cardiac medications nursing review 2011
Post on 18-Oct-2014
5.705 views
DESCRIPTION
TRANSCRIPT
![Page 1: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/1.jpg)
Cardiac Medications: What’s With the Mixing &
Matching?
Michele B. Collins MSN RN CCRNSeptember 2009
![Page 2: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/2.jpg)
![Page 3: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/3.jpg)
Sodium-Potassium PumpSodium OUTSIDE cell & Potassium INSIDE cell before depolarization
Cell has NEGATIVE charge & must CONTRACT to become POSITIVE
SA node has less negativity so it serves as pacemaker
![Page 4: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/4.jpg)
• With cell stimulation, cell permeability allows sodium INTO cell & potassium OUT of cell
• With sodium, can only have STAT (“fast channel”) contraction
• Calcium (“fast channel”) also enters cell, leading to total controlled contraction
![Page 5: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/5.jpg)
Cardiac Repolarization
• Na+ - K+ pump uses energy (ATP) so SODIUM LEAVES cell and POTASSIUM RETURNS to cell
• Calcium also leaves cell at this time
![Page 6: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/6.jpg)
Cardiac Repolarization
If the S-A node does not generate an impulse, another cardiac site WILL (“reentry phenomenon”)
![Page 7: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/7.jpg)
Statistically, if you take six different drugs, you have an80% percent chance of at leastone drug-drug interaction.
Wayne K. Anderson, Dean,State University of New YorkSchool of Pharmacy
![Page 8: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/8.jpg)
Medications Discussed
• Antiarrhythmics• Beta Blockers Ace Inhibitors • Calcium Channel Blockers • ACE Inhibitors• Angiotensin II Receptor Blockers (ARB)• Diuretics• Digitalis• Nitrates• Amiodarone
![Page 9: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/9.jpg)
Why so Many?
• In atrial fibrillation, used to suppress arrhythmias
• Often done to relieve the symptoms associated with loss of the atrial component to ventricular filling (atrial kick) due to atrial fibrillation or flutter.
![Page 10: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/10.jpg)
• In individuals with ventricular arrhythmias, used to suppress arrhythmias. Antiarrhythmic agents may be considered the first-line therapy in the prevention of sudden death in certain forms of structural heart disease
![Page 11: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/11.jpg)
![Page 12: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/12.jpg)
Automaticity• Refers to a cardiac muscle cell firing off
an impulse on its own• All cardiac cells can initiate an
action potential, however, only some of these cells are designed to routinely trigger heart beats
• Found in the 'conduction system' of the heart and include the SA node, AV node, Bundle of HIS and Purkinje fibers
• Sinoatrial node is a single specialized location in the atrium which has a higher automaticity (a faster pacemaker) than the rest of the heart, and therefore is usually responsible for setting the heart rate, and initiating each heart beat.
![Page 13: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/13.jpg)
Re-entry• Occurs when an electrical
impulse recurrently travels in a tight circle within the heart, rather than moving from one end of the heart to the other and then stopping
• If conduction is abnormally slow in some areas, part of the impulse will arrive late and potentially be treated as a new impulse
![Page 14: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/14.jpg)
• Can produce a sustained abnormal circuit rhythm. Re-entry circuits are responsible for atrial flutter, most paroxysmal supraventricular tachycardia, and dangerous ventricular tachycardia.
![Page 15: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/15.jpg)
• Conditions that increase automaticity include sympathetic nervous system stimulation and hypoxia
![Page 16: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/16.jpg)
• Resulting heart rhythm depends on where the first signal begins– if in sinoatrial node, the rhythm remains normal
but rapid– if an ectopic focus, many types of dysrhythmia
may ensue.
