1. 2 3 Classification of Ischemic Heart Disease Ischemic Heart Disease Chronic coronary artery...

33

Classification of Classification of Ischemic Heart DiseaseIschemic Heart Disease

Ischemic Heart Disease

Chronic coronaryartery disease(stable angina)

Acute coronary syndromes

-Unstable Angina-Myocardial infarction

44

1) Drugs that Affect Blood 1) Drugs that Affect Blood CoagulationCoagulation

Used in the prevention and managemenUsed in the prevention and management of thrombotic and thromboembolic dist of thrombotic and thromboembolic disordersorders

55

XIIa

XIa

IXa

Xa X

VII

THROMBINPROTHROMBIN

X

IX

XII

XI

FIBRINOGEN FIBRIN (monomer)

FIBRIN (polymer)

VIIa

Intrinsic System

Extrinsic System (thromboplastin)

=Factor affected by oral anticoagulatants(Vitamin K-dependent clotting factor)

=Factor affected by heparin(factor that can be inactivated by antithrombin)

THE COAGULATION CASCADE

66

(i) Anticoagulant drugs(i) Anticoagulant drugs– Drugs that disrupt the coagulation cascade, & thereDrugs that disrupt the coagulation cascade, & there

by suppress production of fibrinby suppress production of fibrin– Prevention of thrombosis in veinsPrevention of thrombosis in veins– HeparinHeparin

Suppresses coagulation by helping antithrombin III inactivSuppresses coagulation by helping antithrombin III inactivate thrombin, factor Xa and other clotting factorsate thrombin, factor Xa and other clotting factors

Used in:Used in:– Prevention and treatment of pulmonary embolism, stroke, dPrevention and treatment of pulmonary embolism, stroke, d

eep vein thrombosis (DVT)eep vein thrombosis (DVT)– Prevent coagulation in devices in open heart surgery and renPrevent coagulation in devices in open heart surgery and ren

al dialysisal dialysis– Treatment of disseminated intravascular coagulationTreatment of disseminated intravascular coagulation– Adjunct to thrombolytic therapy of acute myocardial infarctiAdjunct to thrombolytic therapy of acute myocardial infarcti

onon

1) Drugs that Affect Blood Coagulation 1) Drugs that Affect Blood Coagulation (Cont’d)(Cont’d)

77

DosageDosage– Based on body weights of the patients & their Based on body weights of the patients & their

indicationsindications

Adverse effectsAdverse effects– HemorrhageHemorrhage– ThrombocytopeniaThrombocytopenia

Decrease platelet countDecrease platelet count– Hypersensitivity reactionsHypersensitivity reactions

Since commercial heparin is extracted from Since commercial heparin is extracted from animal tissueanimal tissue


88

– WarfarinWarfarin Suppress coagulation by acting as an antagonSuppress coagulation by acting as an antagon

ist of vitamin Kist of vitamin K 4 clotting factors (VII, IX, X & prothrombin) req4 clotting factors (VII, IX, X & prothrombin) req

uire vitamin K for their synthesisuire vitamin K for their synthesis Indications:Indications:

– Prevention of venous thrombosis & associated pulPrevention of venous thrombosis & associated pulmonary embolismmonary embolism

– prevention of thromboembolism in patients with pprevention of thromboembolism in patients with prosthetic heart valvesrosthetic heart valves

– Prevention of thrombosis during atrial fibrillationPrevention of thrombosis during atrial fibrillation– Reduce risk of recurrent transient ischemic attacks Reduce risk of recurrent transient ischemic attacks

(TIAs) & recurrent MI(TIAs) & recurrent MI


99

Daily dose Daily dose – usually 3 to 9 mg but it should be based on the INR valusually 3 to 9 mg but it should be based on the INR val

ues.ues.– INR targeted values are different in different indicatioINR targeted values are different in different indicatio

ns, usually within 2 to 3.5ns, usually within 2 to 3.5

Adverse effects:Adverse effects:– HemorrhageHemorrhage– TeratogenicTeratogenic


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(ii) Antiplatelet drugs(ii) Antiplatelet drugs– Suppress platelet aggregationSuppress platelet aggregation– Indicated for prevention of thrombosis iIndicated for prevention of thrombosis i

n n arteriesarteries


1111

Clopidogrel (Plavix)Clopidogrel (Plavix)– Adenosine diphosphate receptor (ADP) antagonistAdenosine diphosphate receptor (ADP) antagonist– Irreversible blocking of ADP receptors on the platelIrreversible blocking of ADP receptors on the platel

et surface et surface – Prevent ADP-stimulated aggregationPrevent ADP-stimulated aggregation– Indicated for prevention of stroke, vascular death Indicated for prevention of stroke, vascular death

& MI & MI

– The combination of aspirin and clopidogrel appears The combination of aspirin and clopidogrel appears to be the most effective and safest therapy for secoto be the most effective and safest therapy for secondary prevention of stroke.ndary prevention of stroke.


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Clopidogrel (Plavix)Clopidogrel (Plavix)

– DoseDose 75 mg po daily with or without food75 mg po daily with or without food

– Adverse effects:Adverse effects: Hemorrhage (GI & Intracranial)Hemorrhage (GI & Intracranial) GI side effectsGI side effects


1313

AspirinAspirin– Suppress platelet aggregation by causing irreverSuppress platelet aggregation by causing irrever

sible inhibition of cyclooxygenase, an enzyme resible inhibition of cyclooxygenase, an enzyme required by platelets to synthesize thromboxane Aquired by platelets to synthesize thromboxane A2 2 (TXA(TXA22))


1414

AspirinAspirin– Indicated in :Indicated in :

Primary prophylaxsis of MIPrimary prophylaxsis of MI Prevention of reinfarction patients who have exPrevention of reinfarction patients who have ex

perienced an acute MIperienced an acute MI Prevention of stroke in patients with a history of Prevention of stroke in patients with a history of

