Pharmacology Ch. 37: Cardiac Glycosides, Antianginals, Antidysrhythmics
Types of antianginal drugs...
*Nitrates: reduction of venous tone, decreased workload of the heart, vasodilation *Beta blockers: decrease the workload of the heart and decrease oxygen demands *Calcium channel blockers: decrease the workload of the heart and decrease oxygen demands
Digitalis (Digoxin) Toxicity
*Overdose or accumulation of digoxin. S/S: anorexia, diarrhea, n/v, bradycardia (pulse less then 60), premature ventricular contractions, cardiac dysrhythmias, headaches, malaise, blurred vision, visual illusions (white,yellow,green halos around objects), confusion, delirium. *Older adults more prone to toxicity *May result in first or second degree, or complete heart block
Types of antidysrhythmic drugs Know what they do, not the classes-according to Lewis
*Restore cardiac rhythm to normal. *4 classes 1. sodium (fast) channel blockers IA, IB, IC 2. beta blockers 3. drugs that prolong repolarization 4. calcium (slow) channel blockers
Calcium Channel Blocker: Verapamil
*Bradycardia is a common problem *Used for angina pectoris, cardiac dysrhythmias, htn s/s:peripheral edema, constipation, dizziness, headache, and hypotension may occur Onset is 10 mins
What are the types of angina pectoris?
*Classic (stable): occurs with predictable stress or exertion *Unstable (Preinfarction): occurs frequently with progressing severity unrelated to activity;unpredictable regarding stress/exertion and intensity. **Often indicates impending MI** *Variant (Prinzmetal, vasospastic): Occurs during rest
What are the side effects of nitroglycerin?
*Most common:Headaches, may become less frequent with continued use Hypotension, dizziness, weakness, and faintness. If ointment or transdermal patch is d/c, dose should be tapered over several weeks to prevent rebound effect of severe pain caused by myocardial ischemia. Reflex tachycardia if given too rapidly.
Calcium Channel Blocker:nifedipine (Procardia, Adalat)
*Most potent of CCBs. *Promotes vasodilation of the coronary and peripheral vessels, hypotension can result. *In immediate-release form (10 mg, 20 mg capsules), have been associated with increased incidence of of sudden cardiac death. Usually only prescribed for acute increase in BP in hospital.
What are the types of antianginal drugs?
*Nitrates, beta blockers, calcium channel blockers Increase blood flow either by increasing oxygen supply or by decreasing oxygen demand by the myocardium. Major systemic effect of nitrates is reduction of venous tone, which decreases the workload of the heart and promotes vasodilation. Beta blockers and calcium channel blockers decrease workload of heart and decrease O2 demands
Cardiac action potentials
*Transient depolarizations followed by repolarizations of myocardial cells. * 5 phases Phase 0: rapid depolarization caused by influx of sodium ions Phase 1: initial repolarization, coincides with termination of sodium ion influx Phase 2: Plateau, influx of calcium ions, which prolong action potential and promote atrial and ventricular muscle contraction Phase 3: rapid repolarization caused by influx of potassium ions Phase 4: resting membrane potential between heartbeats. Normally flat in ventricular muscle, but begins to rise in cells of SA node as they slowly depolarize toward the threshold potential just before depolarization occurs, initiating next heartbeat
What calcium channel blockers have been used for long-term treatment of angina?
*Verapamil (calan), nifedipine (Procardia), diltiazem (Cardizem) Others available include cardene SR, Norvasc, Felendil XL, and Sular
What happens if digoxin cannot control afib?
*When digoxin cannot control afib to a normal heart rhythm, goal is to slow heart rate by decreasing electrical impulsed through AV node. A calcium channel blocker (calan) may be prescribed. Coumadin is also prescribed to prevent thromboemboli.
Chapter 42 information
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NCLEX study questions
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Powerpoint Questions
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A patient is prescribed a beta blocker. The nurse acknowledges that beta blockers are as effective as antianginals because they do what? A.Increase oxygen to the systemic circulation B.Maintain heart rate and blood pressure C.Decrease heart rate and decrease myocardial contractility D.Decrease heart rate and increase myocardial contractility.
