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Pharmacolog
y Exam 3 Study
Guide
Cardiac Drugs – Heart Failure, Antihypertensives, Antianginals, Etc.
(NOT Antidysrhythmic)
- MOA of each class of cardiac drugs, i.e., how do beta blockers work? how do calcium
channel blockers work? etc. (Don’t forget page 27 in your packet –
Antihypertensives)
▪Inhibits Angiotensin Converting Enzymes [ACE]
▪ACE is Responsible for Converting Angiotensin I to Angiotensin II
▪Angiotensin II (2 – TWO)
▪POTENT Vasoconstrictor AND Stimulator of Aldosterone
▪Aldosterone Stimulates Sodium/Water Reabsorption AND
Stimulates Excretion of K+ as well
- Angiotensin II Blockers [ARBs][MOA]
▪Allows Angiotensin II to be Made BUT Blocks the Receptor Sites for it to Bind
▪Prevents Vasoconstriction and Prevents Secretion of Aldosterone
▪ARBS = POTENT VASO DILATORS
- Direct Renin Inhibitors [MOA]
▪Binds with Renin
▪Inhibits Conversion of Angiotensinogen into Angiotensin I
▪Approved ONLY for Hypertension
- Aldosterone Antagonists [MOA]
▪Blocks Receptors for Aldosterone
▪Indicated for Hypertension and Heart Failure (in Severe Stages)
- Beta Blockers [MOA][ -LOL , - OLOL ]
▪ Cardioprotective Quality
▪Prevents Catecholamine-Mediated Actions on the Heart by
Reducing/Blocking SNS Stimulation to the Heart and the
Heart’s Conduction System
▪Decreases Cardiac Output and HR
- B-Type Natriuretic Peptides [ VASODILATORS ][MOA]
▪Vasodilator Effects on BOTH Arteries and Vein=Decreases Preload
AND Afterload
- Phosphodiesterase Inhibitors [MOA]
- Inhibiting the Enzyme Phosphodiesterase
- Milrinone (ONLY Available Phosphodiesterase Inhibitor Drug)
- Cardiac Glycosides [MOA]
▪Positive Inotropic
o Inhibits Na+/K+ Pump
o Allows More Calcium to Stay in the Cardiac Cell
o Increases Myocardial Contractility
o Increased Force and Velocity of Myocardial Contraction (Without an Increase
in Oxygen Consumption)
▪Negative Chronotropic
o Suppresses the SA Nodes (Decreases Heart Rate)
▪Negative Dromotropic Effect
o Decreased Automaticity at SA Node
o Decreased AV Nodal Conduction
- Calcium Channel Blockers [- DIPINE ][MOA]
▪PRIMARY USE: Hypertension AND Angina
▪Prevents Muscle Contractions
▪Blocks the Binding of Calcium which Causes the Smooth Muscle to Relax
▪Promotes Dilation of the Arteries
▪ NO EFFECT on HEART
▪EXCLUDING Verapamil and Diltiazem
▪Promotes Cardiosuppression
▪Used for Hypertension, Angina, AND Dysrhythmias
- What drugs/classes are first line therapy for angina? (remember NBC)
- FIRST Line Therapy for ANGINA ( NBC )
▪ N itrates [Nitrites]
▪ B eta Blockers
▪ C alcium Channel Blockers [CCBs
- What are prodrugs? Which ACE inhibitors are not prodrugs? What is the significance of this?
▪Drugs that are NOT ACTIVE UNTIL they reach the Liver
▪They Become Active when Metabolized (Metabolite)
▪Captopril (Capoten) and Lisinopril (Prinivil) ARE NOT PRODRUGS !!!!!!