TIAsTIAs

– DoseDose Maintenance treatment 75-150 mg daily poMaintenance treatment 75-150 mg daily po

– Adverse effectsAdverse effects GI hemorrhage & also other hemorrhageGI hemorrhage & also other hemorrhage BronchospasmBronchospasm


1515

(iii) Thrombolytic drugs(iii) Thrombolytic drugs– Promote lysis of fibrin, thereby cause disPromote lysis of fibrin, thereby cause dis

solution of thrombisolution of thrombi StreptokinaseStreptokinase

– First bind to plasminogen to form an active complFirst bind to plasminogen to form an active complexex

– The streptokinase-plasminogen complex then catThe streptokinase-plasminogen complex then catalyzes the conversion of other plasminogen molealyzes the conversion of other plasminogen molecules into plasmin, an enzyme that digests the fibcules into plasmin, an enzyme that digests the fibrin meshwork of clotsrin meshwork of clots


1616

Alteplase (tPA)Alteplase (tPA)– Also known as tissue plasminogen activator (tPA)Also known as tissue plasminogen activator (tPA)– Is produced commercially by recombinant DNA teIs produced commercially by recombinant DNA te

chnologychnology– Human tPA is an enzyme that promotes conversiHuman tPA is an enzyme that promotes conversi

on of plasminogen to plasmin, an enzyme that digon of plasminogen to plasmin, an enzyme that digests the fibrin matrix of clotsests the fibrin matrix of clots

Adverse effects:Adverse effects:– Nausea & vomitingNausea & vomiting– BleedingBleeding


1717

Nursing Alerts:Nursing Alerts:– Monitor signs of hemorrhageMonitor signs of hemorrhage

Lowering of blood pressure, elevation of heLowering of blood pressure, elevation of heart rate, discoloration of urine or stools, bruart rate, discoloration of urine or stools, bruises, petechiae, etc.ises, petechiae, etc.

– Monitor INR, APTT, PT regularlyMonitor INR, APTT, PT regularly– Warfarin is contraindicated in pregnancWarfarin is contraindicated in pregnanc

y & breast-feedingy & breast-feeding


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2) Cardiotonics & other2) Cardiotonics & otherInotropic DrugsInotropic Drugs

The cardiotonics are drugs used to inThe cardiotonics are drugs used to increase the efficiency & improve the ccrease the efficiency & improve the contraction of the heart muscle, whicontraction of the heart muscle, which leads to improved blood flow to all h leads to improved blood flow to all tissues of the bodytissues of the body

1919

DigoxinDigoxin– Inhibits the enzyme Na, K-adenosine triphosphInhibits the enzyme Na, K-adenosine triphosph

atase (Na, K-ATPase), increases the movement atase (Na, K-ATPase), increases the movement of Na out of myocardial cells after contraction of Na out of myocardial cells after contraction

– As a result, Ca enters the cell in exchange for Na,As a result, Ca enters the cell in exchange for Na, causing additional Ca to be released from intra causing additional Ca to be released from intracellular binding sites cellular binding sites

– With the increase in intracellular concentration With the increase in intracellular concentration of free Ca ions, more Ca is available to activate tof free Ca ions, more Ca is available to activate the contractile proteins, actin & myosin, & increahe contractile proteins, actin & myosin, & increase myocardial contractilityse myocardial contractility

2) Cardiotonics & other2) Cardiotonics & otherInotropic Drugs (Cont’d)Inotropic Drugs (Cont’d)

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Side effects:Side effects:– Usually associated with excessive doseUsually associated with excessive dose– Digoxin toxicity:Digoxin toxicity:

anorexia, nausea, vomiting, diarrhoea, visuanorexia, nausea, vomiting, diarrhoea, visual disturbance, confusion & mental disturbaal disturbance, confusion & mental disturbance, arrthythmia, heart blocknce, arrthythmia, heart block

Dosage:Dosage:– Maintenance: 62.5-500 mcg dailyMaintenance: 62.5-500 mcg daily


2121

Milrinone (Milrinone (PrimacorPrimacor))– Increase levels of cyclic adenosine monophosIncrease levels of cyclic adenosine monophos

phate (cAMP) in myocardial cells by inhibiting phate (cAMP) in myocardial cells by inhibiting phosphodiesterase (PDE)phosphodiesterase (PDE)

– Relax vascular smooth muscle to produce vasRelax vascular smooth muscle to produce vasodilation & decrease preload & afterloadodilation & decrease preload & afterload

– Used in short term management of acute seveUsed in short term management of acute severe heart failure that is not controlled by digoxire heart failure that is not controlled by digoxin, diuretics & vasodilatorsn, diuretics & vasodilators


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2) Cardiotonics & other In2) Cardiotonics & other Inotropic Drugs (Cont’d)otropic Drugs (Cont’d) Side effects:Side effects:

– Arrhythmias, headache, hypotensionArrhythmias, headache, hypotension

Dosage:Dosage:– Maximum dose: 1.13mg/kg daily Maximum dose: 1.13mg/kg daily

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Nursing Alerts:Nursing Alerts:– Withhold the drug & contact the physician if thWithhold the drug & contact the physician if th

ere are any signs of digoxin toxicity or marked ere are any signs of digoxin toxicity or marked changes in the pulse rate/rhythmchanges in the pulse rate/rhythm

– Monitor digoxin levels closely: should be smallMonitor digoxin levels closely: should be smaller than 2 ng/mler than 2 ng/ml

– Older adults are particularly prone to digoxin tOlder adults are particularly prone to digoxin toxicityoxicity

– Hypokalemia makes the heart muscle more seHypokalemia makes the heart muscle more sensitive to digoxin, thereby increasing the possinsitive to digoxin, thereby increasing the possibility of developing digoxin toxicitybility of developing digoxin toxicity

