Cardiac Drugs Daymar College Lisa H. Young, RN, BSN, MA Ed How to Use a Drug Book

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

Clinical Implications Therapeutic Effectiveness atch?v=Jh_U8V9-Htw watch?v=9mcqPJFB3UE Pharmacologic Principles Drug Names Generic name Brand name/Proprietary name Chemical name

Indications and Usage Contraindications Pharmacologic Principles Drug Interactions Red Flag Drugs: Warfarin Aspirin Cimetinde Theophylline

Drug Reactions Adverse reaction Side effects Pharmacologic Principles Drug Administration Enteral Routes Parenteral Routes

Topicals & Transdermal Pharmacologic Principles Pharmacokinetics Absorption Bioavailability

Therapeutic range Distribution Pharmacologic Priniciples Metabolism Elimination Pharmacodynamics

Tolerance Pharmacologic Principles Half-Life Digoxin Warfarin Heparin 30-60 hours 0.5 3 days 1 2 days

Poisonings/Toxicity Legal Classifications of Drugs Prescription Drugs Nonprescription Drugs Controlled Substances Drug Abuse Drub dependency

Pharmacologic Principles Prescription Orders Patient Name (superscription) Address Drug name (inscription) Drug dose Route (subscription) Frequency of administration Number to be dispensed Number of refills allowed DEA # MD Name/signature MD address MD Phone number /watch?v=Mhqe12Aj1dE Reading & Writing a Prescription Reading Prescription Label t2o ovM Medication Administration Ten Rights Right

Right Right Right Right Right Right Right Right Right patient name drug dosage route & technique time documentation client education to refuse

assessment evaluation h?v=cm7GexPKNOc&list=PLxd OP8vuQhz9SNJLTWjTGzh3yOTs Esd6l h?v=kdB0PmsX2ng /watch?v=yhHq-pV6HO w Pharmacology Abbreviations Abbreviation Meaning

Abbreviation Meaning Ac before meals qhs every night Bid twice daily Rx

take c with s without DC discontinue SL sublingual

dx diagnosis SOA short of air NPO nothing by mouth ss half NS

normal saline suppos suppository p after tid 3 times daily PR per rectum

top topical prn as needed ung ointment q every UT

under tongue Do Not Use Abbreviations Charting Medication Administration Examples of charting: A. 9/1/12 9:00 a.m. nitroglycerin, 1 tab, sublingually. Written instructions given to pt. Precautions explained. Told to call office at 1:00p.m. today to report progress of his condition.M. Richards, CMA (AAMA) B. 1/19/12 11:00 a.m. B 12 vitamin, 10000mcg given IM to left deltoid muscle without complications and band aid applied to injection site. Pt tolerated injection well. Pt. given written instructions for possible side effects and considerations. Pt to return in one monthly to receive monthly B 12 injections as

orderedL.Young, CCT. C. 10/10/2012 1:00 p.m. Mantoux test, 0.01 ml. Tuberculin Purified Protein Derivative, Left forearm, subcutaneous, small wheal noted. Pt. instructed not to rub or cover the are and to return for reading on 10/12/12..M. Richards, CMA (AAMA) Six Cs of Charting Clients own words Clarity Completeness Conciseness Chronological Confidentiality ch?v=mYGf0AdhhI4

ch?v=SDcmXqSvP7A Guidelines for Charting Date/time of entry Legible handwriting Permanent black ink Proper terminology, correct spelling and correct grammar Document in sequence om/watch?v=pe2TQJK XZIs Be concise Correct errors om/watch?v=GMVwo R0YU-I Sign every entry om/watch?v=Bkoic2d LFmY Apothecary System gr = grain gal = gallon dr = dram qt iii = 3 quarts oz = ounce ix = 9 lb = pound qt i = 1 quart m = minims gr = grain fl dr = fluid drams

pt iiiss = 3 pints fl oz = fluid ounce 1 grain = 60 mg pt = pint qt - quart Metric System Metric Conversion Value Chart Kilo Hecto-Deka-Base-Deci-Centi-Milli-X-X-Micro Gram Liter Meter /watch?v=2QR9yCkAEpE