C. Decrease heart rate and decrease myocardial contractility
Stages of heart failure
1(A): High risk for HF w/o symp or structurall heart disease 2(B): Some level of cardiac changes ex:decreased ejection fraction w/o symp of HF 3(C): Structural heart disease w/ symp of HF ex: fatigue, SOB, edema, decreased physical activity 4(D): Severe structural heart disease and marked symp of HF at rest.
When administering antianginal drugs, the nurses identifies which as the most common response? A.Tachycardia B.Bradypnea C.Hypotension D.Dry mouth
C. Hypotension *The most common side effect of antianginal drugs is hypotension.
Suggested steps for Treatment of Classic Angina Table 42-1 p. 611
1. Nitrates (vasodilates blood vessels) 2. Nitrates plus beta-blockers (decrease HR/BP, heart isn't working as hard for preload/afterload) 3. Nitrates plus beta-blockers plus calcium blockers (not good for acute chest pain-increase workload of heart).
Suggested steps for Treatment of Variant Angina Table 42-1 p. 611
1. Nitrates or calcium blockers 2. Nitrates plus calcium blockers 3. Coronary artery bypass graft
What drugs are used for acute heart failure?
First-line drugs: IV inotropic agents (dopamine and dobutamine), and phosphodiesterase inhibitors (milrinone). Secondary drug: Digoxin Other drugs include oral diuretics, beta blockers, ACE inhibitors, angiotensin-receptor blockers (ARBs), calcium channel blockers, vasodilators. These are more convenient to administer
What effects does digitalis preparations have on the heart?
1. positive inotropic action (increases myocardial contraction stroke volume) 2. Negative chronotropic action (decreases heart rate) 3. Negative dromotropic action (decreases conduction of heart cells
Atrial Natriuretic Hormone or Peptide (ANH) (ANP)
20-77 pg/mL normal Elevated may confirm HF ANH is secreted from atria of heart and acts as antagonist to renin and aldosterone. Released during expansion of atrium, produces vasodilation, increases GFR. Results of ANH secretion include a large volume of urine that decreases blood volume and blood pressure
The nurse identifies which drug as a calcium channel blocker used for the treatment of dysrhythmias? A.Diltiazem (Cardizem) B.Esmolol (Brevibloc) C.Flecainide (Tambocor) D.Sotalol HCl (Betapace)
A. Cardizem *Diltiazem (Cardizem) is a calcium channel blocker used to treat dysrhythmias. Esmolol (Brevibloc) is a beta blocker. Flecainide (Tambocor) is a sodium channel blocker. Sotalol HCl (Betapace) is a beta blocker.
A pt who has angina is prescribed nitroglycerin. What are appropriate nursing interventions for nitroglycerin? (Select all that apply). A. Have pt sit or lie down when taking a nitroglycerin sublingual tablet B. Teach pt who has taken a tablet to call 911 in 5 minutes if chest pain persists C. Apply Transderm-Nitro patch to a hairy area to protect skin from burning D. Call the health care provider after taking 5 tablets if chest pain persists E. Warn patient against ingesting alcohol while taking nitroglycerin
A. Have pt sit or lie down when taking a nitroglycerin sublingual tablet B. Teach pt who has taken a tablet to call 911 in 5 minutes if chest pain persists E. Warn patient against ingesting alcohol while taking nitroglycerin
The patient's serum digoxin level is 3.0 ng/mL. What does the nurse know about this serum digoxin level? A.It is in the high (elevated) range B.It is in the low (decreased) range C.It is within the normal range D.It is in the low average range
A. It is in the high (elevated) range
A nurse is administering digoxin, 0.125 mg, to a patient. Which nursing interventions will the nurse implement? (Select all that apply.) A.Checking the apical pulse rate before administration B.Monitoring the patient's serum digoxin level C.Instructing patient to report pulse rate less than 60 D.Advising patient to avoid foods high in potassium E.Always giving an antacid with digoxin to reduce GI distress
A.Checking the apical pulse rate before administration B.Monitoring the patient's serum digoxin level C.Instructing patient to report pulse rate less than 60 *The apical pulse should be taken before digoxin administration and the drug withheld if the heart rate is less than 60. The patient's serum digoxin level should be monitored and withheld if in toxic range. Therapeutic level is 0.5 to 2 ng/mL. Patient should be advised to eat foods high in potassium. Patient should be advised to avoid taking antacids with digoxin because they decrease absorption.
