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CV Part II Flashcards

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1
Q

Cholesterol Reducing Agents-HMG-CoA Reductase Inhibitors“Statins”

A

MOA: decrease the rate of cholesterol production by inhibiting HMG-CoA reductase. The liver requires HMG-CoA reductase to produce cholesterol

Used to:
Reduce total cholesterol
Reduce LDL & VLDL
Increase HDL

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2
Q

Statins- AE’s/warnings

A

Adverse Effects:
Myopathy: report muscle pain or tenderness, check CPK levels may increase
Rhabdomyolysis (rare)
Hepatotoxicity: check liver function tests may increase

Warnings:
Category X for pregnancy
No statins for pregnant women, alcoholic or viral hepatitis

Statins-most effective when taken at bedtime

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3
Q

Cholesterol Reducing Agents–Bile Acid Sequestrants

A

MOA: form insoluble complexes with the bile acids in the GI tract, which causes bile acids to be excreted, thereby lowering the cholesterol level

Uses: when dietary management does not lower cholesterol & the LDL cholesterol is high. Can be used with statins.

Common drugs:

  • cholestyramine (Questran)
  • colesevelam (Welchol)
  • colestipol (Colestid)
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4
Q

Bile Acid Sequestrants- AE’s/Nursing implications

A

Adverse Effects:

  • Constipation
  • Heartburn, nausea, belching, bloating

Nursing Implications:

  • Assess for GI distress, bowel habits
  • Can bind with other drugs (advise to take other meds 1 hour before or 4 hours after)
  • Powder forms must be taken with a liquid, mixed thoroughly, and never taken dry
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5
Q

Cholesterol Reducing Agents-Fibric Acid DerivativesFibrates

A

MOA: activate lipase, which breaks down cholesterol

  • Suppresses the release of free fatty acids from adipose tissue
  • Inhibit the synthesis of triglycerides in the liver
  • increase secretion of cholesterol in the bile

Uses:

  • Decrease triglyceride levels
  • May raise HDLs (by as much as 25%) and lower LDLs

Common drugs:

  • gemfibrozil (Lopid)
  • fenofibrate (Tricor)
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6
Q

Cholesterol Reducing Agents-Fibric Acid DerivativesFibrates

A

Adverse effects:

  • GI: nausea, diarrhea, abdominal discomfort
  • Increased risk of gallstones
  • Enhances action of oral anticoagulants – bleeding tendencies
  • Enhances effects of statins – myopathy, rhabdomyolysis

Warnings:
- Contraindicated for patients with liver/kidney disease or gallbladder disease

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7
Q

Cholesterol Reducing Agents-Niacin (Nicotinic Acid)

A
  • Vitamin B3
  • Lipid-lowering properties require much higher doses than when used as a vitamin
  • Effective, inexpensive, often used in combination with other lipid-lowering drugs
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8
Q

Cholesterol Reducing Agents-Niacin (Nicotinic Acid)

A

MOA: thought to work in the liver and adipose tissue to inhibit the synthesis of triglycerides and VLDL, which can lower LDL

Uses:
- DOC for patients at risk of pancreatitis and have elevated triglycerides
Lowering LDL & triglycerides

Adverse effects:

  • Flushing, itching (minimize flushing w/aspirin or NSAIDs 30 minutes prior, take with meals)
  • GI distress, hepatotoxicity (jaundice), hyperglycemia, gout
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9
Q

Cholesterol Reducing Agents-Cholesterol Absorption Inhibitorezetimibe (Zetia)

A

MOA: Inhibits absorption of cholesterol from the small intestine, results in reduced total cholesterol, LDL, triglycerides levels, also increases HDL levels

Drug: ezetimibe (Zetia)
- Works well when taken with a statin drug

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10
Q

Vasodilators: Nitrates

A

Actions:

  • Decrease oxygen demand
  • Decrease preload by dilating veins
  • Decrease afterload by dilating systemic arteries

Uses:

  • First line treatment for immediate & long term prevention of angina; chronic stable angina
  • Chest pain from lack of oxygenated blood supply to the heart
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11
Q

Nitrates- AE’s/Warnings

A

Adverse effects:

  • CNS – headaches (vasodilation of blood vessels in brain), syncope, flushed feeling, dizziness, weakness
  • CV – hypotension or orthostatic hypotension; reflex tachycardia

Warnings:

  • Avoid ETOH while using
  • Careful when taking other medications that can decrease BP
  • Contraindicated: phosphodiesterase type 5 inhibitors (sildenafil [Viagra])
  • Can cause life-threatening hypotension
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12
Q

