EDGEWOOD COLLEGE

School of Nursing
N 312
CARDIAC DRUGS II
Lipid-Lowering Agents
What do your cholesterol numbers mean?
Total cholesterol
LDL (bad) cholesterol-the main source of cholesterol buildup in the arteries
HDL (good) cholesterol-helps keep cholesterol from building in the arteries
o protective
Triglycerides-another form of fat in your blood
o Reflect your diet for the past several days
o Tend to be dismissed
Total Cholesterol Level
Less than 200 mg/dL
200-239 mg/dL
240 mg/dL
LDL Cholesterol Level
Less than 100 mg/dL
100-129 mg/dL
130-159 mg/dL
160-189 mg/dL
190 mg/dL
HDL Cholesterol Level
> 60
< 40

Category
Optimal
Borderline High
HIgh
Category
Optimal
Near optimal
Borderline high
High
Very high
Category
Optimal Ideal Goal > 80
Too low considered a risk factor

HDL : LDL ratio < 0.4 optimal

HDL cholesterol, the higher the number the better. A level < 40mg/dL is
low and is considered a major risk factor for developing cardiac disease.
HDL levels > 60mg/dL help to lower your risk of heart disease. Aids in
cholesterol removal by returning from peripheral tissue back to liver.
LDL cholesterol is a major contributor to atherosclerosis. A level > 130mg/dL
needs intervention. If there is existing CAD a level > 100mg/dL should be lowered.

 in HDLs will risk for CAD.

in LDLs will risk for CAD.
Management of elevated LDL and cholesterol is diet and reducing risk factors.
Diet recommended, 30% total fat, 10% saturated fat. Other risk factors:
smoking, diabetes mellitus, HTN, obesity.
Lowering cholesterol in anyone at risk for heart disease saves lives. Drug therapy is
always used in conjunction with diet therapy.
HMG CoA reductase inhibitors- these drugs interfere with the enzyme needed for
synthesis of cholesterol.
I (Statins) most effective and newest therapy. Reduce LDL cholesterol significantly and
elevate HDL cholesterol only about 2-5%. Also, reduces inflammation and enhances
blood vessel dilation, decreasing risk of thrombosis. Contraindicated in liver disease.
Liver function tests are needed on a regular basis while on therapy. Taken with other lipid
lowering drugs may develop rhapdomyolysis. Best to take at night, when cholesterol
synthesis is at its peak.
Rhapdomyolysis: when pt complains of leg pain or muscle pain; if develop this
medication needs to be switched because worry of renal failure
Atorvastatin (lipitor)-can lower LDL levels by 60%
lovastatin (mevacor) 50% cheaper than lipitor
simvastatin (zocor)
atorvastatin calcium (lipitor)
II Bile Acid-binding resins- the resin makes the bile acids non-absorbable, preventing
recirculation of bile acid. The liver metabolizes more cholesterol to produce more bile
acids resulting in reduction of cholesterol level. May decrease the absorption of other
medications if given together. Drugs that bind and cannot be absorbed; thiazide diuretics,
digoxin, warfarin, and some antibiotics), should take 1 hour before or after. Prolonged
use may cause deficiency in vit. A, D, E, & K.
-Bile acids are produced from cholesterol
-blocks absorption of bile acids in the stomach into the circulation, therefore bile acids
levels drops, and body will break down cholesterol in order to make
-potential probs with medication: absorption problems (therefore usually dont want to
take with any other medications so it doesnt interfere with absorption)

-if on these for a long period of time has potential to reduce vitamin levels
-Pts may complain of GI problems-such as bloating or constipation
Cholestyramine (questran) can be given if active liver disease. A powder form so
needs to be mixed with liquid. Can be given with meals. Bile acid-resins are not
absorbed, may get GI symptoms; constipation, bloating.
III Niacin (nicotinic acid)- decreases serum levels of cholesterol, LDL, and
triglycerides. Increases HDLs better than any other drug. Also, acts as a vasodilator, so
is used for PVD. If on other vasodilator medications may need to monitor for side
effects. May cause flushing but should diminish over time. Due to its side effects it has
limited use. Is hepatotoxic, shown to increase levels of homocysteine which will increase
risk for CAD. Dose is much higher than what is used as a vitamin supplement. 3-9
grams/day vs. 25 mg/day. Should take with food.
-dose is 6X greater than normal Niacin
-will increase HDL levels better than any other drug (so used for people who have low
HDLs)
-every effective but does cause facial flushing
-can take bendril before it or else they have a nonflushing form available that they can
substitute
Prevention and Treatment of Thromboembolic Disorders
I Anticoagulants most often used to prevent venous thrombosis
Heparin- rapid-acting anticoagulant.
Helps antithrombin III inactivate thrombin, factor Xa
and other factors so fibrin formation is suppressed. Cannot be given orally, given IV or
SC. Onset of action IV is minutes. Half-life is 1.5 hours. Therapy is usually begun
with a bolus and IV drip following. Prescribed in units not milligrams. Dose can vary
from 100units, 5,000units every 12 hrs. to 1200units/hour. Depends on use. Given to
treat pulmonary embolism, evolving stroke, deep vein thrombosis, open-heart surgery and
renal dialysis. Careful monitoring is required. APTT-activated partial
thromboplastin time is a lab test used to monitor heparin. Normal value is 20-35
seconds
Laboratory values will vary from lab to lab.
Heparin blood levels Therapeutic goal for anticoagulant therapy is 1.5-2.5 times the control in seconds.
Drug interactions; aspirin, ibuprofen).
*Never give IM.
Protamine sulfate is the antidote, used for heparin overdose.
PTT (partial thrombo plastin time (sp)Lab test used to test heparin
Enoxaparin (lovenox)- low-molecular weight heparin. Used for prophylaxis purposes;

for DVT after hip, abdominal surgery. APTT is not used for monitoring. Given SC.
Adverse affects same as heparin. Advantage is can be given at home.
--safer for patient
symptoms of DVT
-calf pain
-redness
-swelling
-test: dorsiflexsion (if have pain with that is +)
Heparin is giving SQ because of bruising
HIT heparin induced thrombocytopenia