A patient is taking a potassium-depleting diuretic and digoxin. The nurse expects that a low potassium level (hypokalemia) could have what effect on digoxin (Lanoxin)? A.Increase serum digoxin sensitivity level B.Decrease serum digoxin sensitivity level C.Have no effect on serum digoxin level D.Cause a low average serum digoxin sensitivity level
A.Increase serum digoxin sensitivity level
Lab tests to confirm HF
ANP or BNP
Cardioselective beta blockers
Act more strongly on beta1 receptor, which decreased heart rate but avoids bronchoconstriction, because of lack of activity on beta2 receptor. ex: atenolol (Tenormin), and metoprolol (Lopressor, Toprol XL). *Group of choice for controlling angina pectoris.
Increased afterload
Additional pressure or force in the ventricular wall caused by excess resistance in the aorta. This resistance must be overcome to open the aortic valve so blood can be ejected into the circulation.
Cardiac glycosides (digoxin)
Also used to correct atrial fibrillation (cardiac dysrhythmia w/rapid uncoordinated contractions of atrial myocardium) and atrial flutter (cardiac dysrhythmia w/rapid contractions of 200-300 bpm) *This is accomplished by negative chronotropic effects (decreased heart rate) and negative dromotropic effects (decreased conduction through the AV node).
What would the nurse do if a patient had chest pain?
Always assess patient! Sit pt up, give oxygen ASAP! Give pt nitroglycerin-vasodilates blood vessels. If no order in for nitro, call physician to put order in after given.
What can a pt take if they cannot tolerate ACE inhibitors for treatment of HF?
Angiotension II receptor blockers (ARBs), such as valsartan (diovan) and candesartan (Atacand).
What is a cardiac dysrhythmia?
Any deviation from the normal rate or pattern of the heartbeat. This includes bradycardia, tachycardia, or irregular. *Dysrhythmia= disturbed heart rhythm *Arrhythmia= absence of heart rhythm ECG identifies the type of dysrhythmia *Frequently follow an MI, hypoxia, or hypercapnia, thyroid disease, CAD, cardiac surgery, excess catecholamines, electrolyte imbalance
Nitrates: Sublingual nitroglycerin tablet
Average prescribed dose is 0.4 mg following cardiac pain. If pain has not subsided or is worse, call 911. SL & IV: Onset is 1-3 mins Effects last for 10 mins. After dose, pt may feel dizziness, faintness, headache as result of peripheral vasodilation. *Most commonly used nitrate, also available in other forms and organic nitrates are available (isordil, imdur)
What should the pt avoid when taking antiysrhythmics?
Avoid alcohol, caffeine, and tobacco. Alcohol can intensify hypotensive reaction, caffeine increases catecholamine level, tobacco promotes vasoconstriction
The patient is receiving digoxin for treatment of heart failure. Which finding would suggest to the nurse that heart failure is improving? A.Pale and cool extremities B.Absence of peripheral edema C.Urine output of 60 mL/4h D. Complaints of increasing dyspnea
B. Absence of peripheral edema
The health care provider is planning to discontinue a patient's beta blocker. Which instruction will the nurse give the patient regarding the beta blocker? A.The beta blocker should be abruptly stopped when another cardiac drug is being prescribed B.The beta blocker should not be abruptly stopped; the dose should be tapered down C.The beta blocker dose should be maintained while taking another antianginal drug D.Half the beta blocker dose should be taken for the next several weeks
B. The beta blocker should not be abruptly stopped; the dose should be tapered down
A patient takes an initial dose of a nitrate. Which symptom(s) will the nurse expect to occur? A.Nausea and vomiting B.Headaches C.Stomach cramps D.Irregular pulse rate
B.Headaches
Preventing stable angina
Beta blockers
Beta Blockers
Beta-adrenergic blockers block the beta1 and beta2 receptor sites. Beta blockers decrease the effects of the sympathetic nervous system by blocking the action of the catecholamines (epinephrine and norepinephrine), thereby decreasing the heart rate and BP. *Used as antianginal, antidysrhythmic, and antihypertensive drugs. Effective as antianginals because by decreasing heart rate and myocardial contractility, they reduce the need for O2 consumption and reduce anginal pain. Most useful for classic (stable) angina. *Doses should be low initially and gradually increased. Beneficial effect:1-3 months
Nonselective beta blockers
Block beta1 and beta2 *Decrease heart rate and can cause bronchoconstriction. Should not be used in COPD/ashtma pts. Ex: propranolol (Inderal), nadolol (corgard), and pindolol (Visken).
