HMG-CoA reductase inhibitors (statins)

reduce cholesterol synthesis in the liver and increase clearance of LDL and triglyceride levels

Increases HDL and lowers LDL and VLDL

Hepatotoxicity

(Monitor liver function tests)

myopathy: muscle aches, pain, tenderness

(Report to MD)

Peripheral neuropathy

(Report to MD)

clients with hepatitis induced by viral infection or alcohol

Rosuvastatin should be avoided for Asian descent

Use cautiously with elderly and with those who have renal disease

Take at night

Wear sunscreen and protective clothing r/t photosensitivity

Avoid grapefruit juice: affects metabolism and side effects of drug

Have liver and renal function tests monitored.

Reduce synthesis of triglyceride in the liver

Lower triglyceride levels and raise HDL

GI distress

gallbladder stones

myopathy

hepatotoxicity

CI: those with liver disorders, severe renal dysfunction, and gallbladder disease

GI distress usually mild and self-limiting

Report s/s of gallbladder stones: right upper quadrant pain, fat intolerane, bloating

Report muscle tenderness and pain

Report s/s of hepatotoxicity: anorexia, vomiting, nausea, jaundice

Take meds 30 min prior to meals

GI distress

facial flushing

hyperglycemia

hepatotoxicity

hyperuricemia

CI: those with liver disease and gout

Take with food.

Take ASA 30 min before each dose.

Monitor glucose levels.

Report s/s of liver dysfunction

Encourage to drink 2-3 L of water each day

Take time-released formulations once in the evening

Have kidney function, BUN, and creatinine labs monitored.

Administer allopurinol if uric acid level is elevated.

omega-3 fatty acids

fiber

soy

nitroglycerin

nitro-bid

nitro-dur

nitro-bid IV

isosorbide dinitrate (Isordil)

isosorbide mononitrate (Imdur)

Dilates peripheral blood vessles (less demand on the heart)

Dilates coronary arteries and collateral vessels (increases oxygen supply to the heart)

Decrease preload and afterload

Headache

orthostatic hypotension

reflex tachycardia

tolerance

CI: hypersensitivity to nitrates, have traumatic head injury

Use cautiously in clients taking anti-HTN meds and have renal or liver dysfunction

Nursing Teaching

Monitor BP, relief of chest pain, HA

Use tylenol for HA

Check expiration date.

Store in original container with tightly closed lids.

Don't viagra while on nitrates.  May cause life-threatening hypotension.

Avoid alcohol.  May cause life-threatening hypotension.

Rotate sites if using patches.

Remove the patch at noc to reduce the risk of developing tolerance.  Be med free for at least 8 hrs per day.

IV: start at slow rate (5 mcg/min) and titrate gradually

Recommended for first 24 to 48 hrs for all MI

Action not clear

Lowers cardiac o2 demand and thereby improve exercise tolerance and decrease pain

SE: dizziness, HA, constipation, nausea

QT interval prolongation

elevated blood bressure

Nursing Teaching:

Monitor BP

Administer bid for tx of chronic angina

Monitor digoxin level with concurrent use

CI: QT interval prolongation, liver dysfunction

Use cautiously with elderly

cardioselective: beta 1

metoprolol (lopressor)

atenolol (tenormin)

metoprolol succinate (toprol XL)

emolol HCL (brevibloc)

bisoprolol (Zebeta)

nonselective: beta 1 and beta 2

propranolol (inderal)

nadolol (corgard)

labetalol (normodyne)

carvedilol (coreg)

Decreased cardiac oxygen demand by decreasing contractility, HR, SVR, and BP, decrease myocardial oxygen consumption

Decrease size of infarct, ventricular dysrhythmias, mortality rates

TX: angina, MI, CHF, tachydysrhythmias, hyperthyroidism, migraine HA, stage fright, pheochromocytoma, glaucoma

