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CARDIOVASCULAR DRUGS

The Cardiovascular System made-up of the heart, arteries, veins, and lymphatics. These structures transport life-supporting oxygen and nutrients to cells, remove metabolic waste products, carry hormones from one part of the body to another.

Types of drugs used to improve cardiovascular function include: Inotropic Antiarrhymic Antianginal Antianginal Antihypertensive Diuretic Antilipemic

INOTROPICS Cardiac glycosides and phosphodiesterase (PDE) inhibitors, increase the force of the hearts contractions. Have a positive inotropic effects (inotropic means affecting the force or nergy of mucvular contractions) Cardiac glycosides also the heart rate (called a negative chronotropic effect) and slow electrical impulse conduction through the atrioventricular (AV) node (called a negative dromotropic effect).

Cardiac Glycosides - group of drugs derived from digitalis, a substance that occurs naturally in foxglove plants and in certain toads. The most frequently used cardiac glycoside is digoxin. Digitalis

Digitalis is used to treat congestive heart failure (CHF) and heart rhythm problems (atrial arrhythmias). Digitalis can increase blood flow throughout your body and reduce swelling in your hands and ankles. Mechanism of action

Digitalis medicines strengthen the force of the heartbeat by increasing the amount of calcium in the heart's cells. (Calcium stimulates the heartbeat.) When the medicine reaches the heart muscle, it binds to sodium and potassium receptors. These receptors control the amount of calcium in the heart muscle by stopping the calcium from leaving the cells. As calcium builds up in the cells, it causes a stronger heartbeat. Digitalis medicines control irregular heart rhythms (called arrhythmias) by slowing the signals that start in the sinoatrial (SA) node. This, in turn, reduces the number of signals that travel through the atrioventricular (AV node). Fewer signals mean fewer arrhythmias.

Digitalis Medicines Lanoxicaps (digoxin) Lanoxin (digoxin), Lanoxin Elixir Pediatric (digoxin), Lanoxin Injection (digoxin), Lanoxin Injection Pediatric (digoxin) Interaction Other medicines that you may be taking can increase or decrease the effect of digitalis.

Antiarrhythmia medicines Certain antibiotics Calcium channel blockers Other heart medicines Certain anti-anxiety medicines Certain antifungal medicines Ulcer or stomach medicines Diarrhea medicines (containing diphenoxylate) Antacids Diuretics or water pills Certain cancer medicines Medicines for colitis Certain cholesterol-lowering medicines, especially cholestyramine

While on digitalis, you should also avoid caffeine and should not take diet pills, laxatives, or cough, cold, and sinus medicines.

Considerations

You have allergies to digitalis medicines or allergies to foods or dyes. You are thinking of becoming pregnant, you are pregnant, or you are breast feeding your baby. You are over 60 and are underweight or frail. You have other medical problems, such as thyroid disease, liver disease, lung disease, or kidney disease.

Side effects Serious side effects:

An irregular heartbeat that causes dizziness, the feeling that your heart has skipped a beat (palpitations), shortness of breath, sweating, or fainting Hallucinations, confusion, and mental changes like depression Unusual tiredness or weakness Trouble with your eyesight, such as blurry eyesight, double vision, or seeing yellow, green, or white halos around objects A loss of appetite or an upset stomach

Common side effects:


Erectile dysfunction Breast enlargement in men

Less common side effects:


A skin rash or hives Headache A numbness or tingling sensation over your body Eye sensitivity to light Diarrhea

Nursing responsibilities

Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate

Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different Check dosage and preparation carefully. Avoid IM injections, which may be very painful. Follow diluting instructions carefully, and use diluted solution promptly. Avoid giving with meals; this will delay absorption. Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops. WARNING: Monitor for therapeutic drug levels: 0.52 ng/mL.