▪IMPORTANT Because these Drug Do NOT Need to Reach the Liver
to Become Active
- Common SE of ACE inhibitors, ARBs, calcium channel blockers, beta blockers, nitrates
- ACE Inhibitors [Side Effects]
▪FIRST DOSE PHENOMENON [First-Dose Syncope]=First Dose
- Angiotensin II Receptor Blockers [ARBs][Side Effects]
▪UTI
▪ Angioedema
▪Headache, Dizziness, Fatigue
▪Renal Failure=Occurs in Patients with Bilateral Renal Artery
▪Do NOT Produce Cough
▪May Cause Mild Hyperkalemia
▪Toxicity Manifests with Decreased BP and Increased Pulse
o Potent Vasodilators (↓BP, ↑ Pulse) Reflex Tachycardia
- Beta Blockers [Side Effects]
▪CNS: Fatigue, Dizziness, Depression
▪Cardiac: Bradycardia , CHF, Orthostatic Hypotension
▪Respiratory: Bronchospasms, Dyspnea (SOB)
▪GI: N/V, Diarrhea, Colitis, Constipation
▪GU: Decreased Libido and Impotence
▪Endocrine: Blocks Normal Symptoms of Hypoglycemia
o P roteinuria (Increased Level of Protein in Urine)
o O rthostatic Hypotension (MAJOR)
o R enal Failure/ R ash
o L iver Toxicity/ L eukopenia (Form of
Agranulocytosis)
o A ngioedema (Swelling of the Lips, Tongue, Throat)=Allergic
Reaction
o T aste Changes [Dysgeusia]
o P ruritis
o I ncreased K+ (Especially with Potassium-Sparing Diuretics)
▪-DIPINE Group [Side Effects]
o Dizziness, Facial Flushing, Headache, Peripheral Edema (Ankles/Feet)
ALL the Result of Vasodilation
o GI: CONSTIPATION (Major)
o Gingival Hyperplasia (Overgrowth of the Gums)
o Hypotension
o Exacerbation of HF
o Causes Bradycardia
- Calcium Channel Blockers [CCBs][Side Effects]
➢ Mild = Calcium Channels Blockers [CCBs]
➢ Severe = STOP CCBs
o Reflex Tachycardia
o Partial or Complete AV
Block
o Eczematous Skin Eruptions In the Elderly
▪Verapamil and Diltiazem [Side
Effects]
▪ Headaches
o Intensity/Frequency Diminishes with Continued Use
o Wear Gloves when Applying Patch or Paste
o May Treat with Acetaminophen
▪Reflex Tachycardia
▪Postural (Orthostatic) Hypotension
▪ALL THREE ABOVE EFFECTS are caused by VASODILATION
▪Tolerance May Develop
- What may occur if beta blockers are stopped abruptly? Abrupt Discontinued Use of
Beta Blockers can Result in Increased INTENSITY of Angina OR MI (Heart Attack)
- What is reflex tachycardia? Heartbeat Caused by a Variety of Autonomic Nervous
System Effects
- Why are beta blockers administered to treat reflex tachycardia? Effects (Change in BP,
Fever, Emotional Stress
▪Monitor BP and Apical Pulse [AP]
▪HOLD Diuretics 1 WEEK Prior to Starting ACE Inhibitors
▪Can Cause FETAL HARM
▪Interactions
▪NSAIDs (Decreases Antihypertensive Effects)
▪Lithium (Monitor for Toxicity [>1.5])
▪Potassium-Sparing Diuretics (Hyperkalemia)
▪Antihypertensive and Diuretics (Causes Additive Effect)
- Nitrates drug of choice (DOC) for exertional angina (angina of effort, classic angina),
acute anginal attacks (nitroglycerin)
▪DOC for Exertional angina [Chronic Stable Angina] (Effort
Angina, Classic Angina)
▪DOC for Acute Anginal Attacks (Specifically Nitroglycerin)
- Nitroglycerin has large first pass effect – what does this mean? How does it affect dosage?
