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1. Drug affecting Cardiovascular system Raheem khan

2. CONTENT 1. Cardiac Medication . Beta Blockers Calcium Channel Blockers ACE Inhibitor ARB’s Alpha Blockers 2. Nitrates 3. Vasodilators 4. Diuretics 5. Inotropes 6. Anti arrhythmic 7. Anti platelet 8. Anticoagulants 9.Lipid lowering agent

3. Beta Blocker & Beta Receptor Blockers

4. Beta Blocker & Beta Receptor Blockers These medications are used for various indications, but particularly for the management of cardiac arrhythmias, cardio protection after MI(heart attack),and hypertension. As beta adrenergic receptor antagonists, they diminish the effects of epinephrine (adrenaline) and other stress hormones.

5. Beta blockers block the action of endogenous catecholamine (adrenaline and noradrenalin) B-adrenergic receptors, part of the sympathetic nervous system which mediates the “fight and flight’ response.

6. Beta Receptors There are three types of beta receptors. B1 receptors are located in the Heart and Kidneys. B2 receptors are located mainly in lungs, GI tract, liver, uterus, vascular stomach muscle & skeleton muscle. B3 receptors are located in fat cells.

7. Indications for Beta Blockers Angina pectoris Myocardial Infarction Cardiac arrhythmias(A-fib,VT,SVT) Tremor Hypertension Mitral valve prolapsed Symptomatic control ( tachycardia, tremor) in anxiety and hyperthyroidism.

8. Examples of Beta Blockers Generic Names Trade Names Dosage Atenolol Tenormin 25/50/100 mg Metoprolol Merol/lopressor 25/100 mg Propranolol Inderal 10/40 mg Bisoprolol Concor/Corbis 2.5/5/10 mg Carvedilol Carveda 6.25/12.5/25mg

9. Side effects Cold feet and hands Fatigue Nausea, weakness, and dizziness Dry mouth, skin, and eyes Slow heartbeat Swelling of the hands and feet

10. Contraindication Hypersensitivity drugs Bradycardia Cardiogenic shock 1 st degree heart block Asthma Non allergic bronchospastic disorder Diabetes Impaired renal function.

11. Nursing Care Monitor vital signs and ECG. Teach patient to take his/her pulse before taking a beta blockers. Tell him/her to with hold the dose and alter the drug if his pulse is below 60 bpm. Tell patient to report serious and adverse effects reaction. Advise to change positions slowly to prevent orthostatic hypotension. Warn the patient not to discontinue the medication without doctor’s order.

12. CALCIUM CHANNELS BLOCKERS

13. Pathophysiology ↓ Dilate coronary arteries and peripheral arterioles ↓ Decrease cardiac contractility ( negative inotropic effect ) ↓ Decrease automaticity at the SA node and conduction at the AV node ↓ Increase myocardial oxygen supply

14. Indications for Calcium Channel Blockers SVT Hypertension Cerebrovascular spasm Reduction of cardiovascular hypertrophy Reduction of atherosclerotic lesions Myocardial protection from ischemic damage.

15. Examples Calcium Channel Blockers Generic Name Trade Name Dosage Diltiazem Herbesser/ Dilzem 30/60 mg Herbesser SR 90/180/ mg Etizem SR 90 mg Verapamil Calan 40/80 mg Calan SR 240 mg Isoptin 40/80/240 mg Amlodipine Norvac 5/10 mg

16. Nursing Care Stress the importance of taking drug exactly as prescribed. Teach patient to check pulse before each dose. Notify the doctor if pulse is below 60/min or irregular. Tell patient to limit salt intake if his prescribed drug causes fluid retention.

17. Side effects and Contraindication 1. Patient hypertensive to drug. 2. In lactating mothers and renal impairment

18. ALPHA BLOCKERS

19. These drugs block the sympathetic nerves on blood vessels by binding to alpha-adrenoceptors located on the vascular smooth muscle. Alpha Blockers

20. Indications of Alpha Blockers Hypertension Benign prostatic hyperplasia Ophthalmic hyperemia

21. Examples of Alpha Blockers Generic name Trade name Dosage Doxazosin Cardura 2/4 mg Parazosin Minipress ½ mg Terazosin Hytrin 1/2/5 mg

22. Nursing Care Warn patient not rise suddenly from a lying or sitting position. Perform baseline assessment of VS, peripheral pulses, skin color, temperature, and capillary refill.  Advise patient that alcohols, excessive exercise, prolong standing will intensify adverse effects. Report to doctor if dizziness or irregular heart beat.

