 60 bpm or a

marked decline in pulse rate. marked decline in pulse rate. Do not administer if pulse rate is <60 bpm.Do not administer if pulse rate is <60 bpm.

DIGOXINDIGOXINAntidote for Digitalis Antidote for Digitalis ToxicityToxicityDigoxin immune Fab Digoxin immune Fab

(Digibind,Ovine)(Digibind,Ovine) To correct serious digitalis toxicity. To correct serious digitalis toxicity.

This agent binds with digoxin to This agent binds with digoxin to

form complex molecules. form complex molecules. A serum digoxin level >2.0 ng is A serum digoxin level >2.0 ng is

indicative of digitalis toxicity. indicative of digitalis toxicity.

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) A low serum potassium level A low serum potassium level

enhances the action of digoxin. enhances the action of digoxin. Clients taking digoxin and a Clients taking digoxin and a

potassium-wasting diuretic or potassium-wasting diuretic or cortisone drug may cause cortisone drug may cause hypokalemia, causing digitalis hypokalemia, causing digitalis toxicity. toxicity.


Advise client to eat foods rich in Advise client to eat foods rich in potassium to maintain a desired potassium to maintain a desired serum potassium levelserum potassium level– Foods rich in potassium such as Foods rich in potassium such as

fresh and dried fruits, fruit juices, fresh and dried fruits, fruit juices, and vegetables, including potatoes.and vegetables, including potatoes.

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) Check the serum digoxin level. Check the serum digoxin level.

The normal therapeutic drug range The normal therapeutic drug range

for digoxin is for digoxin is 0.5 to 2 ng/ml.0.5 to 2 ng/ml. A serum digoxin serum potassium A serum digoxin serum potassium

level (normal range, 3.5 to 5.3 level (normal range, 3.5 to 5.3 mEq/L) mEq/L)

Report if hypokalemia (< 3.5 Report if hypokalemia (< 3.5 mEq/L) is present.mEq/L) is present.


Normal therapeutic Normal therapeutic drug range for digoxin drug range for digoxin

0.5 to 2 0.5 to 2 ng/mlng/ml


Report if Report if hypokalemia hypokalemia

(< 3.5 mEq/L) is (< 3.5 mEq/L) is present.present.

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) Determine the signs of peripheral Determine the signs of peripheral

and pulmonary edema, which and pulmonary edema, which indicate congestive heart failure indicate congestive heart failure is present.is present.


Explain to client the importance Explain to client the importance of compliance with the drug of compliance with the drug therapy. therapy.

Advise client not to take OTC Advise client not to take OTC drugs without first consulting the drugs without first consulting the health care provider to avoid health care provider to avoid adverse drug interactions.adverse drug interactions.

Rapid-Acting Digitalis Rapid-Acting Digitalis DIGOXIN (Lanoxin)DIGOXIN (Lanoxin) Keep drugs out of reach of small Keep drugs out of reach of small

children. Request childproof children. Request childproof bottles.bottles.

Instruct client or parent of child to Instruct client or parent of child to check pulse rate before check pulse rate before administering the drug.administering the drug.

Long-Acting DigitalisLong-Acting DigitalisDigitoxinDigitoxin For CHF. Serum therapeutic level For CHF. Serum therapeutic level

is 15-30 mg/ml. is 15-30 mg/ml. Because of its long half-life, this Because of its long half-life, this

drug is seldom given.drug is seldom given.

Phosphodiesterase Phosphodiesterase Inhibitors (Positive Inhibitors (Positive Inotropic Bipyridines)Inotropic Bipyridines)

INHIBITS ENZYME INHIBITS ENZYME PHOSHODIESTERASE THUS PHOSHODIESTERASE THUS PROMOTING A POSITIVE PROMOTING A POSITIVE INOTROPIC RESPONSE AND INOTROPIC RESPONSE AND VASODILATATIONVASODILATATION

Amrinone lactateAmrinone lactate For CHF, amrinone may be prescribed For CHF, amrinone may be prescribed

when digoxin and diuretics have not when digoxin and diuretics have not been effective. been effective.

It may be used in conjunction with It may be used in conjunction with diureticdiuretic

it is incompatible with furosemideit is incompatible with furosemide Drug is for short-term use.Drug is for short-term use.


Milrinone lactateMilrinone lactate For short-term treatment of CHFFor short-term treatment of CHF May be given before heart May be given before heart

transplantation.transplantation. Heart rate and blood pressure should Heart rate and blood pressure should

be monitored.be monitored.


NesiritideNesiritide– To treat acute CHF by increasing sodium To treat acute CHF by increasing sodium

loss. loss. – It is useful in managing dyspnea at rest. It is useful in managing dyspnea at rest. – It causes vasodilation. It causes vasodilation. – Contraindication includes clients with a Contraindication includes clients with a

systolic BP less than 90 mm Hg.systolic BP less than 90 mm Hg.

