Unit 10 cardivascular drugs

As per INC Syllabus lecture is prepared for the 2nd yr B Sc Nursing students.

1. Unit 10 Cardiovascular Drugs 5 Hrs. Mr. Dipti Y. Sorte, Associate Professor Himalayan College of Nursing, SRHU. Dehradun.

2. INC Syllabus Haematinics. Cardiotonics. Anti anginals. Antihypertensives & Vasodilators. Anti – arrhythmic. Plasma expanders. Coagulants & Anticoagulants. Antiplatelets & thrombolytics. Hypolipidemics. Composition, Action, Dosage, Route, Indications, Contraindications, Drug Interactions, Side effects, Adverse effects, Toxicity & Role of nurse

3. Haematinics Haematinics are the drugs which used to stimulate the formation of RBC’s These are used primarily in the treatment of Anemia. Eg. Iron.

4. Mechanism of action They act as supplement and replace depleted iron stores in the bone marrow to assist in the erythropoiesis (RBC production)

5. Drug example and doses S. No. Drugs Doses 1 Ferrous Fumarate Up to 600 mg daily. 2 Ferrous Sulphate 200mg TDS 3 Ferrous Gluconate 300mg as per requirement. 4 Iron Dextran 50mg/ml IM or IV

6. Indications / Uses To prevent and treat iron deficiency anemia. In children during rapid growth period. In pregnant and lactating mother. As dietary supplement of iron. Patient with post gastrectomy.

7. Contraindication / Precautions Patient with hemochromatosis. Hemolytic anemia. Patient with hemosiderosis. Hypersensitivity to the drug.

8. Adverse effects Nausea / vomiting. Constipation. GI distress. Dark stool. Local pain at I.V. site. Parental iron may causes, headache, Vomiting nausea and anaphylaxis. Temporarily stain teeth with liquid iron. Bronchospasm with parenteral iron.

9. Drug interactions Antacids, Tetracyclines, Cimetidine decrease absorption of oral iron preparations. Vit C (ascorbic acid) and chloramphenicol increases absorption of oral iron prepartions .

10. Nursing Responsibilities Nurse should administer drugs according to prescribed routes. Should check for constipation. Monitor patient CBC count, HB and plasma iron levels. Nurse should teach the patient to: Continue regular dosing schedule after missing dose. Drink at least 2 liters of liquid daily. Avoids antacids, caffeine products, dairy products, egg, whole grain breads for 1hour after taking oral iron preparations. Be aware that oral iron preparations may turn stool dark green or black.

11. Cardio-tonics (Cardiac – Glycosides)

12. Introduction These are the drugs which have a positive inotropic effect on heart. They increase the force of myocardial contraction without corresponding increase in O 2 consumption. They are used for the treatment of congestive heart failure.

13. Mechanism of Action Cardiac glycosides inhibit the enzyme Na-K-ATPase present in cardiac muscle. This cause an increase intracellular Na & Ca in heart muscle cells that leads to increase in force of contraction.

14. Drug examples & Doses: S No. Drugs Doses 1 Digoxin 0.125- 0.75 mg PO per day 2 Digitoxin 125-500 mcg once daily.

15. Indication / uses To treat congestive heart failure (commonly given with diuretics) To control the ventricular rate in arterial fibrillation, paroxysmal arterial tachycardia.

16. Contraindication/precautions Contraindicated in uncontrolled ventricular arrythmias, constrictive pericarditis, complete heart block. Risk of Digoxin toxicity is increases with hypercalcemia. Hypokalemia, Hypomagnesemia, renal failure. Elderly patients have more risk of toxicity because they are more sensitive to drug’s effects, anorexia may be an early warning sign of toxicity.

17. Adverse Effects Bradycardia. Weakness. Fatigue. Nausea, vomiting. May cause digoxin toxicity such as anorexia, nausea, vomiting, visual disturbance, confusion, bradycardia, heart block, premature ventricular contractions.

18. Drug interactions. With potassium wasting diuretics because they may cause potassium loss increase the risk of digoxin toxicity. Antacids, aminoglycosides metoclopramide decrease GI absorption of digoxin.

19. Nursing Responsibilities Before giving digoxin, assess apical pulse, sr. drug and electrolyte level of patient with hold drug and notify physician if pulse rate is bellow 60 beat per min or minimum. The nurse should keep a watch a sign and symptoms of toxicity. ( eg. Anorexia, nausea, vomiting, palpitation ) and if occurs further administration of drugs should stop if pulse rate increases to more than 120 it may indicate toxicity. Nurse should know that dose must be reduced in patients with renal failure.

20. Teach patient to: Take prescribed drug properly. Consult physician before discontinuing drug. Count his pulse before taking each dose. Assess signs and symptoms of digoxin toxicity and heart failure.