23. Side Effects and Contraindication Dizziness Orthostatic hypotension Nasal congestion (due to dilation of nasal mucosal arterioles) Headache Reflex tachycardia MI Coronary insufficiency or angina Heart failure Use cautiously in pregnant or breast feeding woman

24. ACE INHIBITORS

25. ACE Inhibitors Angiotensin converting enzyme inhibitors prevent conversion of angiotensin 1 to angiotensin 2, a potent vasoconstrictor. Besides decreasing vasoconstriction and thus reducing peripheral arterial resistance, Inhibition of angiotensin 2 decreases adrenocortical secretions of aldosterone. This reduces sodium and water retention.

26. Indication of ACE Inhabitors Hypertension Heart Failure Diabetic Nephropathy LV Dysfunction

27. Examples of ACE Inhibitors Generic Name Trade Name Dosage Captopril Capoten 25 mg Enalipril Renitac 5/10 mg Lisinopril Zestril 5/10/20 mg

28. Nursing Care Caution patient to avoid sudden position change to minimize orthostatic hypotension. Tell patient that drug may cause dry mouth, persistent cough. Warn patient to seek medical approval before taking self prescribed cold preparation. Contraindication in patients sensitive to ACE inhibitors. Use cautiously in patients with impaired renal function or serious autoimmune disease.

29. ARB’s ( ANGIOTENSIN RECEPTORS 11 BLOCKERS)

30. Angiotensin II Receptor Blockers (ARBs) Are medications that block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced. Reduced blood pressure makes it easier for the heart to pump blood and can improve heart failure. In addition, the progression of kidney disease due to high blood pressure

31. Indication of ARBs High blood pressure Heart failure Atrial fibrillation Nephropathy in type 2 diabetes

32. Example of ARB’s Generic Name Trade Name Dosage Losartaan potassium Cozaar 25/50 mg Tansin DS 100 mg Valsartaan Diovan 80 mg Telmisartan Telmisar 20/40/80 mg

33. Nursing Care Instruct patient to take drug as prescribed. Warn him/her not to stop drug abruptly (quickly). Advise patient to avoid sudden changes in position to prevent dizziness or fainting. Warn patient to avoid physical excretion especially in hot weather.

34. Side Effects and Contraindications 1. Contraindicated in patients sensitive to ACE inhibitors. 2. Use cautiously in patients with impaired renal function or hepatic dysfunction

35. DIURETICS

36. DIURETICS A diuretic is any drug that elevates the rate of urination and thus provides a means of forced diuresis. There are several categories of diuretics. All diuretics increase the excretion of water from bodies, although each class does so in a distinct way.

37. Diuretics

38. Types Loop Diuretics Loop diuretics, such as furosemide , inhibit the body's ability to reabsorb sodium at the ascending loop in the nephron which leads to a retention of water in the urine as water normally follows sodium back into the extracellular fluid (ECF). Thiazides Thiazides diuretics such as hydrochlorothiazide act on the distal convoluted tubule and inhibit the sodium-chloride symporter leading to a retention of water in the urine, as water normally follows penetrating solutes. Frequent urination is due to the increased loss of water that has not been retained from the body as a result of a concomitant relationship with sodium loss from the convoluted tubule

39. Types K Sparing Diuretics Potassium-sparing diuretics are diuretic drugs that do not promote the secretion of potassium into the urine . Potassium-sparing diuretics act to prevent sodium reabsorption in the collecting tubule. Spironolactone (Aldactone, Carospir). Osmotic Diuretics Compounds such as mannitol are filtered in the glomerulus , but cannot be reabsorbed. Their presence leads to an increase in the osmolarity of the filtrate. To maintain osmotic balance, water is retained in the urine