Atrial Natriuretic Atrial Natriuretic Peptide HormonePeptide Hormone

VASODILATORSVASODILATORS– Decrease venous returnDecrease venous return

ACE INHIBITORSACE INHIBITORS DIURETICSDIURETICS

– First line for reducing fluid volumeFirst line for reducing fluid volume

OTHER DRUGS OTHER DRUGS CHFCHF

ANTIANGINALANTIANGINALSS

FINISHED WITH FINISHED WITH CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES

ANTIANGINALANTIANGINALSS

ANGINA PECTORISANGINA PECTORIS

ACUTE CARDIAC PAIN CAUSED BY ACUTE CARDIAC PAIN CAUSED BY INADEQUATE BLOOD FLOW TO INADEQUATE BLOOD FLOW TO THE MYOCARDIUM RESULTING THE MYOCARDIUM RESULTING FROM EITHER: FROM EITHER: – PLAQUE OCCLUSIONS WITHIN PLAQUE OCCLUSIONS WITHIN – SPASMS OF THE CORONARY SPASMS OF THE CORONARY

ARTERIESARTERIES

NONPHARMACOLOGIC NONPHARMACOLOGIC MEASURESMEASURES AVOID: AVOID:

– HEAVY MEALSHEAVY MEALS– SMOKINGSMOKING– EXTREMES IN WEATHER CHANGESEXTREMES IN WEATHER CHANGES– STRENEOUS EXERCISE STRENEOUS EXERCISE – EMOTIONAL UPSETEMOTIONAL UPSET

PROPER NUTRITIONPROPER NUTRITION EXERCISEEXERCISE RESTREST RELAXATION MEASURESRELAXATION MEASURES

ANTIANGINALSANTIANGINALS

NITRATESNITRATES

BETA-ADRENERGIC BLOCKERSBETA-ADRENERGIC BLOCKERS

CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS


NITRATESNITRATESShort ActingShort Acting Nitroglycerin(Nitrostat, Nitro-Bid, Nitroglycerin(Nitrostat, Nitro-Bid,

Transderm-Nitro)Transderm-Nitro)Long ActingLong Acting Isosorbide dinitrate (Isordil, Isosorbide dinitrate (Isordil,

Sorbitrate)Sorbitrate) Isosorbide mononitrate (Imdur)Isosorbide mononitrate (Imdur)

NitratesNitrates

CAUSE GENERALIZED VASCULAR CAUSE GENERALIZED VASCULAR AND CORONARY AND CORONARY VASODILATATIONVASODILATATION

NitratesNitrates

Short-ActingShort-Acting Nitroglycerin (nitrostat, Nitroglycerin (nitrostat,

transderm)transderm)– TO CONTROL ANGINAL PAINTO CONTROL ANGINAL PAIN– DECRESE MYOCARDIAL DEMAND DECRESE MYOCARDIAL DEMAND

FOR O2FOR O2 DECRESE PRELOAD BY DILATING VEINS DECRESE PRELOAD BY DILATING VEINS

THUS DECREASING AFTERLOADTHUS DECREASING AFTERLOAD

NitratesNitrates

Long ActingLong Acting Isosorbide dinitrate (isoket,isordil)Isosorbide dinitrate (isoket,isordil)

– To prevent anginal attacks. To prevent anginal attacks. – Drug can lower blood pressure. Drug can lower blood pressure. – Tolerance builds up over time. Tolerance builds up over time. – Headaches, dizziness, light-headedness, Headaches, dizziness, light-headedness,

and flush may occur.and flush may occur.

NitratesNitrates

Long ActingLong Acting Isosobide mononitrate (indur)Isosobide mononitrate (indur)

– To prevent anginal attacks. To prevent anginal attacks. – Sustained release form provides controlled Sustained release form provides controlled

delivery and a 6 hour drug-free period. delivery and a 6 hour drug-free period. By allowing a drug-free period, tolerance to By allowing a drug-free period, tolerance to

nitrates is reduced; effectiveness is increased.nitrates is reduced; effectiveness is increased.


NITRATESNITRATES



ANTIANGINALS ANTIANGINALS BETA-ADRENERGIC BETA-ADRENERGIC BLOCKERSBLOCKERSAtenolol (Tenormin), B1Atenolol (Tenormin), B1

Metoprolol tratrate (Lopressor), B1Metoprolol tratrate (Lopressor), B1

Nadolol (Cogard) B1, B2Nadolol (Cogard) B1, B2

Propanolol (Inderal) B1, B2Propanolol (Inderal) B1, B2

Atenolol (tenorminm,therabloc)Atenolol (tenorminm,therabloc)– To control angina pectoris. To control angina pectoris. – Also effective in managing hypertension.Also effective in managing hypertension.– Dec blood pressure and heart rate by Dec blood pressure and heart rate by

blocking beta1. blocking beta1. – Can be used by clients with asthma.Can be used by clients with asthma.