21. Anti anginals (Drug used in Angina) Angina pectoris is the chest pain due to anoxia of heart muscles generally due to obstruction or spasm in coronary artery. The drugs used in angina pectoris prevent terminate attacks of angina pectoris are called antianginal drugs. These drugs are mainly classified as: Nitrates . Beta – Blockers. (already described) Calcium channel blockers. (already described)

22. Nitrates Nitrates are the drugs which are vasodilator effects thus used in angina pectoris.

23. Mechanism of action Nitrates release NO (Free radical nitric oxide) which is powerful muscle relaxant. So they produce vasodilation, decreased preload and afterload, reduce myocardial oxygen consumption.

24. Drug example and doses S. No. Drugs Doses 1 Isosorbide Mononitrate 10-20mg orally twice daily. 2 Isosorbide dinitrate 30-480mg orally in divided dose (5-10mg sublingually) 3 Nitroglycerine 0.3mg sublingually.

25. Indications / Uses Acute angina. Prevention of expected and chronic anginal attacks. Long term prevention of angina. Nitroglycerine is also administer I.V to treat surgical hypertension.

26. Adverse effects Headache is most common. Orthostatic hypertension. Flushing. Nausea, vomiting. Dizziness. Tachycardia. Palpitations.

27. Contraindication / Precautions Hypersensitivity to nitrates. Severe anemia. Orthostatic hypertension. Early MI. Increased ICP. Use cautiously in patients with hypotension.

28. Drug interactions Antihypertensives, and sildenafil, tadalafil may increase hypotension effects.

29. Nursing Responsibilities Nurse should teach the patient about proper use and storage of nitroglycerine sublingual tablets. Instruct the patient to sit down and take the drug at the first sign of an acute angina attack. Teach the patient to repeat the dose if no relief occurs in 5minutes and take emergency medical help if no relief occurs after taking 3tablets in 15mins. Inform patient that headache is common side effect of nitrates and typically subsides with continued therapy. Advise patient to avoid beverages. Advise the patient that sublingual tablets may be taken at the onset of activities known to cause angina such as sexual activity.

30. Antihypertensives Hypertension is a disease characterized by abnormally high blood pressure.

31. Classification of Antihypertensive drugs Beta blockers . Eg. Atenolol, timolol, metoprolol, propanol. Calcium channel blockers . Eg. Nifedipine, Amlodipine, verapamil, diltiazem. ACE inhibitors . Eg. Captopril, Ramipril, lisinopril, enalpril . Diuretics . Eg. Furosemide, Amiloride, Spironolactone. Vasodilators . Eg. Hydralazine, minoxidil, diazoxide. Angiotensin antagonist . Eg. Losartan.

32. Mechanism of action (Beta – Adrenergic Blockers). Beta adrenergic receptors causes vasoconstriction in blood vessels. Thus these drugs prevents stimulation of beta – adrenergic receptors of sympathetic nervous system, thereby decreasing cardiac output.

33. Drug example and doses S. No. Drugs Doses 1 Atenolol 50-100mgBD orally 2 Timolol 10-20mg orally twice a day. 3 Propranolol 20-80 mg orally. 4 Betaxolol 10mg orally BD. 5 Metoprolol 50mg every 4-6hrly.

34. Indications / Uses To treat mild hypertension. Angina pectoris.

35. Contraindication / Precautions Contraindicated in patients with asthma, sinus bradycardia, cardiogenic shock, second or third degree heart block. Use these drugs with cautiously in pregnant and breast feeding women and in those with impaired hepatic function.

36. Adverse effects Orthostatic hypertension. Fatigue. Bradycardia. Nausea, vomiting.

37. Drug interactions These drugs cause additive hypotension when used concurrently with alcohol and antihypertensives or calcium channel blockers.

38. Nursing Responsibilities Do not discontinue drug abruptly. Administer propranolol constituently with food, food may increase absorption.

39. Mechanism of action (Calcium channel blockers). They are chemically different but pharmacologically similar drugs. They have commen mechanism of action. They block the entry of Ca⁺⁺ ions into the smooth and cardiac muscle cells that leads to decreased intracellular Ca⁺⁺ ions there by smooth muscle relaxation leads to vasodilation.

40. Graphically: They block the entry of Ca⁺⁺ ions into the smooth and cardiac muscle cells. Decrease intracellular Ca⁺⁺ ions. Smooth muscle relaxation. Vasodilation.

41. Drug example and doses S. No. Drugs Doses 1 Amlodipine 5-10mg OD 2 Verapamil. 80mg TDS orally. 3 Nifedipine 30-60mg orally OD 4 Diltiazem 80-100 mg orally. 5 Perhexiline. 200-400 mg orally in divided dose.

