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Pharm Exam 3
Pharmacology II (NUR 354)
Arizona College of Nursing
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NUR 354 Exam 3 (Modules 5-6)– Outline for Success
Module 5 – Chapter 23 & 27
Heart Failure and Lipids
Drugs for Lipids
Hyperlipidemia High levels of lipids in blood—major risk factor for cardiovascular disease Most patients asymptomatic until cardiovascular disease produces symptoms. Dyslipidemia Abnormal levels of lipoproteins, excess or deficient 3 types of Lipids
- Triglycerides
- Phospholipids
- Steroids
HMG-CoA Reductase Inhibitors/Statins
- Interfere with the synthesis of cholesterol
- First drugs of choice to reduce blood-lipid levels
- Examples: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), rosuvastatin (Crestor), simvastatin (Zocor)
- Monitor liver function tests
- Do not use with pregnancy or breastfeeding
- Watch for signs of GI upset
- Lowers bad cholesterol and increase the good
- Bad= Total cholesterol, Triglycerides, LDL
- Good= HDL
Atorvastatin (Lipitor) MOA:
inhibits HMG-CoA reductase Use: reduces serum-lipid levels Side Effects: headache, fatigue, muscle or joint pain, and heartburn, rarely rhabdomyolysis (occurs when damaged muscle tissue releases its proteins and electrolytes into the blood) Admin Alerts: Administer with food to decrease GI discomfort. May be taken at any time of the day. Pregnancy category X. Women should not breastfeed during therapy. Herbal/Food: Grapefruit juice inhibits the metabolism of statins, allowing them to reach toxic levels. Red yeast rice contains small amounts of natural statins and may increase the effects of atorvastatin. Because statins also decrease the synthesis of coenzyme Q10 (CoQ10), patients may benefit from CoQ supplements.
Bile Acid Sequestrants
- Bind with bile acids to increase excretion of cholesterol in stool
- Used in combination with statins
- Examples: colesevelam (Welchol), colestipol (Colestid)
- Monitor for significant GI effects
- Obtain careful history for past GI disorders
Cholestyramine (Questran) MOA:
bind with bile acids, increasing cholesterol excretion in stool Use:
to lower serum-lipid levels Cholestyramine is a powder that is mixed with fluid before being taken once or twice daily. It may take 30 days or longer to produce its maximum effect. Questran binds with bile acids (containing cholesterol) in an insoluble complex that is excreted in the feces. Cholesterol levels decline due to fecal loss.
Fibric Acid Drugs
- Assess for complaints of GI distress before starting drug
- Use with warfarin may potentiate anticoagulant effects:
- Monitor prothrombin time/international normalized ratio (PT/INR)
Gemfibrozil (Lopid) Use: treating severe hypertriglyceridemia Side Effects: GI distress; watch for bleeding with patients on anticoagulants dyspepsia, diarrhea, nausea, and cramping May increase the likelihood of gallstones and may occasionally affect liver function. Admin Alerts: Administer with meals to decrease GI distress. Pregnancy category B. Contradictions: contraindicated in patients with hepatic impairment, severe chronic kidney disease (C K D), preexisting gallbladder disease, or those with prior hypersensitivity to the drug. Herbal/Food: Fatty foods may decrease the efficacy of gemfibrozil.