Beta-Adrenergic Beta-Adrenergic BlockersBlockers

Metoprolol tartrate (betaloc, Metoprolol tartrate (betaloc, neobloc, cardiostat)neobloc, cardiostat)– Similar to atenolol by blocking beta1. Similar to atenolol by blocking beta1. – High doses of metoprolol can effect High doses of metoprolol can effect

beta2 and could cause beta2 and could cause broncoconstriction. broncoconstriction.

– It can reduce cardiac oxygen demand, It can reduce cardiac oxygen demand, which decreases heart rate and which decreases heart rate and contractility.contractility.


Nedolol (Corgard) B1, B2Nedolol (Corgard) B1, B2– To treat angina pectoris and To treat angina pectoris and

hypertension.hypertension.


Propranolol HCL (inderal)Propranolol HCL (inderal)– First beta-blocker, blocking beta1 and First beta-blocker, blocking beta1 and

beta2. beta2. – it is no longer the drug of choice to it is no longer the drug of choice to

prevent angina because of the risk of prevent angina because of the risk of bronchospasm. bronchospasm.

– Heart rate, blood pressure, and Heart rate, blood pressure, and respiratory status should be monitored.respiratory status should be monitored.



NITRATESNITRATES



Amlodipine (envacar, norvasc)Amlodipine (envacar, norvasc)– Management of angina pectoris and Management of angina pectoris and

hypertension. hypertension.

Calcium Channel Calcium Channel BlockersBlockers

Bepridil HCLBepridil HCL (Vascor)(Vascor)– Treatment of angina pectoris. Treatment of angina pectoris. – May be used as single drug or in May be used as single drug or in

combination with nitrates. combination with nitrates. – Given as a single dose.Given as a single dose.


Diltiazem HCL (dilzem)Diltiazem HCL (dilzem)– For angina pectoris. For angina pectoris. – Hypotensive effect is not as severe Hypotensive effect is not as severe

as with nifedipine. as with nifedipine. – Kidney function should be Kidney function should be

monitored.monitored.


Felodipine (plendil)Felodipine (plendil)– To chronic angina pectoris and To chronic angina pectoris and

manage hypertension. manage hypertension. – Reduces O2 demand by the heart. Reduces O2 demand by the heart. – A potent peripheral vasodilator thus A potent peripheral vasodilator thus

increasing heart rate and myocardial increasing heart rate and myocardial contractility.contractility.


Nifedipine (adalat,calcibloc)Nifedipine (adalat,calcibloc)– Potent calcium channel blocker. Potent calcium channel blocker. – For Angina pectorisFor Angina pectoris– Blood pressure should be monitored, Blood pressure should be monitored,

esp if taken with nitrates or beta-esp if taken with nitrates or beta-blockersblockers


Isradipine (DynaCirc)Isradipine (DynaCirc)– Primary use is to treat Primary use is to treat

hypertension. hypertension. – Also can be given for angina Also can be given for angina

pectoris.pectoris.


Nicardipine HCL (cardepine)Nicardipine HCL (cardepine)– Used for angina pectoris. Used for angina pectoris. – May be used alone or May be used alone or

incombination with other incombination with other antianginals. antianginals.

– Used also for hypertension. Used also for hypertension. – Peripheral edema, headache, Peripheral edema, headache,

dizziness, and light-headedness dizziness, and light-headedness may occur.may occur.


Nisoldipine (Nisocor)Nisoldipine (Nisocor)– To treat angina pectoris and To treat angina pectoris and

hypertension. hypertension. – Suppresses contraction of cardiac Suppresses contraction of cardiac

and vascular smooth muscle. and vascular smooth muscle. – Increases heart rate and cardiac Increases heart rate and cardiac

output. output. – Decreases blood pressure. Decreases blood pressure. – Caution: clients with heart disease Caution: clients with heart disease

are prone to MI and CHF.are prone to MI and CHF.


Verapamil HCL (isoptin)Verapamil HCL (isoptin)– Treatment of angina pectoris, Treatment of angina pectoris,

cardiac dysrhythmias and cardiac dysrhythmias and hypertension.hypertension.

– Peripheral edema, constipation, Peripheral edema, constipation, dizziness, headache, and dizziness, headache, and hypotension may occur.hypotension may occur.


NURSING PROCESSNURSING PROCESSAntianginalsAntianginals

AssessmentAssessment

Obtain baseline vital signs for Obtain baseline vital signs for future comparisonsfuture comparisons

Obtain health and drug histories.Obtain health and drug histories. Nitroglycerin is contraindicated Nitroglycerin is contraindicated

for marked hypotension or acute for marked hypotension or acute myocardial infarction.myocardial infarction.