![Page 17: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/17.jpg)
Positive Inotropes• THE EFFECTS OF STIMULATING ADRENERGIC RECEPTORS• RECEPTOR SITE ACTION• alpha peripheral blood vessels vasoconstriction of
peripheral arterioles• beta 1 myocardium increased heart rate (chronotropic)• increased contraction force
(inotropic) inc. conduction • • (dromotropic)• beta 2 peripheral blood vessels vasodilation of
peripheral arterioles & veins
• bronchioles bronchodilation
![Page 18: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/18.jpg)
![Page 19: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/19.jpg)
ANTIARRHYTMICS (Vaughan Williams classification)
• Class I – Membrane-stabilizing agents• Class II – Beta-blocking agents• Class III – Increase time for cell to
repolarize• Class IV – Calcium Channel blockers
![Page 20: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/20.jpg)
• Class I agents interfere with the sodium (Na+) channel.
• Class II agents are anti-sympathetic nervous system agents. Most agents in this class are beta blockers.
• Class III agents affect potassium (K+) efflux. • Class IV agents affect calcium channels and the
AV node. • Class V agents work by other or unknown
mechanisms.
![Page 21: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/21.jpg)
Class I Antidysrhythmics: • slow rate of spontaneous depolarization of cardiac
cells, thus decreasing automaticity, increasing refractory period, & decreasing susceptibility to escape beats
• Prolong QT interval.• Widen QRS interval: decreased Na+ influx into the
cell decreases conduction velocity and lengthens the QRS interval)
• CLASS I-A (quinidine, procainamide, disopyramide)Not often used today
![Page 22: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/22.jpg)
Class 1c
• Increases blockage of sodium channel • Encainide, Tombocor, Rythmol• severe ventricular dysrhythmias
![Page 23: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/23.jpg)
Class I: Sodium channel blockers
• Disopyramide (Norpace)Flecainide Procainamide Propafenone (Rythmol)Quinidine Tocainide
![Page 24: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/24.jpg)
Beta blockers• Decrease mortality in patients with myocardial
infarction– Decrease infarct size– Decrease ventricular dysrhytmias
• Slow progression of heart failure (HF) and prolong lifespan in patients with HF
• Used in treatment of coronary artery disease, heart failure (HF), & dysrhythmia
![Page 25: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/25.jpg)
Class II Agents: Beta Blockers
• Blockage of beta-1 receptors causes– Decreased force of contraction (- inotrope)– Decreased heart rate (-chronotrope)– Slowed conduction (-dromotrope)
• These 3 mechanisms of action combine to decrease myocardial oxygen demand
• decrease cardiac workload & myocardial oxygen needs
• Treatment of supraventricular tachycardias. They decrease conduction through the AV node.
![Page 26: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/26.jpg)
Side Effects• Angina• Fatigue, nightmares, & slow HR• Males may experience impotence• Patients with asthma or emphysema may not be able to tolerate beta blockers because of an increase in symptoms of shortness
of breath and wheezing• Depression• Weight gain• Assess for cough, fatigue, edema, and other symptoms of
HF• may mask hypoglycemia in diabetics; check blood glucose
frequently• Removed from blood during hemodialysis; hold dose
until treatment finished
![Page 27: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/27.jpg)
Cardioselectivity
• Acebutolol Sectrol• Atenolol Tenormin• Esmolol Brevibloc• Metoprolol Lopressor
![Page 28: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/28.jpg)
Non Cardioselectivity
• Propranolol Inderal• Labetalol normodyne, Trandate (alpha
properties as well)• Carteolol Cartrol• Nadolol Corgard• Pindolol Visken• Timolol Blocadren
![Page 29: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/29.jpg)
Beta Blockers
• Atenolol • Metoprolol • Propranolol • Sotalol • Bisoprolol • Nadolol
Carvedilol Timolol Nadolol Betaxolol Pindolol Labetolol
![Page 30: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/30.jpg)
Calcium Channel Blockers• Block movement of calcium into smooth
muscle cells in vessel walls– Calcium required for muscle contraction;
calcium channel blockers cause relaxation and dilatation of arteries
– By this mechanism, lower BP– Dilate the coronary arteries so also used in
treatment of angina
![Page 31: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/31.jpg)
• Reduce cardiac contractility, PVR, & myocardial O2 needs. Effective on reentrant dysrhythmias that require AV nodal conduction for their continuation
• In contrast to beta blockers, they allow the body to retain adrenergic control of heart rate and contractility.
