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PHARM_WEEK 2_Antihyperlipidemics and Nitrates

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

Continuous use of nitroglycerin can produce tolerance within 24 hours. The mechanism may be depletion of ___.

sulfhydryl groups

Drugs relieve pain of ___ by increasing cardiac oxygen supply. They do not decrease oxygen demand.

variant angina

To prevent tolerance, nitroglycerin should be used in the lowest effective dosage, and long-acting formulations should be used on an intermittent schedule that allows at least 8 drug-free hours every day, usually during the ___.

night

Nitroglycerin undergoes very rapid inactivation in the ____. Hence, when the drug is administered orally, most of each dose is destroyed before reaching the systemic circulation.

liver

Statins can cause ___ damage. Tests of ___ function should be done at baseline and as clinically indicated thereafter.

liver

Treatment of high LDL cholesterol is based on the individual's 10-year risk of having a ___.

major coronary event

Statins can cause ___. Patients who experience unusual muscle pain, soreness, tenderness, and/or weakness should inform their provider. A marker for muscle injury ___ should be measured at baseline, before starting the drug, and whenever signs or symptoms that could be due to myositis or myopathy develop.

myopathy & creatine kinase (CK)

ANGINA PECTORIS

___ protect against ASCVD.

HDLs

Which drug is used for Stable angina and variant angina?

Nitroglycerin (nitroglycerin, isosorbide mono and dinitrate)

KEY POINTS Chapter 51 - Drugs for Angina Pectoris

What interfere with myosin?

Nitrates

For patients with chronic angina, longer acting isosorbide mono & dinitrate drugs must be given with at least an ___ nitrate free interval so that sulfhydryl can replenish.

8 hour (at night)

10. The healthcare provider prescribes lovastatin [Mevacor] for a patient discharged from the hospital post-myocardial infarction. Which instructions are most appropriate for the nurse to include in the patient's teaching plan? (Select all that apply.) A. "Do not start any new medications without first talking to your healthcare provider." B. "Before starting this medication a blood test will be done to check your total cholesterol level and to measure liver enzymes." C. "Take your medication in the morning, with a full glass of water for best results." D. "Take one 325-mg aspirin 30 minutes before your dose to lessen the problem of flushing and itching that can occur with this drug." E. "Lower the total fat and saturated fat in your diet by increasing your intake of fresh fruits and vegetables and whole grains."

A. "Do not start any new medications without first talking to your healthcare provider." B. "Before starting this medication a blood test will be done to check your total cholesterol level and to measure liver enzymes." E. "Lower the total fat and saturated fat in your diet by increasing your intake of fresh fruits and vegetables and whole grains." Lovastatin, simvastatin, and atorvastatin levels may be elevated when these drugs are combined with other drugs that inhibit CYP3A4. If these drugs are combined, caution is warranted. Before starting a statin, obtain a baseline lipid profile that includes total cholesterol and obtain baseline LFTs. The statins are taken once daily with food. It is recommended to take them with the evening meal because endogenous cholesterol synthesis increases during the night. The statins do not typically cause flushing and itching; that effect occurs with niacin. A diet low in total fat and saturated fat is recommended when antilipemic drugs are prescribed.

3. Which drug is the most effective for lowering LDL cholesterol? A. Atorvastatin [Lipitor] B. Cholestyramine [Questran] C. Gemfibrozil [Lopid] D. Ezetimibe [Zetia]

A. Atorvastatin [Lipitor] The statin drugs, such as atorvastatin, are the most effective drugs for lowering LDL cholesterol. They are better tolerated, have fewer adverse effects, and produce better clinical outcomes than any other agents available for lowering LDL.

10. Which are the main types of drugs used to prevent or relieve anginal pain? (Select all that apply.) A. Platelet inhibitors B. Beta blockers C. Nitrates D. Calcium channel blockers E. Statins

ANS: B. Beta blockers C. Nitrates D. Calcium channel blockers Rationale: The three main types of antianginal drugs are organic nitrates, beta blockers, and calcium channel blockers. Platelet inhibitors and statins (unless contraindicated) are incorporated into the treatment plan to reduce the risk of myocardial infarction.

8. Which discharge instructions should the nurse include for a patient prescribed cholestyramine [Questran]? A. Mix the drug with water or juice. B. Take with all other morning medications. C. Take 325 mg of aspirin 30 minutes before each dose. D. Notify the healthcare provider if upper abdominal discomfort occurs.