Nursing Diagnoses Nursing Diagnoses

Decreased cardiac outputDecreased cardiac output Anxiety related to cardiac Anxiety related to cardiac

problemsproblems Acute painAcute pain Activity intoleranceActivity intolerance

PlanningPlanning

Client takes nitroglycerine or Client takes nitroglycerine or other antianginals and angina other antianginals and angina pain is controlled.pain is controlled.

Nursing InterventionsNursing Interventions

Monitor vital signs. Monitor vital signs. – Hypotension is associated with most Hypotension is associated with most

antianginal drugs.antianginal drugs. Have client sit or lie down when Have client sit or lie down when

taking a nitrate for the first time. taking a nitrate for the first time. – After administration, check the vital After administration, check the vital

signs while client is lying down and signs while client is lying down and then sitting up. Have client rise then sitting up. Have client rise slowly to a standing position.slowly to a standing position.


Offer sips of water before giving Offer sips of water before giving sublingual nitrates; dryness may sublingual nitrates; dryness may inhibit drug absorption.inhibit drug absorption.

Monitor effects of IV nitroglycerin. Monitor effects of IV nitroglycerin. Report angina that persists. Report angina that persists.


Apply Nitro-Bid ointment to the Apply Nitro-Bid ointment to the designated mark on paper. designated mark on paper.

Do not use fingers because the Do not use fingers because the drug can be absorbed; use a drug can be absorbed; use a tongue blade or gloves. tongue blade or gloves.


Nito-Bid ointment or the Nito-Bid ointment or the Transderm-Nitro patch Transderm-Nitro patch

Do not apply in any Do not apply in any area on the chest in the area on the chest in the vicinity of defibrillator-vicinity of defibrillator-cardioverter paddle cardioverter paddle placement. placement. – Explosion and skin burns Explosion and skin burns

may result.may result.

IMPORTANTIMPORTANTClient TeachingClient TeachingGeneralGeneral A SL nitroglycerin tablet is used if A SL nitroglycerin tablet is used if

chest pain occurs. chest pain occurs. Repeat in 5 minutes if the pain has Repeat in 5 minutes if the pain has

not subsided and again in another 5 not subsided and again in another 5 minutes if it persists. minutes if it persists.

Do not give more than three tablets. Do not give more than three tablets. If the chest pain persists >15 minutes, If the chest pain persists >15 minutes, immediate medical help is necessary.immediate medical help is necessary.

Client TeachingClient Teaching

GeneralGeneral Instruct client not to ingest alcohol Instruct client not to ingest alcohol

while taking nitroglycerin to avoid while taking nitroglycerin to avoid hypotension, weakness, and hypotension, weakness, and faintness.faintness.

Tolerance to nitroglycerin can occur. Tolerance to nitroglycerin can occur. If client’s chest pain is not completely If client’s chest pain is not completely alleviated, client should notify the alleviated, client should notify the health care provider.health care provider.


Beta-Blockers and Calcium BlockersBeta-Blockers and Calcium Blockers Inform client not to discontinue Inform client not to discontinue

these drugs without the health these drugs without the health care provider’s approval. care provider’s approval. Withdrawal symptoms, such as Withdrawal symptoms, such as reflex tachycardia and pain, may reflex tachycardia and pain, may be severe.be severe.


Self AdministrationSelf Administration Demonstrate to client how Demonstrate to client how

nitroglycerin tablets are taken. nitroglycerin tablets are taken. – The tablet is placed under the The tablet is placed under the

tongue for quick absorption. tongue for quick absorption. – A stinging or biting sensation may A stinging or biting sensation may

indicate the tablet is fresh. With indicate the tablet is fresh. With the newer SL nitroglycerin, the the newer SL nitroglycerin, the biting sensation may not be biting sensation may not be present.present.


Self AdministrationSelf Administration The bottle is stored away from light The bottle is stored away from light

and kept dry. and kept dry. Keep in original screw-cap, amber Keep in original screw-cap, amber

glass bottle.glass bottle.– The amber color of the glass provides light The amber color of the glass provides light

protection and the screw-cap closure protection and the screw-cap closure protects from moisture in the air, which protects from moisture in the air, which can easily reduce the potency of the can easily reduce the potency of the tablets.tablets.

Self AdministrationSelf Administration Instruct client about the Transderm-Instruct client about the Transderm-

Nitro patch. Nitro patch. – Apply once a day, usually in the Apply once a day, usually in the

morning. morning. – Rotation of skin sites is necessary. Rotation of skin sites is necessary. – Usually the patch is applied to the chest Usually the patch is applied to the chest

wall; however, the thighs and arms are wall; however, the thighs and arms are used. used.

– Avoid hairy areas.Avoid hairy areas.


Side EffectsSide Effects

Headaches commonly occur when Headaches commonly occur when first taking nitroglycein products first taking nitroglycein products and last about 30 minutes. and last about 30 minutes.

Acetaminophen is suggested for Acetaminophen is suggested for relief.relief.