Nitrates: Administration

A

Administration routes: sublingual and spray

  • May take up to 3 SL tablets, 5 minutes apart, if no relief after 15 minutes, call 911
  • Tablets are in dark colored bottle – have to be away from light, heat, and moisture
  • Teach patient to carry with them at all times
  • Tablets should be replaced every 3 to 6 months after bottle is opened
  • Spray should be applied directly to the oral mucosa (do not inhale)
  • Tell patient they will experience a tingling feeling under their tongue
  • Sit or lie down before taking to prevent hypotension and syncope
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13
Q

Nitrates: Nursing Implications

A

Administration routes: patches & ointment (transdermal patch; Nitro-dur; Minitran; Nitro-paste)

  • Use a hairless area of the upper arms or body
  • Rotate sites
  • Remove the old patch for 10-12 hours a day & clean off old ointment
  • Use gloves to avoid getting ointment on hands
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14
Q

Nitrates: Nursing Implications

A

Administration routes: oral (Isosorbide)

  • Usually sustained released (tolerance can develop; nitrate-free period recommended)
  • Prophylaxis – not used to manage an acute angina attack; only used to prevent future attacks

Do not withdraw drug abruptly; doing so may precipitate acute angina

Geriatric patients are more susceptible of developing postural hypotension

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15
Q

Immediate treatment of an M.I

A 
“MONA” or “MONA B”
Morphine 
- Helps alleviate chest pain
- Promotes vasodilation 
- Results in lowering cardiac oxygen demand

Oxygen
- Increase oxygen delivery to ischemic myocardium

Nitroglycerin (NTG)

  • Reduces preload -> reduce oxygen demands
  • Inc collateral blood flow in the ischemic region of heart

Aspirin
- Suppresses platelet aggregation

Beta Blocker
- Reduces HR and contractility

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16
Q

Heart failure drugs- Digoxin

A

Positive Inotrope

Cardiac Glycoside

MOA: Influx of Ca++ in cells

  1. Increasing myocardial contractility (+ inotropic)
  2. Increase vagal activity: conduction slowed through AV node and refractory time (– chronotropic, – dromotropic)

“Digitalizing” dose to bring serum levels of drug to a therapeutic level quickly
Uses:
- Chronic a-fib
- 2nd line therapy for HF

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17
Q

Digoxin

A

Adverse effects:
- Cardiac dysrhythmias (especially w/ hypokalemia)
- Non-cardiac effects:
Anorexia (early sign)
Nausea, vomiting
Visual disturbances – blurred vision, yellow vision, halo’s

Potassium – hypokalemia can lead to digoxin toxicity
- Especially if patient is taking a potassium-depleting diuretic

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18
Q

Digoxin: Nursing Implications

A

Predispose to toxicity: hypokalemia, renal dysfunction

Very narrow therapeutic index (0.5 to 2 ng/mL)

Check apical pulse for one minute before administering digoxin
- Adult: 60 or below – hold digoxin, report signs of digoxin toxicity

Antidote:
- Digoxin immune Fab (Digibind, Digifab)

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19
Q

Anticoagulants

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A

Prevent formation of new clots & extension of clots already present by inhibiting certain clotting factors

Have no direct effect on formed clots

Used prophylactically to prevent

  • Clot formation (thrombus)
  • An embolus (dislodged clot)

Risks: bleeding

Dx: coagulation panel: clotting time (measures how long it takes blood to clot)

20
Q

Anticoagulants: Heparin

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A

Action: Short-term use; acts on thrombin (prolong clotting time). Prevents clot formation, but does not break down clots

Uses:

  • Short-term or emergency treatment (MI, DVT) to prevent further thrombus formation/embolization
  • Prevention of DVT/PE

Adverse effects:

  • Bleeding
  • Heparin-induced thrombocytopenia (HIT)*** (an antibody-mediated reaction characterized by a profound decrease in platelets; potentially life-threatening and can cause thrombosis)
  • Allergic reactions
21
Q

Anticoagulants: Heparin

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A

Nursing: Monitor aPTT (activated partial thromboplastin time)

When heparin is used therapeutically (for treatment), measurement of aPTT (usually every 6 hours) is necessary.
- aPTT normally 40 seconds Heparin: 1.5-2.5x normal (~ 80 seconds)

Antidote: protamine sulfate

Prophylaxis: 5,000 units subcutaneously two or three times a day; does not need to be monitored when used for prophylaxis

22
Q

Anticoagulants: HeparinNursing Implications

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A

Assess for bleeding in urine, stool, venipuncture sites, nose, gums, wounds/incisions

Know proper application for SQ or IV route; rotate sites for SQ & do not rub the injection site; use the abdomen for SQ route

Monitor aPTT which should be 1.5 to 2.5 times the normal range for a therapeutic effect

Monitor CBC esp. platelets

23
Q

Low Molecular Weight Heparin (LMWH): enoxaparin (Lovenox)

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A

Action: similar to heparin, inhibit clotting factors specific to factor Xa

  • Synthetic smaller molecular structure
  • More predictable anticoagulant response

Advantage: Do not need to monitor aPTT, SQ injections at home
Drugs:
- enoxaparin (Lovenox)
- dalteparin (Fragmin)

Uses:

  • Prevention and management of DVT/PE
  • Prevention of ischemic complications (unstable angina to prevent MI)

Adverse effects:
- Bleeding – can use protamine sulfate as antidote

24
Q

Anticoagulants (oral): warfarin (Coumadin)

Study These Flashcards
A

Action: inhibit vitamin K–dependent clotting factors II, VII, IX, and X. Prevents clotting by prolonging prothrombin time/INR. Takes approximately 3-5 days for full effect.