45.2 grams = 45200.0 milligrams 1cubic centimeter (cc) = 1 milliliters (ml) Dosage Definitions Dosage unit Dosage strength Dosage ordered

Desired dose Dose on hand Amount to administer Drug Dosage Calculations Drug Calculation: Formula Method Ordered Dose Available Dose X Available Amount Amount to give Ordered dose: 500 mg Available dose: 1000 mg Available amount: 1 ml ch?v=b69Wr008dzM h?v=BMDOk3RAHC4 =Wa9Zi64_HJk Rules of Conversion Apothecary Metric 1 fluid oz 30 mL or cc

1 quart 1000 mL or cc 1 grain 0.065 gram 15 grains 1 gram 2.2 pounds 1 kilogram Household

Metric 1 drop 0.06 mL 1 tsp 4-5 mL 1T 15-16 mL 1 cup 250 mL

2 cups 500 mL Calculating Pediatric Dosages Clarks Rule Frieds Rule Youngs Law

Wests nomogram Body Weight method =AQaeAON4GUM Patient Education Assessment Plan Implementing Document Evaluate Special Needs

Noncompliance ?v=1HQHdpAov-I Professionalism Cultural Considerations The Life Span Understanding and knowledgeable about

medication In the Workplace The Law Inotropic, Chronotropic and Dromotropic Drugs F6vs

?v=mQirK5RxhFo Neurological Control of the Heart and Blood Pressure Sympathetic Nervous System Adrenergic Response _ Catecholamines _ Adrenaline _ Beta 1-Adrenergic Receptors _ Alpha 1-Adrenergic Receptors Ag86SvlY

Neurological Control of the Heart and Blood Pressure Baroreceptors _ Pressure receptors _Mechanoreceptors _Efferent pathways Neurological Control of the Heart and Blood Pressure Chemoreceptors _ carotid artery _ Elevated arterial carbon dioxide level _ Heart rate increases _ Vasoconstriction

Neurological Control of the Heart and Blood Pressure Parasympathetic Nervous System Vagal Response _ Cholinergic Response _ Acetylcholine _ Nicotinic Cholinergic Receptors _ Muscarinic Cholinergic Receptors Neurological Control of the Heart and Blood Pressure

Renin-Angiotensin-Aldosterone System _ Release of Renin _ Angiotensin I Angiotensin II _ Angiotensin-converting enzyme (ACE) Cardiovascular Pharmacology Preload The stretching of the ventricle at the end of diastole. _ Increasing Preload Administer extracellular fluid expander Decrease dose of stop drugs that cause venous vasodilation _ Decreasing Preload

Stop or decrease fluid Diuretics ACE inhibitors Aldosterone antagonists Venous vasodilators ?v=FjdJdoZcbyA atch?v=lPK017oR3bw ?v=mQirK5RxhFo Cardiovascular Pharmacology Afterload

The resistance that the ventricle must overcome to eject its contents. _ Increasing Afterload Sympathomimetics (stimulate alpha receptors) ADH _ Decreasing Afterload Smooth muscle relaxants Calcium channel blockers Alpha receptor blockers ACE inhibitors ARBs & PDE atch?v=NFcg62I54w8 Cardiovascular Pharmacology

Contractility _Increasing Contractility Sympathomimetics (stimulate B1 receptors) PDE inhibitors Cardiac glycosides _Decreasing Contractility Beta-blockers Calcium channel blockers h?v=_sxiloNshfE Cardiovascular Pharmacology Heart Rate

Cardiac output = heart rate X stroke volume Increasing heart rate Parasympatholytics Sympathomimetics (stimulate B1 receptors) Decreasing heart rate Beta-blockers (block B1 receptors) Calcium channel blockers Cardiac glycosides tch?v=PJ8WsZOywgo Other antiarrhythmics tch?v=OVVwyCCyH8E Sympathomimetics/Adrenergics