Teaching points Do not stop taking this drug without notifying your health care provider. Take pulse at the same time each day, and record it on a calendar Weigh yourself every other day with the same clothing and at the same time. Record this on the calendar. Wear or carry a medical alert tag stating that you are using this drug. Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage of this drug. Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, vomiting, blurred or "yellow" vision, unusual tiredness and weakness, swelling of the ankles, legs or fingers, difficulty breathing. Digitalis toxicity Digitalis is a medication prescribed to certain heart patients. Digitalis toxicity is a complication of digitalis therapy, or it may be occur when someone takes more than a large amount of the drug at one time. (This is called an acute ingestion.) The most common prescription form of this medication is called digoxin. Digitoxin is another form of digitalis. Causes Digitalis toxicity can be caused by high levels of digitalis in the body, or a decreased tolerance to the drug. Patients with decreased tolerance may have "normal" digitalis levels in their blood. Digitalis toxicity can occur from a single exposure or chronic overmedication, or it may occur in patients with normal blood levels of digitalis if other risks are present.

People with heart failure who take digoxin are commonly given medications called diuretics, which remove excess fluid from the body. Many diuretics can cause potassium loss. Low levels of potassium in the body increase the risk of digitalis toxicity. Digitalis toxicity may also result in persons who take the drug and who have low levels of magnesium in the body. Risks include taking digitalis medications such as digoxin or digitoxin along with medications that interact with digitalis such as quinidine, verapamil, amiodarone, and others. Reduced kidney function will cause digitalis to build up in the body rather than be removed normally through urine. Therefore, any disorders that disrupt kidney functioning (including dehydration) make digitalis toxicity more likely.

Symptoms

Confusion Irregular pulse Loss of appetite Nausea, vomiting, diarrhea Palpitations Visual changes (unusual) o Blind spots in vision o Blurred vision o Changes in color perception o Halos or rings of light around objects o Seeing lights or bright spots

Treatment In an emergency, assist breathing as needed (CPR) and get professional medical help. Arrhythmias are treated according to which arrhythmia develops. Tube through the mouth into the stomach to wash out the stomach (gastric lavage) Digitoxin blood levels may be lowered with repeated doses of charcoal, given after gastric lavage.

Methods to cause vomiting are usually not performed because vomiting can worsen slow heart rhythms. ANTIHYPERT ENSIVE DRUGS Are drugs which act to reduce blood pressure, are used to treat hypertension, disorder characterized by elevation in systolic blood pressure, diastolic blood pressure, or both.

A. Sympatholytic drugs include several different types of drug, but all reduce blood pressure by inhibiting or blocking the sympathetic nervous system. Central-acting sympathetic nervous system inhibitors (clonidine and methldopa) Alpha-adrenergic blockers (doxazosin, phentolamine, prazosin and terazorin) Mixed alpha-and beta-adrenergic blockers (carvedilol and labetalol) Norepineprine depletors (guandrel, guanethidine, and reserpine these are rarely used) - absorbed well from the GI tract, distributed widely, metabolized in the liver, and excreted primarily in urine. -inhibit stimulation of the sympathetic nervous system, causing dilation of peripheral blood vessels or decreased cardiac output, thereby reducing blood pressure. -If blood pressure fails to come under control with beta-adrenergic blockers and diuretics, an alpha-adrenergic blocker, such as prazosin, or a mixed alpha-and beta- adrenergic blocker, such as la-betalol, may be used. If the patient fails to achieve the desired blood pressure, the physician may add a drug from a different class, substitute a drug in the same class, or increase the drug dosage.