2) Cardiotonics & other In2) Cardiotonics & other Inotropic Drugs (Cont’d)otropic Drugs (Cont’d)

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3) Antihypertensive 3) Antihypertensive Drugs Drugs

– (i) Diuretics(i) Diuretics

Diuretics are drugs that increase renal Diuretics are drugs that increase renal excretion of water, sodium & other excretion of water, sodium & other electrolytes, thereby increasing urine electrolytes, thereby increasing urine formation & outputformation & output

Used in the management of heart failure, Used in the management of heart failure, renal & hepatic disease, hypertension, renal & hepatic disease, hypertension, ophthalmic surgeryophthalmic surgery

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3) Antihypertensive Drugs 3) Antihypertensive Drugs (Cont’d)(Cont’d)

– Thiazide diuretics:Thiazide diuretics: Decrease reabsorption of Na, water, Cl & bicDecrease reabsorption of Na, water, Cl & bic

arbonate in the distal convoluted tubulearbonate in the distal convoluted tubule Hydrocholorothiazide Hydrocholorothiazide

– 25-100 mg daily or BD po25-100 mg daily or BD po Indapamide (Indapamide (NatrilixNatrilix))

– 2.5 mg/1.5mg(S.R.) daily po2.5 mg/1.5mg(S.R.) daily po

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– Loop Diuretics:Loop Diuretics: Inhibit Na & Cl reabsorption in the ascendinInhibit Na & Cl reabsorption in the ascendin

g loop of Henleg loop of Henle FrusemideFrusemide

– 20-80 mg daily po20-80 mg daily po Bumetanide (Bumetanide (BurinexBurinex))

– 0.5-2 mg daily po0.5-2 mg daily po


2828

– Potassium-Sparing Diuretics:Potassium-Sparing Diuretics: Act directly on the distal tubule to decrease Act directly on the distal tubule to decrease

the exchange of Na for Kthe exchange of Na for K– Amiloride :Amiloride : 5-20 mg daily po 5-20 mg daily po– Triamterene:Triamterene: 100-300 mg daily in divided dos 100-300 mg daily in divided dos

e poe po SpironolactoneSpironolactone

– Block the Na-retaining effects of aldosterone in tBlock the Na-retaining effects of aldosterone in the distal tubulehe distal tubule

– 25-200 mg daily po25-200 mg daily po


2929

– Combination ProductsCombination Products Thiazide & related diuretics are available in Thiazide & related diuretics are available in

numerous fixed-dose combination with nonumerous fixed-dose combination with non-diuretic antihypertensive agents & with n-diuretic antihypertensive agents & with K-sparing diuretics. This can increase patieK-sparing diuretics. This can increase patient compliance & prevent K imbalances:nt compliance & prevent K imbalances:

– Dyazide Dyazide (Hydrochlorothiazide 25mg+Triamterene 50(Hydrochlorothiazide 25mg+Triamterene 50mg)mg)

– Moduretic Moduretic (Hydrochlorothiazide 50mg+Amiloride 5m(Hydrochlorothiazide 50mg+Amiloride 5mg)g)

– HyzaarHyzaar (Losartan 50mg+Hydrochlorothiazide 12.5mg) (Losartan 50mg+Hydrochlorothiazide 12.5mg)


3030

Side effectsSide effects Nursing actionsNursing actions RationaleRationale

Increase Increase urine outputurine output

Give in the early morning if Give in the early morning if ordered dailyordered daily

Peak action will occur during Peak action will occur during waking hours & not interrupt waking hours & not interrupt with sleepwith sleep

Keep a bedpan within reach. Keep a bedpan within reach. Assist to the bathroom anyone Assist to the bathroom anyone who is elderly, weak, dizzy, or who is elderly, weak, dizzy, or unsteady in walkingunsteady in walking

Mainly to avoid fallMainly to avoid fall

Postural Postural hypotensionhypotension

Assist the patient to get up slowlyAssist the patient to get up slowly Avoid fallingAvoid falling

Possibility of Possibility of dehydrationdehydration

Record fluid intake & output regularlyRecord fluid intake & output regularly Avoid fluid volume depletion due tAvoid fluid volume depletion due to excessive diuresiso excessive diuresis

Hypo/Hyper-kHypo/Hyper-kalemiaalemia

Monitor serum potassium level (withiMonitor serum potassium level (within 3.5- 5 mEq)n 3.5- 5 mEq)

Avoid K depletion due to thiazide Avoid K depletion due to thiazide & loop diuretics or avoid K accum& loop diuretics or avoid K accumulation in patient taking K-sparing ulation in patient taking K-sparing diuretics diuretics

Electrolytes Electrolytes imbalanceimbalance

Monitor K, Na, Cl, Mg & bicarbonate leMonitor K, Na, Cl, Mg & bicarbonate levelsvels

Avoid electrolyte imbalanceAvoid electrolyte imbalance


3131

(ii) Beta Blockers(ii) Beta Blockers– Block beta-1 receptors in the heartBlock beta-1 receptors in the heart– Hence:Hence:

Reduce heart rateReduce heart rate Reduce force of contractionReduce force of contraction Reduced velocity impulse conduction Reduced velocity impulse conduction

through the AV nodethrough the AV node


3232


– Used in:Used in: HypertensionHypertension Angina pectorisAngina pectoris ArrhythmiasArrhythmias Myocardial InfarctionMyocardial Infarction Heart FailureHeart Failure

3333


– Differ in:Differ in: Receptor selectivityReceptor selectivity Intrinsic sympathomimetic activity (partial agonistIntrinsic sympathomimetic activity (partial agonist

activity), e.g. Oxprenolol. Pindolol, acebutololactivity), e.g. Oxprenolol. Pindolol, acebutolol Lipid solubilityLipid solubility