• Some have a slowing effect on the heart rate and are used in the treatment of arrhythmia
• Used in treatment of hypertension, arrhythmia, and angina
![Page 32: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/32.jpg)
Uses
• Paroxysmal SVT, rate control for a-fib and flutter
• Dilate coronary arteries/decreases BP • Potentiates effects of digoxin• Change position slowly.
![Page 33: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/33.jpg)
Side Effects• Usually go away within a few hours to a day or so and are not said to be
permanent once the medication has "washed out" of the system• Common side effects of these drugs include constipation, dizziness, and
weakness• Swelling of the feet and ankles• Excessive lowering of the blood pressure
– Most common with first dose– Change position slowly
• Rarely an excessively slow heart beat • Worsening of HF• Many calcium channel blockers come in an extended release or sustained
release preparation ( XL, SR) that is convenient for once a day dosing. These tablets should not be cut in half or crushed, as this would affect the rate of drug release into the bloodstream.
![Page 34: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/34.jpg)
Diltiazem (Cardizem)
• Less negative inotropic activity than verapamil• Dilates the coronary arteries
• Treatment of supraventricular arrhythmias
• Oral diltiazem is effective in treatment of reentry tachycardia
![Page 35: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/35.jpg)
• Adverse Effects: fewest adverse effects of this category of drugs Hypotension- AV Block if patient is on Beta Blocker therapy
• Verapamil (Calan, Isoptin): severe hypotension & bradycardia
![Page 36: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/36.jpg)
Calcium Channel Blockers
• Drugs in this class include:
• Nifedipine • Diltiazem • Verapamil • Amlodipine
Felodipine Isradapine Nicardipene Nimodipine Bepridil
![Page 37: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/37.jpg)
ACE Inhibitors (“pril”)
• Used to treat both hypertension and Acute Coronary Syndrome
• Inhibit conversion of angiotension I to angiotension II >>> block release of aldosterone >>> reducing sodium & water retention
![Page 38: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/38.jpg)
ACE Inhibitors• Act to lower the blood pressure
– Dilate blood vessels– Help with cardiac emptying in HF
• Good for patients with heart failure by lowering the net resistance in the vascular bed, thereby facilitating the heart’s task of pumping blood.
![Page 39: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/39.jpg)
![Page 40: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/40.jpg)
![Page 41: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/41.jpg)
Indications
• Mild to severe hypertension• Treatment of heart failure• Given within 48 hours of MI to
prevent ventricular remodeling & development of HF
• Increase survival rate after MI
![Page 42: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/42.jpg)
![Page 43: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/43.jpg)
Side Effects• Hypotension
– have person lie down for 3 hrs after first dose
– temporarily D/C diuretics when starting therapya
– avoid potassium supplements/salt substitutes, diuretics (may cause severe hypotension)
• Hyperkalemia, renal tubular damage
• Cough• Angioedema
![Page 44: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/44.jpg)
• Give one hour before meals• Hold enalapril or lisinopril until after
hemodialysis (both are removed by dialysis)
![Page 45: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/45.jpg)
Ace Inhibitors
• Enalapril Vasotec• Lisinopril Zestril• Captopril Capoten• Quinapril Accupril• Benazopril • Fosinopril
![Page 46: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/46.jpg)
ARBs• Related to ACE inhibitors• Used to treat hypertension• Block the action of angiotensin II to constrict
blood vessels– lower blood pressure– function in a similar way as the ACE
inhibitors, but do not cause the dry, hacking cough that is sometimes associated with ACE inhibitor use.