42. Indications / Uses To treat the mild hypertension. Angina pectoris.

43. Contraindication / Precautions Contraindicated in patient with asthma, sinus bradycardia, cardiogenic shock, second and third heart block. Use these drugs cautiously pregnant and breast feeding women and in those with impaired hepatic function.

44. Adverse effects Dizziness. Headache. Flushing. AV blocks. Edema. Nausea.

45. Drug interactions They may increase risk digoxin toxicity when used with digoxin. May cause heart block when used with other calcium channel blocker.

46. Nursing Responsibilities Nurse should know that nifedipine may be given sublingually. Warn patient not to stop drug abruptly.

47. Mechanism of action (ACE inhibitors). These drugs are also used in the treatment of hypertension, It acts by inhibiting angiotensin converting enzyme and prevents the conservation of angiotensin – I & angiotensin – II and preventing peripheral vasoconstriction.

48. Drug example and doses S. No. Drugs Doses 1 Captopril 25mg TDS 2 Enalapril 2.5 mg daily, 40 mg daily in divided dose. 3 Lisinopril 5-10mg daily 4 Ramipril 2.5mg – 5mg daily.

49. Indications / Uses To treat mild hypertension. Ramipril also used to treat heart failure after myocardial infarction. To reduce the risk of MI and death from cardiovascular causes.

50. Adverse effects Dizziness. Fainting. Palpitations. Proteinuria. Light headedness. Tachycardia. Rash.

51. Contraindication / Precautions Contraindicated in patient with asthma, sinus bradycardia, cardiogenic shock, second and third heart block. Use these drugs cautiously pregnant and lactating mother and in those with impaired hepatic function.

52. Drug interactions Antihypertensives, diuretics may increase hypertensive effects. NSAID’S may decrease it effects. They may increase hypoglycemic effects if used with insulin and oral antidiabetics. ACE inhibiters may increase diuretic effects and increase the risk of hyperkalemia with concurrent use with potassium sparing diuretics.

53. Nursing Responsibilities Antihypertensives captopril on empty stomach. Teach patient to report light headedness and avoid sudden position changes to minimize orthostatic hypertension.

54. Vasodilators (Peripheral vasodilator) These are the drugs which are also vasodilator effects thus reduce blood pressure.

55. Mechanism of action They are potent direct relaxant of vascular smooth muscle and reduce both systolic and diastolic B.P.

56. Drug example and doses S. No. Drugs Doses 1 Hydralazine 10-20mg slowly I.V. injection. 25-200mg daily orally divided doses. 2 Minoxidil 5-50 mg daily orally.

57. Indications / Uses Used in moderate to severe hypertension. To treat severe and essential hypertension.

58. Contraindication / Precautions Contraindicated in patient with asthma, sinus bradycardia, Cardiac failure. Use these drugs cautiously pregnant and breast feeding women and in those with impaired hepatic function.

59. Adverse effects Fluid retention. Orthostatic hypertension. Tachycardia. Severe hypertension. (with IV doses) Minoxidil also can causes excessive hair growth.

60. Drug interactions Sildenafil, hypertensive drugs may potentiate antihypertensive effects of nitroprusside sodium.

61. Nursing Responsibilities Nurse should closely monitor patient for fluid volume excess, monitor patients blood pressure every 5 mins at start of infusion and at least every 15mins during infusion. Assess weight of patient daily and record intake and output. Advise the patient taking minioxidil that excessive hair growth is likely to occur 3to6 months after therapy begins. Reassure the patient that extra growth should be disappear 1to 6 month after therapy ends.

62. Antiarrhythmics Arrhythmias means abnormal cardiac rhythm. It occur due to an abnormal excitability of a part of cardiac muscle or due to an abnormality in conduction system of heart. So these drugs are used for arrhythmia.

63. Mechanism of action These drugs block Na⁺ (Sodium) channel of cell membranes and reduces excitability of cardiac muscle and slows the conduction in heart. Verapamil drug block Ca⁺ channels and prevents accumulation of Ca⁺⁺ ion in myocardial cells and shows the conduction of AV node. Beta blockers also blockage beta adrenoreceptor at heart and reduced excitability of the heart.

64. Drug example and doses S. No Drugs Doses 1 Quinidine 200-300 mg 3-4 times daily orally. 2 Lidocaine 1mg/kg IV/2% injection 3 Lignocaine 100mg IV 4 Verapamil 80mg thrice daily 5 Propranolol 20-80 mg daily 6 Atenolol 50-100 mg twice daily. 7 Bretylium 5-10mg/kg loading dose. 8 Ibutilide 1mg I.V. given over 10minutes

65. Indications / Uses Ventricular arrhythmias. Ventricular tachycardia. Lidocaine used to treat life threatening ventricular arrhythmias. To treat sinus tachycardia ( Propranol ). Also used to treat hypertension.

