Module 3 (2)

ACE Inhibitors=

" prils"

Digitalis Glycosides action:

force of contraction ( + inotropic) decrease heart rate ( - chronotropic )

What are the adverse effects of Milrinone (Primacor)

headache nausea vomiting The most serious AE is ventricular dysrhythmia. The patient's ECG should be monitored continuously during the infusion of the drug. BP is also continuously monitored during the infusion to prevent hypotension.

Common adverse effects of Heparin

hematoma formation, bleeding at injection site

Digitalis Glycosides therefore, improves ______ - less systematic and pulmonary _____ - ____ heart size, better perfusion to kidneys= ___ edema

improves circulation systematic and pulmonary congestion decrease heart size, perfusion to kidneys = decreased edema

Serious adverse effects of fibrinolytic agents

increased risk of bleeding, allergic reactions

Platelet aggregation inhbitor cilostazol Pletal Action: vasodilation & platelet aggregation _____________

inhibition

Hemorrheologic Agents: pentoxifylline (Trental) used to treat

intermittent claudication

Pain secondary to lack of oxygen to the muscles during exercise

intermittent claudication

Platelet Aggregation Inhibitor cilostazol (Pletal) used to treat

intermittent claudication

Drug Class: Phosphodiesterase Inhibitors

milrinone (Primacor)

Arterial disorders are subdivided into those that result from: 1. Arterial ___________ & occlusion= *obstructive* 2. Those caused by arterial spasm= *vasospastic* ________________

narrowing, Raynaud's

Common adverse effects of phosphodiesterase inhibitors

nausea, vomiting, abdominal discomfort

Drug Class: Natriuretic Peptides

nesiritide (Natrecor)

This calcium channel blockers has had the greatest success in reducing the frequency of Raynaud's vasospastic attacks in about two thirds of patients

nifedipine

Drug therapy for Raynaud's -Ca+ channel blockers _____________ is DOC -Adrenergic antagonists (not too successful- many side effects) -ACE _____________ -Direct vasodilators _________________ (for extremities)

nifedipine, inhibitors, nitroglycerin

For more than 50 years ____________ a direct vasodilator has been applied as an ointment base to the hands of patients with Raynaud's disease

nitroglycerin

What are the pharmacokinetics time frames for Metoprolol

onset: 10-15 mins peak: 1.5-4 hrs duration: 6 hrs

What are the pharmacokinetics time frames for Milrinone (Primacor)

onset: 2-10 mins peak: 10 mins duration: variable

What is the pharmacokinetics time frames for digoxin

onset: 30-60 min po; 5-30 min IV peak: 4-6 hrs po; 1.5 hrs IV duration: 6-8 days

PVD can have arterial or venous:

origin

Arteriosclerosis obliterans S & S -_______ -__________ -____________ -tightness -weakness -intermittent claudication

pain, aching, cramping

Side effects to report with pentoxifylline (Trental): -chest ___________ -______________ -SOB

pain, dysrhythmias

Direct vasodilator: relaxes smooth muscle, vasodilates cerebral and coronary blood vessels -also an antidysrhythmic

papaverine hydrochloride pavagen TD

Hemorrheologic agents _______________________ Trental *NOT AN ANTICOAGULANT*

pentoxifylline

Used as an adjunct treatment of intermittent claudication

pentoxifylline

Hemorrheologic Agents - Drug:

pentoxifylline (Trental)

Are the only agents approved by the US Food and drug administration that are specifically indicated for the treatment of intermittent claudication cause by chronic occlusive arterial disease of the limbs

pentoxifylline, cilostazol

Antidote for heparin

protamine sulfate

Digibind is ___ acting of ___ minutes

rapid acting, 30 min

Uses for beta-adrenergic blocking agents

reduce mortality associated with heart failure

Uses of thrombin inhibitor

reduce risk of stroke with non-valvular atrial fibrillation

Serious adverse effects of aspirin

Neutropenia, agranulocytosis, bleeding -With clopidogrel (Plavix): thrombotic thrombocytopenic purpura (TTP)

What is Milrinone (Primacor) used for?

Of the 2 phosphodiesterase inhibitors available milrinone is preferred because it has a shorter half life & fewer side effects given only IV & is primarily used for the short term therapy of advanced HF It has a rapid onset of action Immediate effects of milrinone include an increased force of myocardial contraction & an increase in cardiac output

Peripheral Vascular Disease Assessment of tissues

Oxygenation, Temperature, Peripheral pulses, and limb pain,

Tests for Warfarin

PT/INR

What signs during an assessment indicates increased blood perfusion to the lower extremities?

