Assoc. Prof. Iv. Lambev DRUGS USED IN THE TREATMENT OF CARDIAC FAILURE (Summary)
Cardiac Drugs
description
Transcript of Cardiac Drugs
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Cardiac DrugsDaymar College
Lisa H. Young, RN, BSN, MA Ed
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Classifications and Prototype Drugs (Pr) Pregnancy Category Controlled Substances Availability Uses and Unlabeled Uses Action and Therapeutic Effect Contraindications and Cautious Use Route and Dosage Administration Intravenous Drug Administration Adverse Effects Diagnostic Test Interference Interactions Pharmacokinetics Clinical Implications Therapeutic Effectiveness
How to Use a Drug Book
http://www.youtube.com/watch?v=Jh_U8V9-Htw
http://www.youtube.com/watch?v=9mcqPJFB3UE
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Drug Names Generic name Brand name/Proprietary name Chemical name
Indications and Usage
Contraindications
Pharmacologic Principles
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Drug Interactions◦ “Red Flag” Drugs: Warfarin
Aspirin Cimetinde
Theophylline
Drug Reactions Adverse reaction Side effects
Pharmacologic Principles
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Drug Administration
Enteral Routes
Parenteral Routes
Topicals & Transdermal
Pharmacologic Principles
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Pharmacokinetics
Absorption
Bioavailability
Therapeutic range
Distribution
Pharmacologic Principles
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Metabolism
Elimination
Pharmacodynamics
Tolerance
Pharmacologic Priniciples
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Half-Life◦ Digoxin 30-60 hours◦ Warfarin 0.5 – 3 days◦ Heparin 1 – 2 days
Poisonings/Toxicity
Pharmacologic Principles
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Prescription Drugs
Nonprescription Drugs
Controlled Substances Drug Abuse Drub dependency
Legal Classifications of Drugs
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Prescription Orders◦ Patient Name (superscription)◦ Address◦ Drug name (inscription)◦ Drug dose◦ Route (subscription)◦ Frequency of administration◦ Number to be dispensed◦ Number of refills allowed◦ DEA #◦ MD Name/signature◦ MD address◦ MD Phone number
Pharmacologic Principles
http://www.youtube.com/watch?v=Mhqe12Aj1dE
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Reading & Writing a Prescription
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http://www.youtube.com/watch?v=S0oqYJp9t2o
http://www.youtube.com/watch?v=hRdGLzylovM
Reading Prescription Label
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Ten Rights◦ Right patient name◦ Right drug◦ Right dosage◦ Right route & technique◦ Right time◦ Right documentation◦ Right client education ◦ Right to refuse◦ Right assessment◦ Right evaluation
Medication Administrationhttp://www.youtube.com/watch?v=cm7GexPKNOc&list=PLxdOP8vuQhz9SNJLTWjTGzh3yOTsEsd6l
http://www.youtube.com/watch?v=kdB0PmsX2ng
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Abbreviation Meaning Abbreviation MeaningAc before meals qhs every nightBid twice daily Rx takec with s without
DC discontinue SL sublingualdx diagnosis SOA short of air
NPO nothing by mouth
ss half
NS normal saline suppos suppositoryp after tid 3 times daily
PR per rectum top topicalprn as needed ung ointmentq every UT under tongue
Pharmacology Abbreviations
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“Do Not Use” Abbreviations
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Examples of charting:A. 9/1/12 9:00 a.m. nitroglycerin, 1 tab, sublingually. Written
instructions given to pt. Precautions explained. Told to call office at 1:00p.m. today to report progress of his condition….M. Richards, CMA (AAMA)
B. 1/19/12 11:00 a.m. B 12 vitamin, 10000mcg given IM to left deltoid muscle without complications and band aid applied to injection site. Pt tolerated injection well. Pt. given written instructions for possible side effects and considerations. Pt to return in one monthly to receive monthly B 12 injections as ordered……L.Young, CCT.
