Seminar on drugs used in cardiac diseases Introduction
Cardiovascular drugs encompass a large number of prescription medications that are used to control heart disease. It is a complicated group of drugs with many being used for multiple heart conditions. You may also encounter patients who have one or more cardiovascular conditions such as CHF, hypertension and an arrhythmia. These patients may be taking multiple medications for each condition. If you look at the list of Top 200 drugs, you will find that 25% of those drugs are cardiovascular drugs, which is another good reason to become familiar with these drugs and how they might interact with other medications.
CLASSIFICATION OF CARDIAC USED IN CARDIAC DISEASES
1. Anti-arrhythmic agent The arrhythmias are conceptually sirnple-dysfunctions cause abnormalities in impulse formation and conduction in the myocardium. However, in the clinic, arrhythmias present as a complex family of disorders that show a variety of symptoms. For example, cardiac arrhythmias may cause the heart to beat too slowly (sinus bradycardia) to beat too rapidly (sinus or ventricular tachycardia, atrial or ventricular premature depolarization, atrial flutter) to respond to impulses originating from sites other than the SA node to respond to impulses traveling along accessory (extra) pathways that lead to deviant depolarizations (A-V reentry, Wolff-Parkinson White syndrome). In order to make sense of this large group of disorders, it is useful to organize the arrhythmias into groups according to the anatomic site of the the abnormality-the atria, AV node, or the ventricles. Class of anti-arrhythmia drug Class 1 sodium channel blocker e.g. flecanide, quinidine Class 2 beta adrenoreceptor blocker e.g. metoprolol, propanolol Class 3 sodium channel blocker e.g. amiodarone Class 4 calcium blocker e.g. diltiazem, verapamil, nifedipine Other Anti-arrhythmic drug e.g. adenosine, digoxin
2. Anti-anginal drug Angina pectoris is a characteristic chest pain caused by coronary blood flow that is insufficient to meet the oxygen demands of the myocardium. The imbalance between oxygen delivery and utilization may result from a spasm of the vascular smooth muscle or from obstruction of blood vessels caused by atherosclerotic lesions. Angina is characterized by a sudden, severe pressing substernal pain radiating to the left arm. Organic nitrates e.g. isosorbide dinitrate, nitroglycerin Beta blocker e.g. propanolol Calcium channel blocker e.g. diltiazem, verapamil, nifedipine
3. Drugs affecting blood Platelet inhibitor e.g. aspirin, ticlopidine Anticoagulant e.g. enoxaparin, warfarin, heparin. Thrombolytic agent e.g. urokinase, streptokinase Treatment of bleeding e.g. aminocaproic acid, vitamin k, tranexamic acid Treatment of anemia e.g. folic acid, cyanocobalamine, iron
4. Antihypertensive drug Hypertension is defined as a sustained diastolic blood pressure greater than 90 mm Hg accompanied by an elevated systolic blood pressure (>I 40 mm Hg). Hypertension results from increased peripheral vascular smooth muscle tone, which leads to increased arteriolar resistance and reduced capacitance of the venous system. Elevated blood pressure is an extremely common disorder, Although hypertension may occur secondary to other disease processes, more than 90% of patients have essential hypertension, a disorder of unknown origin affecting the blood pressure-regulating mechanism. A family history of hypertension increases, the likelihood that an individual will develop hypertensive disease. Essential hypertension occurs four times more frequently among blacks than among whites, and it occurs more often aniong middle-aged males than among middle-aged females. Environmental factors such as a stressful lifestyle, high dietary intake of sodium, obesity, and smoking all further predispose an individual to the occurrence of hypertension. Diuretics e.g. hydrochlorothiazide, frusemide, spirolactone Alpha blocker e.g. doxazosin, prazosin Beta blocker e.g. metoprolol, propanolol ACE inhibitor e.g. catopril, analapril, ramipril Angiotensin II antagonist e.g losartan Calcium channel blocker e.g. diltiazem, verapamil, nifedipine, amlodipine
Vasodilators e.g sodium nitropruside
5. Inotropic agents Positive inotropic agent e.g. dobutamine Negative inotropic agent e.g. dopaamine 6. Cardiac glycosides e.g. digoxin, digitoxin 7. Hypolipidemic agents e.g. statin
Group of drug – antiarrhythmic agent, sodium channel blocker Pharmacological name- flecanide Trade name – Almarytm, Apocard, Ecrinal, Flécaine Dose of drug – 1-2.5mg/kg/body wt Route of drug - oral Action - Flecainide is is a class I C antiarrhythmic agent, Flecainide has local anesthetic activity and belongs to the membrane stabilizing (Class 1) group of antiarrhythmic agents; it has electrophysiologic effects characteristic of the IC class of antiarrhythmics, ntiarrhythmic actions are mediated through effects on sodium channels in Purkinje fibers. Flecainide is a sodium channel blocker, binding to voltage gated sodium channels. It stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses. Ventricular excitability is depressed and the stimulation threshold of the ventricle is increased during diastole. Indication: prevention of paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disablin Contraindication: hypersensitivity, cardiogenic shock, CHF, pre-existing sinus node dysfunction or 2nd or 3rd degree heart block (without a pacemaker), renal impairment, pregnancy, lactation or children. Adverse effect Nausea and vomiting, convulsions, hypotension, bradycardia, syncope, extreme widening of the QRS complex, widening of the QT interval, widening of the PR interval, ventricular tachycardia, AV nodal block, asystole, bundle branch block, cardiac failure, and cardiac arrest. CNS – dizziness, anxiety, fatigue, headache, mental depressin. tremor, Blurred vision, Chest pain, CHF
Role and responsibility of nurse Monitor ECG may cause QRS widening, PR prolongation, QT prolongation Monitor intake and output, daily weigh the patient Asses for signs of CHF Monitor Blood pressure and pulse throughout the therapy
Group of drug - antiarrhythmic agent (class 1 A), sodium channel blocker Pharmacological name–Quinidine Dose of drug– PO (Adults): 324–972mg q 8–12 hr. IV (Adults): 200–400 mg given at a rate <10 mg/min until arrhythmia is suppresses Action – decrease myocardial excitability, Slow conduction velocity and suppresses arrhythmias Indication –atrial fibrillation, atrial flutter, recurrent ventricular arrhythmias and treatment of malaria Contraindication - hypersensitivity, conduction defects (without a pacemaker), myasthenia gravis, CHF, severe liver dosease, Hypokalemia or hypomagnesemia(↑ risk of torsades de pointes); Bradycardia (↑risk of torsades de pointes), pregnancy, lactation or children.
