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