Ezetimibe (Zetia) Cholesterol Absorption Inhibitor
MOA/Use:
Inhibits absorption of cholesterol in small intestine, resulting in small reduction in LDL Side Effects:
Serious side effects uncommon; minor side effects nasopharyngitis, myalgia, upper respiratory tract infection, arthralgia, and diarrhea
Can be administered with statins
Drugs for Heart Failure
Heart Failure Inability of ventricles to pump enough blood for body’s needs Weakening of heart muscle due to aging or disease Left-Sided Heart Failure Blood accumulates in left ventricle Left ventricle thickens and enlarges: hypertrophy Cardiac remodelling Blood backs up into lungs Cough and shortness of breath result
Right-Sided Heart Failure Blood backs up into veins Causes peripheral edema and organ engorgement Less common than left-sided HF
Preload Affects cardiac output The degree myocardial fibers are stretched prior to contraction
- Frank–Starling law: The more fibers are stretched, the more forcefully they will contract Drugs that increase preload contractility will increase cardiac output
- Positive inotropic agents
Afterload Affects cardiac output Pressure in aorta that must be overcome before blood is ejected from left ventricle Lowering blood pressure creates less afterload, resulting in less workload for the heart
Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)
- ACE inhibitor: pril
- Reduce afterload
- Drugs of choice for heart failure
- Enhance excretion of sodium and water o Lower peripheral resistance and reduce blood volume
- Increase cardiac output
- Desired outcome for ACE inhibitors is capillary refill 2 seconds
- Indications: Hypertension & Heart Failure
- Side effects: Hypotension, dry non-productive cough, dizziness, angioedema (swelling), hyperkalemia
- Do Not Stop Abruptly
- Pregnancy category D
decreased antihypertensive activity. Because of the additive hypotensive action of lisinopril and diuretics, combined therapy with these or other antihypertensive drugs should be carefully monitored. When lisinopril is taken concurrently with potassium-sparing diuretics, hyperkalemia may result. Herbal/Food:
Excessive intake of foods rich in potassium and potassium-based salt substitutes should be avoided because of the possibility of hyperkalemia. Treatment of Overdose: Overdose causes hypotension, which may be treated with the administration of normal saline or a vasopressor.
Angiotensin Receptor Blocks (ARBs) ARB: sartan Actions very similar to ACE inhibitors Usually used for patients who are unable to tolerate the adverse effects of ACE inhibitors Indications: Hypertension & Heart Failure Side effects: Angioedema (swelling) Contradicted: patients with Renal Artery Stenosis (ARBS can cause renal failure) and in patients that are pregnant Pregnancy category D
Diuretics Increase urine flow Reduce blood volume and cardiac workload Reduce edema and pulmonary congestion Prescribed in combination with other drugs Take in morning not at night Slow position changes Daily weights (report 2-3 lbs) Risk for sunburn Low sodium diet Role of the Nurse: Assess renal function
Monitor electrolyte levels (K+) Monitor vital signs, intake/output Monitor blood glucose and blood-urea nitrogen (BUN)
Cardiac Glycosides Increase force of heartbeat, slow heart rate Improve cardiac output Second-line treatment for HF Narrow therapeutic range Role of the Nurse: Evaluate for ventricular dysrhythmias Assess renal function Monitor for drug interactions Know restriction on use with antidiarrheals/antacids
Digoxin (Lanoxin) MOA:
to cause more forceful heartbeat, slower heart rate Use:
to increase contractility or strength of myocardial contraction Side Effects:
neutropenia, dysrhythmias, digitalis toxicity Nausea, vomiting, fatigue, anorexia, and visual disturbances such as seeing halos, a yellow-green tinge, or blurring Admin Alerts:
Take the apical pulse for 1 full minute, noting rate, rhythm, and quality before administering. If the pulse is below the parameter established by the healthcare provider (usually 60 beats per minute), withhold the dose and notify the provider. Check for recent serum digoxin level results before administering. If the level is higher than the parameter established by the healthcare provider (usually 1 n g/mL), withhold the dose and notify the provider. Use with caution in older adult and pediatric patients because these populations may have inadequate renal and hepatic metabolic enzymes.