Role and responsibility of nurse Monitor ECG, pulse and blood pressure continuously throughput IV administration and periodically during oral administration For IV Use only clear, colorless solution Rapid administration may cause peripheral vascular collapse and severe hypotension. Advice the patient to remain in supine position throughout the IV administration to minimize hypotension
Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker Pharmacological name - metoprolol Trade name - tartarate 25, 50, 100mg Dose of drug– PO (Adults): Antihypertensive/antianginal—25–100 mg/day as a single dose initially or 2 divided doses, 450 mg/day (for angina, give in divided doses) MI—25–50 mg (starting 15 min after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily for a minimum of 3 month. Heartfailure—12.5–25 mg once daily Migraneprevention—50–100 mg 2–4 times daily
IV (Adults): Action Blocks stimulation of beta1(myocardial)-adrenzinergic receptors. Does not usually affect beta2 (pulmonary, vascular, uterine) adrenergic receptor sites. decreases blood pressure and heart rate. De creased frequency of attacks of angina pectoris. Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure Indication - Hypertension. Angina pectoris. Prevention of MI, heart failure due to ischemic, ventricular arrhythmias/tachycardia, Migraine, tremors, drug induced akathesia, anxiety Contraindication - Uncompensated CHF, Pulmonary edema, Cardiogenic shock, Bradycardia or heart block Adverse effect CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia,memory loss, mental status changes, nervousness, nightmares. EENT: blurred vision, stuffy nose. Resp: bronchospasm, wheezing CV: bradycardia, CHF, pulmonary edema, hypotension, peripheral vasoconstriction. MI—5 mg q 2 min for 3 doses, followed by oral dosing
GI: constipation, diarrhea, drug induced hepatitis, drymouth, flatulence, gastricpain, heartburn. GU: erectile dysfunction MS: arthralgia, back pain, joint pain
Role and responsibility of nurse Monitor vital sign and ECG every after parenteral administration, if HR <40 adminiter atropine 0.25-0.50mg IV Monitor intake and output and weigh daily Administer without dilution Angina: Assess frequency and characteristics of anginal attacks periodically during herapy. PO: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify health care professional. Administermetoprolol withmeals or directly after eating Teach patient and family how to check pulse daily and blood pressure biweekly and to report significant changes to health care professional
Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker Pharmacological name - Propanolol Trade name - novopropranolol Dose of drug– Oral Antianginal 80-320mg/day in 2-4 divided doses.(childrens 0.5-1mg/kg/day in 24 divided doses) Antihypertensive 40mgtwice daily (usual range 120-240mg/day) Antiarrhythmia 10-30mg/day
Intravenous Adults 1-3 mg repeated after 2 min and again in 4 hr if needed Children 0.01-0.1 mg/kg repeated after 6-8 hr
Action: Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)adrenergic receptor sites. Decreases heart rate and blood pressure, suppresses arrhythmia and prevents MI Indication Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma. Also used in the prevention and management of MI and prevention of vascular headaches Unlabeled uses: Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic associated akathisia, situational anxiety, and block esophageal varices. Post-traumatic stress disorders (PTSD) . Contraindication Uncompensated CHF, Pulmonary edema; Cardiogenic shock; Bradycardia or heart block Adverse effect CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares. EENT: blurred vision, dry eyes, nasal stuffiness. Resp: bronchospasm, wheezing CV: arrhythmias, bradycardia, CHF, pulmonary edema GU: erectile dysfunction
Role and responsibility of nurse Monitor blood pressure and pulse frequently during dose adjustment period and periodically during therapy. Abrupt withdrawal of propranolol may precipitate life-threatening arrh1hmias, hypertension. or myocardial ischemia. Drug should be tapered over a 2 week period before discontinuation. Assess patient carefully during tapering and after medication is discontinued. Consider that patients taking propranolol for noncardiac indications may have undiagnosed cardiac dosease. Abrupt discontinuation or withdrawal over too-short a period of time (less than 9 days) should be avoided In children assess pediatric patients for signs and symptoms of hypoglycemia, particularly when oral foods and fluids are restricted. Patients receiving propranolol IV must have continuous ECG monitoring and may have pulmonary capillary wedge pressure (PCWP) or central venous pressure (CVP) monitoring during and for several hours after administration. Assess for orthostatic hvpotension when assisting patient up from supine position.
Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnoea, weight gain jugular venous distension Informthe patient abrupt withdrawal can cause life threatening arrhythmias, HT, myocardial ischemia. During intravenous administration should be diluted in 50 ml of NaCL 0.9% or D5% and infuse over 10-15 min
Group of drug - antiarrhythmic class III Pharmacological name – Amiodarone Trade name - cardarone, pacerone Dose of drug: 1ml contains 50 mg amiodarne Oral Adults 800-1600mg/day in 1-2 doses for 1-3 wk, then 600-800mg/day in 1-2 doses for 1 month then 400mg maintenance dose Children 10mg/kg/day for 10 days, then 5 mg/day for several weeks then 2.5 mg/kg/day maintenance dose.
Intravenous Adults: 150 mg over 10 min, followed by 360 mg over the next 6 hr and then 540 mg over the next 18 hr. Continuous infusion at 0.5 mg/min until oral therapy is initiated, if arrhythmia recurs, a small loading infusion of 150 mg over 1 0 min should begiven in addittion,the rate of the maintenance infusion may be increased. Conversion to initial oral therapy—Ifdu ration of IV infusion was <1 wk, oral dose should be 800-1600 mg/day; if IV infusion was 1-3 wk oral dose should be 600-800 mg/day if IV infusion was >3w k. oral dose should be 400 mg/ day. ACLSguidelines for pulseless ventricular fibrillation or ventricular tachycardia 5 mg/kg as bolus. Supraventricular Tachycardia
Adults 600-800mg/day for 1 wk or until desired response occurs or side effects develop,then decrease to 400 mg/day for 3 wk. then maintenance dose of 200—400 mg/day. Children 10 mg/kg/day for 10 days or until response or side effects occur, then 5 mg/kg/day for several weeks, then decreased to 2.5 mg/kg/day lowest effective maintenance dose.
Role and responsibility of nurse Monitor ECG continuously during IV therapy or initiation of oral therapy. Monitor heart rate and rhythm Asses for signs of pulmonary toxicity (rales, crackles, decreased breath sound, pleuritic friction rub) Asses for sign and symptoms of ARDS (dyspnoea, tachycardia, rales or crackles) Monitor liver and thyroid function before administration For continuous infusion dilute 900mg in 500ml of D5%
Group of drug – antiarrhythmia class IV, antihypertensive, antianginals, calcium channel blocker. Pharmacological name - diltiazem Trade name–cardiazem, taztia XT Dose of drug Oral: 30-120 mg 3-4 times daily or 60-120 mg twice daily or 180-240 mg once a day (max 360mg/day) Intravenous: 0.25 mg/kg repeat in 15 min with 0.35mg/kg Continuous infusion at 10 mg/hr for 24 hr (5-15mg/hr)
Action Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation contraction coupling and subsequent contraction, results in decreased blood pressure, coronary vasodilatation and suppresses arrhythmias Indication Hypertension, Angina pectoris and vasospastic angina, Supraventricular tachycardia and rapid ventricular rates in atrial flutter or fibrillation. Contraindication Hypersensitvity, 2nd or 3rd degree AV block, recent MI, pulmonary congestion, blood pressure <90 mm Hg, CHF Adverse effect CNS: abnormal dreams, anxiety, confusion. EENT: blurred vision, disturbed eqilibrium, epistaxis tinnitus. Resp: cough, dyspnoea. CV: arrhythmias, CHF, peripheral edema, bradycardia, chest pain, hvpotension. palpitations, svncope, tachvcardia. Misc: stevens-johnson syndrome, gingival hyperplasia.
Role and responsibility of nurse
Monitor blood pressure arid pulse prior to therapy, during dose titration, and periodically during therapy. Monitor ECG during prolonged therapy, may cause prolonged PR interval, asses for bradycardia Monitor intake and output ratios and daily weight Assess for signs of CHF (peripheral edema, rales/crackles, dvspnoea, weight gain, jugular venous distention). Monitor frequency of Prescription refills to determine adherence. Patients receiving digoxin concurrently with calcium channel blockers should have routine serum digoxin levels checked and bemonitored for signs of digoxin toxicity. Do not open, crush, break or chew sustained capsule or tablet
Group of drug: antianginals, antiarrhythmiac agents class IV, antihypertensive, vascular headache suppressants, calcium channel blocker Pharmacological name: verapamil Trade name : apo-verap, isoptin, verelan Dose of drug Route/Dosage P0 (Adults): 80-1 20 mg 3 times daily, increased as needed. Patients with poor ventricular function, hepatic impairment, orgeriatric patients 40 mg 3 times daily initially. Extended-releasepreparations 120-240 mg/day as a single dose; may he increased as needed (range 240-480 mg/day). P0 (Children up to 15 yr): 4-8 mg/kg/day in divided doses. IV (Adults): 5-10mg (75-150 mcg/kg); may repeat with 10mg (150 mcg/kg) after 15-30 min. IV (Children 1-15 yr): 2-5mg (l00-300 mcg/kg); may repeat after 30 min (initial dose not to exceed 5 mg: repeat dose not to exceed 10mg). IV (Children <1 yr):0.75-mg (100-200 mcg/kg), repeat after 30 min.
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Decreases SA node and AV node conduction and prolongs AV node refractory period in conduction tissue. Systemic vasodilatation, resulting in decreased blood pressure. Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina. Suppression of ventricular tachycarrhythmias.
