Classifica-tion ACE Inhibitors Beta Blockers Ca+ Channel Blockers K+ Channel Blockers MOA ↓ conversion of A-I to A-II; vasodilator decreases HR decreases conduction slows action potential (fibrillation) *atenolol *carvedilol *metoprolol *sotalol *verapamil *diltiazem *amlodipine *nifedipine *felodipine *nicardipine *amiodarone Drug Names *captopril *enalapril *lisinopril *ramipril *trandolapril *fosinapril Cardiac Treat-ment *Alpha's dine & sin *clonidine, *prazosin HTN, AV block, SVT, A.fib/flutter, bradycardia, impaired peripherial circulation, stable angina HTN, CAD, SVT, A.fib/flutter, junctional dysrhythmia, chronic stable CAUTION - in asthma pt's angina bronchospasms; & DM pts - can mask s/s of hypoglycemia hypoT, dizziness, fatigue, headache, ARF, ↑K+, angioedema, Side Effects skin rash, cough, loss of taste, N/V/C, GI irritation Nursing Management N/V, brady, P hypoT, fatigue, bronchospasms, hyperglycemia, head/dizz, drowsiness, CHF, ED *ortho BP, LFT's, weight *assess BP, HR, skin, facial (daily or weekly) edema, K+ serum, renal tests *hold if apical < 60 *hold SBP <100 *hold if SBP < 100 *ASA/NSAIDs may reduce *avoid EtOH, OTC's, & effectivness hazardous tasks if dizzy; rise *full effect on BP slowly may not be seen *do not stop abruptly *caution use with for 3-6 wks African Americans HTN, a.fib/flutter, SVT, junctional dysthythmia, chronic stable angina CAUTION - in HF AV block (prolonged PR interval), bradycardia, hypoT, pulmonary edema, CHF, headache, dizziness, flushing, rash, fever,chills *I/O, s/s of CHF, pulm.edema/lungs, daily weight, pain level *BP & HR q3-4h *hold if apical < 60 *hold if SBP < 100 *may cause 1° HB *take with meals *pines are for BP; varapimil & diltiazem for dysrhythmias* ↑ effects of digoxin *propafenone *procainamide *ibutilide *sotalol A.fibw/RVR SVT, VT/VF HF, AV block, pulmonary toxicity, painful breathing, cough, SOB, weakness in arms/legs, trouble walking, dizziness, lightheadedness *assess BP, RR, apical & radial pulses, renal & LFT *hold HR>120 or <60 *safety/safety/safety *keep all aptmts-MD, labs, etc. & follow diet plan *avoid EtOH, smoking, OTC's, swallow whole, wax may be found in stool Classifica-tion Direct Vasodilators Statin Drugs Antiplatelet Anticoagulation MOA relax arteriolar smooth muscle, causing blood vessel dilation inhibit synthesis of cholesterol in liver decrease platelet aggregation & inhibit thrombus formation prolong the formation of blood clotting *atorvastain *lovastatin *simvastatin *fluvastatin *ASA *clopidogrel bisulfate Antidote = Vitamin K *hydrazaline *nitroglycerin Drug Names Cardiac Treat-ment Side Effects (sublingual, patch, & paste) *isosorbide mononitrate *sodium nitroprusside HTN, chronic stable angina, HF after MI headache, dizziness, palpitations/tachy, N/V, hypoT, flushing *reactions lessen with prolonged use/dose adjust HDL CAD NVCD, elevated liver enzymes, myopathy, rhabdomylosis, GI disturbances, rash *take on an empty stomach *monitor LFT's prior to *if headache develops treat & q6-12wks after w/ASA or acetaminpohen start of therapy *advise patient to take an *use in adjunction with diet Nursing additional dose prior to anticipated therapy; restrictions of saturated Managestress & have drug accessible at all fat & cholesterol ment times *keep record of attacks *review dietary habits, weight, & *assess pregnancy status exercise patterns *avoid EtOH *CK - if muscle pain or weakness *do not mix w/other drugs occurs *warfarin PT- 9.6-11.8seconds INR- 2-3x norm (1.5-2.0) *heparin, *enoxaprin Antidote = Protamine Sulfate aPTT therapeutic - 60-80 MI or re-infarction, CAD, stroke CONTRAINDICATED pregnancy (3rd trimester), bleeding disorders or thrombocytopenia CAUTION PUD, hepatic/renal disease A.fib/flutter, MI, DVT, PE, stroke CONTRAINDICATED thrombocytopenia CAUTION PUD, severe HTN, hemophelia HR, BP, bruising, petechiae, hematuria, bruising, epistaxis, black/tarry stools, bleeding in confusion, GI ulcers or upset, urine/gums, vasculitis, hemorrhage hemorrhage *take with food/milk *advise patient of prolonged bleeding time; notify HCP of unusual bleeding *may cause dizziness or drowsiness *inform HCP before undergoing any procedures or new drug therapy *NO ASA or NSAIDs *avoid all IM injections *inspect & teach for abnormal bleeding *teach a diet consistent in vitamin K is essential *med ID bracelet, electric razor, soft toothbrush *contact HCP prior to taking any OTC or herbal therapy