NURS 305 Cardiology II

A patient is prescribed lovastatin (Mevacor). The nurse will teach the patient to take the medication at which time?

2 hours after a meal

Thrombolytic drugs

Alteplase.

Glycoprotein IIb/IIIa receptor antagonist

Abciximab

A patient is receiving an intravenous infusion of heparin to treat a pulmonary embolism. What laboratory value will the nurse monitor to to evaluate treatment with this medication?

Activated partial thromboplastin time (aPTT)

What to monitor for with Heparin

Activated partial thromboplastin time (aPTT).

Nitroglycerin uses

Acute anginal therapy, Sustained anginal therapy. IV for perioperative control of BP, Controlled hypotension during surgery, and treatment of HF with MI, unstable angina, and uncontrolled exacerbations of chronic angina.

Abciximab uses

Acute coronary syndrome, Percutaneous coronary intervention.

Ezetimibe use

Add to high intensity statin if still not at goal LDL. When added to statin it reduces death and CV events after ACS compared to statin alone, but not by itself.

Nitrates uses

Angina, Vasodilator.

Therapeutic agents for acute management of Unstable angina

Anti-ischemic therapy (antianginal drugs), Antiplatelet therapy, Anticoagulant therapy.

CCBs in management of STEMI

Antianginal, vasodilation, and antihypertensive actions. NOT recommended for routine use in management of STEMI. Only use verapamil and diltiazem if BBs are CI.

What all patients undergoing PCI should receive

Anticoagulant (IV heparin, bivalirudin, LMWH), Antiplatelet drugs (aspirin plus clopidogrel, ticagrelor, prasugrel, or a glycoprotein IIb/IIIa inhibitor).

What all patients undergoing Fibrinolytic therapy should receive

Anticoagulant (IV heparin, enoxaparin, fondaparinux), Antiplatelet (aspirin plus clopidogrel). No glycoprotein IIb/IIIa inhibitor.

Selective factor Xa inhibitor

Apixaban. Produces selective inhibition of factor Xa.

Gemfibrozil MOA

Appears to interact with a specific receptor subtype (PPAR alpha).

Antiplatelet drugs

Aspirin, CLopidogrel.

Drugs post ACS

BANANAS: BB, Aspirin, Nitrate, Antiplatelet, No NSAIDS, ACEI, Statin. (SAAB decreases mortality).

Direct thrombin inhibitors

Bivalirudin, Dabigatran. Prevents clot formation (combined with aspirin) in patients with unstable angina who are undergoing coronary angioplasty.

Adverse effects of Alteplase

Bleeding

Adverse effects of Apixaban

Bleeding

Adverse effects of LMW Heparin

Bleeding (less than unfractioned), Immune-mediated thrombocytopenia), Severe neurologic injury for patients undergoing spinal puncture or spinal epidural anesthesia.

Adverse effects of Aspirin

Bleeding, GI bleeding and hemorrhagic stroke, Enteric-coated tablets may not reduce the risk for GI bleeding.

Adverse effects of Bivalirudin

Bleeding, Nausea, HA.

Verapamil/Diltiazem uses

Block calcium channels in vascular smooth muscle. Used for stable and variant angina.

Adverse effects of Beta blockers

Bradycardia, Decreased AV conduction, Reduced contractility, Asthmatic effects, Use with caution with diabetes, Insomnia, Depression, Bizarre dreams, Sexual dysfunction.

Monitoring Warfarin

Prothrombin time (18), Internationalized normalized ratio (2-3).

Therapeutic agents of Varian Angina (Prinzmetal's)

Calcium channel blockers, Organic nitrates.

Nitroglycerin tolerance

Can develop rapidly, Cross-tolerance to all other nitrates. Use lowest effective dose. 8 drug-free hours per day with long-acting formulas.

Cholestyramine

Can reduce the absorption of other drugs. Bile-acid sequestrant.

ACEI in management of STEMI

Captopril, lisinopril. Adjunct to reperfusion therapy. Should start within 24hrs of symptom onset. Decreases short-term mortality in all patients and long-term mortality in patients with reduced LV function.

Cholestyramine has been prescribed for a patient. Which instruction should the nurse include in patient teaching?

Cholestyramine can impair absorption of fat-soluble vitamins.

Bile-Acid Sequestrants

Cholestyramine, Colesevelam. Primarily used as adjuncts to statins.