Indication Management of hypertension, angina pectoris, vasospastic angina (prinzmetal’s). Management of Supraventricular arrhythmias, rapid ventricular arrhythmia, rapid ventricular rates in atrial flutter or fibrillation. Prevention of migraine, management of cardiomyopathy.
Contraindication Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, BP <90 mmHg,CHF, Severe ventricular dysarrhythmias, cardiogenic shock,
Role and responsibility of nurse Monitor blood pressure and pulse before and after therapy Monitor ECG during prolonged therapy (causes prolonged PR interval and bradycardia) Weigh daily, monitor intake output Asses for signs of CHF (peripheral edema, rales/crackles, dyspnoea, dspnoea, weight gain, jugular vein distension) Administer undiluted and administer over 2min.
Group of drug:- antianginals, antihypertensive, calcium channel blocker. Pharmacological name:- Nifedipine Trade name:- adalat XL, procardia Dose of drug PO (adults):- 10-30mg 3 times daily (not to exceed 180mg/day) or 30-90 mg once daily as sustained release form (CC, XL) (not to exceed 90-120 mg/day) Action
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Systemic vasodilatation, resulting in decreased blood pressure. Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina
Indication Management of hypertension(extended release only), angina pectoris, vasospastic angina. Prevention of migraine headache Management of CHF or cardiomyopathy.
Contraindication Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, BP <90 mmHg Co-administration with grapefruit juice, history of porphyria
Role and responsibility of nurse Monitor blood pressure and pulse before and after therapy Monitor ECG during prolonged therapy (causes prolonged PR interval and bradycardia) Weigh daily, monitor intake output Asses for signs of CHF (peripheral edema, rales/crackles, dyspnoea, dspnoea, weight gain, jugular vein distension) In geriatric patients asses fall risks and institution fall prevention strategies. Do not open, crush, break or chew extended release tablets
Group of drug:- antiarrhythmic Pharmacological name:- adenosine Trade name:- adenocard, adenoscan Dose of drug:IV (adult and children>50kg): Antiarrhythmic- 6mg by rapid bolus; if no result repeat 1-2 min later as 12 mg rapid bolus (dose can be repeated not more than 12mg). Diagnostic:- 140 mcg/kg/min for 6 min (0.84m/kg) IV (children <50kg): Antiarrhythmic- 0.05-0.1 mg/kg as rapid bolus; if no result repeat by 0.05-0.1mg/kg until sinus rhythm is established or maximum dose of 0.3mg/kg is used.
Availability o Injection adenacard 6mg/2ml vial o Injection adenoscan 3mg/1ml in 30 ml vial
Action Restores normal sinus rhythm by interrupting re-enterant pathway in AV node. Slows conduction time through the AV node, also produces coronary vasodilatation. Indication
Paraoxymal Supraventricular tachycardia(PSVT) when vagal maneuvers are unsuccessful. To asses myocardial perfusion defect occurring as a result of coronary artery dosease.
Contraindication Hypersensitivity, 2nd or 3rd degree AV block or sick sinus syndrome Patient of asthama (induces bronchospasm), unstable angina
Role and responsibility of nurse Monitor heart rate frequently 10-15 min& ECG during therapy. Monitor blood pressure & respiratory status. Administer undiluted followed by saline flush Do not refrigerate can develop crystals.
Group of drug:- antiarrhythmic, inotrope, digitalis glycoside Pharmacological name:- digoxin Trade name:- lanoxin Dose of drug IV adults: -0.5-1mg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval IV children >10yr: -8-10mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. IV children 5-10yr: - 15-30mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval.
IV children 2-5yr: - 25-35mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval IV children 1-24month: - 30-50mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval IV infant fullterm: - 20-30mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval IV infant premature: - 15-25mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval.
PO adults: - 0.75-1.5mg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 0.125-0.5mg/day as tablets or 0.35-0.5 mg/day as gelatin capsule, depending on patients lean body weight, renal function & serum level. PO children >10yr: - 10-15mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 2.5-5mcg/kg given as a single dose. PO children 5-10yr: - 20-35mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 5-10mcg/kg given in daily 2 divided doses. PO children 2-5yr: - 30-40mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 7.5-10mcg/kg given in daily 2 divided doses. PO children 1-24month: - 35-60mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 10-15mcg/kg given in daily 2 divided doses. PO infant fullterm: - 25-35mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 6-10mcg/kg given in daily 2 divided doses. PO infant premature: - 20-30mcg/kg given as 50% of dose initially & 1/4th of initial dose in each subsequent dose at 6-12 hrs interval. Maintenance dose 5-7.5mcg/kg given in daily 2 divided doses.