A. Mix the drug with water or juice. Cholestyramine [Questran] is supplied in powdered form. Mix the powder with liquids that include water, fruit juices, and soups because swallowing it can cause esophageal irritation. Certain oral medications should be administrated 1 hour before the sequestrant or 4 hours after. Flushing can occur with niacin and can be reduced by taking 325 mg of aspirin 30 minutes before each dose. Gemfibrozil and fenofibrate increase the risk of gallstones manifested with symptoms such as upper abdominal discomfort.

9. Which are beneficial effects that can be derived from simvastatin [Zocor] and other drugs in this class? (Select all that apply.) A. Reduction of LDLs B. Elevation of HDLs C. Stabilization of the plaque in coronary arteries D. Reduction of risk of cardiovascular events E. Improvement of liver function

A. Reduction of LDLs B. Elevation of HDLs C. Stabilization of the plaque in coronary arteries D. Reduction of risk of cardiovascular events The statin drugs have many benefits, the most important being reduction of LDLs. They also promote an increase in HDLs, stabilization of atherosclerotic plaque, and reduced inflammation at the plaque site. Among other benefits, they also slow progression of coronary artery calcification. The statins reduce the overall risk of cardiovascular events. They can have serious adverse effects on the liver, but these are relatively rare.

9. The nurse understands patients receiving nitroglycerin are at risk for which adverse effects? (Select all that apply.) A. Headache B. Wheezing C. Dizziness D. Tachycardia E. Bradycardia

ANS: A. Headache C. Dizziness D. Tachycardia Rationale: The primary adverse effects of nitroglycerin are headache; orthostatic hypotension, which can lead to dizziness; and reflex tachycardia.

What is the normal processing in the liver? ___, in the presence of ___, gets converted to ___. Then, it is converted to ___. This would raise the levels of cholesterol inside the hepatocyte.

ANS: HMG Co-A HMG Co-A reductase Mevalonic acid Cholesterol Rationale: This is the normal processing in the liver. HMG Co-A, in the presence of HMG Co-A reductase, gets converted to Mevalonic acid. Then, it is converted to cholesterol. This would raise the levels of cholesterol inside the hepatocyte.

6. A patient with angina is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse include? A. "Store the tablets in the original container and tightly close it after use." B. "The tablets are only good for 1 month after the container is opened." C. "Sublingual nitroglycerin tablets are also effective when swallowed whole." D. "Effects of sublingual nitroglycerin begin in 5 to 10 minutes."

ANS: A. "Store the tablets in the original container and tightly close it after use." Rationale: Sublingual nitroglycerin tablets should be stored moisture free at room temperature in their original container, which should be closed tightly after use. If stored correctly, the tablets should remain effective until the expiration date on the container. Sublingual nitroglycerin tablets are ineffective when swallowed whole. Effects of nitroglycerin begin in 1 to 3 minutes.

2. The nurse is providing discharge teaching for a patient with a new prescription for a nitroglycerin transdermal patch. Which statement by the patient indicates a need for further teaching? A. "I will remove my patch at bedtime each evening." B. "I will limit my alcohol to one drink per day." C. "I will not use Viagra as long as I am on nitroglycerin." D. "I will move slowly when changing positions."

ANS: B. "I will limit my alcohol to one drink per day." Rationale: Alcohol can intensify the hypotensive effects of nitrates, so the patient should avoid alcohol. Patients develop tolerance to nitrates rather quickly. Patients receiving transdermal nitrates are recommended to have 10 to 12 hours of patch-free time each evening. Sildenafil [Viagra] and other drugs for erectile dysfunction also can cause significant hypotension with nitroglycerin and are contraindicated. Nitroglycerin causes orthostatic hypotension; therefore, patients should change positions slowly.

5. A patient is receiving isosorbide dinitrate [Isordil] 20 mg 3 times/day for management of newly diagnosed stable angina. Which assessment finding would require an immediate nursing intervention? A. A change in blood pressure from 122/70 to 108/66 mm Hg B. An increase in the resting heart rate to 110 beats/min from baseline rates of 68 to 72 beats/min C. A headache the patient rates as a 5 on a pain scale of 0 to 10 D. Report of increased frequency of urination

ANS: B. An increase in the resting heart rate to 110 beats/min from baseline rates of 68 to 72 beats/min Rationale: Because nitrates lower blood pressure, isosorbide dinitrate can activate the baroreceptor reflex, causing sympathetic stimulation of the heart; this negates the benefits of treatment with nitrates, because it increases the cardiac oxygen demand. For these reasons, addressing the tachycardia becomes the nurse's immediate priority. A decrease in blood pressure would be expected, and there is no indication the patient is experiencing side effects of decreased cardiac output. Headache is an adverse effect and should be treated (eg, with acetaminophen), but it does not require immediate intervention. Increased frequency of urination may be related to the presence of a urinary tract infection and requires follow-up, but it is not the immediate concern.