(Atenolol, nadolol, Sotalol are the most water-solu(Atenolol, nadolol, Sotalol are the most water-soluble)ble)

Duration of action, e.g. EsmololDuration of action, e.g. Esmolol

3434


DrugDrug Receptors Receptors BlockedBlocked

Maintenence Dosage in HypertensionMaintenence Dosage in Hypertension

AtenololAtenolol Beta1Beta1 50mg daily po50mg daily po

MetoprololMetoprolol Beta1Beta1 100-200mg daily in one to two doses po100-200mg daily in one to two doses po

200-400mg daily po (Slow release)200-400mg daily po (Slow release)

CarvedilolCarvedilol Beta1 and 2Beta1 and 2 12.5-50mg bd po12.5-50mg bd po

LabetololLabetolol Beta1 and 2Beta1 and 2 100-200mg bd po with food100-200mg bd po with food

PropranololPropranolol Beta1 and 2Beta1 and 2 160-320mg daily po160-320mg daily po

3535

3) Antihypertensive 3) Antihypertensive Drugs Drugs (Cont’d)(Cont’d)Receptor SubtypeReceptor SubtypeTissueTissue EffectsEffectsAlpha 1,2Alpha 1,2 Vascular smoothVascular smoothContractionContraction

musclemuscle

Beta 1Beta 1 HeartHeart Inc. Heart RateInc. Heart Rate

Inc. Force of Inc. Force of ContractionContraction

Beta 2Beta 2 Smooth muscleSmooth muscle RelaxationRelaxation

3636


– Adverse EffectsAdverse Effects

BradycardiaBradycardia HypotensionHypotension BrochospasmsBrochospasms GI disturbancesGI disturbances Heart failureHeart failure FatigueFatigue

Nursing AlertNursing Alert

– Check blood Check blood pressure & pulse pressure & pulse frequently, frequently, especially when especially when dosage is being dosage is being increasedincreased

3737

(iii) Calcium Channel Blockers (CCB)(iii) Calcium Channel Blockers (CCB)– Drugs that prevent calcium ions from enDrugs that prevent calcium ions from en

tering cells.tering cells.– Have the greatest effect on the heart anHave the greatest effect on the heart an

d blood vessels.d blood vessels.– Widely used to treat hypertension, angiWidely used to treat hypertension, angi

na pectoris and cardiac dysrhythmiasna pectoris and cardiac dysrhythmias


3838

ClassificatiClassificationon

Sites Sites of of actionaction

DosageDosage IndicationsIndications

HypertensionHypertension AnginAnginaa

ArrhythmiArrhythmiasas

OthersOthers

DihydropyridineDihydropyridineAmlodipineAmlodipine ArteriolesArterioles 5-10 mg daily po 5-10 mg daily po YY YY

Felodipine S.R.Felodipine S.R. ArteriolesArterioles 2.5-10 mg daily po2.5-10 mg daily po YY

NifedipineNifedipine ArteriolesArterioles 10-30 mg tid po10-30 mg tid po10 mg bd po (Adal10 mg bd po (Adalat Retard)at Retard)30-60 mg daily po 30-60 mg daily po (Adalat GITS)(Adalat GITS)

YY YY

NimodipineNimodipine ArteriolesArterioles 60 mg q4h for 21 60 mg q4h for 21 daysdays

INDIND

Key: Y-Yes; IND-Ischaemic neurological deficits


3939

ClassificatioClassificationn

Sites of Sites of actionaction

Normal Normal dosagedosage

IndicationsIndications

HypertensioHypertensionn

AnginAnginaa

ArrhythmiasArrhythmias

PhenylakylaminesPhenylakylaminesVerapamilVerapamil ArterioleArteriole

s/hearts/heart40-480 mg 40-480 mg daily in 2-3 daily in 2-3 divided dose, divided dose, depending on depending on indicationsindications

YY YY YY

BenzothiazepinesBenzothiazepinesDiltiazemDiltiazem ArteriolesArterioles

/heart/heart30 mg tid;30 mg tid;90 mg bd (SR)90 mg bd (SR)100-200mg dail100-200mg daily (SR)y (SR)

YY YY YY


4040

– Side effects: Side effects: Hypotension, dizziness, weakness, peripherHypotension, dizziness, weakness, peripher

al edema, headache, heart failure, pulmonaal edema, headache, heart failure, pulmonary edema, nausea, constipationry edema, nausea, constipation

Bradycardia (Verpamil, Diltiazem)Bradycardia (Verpamil, Diltiazem) Tachycardia (Nifedipdine & other dihydropyTachycardia (Nifedipdine & other dihydropy

ridines)ridines)


4141

Nursing Alerts:Nursing Alerts:– The older may have a greater hypotensive effeThe older may have a greater hypotensive effe

ct after taking CCB’s than younger adults. Thct after taking CCB’s than younger adults. The nurse must monitor them closely during dose nurse must monitor them closely during dosage adjustmentsage adjustments

– Make position changes slowly to minimize hypMake position changes slowly to minimize hypotensive effectsotensive effects

– Some patients may experience dizziness and liSome patients may experience dizziness and light-headedness, especially during early theraght-headedness, especially during early therapy. The nurse should assist the patient with all py. The nurse should assist the patient with all ambulatory activities and instructs the patientambulatory activities and instructs the patients to ask for help when getting out of bed or ams to ask for help when getting out of bed or ambulatingbulating


4242

(iv) Drug Acting on Renin-Angiotensin (iv) Drug Acting on Renin-Angiotensin SystemSystem– There are 2 families of drugs:There are 2 families of drugs:

Angiotensin-converting enzyme (ACE) inhibitoAngiotensin-converting enzyme (ACE) inhibitorsrs