Metoprolol (Lopressor, Troprol XL) MOA:
block cardiac action of sympathetic nervous system to slow heart rate and BP, reducing workload of heart Use:
to reduce symptoms of heart failure and slow progression of disease
Side Effects:
fluid retention, worsening of heart failure, fatigue, hypotension, bradycardia, heart block Admin Alerts:
During IV administration, monitor the ECG, blood pressure, and pulse frequently. Assess the pulse and blood pressure before oral administration. Hold if the pulse is below 60 beats per minute or if the patient is hypotensive. Advise the patient not to crush or chew sustained-release tablets. Safety and efficacy in children under age 6 have not been established. Doses should be reduced for older patients because they are at risk for dizziness and falls. Pregnancy category C. Black Box Warning:
Abrupt withdrawal may exacerbate angina or cause MI. Dosage should gradually be reduced over 1 to 2 weeks, and the drug should be reinstituted if angina symptoms develop during this period Contradictions:
Contraindicated in patients with cardiogenic shock, sinus bradycardia, heart block greater than first degree, hypotension, and overt cardiac failure. Metoprolol should be used with caution in patients with asthma and those with a history of bronchospasm because the drug may affect beta 2 receptors at high doses Drug to Drug:
Concurrent use with digoxin may result in bradycardia. Use with antihypertensives, including ACE inhibitors, ARBs, and other beta blockers, may result in additive hypotension. Metoprolol may enhance the hypoglycemic effects of insulin and oral antidiabetic drugs. Concurrent use with verapamil increase the risk of heart block and bradycardia. Herbal/Food:
Hawthorn should be avoided because it may increase the actions of beta adrenergic blockers. Treatment of Overdose: Atropine or isoproterenol can be used to reverse bradycardia caused by
used. Safety and efficacy have not been established in older adult and pediatric patients. Pregnancy category C. Drug to Drug: Milrinone interacts with disopyramide, causing excessive hypotension. Caution should be used when administering milrinone with digoxin, dobutamine, or other inotropic drugs because their positive inotropic effects on the heart may be additive Contradictions: Contraindication to milrinone is previous hypersensitivity to the drug. Milrinone should be used with caution in patients with pre-existing dysrhythmias Treatment of Overdose: Overdose causes hypotension, which is treated with the administration of normal saline or a vasopressor
Module 6 – Chapter 30 & 31
Cardiovascular Dysrhythmias and Coagulation
Classification of Antidysrhythmics
Class Action Indications
One (I): Sodium channel blockers A example: procainamide B example: lidocaine C example: flecainide
Delays repolarization; slows conduction velocity; increases duration of the action potential Accelerates repolarization; slows conduction velocity; decreases duration of action potential No significant effect on repolarization; slows
Atrial fibrillation Premature atrial contractions PVCs Ventricular tachycardia Severe ventricular dysrhythmias
conduction velocity
Two (II): Beta-adrenergic antagonists Example: propranolol
Slows conduction velocity; decreases automaticity; prolongs refractory period
Atrial flutter and fibrillation Tachydysrhythmia Ventricular dysrhythmias
Three (III): Potassium channel blockers Example: amiodarone
Slows repolarization; increases duration of action potential; prolongs refractory period
Severe atrial and ventricular dysrhythmias
Four (IV): Calcium channel blockers Example: verapamil
Slows conduction velocity; decreases contractility; prolongs refractory period
Paroxysmal supraventricular tachycardia (PSVT) Supraventricular tachydysrhythmia
Antidysrhythmic adverse effects: palpitations, chest pain, weakness, and fatigue.
Take antidysrhythmic before bed
Drugs for Dysrhythmias
Sodium Channel blockers Delay or accelerate repolarization, slow conduction velocity, may alter duration of action potential
Procainamide MOA:
to block sodium ion channels, which slows rate of impulse conduction across heart Use:
to correct atrial and ventricular dysrhythmias Side Effects:
Can create new dysrhythmias or worsen existing ones Lupus effect, nausea, vomiting, abdominal pain, headache
- Hypoglycemia, diminished libido, potential accumulation to toxic levels in patients with reduced renal output Admin Alerts: Abrupt discontinuation may cause MI, severe HTN, and ventricular dysrhythmias. Swallow extended-release tablets whole: Do not crush or chew contents. If pulse is less than 60 beats per minute, notify the healthcare provider. Pregnancy category C. Black Box Warning: Abrupt withdrawal is not advised in patients with angina or heart disease. Dosage should gradually be reduced over 1 to 2 weeks and the drug should be reinstituted if angina symptoms develop during this period. Contradictions: Because of its depressive effects on the heart, propranolol is contraindicated in patients with cardiogenic shock, sinus bradycardia, greater than first-degree heart block, and HF. Because it constricts smooth muscle in the airways, the drug is contraindicated in patients with COPD or asthma.