8. The nurse is caring for a patient who is receiving enteral feedings because of dysphagia. The healthcare provider prescribes isosorbide mononitrate [Imdur] 60 mg SR daily via the enteral tube. What is the most appropriate action by the nurse? A. Have the patient swallow the pill, because it cannot be crushed. B. Call the healthcare provider about an alternate form of nitrate for administration. C. Crush the Imdur into a fine powder, dilute it with water, and administer it via the enteral tube. D. Place the nitrate under the patient's tongue and let it dissolve, because the person has dysphagia.

ANS: B. Call the healthcare provider about an alternate form of nitrate for administration. Rationale: The nurse should contact the prescriber for an alternate form of nitrate, such as a non-sustained-release pill, transdermal patch, topical ointment, or immediate release. Because isosorbide mononitrate is a sustained-release pill, it cannot be crushed. Because the patient has dysphagia, attempting to administer the pill orally could result in aspiration. Sustained-release tablets must be administered whole.

4. Which medication combination is useful in the treatment of variant angina? A. Metoprolol [Lopressor] and ranolazine [Ranexa] B. Isosorbide dinitrate [Isordil] and metoprolol [Lopressor] C. Diltiazem [Cardizem] and isosorbide mononitrate [Imdur] D. Propranolol [Inderal] and diltiazem [Cardizem]

ANS: C. Diltiazem [Cardizem] and isosorbide mononitrate [Imdur] Rationale: Variant angina, also known as Prinzmetal's or vasospastic angina, is a result of coronary artery vasospasm. Drug combinations used to prevent and/or relax the coronary artery are calcium channel blockers (eg, diltiazem) and organic nitrates (eg, isosorbide mononitrate). Beta blockers (metoprolol and propranolol) and ranolazine, although effective in stable angina, are ineffective for treating variant angina.

3. The nurse is monitoring a patient receiving ranolazine [Ranexa] for angina. Which assessment finding indicates an adverse effect of this drug? A. Blood pressure of 90/50 mm Hg B. Frequent bloody stools C. QT prolongation on the electrocardiogram D. Respiratory rate of 11 breaths per minute

ANS: C. QT prolongation on the electrocardiogram Rationale: Ranolazine can cause an increase in the QT interval on the electrocardiogram (ECG), mostly with increased doses. Other adverse effects include elevated blood pressure, headache, nausea, dizziness, and constipation.

1. The nurse is caring for a patient receiving nitrates for relief of angina. What pharmacodynamic action is responsible for the relief of anginal pain with nitrates? A. Vasoconstriction leads to improved cardiac output. B. Decreased force of contraction leads to decreased oxygen demand. C. Vasodilation leads to decreased preload, which decreases oxygen demand. D. Influx of calcium ions leads to relaxation of vascular smooth muscle.

ANS: C. Vasodilation leads to decreased preload, which decreases oxygen demand. Rationale: The primary action of nitroglycerin is vasodilation, which leads to decreased venous return, decreased ventricular filling, and decreased preload, thus reducing oxygen demand on the heart.

7. The home health nurse observes the patient for proper use of topical nitroglycerin ointment. Which action by the patient indicates the need for further teaching? A. Rotates the application sites to minimize skin irritation. B. Uses the applicator paper to measure the prescribed dose. C. Removes ointment from a previous dose before applying the next dose. D. Applies the prescribed ribbon of ointment to the applicator paper and places it on the chest.

ANS: D. Applies the prescribed ribbon of ointment to the applicator paper and places it on the chest. Rationale: Once the prescribed ribbon of ointment has been squeezed onto the applicator paper provided, the paper is used to spread the ointment over an area at least 2.5 by 3.5 inches. It is then covered with plastic wrap to prevent the ointment from being absorbed into the clothing. There is no mechanistic advantage to applying the ointment on the chest (over the heart). The ointment can be applied to the back, abdomen, or anterior thigh, as well as the chest. Sites should be rotated to minimize skin irritation.