▪Has a LARGE First Pass Effect=Means Drug Dosage is
GREATLY REDUCED by the Liver when Ingested and Dosage
Needs to Be Increased
- Know contraindications for and drug interactions with nitrates (especially drugs for ED)
- Nitrates [Nursing Contraindications]
o Causes Absorption to be More Gradual and Effective
▪Administer IV Forms with Extreme Caution ( ALWAYS Use an IV Pump )
▪Remind Patient that Medication is Only Part of Therapy
o Patients Should Manage Diet, Stress Level, Weight, Alcohol Intake
▪Instruct Patients to Avoid Smoking and Eating Foods High in Sodium
▪Encourage Supervised Exercise
▪Teach Patient to Change Positions Slowly
o Performed to Avoid Syncope from Postural Hypotension
▪Instruct Patients to Report Unusual Shortness of Breath, Dyspnea,
Swelling of the Feet/Ankles/Around the Eyes, Weight Gain/Loss, Chest
Pain, Palpitations, Excessive Fatigue
▪ Male Patients who Take These Drugs May NOT Be Aware of that
Impotence is an Expected Side Effect (Inform them of Side Effect)
o This May Influence Compliance with Drug Therapy
▪If Patient is Experiencing Serious Adverse Effects OR Believe the
Dose/Med Needs to be Changed, They Should Contact Their
HPC IMMEDIATELY
▪Things that Can Lower BP (Leads to Fainting + Injury)
o Hot Tubs, Showers, or Baths
o Hot Weather
o Prolonged Sitting/Standing
o Physical Exercise
o Alcohol Ingestion
▪Patient Should Sit/Lie Down Until Symptoms of Dizziness Subside
▪Patients SHOULD NOT Take Other Meds Without Getting Approval from HPC
▪ ]
o Causes Vasodilation AND Lowers
BP
-DIPINE Group [Side Effects
o NO EFFECT on HEART
o Promotes Dilation of the Arteries
- Calcium Channel Blockers [- DIPINE ]
Smooth Muscle to Relax
- What are the differences in the two groups of calcium channel blockers? Know the MOA
▪-DIPINE Group [MOA]=PRIMARY USE: Hypertension AND
Angina o Prevents Muscle Contractions=Blocks the Binding of Calcium which Causes the
and SE of both groups
o Gingival Hyperplasia (Overgrowth of the Gums)
o Dizziness, Facial Flushing, Headache, Peripheral Edema (Ankles/Feet)
➢ ALL the Result of Vasodilation
o Eczematous Skin Eruptions In the Elderly
➢ Mild = Calcium Channels Blockers [CCBs]
o GI: CONSTIPATION (Major)
➢ Severe = STOP CCBs
- Verapamil and Diltiazem [MOA]
o Promotes Cardiosuppression
o Used for Hypertension, Angina, AND Dysrhythmias
o Blocks Calcium Channels in Vascular Smooth Muscle AND THE HEART
o PROMOTES CARDIOSUPPRESSSION
➢ Dilation of Arterioles ( Decreases BP )
➢ Increases Coronary (Heart) Perfusion
➢ Decreases Heart Rate
➢ Decreases AV Nodal Conduction
➢ Decreases Force of Contraction
▪Verapamil and Diltiazem [Side Effects]
o Hypotension
o Partial or Complete AV Block
o Exacerbation of HF
o Causes Bradycardia
- Monitor urine output for patients on cardiac drugs (what is minimal acceptable
urine output per hour?)
- Minimal Acceptable Urine Output PER Hour
▪ 30 ml Per Hour
- What to do for Patients receiving IV cardiac meds?
▪Patients SHOULD BE MONITORED for the First Couple of
Hours (Minimum) When Receiving IV CARDIAC MEDS
- What are first-line drugs for heart failure? (see heading on Heart Failure handout)
st
Line Drugs for Heart Failure
▪Loop Diuretics
▪ACE Inhibitors
▪Angiotensin II Receptor Blockers [ARBs]
▪Beta Blockers
- Nursing implications for administering digoxin; what is positive inotropic and
negative chronotropic?