40. Clinical use To treat or prevent ARF. CHF Ascities Nephrotic syndrome To reduce intra-ocular pressure in glaucoma

41. Examples of Diuretics Category Generic Name Trade Name Dosage Loop Diuretic Furosemide Lasix 20,40,80mg,PO Potassium sparing diuretics Spironolactone Aldactone 25,50,100 mg PO Osmotic diuretics glycerin (Glycerol) Isosorbide Mannitol 500ml IV Thiazides diuretics Chlorothiazide Indapamide Hydrochlorothiazide Metolazone DIural Lozol Hydrodiuril Zaroxolyn,Diulo 250 mg IN 5ml

42. Side effects and Contraindication Contraindicated in patient with anuria or hypersensitivity to drug. Hypovolemia, hypokalemia, hyponatremia, metabolic alkalosis (loop diuretics). Fever, vertigo, headache, weakness (lasix toxicity). Gout, seizures.

43. Nursing Care Monitor patient weight, peripheral edema, breath sounds, and BP, I/O, and serum electrolytes. Advise patient to stand slowly to prevent dizziness. Instruct patient to report ringing in ear, severe abdominal pain, or fever because they may indicate lasix toxicity.

44. Cardiac glycosides

45. Cardiac glycosides The first line of inotropes include all digitalis derivatives  derived from foxgloves. Digitalis Glycosides have a direct effect on cardiac muscle and the conduction system. An indirect effect on the cardiovascular system regulated by the autonomic nervous system which is responsible for the effect on the sino -atrial (SA) and atrio -ventricular (AV) nodes.

46. The result of these direct and indirect effects are  An increase in force and velocity of myocardial contractility (positive inotrope effect). Slowing of heart rate (negative chronographic effect). Decreased conduction velocity through the AV node. Digoxin is the most commonly prescribed cardiac glycoside

47. Digoxin DIGOXIN ADMINISTRATION Digoxin can be administered intravenously or orally. IV injection should be carried out over 15 minutes to avoid vasoconstriction responses. Intramuscular Digoxin is absorbed unpredictably, causing local pain, and is not recommended. Onset action 0.5 to 2 h (oral), 5 to 30 min (IV).

48. DIGOXIN LOADING DOSE Loading doses of Digoxin is 0.5mg and then 0.25mg repeat after 6-8 hrs (2doses)1mg/day Diluted in 0.9%sodium,5%D/W and distal water Digoxin can be given orally, but with a slower onset of action and peak effect. DIGOXIN MAINTAINCE DOSE Initial therapy of Digoxin is usually started at 0.125 to 0.375 mg/day

49. ANTI ARRHYTHMIC

50. ANTI ARRHYTHMIC Antiarrhythmic agents prolong the action potential and suppress the calcium inward current and calcium-dependent action potentials. Clinical use Atrial fibrillation Ventricular tachycardia

51. Examples of Anti Arrhythmic Drugs Generic Name Trade Name Dosage Amiodarone Cordarone 100/200 mg PO 150mg/3ml (IV) Lidocaine Xylocaine 1-2 gm IV Quinidine Gluconate Quinidine Sulfate 200/300 mg /PO

52. Nursing Care Stress the importance of taking drug exactly as prescribed. Teach patient to take his pulse before each dose. Tell him to notify physician if pulse is irregular or below 60 beats/min. Instruct patient to avoid hazardous activities. Tell patient to limit fluid and salt intake if his prescribed drug causes fluid retention.

53. Side effects and Contraindication Contraindicated in patients hypersensitivity to drug. Many antiarrhythmics are contraindicated or require cautious use in patient with Cardiogenic shock Second or third degree heart blocks.

54. NITRATES

55. NITRATES Works by relaxation of smooth muscle, producing a vasodilator effect on the peripheral veins and arteries with more prominent effects on the veins. Primarily reduces cardiac oxygen demand by decreasing preload (left ventricular end-diastolic pressure); dilates coronary arteries and improves collateral flow to ischemic regions.