Calcium channel blockers
Block calcium influx, slow conduction velocity, decrease myocardial contractility (negative inotropic), increase refraction in AV node *Used for supraventricular tachydysrhythmias, prevention of PSVT Ex: verapamil (Calan,Isoptin), diltiazem (Cardizem)-slow calcium channel blocker that blocks calcium influx, thereby decreasing the excitability and contractility of myocardium. Contraindicated for patients with AV block or HF.
Side effects and reverse reactions to beta blockers
Both nonselective and selective beta blockers cause a decrease in heart rate and blood pressure. *For nonselective:bronchospasm, behavioral/psychotic response, impotence (With use of Inderal). *Vital signs need to be closely monitored in early stages
The beta blocker acebutrol (Sectral) is prescribed for dysrhythmias. The nurse knows that what is the primary purpose of the drug? A. Increase beta1 and beta2 receptors in cardiac tissues B. Increase the flow of oxygen to cardiac tissues C. Block beta1-adrenergic receptors in cardiac tissues D. Block beta2-adrenergic receptors in cardiac tissues
C. Block beta1-adrenergic receptors in cardiac tissues
Cardiotoxicity resulting from digitalis toxicity
Cardiotoxicity=serious adverse reaction;ventricular dysrhythmias resulting from 1. Supression of AV conduction 2. Increased automaticity 3. Decreased refractory period in ventricular muscle *Antidysrhythmics phenytonin and lidocaine can treat
Nitrates
Cause generalized vascular and coronary vasodilation, which increases blood flow through the coronary arteries to the myocardial cells. Reduces preload and afterload. *Reduces myocardial ischemia but can cause hypotension
Angina Pectoris
Condition of acute cardiac pain caused by inadequate blood flow to myocardium due to plaque occlusions within or spasms of the coronary arteries. With decreased blood flow, there is decrease in O2 to myocardium, which results in pain. s/s: tightness, pressure in center of chest, pain radiating down left arm. Referred pain felt in neck/left arm occur with severe angina pectoris
The nurse is assessing a pt for possible evidence of digitalis toxicity. The nurse acknowledges that which is included in the signs and symptoms for digitalis toxicity? A.Apical pulse rate of 100 bpm B.Apical pulse rate of 72 bpm with irregular rate C.Apical pulse of 90 bpm and an irregular rate D.Apical pulse of 48 bpm and irregular rate
D. Apical pulse of 48 bpm and irregular rate
A patient with angina and a long history of severe chronic obstructive pulmonary disease is ordered beta blocker therapy. Which beta blocker would be most effective for this patient? A.Propranolol (Inderal) B.Nadolol (Corgard) C.Pindolol (Visken) D.Atenolol (Tenormin)
D. Atenolol (Tenormin) *Cardioselective beta blockers act more strongly on the beta1 receptor, which decreases the heart rate but avoids bronchoconstriction. Examples of selective beta blockers are atenolol (Tenormin) and metoprolol (Lopressor, Toprol-XL). Examples of nonselective beta blockers are propranolol (Inderal), nadolol (Corgard), and pindolol (Visken). These drugs decrease the heart rate and can cause bronchoconstriction.
Sodium Channel Blockers
Decreases sodium influx into cardiac cells. Responses to the drug are decreased conduction velocity in cardiac tissues, suppression of automaticity, increased recovery time (repolarization or refractory period) *Used for atrial/ventricular dysrhythmias, PAT, supraventricular dysrhythmia
Brain Natriuretic Peptide (BNP)
Desired value: less than 100 pg/mL Positive value: greater than 100 pg/mL Secreted from atrial cardiac cells, when tested, aids in diagnosis of HF. Diagnosing HF is difficult in pts with lung disease who are experiencing dyspnea, those who are obese, or who are older. Elevated BNP=dyspnea due to HF rather than lung dysfunction BNP=higher than 100 pg/mL in women 65+, BNP is remarkably higher in HF (ex:400) *BNP is more sensitive in diagnosing HF than ANP.
What is the antidote to treat Digitalis toxicity?