Beta 1 blockade:

bradycardia

decreased cardiac output

AV block

orthostatic hypotension

rebound myocardium excitation

Beta 2 blockade:

bronchoconstriction

inhibition of glycogenolysis

fatigue

weakness

impotence

CI: AV block and sinus bradycardia, resp issues: asthma, CHF, bronchospams, DM, hx of severe allergies, and depression

Monitor BP and pulse

Can mask s/s of hypoglycemia

Observe for worsening of CHF

Sit or lie down if you experience dizziness or faintness

Change positions slowly

With asthma or DM should be administered with a beta 1 selective agent

nifedipine (Procardia), verapamil (Calan, Isoptin)

diltiazem (Cardize), nicardipine (Cardene)

amlodipine (Norvasc), felodipine (Plendil)

nifedipine:  blocking of calcium channels in blood vessels lead to vasodilation of peropheral arterioles and arteries/arterioles of the heart

verapamil, diltiazem: blocking of Ca channels in blood vessels leads to vasodilation of peripheral arterioles and arteries/arterioles of the heart

Also leads to SA and AV node to decreased force of contraction, decreased HR, and slowing of the rate of conduction through AV node

nifedipine: reflex tachycardia, peripheral edema, acute toxicity

verapamil, diltiazem: orthostatic hypotension, peripheral edema, constipation, suppression of cardiac function, dysrhytmias, acute toxicity

CI: use cautiously with women who are lactating

Clients who have heart block, hypotension, bradycardia, aortic stenosis, or CHF

Use cautiously with those who use digoxin and beta blockers

(BB: slows down the heart and D: increase digoxin levels)

Use cautiously with clients who have kidney and liver disorders and mild to moderate CHF

Patients:

Don't consume grapefruit juice (leads to toxicity)

Monitor HR and BP

Monitor weight

Monitor for swelling in lower extremities

Don't crush or chew sustained-release tablets

Nurses:

Acute toxicity: hypotension, bradycardia, AV block and ventricular tachydysrhythmias

What to do: Monitor VS and EKG.  Gastric lavage and cathartic may be needed.  Administer meds (norepinephrine, Ca, isoproterenol, lidocaine, and IV fluids)

Have equip for cardioversion and cardiac pacer available

Administer injections slowly over a period of two to three minutes

MOA: inhibition of COX-1 can result in decreased platelet aggregation and kidney damage, inhibition of COX-2 results in decreased inflammation, fever, and pain

SE: GI discomfort, renal dysfunction

Salicylism: tinnitus, sweating, HA, dizziness, resp alkalosis

reye syndrome

Apirin toxicity

Nursing Teaching:

Don't give to children who have a viral illness or under 12 years old

Take with milk or fluids

Nurses: can lead to acidosis.  Bicarbonate used for reversal process and promotion of ASA removal.

Tissue plasminogen activator (t-PA, alteplase or Activase)

Reteplase (retavase)

ansioylated plasminogenstreptokinase activator complex (APSAC)

Tenecteplase (TNKase)

IV or intracoronary

Most effective if w/in six hours of MI

Anti-platelets

oral

Antiplatelet/glycoprotein inhibitor: abciximab (reopro), eptifibatide (integrillin), tirobiban (aggrastat)

Antiplatelet/ADP inhibitors: clopidogrel (plavix), ticlopidine (ticlid)

Antiplatelet/arterial vasodilator: pentoxifylline (trental), dipyridamole (persantine), cilostazol (pletal)

TX: prevention of MI, stroke, acute coronary syndromes, intermittent claudication

Prevent platelets from clumping together by inhibiting enzymes and factors that normally lead to arterial clotting

Inhibit platelet aggregation at the onset of the clotting process.