Drug Interaction: Carvedilol with Antidiabetics

Carvedilol with Ca channel blocker Carvedilol with digoxin Carvedilol with rifampicin Clonidine plus tricyclic antidepressants may worse CNS depression Reserpine with diuretics or other hypotensive agents can increase the hypotensive effects of reserpine Reserpine with cardiac glycoside can lead to cardiac arrthymias. B. VASODILATING DRUGS There are two types of Vasodilating Drugs: Direct vasodilators and calcium channel blockers. Both types decrease systolic and diastolic blood pressure. Direct vasodilators act on arteries, veins, or both. They include: used to treat resistant or refractory hypertension reserved for use in hypertensive crisis

Hydralazine Minoxidil Diazoxide Nitroprusside Absorbed rapidly and well-distributed. Metabolized in the liver, and most are excreted by the kidneys. Relaxes peripheral vascular smooth muscle causing blood vessels to dilate. The increased diameter of the blod vessels reduces total peripheral resistance, which lowers blood pressure. Rarely used alone to treat hypertension. Usually combined with other drugs to treat the patient with moderate to severe hypertension. Drug Interaction: o The antihypertensive effects of hydralazine and minoxidil are increased when theyre given with other antihypertensive drugs, such as methyldopa or reserpine. o o May produce additive effects when given with nitrates, such as isosorbide dinitrate or nitroglycerin. Adverse reactions: palpitation, angina, edema, breast tenderness, fatigue, headache, rash.

C. Angiotensin Converting Enzyme (ACE) Inhibitors Group of drugs used primarily for the treatment of hypertension (high blood pressure) and congestive heart failure. Originally synthesized from compounds found in pit viper venom, they inhibit angiotensin-converting enzyme (ACE), a component of the blood pressure-regulating renin-angiotensin system. ACE inhibitors are used primarily to treat hypertension, although they may also be prescribed for cardiac failure, diabetic nephropathy, renal disease, systemic sclerosis, left ventricular hypertrophy and other disorders Typically used when beta blockers or diuretics are ineffective. Commonly prescribed ACE inhibitors include: o Benazepril, captopril, enalapril, enalaprilat, fosinopril, isinopril, moexipril, quinapril,ramipril,trandolapril. Absorbed from the GI tract, distributed to most body tissues, metabolized somewhat in the liver, and excreted by the kidneys. Ramipril is also excreted in stool. Enalaprilat is the only ACE inhibitor thats administered IV. Angiotensin-converting enzyme inhibitors reduce the activity of the renin-angiotensinaldosterone system. Mechanism of Action o Inhibit synthesis of Angiotensin II Decreases Peripheral vascular resistance and Blood Pressure o decrease BP - Action o Dereases peripheral vascular resistance without increased in cardiac output, cardiac rate, cardiac contractility Reduced aldosterone Na/H2O retention decreased Stroke Volume

The ACE inhibitors are contraindicated in patients with: Previous angioedema associated with ACE inhibitor therapy Renal artery stenosis (bilateral, or unilateral with a solitary functioning kidney) Hypersensitivity to ACE inhibitors

ACE inhibitors should be used with caution in patients with: Impaired renal function Aortic valve stenosis or cardiac outflow obstruction Hypovolemia or dehydration Adverse Effects Orthostatic Hypotension Renal insufficiency Cough GI distress Hyperkalemia Hyperreninemia Headache Ageusia Skin rash Proteinuria Neutropenia Advantages Infrequent orthostatic hypotension Lack of aggravation of pulmonary disorder Lack of aggravation with DM Increase renal blood flow Can be used with thiazide diuretic and digitalis

D. Angiotensin II Receptor Blockers (ARBs) Group of pharmaceuticals which modulate the renin-angiotensinaldosterone system. - Their main uses are in the treatment of hypertension (high blood pressure), diabetic nephropathy (kidney damage due to diabetes) and congestive heart failure Mechanism of Action - Block the activation of angiotensin II receptors Vasodilation Reduces secretion of vasopressin Reduces production and secretion of aldosterone Decreased Peripheral Resistance Decreased Blood Pressure Examples: Losartan (Coxaar) Telmisartan (Micardis) Irbesartan (Avapro) Eprosartan (Teveten) Olmesartan (Benicar)

Contraindication

Valsartan (Diovan) Candesartan (Atacand) Pregnancy Renovascular Disease

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