Statins can slow progression of ___, decrease the number of adverse cardiac events, and reduce mortality.

ASCVD

Which lab test should be performed for hepatic damage?

AST,ALT, bilirubin

What are the Nursing considerations of Nitroglycerine?

Administration Preventing tolerance Patient safety Class Rationales: • Administration: Match the route to the required onset of action. If angina anticipated or present, give route with immediate onset of action. If managing chronic angina, give route that provides longer duration of action. • Preventing tolerance and nitrate free time. Depletion of sulfhydryl groups blocks the mechanism of nitrates. For patients with chronic angina, longer acting drugs must be given with at least an 8 hour nitrate free interval so that sulfhydryl can replenish. • Patient safety, especially with other antihypertensives - additive blood pressure lowering effect and risk of orthostasis.

___ has three forms: chronic stable angina, variant (vasospastic) angina, and unstable angina.

Angina pectoris

If a patient has person acute coronary syndrome, what is their clinical findings?

Angina, irreversible rest ischemia Class Rationale: Let's get the person acute coronary syndrome. Drawing: In our coronary artery, we have the atheroma and thrombosis as well. The the clinical definition of ACS is that the patient has thrombotic lesions (thrombosis as well). In this situation, the coronary arteries is blocked by atheroma and an overline thrombosis. In fact, there may be no blood flow through it. So, it doesn't even really matter what myocardial oxygen demand is, because the absence of blood flow through it is going to imbalance oxygen supply and demand. That situations only get worse if the person is exercising. In the case of ACS, either at rest or with exercising, there is really such restricted blood flow through the coronary artery that it can't possibly meet the demand to the myocardium. Clinical Finding: So what will that patient have? That patient will have angina (or its equivalent) and irreversible (if we don't do anything about it) rest ischemia (that is it patient does not need be exercising)

___ is prevented with one or more long-acting antianginal drugs (beta blocker, CCB, long-acting nitrate) supplemented with sublingual nitroglycerin when break- through pain occurs.

Anginal pain

___ occurs when cardiac oxygen supply is insufficient to meet cardiac oxygen demand.

Anginal pain

9. A patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. What do you educate the patient to do next?* A. Take another dose of Nitroglycerin in 5 minutes. B. Call 911 immediately C. Lie down and rest to see if that helps with relieving the pain D. Take two doses of Nitroglycerin in 5 minutes

Answer: B. Call 911 immediately If a patient's chest pain is not relieved with 3 doses of Nitroglycerin, taken 5 minutes apart, they should call 911 immediately. The patient should never exceed more than 3 doses of Nitroglycerin or take 2 doses at one time.

11. A patient taking Zocor is reporting muscle pain. You are evaluating the patient's lab work and note that which of the following findings could cause muscle pain?* A. Elevated potassium level B. Elevated CPK (creatine kinase level) C. Decreased potassium level D. Decreased CPK (creatine kinase level)

Answer: B. Elevated CPK (creatine kinase level) Zocor (a statin medication used for lowering cholestorl) can cause increased CPK levels which will lead to a patient experiencing muscle pain. Therefore, CPK levels must be monitored while a patient is taking this medication.

2. Which coronary artery provides blood to the left atrium and left ventricle:* A. Right marginal artery B. Posterior descending artery C. Left circumflex artery D. Right coronary artery

Answer: C. Left circumflex artery Rationale: The LCA provides blood to the left atrium and left ventricle.

4. A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as:* A. Unstable angina B. Variant angina C. Stable angina D. Prinzmetal angina

Answer: C. Stable angina Stable angina occurs during activities but goes away when the patient rests. Variant and Prinzmetal angina are the same and occur at rest during cycles. Unstable angina is chest pain felt during rest and is more severe.

12. A patient who has diabetes will be started on Metoprolol for medical management of coronary artery disease. Which of the following will you include in your discharge teaching about this medication?* A. Check your heart rate regularly because Metoprolol can cause an irregular heart rate. B. Check your glucose regularly because this medication can cause hyperglycemia. C. Check your blood pressure regularly because this medication can cause hypertension. D. Check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia.

Answer: D. Check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia. This patient needs to be educated to check their glucose levels regularly because this medication can mask the typical signs and symptoms of hypoglycemia. This is very important since the patient is diabetic.