Potassium channel blockers Delay repolarization, increase duration of action potential, lengthen refractory period—stabilize dysrhythmias
Amiodarone (Cordarone, Pacerone) Use:
to treat resistant ventricular tachycardia, atrial dysrhythmias with heart failure; use is limited due to adverse effects Side Effects:
potentially fatal pneumonia-like syndrome, elevated liver enzymes, thyroid dysfunction, blue-gray skin discoloration, blurred vision, rashes, photosensitivity, nausea, vomiting, anorexia, fatigue, dizziness, and hypotension - Can create new dysrhythmias or worsen existing ones Admin Alerts:
Hypokalemia and hypomagnesemia should be corrected prior to initiating
therapy. Pregnancy category D Amiodarone can block the metabolism of warfarin Black Box Warning:
Amiodarone causes a pneumonia-like syndrome in the lungs. Because the pulmonary toxicity may be fatal, baseline and periodic assessment of lung function is essential. Amiodarone has pro-dysrhythmic action and may cause bradycardia, cardiogenic shock, or AV block. Mild liver injury is frequent with amiodarone. Contradictions:
Amiodarone is contraindicated in patients with severe bradycardia, cardiogenic shock, sick sinus syndrome, severe sinus node dysfunction, or third-degree AV block.
Avoid drinking grapefruit juice Avoid the use of St. John’s wort Effect of prescription will last 4-8 wks after its stopped Monitor Bp
Calcium channel blockers Slow conduction velocity, decrease contractility, prolong refractory period
Verapamil (Calan, others) MOA:
to block calcium ion channels, which reduces automaticity and slows myocardial (AV) conduction velocity Use:
to treat supraventricular dysrhythmias Side Effects:
Because verapamil can cause bradycardia and decrease the contractility of the heart, patients with HF should be carefully monitored. Headaches, edema, dizziness Admin Alerts:
Anticoagulants Inhibit clotting factors, prevent thrombus growth
- Mechanism of action: to inhibit specific clotting factors to prevent formation or enlargement of clots
- Primary use: to prevent formation of clots in veins, to treat thromboembolic disorders Role of the Nurse
- Most serious side effect to assess is bleeding
- To assess internal bleeding:
- Monitor CBC, lumbar pain, abdominal bulging, guaiac tests on stool
- Essential for patient safety to assess coagulation studies
- Bleeding risk increases during transition from heparin to warfarin
- Do not give warfarin to pregnant patients
- Heparin, low–molecular weight heparin can be given to pregnant patients
- Monitor intake of vitamin K–rich foods; limit intake of garlic
Heparin (parenteral) MOA:
to prolong coagulation time, thereby preventing excessive clotting within blood vessels. Use:
heparin prevents the enlargement of existing clots and the formation of new ones. It has no ability to dissolve existing clots. Heparin has both prophylactic and treatment indications. Side Effects:
Abnormal bleeding Heparin-induced thrombocytopenia (HIT) is a serious complication that occurs in up to 30% of patients taking the drug Admin Alerts:
When administering heparin subcutaneously, never draw back the syringe plunger once the needle has entered the skin, and never massage the site after injection. Doing either can contribute to bleeding or tissue damage. Intramuscular (IM) administration is contraindicated due to bleeding risk. Given every 6 hrs IV. Monitor aPTT. Change to every day after it has been
stable for 24hrs. Volume 60 – 80 sec Pregnancy category C. Black Box Warning:
Epidural or spinal hematomas may occur when heparin or LMWHs are used in patients receiving spinal anesthesia or lumbar puncture. Because these can result in long-term or permanent paralysis, frequent monitoring for neurologic impairment is essential. Drug to Drug:
Other anticoagulants, including warfarin, potentiate the action of heparin and can lead to serious bleeding. Drugs that inhibit platelet aggregation, such as aspirin, indomethacin, and ibuprofen, may induce bleeding. Nicotine, digoxin, tetracyclines, or antihistamines may inhibit anticoagulation. Contradictions:
Heparin should not be administered to patients with active internal bleeding, bleeding disorders, severe HTN, recent trauma, intracranial hemorrhage, or bacterial endocarditis Herbal/Food:
Herbal supplements that may affect coagulation, such as ginger, garlic, green tea, feverfew, or ginkgo, should be avoided because they may increase the risk of bleeding. Treatment of Overdose: Protamine sulfate may be administered IV (1 mg for every 100 units of heparin) to neutralize heparin’s anticoagulant activity. Protamine sulfate has an onset of action of 5 minutes and is also an antagonist to the LMWHs.
Low molecular heparin is Lovenox
Warfarin (oral) MOA/USE:
to prevent thromboembolic events in high-risk patients following an MI or an atrial fibrillation episode. Warfarin can take several days to reach its maximum effect. This explains
Pharm Exam 3
Course: Pharmacology II (NUR 354)
University: Arizona College of Nursing
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