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Exam 2 Study Guide Week two lecture (Dr.

Note: Bring calculator
ACE inhibitors (Prils)

Priority assessments include Contraindications including impaired renal function

Blocks the conversion of Angiotensin I to the vasoconstrictor Angiotensin II that occurs
in the lungs
Drug of choice in treatment of CHF patients
ACE Inhibitors - are good for people with normal kidney function
Good for Diabetics - it will protect the kidneys
But if patient has early Renal Insufficiency - the ACE Inhibitor will INCREASE the

Beta Blockers (LOLs)

Onset 15 minutes
SE: Atrioventricular (AV) block,
Bronchospasm, nightmares, hypoglycemia in
Inderal (propranolol) (specifically): Insomnia
Expected results: decreased HR, decreased B/P, Reduction of workload
of the heart
Measuring effectiveness: Reduction in angina, reduction of symptoms
associated with ADLs
Decrease CO, Decreases Renin Secretions

Ca Channel blockers (Review SE) slide 30 Ca meds

Treatment of essential hypertension in the extended release form

Contraindications: Allergy, heart block or sick sinus syndrome, renal or
hepatic dysfunction, pregnancy, and lactation
NO GRAPEFRUIT JUICE!!! When grapefruit juice is present in the body,
the concentrations of calcium channel blockers increase, sometimes to
toxic levels.

ARB Review SE Slide 24 Cardiac meds (What would you teach a

patient to report to MD?)

Contraindications: Allergy, pregnancy, and lactation

Angiotensin IIreceptor blockers are associated with a cough, back
pain, fever, muscle weakness, and upper respiratory tract infections,
so the patient should be taught to report a fever or cough to his health
care provider.

Adverse Effects: Headache, dizziness, syncope, weakness, GI

complaints, and Skin rash/dry skin

The mechanism of action of an ACE inhibitor is the blocking of ACE from

converting angiotensin I to angiotensin II. What does this cause?
Decrease in aldosterone production

BiDil (combo drug: isosorbide dinitrate and hydralazine)

In Cardiotonic Agent case study: Review SE

Vasodilates due to the release of nitric oxide

Specifically used for African American pts with CHF and HTN that do not
respond well to a traditional therapy
SE: Dizziness, light headedness, nausea, and flushing

What are Ca glycosides and phosphodiesterase commonality?

Slide 21 (Drugs affecting BP) & (Notes slide 32 Cardiac meds) Increases Ca

Tx: Heart Failure, Tachyarrhythmias (PAT, atrial fibrillation, atrial flutter)

+ Inotropic effect- Increases Contractility
- Chronotropic Effect: Decreases Heart Rate
Decreases Conduction- This reduces the HR and helps to counteract atrial fibrillation
commonly seen in CHF.
Phosphodiesterase INCREASES cellular levels of c-AMP (cyclic adenosine
monophosphate phosphodiesterase) that INCREASES calcium!
o Unlike digoxin, it does not inhibit sodium-potassium adenosine tri-phosphatase

Phosphodiesterase drugs: Review Inocor (Increases C-amp-slide 21

drugs affecting BP and vasodilators)
Review Primacor (milrinone)

Note these drugs contraindicated in allergy to the drug or bisulfates!

Only given IV (slide 21)
The phosphodiesterase inhibitors block the enzyme phosphodiesterase. This blocking
effect leads to an increase in myocardial cell cyclic adenosine monophosphate (cAMP),
which increases calcium levels in the cell. Increased cellular calcium causes a stronger
contraction and prolongs the effects of sympathetic stimulation, which can lead to
vasodilation, increased oxygen consumption, and arrhythmias. Digoxin also increases
intracellular calcium and allows more calcium to enter myocardial cells during


Preparing to administer a digitalizing dosage of digoxin to a geriatric

patient, what factors will to avoid digoxin toxicity will the nurse review?
Renal function, Low body mass, Hydration
Review S & S of toxicity N/V, Anorexia, Visual disturbances yellow
vision, Headaches, Fatigue/Maliase, Arrhythmias (PVCs, A-fib, 1st degree
block), Bradycardia
What if the patient shows symptoms? Treat patient with DIGIBIND (digoxin
immune fab), Digoxin Immune Fab (Ovine), is indicated for treatment of
potentially life-threatening digoxin intoxication.
Dig for infants-* Must have another nurse check dosage calculations