![Page 47: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/47.jpg)
![Page 48: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/48.jpg)
Angiotensin II Receptor Blockers (ARBs)
• Losartan • Valsartan • Candesartan • Irbesartan
![Page 49: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/49.jpg)
Digitalis • First medication useful in treating
disorders of the heartbeat (1800s)• Digitalis leaf from the foxglove plant• Used to treat atrial fibrillation and heart
failure
![Page 50: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/50.jpg)
Actions• Direct: increases myocardial contractility and CO
– Vagal effect on SA & AV nodes so decreases heart rate– Slows conduction through AV node (positive inotrope, negative
chronotrope and negative dromotrope)
• Indirect– decreases diastolic cardiac size– reduces cardiac wall tension– increases renal Na+ & H2O excretion– decreases peripheral vasoconstriction
•
![Page 51: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/51.jpg)
• Slows HR so used in treatment of atrial fibrillation and atrial flutter– does not suppress or prevent arrhythmias
but only works to slow them down and relieve symptoms
of palpitations• Frequently used in heart failure (HF)
– Reduces frequency of HF exacerbations – Does not reduce mortality from HF
![Page 52: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/52.jpg)
Digitalis Toxicity– anorexia, n & v, visual disturbances– lethargy, bradycardia, heart block,
tachydysrhythmias– Take apical heart rate for one full minute before
administering – Monitor digoxin levels: narrow therapeutic
window: 0.8-2.0 ng/ml– Monitor potassium levels: hypokalemia more
likely to become digtoxic
![Page 53: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/53.jpg)
Drug Interactions
• Decreased digoxin absorption with antacids & laxatives
• Decreased digoxin effect: metoclopramide, aminoglycosides, thyroid supplements
• Increased digoxin effect Amphotericin B, corticosteroids, non-potassium-sparing diuretics, amiodarone
![Page 54: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/54.jpg)
Digoxin Fab (Digibind)• Used for life-threatening digoxin toxicity
• Mechanism: antibody complex formation to digoxin
• Adverse Events– exacerbation of heart failure or a-fib due to withdrawal of
digoxin– potential for complex dissociation with repeat toxicity in end-
stage renal disease– digoxin levels meaningless for 7 days post Digibind use.
![Page 55: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/55.jpg)
Nitrates
• Vasodilator: increases coronary blood flow by dilating coronary arteries and improving blood flow to ischemic regions of the heart– Decreases preload by dilating peripheral veins– Decreases afterload– Decreases myocardial oxygen demand to decrease
angina
![Page 56: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/56.jpg)
![Page 57: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/57.jpg)
• Used for angina, hypertension, MI• Used in heart failure to diminish symptoms
of shortness of breath• Do not reduce mortality in coronary artery
disease or heart failure. Their use is principally for symptom relief.