Side EffectsSide Effects

If hypotension results from SL If hypotension results from SL nitroglycerin, place client is nitroglycerin, place client is supine position with legs supine position with legs elevated.elevated.

Beta-Blockers and Calcium BlockersBeta-Blockers and Calcium Blockers Instruct client how to take a pulse Instruct client how to take a pulse

rate. rate. Advise that client to call the Advise that client to call the

health care provider if dizziness health care provider if dizziness or faintness occurs; this may or faintness occurs; this may indicate hypotension indicate hypotension

EvaluationEvaluation Evaluate client’s response to Evaluate client’s response to

nitrate product for relieving nitrate product for relieving anginal pain. Note headache, anginal pain. Note headache, dizziness or faintness.dizziness or faintness.

AntidysrhythmiAntidysrhythmicscs

CARDIAC CARDIAC DYSRHYTHMIASDYSRHYTHMIAS ANY DEVIATION FROM THE ANY DEVIATION FROM THE

NORMAL RATE OR PATTERN OF NORMAL RATE OR PATTERN OF HEARTBEATHEARTBEAT

AntidysrhythmicsAntidysrhythmics

DESIRED ACTION IS TO RESTORE DESIRED ACTION IS TO RESTORE CARDIAC RHYTHMCARDIAC RHYTHM

CARDIAC ACTION CARDIAC ACTION POTENTIALPOTENTIAL

MECH OF ACTIONMECH OF ACTION

BLOCK ADRENERGIC STIMULATION OF BLOCK ADRENERGIC STIMULATION OF THE HEARTTHE HEART

DEPRESS MYOCARDIAL DEPRESS MYOCARDIAL CONTRACTILITY AND EXCITABILITYCONTRACTILITY AND EXCITABILITY

DECREASE CONDUCTION VELOCITY IN DECREASE CONDUCTION VELOCITY IN CARDIAC TISSUECARDIAC TISSUE

INCREASE RECOVERY TIME INCREASE RECOVERY TIME (REPOLARIZATION) OF THE (REPOLARIZATION) OF THE MYOCARDIUMMYOCARDIUM

SUPRESS AUTOMATICITYSUPRESS AUTOMATICITY

CLASS 1 FAST NA CHANNEL BLOCKERSCLASS 1 FAST NA CHANNEL BLOCKERS IA SLOWS CONDUCTION AND PROLONGS IA SLOWS CONDUCTION AND PROLONGS

REPOLARIZATIONREPOLARIZATION IB SLOWS CONDUCTION AND SHORTENS IB SLOWS CONDUCTION AND SHORTENS

REPOLARIZATIONREPOLARIZATION 1C PROLONGS CONDUCTION WITH LITTLE EFFECT ON 1C PROLONGS CONDUCTION WITH LITTLE EFFECT ON

REPOLARIZATIONREPOLARIZATION

CLASS 11 BETA-BLOCKERSCLASS 11 BETA-BLOCKERS REDUCES CA ENTRY, DEC CONDUCTIONVELOCITY, REDUCES CA ENTRY, DEC CONDUCTIONVELOCITY,

AUTOMATICITY AND RECOVERY TIME (REFRACTORY AUTOMATICITY AND RECOVERY TIME (REFRACTORY PERIOD)PERIOD)

CLASS 111 PROLONG REPOLCLASS 111 PROLONG REPOL PROLONG REPOL DURING VENTRICULAR DYSRHYTMIAS, PROLONG REPOL DURING VENTRICULAR DYSRHYTMIAS,

PROLONGS ACTION POTENTIAL DURATIONPROLONGS ACTION POTENTIAL DURATION

CLASS IV CALCIUM CHANNEL BLOCKERSCLASS IV CALCIUM CHANNEL BLOCKERS BLOCKS CALCIUM INFLUX, SLOWS CONDUCTION BLOCKS CALCIUM INFLUX, SLOWS CONDUCTION

VELOCITY, DEFCREASES MYOCARDIAL CONTRACTILITY VELOCITY, DEFCREASES MYOCARDIAL CONTRACTILITY AND INC REFRACTION IN AV NODEAND INC REFRACTION IN AV NODE


Class IClass IFast (Sodium) Channel Blockers IAFast (Sodium) Channel Blockers IA Disopyramide phosphate (Norpace)Disopyramide phosphate (Norpace)

– Prevention and suppression of unifocal and Prevention and suppression of unifocal and multifocal premature ventricular contractions multifocal premature ventricular contractions (PVCs). (PVCs).

– For ventricular dysrhythmias. For ventricular dysrhythmias. – May cause anticholinergic symptoms. May cause anticholinergic symptoms. – Serum therapeutic level 3-8 mcg/ml.Serum therapeutic level 3-8 mcg/ml.


Class IClass IFast (Sodium) Channel Blockers IAFast (Sodium) Channel Blockers IA Procainamide HCL (Procan)Procainamide HCL (Procan)

– It controls dysrhythmias (PVC), ventricular It controls dysrhythmias (PVC), ventricular tachycardia. tachycardia.