Stimulate the sympathetic nervous system Increase heart rate Increase contractility Increase afterload ch?v=HklZH5QdOeE Epinephrine Stimulates: B1 & B2 (low dose) & Alpha

receptors (high doses) Results: increased contractility, automaticity, bronchodilation and selective vasoconstriction Uses: advanced cardiac life support, anaphylactic shock, hypotension/profound bradycardia Considerations: instant onset, peak 20 minutes and given IV every 3 5 minutes for cardiac standstill ch?v=9cpD8lG6DvY Dobutamine Stimulates: primarily B1, some alpha receptors and modest B2 Results: increased contractility, increased

AV node conduction, modest vasoconstriction Uses: as an inotrope with modest afterload reduction Considerations: onset 1 2 minutes, peak 10 minutes, blood pressure is variable: B2 causes vasodilation, increased cardiac output increases blood pressure Dopamine

Stimulates: dopaminergic and some B1 at low doses, B1 at moderate doses, pure alpha stimulation at high doses (>10 mcg/kg/min) Results: increased contractility at small and moderate doses, increased conduction, vasoconstriction at high doses, does not treat or prevent renal failure at low doses Uses: refractory hypotension and shock Considerations: IV onset 1 2 minutes & peak 10 minutes =YrEn_1FBBsw Norepinephrine Stimulates: primarily alpha stimulation, some B1

Results: potent vasoconstriction (vasopressor) and some increased contractility (positive inotrope) Uses: refractory hypotension, shock, used as vsopressor but with inotrope properties Considerations: Rapid IV onset, duration 1-2 minutes Phenylephrine (synthetic compound)

Stimulates: direct effect is dominant alpha stimulation, no substantial B1 effect at therapeutic doses, indirect effect; causes release of norepinephrine Results: potent vasoconstriction (vasopressor) Uses: refractory hypotension Considerations: rapid IV onset, duration of action 10 15 minutes Non-Sympathomimetic Medications Arginine vasopressin used as vasopressor

Milrinone (phosphodiesterase inhibitor) used as an inotrope Side effects: ventricular dysrhythmias exacerbation of accelerated ventricular rate with atrial dysrhythmias Medications Affect ReninAngiotensin-Aldosterone System Angiotensin-Converting Enzymes (ACE) Inhibitors prevent conversion of angiotensin I to angiotensin II inhibits angiotensin-converting enzyme promotes arterial vasodilation reduces afterload Benazepril

Lisinopril Captopril Quinapril Enalapril Ramipril Fosinopril Angiotensin II Receptor Blockers Blocks angiotensin II Similar hemodynamic effects as ACE inhibitors Used in place of ACE inhibitors if they are not tolerated due to intractable cough or

angioedema ARBs end with sartan Candesartan, first drug approved by FDA for heart failure Candesartan Irbesartan Telmisartan Eprosartan Losartan Valsartan Aldosterone Antagonists mineralocorticoid hormone hold sodium and water and excrete potassium potassium-sparing diuretics decrease in preload minimized release of catecholamines

improved endothelial function antithrombotic effects decreased vascular inflammation and myocardial fibrosis Spironolactone Eplerenone bKN6AuWE Beta-Blockers block B1 or B2 receptors decrease heart rate and contractility bronchial and peripheral vasoconstriction management of heart failure management of stable angina management of acute coronary syndromes

decrease myocardial oxygen demand increase coronary perfusion management of hypertension Atenolol Metoprolol Propranolol Esmolol Calcium Channel Blockers decrease the flux of calcium decrease heart rate, contractility and afterload degree of negative inotropic effect reduce coronary and systemic vascular resistance decreasing myocardial oxygen demand not indicated in the treatment of heart failure

adverse effects: peripheral edema, worsening heart failure, hypotension and constipation Calcium Channel Blockers Action Verapamil Dihydropyridi ne calcium channel blockers Diltiazem Heart rate

AV nodal conduction Neutral Contractility

Arterial vasodilation Arterial and Venous Vasodilators Nitroglycerin and Nitrates