![Page 58: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/58.jpg)
Short-acting: Nitroglycerin
• For acute anginal attacks. SL dosage (0.4mg):· Instruct patient to lie down· Repeat at 5 minute intervals; if pain not
relieved, up to 3 tablets· If anginal pain persists after 3 doses, go to ED· Stay with patient and monitor VS (esp. BP)· Headache & hypotension are major side effects
![Page 59: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/59.jpg)
Long-acting Nitrates: Isordil, nitroglycerin ointment, nitroglycerin
transdermal patch
• Ointment: use appropriate application paper; don’t “rub in”
• Rotate sites (remove old patch, ointments)
• Avoid contact with skin
Nitrate-free periods (6 – 10 hrs/ 24 hr period) to prevent tolerance
Remove patch before defibrillating as patch may explode
![Page 60: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/60.jpg)
Side Effects
• Hypotension, diaphoresis, nausea• Tachy- and bradydysrhythmias• Headache; reflex tachycardia
![Page 61: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/61.jpg)
Drug Interactions
• Sympathomimetics, thyroid hormones, nicotine
• All increase cardiac workload so counteract NTG effects
![Page 62: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/62.jpg)
Nitrates
• Drugs in this class include: • Isosorbide Dinitrate • Isosorbide Mononitrate
![Page 63: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/63.jpg)
Amiodarone• Principal effect on cardiac tissue to increase time for cell to repolarize • Mainly block potassium channels, thereby prolonging
repolarization.• Do not affect the sodium channel so conduction velocity is
not decreased• Used to treat atrial arrhythmias (atrial fibrillation and atrial
flutter) as well as ventricular arrhythmias (ventricular fibrillation
• Prevent re-entrant arrhythmias• results in "chemical antifibrillatory" action
![Page 64: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/64.jpg)
Side Effects
• Pulmonary fibrosis• Abnormal thyroid function• Photophobia,• Nausea, vomiting• Blue-gray skin color• Seeing halos around objects
![Page 65: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/65.jpg)
• May take over 3 weeks to work; half-life about 50 days
• Monitor with patients in HF and elderly for decreased BP and pulse
• Assess for fluid retention
![Page 66: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/66.jpg)
• Have patient swallow whole• Do not stop abruptly• Take one hour before meals or 2 hours after
meals• High fat meals elevate levels• Use sunscreens and sunglasses when outside
![Page 67: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/67.jpg)
Drug Interactions
• Anticoagulants increase anticoagulation• Increased digoxin effects• Avoid grapefruit juice as it will increase serum
levels causing hypotension
![Page 68: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/68.jpg)
Class III — Potassium Channel Blockers
• Amiodarone (Cordarone)
• Dofetilide (Tikosyn)
• Ibutilide (Corvert)
![Page 69: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/69.jpg)
So How Does This Relate to My Patients? HTN
• Goal – Two primary regulatory factors
• Blood flow (volume) • Peripheral Vascular Resistance (PVR)
– Primary groups of drugs are used: • Diuretics • Adrenergic inhibitors (Beta-blockers) • Vasodilators • ACE inhibitors
• Calcium antagonists
![Page 70: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/70.jpg)
Pharmacologic Treatment
• For patients with systolic dysfunction (ejection fraction <40%) – Angiotensin-converting enzyme (ACE) inhibitors
for all patients – Beta blockers for all patients except
• Hemodynamic instability or• Dyspnea at rest with signs of
congestion
![Page 71: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/71.jpg)
–Aldosterone antagonist (ACE inhibitor or ARB) for those with• dyspnea at rest or• symptomatic patients who have suffered
a recent myocardial infarction • ARB as a substitute for patients intolerant
of ACE inhibitors
![Page 72: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/72.jpg)
• Digoxin only for patients who remain symptomatic despite treatment with– Diuretics, ACE inhibitors, and beta blockers– or for those in atrial fibrillation – Diuretics for symptomatic patients to maintain
appropriate fluid balance .
![Page 73: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/73.jpg)
• HF patients on multiple medications are at a risk of potential drug interactions and side effects– risk of hyperkalemia is increased with renal
insufficiency treated with an aldosterone antagonist and an ACE inhibitor.
![Page 74: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/74.jpg)
Goals for Mgt of Heart Disease
• Maximize blood flow to heart muscle • Maximize preload & minimize afterload • Maximize cardiac contractility (inotropic
effect)
![Page 75: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/75.jpg)
• Reduce chances of clot formation • Reduce overall blood volume if overload • Maintain heart rate between 60-80 beats/min
to maximize cardiac output and filling pressures
![Page 76: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/76.jpg)
What Drugs Help to Meet these Goals?
• Maximize preload I.V. fluids, volume expanders
• Minimize afterloadACE inhibitors • Maximize cardiac contractility Digoxin, Dopamine • Decrease preload, inc coronary circulation & reduce pulmonary congestion Nitrates
![Page 77: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/77.jpg)
What Drugs Help to Meet these Goals (cont’d)?