56. Clinical use Angina prophylaxis Congestive heart failure Hypertension related to surgery or hypertensive crisis

57. Examples of Nitrates Generic Name Trade Name Dosage Isosorbide mononitrates Elantan 20/40 mg Ismo/monis 20/40 mg Monis XR 60 mg

58. Generic name Trade name Dosage Isosorbide Dinitrate Isocord-D5 5 mg Isoket 20 mg Isordil 10 mg Glycerine Trinitrates Sustac 2-6 to 6-4 mg Nitromint 2-6/ 12-8 mg Examples of Nitrates

59. Nursing Care Monitor vital signs every hourly. Monitor for effectiveness of prescribed drug. Observe for adverse reactions. Warn patient not to discontinue drug abruptly. Advise patient to stand slowly to prevent dizziness. Instruct patient go the ER if 3 tablets taken 5 mints apart don’t relieve pain

60. Side effects and Contraindication Headache, flushing, and dizziness are the most common side effects, Nitrate is contraindicated in hypertrophic obstructive cardiomyopathy, aortic stenosis, constrictive pericarditis, mitral stenosis or closed-angle glaucoma.

61. ANTI PLATELETS

62. Anti Platelets These drugs appear to impede clotting by blocking prostaglandin synthesis, which prevent formation of platelets-aggregation substance thromboxane A2.

63. Clinical use Heart Attack and Stroke Acute Coronary Syndrome Peripheral Artery Disease Atrial Fibrillation

64. Examples for Anti platelet Generic Name Trade Name Dosage Acetyl salicylate Ascard 75/150 mg Clopidogrel Lowplat/Plavix 75 mg Dipyridamole Persantin 25/100 mg

65. Nursing Care Be alert for adverse reactions i.e. headache, bleeding, dizziness. Give oral anti-platelets with food, milk, antacid or large glass of water to reduce adverse GI reactions. Hold dose and notify doctor if bleeding or adverse GI reactions develop. Advise patient to avoid alcohol consumption. Encourage use of soft toothbrush.

66. ANTI COGULANT

67. Anti Coagulants An anticoagulant is a substance that prevents coagulation. It stops blood from clotting.

68. Clinical use DVT Deep vein thrombosis Pulmonary embolism Myocardial infarction Stroke Congestive heart failure

69. Examples of Anti-cogulant Generic Name Trade Name Dosage Anti dote Warfarin Coumadin According to INR Vitamin K Heparin Sodium Heparin 25000 Unit/5ml Protamine Sulphate

70. Nursing Care Asses patient underlying condition before therapy. Draw blood to establish baseline coagulation values before therapy. If patient on heparin infusion than monitor PT,APTT every 6 hourly. During intermittent I.V therapy, always draw blood 30 minutes before next dose to avoid falsely elevated. Monitor INR regularly if patient on Warfarin. Evaluate patient and family knowledge about drug therapy.

71. LIPID LOWERING AGENTS (STATINS)

72. Mode Of Action Inhibit cholesterol synthesis in the liver by blocking the action of cholesterol producing enzyme HMG-CoA reductase  .Thus lowering the amount of cholesterol circulation in the blood.

73. S# GENERIC NAME TRADE NAME DOSAGE 1. Simvastatin Zocor / Survive 10 / 20 mg 2. Rosuvastatin Monitor / X-plendid / Rolip / Rosubar 5 / 10 /20 mg 3. Ezetimibe Ezita / Ezebrix 10 mg 4. Atorvastatin Lipiget / Lipitor / Atorva / Sensicor / Lipotrim / Snolip / Descol/Orva 10 / 20 mg

74. Indication Hypercholesterolemia Atherosclerosis Coronary Artery Disease Myocardial Infarction

75. Side/Adverse Effects Muscle pain Liver damage Headache Insomnia Mental confusion Tingling or loss of sensation Increased blood sugar or type 2 diabetes

76. Conti…. Rash Dizziness Fatigue GI upset Abdominal cramp Flatulence Memory loss Drowsiness Myalgia (Pain in muscle)

77. Contraindication Pregnancy Breastfeeding Active Liver Disease

78. Nursing Care Obtain complete health history including allergies. Assess baseline liver function tests, lipid studies, and pregnancy test in women of child bearing age. Assess for history of liver disease and muscle disease. Monitor for concurrent alcohol use. (Alcohol may affect liver function). Monitor blood cholesterol and triglyceride levels at intervals during therapy. Monitor CPK (creatinine phosphokinase) levels if muscle tenderness or weakness develops. Instruct patient to take low saturated fat, low cholesterol diet.