– Block the enzyme (ACE) that normally converts angiBlock the enzyme (ACE) that normally converts angiotensin I to the potent vasoconstrictor angiotensin otensin I to the potent vasoconstrictor angiotensin IIII

– Decrease vasoconstriction & decrease aldosterone Decrease vasoconstriction & decrease aldosterone production, reducing retention of Na and waterproduction, reducing retention of Na and water


4343

*A-II is the major stimulator of aldosterone secretion

4444

(iv) Drug Acting on Renin-Angiotensin (iv) Drug Acting on Renin-Angiotensin SystemSystem– There are 2 families of drugs:There are 2 families of drugs:

Angiotensin-converting enzyme (ACE) inhibitoAngiotensin-converting enzyme (ACE) inhibitorsrs

– Block the enzyme (ACE) that normally converts angiBlock the enzyme (ACE) that normally converts angiotensin I to the potent vasoconstrictor angiotensin otensin I to the potent vasoconstrictor angiotensin IIII

– Decrease vasoconstriction & decrease aldosterone Decrease vasoconstriction & decrease aldosterone production, reducing retention of Na and waterproduction, reducing retention of Na and water


4545

Used to treat hypertension, heart failure, myocarUsed to treat hypertension, heart failure, myocardial infarction, and nephropathydial infarction, and nephropathy

– EnalaprilEnalapril 10-40mg/day in 1 or 2 doses 10-40mg/day in 1 or 2 doses– LisinoprilLisinopril 10-40mg once daily 10-40mg once daily– PerindoprilPerindopril 2-8mg daily 2-8mg daily– RamiprilRamipril 1.25-10mg once daily 1.25-10mg once daily

Side Effects:Side Effects:– Can produce serious first-dose hypotensionCan produce serious first-dose hypotension– Cough, due to accumulation of bradykininCough, due to accumulation of bradykinin– Hyperkalaemia, due to inhibition of aldosterone releasHyperkalaemia, due to inhibition of aldosterone releas

ee


4646

Angiotensin II receptor blockers (ARBs)Angiotensin II receptor blockers (ARBs)– Compete with angiotensin II for tissue binding siteCompete with angiotensin II for tissue binding site

s & prevent angiotensin II from combining with its rs & prevent angiotensin II from combining with its receptors in body tissueseceptors in body tissues

– Used for hypertension, may be used as an alternatiUsed for hypertension, may be used as an alternative to ACE inhibitors in the management of heart faive to ACE inhibitors in the management of heart failure and diabetic nephropathy.lure and diabetic nephropathy.

Irbesartan Irbesartan 150-300mg once daily150-300mg once daily Losartan Losartan 25-100mg once daily25-100mg once daily Valsartan Valsartan 80-160mg once daily80-160mg once daily


4747


Side-effectsSide-effects– HypotensionHypotension– Less likely to cause cough and hyperkalaemia thaLess likely to cause cough and hyperkalaemia tha

n ACE inhibitorsn ACE inhibitors

4848

Nursing AlertsNursing Alerts

Potential Adverse Potential Adverse EffectsEffects

Nursing ActionsNursing Actions

ACE inhbitors and AngiotensiACE inhbitors and Angiotensin II receptor antagonists may n II receptor antagonists may cause cause first dose hypotensiofirst dose hypotensionn

Instruct the patient to lie Instruct the patient to lie down if hypotension down if hypotension developsdevelops

ACE inhibitors may ACE inhibitors may produceproduce

coughcough

Warn patients about the Warn patients about the possibility of cough. Consult possibility of cough. Consult the doctor if the cough is the doctor if the cough is bothersome to the patientbothersome to the patient


4949

Potential Adverse EffectsPotential Adverse Effects Nursing ActionsNursing Actions

ACE inhibitors may cause hyperkACE inhibitors may cause hyperkalaemiaalaemia

Avoid potassium supplements, Avoid potassium supplements, potassium containing salt potassium containing salt substitutes and potassium-substitutes and potassium-sparing diureticssparing diuretics

ACE inhibitors and Angiotensin II ACE inhibitors and Angiotensin II receptor antagonists are contra-ireceptor antagonists are contra-indicated in pregnancyndicated in pregnancy

Avoid these dugs in Avoid these dugs in pregnancypregnancy

Nursing Alerts (cont’d)Nursing Alerts (cont’d)


5050

4) Antianginal Drugs4) Antianginal Drugs

Organic NitratesOrganic Nitrates– Used to treat or prevent anginaUsed to treat or prevent angina– Mechanism:Mechanism:

Nitrates are converted to NO in vascular smNitrates are converted to NO in vascular smooth muscleooth muscle

NO activates guanylate cyclaseNO activates guanylate cyclase Increase formation of cGMP so that the intrIncrease formation of cGMP so that the intr

acellular calcium levels decreaseacellular calcium levels decrease VasodilationVasodilation

5151

4) Antianginal Drugs(Cont’d)4) Antianginal Drugs(Cont’d)

– Relieves anginal pain by relaxing smooth mRelieves anginal pain by relaxing smooth muscles in the blood vessels (vasodilation) by uscles in the blood vessels (vasodilation) by several mechanismsseveral mechanisms Dilate veinsDilate veins Dilate coronary arteriesDilate coronary arteries Dilate arteriolesDilate arterioles

5252

– Most widely used nitrate is nitroglycerin (GlyMost widely used nitrate is nitroglycerin (Glyceryl trinitrate)ceryl trinitrate) Since it is highly lipid soluble, it can be administSince it is highly lipid soluble, it can be administ

ered by sublingual and transdermal route, as weered by sublingual and transdermal route, as well as oral and intravenous routesll as oral and intravenous routes

4) Antianginal Drugs (Cont’d)4) Antianginal Drugs (Cont’d)