Cardiotonics decreasses conduction of electrical impulses *adenosine *digoxin (0.8 - 2 ng/mL) *digitoxin (14 - 26 ng/mL) SVT, A.fib, CHF/HF CONTRAINDICATED heart block, V.tach/fib, pregnancy CAUTION advanced HF & renal insuffieiency digoxin toxicity: KCL - IV or PO early s/s - N/V/D, brady/tachy, PVC's, bi/trigeminy late s/s - visual changes *assess BP, AP, lung sounds, JVD, weight, sputum, extremity edema, renal & LFT's *teach pt's s/s of digoxin toxicity *no herbal drugs *K+ rich diet; monitor K+ levels Anticholinergenic antiparasympathetic; transient phase of stimulation *atropine bradycardia, Mobitz II can't see, can't pee can't spit, can't sh*t tachycardia, agitation, delirium, NVC, ED *assess for tachycardia; may lead to V.fib *monitor I/O; may cause urinary retention *give IV over 1 minute Dysrhythmia EKG Characteristics Causative Agents Sinus Bradycardia < 60 bpm & regular bb, CCB, MI, ICP/IOP, hypothermia, hypoglycemia, Sinus Tachycardia 101 - 200 bpm & regular exercise, fever, fear, anxiety, pain, hypoT, hypovolemia, anemia, hypoxia, hypoglycemia, hyperthyroid, MI, HF Premature Atrial Contraction (PAC) 60 - 100 bpm & irregular; P-wave may be hidden in the preceding T-wave stress, physical fatigue, caffeine, EtOH, tobacco, electrolyte balances, hyperthyroid, hypoxia, COPD, CAD Supraventricular Tachycardia (SVT) 150 - 220 bpm & regular; P-wave often hidden in the T-wave hypokalemia, digitalis toxicity, ischemia, CAD, cor pulmonale, rheumatic heart disease *a.flutter = F waves; a.fib = irregular* HTN, CAD, cardiomyopathy, digoxin, epinephrine, HF, EtOH intoxication, caffeine, stress, cardiac surgery 1° AV Block prolonged P-R interval; If R is far from P = 1st ° digoxin toxicity, bb, CCB, MI, CAD 2° AV Block; Wenkenbach P-wave = longer, longer, longer, DROP = Wenkenbach digoxin toxicity, bb, CAD 2° AV Block; Mobitz II If some QRS's don't get through = Mobitz II digoxin toxicity, CAD, anterior MI, rheumatic heart disease 3° AV Block; complete If P's & Q's don't agree = 3rd ° severe heart disease, CAD, MI, myocarditis, CM, bb, CCB, scleroedema, amyloidosis PVC PVC's occur at variable rates; unifocal or multifocal, couplets, bi/tri/quadrigeminy; 3+ sequential PVC's = VT caffeine, EtOH, nicotine, amniophylline, epinephrine, digoxin, isoproterenol, hypoxia, fever, emotional stress, exercise, MI, HF, CAD, MV prolapse V.Tach/V.Fib 150 - 250 bpm; QRS's are wide & distorted; not measurable in v.fib hyperkalemia, drug toxicity, acidosis, CM, MI, CAD, MV prolapse, HF, cardiac cath, CNS disorders A.Flutter/ A.Fib A: 200 - 600 bpm; V: > or < 100 bmp Treatments O2, atropine, pacemaker, drug dosage adjusted or discontinued O2, bb, treat underlying cause, antipyretics-fever, analgesics-pain remove cause, bb, observation O2, remove cause, IV adenosine, amiodarone, bb, CCB, cardioversion, observation O2, digoxin, bb, CCB, warfarin, cardioversion, ablation A.fib w/RVR*amiodarone, propafenone O2, check meds/labs, call HCP *if new onset, continue to monitor O2, temp pacemaker, ERT, VS, atropine, check meds/labs, call HCP, permanent pacemaker O2, temp pacemaker, ERT, VS, meds/labs, call HCP, *permanent pacemaker O2, ERT, VS, meds/labs, call HCP, *permanent pacemaker ASAP O2, bb, amiodarone, procainamide, lidocaine CPR, defibrillate, epinephrine Dx Tests Description & Purpose EKG recording for 24-48 hours correlating rhythm changes w/symptoms in diary; recorder Holter Monitoring is used to store, recall, print & analyze info for rhythm disturbances Echocardiogram ultrasound of chest & heart; measures EF% - IV contrast may be used to enhance images; also records direction of blood flow across valves Pharmacologic Echo sused as substitute for exercise stress test in people unable to exercise; dobutamine or dipyridamole infused via IV & dose increased in 5 min intervals to detect abnormalaties Transesophageal Echocardiogram (TEE) probe w/ultrasound transducer is swallowed & passes down esophagus; contrast may be injected IV for evaluating blood flow if atrial or ventricular septa defect is suspected Exercise Stress Test exercise tolerance, ADL's, rhythm disturbances, EKG changes; contraindications acute CV disease, recent MI (2 weeks), angina Exercise Nuclear Imaging nuclear images are taken at rest & after exercise; injection given at max HR on bicycle/treadmill & continue for 1 min to circulate; scanning done 15-60min after exercise; resting scan 60-90min after initial infusion or 24 hours