Digibond, ovine
What is frequently prescribed with digoxin or other agents?
Diuretics, first line drug treatment for reducing fluid volume
What are the drug interactions with nitrates?
Enhance hypotensive effect= beta blockers, calcium channel blockers,vasodilators, alcohol IV nitroglycerin= antagonize effects of heparin
What are some herbal alerts for digoxin?
Ginseng may falsely elevate levels St. Johns' Wort decreases absorption of dig and decreases serum digoxin levels Metamucil (psyllium)-decrease dig absorption Hawthorn-increase effect of dig Licorice- can potentiate effect of dig. Promotes potassium loss, which increases effect of dig. May cause dig toxicity Aloe-Increase risk of dig toxicity Ma-huang/ephedra-increases risk of dig toxicity Goldenseal-decrease effects of cardiac glycosides and increase effects of antidysrhythmics.
Right-sided heart failure
Heart does not sufficiently pump the blood returned into the right atrium from the systemic circulation. The blood and constituents are backed up into peripheral tissues, causing peripheral edema. May lead to left-sided failure or vice versa.
What is heart failure (pump failure)?
Heart muscle weakens and enlarges, loses ability to pump blood through the heart and into systemic circulation. When these compensatory mechanisms fail and the peripheral and lung tissues are congested, this is CHF.
Left-sided heart failure
Left ventricle does not contract sufficiently to pump blood returned from the lungs and left atrium out through the aorta into the peripheral circulation. This causes blood to back up into lung tissue. Pt has SOB and dyspnea.
Thyroid dysfunction while taking digoxin
Hypothyroidism=dose of digoxin should be decreased Hyperthyroidism=dose of digoxin should be increased
Treating unstable angina
Immediate medical care is necessary. Nitrates are usually given sublingually and IV as needed. If cardiac pain continues, beta blocker is given IV, if pt is unable to tolerate a beta blocker, a calcium channel blocker may be used.
Blood flow of heart
Inferior vena cava right atrium (deox blood) tricuspid valve right ventricle pulmonary semilunar valve pulmonary arteries Lungs (oxygenated blood) pulmonary veins left atrium bicuspid valve left ventricle aortic semilunar valve aorta rest of body arteries capillaries veins back to heart
Cardiac glycosides (digitalis glycosides)
Inhibits sodium-potassium pump, resulting in an increase in intracellular sodium. This increase leads to an influx of calcium, causing the cardiac muscle fibers to contract more efficiently.
What is the long acting Nitrate?
Isosorbide dinitrate (Isordil, Sorbitrate) *Prevents anginal pectoris attacks, can lower BP. Tolerance builds up over time. s/s: hadaches,dizziness, lightheadedness,flush may occur
Ventricular dysrhythmias
Life-threatening because ineffective filling of the ventricle and ineffective pumping results in decreased or absent cardiac output. With ventricular tachycardia, ventricular fibrillation is likely to occur, followed by death. CPR is necessary to treat these pts
Nonpharmacologic measures to treat HF
Limit salt intake to 2 g/day Alcohol decreased to 1 drink/day or avoided Fluid intake restrictions Avoid smoking Mild exercise Obese pts losing weight
Treating variant (vasospastic) angina
Nitrates and calcium channel blockers
Electrical impulses
Originates in SA node (Pacemaker) in right atrium AV node Bundle of His Bundle branches Purkinje fibers
spironolactone (Aldactone)- Potassium sparing diuretic Dose: 12.5-25 mg/day
Potassium-sparing diuretic used to treat mod to severe HF. Promotes body loss of potassium and magnesium needed by heart and increases sodium and water retention. (Blocks production of aldosterone) Improves heart rate variability , decreases myocardial fibrosis by cardioprotective effect of blocking aldosterone in heart and blood vessels to promote cardiac remodeling *Serum potassium should be monitored
What are the drug interactions with digitalis preparations that can cause dig toxicity?
Potent diuretics-Lasix, Hydrochlorothiazide-Esidrix, microzide *Promote loss of potassium-Hypokalemia increase effect of digoxin at myocardial cell site of action. Cortisone preparations taken systemically promote sodium retention and potassium excretion or loss which can also cause hypokalemia. * Pts who take these meds with digoxin should consume potassium rich foods or take potassium supplements Antacids decrease digitalis absorption if taken at the same time. Doses should be staggered to prevent this.