Warfarin (coumadin)- long-term oral anticoagulant. Does not affect clot already
present but used as a preventive. Used for those needing long-term prophylaxis such as;
patients with prosthetic valves, those with atrial fibrillation, and prevention of PE.
Blocks vitaminK, therefore synthetic vitamin K is used for warfarin overdose. For mild
bleeding given orally, for severe bleeding, 5-50mg. vit K given IM or SC.
The prothrombin time (PT) (INR) is the lab test used to monitor warfarin therapy.
INR, international normalized ratio to be therapeutic should be 2.0-3.0 while some
patients need an INR 3-4.5. Monitoring is done daily initially, then once/week for 12months, every 2-4 weeks after that. Onset of drug takes several days, after
discontinuing drug; effects may still be present for 2-5 days.
Patient education diet, medications, risk for bleeding. Very effective if pts. are in a
setting where an anticoagulant management service is present.
Genetic markers identified as cause for variable response
**INR (international normalized ratio)
PT measures seconds it takes the blood to clotINR therapeutic is usually 2-3;
sometimes physicians want it higher
-INR 1 or less is considered normal
-long half life so slow onset
-fluids with high amount of vitamin Kleafy veggies, salads
-reversible for warfarin-Vitamin K
-discovered that certain individuals react very different to dose and have a problem with
bleeding (screening test)
DTI-direct thrombin inhibitor- new drug group, approved 2011. A good alternative to
Warfarin anticoagulant therapy. Does not require therapeutic INR monitoring.

Dabigatran etexialte (pradaxa)- the first oral DTI in the US. Indicated to reduce risk of
stroke and systemic embolism from atrial fibrillation. Advantages: oral route, rapid onset
of action, and predictable anticoagulant. Is not an inducer or inhibitor of cytochrome
P450 isoenzymes.
II Antiplatelets- suppresses platelet aggregation, used primarily to prevent thrombosis
in arteries.
Aspirin-used for prophylaxis of MI, reinfarction and stroke. Dosing 60mg. 325mg./day.
May cause GI irritation and increased bleeding.
--cheapest and most commonly used
Clopidogrel (plavix) inhibits platelet aggregation. May prolong bleeding time. The
first one approved and is used the most. Does have a delayedonset and variable response
because it can be activated by cytochrome P450 enzymes in the liver.
--should not be used with prilosec (this combo reduces amount of plavix by 50%; wont
get full benefits of plavix)
-two GERD meds can take: pepsid and zantec
Ticlopidine (ticlid)- effects are similar to aspirin. Used for patients allergic or
unable to tolerate aspirin. Can cause thrombocytopenia (lowering of platelets)
If platelets less than 90,000, do not give plavix, because if have low platelets this could
increase patients change of bleeding
All platelet meds should be stopped a week before surgery because of bleeding
Dipyridamole (persantine)- usually used for prevention after heart valve surgery and
used with warfarin. Also dilates coronary arteries.
All of these should be stopped 7 days prior to surgery.
III Thrombolytics-used to remove thrombi already formed, also known as fibrinolytics.
Most optimal to use within 6 hours of the event.
-short half life
-usually given in emergency room
-if patient recognizes signs and symptomsif 6 hours within stroke of heart attack can
use
-if any recent falls of surgeries patient is not a candidate because it will destroy any other
clot in body
-used for acute heart attack, stroke, occluded blood vessel
Binds with plasminogen to convert it to plasmin to digest fibrin meshwork of clot. Used
for acute coronary thrombosis (MI), massive pulmonary emboli, stroke, for DVT and
peripheral arterial clot. Given IV directly into occluded vessel if possible. Half-life is

very short. Careful screening needs to be done prior to therapy. Adverse effects; bleeding
(intracranial 1%), allergic reaction, hypotension, fever. Can be used to dissolve clots in
central lines and AV cannulas.
Alteplase (tPA) tissue type plasminogen activator- does not cause hypotension or
allergic reaction. In 2009, the window for tPA administration for eligible patients was
extended from 3-4.5 hours where the clot dissolving can reverse the effects of a stroke.
Amazing!
Exclusion Criteria:
Age older than 80
INR < 1.7
NIHSS stroke scale > 25
History of both diabetes and stroke
Alterations to adjust HDL and LDL
-Diet to a certain extend
-Exercise
-Smoking cessation (smoking causes LDL to be high)
*Research has shown support groups or coaches are the best way for people to make
successful lifestyle changes
Anticoagulant- medication that is going to prevent future clots from occurring; cannot
break down an existing clot
-used as preventative measure or preventing an already exisiting clot from getting larger
antiplatelets
-work on platelets (RBCs tend to clump together and go to site of injury); work on
making them not clump together, instead slippery, helps avoid clots
thrombolytics- clot busting medications; will break down exisiting clots

Questions
**Warfarin therapy is monitored by measuring the PT expressed as an INR. A patient has
an mechanical artificial valve. You would expect the target INR to be:
If not on warfarin, INR should be less than one
Mechanical artificial valve usually want a little higher than therapeutic, like 3-3.5