C. 10/10/2012 1:00 p.m. Mantoux test, 0.01 ml. Tuberculin Purified Protein Derivative, Left forearm, subcutaneous, small wheal noted. Pt. instructed not to rub or cover the are and to return for reading on 10/12/12…..M. Richards, CMA (AAMA)
Charting Medication Administration
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Client’s own words Clarity Completeness Conciseness Chronological Confidentiality
Six Cs of Charting
http://www.youtube.com/watch?v=mYGf0AdhhI4
http://www.youtube.com/watch?v=SDcmXqSvP7A
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Date/time of entry Legible handwriting Permanent black ink Proper terminology, correct spelling and
correct grammar Document in sequence Be concise Correct errors Sign every entry
Guidelines for Charting
http://www.youtube.com/watch?v=pe2TQJKXZIs
http://www.youtube.com/watch?v=GMVwoR0YU-I
http://www.youtube.com/watch?v=Bkoic2dLFmY
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gr = grain gal = gallon dr = dram qt iii = 3 quarts oz = ounce ix = 9 lb = pound qt i = 1 quart m = minims gr ½ = ½ grain fl dr = fluid drams pt iiiss = 3 ½
pints fl oz = fluid ounce 1 grain = 60 mg pt = pint qt - quart
Apothecary System
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Metric Conversion Value Chart
Kilo – Hecto-Deka-Base-Deci-Centi-Milli-X-X-Micro Gram Liter Meter
45.2 grams = 45200.0 milligrams
1cubic centimeter (cc) = 1 milliliters (ml)
Metric System
http://www.youtube.com/watch?v=2QR9yCkAEpE
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Dosage unit
Dosage strength
Dosage ordered
Desired dose
Dose on hand Amount to administer
Dosage Definitions
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Drug Calculation: Formula Method
Ordered Dose X Available Amount
Available Dose Amount to give
Ordered dose: 500 mgAvailable dose: 1000 mgAvailable amount: 1 ml
Drug Dosage Calculations
http://www.youtube.com/watch?v=b69Wr008dzM
http://www.youtube.com/watch?v=BMDOk3RAHC4
http://www.youtube.com/watch?v=Wa9Zi64_HJk
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Rules of ConversionApothecary Metric
1 fluid oz 30 mL or cc1 quart 1000 mL or cc1 grain 0.065 gram
15 grains 1 gram2.2 pounds 1 kilogram
Household Metric1 drop 0.06 mL1 tsp 4-5 mL1 T 15-16 mL
1 cup 250 mL2 cups 500 mL
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Clark’s Rule
Fried’s Rule
Young’s Law
West’s nomogram
Body Weight method
Calculating Pediatric Dosages
http://www.youtube.com/watch?v=AQaeAON4GUM
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Assessment Plan Implementing Document Evaluate Special Needs Noncompliance
Patient Education
http://www.youtube.com/watch?v=1HQHdpAov-I
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Cultural Considerations
The Life Span
Understanding and knowledgeable about medication
In the Workplace
The Law
Professionalism
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http://www.youtube.com/watch?v=eboZYnTF6vs
Inotropic, Chronotropic and Dromotropic Drugs
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http://www.youtube.com/watch?v=mQirK5RxhFo
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Sympathetic Nervous System
Adrenergic Response_ Catecholamines_ Adrenaline_ Beta 1-Adrenergic Receptors
_ Alpha 1-Adrenergic Receptors
Neurological Control of the Heart and Blood Pressure
http://www.youtube.com/watch?v=lw1Ag86SvlY
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Baroreceptors_ Pressure receptors
_Mechanoreceptors
_Efferent pathways
Neurological Control of the Heart and Blood Pressure
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Chemoreceptors_ carotid artery
_ Elevated arterial carbon dioxide level
_ Heart rate increases
_ Vasoconstriction
Neurological Control of the Heart and Blood Pressure
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Parasympathetic Nervous System
Vagal Response _ Cholinergic Response _ Acetylcholine _ Nicotinic Cholinergic Receptors _ Muscarinic Cholinergic Receptors
Neurological Control of the Heart and Blood Pressure
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Renin-Angiotensin-Aldosterone System_ Release of Renin_ Angiotensin I → Angiotensin II_ Angiotensin-converting enzyme (ACE)
Neurological Control of the Heart and Blood Pressure
http://www.youtube.com/watch?v=M0vpn6YVwiI
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Preload The stretching of the ventricle at the end of diastole.
_ Increasing Preload Administer extracellular fluid expander Decrease dose of stop drugs that cause venous vasodilation
_ Decreasing Preload Stop or decrease fluid Diuretics ACE inhibitors Aldosterone antagonists Venous vasodilators
Cardiovascular Pharmacology
http://www.youtube.com/watch?v=lPK017oR3bw
http://www.youtube.com/watch?v=mQirK5RxhFo
http://www.youtube.com/watch?v=FjdJdoZcbyA
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Afterload The resistance that the ventricle must overcome to eject
its contents.