Abciximab: hypotension, bradycardia, prolonged bleeding time, thrombocytopenia, bleed from cardiac catherization site

CI:  bleeding diorders, thrombocytopenia, recent stroke, AV malformation, aneurysm, uncontrolled hypertension, recent surgery

Clopidogrel: prolonged bleeding time, gastric bleed, thrombocytopenia

CI: Bleeding disorders, thrombocytopenia, peptic disease, intracranial bleed

Pentoxifylline: dyspepsia, n/v

CI:  bleeding disorders, retinal or cerebral bleeds

Use cautiously in clients with PUD, severe renal/hepatic disorders

Abciximab: Don't use NSAIDs or other meds that enhance bleeding.  (can prolong bleeding time)

Clopidogrel:  Don't use NSAIDs or other meds that enhance bleeding (can prolong bleeding time)

Pentoxifylline: Don't use NSAIDs or other meds that enhance bleeding (can prolong bleeding time)

Anticoagulants

oral

warfarin (coumadin)

TX:  venous thrombosis, afib or prosthetic heart valves, prevention of MI, TIA

hemorrhage, hepatitis, toxicity, overdose

CI:  Don't use in pregnancy.

Clients with low platelet counts or uncontrollable bleeding

Clients with Vit K deficiencies, liver disorders, alcoholism

Cliensts with hemophilia, dissecting aneurysm, pud, htn, or threatened abortion

Call MD if s/s of tachycardia, decreased BP, petechiae, hematomas, black or tarry stools.

Call MD if abdominal pain, jaundice occurs.

Don't eat foods with Vit K.

Don't use NSAIDs or other meds that enhance bleeding.

Nursing

administer vit K (mephyton) if high INR orally.

If given IV, administer slowly and in diluted solution.

Administer in small amounts.

If it doesn't work, brepare to administer fresh frozen plasma or whole blood.

Anticoagulants

(parental)

Heparin

Low molecular weight heparin: enoxaparin (lovenox), dalteparin sodium (fragmin), tinzaparin (innohep)

Activated factor X inhibitor:  fondaparinux sodium (arixtra)

TX: open heart surgery or renal dialysis, situations that need prompt anticoagulation activity (evlolving stroke, pulmonary embolism, massive deep venous thrombosis)

Used to prevent thrombosis in hip/knee/abdominal surgeries

 prevents bleeding by inactivation of thrombin formation and factor Xa resulting in inhibition of the formation of fibrin

hemorrhage, heparin-induced thrombocytopenia, hypersensitivity reactions, toxicity/overdose

enoxaparin: hemorrhage, neurologic damage from hematoma, thrombocytopenia, toxicity/overdose

Fondaparinux sodium: hemorrhage, neurologic damage from hematoma, thrombocytopenia

CI:  clients with low platelet counts or uncontrolled bleeding

Don't use if follow surgeries: eye, brain, or spinal cord, lumbar puncture, or regional anesthesia,

clients with hemophilia, dissecting aneurysm, pud, severe htn, hepatic or renal disease, or threatened abortion

Monitor VS, CBC labs.

Don't use NSAIDs or other meds that enhance bleeding.

Report s/s of bleeding (tachycardia, decreased bp, bruising, petechiae, hematomas, black tarry stool)

Use electric razors and soft toothbrushes. 

Nurse:

Client will be checked with PTT labs.

Protamine sulfate (antidote):  administer slowly, no faster than 20 mg/min or 50 mg in 10 min

ACE inhibitors

captoprin (capoten), enalapril (vasotec), enalaprilat (vasotec IV), fosinopril (monopril), lisinopril (prinivil), ramipril (Altace)

TX: htn, heart failure, MI, diabetic and nondiabetic nephropathy

orthostatic hypotension, cough, hyperkalemia, rash and dysgeuia, angioedema, neutropenia

CI:  clients with renal stenosis, hx of angioedema following ace inhibitor

Use cautiously with renal impairments and collagen vascular disease.

Monitor BP, pulse

Avoid salt substitutes with K+.

Monitor lithium levels (can increase toxicity)

Don't use NSAIDs (decrease effect of med)

Report dry cough to MD.

Monitor K+ levels.

Report rash or lack of taste to MD.

