Cardiac Glycosides And Anti-Anginal Drugs

Front 1

Drug Therapy for HF
•General aims are for benefit of

Back 1

heart or kidneys

Front 2

drugs Improve cardiac contractility

Back 2

ACE inhibitors or ARBs
•Cardiac glycosides

Front 3

drug Reduce preload
•

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diuretics to reduce excess fluid

Front 4

drug Reduce afterload:

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vasodilators

Front 5

Ventricular restructuring and rate control

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•beta-blocker

Front 6

Digitalis (Cardiac Glucosides)
•Prototype:

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digoxin (Lanoxin)

Front 7

Digitalis (Cardiac Glucosides)
•Prototype: digoxin (Lanoxin)
•Action AND ADME

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action
–positive inotrope, negative chronotrope and negative dromotrope
–potent, small doses (0.125 or 0.25 mg/day)
•ADME
–oral, IM, or IV administration
•formulation greatly affects absorption
–t 1/2 is 36 hrs
–narrow therapeutic range: 0.5-0.8 mg/mL

Front 8

Digoxin
•Pharmacological effects and indication

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•Pharmacological effects
–increases cardiac contractility
–decreases electrical conduction rate
–indirectly decreases HR and increases sodium and water excretion
•Indications
–HF
–atrial fibrillation or other supraventricular dysrhythmia when ventricular rate too rapid

Front 9

What is a pulse deficit?

Back 9

Difference between
apical and radial

Front 10

digoxin Drug-drug interactions

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Drug-drug interactions
– drugs that reduce absorption or decrease fxn
• antacids, laxatives, cholesterol-lowering agents, ACE/ARB
– drugs that depress cardiac function
• beta blockers, calcium channel blockers
– hypokalemia
• the most common cause of dig overdose
• even therapeutic levels may be too high if K is low
• most common offender is diuretic use

Front 11

Nursing Considerations of Digoxin

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• Cardiac function
– watch HR, dysrhythmias
• Electrolyte imbalances
– hypokalemia and hypomagnesemia increase risk of toxicity
Monitor effect of other drugs containing
sodium or potassium, use of diuretics
• Check heart rate:
– Need to take apical pulse for 1 full minute prior to
administering drug
– Okay to give with food but not if meal has high
fiber content--best if 1 hr ac or 2 hr pc
– hyperkalemia and hypercalcemia may produce
dysrhythmias
• Renal insufficiency patients
– decreases excretion of dig; easier toxic
• Female patients

Front 12

def Angina Pectoris

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•Myocardial ischemia
–inadequate flow of oxygenated blood to the heart muscle
–S/S: constricting pain in the chest which can radiate to the L arm, jaw, face, back, etc.
•Is not the same as Myocardial infarction
–Angina is ischemia of heart tissue, not death
–If remove trigger (i.e. rest) pain subsides

Front 13

Chronic Angina
•Treatment

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Chronic Angina
•Treatment
–first line is drug therapy
–secondly angioplasty(血管重建術)/stent or bypass

Front 14

Chronic Angina three drug categories

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•Three drug categories
–beta adrenergic blockers
–calcium channel blockers
–organic nitrate vasodilators

Front 15

Chronic Angina
•Goals of treatment

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–relieve pain
–bring balance to MvO2supply and demand
–decrease the severity and frequency of anginal episodes
–Prevention of future MI

Front 16

What is MVO2?

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Myocardial oxygen

Front 17

Organic Nitrate Vasodilators
•Prototype:

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nitroglycerin (NTG)

Front 18

nitroglycerin (NTG) action

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Action
–vasodilates vessels in the periphery thereby decreases workload of the heart
–Dilates coronary arteries improving blood flow
–does not dilate plaque covered, damaged vessels
–comes in metered tablets, sprays, ointments

Front 19

nitroglycerin (NTG)
•Effects

Back 19

NTG
•Effects
–Dilation of peripheral vessels by relaxing smooth muscle lining of vessels.
•Decreases afterload
–Decreases the amount of blood returning to the heart (preload)
–Reflex tachycardia
•anytime BP falls, sympathetic activity occurs

Front 20

nitroglycerin (NTG) indication and nursing implication

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Indications: angina
–Emergent CP: SL tablet, wait 5 min; if pain continues, can repeat with second and third dose. If CP continues after second dose, call 911 (used to be 3 doses)
–Allow to dissolve slowly, don’t eat, drink, or smoke. Patient should feel tingling sensation under tongue, if not present the drug may have lost its potency.

Front 21

Nirtoglycerin nursing implication

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IV: for emergent use following an MI or severe refractory angina
–IV NTG binds with PVC, need to use special tubing and glass bottle
•glass bottles need vented spike on tubing!!
–Must run through pump
–Close monitoring of BP
–High falls risk
Long term use
–ointment: measured length, apply to hairless surface and cover with plastic
–transdermal patch:
•don’t soak in water
•rotate placement
•12 hr on and 12 hr off
•Nurses wear gloves

Front 22

Toxicity of Nitroglycerin

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NTG
• Toxicity
– dose dependent hypotension and reflex
tachycardia
– nitro has a very short half-life so is gone quickly
– Tx: vasopressors (but not epinephrine) and O2

Front 23

Name two Beta blockers we use to treat angina

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Beta blockers
– those approved for angina include propranolol
and atenolol
• remember that propranolol is non-selective and has
affinity for all beta receptors
• atenolol is cardioselective with affinity for beta1

Front 24

some things to considered about for betablockers

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prophylaxis only, not short term tx
– worsens vasospastic angina
– don’t stop drug abruptly

Front 25

Ca channel blocker

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CCBs
•Action
–decreases myocardial contractile force (negative inotropic effect)
–decreases HR (chronotropic effect)
–decreases automaticity (dromotropic effect)
–decreases vasoconstriction in coronary and systemic circulations
–this explains why CCBs are effective in vasospastic angina

Front 26

def Dysrhythmias

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Defined as a deviation from the normal rhythm of the heartbeat

Front 27

cause of dysrhythimias

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abnormal automaticity
abnormal conduction
block of impulse conduction
re-entry phenomenon

Front 28

Ectopic Impulse

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Increased automaticity from elsewhere
hypoxia, ischemia, drugs
Electricity outside normal pathway
atrial, ventricular, anywhere on pathway
Can discharge on regular or irregular pattern
Can be an escape beat

Front 29

Def Refractory period

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Refractory period
time it takes for the cell to recover and prepare for action again

Front 30

Def conductivity.