Pedal pulse amplification

Approved by the FDA to treat intermittent claudication due to chronic occlusive arterial disease of the limbs

Pentoxifylline (Trental)—hemorheologic agent; enhances RBC flexibility Cilostazol (Pletal)—platelet aggregation inhibitor

2 types of PVD

Peripheral arterial disease (PAD) Venous Disorders

Broad group of illnesses associated with blood vessels *outside of the heart* (peripheral vessels) -generally BV of the *arms & legs*

Peripheral vascular disease

What is Pharmacologic Class of Milrinone (Primacor

Phosphodiesterase inhibitor

Use of glycoprotein IIb/IIIa inhibitors

Prevent clots forming from the debris often released during percutaneous coronary intervention (PCI) procedures

Uses for dalteparin (Fragmin) and enoxaparin (Lovenox)

Prevent deep vein thrombosis after hip replacements or abdominal surgery; prevent MIs, combined with aspirin

What are the contraindications of Milrinone (Primacor)

Previous hypersensitivity to the drug. Use w/caution in patients w/ preexisting dysrhythmias

Uses of aspirin

Primary prevention of MIs and stroke; prevent blood clots from forming. Used to prevent clotting post cardiac stent.

What are the contraindications of Digoxin (Lanoxin, Lanoxicaps)

Pts w/AV block or ventricular dysrhythmias unrelated to HF if given digoxin could worsen condition Caution with older adults because these pts experience a higher incidence of AE Pts w/renal impairment should receive lower doses of digoxin because the drug is excreted in the kidneys Pts w/MI, hypothyroidism, and cor pulmonale

Peripheral vascular disease caused by arterial vasospasm is known as ______________ disease -primary cause unknown

Raynaud's

Treatment of Peripheral Vascular Disease - Goals of treatment

Reversal of the progression of atherosclerosis, Improve blood flow, Pain relief, Prevention of skin ulceration, Prevention of gangrene

Patient Education for Peripheral Vascular Disease

Self-care measures that promote circulation Smoking cessation Avoid tight-fitting clothing Diet designed to control obesity and lipid levels Check extremities for infection, meticulous care Avoid sitting or standing for long periods Maintain and foster maximum mobility Medication education and expectations

Heparin

Subcutaneous injection into abdomen (Figure 26-2), don't massage site, alternate sites, use 90-degree angle, apply gentle pressure after

if lifestyle modifications are unsuccessful next step is

Surgical interventions

What are the administration alerts for Digoxin (Lanoxin, Lanoxicaps)

Take the apical pulse for 1 full min. noting rate, rhythm, & quality before administering If the pulse is below the parameter established by the health care provider (usually 60 beat/min) w/hold the dose & notify the provider Check for recent serum digoxin level results before administering. If the level is higher than the parameter established by the health care provider (usually 1.8 mg/ml) w/hold the dose & notify the provider Use w/caution in geriatrics & pediatric patients because these populations may have inadequate renal & hepatic metabolic enzymes Pregnancy category A

Drug Class: Glycoprotein IIb/IIIa Inhibitors

abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat)

Arteriosclerosis Obliterans S & S

aching, cramping, tightness, weakness during exercise resulting in ischemia - AKA intermittent claudication

Treatment of PVD -try to reverse the progression of atherosclerosis -pain __________ -improve blood ___________ -prevent ulcers to skin (foot care prevent gangrene) -get other disease under control (DM, HTN, angina, hyperlipidemia) -establish diet/smoking/exercise regime

relief, flow

What signs indicate that Pletal is working?

relieves pain due to exercise

Diuretics: now that ___ perfusion is improved: add diuretics to increase ___ and ___ excretion reduces the workload of the heart

renal profusion increase NA and H2O

Beta - Adrenergic Blocking Agents also inhibit ____

renin release

stimulate heart rate and ____ force of contraction = _____ cardiac output

( Inotropics) increase force of contraction, increase cardiac output ( increase urine, decrease edema, increase pulmonary congestion)

Nursing Diagnosis R/T Heart Failure

- Activity intolerance r/t weakness and fatigue - Impaired gas exchange r/t fluid in interstitial space of lungs - Decreased cardiac output r/t impaired cardiac function - Excess fluid volume r/t impaired excretion of sodium and water - Fear r/t threat to one's own well-being

Dig Toxicity early symptoms

- anorexia -mild nausea -hypokalemia predisposes pt. to Dig Toxicity

Nursing Process for Digoxin

- check apical pulse for one minute, don't give if less than 60/min or greater than 100 /min separate cup, notify MD - monitor digoxin levels - be careful with doses very small 0.25/ 0.125 - monitor digoxin levels - give after meals to minimize GI distress - monitor s/s of toxicity - teach patient to monitor own pulse

Digoxin side effects to report

- digitalis toxicity - cardiac tachycardia, bradycardia - pulse deficit - bigeminy ( cardiac dysrhythmia)

Nursing Process for Heart Failure Patient Education

- emphasize life long treatment - learn and teach pt to assess for CHF - emphasize diet -activity - meds - perform daily weights

Other diseases which may increase potential for digoxin toxicity

- hypothyroidism - MI - renal disease - pulmonary disease - advanced heart failure

Noncardiac : Signs of Dig Toxicity

- loss of appetite - N/V - diarrhea - fatigue and weakness - hallucinations - confusion - visual disturbances

Digitalis Glycosides results:

- slows ad strengthens the heart - allows heart to fill and empty more completely

Goals of treatment:

- to decrease s/s associated with fluid overload - increase exercise tolerance - prolongation of life left side - lungs (crackles, wheezing, weight gain, shortness of breath) right side - edema ( low extremities, weight gain)

VASODILATORS: to reduce _____ on the ___ ventricle by reducing the systemic vascular resistance ( afterload) against which left ventricle is working ( oxygenate tissues)

- to reduce strain - left ventricle

Digitalis Glycosides uses:

- treat heart failure - if not responding to beta blockers, ACE Inhibitors, and diuretics - atrial dysrhythmias -paroxysmal tachycardia ( begins and ends abruptly)

Drug Therapy of Heart Failure

- vasodilators ( enlarge, open vessels) - inotropic agents ( increase MI, contractility, contraction is stronger) - diuretics ( water pills, sodium and water out of body)

What are the administration alerts for Lisinopril (Prinivil, Zestril)

-Assess blood pressure just prior to administering lisinopril to be certain that effects are lasting for 24 hours and to determine whether the patient's blood pressure is within the acceptable range. -Safety and efficacy have been established for the use of this medication in children age 6 and older. -Geriatric patients may have higher blood levels related to renal failure. -Pregnancy category C (frst trimester) or D (second and third trimesters). Discontinue use as soon as pregnancy is suspected.

What is Lisinopril (Prinivil, Zestril) used for?

-Because of its value in the treatment of both HF and HTN, lisinopril has become one of the most frequently prescribed drugs. -Lisinopril acts by inhibiting ACE and decreasing aldosterone secretion. Blood pressure is decreased and cardiac output is increased. -As with other ACE inhibitors, 2 to 3 weeks of therapy may be required to reach maximum effectiveness, and several months of therapy may be needed for cardiac function to return to normal. -An additional indication for lisinopril is to improve survival in patients when given within 24 hours of an acute MI. -Fixed-dose combinations of lisinopril and hydrochlorothiazide (a diuretic) are marketed for HTN as Prinzide and Zestoretic. -Treatment of migraines is an off-label indication for lisinopril.

Arteriosclerosis obliterans As the disease progresses & without treatment patient may develop: -Pain at ________ -_________________ (numbness with a tingling sensation)

rest, paresthesias

What are the interactions with Lisinopril (Prinivil, Zestril)

-Drug-Drug: Indomethacin and other NSAIDs may interact with lisinopril, causing decreased antihypertensive activity. Because of the additive hypotensive action of lisinopril and diuretics, combined therapy with these or other antihypertensive drugs should be carefully monitored. When lisinopril is taken concurrently with potassium-sparing diuretics, hyperkalemia may result. Aliskirin (Tekturna), a renin inhibitor, should not be used concurrently with lisinopril due to an increased risk of hypotension and renal impairment. Lisinopril may increase lithium levels and cause lithium toxicity. -Lab Tests: May cause positive antinuclear antibody (ANA) titer and increase values of the following: blood urea nitrogen (BUN), serum bilirubin, serum alkaline phosphatase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Herbal/Food: -Excessive intake of foods rich in potassium and potassium-based salt substitutes should be avoided because of the possibility of hyperkalemia. -Treatment of overdose: --Overdose causes hypotension, which may be treated with the administration of normal saline or a vasopressor.

Uses of Heparin

-Treat deep vein thrombosis, pulmonary embolism, cerebral embolism • Can be given subcutaneously, IV push, IV infusion • Dosages vary depending on route • Monitor aPTT, platelets, hematocrit

Major causes of thrombus formation are:

1. Immobility 2. Surgery and the postoperative period 3. Trauma to lower limbs 4. Certain illnesses such as vasospasm, ulcerative colitis, heart failure. 5. Cancer 6. Pregnancy 7. Oral contraceptives and female hormone replacement therapy (HRT) 8. Heredity

Thromboembolic disease; Five types of agents

1. Platelet inhibitors 2. Anticoagulants 3. Glycoprotein IIb/IIIa inhibitors 4. Thrombolytics 5. Fibrinolytics- used to dissolve the arterial cot before it is permanently attached to the vessel walls, causing complete obstruction

What are the 2 primary actions of ACE inhibitors?

1. to lower peripheral resistance (decrease blood pressure) and 2. inhibit aldosterone secretion (reduce blood volume). The resultant reduction of arterial blood pressure diminishes the afterload, thus improving cardiac output. An additional effect of ACE inhibitors is dilation of veins. This action decreases pulmonary congestion and reduces peripheral edema.

Triglyceride levels need to be under

150

*A 36-year-old client with a 7-year history of Raynaud's disease comes to donate blood during a community blood drive.* When preparing the client's teaching plan, the nurse should include information on the importance of avoiding which one of the following? 1. Wearing gloves 2. Emotional stress 3. Drinking alcoholic beverages 4. Bathing with perfumed soap

2 (Rationale: Emotional stress stimulates vasoconstriction)

Cholesterol levels need to be under

200

Nifedipine (Procardia) has been prescribed for a client with Raynaud's disease, and the nurse reinforces medication instructions with the client about the medication. Which statement by the client indicates a need for further teaching? 1. "I will contact my doctor if I get short of breath." 2. "I will call my doctor if I get headaches that worsen." 3. "Nausea and drowsiness are expected, and if they occur, I don't really need to worry about it." 4. "I need to get up slowly when I change positions because the medicine causes hypotension."