10. Lipitor is prescribed for a patient with a high cholesterol level. As the nurse, how do you educate the patient on how this drugs works on the body?* A. Lipitor increases LDL levels and decreases HDL levels, total cholesterol, and triglyceride levels. B. Lipitor decreases LDL, HDL levels, total cholesterol, and triglyceride levels. C. Lipitor increases HDL levels, total cholesterol, and triglyceride levels. D. Lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels.

Answer: D. Lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels. Lipitor is a common "statin" medication used to lower cholesterol in CAD. It works by increasing HDL levels (the "good" cholesterol") and decreases LDL (the "bad" cholesterol"), total cholesterol, and triglyceride levels.

7. A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction?* A. absent Q wave B. QRS widening C. absent P-wave D. ST segment elevation

Answer: DST segment elevation This is a common finding on an EKG when a patient is having a myocardial infraction due to muscle damage.

13. True or False: ACE inhibitors work to decrease the workload on the heart by blocking the conversion of Angiotensin II to Angiotensin I which causes vasodilation.* True False

Answer: False. ACE inhibitors work to decrease the workload on the heart by blocking the conversion of Angiotensin I to Angiotensin II (not Angiotensin II to Angiotensin I as stated in the question) which causes vasodilation.

1. True or False: The left anterior descending coronary artery provides blood supply to the left ventricle, front of the septum and part of the right ventricle.* True False

Answer: True Rationale: ...the LAD (left anterior descending artery) provides blood supply to the left ventricle, front of the septum and collateral circulation to the right ventricle.

5. Keeping the patient in question 4 in mind: What type of diagnostic tests will the physician most likely order (at first) for this patient to evaluate the cause of the patient's symptoms? Select-all-that-apply:* A. EKG B. Stress test C. Heart catheterization D. Balloon angioplasty

Answers: A and B. A. EKG B. Stress test If the patient is experiencing STABLE angina (which in question 4 the patient's symptoms are stable) an EKG or stress test would be ordered to investigate if there are any EKG changes (ST depression) during exercise. These tests are usually ordered first and then the doctor may proceed with a heart catheterization. A balloon angioplasty is sometimes performed during a heart cath.

8. A patient is receiving treatment for stable coronary artery disease. The doctor prescribes the patient Plavix. What important information will you include in the patient's teaching? Select-all-that-apply:* A. If you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure. B. A normal side effect of this medication is a dry cough. C. Avoid green leafy vegetables while taking Plavix. D. Notify the doctor, immediately, if you develop bruising, problems urinating, or fever.

Answers: A and D. A. If you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure. D. Notify the doctor, immediately, if you develop bruising, problems urinating, or fever. Patients on Plavix should let their doctor know that they are taking Plavix because it should be discontinued 5 to 7 days before a surgical procedure due to increased risk of bleeding. Also, option D represents signs and symptoms of Thrombotic Thrombocytopenic Purpura a clotting disorder where clots form in the vessels of the body which is a complication of Plavix.

6. You're providing education to a patient who will be undergoing a heart catheterization. Which statement by the patient requires you to re-educate the patient about this procedure?* A. "The brachial artery is most commonly used for this procedure." B. "A dye is injected into the coronary arteries to assess for blockages." C. "Not all patients who have a heart catheterization will need a stent placement." D. "I will not be completely asleep and will be able to breathe on my own during the procedure."

Answers: A. "The brachial artery is most commonly used for this procedure." The femoral or radial artery is used during a heart cath...not the brachial.

3. Which patient(s) are most at risk for developing coronary artery disease? Select-all-that-apply:* A. A 25 year old patient who exercises 3 times per week for 30 minutes a day and has a history of cervical cancer. B. A 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day. C. A 45 year old female that reports her father died at the age of 42 from a myocardial infraction. D. A 29 year old that has type I diabetes.

Answers: B,C, D. B. A 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day. C. A 45 year old female that reports her father died at the age of 42 from a myocardial infraction. D. A 29 year old that has type I diabetes. Rationale: Remember risk factors for developing CAD include: smoking, family history, diabetes, being overweight or obese, and high cholesterol.

___ is a chronic inflammatory process that begins with accumulation of LDLs beneath the arterial endothelium, followed by oxidation of LDLs.