Increases the force of myocardial contraction. Prolongs refractory period of the AV node. Decreases conduction through the SA & AV nodes. Increases cardiac output (positive inotropic effect) and slowing of heart rate (negative inotrope). Indication CHF, tachycardia, Atrial fibrillation and atrial flutter, paraoxysmal atrial tachycardia. Contraindication Hypersensitivity, uncontrolled ventricular arrhythmias, AV block Idiopathic hypertrophic subaortic stenosis, constrictive pericarditis, Alcohol intolerance
Role and responsibility of nurse Monitor apical pulse for 1 full minute before administration. Withhold dose and notify physician if pulse rate is <60/min in adult, <70/min in children, <90/min in infant. Monitor blood pressure periodically in patient receiving IV digoxin. Monitor ECG throughout IV administration and 6 hours after each dose Observe IV site for redness or infiltration, extravasation can lead to tissue irritation and sloughing. Monitor intake and output, weigh daily. Enquire history of previous digitalis therapy after administration. Teach the patient about pulse monitoring and notify, if <60min and >100 min. Instruct the patient for follow up. Assess the patient’s clinical response to digoxin therapy by evaluatingrelief of symptoms such as dyspnea, orthopnea, crackles, hepatomegaly and peripheral edema. Monitor serum potassium levels in patients receiving digoxin,especially those receiving both digoxin and diuretics. Anundetected, uncorrected potassium imbalance predisposes patients to digoxin toxicity and dysrhythmias. Assess for symptoms of electrolyte depletion: lassitude, apathy, mental confusion, anorexia, decreasing urinary output, azotemia. Monitor the patient for factors that increase the risk of toxicity:
o Oral antibiotics, quinidine, amiodarone, calcium channelblocker therapy. o Decreased potassium level (hypokalemia), which increases theaction of digoxin and which may be caused by malnutrition,diarrhea, vomiting, or prolonged muscle wasting o Impaired renal function, particularly in patients age 65 andolder with decreased renal clearance. Before administering digoxin, it is standard nursing practice to asses sapical heart rate. When the patient’s rhythm is atrial fibrillation and the heart rate is less than 60, or the rhythm becomes regular, the nurse may withhold the medication and notify thephysician, because these signs indicate the development of AVconduction block. Although withholding digoxin is a common practice, the medication does not need to be withheld for a heartrate of less than 60 if the patient is in sinus rhythm becausedigoxin does not affect sinoatrial node automaticity. Measuringthe PR interval for a patient with cardiac monitoring is moreimportant than the apical pulse in determining whether digoxinshould be held.Note: If monitoring discloses that the patient is in sinusrhythm, the nurse monitors the patient’s PR interval instead ofthe patient’s heart rate. If the patient is in atrial fibrillation, thenurse monitors for the development of regular R-R intervals,indicating AV block. Monitor for gastrointestinal side effects: anorexia, nausea, vomiting,abdominal pain and distention. Monitor for neurologic side effects: headache, malaise, nightmares,forgetfulness, social withdrawal, depression, agitation,confusion, paranoia, hallucinations, decreased visual acuity,Yellow or green halo around objects (especially lights), or―snowy‖ vision. Observe for and anticipate potential drug interactions whenother medications are added to the patient’s regimen. This isan important step in preventing toxicity. For example, antiarrhythmicand antibiotic medications may increase theamount of digoxin available to the patient. Diuretics maydecrease the amount of potassium and increase the availabilityof digoxin. In addition, because digoxin is eliminated by thekidneys, renal function (serum creatinine and urine creatinineclearance) are monitored carefully.
Group of drug:- antaniginal, Pharmacological name:- isosorbide dinitrate Dose of drug
ISOSOBIDE DINITRATE SL (ADULTS): Acute attack of angina pectoris: - 2.5-5mg repeated after 5-10 min for 3 doses in 15-3 min PO (ADULTS): Prophylaxis of angina :- 5-20mg 2-3 times daily
ISOSORBIDE MONONITRATE PO (ADULT): 5-20mg twice daily with 2 doses given 7 hours apart
Action Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks. Indication Acute treatment of angina attack Prophylactic management of angina pectoris Unlabeled CHF
Contraindication Hypersensitivity Concurrent use of sildenafil,verdanefil
Adverse effect CNSdizziness, headache CVhypotension, tachycardia, paradoxic bradycardia, syncope GI nausea and vomiting
Role and responsibility of nurse Assess location, duration, intensity and precipitating factors of angina pain.
Monitor blood pressure and pulse during the regimen Extended release capsules should be swallowed whole, do not crush, break or chew. Avoid drinking, eating or smoking. Inform the patient headache is common side effect should decrease with continuing therapy
Group of drug:- antianginals Pharmacological name:- nitroglycerin Trade name:- nitrocard,nitrol, nitrostat Dose of drug SL (adults):- 0.3-0.6mg, subligual spray1-2 sprays, 5-10 min before activities that may precipitate an caute attack. BUCCAL (adults):- 1mg every 5 hourly PO (adults) extended release capsules:- 2.5-9mg every 8-112 hr IV (adult):- 5mcg/min to 20mcg/min, then increase by 10-20mcg/min TRANSDERMAL (adults):- ointment 1 inch = 15mg, 1-2 inches every 8hrly (transdermal patch 0.1-0.6 mg/hr upto 0.8mg/hr)
Action Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks, increases cardiac output and reduces blood pressure.
Indication Prophylactic management of angina pectoris Acute MI Adjunct treatment of CHF
Adverse effect Dizziness, headache, hypotension, tachycardia, syncope, abdominal pain, alcohol intoxication(in case of large IV dose) Role and responsibility of nurse Assess location, duration, intensity and precipitating factors of angina pain. Monitor blood pressure and pulse during the regimen Sustained release capsules should be swallowed whole, do not crush, break or chew. Avoid drinking, eating or smoking. Doses must be diluted and administered as an infusion. Standard infusion sets made up of polyvinyl chloride may absorb 80% of nitroglycerin so glass bottles and special tubing should be used. In case of lingual spray lift the tongue and spray under the tongue.