_ Increasing Afterload Sympathomimetics (stimulate alpha receptors) ADH
_ Decreasing Afterload Smooth muscle relaxants Calcium channel blockers Alpha receptor blockers ACE inhibitors ARBs & PDE
Cardiovascular Pharmacology
http://www.youtube.com/watch?v=NFcg62I54w8
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Contractility
_Increasing Contractility Sympathomimetics (stimulate B1 receptors) PDE inhibitors Cardiac glycosides
_Decreasing Contractility Beta-blockers Calcium channel blockers
Cardiovascular Pharmacology
http://www.youtube.com/watch?v=_sxiloNshfE
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Heart Rate Cardiac output = heart rate X stroke volume
Increasing heart rate Parasympatholytics Sympathomimetics (stimulate B1 receptors)
Decreasing heart rate Beta-blockers (block B1 receptors) Calcium channel blockers Cardiac glycosides Other antiarrhythmics
Cardiovascular Pharmacology
http://www.youtube.com/watch?v=PJ8WsZOywgo
http://www.youtube.com/watch?v=OVVwyCCyH8E
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Stimulate the sympathetic nervous system
Increase heart rate
Increase contractility
Increase afterload
Sympathomimetics/Adrenergics
http://www.youtube.com/watch?v=HklZH5QdOeE
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Stimulates: B1 & B2 (low dose) & Alpha receptors (high doses)
Results: increased contractility, automaticity, bronchodilation and selective vasoconstriction
Uses: advanced cardiac life support, anaphylactic shock, hypotension/profound bradycardia
Considerations: instant onset, peak 20 minutes and given IV every 3 – 5 minutes for cardiac standstill
Epinephrine
http://www.youtube.com/watch?v=9cpD8lG6DvY
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Stimulates: primarily B1, some alpha receptors and modest B2
Results: increased contractility, increased AV node conduction, modest vasoconstriction
Uses: as an inotrope with modest afterload reduction
Considerations: onset 1 – 2 minutes, peak 10 minutes, blood pressure is variable: B2 causes vasodilation, increased cardiac output increases blood pressure
Dobutamine
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Stimulates: dopaminergic and some B1 at low doses, B1 at moderate doses, pure alpha stimulation at high doses (>10 mcg/kg/min)
Results: increased contractility at small and moderate doses, increased conduction, vasoconstriction at high doses, does not treat or prevent renal failure at low doses
Uses: refractory hypotension and shock Considerations: IV onset 1 – 2 minutes & peak
10 minutes
Dopamine
http://www.youtube.com/watch?v=YrEn_1FBBsw
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Stimulates: primarily alpha stimulation, some B1
Results: potent vasoconstriction (vasopressor) and some increased contractility (positive inotrope)
Uses: refractory hypotension, shock, used as vsopressor but with inotrope properties
Considerations: Rapid IV onset, duration 1-2 minutes
Norepinephrine
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Stimulates: direct effect is dominant alpha stimulation, no substantial B1 effect at therapeutic doses, indirect effect; causes release of norepinephrine
Results: potent vasoconstriction (vasopressor)
Uses: refractory hypotension Considerations: rapid IV onset, duration of
action 10 – 15 minutes
Phenylephrine (synthetic compound)
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Arginine vasopressin used as vasopressor
Milrinone (phosphodiesterase inhibitor) used as an inotrope◦ Side effects: ventricular dysrhythmias exacerbation of accelerated
ventricular rate with atrial dysrhythmias
Non-Sympathomimetic Medications
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Angiotensin-Converting Enzymes (ACE) Inhibitors
prevent conversion of angiotensin I to angiotensin II
inhibits angiotensin-converting enzyme promotes arterial vasodilation reduces afterload
Benazepril Captopril Enalapril FosinoprilLisinopril Quinapril Ramipril
Medications Affect Renin-Angiotensin-Aldosterone System
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Blocks angiotensin II Similar hemodynamic effects as ACE
inhibitors Used in place of ACE inhibitors if they are
not tolerated due to intractable cough or angioedema
ARBs end with “sartan” Candesartan, first drug approved by FDA for
heart failure Candesartan Irbesartan Telmisartan Eprosartan Losartan Valsartan
Angiotensin II Receptor Blockers
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mineralocorticoid hormone hold sodium and water and excrete potassium potassium-sparing diuretics decrease in preload minimized release of catecholamines improved endothelial function antithrombotic effects decreased vascular inflammation and
myocardial fibrosis Spironolactone Eplerenone
Aldosterone Antagonists
http://www.youtube.com/watch?v=OAkbKN6AuWE