Adults-excreted in urine unchanged---So---Monitor for kidney function before giving!

o Increased contraction which improves circulation. Will that increase or decrease
o Know Adult loading dose 0.75 to 1.25 mg orally or 0.125 to 0.25 mg IV, then
oral maintenance
dose of 0.125 to 0.25 mg/d; decrease dose with renal
o Rapid onset-Oral 30-120 minutes: 5---30 minutes for IV
o Teaching points: Avoid taking with food or antacids: may slow absorption
o Increased digoxin toxicity has been reported with ginseng, hawthorn, and licorice,
& St Johns Wart

What antibiotic is safe with digoxin? Zithromax may be given without

impacting the effects of digoxin. There is a risk of increased therapeutic effects and
toxic effects of digoxin if it is taken with verapamil, amiodarone, quinidine, quinine,
erythromycin, tetracycline, or cyclosporine. If digoxin is combined with any of these
drugs, it may be necessary to decrease the digoxin dose to prevent toxicity. If one of
these drugs has been part of a medical regimen with digoxin and is discontinued,
the digoxin dose may need to be increased.
Review slide 32 Ca meds: Risk for dig toxicity
Patients are at risk for toxicity if they are currently taking Diuretics, Beta
blockers, Calcium preparations, Amiodarone (Cordarone), Cardizem
(Diltiazem), Erythromycin, omeprazole, Verapamil, and/or Quinidine.

Diuretics= produce low potassium

Beta Blockers = effect is HR
Calcium preparations = increase circulating calcium
Ask for Dig level if you havent seen one in a while
Digibind (digoxin immune Fab): Serum digoxin levels will be very high and
unreliable for
about 3 days after the digoxin immune Fab infusion

because of the high levels of digoxin in the blood; in this scenario-observe

and follow dig levels. The patient should not be redigitalized for several days
to 1 week after digoxin immune Fab has been used,
Dig levels: narrow therapeutic range of 0.5-2.0.
When preparing to digitalize; assess for renal function, low body mass, &
hydration. These issues lead to
toxicity so must be assessed before giving a
loading dose.

Amiodarone: Slide 31 Ca Drugs (SE include: may cause serious Ca


Amiodarone causes anorexia, pts. C/O funny taste Can cause serious cardiac
o Megase may be ordered to increase appetite, however causes prolonged
QT Interval
Marinal (Marijuana derivative) INCREASES appetite, but does not hurt the heart

Lidocaine-See slide 41 Ca drugs SE

1-4 mg/min

Loading dose followed by IV infusion of

Monitor for signs of confusion (toxicity) and dizziness

Onset & Peak is Immediate
With Lidocaine, monitor patient for signs of dizziness or toxicity

What drug does the nurse keep on hand to reverse the

effects of

A) Antithrombin (Thrombate III)
B) Desirudin (Iprivask)
C) Protamine sulfate
Ask about peptic ulcers
Note: Heparin does not enter breast milk

Lovenox: Review action-what does it do? Used prophylactically to

prevent clot formation (thrombus) and an embolus (dislodged clot).

Cordarone (antiarrythmics) During administration SE: possible

development of very serious


Ca Channel Blockers=SE: H/A & Dizziness

1) Nifedipine (adalat)*SE=Peripheral edema

Clonadine with non-selective beta-blockers : can antagonize or

reverse the
antihypertensive effect of clonidine
Nitro: after 3 nitro, if no relief from CP call 911; onset 1=3 minutes
Pt. teaching action decreases amount of O2 needed by the heart 8

Lab testing slide 3

Troponin protein released with injury of myocardial cells

o Two types I & T
Troponin I (begins to rise as early as 1 hour post pain) _ Lewis textbook
o <0.4 normal baseline (Lewis)
o These values vary greatly depending on the reference you use and
laboratory equipment.