Anticoagulant therapy

Choose 1: UFH, Enoxaparin, Fondaparinux, Bivalirudin. UFH only agent not affected by renal impairment (go-to when in doubt). Bivalirudin go-to for HIT, LMW heparins preferred with lytic treatment.

Oral P2Y12 inhibitor

Clopidogrel

Adverse effects of Colesevelam

Constipation

Isosorbide mononitrate/Isosorbide dinitrate

Identical actions to nitroglycerin. Used for angina. Produce HA, hypotension, and reflex tachycardia.

Adverse effects of CCBs

Dilation of peripheral arterioles, Reflex tachycardia, Hypotension, Bradycardia, HF (do not use), Edema, Constipation.

Thrombolytics

Dissolves existing clots.

Adverse effects of Dabigatran

Dyspepsia, Bleeding.

LMW Heparin

Enoxaparin. Heparin preparations composed of molecules that are shorter than those found in unfractioned heparin.

PCSK9 Inhibitor

Evolocumab

Bivalirudin MOA

Facilitates the actions of antithrombin, Prevents conversion of fibrinogen to fibrin, Prevents activation of factor XIII.

Ranolazine

First new class of antianginal agents approved in more than 25 years. Exact mechanism unknown. Not a first-line therapy; combine with first-line agents for inadequate response to other first-line meds.

Side effects of Nitrates

Flushing, HA, Dizziness, Orthostatic hypotension, Reflex tachycardia.

Fibric acid derivatives (Fibrates)

Gemfibrozil

Adverse effects of Ezetimibe

HA, Rash, No monitoring necessary except LFTs when given with statins.

Adverse effects of Warfarin

Hemorrhage, Fetal hemorrhage and teratogenesis (Category X).

Adverse effects of Heparin

Hemorrhage, Heparin-induced thrombocytopenia, Hypersensitivity reactions.

Statin properties that increase the risk of SAMS

High systemic exposure, Lipophilicity, High bioavailability, Potential for DIs metabolized by CYP pathways.

Therapeutic uses for Statins

Hypercholesterolemia, Primary and secondary prevention of CV events, Post-MI therapy, Diabetes.

Colesevelam MOA

Increases LDL receptors on hepatocytes, Prevents reabsorption of bile acids.

Patient characteristics that increase risk of SAMS

Increasing age, Female, Renal insufficiency, Hepatic dysfunction, Hypothyroidism, Diet (grapefruit juice), Polypharmacy, Alcohol abuse.

Ezetimibe MOA

Inhibits cholesterol absorption.

Anticoagulants

Inhibits coagulation cascade.

Management of Variant angina

Initially CCB or long-acting nitrate. If inadequate add a nitrate. If combo fails, CABG may be indicated. Beta blockers not effective.

Adverse effects of Evolocumab

Injection-site reactions, Respiratory infections.

Adverse effects of Niacin

Intense flushing initially (pretreat with aspirin), Itching, GI, Hepatotoxicity, Hyperglycemia, Gouty arthritis, Can raise blood levels of uric acid.

Aspirin (ASA)

Irreversible inhibition of cyclooxygenase. Increases risk for GI bleeding.

Aspirin uses

Ischemic stroke, TIA, Chronic stable angina, Unstable angina, Coronary stenting, Acute MI, Previous MI, Primary prevention of MI.

Ezetimibe

Lowers LDL, May raise HDL, Lowers TG.

Evolocumab

Lowers LDL-C 50-60%. Recently shown to improve CV outcomes.

Adverse effects of Abciximab

Major bleeding, Monitor for bleeding and platelet count.

Things Statins reduce

Major coronary events, CHD mortality, Coronary procedures, Stroke, Total mortality

Evolocumab MOA

Monoclonal antibody that inhibits a protein called PCSK9, increasing cholesterol clearance from the liver.

Statins

Most effective drugs for lowering LDL. Elevate HDL cholesterol, Reduce TG levels. Promote plaque stability, Reduce risk for CV events, Increase bone formation.

Gemfibrozil use

Most effective for lowering TG, Can raise HDL, Little or no effect on LDL. Can increase the risk for bleeding in patients on warfarin, Can increase the risk for rhabdomyolysis in patients taking statins.

Colesevelam

Newest and better-tolerated drug, Does not decrease uptake of fat-soluble vitamins. Does not significantly reduce the absorption of statins, warfarin, digoxin, and most other drugs.

Nicotinic acid

Niacin

Nitrates

Nitroglycerin, Isosorbide dinitrate. Act directly on VSM to promote vasodilation. Produces decreased venous return to the heart (preload), which decreases cardiac workload and oxygen requirements. Dilate the coronary arteries and increase blood flow to the heart tissue.