IV a primary venous vasodilator sublingual produces both venous and arterial vasodilation decreases preload reducing myocardial oxygen demand higher doses = coronary artery dilation exhibits antithrombotic and antiplatelet effects Nitroprusside mixed venous and arterial vasodilative arterial vasodilator indicated in hypertensive crisis cardiac emergencies hypotension side effect possible thiocyanate toxicity

Nesiritide synthetic brain natriuretic peptide (BNP) counteract the effects of RAAS venous and arterial vasodilative effects management of acute decompensated heart failure decrease preload and afterload lowers blood pressure Digoxin cardiac glycoside weak inotropic properties parpasympathetic properties used in treatment of heart failure narrow therapeutic range easy to develop toxicity electrolyte increase effect of digoxin

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

Bumex Lasix Demadex Thiazide Diuretics Inhibit reabsorption of sodium & chloride Less potent than loop diuretics Decreased effectiveness with renal dysfunction Low-ceiling diuretics Bendrofluazide Hydrochlorothiazide Indapamide Metolazone

Cyclothiazide Chlorothiazide Polythiazide Trichlormethiazide Emergency Medications Direct renin inhibitors Aliskiren _ treatment of hypertension _ impact RAAS Vasopressin 2 Antagonists Tolvaptan _ oral medication _ renal collecting ducts _ treatment of heart failure with volume

overload Lipid-Lowering Medications o o o o o Low-Density Lipoprotein Cholesterol primary goal in the management of coronary heart disease HMG-CoA reductase inhibitors (statins) Bile acid resins Nicotine acid

Dose dependent effect on LDL-C Triglycerides and High-Density Lipoprotein Cholesterol Nicotinic acid (Niacin) Fibrates Statins

Bile acid resins Bile acid sequestrants Bile Acid Sequestrants (Resins) Combine with bile acids Hepatic circulation More production of cholesterol Breaks cholesterol to make bile acids Increases LDL-C receptors Net decrease in total cholesterol Net decrease in LDL-C Constipation Questran Colestid

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

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

Reduced lipid levels Reduced future coronary events Reduce the risk of coronary mortality & morbidity Inhibition of HMG-CoA reductase Reduce the quantity of mevalonic acid Mevacor Zocor Lescol Lipitor Crestor Intestinal Absorption of Inhibitors

Newest class of lipid-lowering medications May be combined with HMG-CoA reductase inhibitor Ezetimibe Blocks the absorption of cholesterol in the small intestine Coagulation Overview

To protect the integrity of the vessels and prevent harmful bleeding To maintain the fluid state of the blood These two goals must be achieved simultaneously to maintain health Clotting Cascade Platelet Aggregation Release Thromoboplastin Prothrombin

Thrombin Fibrinogen cxE&list=PL2UREUiTlHRn3iW9DhoeLjxNDM7L y5vrA Thrombolytics & Fibrinolytics Type Actions/ Physiologic Effect Agents Fibrin specific Plasminogen

activation Rapid clot lysis Clot specific Tissue plasminogen activators (t-PAs) Alteplase Reteplase Tenecteplase Nonfibrin specific Systemic lysis Slow clot lysis More prolonged, systemic effect Streptokinase

Anistreplase (APSAC) Streptokinase Earliest clot busting medication Dissolves clots during an acute MI Produce antistreptokinase antibodies Contraindicated to use streptokinase in these patients Anistreplase (APSAC)

Anisoylated plasminogen streptokinase activator complex Altered form of streptokinase Converts circulating plasminogen into plasmin May be given as an IV bolus over 2 5 minutes Particular affinity for fibrin Activates the plasminogen that is bound to fibrin Anticoagulants Unfractionated Heparin (UFH) Antithrombotic agent Prevents the conversion of prothrombin to thrombin

Binds to plasma proteins, blood cells, and endothelial cells Administered intravenously Weight-based protocol Administrated subcutaneoulsy aPTT , PT, INR, platelet count, hemoglobin level and hematocrit Bleeding potential complication Thrombocytopenia Anticoagulants Low-molecular-weight Heparin (LMWH) Accelerating the activity of antithrombin III Longer half-life than UFH No clotting times need to be monitored Lower incidence of HIT