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Impulse of the heart to beat originates in the SA node (primary pacemaker) and passes the current from cell to cell in a ripple effect to cause myocardial This is conductivity.

Front 31

The time where an action potential CANNOT be produced is….

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The absolute refractory period

Front 32

Labeled by their source of origination
name two categories of dysrhythmias

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supraventricular
sinus tachycardia, atrial flutter, atrial fibrillation, premature atrial contractions (PACs)
ventricular
Premature ventricular contractions (PVCs), ventricular tachycardia, ventricular fibrillation

Front 33

the only way to access if the antidysrthythmics drugs work is through

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EKG

Front 34

when taking what drugs we need to monitor their HR for one full minutes before dose

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1. all antidysrhythmics
2. glycoside

Front 35

why antidysrhythmics falling our of favor

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All antidysrhythmics have the potential to worsen the dysrhythmia or create a new one

Front 36

name four different drugs categories for Antidysrhythmic Drugs

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fast sodium channel blockers
belta blockers
potassium channel blockers
calcium antagonists

Front 37

fast sodium channel blockers prototype

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Prototype: quinidine

Front 38

action of quinidine

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Action
slow depolarization and repolarization in the atria, ventricles, and His-Purkinje system
stabilizes cell membrane, prevents influx of sodium, result is depression of conduction velocity

Front 39

effect of quindine

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Effects
works by directly depressing the excitability of cardiac tissues, slows conduction through both SA and AV nodes
blocks vagal input into the heart

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indication of quindine

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Indications
long-term prophylaxis of supraventricular rhythms, often used after cardioversion of atrial flutter or atrial fibrillation

Front 41

SE for quinidine

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SE
CV--depressed cardiac function, heart block
CNS: confusion, tinnitus, vision changes
GI--n/v/d, bitter taste
hypotension

Front 42

Drug-drug interactions for quinidine

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Drug-drug interactions
Decreases digoxin excretion

Front 43

nursing implication for quinidine

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Low Margin of safety (narrow window)
Measure width of QRS
Stop drug if increases by 50%
Increases risk of Digoxin toxicity
Monitor for heart block

Front 44

Group I-B--Sodium channel blockers prototype

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lidocaine (Xylocaine)

Front 45

Prototype: lidocaine (Xylocaine)
Action and implication

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Action
slows depolarization of muscle contraction and has a preferential effect on abnormally functioning tissue, e.g., ectopic foci or infarcted tissues (shortens duration action potential)
Indications
acute ventricular dysrhythmias

Front 46

what is Lidocaine also used for

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local anesthesia

Front 47

SE and things to watch for Lidocaine

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Low margin of safety: Toxicity
max dose 3 mg/kg
tremors, twitching, blurred vision, tinnitus
dyspnea, severe dizziness, fainting, bradycardia, convulsions (esp in elders)
Needs EKG monitoring

Front 48

Group I-C--Sodium channel blockers prototype

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flecainide (Tambocor)

Front 49

Action, indication and SE for Flecainide

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Action
suppresses PVCs (Premature ventricular contractions )
Indications
used in serious ventricular dysrhythmias only
prophylaxis of supraventricular dysrhythmias
SE
blurred vision, dizziness

Front 50

indications of Beta Blocker

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ventricular dysrhythmias
shown to be particularly effective with post-MI dysrhythmias
HTN
Hyperanxiety (stage fright)
Also hyperthyroid (racing heart)

Front 51

what do Group III—Potassium Channel Blockers do

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Delay Repolarization

Front 52

Prototype: amiodarone (Cordarone) action ?

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Prototype: amiodarone (Cordarone)
Action
prolongs action potential, increases the refractory period in all cardiac tissues
decreased automaticity, prolonged AV conduction, blocks sodium, potassium, and calcium channels

Front 53

what is Prototype for Potassium Channel Blockers

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Prototype: amiodarone (Cordarone)

Front 54

side effect for amiodarone

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pulmonary fibrosis, thyrotoxicosis
blue-gray skin color

Front 55

prototype for Cacium channel blocker (antidysrthymics)

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adenosine (Adenocard)

Front 56

What is different about adenosine delivery compared to other meds?

Back 56

Must infuse it very fast over 3 seconds

Front 57

action, indicaiton and SE for adenosine

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Action
slows AV node conduction
Indication
PSVT (paraoxsysmal supraventricular tachycardia)
SE
chest pain

Front 58

what others two drugs also used to treat dysrhymics

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Atropine and Digoxin

Front 59

how Atropine act to help dysrthymia

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action is anticholinergic effect, blocks vagal stimulation and increases HR (increases conduction thru the AV node)
indication is bradycardia

Front 60

how digoxin act to help dysrthymia

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action is to slow HR and improve conduction and increase contractility

Front 61

what test is an indication of the inflammation

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When there is inflammation, cholesterol is more likely to be deposited.
C-reactive protein levels indicate if present

Front 62

what we do to treat hyperlipidemia initialy

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1 lifestyle modification for 3-6 mth
2. Reduce lipid elevating drugs, such as Thiazides, and estrogens