– It depresses myocardial excitability by slowing It depresses myocardial excitability by slowing down conduction of cardiac tissue.down conduction of cardiac tissue.


Class IClass IFast (Sodium) Channel Blockers IAFast (Sodium) Channel Blockers IA Quinidine sulfate, polygalacturonate, Quinidine sulfate, polygalacturonate,

gluconate (kinidin)gluconate (kinidin)– For atrial, ventricular, and supraventricular For atrial, ventricular, and supraventricular

dysrhythmias. dysrhythmias. – Nausea, vomiting, diarrhea, abdominal pain or Nausea, vomiting, diarrhea, abdominal pain or

cramps are common side effects.cramps are common side effects.– It can increase digoxin concentrationIt can increase digoxin concentration– Serum therapeutic level: 2-6 mcg/ml.Serum therapeutic level: 2-6 mcg/ml.

Fast (Sodium) Channel Blockers IBFast (Sodium) Channel Blockers IB Lidocaine (xylocaine)Lidocaine (xylocaine)

– For acute ventricular dysrhythmias following For acute ventricular dysrhythmias following MI and cardiac surgery. MI and cardiac surgery.

– Serum therapeutic range: 1.5-6 mcg/ml.Serum therapeutic range: 1.5-6 mcg/ml.


Fast (Sodium) Channel Blockers IBFast (Sodium) Channel Blockers IB Mexiletine HCL [Mexitil]Mexiletine HCL [Mexitil]

– Analogue of lidocaine. Analogue of lidocaine. – Treatment for acute and chronic Treatment for acute and chronic

ventricular dysrhythmias. ventricular dysrhythmias. – Take with food to decrease GI distress. Take with food to decrease GI distress. – Common side effects include nausea, Common side effects include nausea,

vomiting, heartburn, tremor, dizziness, vomiting, heartburn, tremor, dizziness, nervousness, lightheadedness. nervousness, lightheadedness.

– Serum therapeutic range: 0.5-2 mcg/ml.Serum therapeutic range: 0.5-2 mcg/ml.


Fast (Sodium) Channel Blockers IBFast (Sodium) Channel Blockers IB Tocainide HCL [Tonocard]Tocainide HCL [Tonocard]

– For ventricular dysrhythmias, For ventricular dysrhythmias, especially PVC. especially PVC.

– Similar to lidocaine except in oral Similar to lidocaine except in oral form. form.

– Serum therapeutic level: 4-10mcg/ml.Serum therapeutic level: 4-10mcg/ml.


Fast (Sodium) Channel Blockers ICFast (Sodium) Channel Blockers IC Flecainide (Tambocor)Flecainide (Tambocor)

– For life-threatening ventricular For life-threatening ventricular dysrhythmias; dysrhythmias;

– prevention of paroxysmal prevention of paroxysmal supraventricular tachycardia (PSVT) supraventricular tachycardia (PSVT) and paroxysmal atrial fibrillation or and paroxysmal atrial fibrillation or flutter (PAF). flutter (PAF).

– Avoid use in cardiogenic shock, Avoid use in cardiogenic shock, second-or third-degree heart block, second-or third-degree heart block, or right bundle branch block.or right bundle branch block.


Fast (Sodium) Channel Blockers ICFast (Sodium) Channel Blockers IC Propafenone HCLPropafenone HCL

– Treatment of life-threatening Treatment of life-threatening ventricular dysrhythmias. ventricular dysrhythmias.

– Avoid use if cardiogenic shock, Avoid use if cardiogenic shock, uncontrolled CHF, heart block, severe uncontrolled CHF, heart block, severe hypotension, bradycardia, and hypotension, bradycardia, and bronchospasms occur.bronchospasms occur.



Other Class IOther Class I MoricizineMoricizine

– To treat life-threatening ventricular To treat life-threatening ventricular dysrhythmias. dysrhythmias.

– Blocks sodium channels, decreases Blocks sodium channels, decreases conduction velocity in atria and conduction velocity in atria and ventricles, and prolongs refractory ventricles, and prolongs refractory period in the AV node. period in the AV node.

– May cause bradycardia, heart block, May cause bradycardia, heart block, and CHF in high doses.and CHF in high doses.

Class IIClass IIBeta-Adrenergic BlockersBeta-Adrenergic Blockers Acebutolol HCL (Sectral) B1Acebutolol HCL (Sectral) B1

– Management of ventricular dysrhythmias. Management of ventricular dysrhythmias. – Also used for angina pectoris and Also used for angina pectoris and

hypertension. hypertension. – Primarily for PVC. Primarily for PVC. – New beta-blocker that affects the beta1 New beta-blocker that affects the beta1

receptor in the heart. receptor in the heart. – Can cause bradycardia and decrease Can cause bradycardia and decrease

cardiac output.cardiac output.