Cardiac glycoside

digoxin (lanoxin, lanoxicaps, and digitek)

Tx: CHF, Afib

Positive inotropic effect=increased force of myocardial contraction

Increased force and efficiency of myocardial contraction improves the heart's effectives as a pump, improving stroke volume and cardiac ouput.

Negative chronotropic effect=decreased heart rate

At therapeutic levels, slows the rate of SA node depolarization and the rate of impulses through the conduction system of the heart.

Decreased heart rate gives the ventricles more time to fill with blood coming from the atria, which leads to increased SV and increased CO

dysrhythmias (by interfering with the electrical conduction in the myocardium)

cardiotoxicity (n/v, general weakness)

GI effects: anorexia, n/v, and abdominal pain

CNS effects (fatigue, weakness, vision changes)

CI: disturbances in ventricular rhythm, hypokalemia, partial AV block, advanced CHF, and renal insufficiency

MFI: thiazide diuretics and loop diuretics may cause hypokalemia

ACE inhibitors and ARBS increase the risk of hyperkalemia

Sympathomimetic meds combined with digoxin may cause tachydysrhythmias

Quinidine increases the risk of toxicity

Verapamil increases plasma levels of digoxin

Patient: 

If dose is missed, don't double with the next dose.

Check pulse before taking it.

Notify MD if pulse is < 60 in adults, < 70 in children, and < 90 in infants.

Take it at the same time of day.

Digoxin levels will be tested periodically (0.5 to 2.0: safe level)

Notify clients if s/s of hypokalemia or digoxin toxicity (anorexia, fatigue, weakness) occur.

Nurses:

Tx of digoxin toxicity: stop digoxin and K+sparing diuretics immediately.

Monitor K+levels.  Administer K+ IV or po.  Don't give K+ if levels > 5.0.

Treat dysrhythmias with phenytoin or lidocaine.

Treat bradycardia with atropine.

For excessive overdose, activated charcoal, cholestryamine, or digibind can be used to bind digoxin and prevent absorption.

If taking a diuretic, potassium supplements may be used. 

Teach clients to consume high potassium foods.

Catecholamines: epinephrine, dopamine (inotropin), dobutamine (dobutrex)

Isoproterernol

Terbutaline: noncatecholamine

Heart stimulation leads to increased HR, increased myocardial contractility, and increated rate of conduction through the AV node.

Activation of receptors in the kidney lead to release of renin

activation of receptors in the arterioles of the heart, lungs, and skeletal muscles lead to vaso dilation

bronchial stimulation leads to bronchodilation

activation of receptors in uterine smooth muscle causes relaxation

activation of receptors in the live cause glycogenolysis

Skeletal muscle receptor activation leads to muscle contraction

Alpha 1: vasoconstriction

Beta 1: increased HR, myocardial contractility, rate of conduction through the AV node

Beta 2: bronchoconstriction

Tx: asthma, AV block, cardiac arrest, increase BP, local anesthetics, superficial bleeding, congestion of nasal mucosa

Low dose: renal blood vessel dilation

Moderate dose:beta 1 and dopamine: renal blood vessel dilation, Increased HR, myocardial contractility, rate of conduction through the AV node

High dose: dopamine, beta 1, and alpha 1: same effects as above and vasoconstriction

TX: shock, CHF

What's the MOA of dobutamine?

beta 1: inreased HR, myocardial contractility, rate of conduction through the AV node

TX: CHF

vasoconstriction

dysrhythmias, angina

dysrhythmias, angina, necrosis at IV site

CI: tachydysrhytmias and ventricular fibrillation

Use cautiously in hyperthyroidism, angina, hx of MI, HTN, and diabetes

Same CI for epinephrine and dopamine

MFI: MAOIs, tricyclic antidepressants, general anesthetics, alpha-adrenergic blocking agents,

beta-adrenergic blocking agents

diuretics

Med must be administered IV by continuous infusion.

Use IV pump to control infusion.

Dosage is titrated based on BP resonse. 