3 (Rationale: Nifedipine is a calcium antagonist that reduces smooth muscle contractibility by inhibiting the movement of calcium ions in slow channels. Its side effects include headache, flushing, peripheral edema, and postural hypotension. Overdose of the medication produces nausea, drowsiness, confusion, and slurred speech. If signs of overdose occur, the health care provider is notified.)

Arteriosclerosis obliterans Patients tend to remain free of symptoms until there is significant narrowing __% to __% in key locations of the major arteries & arterioles of the legs

75 to 90

A patient is newly diagnosed with Raynaud's disease. Which medication is most beneficial for the patient? A. Nifedipine (Procardia) B. Methyldopa (Aldopam) C. Prazosin (Minipress) D. Reserpine (Serpalan)

A (Rationale: Calcium channel blockers and adrenergic antagonists are used to treat Raynaud's disease. Calcium ion antagonists such as nifedipine (Procardia) are most beneficial in patients with Raynaud's disease because they greatly reduce vasospastic attack. Adrenergic antagonists such as prazosin (Minipress), reserpine (Serpalan), and methyldopa (Aldopam) are also used to treat Reynaud's disease, but they are only moderately successful due to the adverse effects associated with these medications.)

Drug Class: Fibrinolytic Agents

streptokinase, alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase)

Beta - Adrenergic Blocking Agents usually used with ____ to treat heart failure

ACE Inhibitors

What is Pharmacologic Class of Lisinopril (Prinivil, Zestril)

ACE inhibitor

Common adverse effects of aspirin

Abdominal distress, hypotension

Which class of drugs used to treat Raynaud's disease causes an increase in bradykinins? A. Adrenergic antagonists B. Angiotensin-converting enzyme (ACE) inhibitors C. Calcium channel blockers D. Direct vasodilators

B (Rationale: Angiotensin-converting enzyme (ACE) inhibitors cause an increase in bradykinins, a potent vasodilator. Direct vasodilators such as nitroglycerin (Nitrostat) are used to reduce the frequency and severity of attacks in patients with Reynaud's disease. Adrenergic antagonists are used in moderation to treat Reynaud's disease because of adverse effects associated with these drugs. Calcium channel blockers reduce the frequency of vasospastic attacks in patients with Reynaud's disease.)

Thrombosis

the process of formation of a fibrin blood clot (thrombus)

What are the adverse effects of Metoprolol (Lopressor, Toprol XL)

Because it is selective for blocking beta1 receptors in the heart, metoprolol has few adverse effects on other autonomic targets and thus is preferred over nonselective beta blockers such as propranolol for patients with respiratory disorders. Adverse effects are generally minor and relate to its autonomic activity, such as slowing of the heart rate and hypotension. patients with HF should be carefully monitored. Other frequent adverse effects include abnormal sexual function, drowsiness, fatigue, and insomnia. Black Box Warning: Abrupt withdrawal is not advised in patients with angina or heart disease. Dosage should gradually be reduced over 1 to 2 weeks and the drug should be reinstituted if angina symptoms develop during this period.

Notes on Metoprolol (Lopressor, Toprol XL)

Beta blockers are rarely used as monotherapy for this disease, but instead are usually combined with other medications, especially ACE inhibitors. `

What is Pharmacologic Class of Metoprolol (Lopressor, Toprol XL)

Beta-adrenergic blocker

Drug Class: Beta-Adrenergic Blocking Agents "olol"

Bisoprolol, long-acting metoprolol (Toprol XL), carvedilol (Coreg

Serious adverse effects of dalteparin (Fragmin) and enoxaparin (Lovenox)

Bleeding, thrombocytopenia

Serious adverse effects of glycoprotein IIb/IIIa inhibitors

Bleeding, thrombocytopenia

What is the primary function of phosphodiesterase inhibitors

Blocking phosphodiesterase has the effect of increasing the amount of calcium available for myocardial contraction. The inhibition results in 2 main actions that benefit patients with HF; a positive inotropic action and vasodilation

Common adverse effects of beta-adrenergic blocking agents

Bradycardia, peripheral vasoconstriction (purple, mottled skin); heart failure; bronchospasm, wheezing; masks hypoglycemia in diabetic patients

Which serious adverse effect of cilostazol (Pletal) must be evaluated further by the healthcare provider? A. Tingling of the hands and feet B. Constipation C. Palpitations D. Increased urine output

C (Rationale: Palpitations, along with angina, dysrhythmias, and shortness of breath should be reported to, and further evaluated by, a healthcare professional. Cilostazol does not affect urine output and may cause diarrhea, but not constipation. Tingling of the hands and feet is not a side effect of cilostazol.)