Atherogenesis

6. The nurse is caring for a patient prescribed a cholesterol-lowering drug. Which drug is least likely to cause systemic side effects? A. Simvastatin [Zocor] B. Colesevelam [Welchol] C. Nicotinic acid [Niaspan] D. Gemfibrozil [Lopid]

B. Colesevelam [Welchol] Colesevelam, a bile acid sequestrant, is a nonabsorbable resin that works directly in the gastrointestinal tract. Because it and other bile acid sequestrants (eg, cholestyramine [Questran] and colestipol [Colestid]) are not absorbed, they do not have systemic effects. The bile acid sequestrants' most common complication is constipation. The other agents have potential systemic adverse effects.

How do we reduce myocardial oxygen demand side of the equation?

Beta Blockers (BB) ACEi/ARBs Calcium Channel Blockers (CCBs) Class Rationale: Pharmacologic therapy manipulates the myocardial oxygen demand side of the equation to reduce the work of the heart muscle. Drugs that lower blood pressure (BB, ACEi/ARBs, CCBs) will lower myocardial oxygen demand and often used to manage angina and ischemic heart disease. Class Rationale: How do we reduce myocardial oxygen demand? We reduce it by giving the patient a drug that will lower the components of the blood pressure. Drugs that lower blood pressure (beta blockers, calcium channel blockers, aces and arbs) will lower oxygen demand. and that maybe their indication for a patient. You might have a patient that is getting this drug, and you think "oh they must have hypertension." Well maybe they do, but maybe also have ischemic heart disease.

___ prevent pain of stable angina primarily by decreasing heart rate and contractility, which reduces cardiac oxygen demand.

Beta blockers

1. The nurse is teaching a group of patients about dietary approaches to reduce cholesterol levels. Which statement is most important to include in the teaching? A. "Lower your cholesterol to 300 mg/day." B. "Eliminate red meat and pork from your diet." C. "Read food labels and reduce your intake of saturated fats." D. "Reduce salt consumption to keep your sodium intake to 2400 mg/day."

C. "Read food labels and reduce your intake of saturated fats." An increase in dietary cholesterol intake does not produce a large increase in blood cholesterol because of the body's feedback system. When cholesterol intake increases, endogenous production decreases. However, because the body uses dietary saturated fats to make cholesterol, an increase in saturated fat intake can produce a significant increase in blood cholesterol levels. To lower blood cholesterol, it is most important to lower saturated fat intake. Although red meat and pork should be limited, it is not necessary to eliminate them from the diet. Sodium intake is not directly related to lowering cholesterol levels.

5. A patient with an elevated triglyceride level is prescribed a sustained-release form of nicotinic acid [Slo-Niacin]. Which laboratory value is most important for the nurse to monitor for in this patient? A. Blood urea nitrogen (BUN) B. Complete blood count (CBC) C. Alanine aminotransferase (ALT) D. Creatine kinase (CK)

C. Alanine aminotransferase (ALT) The alanine aminotransferase (ALT or SGPT) would receive priority, because nicotinic acid is hepatotoxic and severe liver injury has been reported. Hepatotoxicity is more common with the sustained-release, controlled-release, or timed-released formulation.

2. The nurse understands that cholesterol is carried through the blood by lipoproteins. Which lipoprotein is most closely associated with coronary atherosclerosis? A. Very-low-density lipoprotein (VLDL) B. Apolipoprotein B-100 C. Low-density lipoprotein (LDL) D. High-density lipoprotein (HDL)

C. Low-density lipoprotein (LDL) Cholesterol is the primary core lipid of LDLs, which are responsible for carrying cholesterol to tissues outside the liver. Of all the lipoproteins, LDLs are the most significant contributors to coronary atherosclerosis. When pharmacologic agents are used to lower cholesterol, the primary goal is to reduce elevated LDL levels.

When a ___ is combined with a beta blocker, a dihydro- pyridine (e.g., nifedipine) is preferred to verapamil or diltiazem. Verapamil and diltiazem will intensify cardiosup- pression caused by the beta blocker, whereas a dihydro- pyridine will not.

CCB

___ relieve pain of variant angina by increasing cardiac oxygen supply. The mechanism is relaxation of coronary artery spasm.

CCBs

___ relieve the pain of stable angina by reducing cardiac oxygen demand. Two mechanisms are involved. First, all CCBs relax peripheral arterioles and decrease afterload. Second, verapamil and diltiazem reduce heart rate and contractility (in addition to decreasing afterload).

CCBs

Four statins—atorvastatin, fluvastatin, lovastatin, and simvastatin—are metabolized by ___, and hence their levels can be increased by ___ (e.g., cyclosporine, erythromycin, ketoconazole, ritonavir).