Class IIClass IIBeta-Adrenergic BlockersBeta-Adrenergic Blockers Esmolol (Brevibloc) B1Esmolol (Brevibloc) B1

– To control atrial flutter and fibrillation. To control atrial flutter and fibrillation. – For short-term use only. For short-term use only. – Mainly for clients having dysrhythmias Mainly for clients having dysrhythmias

during surgery. during surgery. – May cause bradycardia and decrease May cause bradycardia and decrease

cardiac output.cardiac output.


Class IIClass IIBeta-Adrenergic BlockersBeta-Adrenergic Blockers Propranolol HCL (inderal) B1,B2Propranolol HCL (inderal) B1,B2

– For ventricular dysrhythmias, PAT,and atrial For ventricular dysrhythmias, PAT,and atrial and ventricular ectopic beats. Clidnts with and ventricular ectopic beats. Clidnts with asthma should not use drug.asthma should not use drug.


Class IIClass IIBeta-Adrenergic BlockersBeta-Adrenergic Blockers

Sotalol HCL (sotalex) B1,B2Sotalol HCL (sotalex) B1,B2– For ventricular dysrhythmias. For ventricular dysrhythmias. – Avoid if bronchial asthma or heart Avoid if bronchial asthma or heart

block is present.block is present.



Class IIIClass III

Prolong RepolarizationProlong Repolarization Adenosine (Cardiovert)Adenosine (Cardiovert)

– Treatment of PSVT, Treatment of PSVT, – Wolff-Parkinson-White syndrome. Wolff-Parkinson-White syndrome. – Avoid if second- or third-degree AV block Avoid if second- or third-degree AV block

or atrial flutter or fibrillation is present.or atrial flutter or fibrillation is present.


Class IIIClass III

Prolong RepolarizationProlong Repolarization Amiodarone HCL (Cordarone)Amiodarone HCL (Cordarone)

– For life-threatening ventricular For life-threatening ventricular dysrhythmias. dysrhythmias.

– Initially dosage is greater and then Initially dosage is greater and then decreases over time. decreases over time.

– Therapeutic serum level; 1-2.5 Therapeutic serum level; 1-2.5 mcg/ml.mcg/ml.


Class IIIClass III

Prolong RepolarizationProlong Repolarization Bretylium tosylateBretylium tosylate

– For ventricular tachycardia and For ventricular tachycardia and fibrillation (to convert to a normal fibrillation (to convert to a normal sinus rhythm).sinus rhythm).

– Used when lidocaine and Used when lidocaine and procainamide are ineffective.procainamide are ineffective.


Class IIIClass III

Prolong RepolarizationProlong Repolarization

Sotalol (Sotalex)Sotalol (Sotalex)– Beta-blocker. Beta-blocker. – Can be classified as Class II or III. Can be classified as Class II or III. – To treat life-threatening ventricular To treat life-threatening ventricular

dysrhythmias (ventricular tachycardia). dysrhythmias (ventricular tachycardia). – Slows heart rate, decreases AV conduction, Slows heart rate, decreases AV conduction,

increases AV refractory period, and increases AV refractory period, and decreases systolic and diastolic BP. decreases systolic and diastolic BP.

– Caution: second- and third-degree heart Caution: second- and third-degree heart block.block.


Class IIIClass III

Prolong RepolarizationProlong Repolarization

DofetilideDofetilide– A selective potassium-channel blocker

that prolongs repolarization. – Prescribed for atrial flutter and

fibrillation. – Renal function should be monitored.


Class IVClass IVCalcium Channel BlockersCalcium Channel Blockers Verapamil HCL (isoptin)Verapamil HCL (isoptin)

– For supraventricular tachydysrhythmias, For supraventricular tachydysrhythmias, prevention of PSVT. prevention of PSVT.

– Also used for angina pectoris and Also used for angina pectoris and hypertension. hypertension.

– Avoid use if cardiogenic shock, second- or Avoid use if cardiogenic shock, second- or third-degree AV block, severe hypotension, third-degree AV block, severe hypotension, severe CHF occur. severe CHF occur.

– Serum therapeutic level 80-300 ng/ml or Serum therapeutic level 80-300 ng/ml or 0.08-0.3 mcg/ml.0.08-0.3 mcg/ml.


Class IVClass IVCalcium Channel BlockersCalcium Channel Blockers DiltiazemDiltiazem

– For PSVT and atrial flutter or fibrillation. For PSVT and atrial flutter or fibrillation. – Avoid use if second- or third-degree AV Avoid use if second- or third-degree AV

block or hypotension occurs.block or hypotension occurs.

AntidysrhythmicsAntidysrhythmicsOthersOthers Phenytoin (Dilantin)Phenytoin (Dilantin)

– Treatment of digitalis-induced dysrhythmias. Treatment of digitalis-induced dysrhythmias. Not approved as dysrhythmic drug by FDA. Not approved as dysrhythmic drug by FDA. Serum level <20 mcg/ml.Serum level <20 mcg/ml.