How does pentoxifylline (Pentoxil) stop intermittent claudication? A. By increasing the concentration of fibrinogen in the blood B. By increasing blood viscosity C. By increasing red blood cell flexibility D. By increasing the bradykinin level

C (Rationale: Pentoxifylline (Trental) is a hemorheologic agent that increases red blood cell flexibility. This action reduces blood viscosity and provides better oxygenation to muscle tissues to stop intermittent claudication. Pentoxifylline (Trental) decreases blood viscosity. Angiotensin-converting enzyme (ACE) inhibitors increase bradykinin levels. Pentoxifylline (Trental) decreases the concentration of fibrinogen in the blood.)

When evaluating a patient's response to pentoxifylline (Trental), which sign/symptom does the nurse assess? A. Allergy symptoms B. Urinary output C. Leg pain D. Motor coordination

C (Rationale: Pentoxifylline is used to treat intermittent claudication, which is characterized by leg pain on walking. Urinary output, allergy symptoms, and motor coordination are not associated with the use of pentoxifylline.)

What are the serious adverse effects of pentoxifylline (Trental)? (Select all that apply.) A. Diarrhea B. Dyspepsia C. Chest pain D. Dizziness E. Shortness of breath

C, E (Rationale: Pentoxifylline (Trental) is a hemorheologic agent that is used to treat peripheral vascular disease. Chest pain and shortness of breath are serious adverse effects of pentoxifylline (Trental). Diarrhea is a common adverse effect of cilostazol (Pletal). Dizziness and dyspepsia are common adverse effects of pentoxifylline (Trental).)

Potential Classes of Drugs to Treat Raynaud's Disease

Calcium ion agonists Diltiazem (Cardizem) Nifedipine (Procardia) Verapamil (Calan, Isoptin) Adrenergic antagonists Prazosin (Minipress), reserpine Guanethidine (Ismelin), methyldopa ACE inhibitor Captopril (Capoten) Direct vasodilator Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur)

What is Pharmacologic Class of Digoxin (Lanoxin, Lanoxicaps)

Cardiac glycoside

Notes on Milrinone (Primacor)

Cardiac output is improved because of the increase in contractility and the decrease in left ventricular afterload. The phosphodiesterase inhibitors have a very brief half-life and are occasionally used for the short-term control of acute HF. Phosphodiesterase inhibitors have serious toxicity that limits their use to patients with resistant HF who have not responded to ACE inhibitors, digoxin, or other therapies. Therapy is limited to 2 to 3 days and the patient is continuously monitored for ventricular dysrhythmias. If the patient presents with hypokalemia, it should be corrected before administering phosphodiesterase inhibitors because it can increase the likelihood of dysrhythmias. These medications can also cause hypotension

Hemorrheologic Agents: pentoxifylline (Trental) Serious adverse effects

Chest pain, dysrhythmias, shortness of breath

Raynaud's disease (r/t arterial vasospam, PVD) S & S -numbness, tingling & sense of the skin tightness in affected ______________ -blanching of the skin followed by ______________

extremity, cyanosis

What are the interactions with Digoxin (Lanoxin, Lanoxicaps)

Concurrent use w/ diuretics can cause hypokalemia & increase risk of dysrhythmias Use w/ACE inhibitors, spironolactone, or K+ supplements can lead to hyperkalemia & reduce the therapeutic action of digoxin Administration with other + inotropic drugs can cause additive effects on heart contractility antacids & cholesterol lowering drugs can decrease the adsorption of digoxin If administered concurrently with calcium via IV it can increase the risk of dysrhythmias Ginsen may increase the risk of digoxin toxicity

Arteriosclerosis obliterans Risk factors: -___ -_________ -increasing triglycerides & cholesterol -diabetes mellitus

HTN, smoking

Venous PVD -___ -_______________ -_______________ mellitus

DVT, varicosities, diabetes

Angiotensin Converting Enzyme Inhibitors now recommended over ____ for mild to moderate failure

Digoxin

Antidote for severe Dig intoxication

Digoxin Immune Fab (Digibind)

Name the cardiac glycosides under the Digoxin (Lanoxin, Lanoxicaps) prototype

Digoxin is the only drug in this class approved for use in the United States

Pletal - drug interactions:

Diltiazem - calcium channel blocker Erythromycin - anti-infective Omeprazole - anti ulcer Fluconazole - anti fungal Fluoxetine - Prozac - SSRI Sertraline - Zoloft - SSRI Ketoconazole - anti fungal Grapefruit juice

Peripheral Vascular Disease is

Diseases of blood vessels in the extremities

Uses of fibrinolytic agents

Dissolve fibrin clots secondary to coronary artery occlusion (MI), pulmonary emboli, cerebral emboli, deep venous thrombosis

What is the therapeutic class of Milrinone (Primacor

Drug for heart failure

What is the therapeutic class of digoxin

Drug for heart failure

What is the therapeutic class of Lisinopril (Prinivil, Zestril)

Drug for heart failure and HTN

What is the therapeutic class of Metoprolol (Lopressor, Toprol XL)

Drug for heart failure and HTN

What are the interactions with Metoprolol (Lopressor, Toprol XL)

Drug-Drug: Concurrent use with digoxin may result in bradycardia. Oral contraceptives may cause increased metoprolol effects. Use with alcohol or antihypertensives may result in additive hypotension. Metoprolol may enhance the hypoglycemic effects of insulin and oral hypoglycemic drugs. Concurrent use with verapamil increases the risk of heart block and bradycardia. Lab Tests: Metoprolol may increase values for the following: uric acid, lipids, potassium, bilirubin, alkaline phosphatase, creatinine, and ANA Herbal/Food: Unknown Treatment of overdose: Atropine or isoproterenol can be used to reverse bradycardia caused by metoprolol overdose. Hypotension may be reversed by a vasopressor such as parenteral dopamine or dobutamine.