Stop the infusion at first evidence of infiltration. 

Assess for chest pain.

Provide continuous EKG monitoring.

If extravasation, inject phentolamine into infiltrated site.

If dose too high, will cause vasoconstriction and impair renal perfusion.

Monitor urine output (> 30 ml/hr)

losartan (Cozaar)

valsartan (diovan)

irbesartan (avapro)

candesartan (atacand)

olmesartan (benicar)

Tx: htn, CHF, prevention of mortality following MI,

stroke prevention, delay progression of diabetic nephropathy

vasodilation (arteriole)

excretion of sodium and water, and retention of potassium through the effects of the kidney

fetal injury, angioedema

CI: pregnancy, renal stenosis, used cautiously with those who have experienced angioedema while on ace inhibitor

MFI: AHTN meds

milrinone (primacor)

amrinone (inocor)

furosemide (lasix)

ethacrynic acid (edecrin)

bumetanide (bumex)

torsemide (demadex)

TX: pulmonary edema, hypercalcemia, conditions not responsive to other diuretics such as edema caused by liver, cardiac, or kidney disease; htn

Work in the ascending limb of loop of Henle to:

1. block reabsorption of sodium and water

2. cause extensive diuresis even with severe renal impairment

3. excretion of K+

dehydration, hyponatremia, hypotension, ototoxicity, hypokalemia, hyperglycemia, hyperuricemia, and decrease in calcium and magnesium levels

CI: pregnancy

Use cautiously in clients who have diabetes/gout

MFI: NSAIDs, digoxin, antihypertension meds

 Obtain baseline VS, weight, electrolytes

weigh clients in the morning before breakfast

administer at 0800 and 1400

Infuse IV doses at 20 mg/min or slower to avoid arupt hypotension and hypovolemia

If K+ levels drop < 3.5, administer K+ supplement.

Get up slowly.

Report significant wt loss, lightheadedness, dizziness, GI distress, weakness to MD.

Consume foods high in potassium.

Monitor for elevated glucose levels.

Report s/s of low magnesium: muscle twitching and tremors

Monitor blood pressure.

hydrochlorothiazide (hydrodiuril)

chlorothiazide (diuril)

methyclothiazide (enduron)

thiazide-type diuretics: indapamide (lozide, lozol)

chlorthalidone (hygroton)

metolazone (zaroxolyn)

TX: 1st choice in HTN, mild to moderate chf, liver and kidney disease

work in the early distal convoluted tubule to:

1.  block reabsorption of sodium and water

2. promote diuresis when renal function isn't impaired.

3. causes excretion of potassium

 dehydration, hypokalemia, hyperglycemia

CI: pregnancy

MFI: digoxin, antihypertension meds, NSAIDs

Monitor baseline VS, weight, and electrolytes

Take in Am, if bid, take 0800 and 1400

consume high potassium foods and lots of fluids

if gi upset occurs, take with or after meals

alternate day dosing can decrease electrolyte imbalances

spironolactone (aldactone)

triamterene (dyrenium), amiloride (midamor)

TX: CHF, primary hyperaldosteronism

hyperkalemia

endocrine effects (impotence in males, irregular menstrual cycles in women)

CI: hyperkalemia, severe renal failure and anuria

MFI: ace inhibors, potassium supplements

Avoid salt substitutes with potssium

Monitor BP and potassium levels.

Weigh every day.

Triameterene may turn urine a bluish color.

α-Adrenergic Blockers

Centrally Acting α₂ Agonists

Meds for Hypertensive Crisis

Antidysrhythmics

(Class IA: Na⁺-Channel Blockers)

Anticholinergic Effects

·      Dry Mouth

·      Urinary retention

·      Constipation

·      Tachycardia

·      Blurred vision

·      Mydriasis

Antidysrhythmics

(Class IB: Na⁺-Channel Blockers)

Antidysrhythmics

(Class III: K⁺-Channel Blockers

Antidysrhythmics

(Endogenous Glucoside)