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block B1 or B2 receptors decrease heart rate and contractility bronchial and peripheral vasoconstriction management of heart failure management of stable angina management of acute coronary syndromes decrease myocardial oxygen demand increase coronary perfusion management of hypertensionAtenolol Metoprolol Propranolol Esmolol
Beta-Blockers
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decrease the flux of calcium decrease heart rate, contractility and
afterload degree of negative inotropic effect reduce coronary and systemic vascular
resistance decreasing myocardial oxygen demand not indicated in the treatment of heart
failure adverse effects: peripheral edema,
worsening heart failure, hypotension and constipation
Verapamil Dihydropyridine CCB Diltiazem
Calcium Channel Blockers
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Action Verapamil Dihydropyridine calcium channel blockers
Diltiazem
Heart rate ⇓ ⇑ ⇓
AV nodal conduction
⇓ Neutral ⇓
Contractility ⇓ ⇓ ⇓
Arterial vasodilation
⇑ ⇑ ⇑
Calcium Channel Blockers
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Nitroglycerin and Nitrates IV a primary venous vasodilator sublingual produces both venous and
arterial vasodilation decreases preload reducing myocardial oxygen demand higher doses = coronary artery dilation exhibits antithrombotic and antiplatelet
effects
Arterial and Venous Vasodilators
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mixed venous and arterial vasodilative arterial vasodilator indicated in hypertensive crisis cardiac emergencies hypotension side effect possible thiocyanate toxicity
Nitroprusside
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synthetic brain natriuretic peptide (BNP) counteract the effects of RAAS venous and arterial vasodilative effects management of acute decompensated
heart failure decrease preload and afterload lowers blood pressure
Nesiritide
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cardiac glycoside weak inotropic properties parpasympathetic properties used in treatment of heart failure narrow therapeutic range easy to develop toxicity electrolyte increase effect of digoxin
Digoxin
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reduce preload ascending loop of Henle promote venous vasodilation reduce preload rapid onset and short duration of action high-ceiling diuretics effective for renal dysfunction Bumex Lasix Demadex
Loop Diuretics
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Inhibit reabsorption of sodium & chloride Less potent than loop diuretics Decreased effectiveness with renal dysfunction Low-ceiling diuretics
Bendrofluazide Cyclothiazide Hydrochlorothiazide Chlorothiazide Indapamide Polythiazide Metolazone Trichlormethiazide
Thiazide Diuretics
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Direct renin inhibitors – Aliskiren _ treatment of hypertension _ impact RAAS
Vasopressin 2 Antagonists – Tolvaptan _ oral medication _ renal collecting ducts _ treatment of heart failure with volume overload
Emergency Medications
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Low-Density Lipoprotein Cholesterolo primary goal in the management of
coronary heart diseaseo HMG-CoA reductase inhibitors (statins)o Bile acid resinso Nicotine acido Dose dependent effect on LDL-C
Lipid-Lowering Medications
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Nicotinic acid (Niacin)
Fibrates
Statins
Bile acid resins
Bile acid sequestrants
Triglycerides and High-Density Lipoprotein Cholesterol
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Combine with bile acids Hepatic circulation More production of cholesterol Breaks cholesterol to make bile acids Increases LDL-C receptors Net decrease in total cholesterol Net decrease in LDL-C Constipation Questran Colestid WelChol
Bile Acid Sequestrants (Resins)
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B complex vitamin Dilates the cutaneous blood vessels Increases blood flow to face, neck and chest Vasodilation – “flush” Increase gastric acid secretion Decrease mortality in MI Decrease VLDL-C production Decreases lipolysis of triglycerides Decreases hepatic triglyceride synthesis Niacor Slo-Niacin Niaspan
Nicotinic Acid (Niacin)
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Fibric acid agents Not fully understood Stimulate lipoprotein lipase activity Decrease hepatic triglyceride production Decrease cholesterol synthesis Increase mobilization of cholesterol Enhance the removal of cholesterol Increase cholesterol excretion Raise HDL-C levels Atromid-S Tricor Lopid
Fibrates
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Statins Reduced lipid levels Reduced future coronary events Reduce the risk of coronary mortality &
morbidity Inhibition of HMG-CoA reductase Reduce the quantity of mevalonic acid
Mevacor Zocor Lescol Lipitor Crestor