Troponin T & Troponin I only present in cardiac tissue, therefore, troponin is the
preferred test for a suspected heart attack because it is more specific for
heart injury than other tests (which may be elevated in the blood with skeletal
muscle injury) and remain elevated for a longer period of time.
Troponin is attached to the protein tropomyosin and lies within the groove between
actin filaments in muscle tissue. In a relaxed muscle, tropomyosin blocks the
attachment site for the myosin crossbridge, thus preventing contraction. When the
muscle cell is stimulated to contract by an action potential, calcium channels open
in the sarcoplasmic membrane and release calcium into the sarcoplasm. Some of
this calcium attaches to troponin, which causes it to change shape, exposing
binding sites for myosin (active sites) on the actin filaments. Myosins binding to
actin causes crossbridge formation, and contraction of the muscle begins.
In other words, the electrolyte, Calcium, inactivates troponin and allows actin
and myosin to form a bridge enabling the muscle fibers to contract.
Note: Troponin is found in both skeletal muscle and cardiac muscle, but the specific
versions of troponin differ between types of muscle. The main difference is that the
TnC subunit of troponin in skeletal muscle has four calcium ion-binding sites,

whereas in cardiac muscle there are only three. Views on the actual amount of
calcium that binds to troponin vary from expert to expert and source to source
Troponin is detectable within hours (average, 4 to 6 hours), peaks at 10 to 24 hours,
and can be detected for up to 10 to 14 days.

Review Labs and their role in Dx of atherosclerosis: C-reactive


Abnormal protein produced by the liver during an acute inflammatory process

Positive test indicates the presence of inflammatory disease but not the cause
May be diagnostic of: bacterial infectious disease or Inflammatory diseases
Will be elevated when CK-MB levels are elevated
Peaks occur 1-3 days later
Homocysteine Amino Acid identified as a risk factor to CV disease
o May cause damage to the endothelium or be involved in clot formation.
Significance of LDLs and HDLs; when should lipid profiles be
drawn to maximize accuracy of results? What is plaque composed
of? What is the desired goal for
cholesterol levels?
Lab test for heart failure (BNP)

<100pg/ml = Normal
Brain Natriuretic Peptide
Increases in CHF
Related to reduction in Na= ions, the bodys attempt to control fluid
overload in the lungs
Misnomer, highest level does not exist in the brain, but in cardiac
ventricular muscle
These peptides oppose the renin-angiotensin system.
BNP are secreted when there is a stretch in the atrial or ventricular
Corresponds to left ventricular pressure
If BNP level is elevated, the SOB is caused by CHF
If BNP is normal, SOB is pulmonary
BNP can be elevated with acute MI, and prolonged systemic HTN

chronotropic or chronotropy- Change the heart
rate/contractions. Firing of sinoatrial node.
Review Nitroglycerine and adverse effects.

Systemic vasculature
o Vasodilation - (venous dilation > arterial dilation)
o decreased venous pressure
o decreased arterial pressure (small effect)
Cardiac-reduced preload and afterload (decreased wall stress)
o decreased oxygen demand
Coronary-prevents/reverses vasospasm
o vasodilation (primarily epicardial vessels)
o improves sub-endocardial perfusion
o increased oxygen delivery
Nitrodilators are drugs that mimic the actions of endogenous Nitric
Oxide by releasing NO or forming NO within tissues. These drugs act directly
on the vascular smooth muscle to cause relaxation and therefore serve as
endothelial-independent vasodilators.
Therapeutic Indications: The primary pharmacologic action of
nitrodilators, arterial and venous dilation, make these compounds useful in
the treatment of hypertension, heart failure, angina and myocardial
infarction. Another beneficial action of nitrodilators is their ability to inhibit
platelet aggregation.
Hypertension: Nitrodilators are not used to treat chronic primary or
secondary hypertension; however, sodium nitroprusside and nitroglycerine
are used to lower blood pressure in acute hypertensive emergencies that
may result from a p
heochromocytoma, renal artery stenosis, aortic dissection, etc.
Nitrodilators may also be used during surgery to control arterial pressure
within desired limits.
Heart failure: Nitrodilators are used in acute heart failure and in severe
chronic heart failure. Arterial dilation reduces afterload on the failing
ventricle and leads to an increase in stroke volume and ejection fraction.
Furthermore, the venous dilation reduces venous pressure, which helps to
reduce edema. Reducing both afterload and preload on the heart also helps
to improve the mechanical efficiency of dilated hearts and to reduce wall
stress and the oxygen demands placed on the failing heart.