66. Contraindication / Precautions Persistent severe bradycardia. Cardiac failure. Hypersensitivity to these drugs. Cardiogenic shock. Complete atrioventricular block. 2 nd & 3 rd degree heart block.

67. Adverse effects Hypotension. Heart failure. Dizziness. Fatigue. Nausea / Vomiting.

68. Drug interactions Simultaneously use with antihypertensives causes additive hypotension. Propranolol may increases hypotensive effects when used with NSAID’s indomethacin, Ca⁺ channel blockers. Concurrent use with digoxin may increased digoxin levels and worsen arrhythmias.

69. Nursing Responsibilities Before administering lidocaine always check label to prevent administering from containing epinephrine, or preservatives. After administering Bretylium keep patient supine and observe for hypotension. Teach patient to change position slowly if taking Bretylium. Administer IV bolus for ventricular arrhythmias followed by continuous IV infusion as ordered.

70. Assignment: Plasma Expanders & Coagulants

71. Plasma expanders

72. Mechanism of action

73. Drug example and doses S. No. Drugs Doses 1 2 3 4 5

74. Indications / Uses

75. Contraindication / Precautions

76. Adverse effects

77. Drug interactions

78. Nursing Responsibilities

79. Coagulants

80. Mechanism of action

81. Drug example and doses S. No. Drugs Doses 1 2 3 4 5

82. Indications / Uses

83. Contraindication / Precautions

84. Adverse effects

85. Drug interactions

86. Nursing Responsibilities

87. Anticoagulants These are the agents which inhibit the process of clotting, thus they are used to prevent unwanted thrombosis.

88. Mechanism of action They prevent extension and formation of clots by inhibiting factors in the clotting cascade.

89. Drug example and doses S. No. Drugs Doses 1 Heparin 5,000-10,000 unit by I.V. 2 Warfarin 20-30mg PO 3 Phenindione 200-300mg PO

90. Indications / Uses Thrombosis in deep veins. Unstable angina in PTCA. Open heart surgery. To treat and prevent thromboembolic disorders and ischemic complications.

91. Contraindication / Precautions Bleeding including thrombocytopenia. Peptic ulcer disease. Recent surgery. Coagulation disorders.

92. Adverse effects Hyperlipidemia. Hemorrhages. Nausea. Insomnia. Thrombocytopenia. Pain at injection site. Constipation.

93. Drug interactions Chloramphenicol, metronidazole, androgens, quinidine, thrombolytics increase the risk of bleeding and may increase effects the risk of warfarin. Alcohol, barbiturates, estrogen containing hormonal contraceptives and some food rich in vit. K increase the risk of clotting and may decrease the effects of warfarin. Prolonged or regular use with other drugs that effect platelet function such as aspirin, NSAID’s may increase the risk bleeding.

94. Nursing Responsibilities Don’t give heparin by IM route. Asses the early signs of unusual bleeding. Nurse should minimize venipunctures and injections, apply pressure to all puncture sites. Monitor hemoglobin and clotting factor and platelet level. Nurse should teach the patient to: Not to take drugs or vitamins, including over the counter or herbal products, without medical approval. Inform physician and dentist of therapy regimens before undergoing any medical treatment.

95. Antiplatelets These are the drugs which interfere with platelet function and are useful in the prophylaxis of thrombosis disorders.

96. Mechanism of action They interfere with platelets function and inhibits platelets clumping.

97. Drug example and doses S. No. Drugs Doses 1 Aspirin 2 Clopidogrel 3 Dipyridamole 4 Ticlopidine.

98. Indications / Uses Used as prophylaxis for thromboembolic events. Aspirin used in patients with previous MI or unstable angina to reduce the risk of death from these conditions and in men to reduce the risk of transient ischemic stroke. Clopidogrel is use to reduce a cardiovascular events. Myocardial infarction.

99. Contraindication / Precautions Active bleeding. Coagulation disorder. Ulcer disorder. Recent surgery. Cancer. Thrombocytopenia.

100. Adverse effects Bleeding/Hemorrhage. Neutropenia. Abnormal stool. Rash. Pain in injection site. Pancytopenia. Dizziness. Headache. Nausea.

101. Drug interactions Prolonged or regular use with other drugs that effect platelet function such as aspirin, NSAID’s may increase the risk of bleeding.

102. Nursing Responsibilities Monitor patient for bruising or bleeding. Assess the early signs of unusual bleeding. Nurse should minimize venipuncture and injections, apply pressure to all puncture sites. Monitor hemoglobin and clotting factor and platelets level.

103. Thrombolytics (Fibrinolytics) These drugs are used to lyse (Dissolve) thrombus or clot.

104. Mechanism of action These agents activate plasminogen to form plasmin thus dissolve clot or thrombosis. (Plasminogen Plasma Clot dissolution).