5353

Nitrate preparations and dosageNitrate preparations and dosage

Drug and dosage Drug and dosage formform

RouteRoute DosageDosage

Glyceryl TrinitrateGlyceryl TrinitrateSublingual tablet Sublingual tablet 500mcg500mcg

SublingualSublingual 1 tablet under the 1 tablet under the tongue tongue immediately as immediately as requiredrequired

Spray 0.4mg/dose Spray 0.4mg/dose SublingualSublingual Spray 1-2 doses Spray 1-2 doses under tongueunder tongue

Capsule 2.5mg Capsule 2.5mg (Retard)(Retard)

OralOral 1-2 capsules 2-3 1-2 capsules 2-3 times a daytimes a day


5454



Glyceryl Trinitrate (Cont’d) Glyceryl Trinitrate (Cont’d) Transdermal patcheTransdermal patches 5mg / 10mgs 5mg / 10mg

TransdermalTransdermal 1 patch every 24 1 patch every 24 hourshours

Isosorbide MononitrateIsosorbide MononitrateTablet 20mgTablet 20mg OralOral 20mg bd to tid / 40m20mg bd to tid / 40m

g bdg bdTablet 60mg Tablet 60mg (controlled (controlled release)release)

OralOral 30-120mg in the 30-120mg in the morningmorning

Capsule 50mg Capsule 50mg (sustained release)(sustained release)

OralOral 1-2 capsules in the 1-2 capsules in the morningmorning


5555



Isosorbide DinitrateIsosorbide DinitrateTablet 10mgTablet 10mg OralOral 30-240mg in 30-240mg in

divided dosesdivided doses

Tablet 40mg Tablet 40mg (sustained (sustained release)release)

OralOral 20-40mg every 12 20-40mg every 12 hourshours

Capsule 20mg Capsule 20mg (sustained (sustained release)release)

OralOral 1 capsule bd or tid 1 capsule bd or tid


5656

– ToleranceTolerance Tolerance to nitrate induced vasodilation caTolerance to nitrate induced vasodilation ca

n develop rapidlyn develop rapidly This may be due to depletion of sulfhydryl This may be due to depletion of sulfhydryl

(S-H) groups in the vascular smooth muscle. (S-H) groups in the vascular smooth muscle. These groups are needed to convert nitrate These groups are needed to convert nitrate to NOto NO


5757


– Adverse EffectsAdverse Effects HeadacheHeadache Orthostatic hypotensionOrthostatic hypotension

– Symptoms include light headedness Symptoms include light headedness and dizzinessand dizziness

Reflex tachycardiaReflex tachycardia

5858

Nursing Alerts:Nursing Alerts:

Potential Adverse EffectsPotential Adverse Effects Nursing ActionsNursing ActionsHeadacheHeadache Inform patients that headache will Inform patients that headache will

diminish with continued drug use. diminish with continued drug use. Can be relieved by mild analgesicsCan be relieved by mild analgesics

Orthostatic hypotensionOrthostatic hypotension Slowly change from a sitting or lying Slowly change from a sitting or lying position to an upright position. Advisposition to an upright position. Advise the patient to lie or sit down if sympe the patient to lie or sit down if symptoms of hypotension (eg. dizziness, ligtoms of hypotension (eg. dizziness, lightheadedness) occurhtheadedness) occur

ToleranceTolerance To prevent tolerance, use the To prevent tolerance, use the minimum effective dose. For long-minimum effective dose. For long-acting preparations, they should acting preparations, they should be used on an intermittent be used on an intermittent schedule to allow at least 8 drug-schedule to allow at least 8 drug-free hoursfree hours

4) Antianginal Drugs (Cont’4) Antianginal Drugs (Cont’d)d)

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5) Antiarrhythmic Drugs5) Antiarrhythmic Drugs

Antiarrhythmic drugs are primary usAntiarrhythmic drugs are primary used to treat cardiac arrhythmias, whiced to treat cardiac arrhythmias, which is a disturbance or irregularity in thh is a disturbance or irregularity in the heart rate, rhythm, or bothe heart rate, rhythm, or both

Antiarrhythmic drugs are divided intAntiarrhythmic drugs are divided into 4 classeso 4 classes

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(i) Class I(i) Class I– Sodium channel blockersSodium channel blockers– Have a membrance-stablizing or anaesthetiHave a membrance-stablizing or anaestheti

c effect on the cell of the myocardiumc effect on the cell of the myocardium– Are subdivided into I-A, I-B, I-CAre subdivided into I-A, I-B, I-C

I-A: I-A: QuinidineQuinidine

– 200-400 mg tid or qid po200-400 mg tid or qid po ProcainamideProcainamide

– 25-50 mg/min slow iv injection; max:1g daily25-50 mg/min slow iv injection; max:1g daily

5) Antiarrhythmic Drugs (Cont’5) Antiarrhythmic Drugs (Cont’d)d)

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I-B: I-B: LidocaineLidocaine

– 50- 100 mg single bolus injection; followed by 1-50- 100 mg single bolus injection; followed by 1-4 mg/min infusion4 mg/min infusion

I-C: I-C: FlecainideFlecainide

– 100 mg bd po; max: 400 mg daily100 mg bd po; max: 400 mg daily PropafenonePropafenone

– 150-300 mg tid po150-300 mg tid po


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– Side effects of Class I:Side effects of Class I: Nausea, vomitingNausea, vomiting DizzinessDizziness Visual disturbancesVisual disturbances Pro-arrhythmic effectPro-arrhythmic effect Heart blockHeart block


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(II) Class II(II) Class II– Beta BlockersBeta Blockers– Block sympathetic stimulation of beta recepBlock sympathetic stimulation of beta recep

tors in the heart & decrease the heart ratetors in the heart & decrease the heart rate PropranololPropranolol

– 10-40 mg tid or qid po10-40 mg tid or qid po AcebutololAcebutolol

– 400-1200 mg daily po in 2 to 3 divided dose400-1200 mg daily po in 2 to 3 divided dose EsmololEsmolol