Statins dosing

Once daily in the evening (endogenous cholesterol synthesis increases during the night, greatest impact), Monitor LFTs.

Warfarin uses

Oral anticoagulant with delayed onset, Vitamin K antagonist, Not useful in emergencies, Long-term prophylaxis of thrombosis.

Antianginal agents

Organic nitrates (nitroglycerin), Beta blockers, Calcium channel blockers.

Therapeutic agents for Chronic stable angina (symptomatic relief)

Organic nitrates, Beta blockers (decrease afterload), Calcium channel blockers (dilate arterioles, decrease HR and contractility), Ranolazine.

Alteplase uses

PE, Acute MI (not used much), Ischemic stroke, Blocked central venous catheter.

Heparin uses

Preferred anticoagulant during pregnancy and when rapid anticoagulation is required, PE, Stroke evolving, DVT, Open heart surgery, Renal dialysis,, Low-dose therapy post-op, DIC, Adjunct to thrombolytics.

Calcium channel blockers uses

Prevent movement of extracellular calcium into the cell. Decrease muscle contraction, dilates coronary arteries and peripheral arteries. Decrease oxygen demand.

Beta-Blockers uses

Prevent or inhibit sympathetic stimulation of the heart. Slow heart rate, decrease contractility, and lower BP reducing myocardial oxygen demand. Keep blood in diastole longer providing better myocardial perfusion. Long-term to decrease frequency and severity of angina and increase exercise tolerance.

LMW Heparin uses

Prevention of DVT following surgery, Treatment of established DVT, Prevention of ischemic complications (unstable angina, non-Q-wave MI, STEMI).

Apixaban uses

Prevention of stroke and systemic embolism in patients with nonvalvular afib. Category B for pregnancy.

Antiplatelets

Prevents activation of platelets.

Clopidogrel uses

Prevents blockage of coronary artery stents, Reduces thrombotic events in patients with acute coronary syndromes (MI, ischemic stroke, vascular death).

Reperfusion therapy

Primary percutaneous coronary intervention (PREFERRED), Fibrinolytic therapy if PCI not possible (alteplase).

Antidote for Heparin overdose

Protamine sulfate

Adverse effects of Gemfibrozil

Rashes, GI disturbances, Gallstones, Myopathy, Liver injury (hepatotoxic).

ARBs in management of STEMI

Recommended for STEMI patients who are intolerant of ACEIs and who have HF or reduced LV function.

Colesevelam use

Reduce LDL (in conjunction with modified diet and exercise), Increased VLDL in some pts.

Niacin use

Reduces LDL and TG, Increases HDL more effectively than any other drug.

Abciximab MOA

Reversible blockage of GP IIb/IIIa, thus inhibiting the final step in platelet aggregation.

Drugs used to prevent Myocardial re-infarction and Death

SAAB - Statin, Antiplatelet (Aspirin), ACEI, Beta blocker.

Adverse effects of Statins

SAMS: Myalgia, Myopathy, Rhabdomyolysis

Apixaban MOA

Selective inhibition of factor Xa, Inhibits free and clot-bound factor Xa as well as prothrombinase activity.

Adverse effects of Clopidogrel

Similar to aspirin (Bleeding, GI bleeding and hemorrhagic stroke, Enteric-coated tablets may not reduce the risk for GI bleeding)

HMG-CoA Reductase Inhibitor

Statins

Heparin MOA

Suppresses coagulation by helping antithrombin inactivate thrombin, factor Xa, and other clotting factors thus reducing fibrin production.

Dabigatran education

Take with full glass of water. Discard 4 months after opening container.

The nurse will teach a patient who is prescribed niacin (Niacor) to prevent flushing of the face by doing what?

Taking 325 mg of aspirin 30 minutes before each dose

THROMBINS2

Thienopyridines (clopidogrel), Heparin, RAS (ACEI/ARB), Oxygen, Morphine, Beta blockers (atenolol, metoprolol), Invasive intervention (PCI/CABG), Nitroglycerin, Statins, 2 (aspirin)

Heparin contraindications

Thrombocytopenia, Uncontrollable bleeding, During and immediately after surgery of the eye, brain, or spinal cord.

Antidote for Warfarin overdose

Vitamin K

Oral anticoagulation therapy

Warfarin (increased risk of bleeding), Dabigatran, Apixaban