Angina and myocardial infarction: Organic nitrates are used extensively

to treat angina and myocardial infarction.
o Chronotropic- Firing of the SA Node/HR
o Inotropic- contractions of the Heart. The force of the beating heart.
o Dromotropic- affects the conduction of the speed in the AV node, rate of
the electrical impulses.
o Hemodynamic- monitoring of the pressures and cardiac output/perfusion.

Review questions/answers in PP
What common action do both cardiac glycosides and
phosphodiesterase inhibitors have in common related to therapeutic
action? They both increase calcium in the cell
The phosphodiasterase inhibitors block the enzyme phosodiasterase.
This blocking effect leads to an increase in myocardial cell cyclic
adenosine monophosphate (cAMP), which increases Ca+ levels in the
Digoxin also increases intracellular calcium and allows more Ca+ to
enter myocardial cells during contraction.
True or False: The use of a loop diuretic is the first drug used in the
Step Care Management program to treat hypertension.
False: A somewhat controversial study, the ALLHAT study, reported
in 2002 that patients taking the less expensive, less toxic diuretics
did better and had better blood pressure control than patients using
other antihypertensive agents. Replications of this study have
supported its findings and the use of a thiazide diuretic is currently
considered the first drug used in the Step Care Management of
The mechanism of action of an ACE inhibitor is the blocking of ACE
from converting angiotensin I to angiotensin II. What does this
cause? Decrease in aldosterone production

o Blocks ACE from converting angiotensin I to angiotensin II, leading

to a decrease in blood pressure, a decrease in aldosterone production,
and a small increase in serum potassium levels along with sodium and
fluid loss

What is the leading cause of Heart Failure? CAD is the leading cause of HF,
accounting for approximately 95% of the cases diagnosed. CAD results in
an insufficient supply of blood to meet the oxygen demands of the
myocardium. Consequently, the muscles become hypoxic and can no
longer function efficiently. When CAD evolves into a myocardial infarction,
muscle cells die or are damaged, leading to an inefficient pumping effort.
The nurse is caring for a patient whose physician has just ordered
Cyclomen PO 800 mg daily in 2 divided doses. What disease process
would the physician be ordering the Cyclomen for? Endometriosis

In women, danazol (Cyclomen) may be used to prevent or treat

endometriosis or fibrocystic breast disease. Anabolic steroids are more often
abused for body-building purposes than used for therapeutic effects.

The nurse is caring for a 27-year-old African American woman who was
just prescribed an ACE inhibitor for management of her hypertension.
What should be advised related to contraception?
Use barrier contraceptives to prevent pregnancy while taking these drugs.

The safety for the use of these drugs during pregnancy has not been
established. ACE inhibitors, ARBs, and renin inhibitors should not be used
during pregnancy, and women of child-bearing age should be advised to use
barrier contraceptives to prevent pregnancy while taking these drugs.

True or False: The primary treatment for congestive heart failure is to

make the heart beat harder and faster.
False: Primary treatment involves increasing muscle contractility, bringing
the system back into balance
The nurse is caring for a patient who has presented to the emergency
department with signs and symptoms of an acute MI. While making an
initial assessment of this patient the nurse notes the patient has had
adverse reactions to digoxin and a history of congestive heart failure. The
physician writes admission orders. Which of the following drugs would be
of concern? Milrinone (Primacor)

They are contraindicated in the following conditions: severe aortic or

pulmonic valvular disease, which could be exacerbated by increased
contraction; acute MI, which could be exacerbated by increased oxygen
consumption and increased force of contraction; fluid volume deficit, which

could be made worse by increased renal perfusion; and ventricular

arrhythmias, which could be exacerbated by these drugs.
http://www.heartsite.com/html/cad.html-good information