Digoxin (Lanoxin)Digoxin (Lanoxin)– For atrial flutter of fibrillation; to prevent For atrial flutter of fibrillation; to prevent

recurrence of paroxysmal atrial tachycardia.recurrence of paroxysmal atrial tachycardia. Ibutilide fumarate [Corvert]Ibutilide fumarate [Corvert]

– To treat atrial flutter and fibrillation. Prolong To treat atrial flutter and fibrillation. Prolong cardiac action potential and increases atrial cardiac action potential and increases atrial and ventricular refractories.and ventricular refractories.

NURSING PROCESSNURSING PROCESSAntidysrhythmicsAntidysrhythmics

Antidysrhythmics Antidysrhythmics AssessmentAssessment Obtain health and drug histories. Obtain health and drug histories.

– The history may include shortness of The history may include shortness of breath (SOB)breath (SOB)

– heart palpitationsheart palpitations– CoughingCoughing– chest pain (type, duration, and severity)chest pain (type, duration, and severity)– previous angina or cardiac dysrhythmiasprevious angina or cardiac dysrhythmias– drugs that client currently takes.drugs that client currently takes.

Antidysrhythmics Antidysrhythmics AssessmentAssessment Obtain baseline vital signs and Obtain baseline vital signs and

electrocardiogram (ECG) for future electrocardiogram (ECG) for future comparisonscomparisons

Check early cardiac enzyme results Check early cardiac enzyme results (aspartate aminotrasferase, lactate (aspartate aminotrasferase, lactate dehydrogenase, creatine dehydrogenase, creatine phosphokinase) to compare with phosphokinase) to compare with future laboratory results.future laboratory results.

Antidysrhythmics Antidysrhythmics Nursing DiagnosesNursing Diagnoses Decreased cardiac outputDecreased cardiac output Anxiety related to irregular Anxiety related to irregular

heartbeatheartbeat Risk for activity intoleranceRisk for activity intolerance

Antidysrhythmics Antidysrhythmics PlanningPlanning Client will no longer experience Client will no longer experience

abnormal sinus rhythm.abnormal sinus rhythm. Client will comply with the Client will comply with the

antidysrhythmic drug regimen.antidysrhythmic drug regimen.

Antidysrhythmics Antidysrhythmics Nursing InterventionsNursing Interventions Monitor vital signs. Monitor vital signs.

– Hypotension can occur.Hypotension can occur. Administer drug by IV push or bolus Administer drug by IV push or bolus

over a period of 2 to 3 minutes or as over a period of 2 to 3 minutes or as prescribed.prescribed.

Antidysrhythmics Antidysrhythmics Nursing InterventionsNursing Interventions Monitor ECG for abnormal patterns and Monitor ECG for abnormal patterns and

report findings, such as prematue report findings, such as prematue ventricular contractions (PVCs), ventricular contractions (PVCs), increased PR and QT intervals, and /or increased PR and QT intervals, and /or widening of the QRS complex. widening of the QRS complex.

Antidysrhythmics Antidysrhythmics Nursing InterventionsNursing Interventions


GeneralGeneral Instruct client to take the Instruct client to take the

prescribed drug as ordered. Drug prescribed drug as ordered. Drug compliance is essentialcompliance is essential

Provide specific instructions for Provide specific instructions for each drug (e.g., photosensitivity each drug (e.g., photosensitivity for amiodarone for amiodarone


Side EffectsSide Effects Instruct client to report side effects Instruct client to report side effects

and adverse reactions to the health and adverse reactions to the health care provider. care provider. – These can include dizziness, faintness, These can include dizziness, faintness,

nausea, and vomiting.nausea, and vomiting.


Side EffectsSide Effects Advise client to avoid alcohol, caffeine, Advise client to avoid alcohol, caffeine,

and tobacco. and tobacco. – Alcohol can intensify the hypotensive Alcohol can intensify the hypotensive

reactionreaction– caffeine increases the catecholamine levelcaffeine increases the catecholamine level– tobacco promotes vasoconstriction.tobacco promotes vasoconstriction.

Antidysrhythmics Antidysrhythmics Nursing InterventionsNursing InterventionsEvaluationEvaluation Evaluate the effectiveness of the prescribed Evaluate the effectiveness of the prescribed

antidysrhythmic by comparing heart rates antidysrhythmic by comparing heart rates with the baseline heart rate and assessing with the baseline heart rate and assessing client’s response to the drug. client’s response to the drug.

Report side effects and adverse reactions. Report side effects and adverse reactions. The drug regimen may need to be adjusted. The drug regimen may need to be adjusted.

A proarrhythmic effect may occur, which may A proarrhythmic effect may occur, which may require discontinuation of the drug.require discontinuation of the drug.

11cardiac glycosides, antianginals, and antidysrhythmics

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