– 50-200 mcg/kg/min IV infusion50-200 mcg/kg/min IV infusion


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– Side effects of Class II:Side effects of Class II: NauseaNausea HeadacheHeadache HypotensionHypotension DizzinessDizziness


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(III) Class III(III) Class III– Potassium channel blockerPotassium channel blocker– Prolong duration of action potential, sloProlong duration of action potential, slo

w repolarization, and prolong the refractw repolarization, and prolong the refractory period in both atria and ventriclesory period in both atria and ventricles AmiodaroneAmiodarone

– 200 mg one to three times daily po200 mg one to three times daily po BretyliumBretylium

– 5-10 mg/kg IV infusion over 15-30 min q6-8h5-10 mg/kg IV infusion over 15-30 min q6-8h


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SotalolSotalol– Has combined Class II & Class III effectsHas combined Class II & Class III effects– A beta blocker that also delays repolarizationA beta blocker that also delays repolarization– 160-320 mg po daily in 2 divided dose160-320 mg po daily in 2 divided dose

– Side effects of Class III:Side effects of Class III: Proarrhythmias (Amiodarone & Sotalol)Proarrhythmias (Amiodarone & Sotalol) Hypotension (Bretylium & Sotalol)Hypotension (Bretylium & Sotalol) Malaise, fatigue & tremor (Amiodarone)Malaise, fatigue & tremor (Amiodarone)


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Class IV:Class IV:– Calcium Channel Blockers (CCB)Calcium Channel Blockers (CCB)– Block the movement of Ca into conductile Block the movement of Ca into conductile

& contractile myocardial cells& contractile myocardial cells– Verapamil & Diltiazem are the only approvVerapamil & Diltiazem are the only approv

ed CCB in arrhythmiased CCB in arrhythmias VerapamilVerapamil

– 40-120 mg tid po40-120 mg tid po


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DiltiazemDiltiazem– 0.25 mg/kg IV injection over 2 min, second bolus of 0.30.25 mg/kg IV injection over 2 min, second bolus of 0.3

5 mg/kg if needed; followed by 5-15 mg/hr continuous 5 mg/kg if needed; followed by 5-15 mg/hr continuous IV infusion if necessary IV infusion if necessary

– Side effects of Class IV:Side effects of Class IV: Proarrhythmias (Verapamil)Proarrhythmias (Verapamil) Heart blockHeart block Hypotension, headache, dizziness, constipationHypotension, headache, dizziness, constipation


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Nursing AlertsNursing Alerts– Antiarrhythmic drugs are capable of causing new Antiarrhythmic drugs are capable of causing new

arrhythmias, as well as an exacerbation of existinarrhythmias, as well as an exacerbation of existing arrhythmiasg arrhythmias

– Older adults taking antiarrhythmic drugs are at gOlder adults taking antiarrhythmic drugs are at greater risk for adverse reactions such as developreater risk for adverse reactions such as development of additional arrhythmias or aggravating of ment of additional arrhythmias or aggravating of existing arrhythmias, hypotension, and congestiexisting arrhythmias, hypotension, and congestive heart failure. Careful monitoring is necessary fve heart failure. Careful monitoring is necessary for early identification and management of adveror early identification and management of adverse effectsse effects

5) Antiarrhythmic Drugs (Cont’d)5) Antiarrhythmic Drugs (Cont’d)

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6) Drugs used for Dyslipidemia6) Drugs used for Dyslipidemia

Used in the management of elevated Used in the management of elevated blood lipids, which is a major risk blood lipids, which is a major risk factor for atherosclerosis and factor for atherosclerosis and vascular disorders such as coronary vascular disorders such as coronary artery disease and strokesartery disease and strokes

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(i) HMG CoA reductase inhibitors (St(i) HMG CoA reductase inhibitors (Statins)atins)– Inhibits HMG CoA reductase, the rate-liInhibits HMG CoA reductase, the rate-li

miting enzyme in cholesterol synthesismiting enzyme in cholesterol synthesis– Increase LDL receptors in hepatocytesIncrease LDL receptors in hepatocytes

This enables hepatocytes to remove more LThis enables hepatocytes to remove more LDLs from the bloodDLs from the blood

– Also decrease VLDL levels and increase Also decrease VLDL levels and increase HDL levelsHDL levels

6) Drugs used for Dyslipidemia (Cont’6) Drugs used for Dyslipidemia (Cont’d)d)

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DrugDrug Usual DosageUsual Dosage CommentsComments

AtorvastatinAtorvastatin 10-80mg taken at anytime10-80mg taken at anytime Take with or without Take with or without foodfood

FluvastatinFluvastatin 20-40mg daily in the 20-40mg daily in the evening, up to 40mg twice evening, up to 40mg twice dailydaily

Take with or without Take with or without foodfood

PravastatinPravastatin 10-40mg at night10-40mg at night Take with food to Take with food to reduce dyspepsiareduce dyspepsia

SimvastatinSimvastatin 5-80mg at night5-80mg at night Take with food to Take with food to reduce dyspepsiareduce dyspepsia

6) Drugs used for Dyslipidemia (Cont’d)6) Drugs used for Dyslipidemia (Cont’d)

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– Adverse EffectsAdverse Effects Headache, GI side effects (e.g. abdominal pain, flatulence, diarrhoea, nausea and Headache, GI side effects (e.g. abdominal pain, flatulence, diarrhoea, nausea and

vomiting) vomiting)

HepatoxicityHepatoxicity MyopathyMyopathy

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(ii) Fibric acid derivatives (Fibrates)(ii) Fibric acid derivatives (Fibrates)– Increase oxidation of fatty acids in liver Increase oxidation of fatty acids in liver

and muscle tissue, decrease hepatic proand muscle tissue, decrease hepatic production of triglycerides, decrease VLDL duction of triglycerides, decrease VLDL cholesterol and increase HDL cholestercholesterol and increase HDL cholesterolol