HMG-CoA Reductase Inhibitors
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Newest class of lipid-lowering medications
May be combined with HMG-CoA reductase inhibitor
Ezetimibe
Blocks the absorption of cholesterol in the small intestine
Intestinal Absorption of Inhibitors
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To protect the integrity of the vessels and prevent harmful bleeding
To maintain the fluid state of the blood
These two goals must be achieved simultaneously to maintain health
Coagulation Overview
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Clotting CascadePlatelet Aggregation
Release Thromoboplastin
Prothrombin
Thrombin
Fibrinogenhttp://www.youtube.com/watch?v=IEuFUSuGcxE&list=PL2UREUiTlHRn3iW9DhoeLjxNDM7Ly5vrA
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Thrombolytics & Fibrinolytics
Type Actions/ Physiologic Effect
Agents
Fibrin specific Plasminogen activationRapid clot lysisClot specific
Tissue plasminogen activators (t-PAs)Alteplase Reteplase Tenecteplase
Nonfibrin specific Systemic lysisSlow clot lysisMore prolonged, systemic effect
StreptokinaseAnistreplase (APSAC)
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Earliest “clot busting” medication
Dissolves clots during an acute MI
Produce antistreptokinase antibodies Contraindicated to use streptokinase in
these patients
Streptokinase
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Anisoylated plasminogen streptokinase activator complex
Altered form of streptokinase Converts circulating plasminogen into
plasmin May be given as an IV bolus over 2 – 5
minutes Particular affinity for fibrin Activates the plasminogen that is bound to
fibrin
Anistreplase (APSAC)
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Unfractionated Heparin (UFH)◦ Antithrombotic agent◦ Prevents the conversion of prothrombin to thrombin◦ Binds to plasma proteins, blood cells, and
endothelial cells◦ Administered intravenously◦ Weight-based protocol◦ Administrated subcutaneoulsy◦ aPTT , PT, INR, platelet count, hemoglobin level and
hematocrit◦ Bleeding potential complication◦ Thrombocytopenia
Anticoagulants
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Low-molecular-weight Heparin (LMWH)◦ Accelerating the activity of antithrombin III◦ Longer half-life than UFH◦ No clotting times need to be monitored◦ Lower incidence of HIT◦ Higher rate of minor bleeding◦ Special dosing required for patients with chronic renal
insufficiency◦ Protamine used for reversing effects◦ Administered subcutaneously◦ Enoxaparin
Anticoagulants
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Direct Thrombin Inhibitors◦ Treatment of thrombosis in patients with HIT◦ Ability to inactivate fibrin-bound thrombin◦ Lepirudin and desirudin◦ Argatroban◦ Bivalirudin◦ Pradaxa
Anticoagulants
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Factor Xa Inhibitors◦ New class of anticoagulants◦ Fondaparinux◦ DVT and PE prophylaxis treatment◦ Antithrombotic action by neutralizing factor Xa◦ Subcutaneous injection ◦ No need for laboratory monitoring◦ No reports of HIT◦ Contraindicated in severe renal dysfunction
Anticoagulants
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Warfarin (Coumadin)◦ Oral anticoagulant◦ Inhibition of the synthesis of factor II
(prothrombin)◦ Altering the synthesis of other vitamin K-
dependent factors ◦ Primarily bound to albumin in the blood◦ Monitor PT and INR levels◦ Lifelong therapy for atrial fibrillation◦ Many drugs interact with warfarin ◦ No aspirin, ibuprofen or naprosyn
Anticoagulants
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Glycoprotein Iib/IIIa Inhibitors◦ Interfere with the final pathway of platelet
aggregation◦ Prevent fibrinogen binding◦ Administrated intravenously◦ May be given with aspirin, clopidogrel & heparin◦ Abciximab (ReoPro)◦ Monitor platelet count and hemoglobin level◦ Treatment of unstable angina and non-STEMI
Antiplatelet Therapy
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Adenosine Diphosphate Inhibitors◦ Clopidogrel (Plavix)◦ Prevents adenosine diphosphate (ADP) activation
of platelets◦ Treatment of unstable angina & non-STEMI◦ Avoid use of omeprazole (Prilosec)◦ Warning for patients who are poor metabolizers◦ Prasugrel
Antiplatelet Therapy
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Aspirin◦ Anti-inflammatory, analgesic, antipyretic &
antithrombotic◦ Treatment of acute or chronic ischemic heart
disease◦ Inhibiting cyclooxygenase and inhibiting the
synthesis of thromboxane A2.◦ Inhibits endothelial production of prostabladin I2◦ Chewing aspirin accelerates absorption◦ GI side effects
Antiplatelet Therapy
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Oxygen Aspirin Sublingual or Intravenous Nitroglycerin Intravenous Beta Blocker Unfractionated Heparin Glycoprotein IIb/IIIa Receptor Blocker
Treatment for Myocardial Infarction