Group of drug:- antiplatelet agent, platelet aggregation factor Pharmacological name:-ticlopidine Dose of drug PO (adult):- 250mg twice a day with food Availability: - 250mg Action Inhibitsplatelet aggregation by altering the function of platelet membranes. Prolongs bleeding time & decreases incidence of stroke in high risk patients
Indication Prevention of stroke in patients who have completed thrombotic stroke or precursor of stroke and unable to tolerate aspirin Prevention of early restenosis in intra-coronary stents
Contraindication Hypersensitivity Bleeding disorder, active bleeding, sever liver disease
Role and responsibility of nurse Asses the patient for symptoms of stroke Monitor bleeding time throughout the therapy. Monitor CBC with differential and platelet count every 2weeks if neutrophils count is declining. Administer with food or immediately after eating food to minimize GI discomfort. Monitor for side-effect
Group of drug - anticoagulant Pharmacological name - warfarin Trade name – warfiline, coumadin Dose of drug – Action PO or IV (adults) : 2.5-1.mg/day for 2-4 days and then adjust by result of prothrombin time or international normalized time (INR). Availability tablets 1mg, 2.5mg, 4mg, 5mg.
It interferes with the hepatic synthesis of vitamin K dependent clotting factors (2, 7, 9 and 10), and prevents the thrombus formation and thus decreases the density of blood. It decreases risk of subsequent MI Indication Prophylaxis and treatment of venous thrombus, pulmonary thrombus, pulmonary embolism, atrial fibrillation with embolization. Prevention of thrombus and embolization after prosthetic valve placement.
Contraindication Uncontrolled bleeding, active ulcer disease, Severe liver or kidney disease, Uncontrolled hpertension
Role and responsibility of nurse Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose Liver function should be monitored before and after therapy. Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving Avoid IM injections Instruct the patient to avoid alcohol, NSAIDs intake during the therapy
Dose of drug Fragmin - Unstable angina or non STEMI 120IU/kg (subcutenous) Enoxaparin - Unstable angina or non STEMI 1mg/kg with aspirin. STEMI 30mg + 1mg/kg IV
Action Potentiate the inhibitory effect of anti-thrombin on factor Xa & thrombin and thus prevents thrombus formation. Indication Prevention of ischemic unstable angina & non STEMI Treatment of acute STEMI with percutenous coronary intervention DVT Venous thromboembolism
Contraindication Contraindications with specific agent or pork products Active major bleeding History of heparin induced thrombocytopenia Severe liver or kidney diseases
Role and responsibility of nurse Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) Monitor for hypersensitivity reaction. Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose Liver function should be monitored before and after therapy.
Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving Avoid IM injections Instruct the patient to avoid alcohol, NSAIDs intake during the therapy Observe subcutenous injection site for hematomas, ecchymosis or inflammation During administering subcutenous injection use alternate sites (ant. Abdominal wall, upper thigh or buttocks)
Group of drug: thrombolytic agent, plasminogen activator Pharmacological name: urokinase, streptokinase Dose of drug Streptokinase IV (adults): 1.5 million units is given as a continous infusion over 60 min. Intracoronary: 20,000 unit bolus followed by 2000-4000 units/ min infusion for 30-90 min
Urokinase Action Convert plasminogen to plasma, which is then able to degrade fibrin present in clots. Urokinase directly activates plasminogen, streptokinase combines plasminogento form activator or complexes, which then converts plasminogen into plasmin. Which results in lysis of thrombi with preservation or improvement of ventricular function (decreases the rish of CHF or death). Indication Urokinase: acute massive pulmonary emboli. Streptokinase: acute arterial thrombi(MI) IV (adults): 4400 nits/kg loading dose, followed by 4400 unit/kg/hr for 12 hr
Contraindication Active internal bledding
History of cerebrovascular accident(can case intracranial bleeding), Recent intracranial or intraspinal injury or trauma, intracranial neoplasm, AV malformation Severe uncontrolled hypertension, hypersensitivity
Role and responsibility of nurse History collection of CVA, head trauma Monitor the vital signs before during and after the therapy. Check for hypesensitivity reaction. Do not administer bolus proper dilution should be should be done, intracranial bolus should be administered for over 15-90 seconds Flush IV line before infusion Asses the patient for bleeding for every 15 min during 1st hour of therapy, every 1-2 hourly after the drug administration, if bleeding occurs stop the drug immediately. Monitor ECG continuously If local bleeding occurs apply pressure to site and discontinue the infusion
Group of drug: antihypertensive, thiazide diuretics Pharmacological name: hydrochlorothiazide Dose of drug PO(adults): 12.5-100mg/day in 1-2 divided doses, should not exceed 50mg/day for hypertension, (doses >25mg are associated to have electrolyte imbalance abnormality) PO(children): 1-3mg/kg/day in 1-2 divided doses max 37.5mg/day
Action Increases excretion and sodium and water by inhibiting sodium reabsorption in distal tubule. Promotes excretion of chloride, potassium, magnesium and bicarbonate. It produces arteriolar dilation and thus reduces blood pressure in hypertensive patients and mobilizes oedema. Indication Management of mild to moderate hypertension Oedema assocoiated with CHF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy.
Contraindication Hypersensitivity with thiazide or sulfonamides Some products contain tartazine and should be avoided in patient with anuria, intolerance, lactation.
Role and responsibility of nurse Monitor blood pressure, intake output Daily weigh the patient Investigate serum electrolyte and monitor the behavior of the patient (may cause increase glucose level in diabetic patient, sr. bilirubin) Administer in morning to prevent disruption of sleep cycle.