What are the interactions with Milrinone (Primacor)

Drug-Drug: Milrinone interacts with disopyramide, causing excessive hypotension. Caution should be used when administering milrinone with digoxin, dobutamine, or other inotropic drugs, because their positive inotropic effects on the heart may be additive. Lab Tests: Unknown Herbal/Food: Unknown Treatment of overdose: Overdose causes hypotension, which is treated with the administration of normal saline or a vasopressor.

Diagnostic tests

Echocardiogram, ECG, nuclear imaging studies, chest x-ray

What is Metoprolol (Lopressor, Toprol XL) used for?

For angina, HTN and for reducing cardiac complications following an MI It is a selective beta 1 adrenergic blocker but at higher doses it may also affect beta2 receptors

Side effects of pentoxifylline (Trental): -__-n/v, dyspepsia -__________ -_____________

GI, headache, dizziness

Name the adverse effects of ACE inhibitors under the Lisininopril prototype

Headache dizziness orthostatic hypotension Cough SEVERE: Severe hypotension, syncope(fainting), angioedema, blood dycrasias (morbid general state resulting from the presence of abnormal material in the blood, usually applied to diseases affecting blood cells or platelets, fetal toxicity

Common adverse effects of dalteparin (Fragmin) and enoxaparin (Lovenox)

Hematoma formation, bleeding at injection site

Anticoagulants

Heparin

Arteriosclerosis Obliterans Risk Factors:

High LDL C, cigarette smoking, Low HDL C, DM

Baseline Assessments for Peripheral Vascular Disease

History of risk factors such as hypertension, high serum lipids, Dietary habits, obesity, Smoking, Level of exercise tolerated and ability to control stressful situations

Target of coumadin

INR of 2-3 for patients with atrial fibrillation, stroke, MI, and DVT

Uses of platelet inhibitors

In men, reduces risk of MI, in females reduces risk of stroke; used in males and females with acute MI

Hemorrheologic Agents: pentoxifylline (Trental) Actions

Increase erythrocyte flexibility, decrease amount of fibrinogen in blood, prevent aggregation of RBCs and platelets

What is Digoxin (Lanoxin, Lanoxicaps) used for?

Increase the contractility of strength of myocardial contraction Inhibites Na+ K+ ATpase By increasing cardiac output it helps to alleviate symptoms of HF & improve exercise tolerance. Improved cardiac output results in increased urine production & a desirable reduction in blood volume, relieving distressing symptoms of pulmonary congestion & peripheral edema Suppresses SA node & slows electrical conduction through the AV node helping to treat dysrhythmias

Drugs: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), ticlopidine (Ticlid).

Inhibit platelet aggregation

Notes on Digoxin (Lanoxin, Lanoxicaps)

It does not reduce mortality from HF Primarily used for more advanced stages of HF in combination w/other medications Margin of safety between therapeutic dose & a toxic dose is narrow

What are the contraindications of Lisinopril (Prinivil, Zestril)

Lisinopril is contraindicated in patients with hyperkalemia and in those who have previously experienced angioedema caused by ACE inhibitor therapy. It should not be used during pregnancy

What are the adverse effects of Lisinopril (Prinivil, Zestril)

Lisinopril is well tolerated by most patients. The most common adverse effects are cough, headache, dizziness, orthostatic hypotension, and rash. -Hyperkalemia may occur during therapy; thus, electrolyte levels are usually monitored periodically. -Other effects include taste disturbances, chest pain, nausea, vomiting, and diarrhea. -Though rare, angioedema (the rapid edema, or swelling, of the area beneath the skin or mucosa. ) is a serious adverse effect. -BLACK BOX WARNING: Fetal injury and death may occur when ACE inhibitors are taken during pregnancy. When pregnancy is detected, they should be discontinued as soon as possible

Hemorrheologic Agents: pentoxifylline (Trental) Common adverse effects

Nausea, vomiting, dyspepsia; dizziness, headache

What are the adverse effects of Digoxin (Lanoxin, Lanoxicaps)

The most dangerous A.E. is its ability to create dysrhythmias, particularly in pts who have hypokalemia or impaired renal function. Concurrent use of digoxin & diuretics must be carefully monitored because diuretics can cause hypokalemia and are often used to treat HF Other A.E. include nausea, vomiting, anorexia, visual disturbances such as seeing halos, a yellow green tinge or blurring Periodic serum drug levels should be obtained to determine whether the digoxin concentration is w/in the therapeutic range

What is the primary function of beta adrenergic blockers

They block the cardiac actions of the sympathetic nervous system, slowing the heart rate & reducing BP. Workload on the heart is decreased; after several months of therapy, heart size, shape, and function return to normal in some pts Betablockers produce a negative inotropic effect

What are the contraindications of Metoprolol (Lopressor, Toprol XL)

This drug is contraindicated in patients with cardiogenic shock, sinus bradycardia, heart block greater than first degree, hypotension, and overt cardiac failure. Metoprolol should be used with caution in patients with asthma and those with a history of bronchospasm, because the drug may affect beta2 receptors at high doses.