- Digoxin [Nursing Considerations]
▪ NOTHING TO BP!! (NOT A CARDIOVASCULAR DRUG)
▪ Does Digoxin is taken Once Per Day
o If MISSED, it can be Taken No More than 12 Hours After Passed
Scheduled Time
Antilipemic (Cholesterol Lowering) Drugs
- Desired levels of total cholesterol, HDL, LDL, VLDL, and triglycerides (Cholesterol
is ONLY FOUND IN ANIMAL PRODUCTS)
▪200mg or LOWER
▪Limit Fat Intake; Limit Cholesterol Intake to Less than 300mg/day
- HIGH-Density Lipoproteins ( THE GOOD STUFF )(RECYCLES Cholesterol)
▪60mg or HIGHER (HIGHER = REMOVES ONE RISK FACTOR)
▪Can INCREASE Value with EXERCISE
- LOW-Density Lipoproteins [LDL]
▪LESS THAN 130
▪LESS THAN 100 (FOR CAD Patient’s)
- VERY LOW-Density Lipoproteins [VLDL]
▪LESS THAN 130
▪DIET Can LOWER This Value
▪LESS THAN 150
▪Increases with Diabetes Mellitus [DM] and Pancreatitis
- Risk factors for CAD
- Cholesterol Levels of 300 mg/dL
▪Three to Four Times Greater than Patients under 200 mg/dL
- Obesity, Diabetes, High BP, Stroke, Peripheral Heart Disease
- Physical Inactivity, Smoking, Age, Gender, Family History
- Which class of drug is best for lowering total cholesterol?
- DOC for Lowering Total Cholesterol
▪-STATINs
- When (what time of day) are statins administered? With or without food? Why?
- -STATINs Should be Taken in the EVENING
▪Take with 6 – 8 oz of Water
▪Food is Recommended to Decrease GI Distress
▪Lovastatin REQUIRES to be Taking with The EVENING MEAL
o “I LOVE My EVENING MEAL”
- Statins – contraindicated for alcoholic liver disease; acceptable for non-alcoholic
liver disease
- -STATIN [Contraindications]
▪ALCOHOLIC Liver Disease
o It is OKAY for NON-ALCOHOLIC Liver Disease
- What labs to check prior to and throughout statin drug use
- LFTs Are Check Before AND During Use of - STATINs
- SE for each class of antilipemics
- HMG-CoA Reductase Inhibitor (- STATIN )[Side Effects]
▪Mild, Transient Gastrointestinal (GI) Disturbances (MOST COMMON)
o Constipation (MOST COMMON), Dyspepsia [Heart
Burn], Cramps, Flatulence
▪Rash
▪Headache
▪Peripheral Vasodilation
▪Myopathy [Muscle Pain]
▪ Hepatotoxicity (CHECK LFTs)
- Cholesterol Absorption Inhibitors [Ezetimibe (Zetia) – ONLY CAI]
- Bile Acid Sequestrants [SE](SAFEST Drugs for Lowering Cholesterol)[SE]
▪Not Absorbed from GI Tract
▪NO Systemic Side Effects (SAFEST)
▪Constipation
▪Heartburn [Dyspepsia], Nausea, Belching, Bloating
o These May Increase Triglycerides
o Disappear Over Time
o Food Decreases GI Distress
o Increased Fiber (Fiber Supplements [Psyllium] Work as well)
➢ Relieves Constipation and Bloating
- Fibric Acid Derivatives [Fibrates][- FIBR - Can Be Found in Names][SE]
▪Ex. Feno FIBR ate
▪ DIARRHEA (THINK: “Fiber” will Produce Diarrhea)
o Only Fibrates Cause Diarrhea
▪Blurred Vision, Headache
▪Increased Risk of Gallstones
▪Prolonged Prothrombin Time (PT)
▪Liver Studies may Show Increased Enzyme Levels
- Niacin [Nicotinic Acid][Side Effects]
▪Intense Flushing (Caused by Histamine Release)
▪Pruritus
▪GI Distress
▪Liver Injury (Hepatotoxic)
▪Vasodilation (Related to Prostaglandin and Histamine)
o Small Dose Aspirin and Other NSAIDs 30 Minutes Before Niacin
➢ May Help Cutaneous Flushing and Itching
o Due to Bile Acid Sequestrants Not Being Absorbed
o TREATMENT = Restoring Gut Motility
▪Drug Interactions
o ALL Drugs Must be Taken 1 Hour BEFORE OR 4 – 6 Hours AFTER
➢ Avoids Decreased Absorption of the Other Drugs