Group of drug: Loop diuretic Trade name: lasix Dose of drug:
PO (adults): 20-40mg q6-8hr until desired response in hypertension In case of CCF max. 2.5mg/day Hypercalcemia: 120mg/day in 2-3 doses PO (childrens): 2mg/kg/day max. 6mg/kg/day IV (adults): 20-40mg/day and can be repeated, for continous infusion bolus- 0.1mg/kg followed by 0.1-0.4mg/kg/hr
Action: Inhibits the absorption of sodium and chloride from loop of henle and distal renal tubule, increases renal excretion of water,sodium, chloride magnesium, potassium, and calcium. Inturn causes diuresis and lowers down the blood pressure Indication Oedema due to heart failure, hepatic impairment or renal disease Hypertension
Contraindication Hypersensitivity with thiazide or sulfonamides may cause hepatic coma or anuria Some products contain alcohol and should be avoided in patient with alcohol intolerance
Role and responsibility of nurse Monitor blood pressure, intake output Monitor the fluid stats of the patient Monitor the patient for tinnitus or hearing loss Daily weigh the patient Investigate serum electrolyte and monitor the behavior of the patient (may cause increase glucose level in diabetic patient, sr. bilirubin) Administer in morning to prevent disruption of sleep cycle.
Group of drug: spatassium sparing diuretic Pharmacological name: Spirolactone Trade name: novospartin, aldactone Dose of drug Action Inhibition of sodium reabsorption in the kidney while saving potassiumand hydrogen ions (spironolactone achieves this effect by antagonizing aldosterone receptors). Weak diuretic and antihypertensive response wwhen compared with other diuretics but conserves potassium. Indication To counteract potassium loss caused due to other diuretics Primary aldosteronism Management of CCF PO (Adults): HTN—5–10mg/day (up to 20mg) PO (Adults): Edema—25–200 mg/day in 1–2 divided doses Diagnosis of primary hyperaldosteronism- 100–400 mg/day in 1–2 divided dose. CHF: 12.5–25 mg/day (unlabeled use)
Adverse effect Clumsiness, headache Hperkalemia, hyponatremia Erectile dysfunction Increases hypotension with ingestion of alcohol
Role and responsibility of nurse Monitor blood pressure, intake output Daily weigh the patient
Monitor for signs of hyperkalaemia weakness, fatigue, paraesthesia, dyspnea, cardiac arrhythmias Monitor sr. potassium level before and after therapy
Group of drug: ACE INHIBITOR Pharmacological name: enalapril, ramipril, captopril Trade name: vasotec, monopril, altace Dose of drug Captopril: PO (Adults): Hypertension—12.5–25mg 2-3 times daily, may be increased at 1–2 wk intervals up to 150 mg 3 times daily (begin with 6.25–12.5 mg 2–3 times daily in patients receiving diuretics) (maximum dose = 450 mg/ day). CHF—25 mg 3 times daily (6.25–12.5 mg, 3 times daily. Post-MI—6.25-mg test dose, followed by 12.5 mg 3 times daily, may be increased up to 50 mg 3 times daily. Enalapril: PO (Adults): Hypertension—2.5–5 mg once daily, increase as required up to 40 mg/day in 1–2 divided doses (initiate therapy at 2.5mg once daily in patients receiving diuretics). CHF—2.5 mg 1–2 times daily, titrated up to target dose of 10mg twice daily; begin with 2.5 mg once daily in patients with hyponatremia (serum sodium<130mEq/L). Asymptomatic left ventricular dysfunction—2.5mg twice daily, titrated up to a target dose of 10 mg twice daily. IV (adults): 0.625-1.25mg/kg/day if receiving diuretics Action: it blocks the conversion of anfiotensin I to the vasoconstrictor angiotensin II and also prevents the degradation of bradykinin and other vasodilatory prostaglandins. It increases the plasma rennin levels and reduces aldosterone Indication Primary Hypertension Development of CCF followed by MI Reduction in MI, Stoke Diabetic neuropathy
Hypersensitivity Previous angioedema caused by ACE inhibitors Womans with child bearing
Role and responsibility of nurse Monitor blood pressure Asses for signs of angioedema (dyspnea, facial swelling) Monitor weight and resolution of fluid overload Administer empt stomach 1 hr before meal to prevent GI disturbances
Group of drug: inotropic, adrenergic Trade name: dobutrex Dose of drug IV (Adults and Children): Start with low infusion rates (0.5–1 mcg/kg/min), titrated at intervals of a few minutes, guided by the patient’s response (range 2–20 mcg/kg/min, up to 40 mcg/kg/min) Action Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alphaadrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance (decreased afterload). Dobutamine enhances the strength of cardiac contraction, improving stroke volume ejection and overall cardiac output without significant increased heart rate. Indication: cardiac decompensation caused by heart disease or surgical procedures Contraindication: Hypersensitivity to dobutamine
Role and responsibility of nurse Monitor blood pressure, heart rate, ECG, cardiac output, urinary output Palpate peripheral pulses and temperature of extremities (vasodilation can cause oedema and retention) Vials must be diluted before use Dilute 250–1000 mg in 250–500 ml of D5W, 0.9% NaCl, 0.45% NaCl, D5/0.45%NaCl, D5/0.9% NaCl. Monitor electrolytes Monitor for hpokalaemia (weakness, faigue, U wave in ECG)
Group of drug: inotropic, vasopressor, adrenergic Pharmacological name: dopamine Dose of drug Small doses (0.5–3 mcg/kg/min) stimulate dopaminergic receptors, producing renal vasodilation. Larger doses (2–10 mcg/kg/min) stimulate dopaminergic and beta1-adrenergic receptors, producing cardiac stimulation and renal vasodilation. Doses greater than 10 mcg/kg/min stimulate alpha-adrenergic receptors and may cause renal vasoconstriction.