What are the primary actions of digoxin?

To cause the heart to beat more forcefully (positive inotropic effect) and more slowly, thus improving cardiac output. The rescued heart rate, combined w/more forceful contractions, allow for much greater efficiency of the heart

Use for ACE inhibitors

Treat mild to moderate systolic dysfunction heart failure

Use of natriuretic peptides

Treat severe heart failure

increases red blood cell flexibility

Trental

Platelet Aggregation Inhibitor cilostazol (Pletal) Action

Vasodilation and inhibits platelet aggregation; increased tissue perfusion; reduce pain; improve tolerance of exercise; improve peripheral pulses.

Raynaud's disease is caused by

Vasospastic: arterial spasms

serious adverse effects of phosphodiesterase

Ventricular dysrhythmias, hypotension, thrombocytopenia, hepatotoxicity

What are the administration alerts for Milrinone (Primacor)

When this med is admin. IV a microchip set & an infusion pump should be used safety & efficacy have not been established in geriatric & led patients Pregnancy category C

milrinone Primacor is a ___ agent vascular ___ muscle relaxant used for short term management for severe ___ dysfunction heart failure

a inotropic agent smooth muscle relaxant severe systolic dysfunction

What does Digitalization refer to

a procedure in which the dose of digoxin is gradually increased until tissues become saturated w/ the drug & the symptoms of HF diminish

Embolus

a small fragment of a thrombus that breaks off and circulates until it becomes trapped in a capillary, causing ischemia or infarction to the area distal to the obstruction (ex. cerebral aneurysm, pulmonary embolism).

Tests for Heparin

aPTT, platelets, hematocrit

What are the administration alerts for Metoprolol (Lopressor, Toprol XL)

advise the patient not to crush or chew sustained release tabs assess the pulse & BP before oral admin. Hold if the pulse is below 60 beats/min or if the patient is hypotensive doses should be reduced for older patients because they are @ risk for dizziness & falls Pregnancy category C

Angiotensin Converting Enzyme Inhibitors inhibit ____

aldosterone

Drug therapy for PVD -treat the underlying pathology example DM, HTN, hyperlipidemia, ______ -___________________ Trental -____________ Pletal -______________ therapy

angina, pentoxifylline, cilostazol, vasodilator

The most common form of obstructive arterial narrowing disease is __________________ ___________ (loss of function) -Atherosclerotic plaque build up & narrowing of the lower aorta & major arteries that provide circulation to the _______

arteriosclerosis obliterans, legs

Natiuretic Peptides given IV as a ______ in severe heart failure if pt. has ____ @ rest or with minimal activity

as a vasodilator pt. has dyspnea

Drug Class: Platelet Inhibitors

aspirin

What is included in teaching plan for Raynaud's

avoid cold climate, no smoking, wear warm clothes, keep hands warm

Ways to prevent vaso-spasms

avoid holding cold drinks, limit caffeine, maintain maximum mobility, encourage performing usual ADL's, avoid skin breakage

Drug Class: ACE Inhibitors "pril"

benazepril (Lotensin), captopril, enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), quinapril (Accupril), Ramipril (Altace)

Adverse effects of thrombin inhibitor

bleeding

Serious adverse effects of Heparin

bleeding, thrombocytopenia

Beta - Adrenergic Blocking Agents block ______= reduction in ____, ____, and ___

block beta receptors reduction in heart rate, cardiac output, and BP

Arteriosclerosis Obliterans Primary cause is

buildup of atherosclerotic plaque, resulting in narrowing of the lower aorta and the major arteries that provide circulation to the legs.

Natiuretic Peptides: hormone normally secreted by the ____ ventricles in response to ___ and ____

by the cardiac ventricles response to fluid and pressure overload

PVD surgical intervention

bypass grafting endartertomy angioplasty amputation

Natiuretic Peptides helps the heart recover from deteriorating _____

cardiac function

ACE inhibitors -end in "pril" -cause an increase in bradykinin -has been shown to reduce the frequency & severity of Raynaud's attacks

catopril

Platelet aggregation inhibitor ________________ Pletal

cilostazol

Should not be used to treat patients with heart failure of any severity

cilostazol

Used for treatment of intermittent claudication & should be used as an adjunct with: weight loss, smoking cessation, exercise, bypass surgery, & or removal of arterial obstructions

cilostazol

Platelet Aggregation Inhibitor - Drug:

cilostazol (Pletal)