Uses:

  • Slow down or prevent the extension of a blood clot; will not dissolve existing clot
  • Long-term prevention/management of: DVT/PE, embolization associated with atrial fibrillation, prosthetic heart valves

Adverse effects: bleeding (hematuria, epistaxis, ecchymosis, melena, black/tarry stools, bleeding gums)

25
Anticoagulants: warfarin (Coumadin)
Careful monitoring of PT (prothrombin time), INR normal 0.8-1.1 (international normalized ratio). - Target INR = 2.0 to 3.0 (on Coumadin) Side effects: bleeding (hematuria, hematoma, epistaxis, ecchymosis) Several drug interactions Dietary considerations consistent foods with vitamin K: leafy green vegetables – kale, spinach, collard green Antidote: vitamin K Transition from IV heparin to oral warfarin: - Give together for 5 days to achieve therapeutic INR
26
Anticoagulants: Direct Thrombin Inhibitors
MOA: interfere w/ blood clotting mechanisms by blocking the direct activity of thrombin. Drugs: - argatroban (Argatroban) IV: used for active HIT - dabigatran (Pradaxa): used for prevention of strokes and embolism in patients with atrial fibrillation Adverse effects: bleeding, GI bleeding
27
Anticoagulants: Factor Xa Inhibitors
MOA: selectively inhibit factor Xa Drugs: - fondaparinux (Arixtra) SQ - rivaroxaban (Xarelto) - apixaban (Eliquis) Uses: - Prevention and treatment of DVT - Prevention of strokes in patients with atrial fibrillation Adverse effects: Bleeding
28
Antiplatelet Drugs: aspirin (ASA)
Antiplatelets: work to prevent platelet adhesion at the site of blood vessel injury MOA: suppresses platelet aggregation and results in reducing risk of arterial thrombosis Uses: prevent thrombosis in arteries (stroke or MI prophylaxis) Dose: 81 mg (baby aspirin) – 325 mg Side effects: bleeding, stomach ulcers, tinnitus Stop at least 7 days before surgery Contraindicated for flulike symptoms in children and teenagers - Reye’s syndrome
29
Antiplatelet Drugs: clopidogrel (Plavix)
MOA: block adenosine diphosphate (ADP) receptors on the platelet surface and thereby prevent platelet aggregation Oral use Use: prevent MI, stroke Drugs: - clopidogrel (Plavix) - prasugrel (Effient) Adverse effects: - Bleeding - Thrombotic thrombocytopenic purpura (TTP) – rare - Stop 7 days before surgery
30
Thrombolytic (Fibrinolytic) Drug: alteplase (t-PA)
Action: dissolve clot by converting plasminogen to plasmin, which breaks down (lyses) the thrombus. Uses: - Stroke caused by clots, MI, PE Drug: alteplase (t-PA): has a very short half-life (5 minutes) Side effects: bleeding, dysrhythmias, nausea/vomiting, neurological problems, increased tendency to bleed with drugs that alter coagulation or platelets
31
Sinus Dysrthymias
impulse originates in SA node. Only significant if severe or prolonged
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Atrial dysrhythmias
ectopic sites replace SA node as pacemaker
33
Ventricular dysrhythmias
impulse forms in ventricles, potentially most serious class of dysrhythmias – need immediate attention, can impair pumping ability of heart
34
Class Ia Sodium Channel Blockers
Inhibit sodium channels Ia: quinidine, procainamide Action: slow atrial and ventricular conduction Used for atrial fibrillation, premature atrial/ventricular contractions Side effects: - Cinchonism (tinnitus, headache, nausea, vertigo), thrombocytopenia - Cardiotoxic – hypotension, high doses – heart block
35
Class Ib Sodium Channel Blockers
Inhibit sodium channels Ib: lidocaine, phenytoin Action: decrease action potential duration, reduces automaticity Use: ventricular dysrhythmias, slows spontaneous firing or ectopic ventricular rhythm Side effects: drowsiness, dizziness, hypotension, bradycardia CNS toxic effects: twitching, seizures, confusion
36
Other Uses: Lidocaine
Other uses: - Used as patch for neuropathic pain - Anesthetize the throat (spray) for procedures - Lidocaine with epinephrine (anesthetize prior to biopsies, suturing, etc) Used ONLY as local anesthetic; never for other uses because of epinephrine Nursing Care - If used as an dysrhythmic drug, must be on telemetry (ECG) - If used for pain, monitor for pain relief - If used to anesthetize the throat, must check gag reflex. Can’t give fluids or food until gag reflex returns How do you check?
37
Class Ic Sodium Channel Blockers