Action Dopamine (Intropin) is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It increases cardiac otput, increases blood pressure and improves renal blood
flow. It may be used with dobutamine and nitroglycerine to improve tissue perfusion. Low-dose dopamine (0.5 to 3.0 μg/kg/min) increases renal and mesenteric blood flow, thereby preventing ischemia of these organs because shock causes blood to be shunted away from the kidneys and the mesentery. This dosage, however, does not improve cardiac output. Medium-dose dopamine (4 to 8 μg/kg/min) has sympathomimetic properties and improves contractility (inotropic action) and slightly increases the heart rate (chronotropic action). At this dosage, dopamine increases cardiac output and therefore is desirable. High-dose dopamine (8 to 10 μg/kg/min) predominantly causes vasoconstriction, which increases afterload and thus increases cardiac workload.
Adverse effect Arrhtmias, hypotension, angina, ECG changes, palpitations, vasoconstriction Role and responsibility of nurse Monitor blood pressure, heart rate, ECG, cardiac output, urinary output Palpate peripheral pulses and temperature of extremities (vasodilation can cause oedema and retention) If hypotension occurs notify physician (to increase dose temporarily) If hypertension occurs notify physician (to decrease temporarily dose) Extravasation causes severe irritation so administer into large vein and monitor the site frequently. Vials must be diluted before use Dilute 250–1000 mg in 250–500 ml of D5W, 0.9% NaCl, 0.45% NaCl, D5/0.45%NaCl, D5/0.9% NaCl. Monitor electrolytes Monitor for hpokalaemia (weakness, faigue, U wave in ECG)
SUMMARY Till now we have seen about the classification of cardiac drugs and subtypes with examples
Conclusion Though cardiac drugs are the ones which are extensively used, but as a nurse while administering and prescribing this drugs one must remember the the action indication side effect and necessary observations otherwise this life saving drugs can be fatal if not admininstered or monitored at right time, right place.
USE OF CARDIAC DRUGS RELATES TO DAMPENED BLOOD PRESSURE CHANGES AND REDUCED MORTALITY IN INCIDENT HEMODIALYSIS PATIENTS
INTRODUCTION AND AIMS: It has been shown that both absolute blood pressure levels and changes in blood pressure over time relate to mortality in hemodialysis (HD) patients (pts). We aimed to study the association between cardiac drug (CD) use, blood pressure changes over time and mortality in incident HD pts. METHODS: Renal Research Institute in-center incident HD pts between Jan 1, 2000 and Feb 28, 2010 were followed for 1 year each. Pre HD systolic blood pressures (SBPs) were averaged for each pt over the first 30 days on HD (―starting SBP‖); the slope of SBP was computed by linear regression using all SBP values in the first year of HD. Pts were grouped by (a) starting SBP, and (b) first year SBP slope (increased: >1 mmHg/month, decreased: <-1 mmHg/mo, stable: between -1 and + 1 mmHg/mo). Cox regression was used to analyze the hazard ratio (HR) of death adjusted for starting SBP, interdialytic weight gain, BMI, gender, age, race, ethnicity, serum albumin, use of CD, and 13 comorbid conditions. Presence of CD therapy was based on whether a patient was prescribed ACE inhibitors, ARBs, or beta blockers at any time before the end of year one on HD (incl. before initiating HD). RESULTS: We studied 10,245 pts (57% male, 38% black, 54% white, 54% diabetic, age±SD 62.1±15.6 years). Starting SBP was positively related to percent of patients on CD (54% CD use in pts with starting SBP<120 mmHg, compared to 69% in pts with SBP>180). Patients whose SBP declined or remained stable were more likely to be on CD than those in whom SBP increased. CD therapy was associated with reduced mortality with a HR of 0.72 (95% CI: 0.63-0.81). Among pts whose SBP declined, those on CD showed a shallower decline in their SBP than those who did not use CD (Fig 1A). Likewise, in pts whose SBP increased, the increase was less in those on CD than in those not on CD (Fig 1B). These findings were significant for all SBP groups >120 mmHg and were also present, albeit less pronounced, for diastolic blood pressures. CD use was significantly associated with a dampened SBP slope in both SBP increasers and decliners, even after adjustment for relevant covariates. In SBP decliners, the decline was less steep by 1.02 mmHg per month in pts on CD, while in SBP increasers, the increase was smaller by 0.81 mmHg per month in those on CD. CONCLUSIONS: These results suggest that use of CD is linked to a 28% risk reduction for mortality in incident HD pts. Given that pts with a stable SBP slope in the first year on dialysis show lower mortality rates than those with increasing or decreasing SBP (Usvyat, WCN/ASN 2011), our finding of CD use being related to dampened SBP changes suggests a possible mechanism by which these drugs may mediate improved survival. Prospective randomized trials are warranted to help discern cause and effect.
Group of drug Pharmacological name Trade name Dose of drug Route of drug Action Indication Contraindication Adverse effect Role and responsibility of nurse