Atrial dysrhythmias
Prevent proper filling of ventricles and decrease cardiac output by 33%
Who should not take beta blockers?
Pts who have decreased heart rate and blood pressure. Pts who have second or third degree AV block
Beta Blockers..
Reduce calcium entry, decrease conduction velocity, automaticity, and recovery time (refractory period). *Used for atrial flutter and fibrillation, tachdysrhythmias, ventricular and supraventricular dysrhythmias *more frequently prescribed for dysrhythmias than calcium channel blockers Ex: propranolol (Inderal), acebutolol (sectral), esmolol (Brevibloc), and sotalol (Betapace).
What do cardiac glycosides, antianginals, and antidysrhythmics do?
Regulate heart contraction, heart rate and rhythm, and blood flow to the myocardium (heart muscle)
Increased preload
Results from an excess of blood volume in the ventricle at the end of diastole. There is increase in the stretching and thickening of the ventricular walls, which allows greater filling pressure associated with a weakened heart.
What should be checked when taking CCBs?
Serum liver enzymes should be checked periodically, can cause changes in liver and kidney function. *CCBs are frequently given with other antianginal drugs such as nitrates to prevent angina
What does the increased myocardial contractility from Digoxin strengthen?
Strengthens cardiac, peripheral, and kidney function by enhancing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and promoting fluid excretion. As a result, fluid retention in the lung and extremities are decreased. Digoxin doesn't prolong life, it acts by increasing the force and velocity of myocardial systolic contraction.
Why shouldn't beta blockers be abruptly discontinued?
Tachycardia and recurrence of anginal pain can occur, dose should be tapered over a specified numbers of days.
What should the nurse do if a pt is on digoxin?
obtain baseline pulse:Apical pulse should be taken for a full minute and should be greater than 60 bpm Assess for s/s of digitalis toxicity Determine signs of peripheral and pulmonary edema, which indicate HF is present. Monitor serum digoxin level. Serum greater than 2 ng/mL is indicative of digitalis toxicity. Monitor serum potassium level (3.5-5.3 mEq/L), report if hypokalemia is present. Advise pt to eat foods high in potassium: fresh and dried fruits, fruit juices, vegetables, including potatoes.
Drugs that prolong repolarization
prolong repolarization during ventricular dysrhythmias, prolong action potential duration *Used for life-threatening atrial and ventricular dysrhythmias resistant to other drugs Ex: Amiodarone (cordarone)-increases refractory period (recovery time) and prolongs the action potential duration (cardiac cell activity).
Digoxin serum level
Therapeutic serum level= 0.8-2.0 ng/mL To treat HF, lower serum levels should be obtained. To treat afib, higher serum levels are required.
Calcium Channel blockers
Treatment of stable and variant angina pectoris, certain dysrhythmias, HTN. Calcium activates myocardial contraction, increasing the workload of the heart and the need for more oxygen. CCBs relax coronary artery spasm (variant angina) and relax peripheral arterioles (stable angina), decreasing cardiac oxygen demand. Also decrease cardiac contractility (Negative inotropic effect that relaxes smooth muscle), decrease afterload, decrease peripheral resistance, and reduce the workload of the heart, which decreases the need for O2. *variant (vasospastic) angina-relax coronary arteries *classic (stable) angina-decreasing O2 demand
ACE inhibitors
Usually prescribed for HF Dilate venules and arterioles, improving renal blood flow and decreasing fluid blood volume. Moderately decrease aldosterone, which in turn reduces sodium and fluid retention. Can increase potassium levels, serum should be monitored, especially if potassium-sparing diuretics (Aldactone) are being taken
Nonpharmacologic measures to control angina
avoid heavy meals, smoking, extreme weather changes, strenuous exercise, and emotional upset. Proper nutrition, moderate exercise, adequate rest, and relaxation techniques are used as preventive measures
-lol
beta blockers
cardizem
cardizem=CARDI=heart=dysrhytmias
What are the causes of heart failure?
chronic HTN, myocardial infarction, CAD, valvular heart disease, congenital heart disease, arteriosclerosis
What does digitalis help treat?
heart failure (cardiac failure), previously referred to CHF
Antidysrhythmics-medications
know uses and considerations p. 614-615
Hcl
lasix type