Inhibit sodium channels (more pronounced effect); decrease conduction in atrial, AV node, and ventricles Ic: flecainide (Tambocor) Use: sustained ventricular dysrhythmias, acute atrial fibrillation Side effects: dizziness, visual disturbances, and dyspnea Black box warning: proarrhythmic, increased mortality in patients with non-life-threatening ventricular arrhythmias
38
Class II Beta-Adrenergic Blockers
Reduce or block sympathetic nervous system stimulation, thus reducing transmission of impulses in the heart’s conduction system II: Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor) Use: supraventricular and ventricular dysrhythmias Side effects: bradycardia, dizziness, fatigue, hypotension, heart block, bronchospasm
39
Class III Potassium Channel Blockers
Slow depolarization/prolong refractory period III: amiodarone (Cordarone) Use: life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter that is resistant to other drugs Many possible side effects
40
Side Effects: Amiodarone
Side effects: - Corneal microdeposits (visual halos, photophobia, and dry eyes) - Pulmonary toxicity (fatigue, shortness of breath, cough, fibrosis) careful resp assessment - Thyroid toxicity: hypothyroidism or hyperthyroidism (monitor thyroid) - Hepatotoxicity (monitor LFTs, constipation, GI upset) - Dysrhythmias (monitor rhythm) - Hypotension, bradycardia (monitor BP & pulse closely) - Neurologic: abnormal gait Side effects may last for weeks to months after stopping
41
Patient Teaching: Amiodarone
- Check BP and pulse daily. Report a pulse < 60 - Use dark glasses to ease photophobia - Follow recommendation for regular ophthalmic exams, including fundoscopy and slit-lamp exam - Wear protective clothing and a barrier-type sunscreen that physically blocks penetration of skin by ultraviolet light (e.g., titanium oxide or zinc formulations) to prevent a photosensitivity reaction (erythema, pruritus); avoid exposure to sun and sunlamps. - Do not take with grapefruit juice
42
Class IV Calcium Channel Blockers
Inhibit calcium-dependent pathways, reduce automaticity of SA node and ectopic pacemakers, slow conduction IV: verapamil (Calan), diltiazem (Cardizem) Use: atrial dysrhythmias, atrial fibrillation Side effects: dizziness, hypotension, edema, heart block, constipation
43
Other Antidysrhythmic Drug
Drug: adenosine (Adenocard) - Use: converts paroxysmal supraventricular tachycardia to sinus rhythm MOA: - Slows automaticity in SA node; slows conduction - Very short half-life (<10 seconds) - Only administered as fast IV push - May cause asystole for a few seconds - Other side effects minimal
44
Antidysrhythmic Drugs: Adverse Effects
All antidysrhythmic drugs can cause dysrhythmias! ``` Ensure that the patient knows to notify health care provider of any worsening of dysrhythmia or toxic effects: - Hypersensitivity reactions Nausea/vomiting - Shortness of breath - Dizziness - Blurred vision - Chest pain - Edema - Many can lead to prolongation of the QT interval ```
45
Epinephrine
Adrenergic Agonist (catecholamine): alpha & beta receptors Uses: - Alpha1-mediated vasoconstriction – used to control superficial bleeding, elevate BP - Emergency drug for cardiac arrest – restore cardiac function - Activation of beta2 – bronchodilation of lungs - Treatment of choice for anaphylactic shock (epi-pen) Adverse effects: - Hypertensive crisis - Dysrhythmias - Angina - Hyperglycemia - Necrosis following extravasation
46
Dopamine
``` Adrenergic Agonist (catecholamine) - Receptor specificity includes dopamine, beta1 & alpha1 (high doses) ``` Uses: Shock - Increases cardiac output, improves tissue perfusion - Binds w/ dopamine receptors in kidneys, improve renal perfusion as seen w/ increased urine output Heart failure Inc. myocardial contractility, increase cardiac output Acute renal failure Low-dose dopamine binds w/ dopamine receptors in kidneys Inc. blood flow to kidneys, increase urine output
47
Dopamine- AE's
``` Adverse effects: Activation of the beta1 receptors - Tachycardia - Dysrhythmias - Anginal pain ``` Skin – high concentrations activate alpha1 receptors resulting in vasoconstriction - Administer into large vein to prevent the possibility of extravasation (central line administration) - Never give via peripheral IV – if extravasates, can result in necrosis

Pharm (2 decks)

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