CYP3A4 inhibitors

What are the Drug interactions of Statins?

CYP3A4 inhibitors: erythromycin, grapefruit juice, Nifedipine Rationale: This is a drug with some interactions particularly with drugs that inhibit the side from P3A4 systems. some of the common drugs that do that will come talk about in this content: Nifedipine, erythromycin, grapefruit juice. Those drugs would inhibit the enzyme responsible for the biotransformation of statins. The result is that the Statin level in the blood would go up.

___ is determined by heart rate, contractility, preload, and afterload. Drugs that reduce these factors can help relieve anginal pain.

Cardiac oxygen demand

___ is determined by myocardial blood flow. Drugs that increase oxygen supply will reduce anginal pain.

Cardiac oxygen supply

Coronary Artery Disease (CAD) NCLEX Questions Registered RN

7. The nurse is caring for a patient prescribed gemfibrozil [Lopid]. For which patient should the nurse question the use of this drug? A. A patient with cardiovascular disease and elevated triglycerides B. A patient with elevated very-low-density lipoprotein (VLDL) levels C. A patient with elevated triglycerides who has not responded to dietary changes D. A patient with history of gallstones and elevated triglycerides

D. A patient with history of gallstones and elevated triglycerides Gemfibrozil is indicated to reduce elevated triglycerides and very-low-density lipoprotein levels primarily in patients who have not responded adequately to diet modification. It can also raise HDL but does not reduce LDL to a significant degree. Gemfibrozil increases the risk of gallstone formation and should not be used in patients with preexisting gallbladder disease.

4. A patient with cardiovascular disease is taking rosuvastatin [Crestor]. The nurse is monitoring for potential adverse effects. Which finding indicates a potential adverse effect of this drug? A. Blood pressure of 140/90 mm Hg B. Wheezing and shortness of breath C. Platelet count of 100 × 103/mm3 D. Muscle pain and tenderness

D. Muscle pain and tenderness The statins typically are well tolerated; however, in rare cases they can cause the serious adverse effect of myopathy and rhabdomyolysis. If unexplained muscle pain and tenderness develop, the prescriber should be notified. The other effects would not likely be caused by rosuvastatin.

If a patient is receiving isosorbide mono & dinitrate orally and continuously, what is the issue with this?

Deplete sulfhydrl group • Preventing tolerance and nitrate free time. Depletion of sulfhydryl groups blocks the mechanism of nitrates. For patients with chronic angina, longer acting drugs must be given with at least an 8 hour nitrate free interval so that sulfhydryl can replenish.

___ lowers LDL cholesterol by reducing cholesterol absorption in the small intestine. Like the statins, ___ can cause muscle injury.

Ezetimibe

Which drug More expensive then statins, but not by much?

Ezetimibe (Zetia) Class Rationale: Ezetimibe (Zetia) is mentioned this because it's it's on one of the algorithms for patients with the highest risk. This is an orally administered drug that just inhibits cholesterol absorption from the gut. its effects are very beneficial. You might see these two drugs combined. A patient gets a Statin because its mechanism of action is the liver & Ezetimibe (Zetia) because its mechanism of action is in the gut.

Which drug can be combined with a statin?

Which drug has an Effect on cholesterol (all the right things): Reduces total cholesterol, LDL cholesterol, TGs, and apolipoprotein B. Increases HDL cholesterol.?

Which drug is Not usually a first line therapy for Secondary and Primary prevention?

Which drug's mechanism of action is Orally administered drug that Inhibits dietary cholesterol absorption and reabsorption of cholesterol from bile?

True or False: Nitroglycerin is a vasodilator (dilates veins) so must dilate coronary arteries and therefore it must improve myocardial oxygen supply.

False Class Rationale: The mistake that people said it had is that they say "Oh, it's a vasodilator so must dilate coronary arteries and therefore it must improve myocardial oxygen supply?." The answer to that is NO. This is because the coronary artery is diseased with atheroma. That atheroma plaque is fixing the diameter of the blood vessel. It doesn't have vasodilating capabilities to it. (The veins will vasodilate because the arteries can't vasodilate) Drawing: In the drawing, the coronary artery cannot vasodilate because it has got this atheroma that's fixing it in place. That's why nitroglycerin does not vasodilate coronary arteries that are diseased.

Which drug Block hepatic cholesterol synthesis and intracellular cholesterol levels drop. In response, the hepatocyte upregulates LDL receptors which then remove LDL cholesterol from the blood stream.?