– Main indication is hypertriglceridemia Main indication is hypertriglceridemia (high plasma triglycerides)(high plasma triglycerides)


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Drug and dosage formDrug and dosage form Usual DosageUsual Dosage

ClofibrateClofibratecapsule 500mgcapsule 500mg 2g daily in 2-4 divided 2g daily in 2-4 divided

dosesdoses

FenofibrateFenofibrateCapsule 100mg Capsule 100mg 3 capsules daily in the 3 capsules daily in the

course of main mealscourse of main meals

Capsule (Micronized fenofibraCapsule (Micronized fenofibrate) 200mgte) 200mg

1 capsule daily1 capsule daily


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Drug and dosage formDrug and dosage form Usual DosageUsual Dosage

GemfibrozilGemfibrozilCapsule 300mg Capsule 300mg 1.2g daily in 2 divided 1.2g daily in 2 divided

dosesdoses

Usual range 0.9-1.5g dailyUsual range 0.9-1.5g dailyTablet 600mgTablet 600mg


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– Adverse EffectsAdverse Effects Nausea, vomiting and GI upsetNausea, vomiting and GI upset Cholelithiasis (stones in the gall bladder) anCholelithiasis (stones in the gall bladder) an

d cholecystitis (inflammation of the gallblad cholecystitis (inflammation of the gallbladder)dder)

MyopathyMyopathy


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(iii) Bile acid sequestrants(iii) Bile acid sequestrants– Bind bile acids in the intestinal lumen. TBind bile acids in the intestinal lumen. T

his causes the bile acids to be excreted ihis causes the bile acids to be excreted in faeces and prevents them being re-cirn faeces and prevents them being re-circulated to the liverculated to the liver

– Mainly used as an adjunct to Statins to Mainly used as an adjunct to Statins to decrease LDL cholesterol levelsdecrease LDL cholesterol levels


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– CholestyramineCholestyramine Usual dosageUsual dosage

– 12-24g daily in water in one to four divided dose12-24g daily in water in one to four divided doses; Max: 36g dailys; Max: 36g daily

Adverse effectsAdverse effects– Constipation, diarrhoea, nausea, vomiting, gastrConstipation, diarrhoea, nausea, vomiting, gastr

o-intestinal discomforto-intestinal discomfort– Decreased absorption of fat-soluble vitaminsDecreased absorption of fat-soluble vitamins


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(iv) Nicotinic acid(iv) Nicotinic acid– Inhibits mobilization of free fatty acids fInhibits mobilization of free fatty acids f

rom peripheral tissues, thereby reducinrom peripheral tissues, thereby reducing hepatic synthesis of triglycerides and g hepatic synthesis of triglycerides and secretion of VLDL, which leads to decresecretion of VLDL, which leads to decreased production of of LDL cholesterolased production of of LDL cholesterol

– Besides reducing LDL and VLDL levels, aBesides reducing LDL and VLDL levels, also effective in increasing HDL levelslso effective in increasing HDL levels


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– Normal doseNormal dose 1-2g three times daily1-2g three times daily

– Adverse effectsAdverse effects Flushing, itching, nausea, vomiting, diarrhoFlushing, itching, nausea, vomiting, diarrho

eaea HepatotoxicHepatotoxic Hyperglycaemia and hyperuricaemiaHyperglycaemia and hyperuricaemia


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Nursing alerts:Nursing alerts:



StatinsStatinsHepatotoxicityHepatotoxicity Liver function should be Liver function should be

monitored during therapymonitored during therapy

MyopathyMyopathy Inform patient about the risk oInform patient about the risk of myopathy. Instruct them to nf myopathy. Instruct them to notify physician if unexplained otify physician if unexplained muscle pain or tenderness occmuscle pain or tenderness occursurs


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FibratesFibratesGallstonesGallstones Inform patients about symptoms Inform patients about symptoms

of gallbladder disease (e.g. of gallbladder disease (e.g. upper abdominal discomfort, upper abdominal discomfort, intolerance of fried foods, intolerance of fried foods, bloating) and instruct them to bloating) and instruct them to notify the physician if these notify the physician if these developdevelop

MyopathyMyopathy Warn patient to report any signs Warn patient to report any signs of muscle injury, such as of muscle injury, such as tenderness, weakness, or tenderness, weakness, or unusual muscle painunusual muscle pain

Liver DiseaseLiver Disease Obtain periodic tests of liver Obtain periodic tests of liver functionfunction


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Bile acid sequestrantsBile acid sequestrantsConstipationConstipation Inform patients that Inform patients that

constipation can be minimized constipation can be minimized by increasing dietary fiber and by increasing dietary fiber and fluids. A mild laxative may be fluids. A mild laxative may be used if needed.used if needed.

Vitamin deficiencyVitamin deficiency Absorption of fat-soluble Absorption of fat-soluble vitamins (A, D, E, K) may be vitamins (A, D, E, K) may be impaired. Vitamin impaired. Vitamin supplements may be requiredsupplements may be required


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Nicotinic acidNicotinic acidFlushingFlushing Contact physician if the patient Contact physician if the patient

experiences flushing (face, experiences flushing (face, neck, ears)neck, ears)

HepatotoxicityHepatotoxicity Monitor liver function during Monitor liver function during treatmenttreatment

HyperglycaemiaHyperglycaemia Blood glucose should be Blood glucose should be monitored frequentlymonitored frequently

HyperuricaemiaHyperuricaemia Exercise caution in patients with Exercise caution in patients with goutgout


1. 2 3 Classification of Ischemic Heart Disease Ischemic Heart Disease Chronic coronary artery...

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