• Reduce chances of ASA or other anti-platelet clot formation agents • Reduce fluid volume overload Diuretics
• Keep heart rate btw Beta blockers & 60-80/min Calcium-channel blockers • Dysrhythmias Antidysrhytmics
![Page 78: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/78.jpg)
Treatment Goals for HF
– Relieve symptoms & improve quality of life – Prevent readmission to hospital, and/or recurrent
ischemic events – Reduce mortality – Medications used:
• ACE Inhibitors • Beta Blockers • Diuretics • Vasodilators • Digitalis
![Page 79: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/79.jpg)
ACE Inhibitors
• Increase lifespan of patients with heart failure
• Effects on blood vessels that seem to counteract the process of atherosclerosis and have been shown to reduce heart attack, stroke, and mortality in CAD
![Page 80: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/80.jpg)
Beta-Blockers
• Lower blood pressure & slow heart rate (including protection against arrhythmias)
• Helps lower risk of stroke and heart attacks
![Page 81: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/81.jpg)
Nitrates
• Used to treat angina • Vasodilates and
stops chest pain by increasing myocardial oxygen supply & decreasing demand
![Page 82: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/82.jpg)
Antidysrhythmic Drugs
• Used to bring under control abnormal rhythms of the heart (including atrial fibrillation), so the heart can pump more effectively
![Page 83: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/83.jpg)
Antihypertensives
• Used to control BP & risk of stroke & MI• Categories
– ACE Inhibitors– Beta-Blockers– Calcium-Channel Blockers
![Page 84: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/84.jpg)
Managing the Cost
• Patients may be taking two to four drugs to
manage cardiac condition – in addition to meds for other health
issues such as diabetes
– Med treatment for a chronic condition becomes expensive with each drug added
![Page 85: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/85.jpg)
• Even with worsening condition some people try to limit costs– May or may not ask which can be decreased or
stopped
• Best if medication regimen is kept simple so patients without insurance can purchase generic versions without rationing their doses.
![Page 86: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/86.jpg)
Refill Red Tape
• Patients and HCPs often face red tape when it comes to refills and preapproved status.
• If desired med is not on insurance company's preferred list– Must complete preauthorization form– Also must talk with insurance company about why
that particular medication is needed
![Page 87: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/87.jpg)
• Patients receiving non-formulary drugs often pay more– May only be able to get partially filled
prescriptions– Providers should seek generic or less
expensive alternatives whenever possible
![Page 88: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/88.jpg)
![Page 89: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/89.jpg)
Simple Steps: Lifestyle Changes
• Decrease sodium intake
• Exercise & weight loss
![Page 90: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/90.jpg)
Preload or Afterload?Arterial vasoconstriction
BP 190/124
Administration of hydralazine or nitroprusside
Administration of Nitroglycerin
Diuretic therapy
Arterial vasodilation
![Page 91: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/91.jpg)
• List some positive and negative aspects to the administration of beta blockers
![Page 92: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/92.jpg)
• The desired effect from the use of diuretics in the patient with acute left ventricular failure is to …
![Page 93: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/93.jpg)
• List some medications that decrease myocardial contractility
![Page 94: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/94.jpg)
• What are some of the signs & symptoms of left sided heart failure?
![Page 95: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/95.jpg)
• Your patient on digoxin has a morning heart rate of 56 BPM and is supposed to be discharged today. Your first priority is to…
![Page 96: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/96.jpg)
• What are some positive and negative aspects related to Nitroglycerin administration?
![Page 97: Cardiac medications nursing review 2011](https://reader036.vdocument.in/reader036/viewer/2022081412/544248e1afaf9fef098b45d0/html5/thumbnails/97.jpg)
A patient with a dysrhythmia is placed on digoxin and metoprolol (Lopressor). Because of the combined effects of these drugs, what area(s) need to be the most closely monitored?