Raynaud's disease (r/t arterial vasospam, PVD) Secondary causes -exposure to ________ -obstructive arterial disease -occupational _______ (pianists), certain drugs (beta blockers) -more frequent in _____________

cold, trauma, women

Raynaud's disease is thought to be caused by vasospasm (vasoconstriction of blood vessels) and subsequent ischemia of the arteries of the skin of the hands, fingers, and sometimes, toes. Sudden __________ applied to the extremity, such as cold water, can induce an attack

coldness

Drug Class: Thrombin Inhibitor

dabigatran (Pradaxa)

Anticoagulant drugs besides heparin and warfarin

dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), tinzaparin (Innohep)

Hemorrheologic agents Actions of pentoxifylline Trental: -____________ the concentration of fibrinogen in blood -_____________ erythrocyte flexibility -____________ aggregation of RBCs & platelets -____________ viscosity & improves blood flow- resulting in enhanced tissue oxygenation -decreased pain

decrease, increase, prevent, decreased

Arteriosclerosis obliterans Physical findings on the lower extremities are -___________ pulse -____________ pale dry skin -_____________ over the involved arteries -decreased skin temp -weakness -increased blood _________ which causes numbness to sensation (thickness of blood)

decrease, waxy, bruits, viscosity

VASODILATORS : to reduce preload so that high volume of blood returning to the heart is ____ ( less pulmonary congestion, breath easier)

decreased

Implementation: _____ ( larger loading doses) done __ to ___ hours to reach a therapeutic level or desired cardiac effect maintenance dose after loading - usually ____ a day, usually for the rest of their life

digitalization ( larger loading doses) done 24- 48 hours usually once a day

Drug Class: Digitalis Glycosides

digoxin (Lanoxin)

Thromboembolic diseases

diseases associated with abnormal clotting within blood vessels. Major cause of morbidity & mortality.

what should the pt. due to maintain blood volume and reduce vasoconstriction If not contraindicated

drink 8- 8 oz glasses of water

Six cardinal signs of heart disease

dyspnea, chest pain, fatigue, edema, syncope, palpitations.

uses of anticoagulants

treatment/prophylaxis of DVT, embolization from atrial fibrillation or heart valve replacement, pulmonary embolism

Angiotensin Converting Enzyme Inhibitors cause

vasodilation

Drug Class: Anticoagulants

warfarin (Coumadin)

Before starting pentoxifylline (Trental) therapy patient should be asked about intolerance to _____________ derivatives -pentoxifylline is a xanthine derivative -caffeine -theophylline -theobromine

xanthine

Coumadin nursing implications

• Warfarin inhibits vitamin K activity, which activates clotting factors II, VII, IX, and X. High intake of leafy green vegetables may interfere with the effectiveness of anticoagulants; they contain vitamin K, which is used as an antidote for high doses of warfarin. • Anticoagulants must be administered on schedule exactly as directed, and not in larger, more frequent doses for longer than the prescribed time. Taking too much medication can cause severe bleeding. • Anticoagulants do not dissolve clots; only thrombolytics do this.

Nonpharmacologic Treatment of Thromboembolic Diseases:

• Ways to prevent stasis: leg exercises, wearing stockings, leg elevation, sequential compression devices. • Revascularization treatments: percutaneous coronary intervention (also known as angioplasty), coronary artery bypass graft, Percutaneous peripheral interventions, femoral/popliteal bypass grafting. • Prevention is the best treatment. • Patients need early, regular ambulation after surgery; develop and follow a turning schedule for patients on bedrest.

Lab Tests for Thromboembolic Diseases/ Anticoagulant Therapy:

•Coagulation tests -PT (prothrombin time)- Monitors warfarin therapy -aPTT (activated partial thromboplastin time- Monitors IV heparin therapy -INR (International Normalized Ratio)- Monitors warfarin therapy -Platelet counts •Diagnostic tests -PT, aPTT, hematocrit, platelet count, Doppler studies, exercise testing, serum cholesterol & triglycerides, arteriogram, cardiac enzyme studies, ankle/brachial indices. •PT evaluates the adequacy of the extrinsic system. •aPTT evaluates the intrinsic coagulation system

Digitalis Toxicity:

•Early signs: anorexia, nausea, fatigue, psychiatric disturbances, visual disturbances; these are frequently overlooked •Antidote: digoxin immune Fab (Digibind) or DigiFab

laboratory tests

•Electrolytes: mainly K+, Ca+, Mg+, Na+ •B-type natriuretic peptide (BNP) level (>100) •Arterial blood gases (ABG's) •Kidney functions: BUN & creatinine (may be increased from poor perfusion) •Lipid levels •Digoxin level if patient is on digoxin

Uses for phosphodiesterase inhibitors

•Short-term management of severe systolic dysfunction heart failure in patients not responding adequately to digoxin, diuretics, or vasodilator therapy •Not used to treat diastolic heart failure, and may worsen this condition

Uses of Digoxin

•Treat moderate to severe systolic failure not responding to diuretics and ACE inhibitors •Treats atrial fibrillation, atrial flutter, paroxysmal tachycardia

Drug Therapy for Heart Failure

•Vasodilators •Inotropic agents •Diuretics