later Pharmacologic Nuclear Imaging dipyridamole or adenosine to promote vasodilation when unable to exercise Nuclear Cardiology IV injection of radioisotopes; measures blood flow to heart at rest & while your heart is working harder as a result of exertion or medication; HCP suspects CAD Single-photon Emission Computed Tomography (SPECT) used to evaluate myocardium at risk for MI; small amounts of radioactive isotope injected via IV; detects coronary artery blood flow, intracardiac shunts, motion of ventricles, EF% & size of heart chambers Dx Tests Description & Purpose Cardiac Catheterization contrast injected to examine structure & motion of heart & coronary arteries; also provides information to determine need for angioplasty or stenting small amount of blood removed, mixed w/radioactive Multigated isotope & reinjected; EKG's used for timing, images Acquisition Scan acquired during cardiac cycle; indicated for MI, HF, valvular HD, (MUGA) cardiotoxic drugs on the heart Magnetic Resonance Angiography (MRA) used for vascular occlusive disease & AAA; same as MRI but with use of gadolinium as IV contrast Cardiac CT Scan evaluates heart muscle, coronary artery circulation, pulmonary veins, thoracic aorta, pericardium; IV contrast Electrophysiology Study (EPS) invasive study to record cardiac electrical conduction using catheters via femoral & jugular veins into right side of heart; dysrhythmia can be induced & terminated Peripherial Arteriography & Venography injection of contrast into veins or arteries followed by serial x-rays to detect atherosclerotic plaques, occlusions, aneurysms, or trauma Dx Labs Description & Purpose Troponin - I * earliest increase 4-6 hours, peak hours 10-24 hrs * duration of increase 4-7 days * specificity 95%; sensitivity at peak 98% Creatine Kinase (CK) * earlies increase 4-8 hrs; peak hours 24-36 hrs * duration of increase 36-48 hours * specificity 57-88%; sensitivity at peak 93-100% CK-MB * earliest increase 3-4 hours; peak hrs 15-24 hrs * duration of increase 24-36 hours * specificity 93-100%; sensitivity at peak 94-100% Myoglobin 99-100% sensitive for MI; serum concentration rise 30-60min after MI male: 5.2-12.9 umol/L; female: 3.7-10.4 umol/L Nursing Considerations encourage to stimulate conditions that produce symptoms; keep an accurate diary of activities & symptoms; no bath or shower assess for allergy to shellfish; supine position on left side of equipment; no contraindications to procedure unless contrast is being used start IV infusion; monitor VS before/during/after until baseline achieved; aminophylline given to prevent or reverse side effects of dipyridamole NPO 6 hours prior; IV sedation & throat anesthetized; designated driver needed; bite block placed-suctioning as needed; no eating/drinking until gag reflex returns pt to wear comfortable clothes/shoes & walk as quickly as possible; hold bb & caffeine 24 hrs prior to procedure; no smoking 3 hrs prior; test is terminated for chest discomfort explain to eat only a light meal between scans; certain medications may need to be held for 1-2 days before the scan hold all caffeine products 12 hours prior to procedure; hold bb & CCB 24 hours prior establish IV line - pt will have to lie still on back with arms extended for 20 minutes; repeat scans are performed within a few minutes to hours after the injection establish IV line; ECG monitoring Nursing Considerations withhold food/fluids 6-18 hours; give sedative; instruct patient to deep breath when dye is injected; assess circulation, peripherial pulses, color, & sensation q15min/1 hour after establish IV line, EKG monitoring; procedure involves little risk contraindicated w/allergies to contrast or implanted metal devices procedure is quick & involves little to no risk; assess for shellfish allergies discontinue antidysrhythmic meds several days prior to study; NPO 6-8h, IV sedation if needed; frequent VS & continuous EKG after procedure check for iodine allergy; mild sedative; check extremity puncture, pulsation, warmth, motion, swelling, bleeding; Nursing Considerations < 0.5 ng/mL - normal 0.5 - 2.3 ng/mL - suspicious for MI injury > 2.3 ng/mL - positive for MI injury cardiac biomarker used to diagnose MI & necrosis explain the purpose of serial sampling (e.g. 3x q6-8h); normal is 0.3 mcg/L in conjunction with serial EKG's cleared from circulation rapidly & most diagnostic if measured within first 12 hours of onset of chest pain