o High Doses of BAS Decrease Absorption of Fat-Soluble Vitamins
➢ Fat-Soluble Vitamins [A, D, E, K]
o Thiazide, Diuretics, Digoxin, Warfarin, and Some Antibiotics
- Fibric Acid Derivatives [Fibrates][Interactions]
▪Oral Anticoagulants (INCREASES Risk of Bleeding)
▪STATINS (Increases risk of Rhabdomyolysis, Myalgias, and Myositis)
- Niacin [Nicotinic Acid][Interactions]
▪Niacin + - STATINs
o Increases Risk of Myopathy
▪Niacin + Antihypertensives
o Further Lowers BP (Vasodilation)
▪Contraindication in Patients with Increased Serum Uric Acid (Ex. Gout)
- SE of niacin (nicotinic acid) and how to treat these
- Niacin [Nicotinic Acid][Side Effects]
▪Intense Flushing (Caused by Histamine Release)
▪Pruritus
▪GI Distress
▪Liver Injury (Hepatotoxic)
▪Vasodilation (Related to Prostaglandin and Histamine)
o Small Dose Aspirin and Other NSAIDs 30 Minutes Before Niacin
➢ May Help Cutaneous Flushing and Itching
▪Take with or After Meals (Decreases GI Side Effects)
▪Symptoms Usually Decrease After 2 Weeks of Therapy
- Patient teaching for antilipemic agents
▪Obtain a Thorough Health/Medication History
- Assess Dietary Patterns, Exercise Level, Weight, Height, Vital Signs, Tobacco
and Alcohol Use, and Family History
- Assess for Contraindications, Conditions that Require Cautious Use, Drug Interactions
▪Includes Biliary Obstruction, Liver Dysfunction, Active Liver Disease
- Obtain Baseline Liver Function Studies
- Patients on Long-Term Therapy May Need Supplemental Fat-Soluble Vitamins
▪Fat-Soluble Vitamins [A, D, E, K]
- Refer to Guidelines Regarding Administration Times and Meals
- Counsel Patient Concerning Diet and Nutrition on an Ongoing Basis
- Powder Forms MUST Be Taken with a Liquid, Mixed Thoroughly (and
Gently), and NEVER TAKEN DRY
▪Can Cause Esophageal Irritation If Swallowed Dry
- Other Drugs Should be Taken 1 Hour BEFORE OR 4 – 6 Hours AFTER BAS
▪Avoids Interference with Absorption of Other Drugs
- Start Niacin on Low Initial Dose and Gradually Increase it (+ Take with Meals)
▪Helps Minimize Adverse Effects of Niacin
- Small Doses of Aspirin or NSAIDs may be Taken 30 Minutes BEFORE Niacin
▪Helps Minimize Cutaneous Flushing
▪Acetaminophen (Tylenol) Is NOT AN NSAID!!!!
- Provide Teaching Regarding Use of NSAIDs and Aspirin
- Inform Patients that These Drugs may Take Several Weeks to Show Effectiveness
- Instruct Patients to Report Persistent GI Upset, Constipation, Abnormal
or Unusual Bleeding, and Yellow Discoloration of the Skin
- Monitor for Therapeutic Effects
▪Reduced Cholesterol and Triglyceride Levels
o Specifically Decreased Total Cholesterol, LDL, Triglycerides
o Increase in HDL (THE GOOD STUFF)
- -STATINs Are CATEGORY X DRUGS!!!!
▪Inform Patient to Notify HCP if Pregnancy is Planned/Expected
- Antilipemic Agents are HIGHLY PROTEIN BOUND
- Food is Recommended when Taking -STATINs to Decrease GI Distress
- Recommend Patient to Take Antilipemic Drugs in the Evening
▪Cholesterol is Synthesized (Produced) Between 12am [Midnight] – 5am
- Fibrates are PRIMARILY Affect Triglycerides
▪Can Lower Total Cholesterol/LDL and Raise HDL
Dosage Calculations – to include:
- IV drip rates (mL/hr, gtt/min., etc.); know that on an infusion device (pump) you
must calculate for an hour – know how to do this even if something ordered for less
than an hour
- Calculate dosages and weight-based calculations, including heparin bolus
and drip/infusion rates