Higher rate of minor bleeding Special dosing required for patients with chronic renal insufficiency Protamine used for reversing effects Administered subcutaneously Enoxaparin Anticoagulants Direct Thrombin Inhibitors Treatment of thrombosis in patients with HIT Ability to inactivate fibrin-bound thrombin Lepirudin and desirudin Argatroban Bivalirudin Pradaxa

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

Inhibition of the synthesis of factor II (prothrombin) Altering the synthesis of other vitamin Kdependent factors Primarily bound to albumin in the blood Monitor PT and INR levels Lifelong therapy for atrial fibrillation Many drugs interact with warfarin No aspirin, ibuprofen or naprosyn Antiplatelet Therapy Glycoprotein Iib/IIIa Inhibitors Interfere with the final pathway of platelet aggregation Prevent fibrinogen binding Administrated intravenously May be given with aspirin, clopidogrel & heparin

Abciximab (ReoPro) Monitor platelet count and hemoglobin level Treatment of unstable angina and non-STEMI Antiplatelet Therapy Adenosine Diphosphate Inhibitors Clopidogrel (Plavix) Prevents adenosine diphosphate (ADP) activation of platelets Treatment of unstable angina & non-STEMI Avoid use of omeprazole (Prilosec) Warning for patients who are poor metabolizers Prasugrel Antiplatelet Therapy

Aspirin Anti-inflammatory, analgesic, antipyretic & antithrombotic Treatment of acute or chronic ischemic heart disease Inhibiting cyclooxygenase and inhibiting the synthesis of thromboxane A2. Inhibits endothelial production of prostabladin I2 Chewing aspirin accelerates absorption GI side effects Treatment for Myocardial Infarction Oxygen Aspirin Sublingual or Intravenous Nitroglycerin Intravenous Beta Blocker

Unfractionated Heparin Glycoprotein IIb/IIIa Receptor Blocker Antiarrhythmics Stops irregular beats and maintain regular heart beat

Medications must be taken on time Take pulse before each dose Limit fluid and salt intake Avoid antacids and limit citrus, some vegetables Monitor for tiredness Some are light sensitivity Regular monitoring Antiarrhythmics Continued Four Classes of Antiarrhythmics Class I Sodium Channel Blockers Class I A: treat a wide variety of atrial & ventricular arrhythmias Control arrhythmias by altering the myocardial cell

membrane and interfering with ANS control of pacemaker cells Blocking sodium channels in cell membrane during an action potential Block parasympathetic stimulation of the SA & AV node Antiarrhythmics Continued Class I B Blocks rapid influx of sodium ions during depolarization phase Decreased refractory period Affects Purkinje fibers & myocardial cells in the ventricles Used only to treat ventricular arrhythmias May exhibit additive or antagonistic effects when administered with other antiarrhythmics

Antiarrhythmics Continued Class IC Primarily slows conduction along the conduction pathway Used to treat severe, refractory ventricular arrhythmias May be used for treatment of SVT Treat life threatening ventricular arrhythmias Adenosine Antiarrhythmics Continued Class II Composed of beta-adrenergic antagonists (beta

blockers) Block beta-adrenergic receptor sites in the conduction system of the heart SA node firing is slowed AV node and other cells receive and conduct impulses slowly Reduces strength of contraction Slow ventricular rates in afib, aflutter and PAT Antiarrhythmic Continued Class III Treat ventricular arrhythmias Asymptomatic A fib and A flutter treatment is possible Amiodarone is first line drug choice for the treatment of VT and V Fib.

Antiarrhythmics Continued Class IV Calcium Channel Blockers Treat SVT with rapid rates Inhibits calcium ion influx across cardiac and smooth muscle cells Decrease contractility and oxygen demand Dilate coronary arteries and arterioles Used to relieve angina, lower blood pressure, and restore normal sinus rhythm

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