Classification ACE Inhibitors Beta Blockers Ca+ Channel Blockers K+ Channel Blockers Cardiotonics MOA ↓ conversion of A-I to A-II; vasodilator decreases HR decreases conduction slows action potential (fibrillation) decreasses conduction of electrical impulses *atenolol *carvedilol *metoprolol *sotalol *verapamil *diltiazem *amlodipine *nifedipine *felodipine *nicardipine *amiodarone Drug Names *captopril *enalapril *lisinopril *ramipril *trandolapril *fosinapril *adenosine *digoxin Cardiac Treatment *Alpha's dine & sin *clonidine, *prazosin HTN, AV block, SVT, HTN, a.fib/flutter, HTN, CAD, SVT, A.fib/flutter, SVT, junctional bradycardia, impaired A.fib/flutter, dysthythmia, peripherial circulation, junctional chronic stable stable angina dysrhythmia, chronic CAUTION - in asthma pt's angina stable angina bronchospasms; & DM pts - can mask s/s of hypoglycemia Side Effects Nursing Management hypoT, dizziness, fatigue, N/V, brady, P hypoT, headache, ARF, ↑K+, fatigue, bronchospasms, angioedema, skin rash, hyperglycemia, head/dizz, cough, loss of taste, drowsiness, CHF, ED N/V/C, GI irritation ↑ effects of digoxin *propafenone *procainamide *ibutilide *sotalol A.fibw/RVR SVT, VT/VF *ortho BP, LFT's, *I/O, s/s of CHF, *assess BP, HR, skin, weight (daily or weekly) pulm.edema/lungs, facial edema, K+ *hold if apical < 60 daily weight, pain level serum, renal tests *hold if SBP < 100 *BP & HR q3-4h *hold SBP <100 *ASA/NSAIDs may *avoid EtOH, OTC's, *hold if apical < 60 & hazardous tasks if *hold if SBP < 100 reduce effectivness dizzy; rise slowly *may cause 1° HB *full effect on BP *do not stop abruptly *take with meals may not be seen *caution use with *pines are for BP; varapimil for 3-6 wks & diltiazem for dysrhythmias* African Americans *digitoxin (14 - 26 ng/mL) SVT, A.fib, CHF/HF CONTRAINDICATED heart block, V.tach/fib, pregnancy CAUTION advanced HF & renal insuffieiency CAUTION - in HF AV block (prolonged PR interval), bradycardia, hypoT, pulmonary edema, CHF, headache, dizziness, flushing, rash, fever,chills (0.8 - 2 ng/mL) HF, AV block, pulmonary toxicity, painful breathing, cough, SOB, weakness in arms/legs, trouble walking, dizziness, lightheadedness 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 *assess BP, RR, apical & radial pulses, renal & LFT sounds, JVD, weight, sputum, extremity *hold HR>120 or <60 edema, renal & LFT's *safety/safety/safety *keep all aptmts-MD, labs, *teach pt's s/s of etc. & follow diet plan digoxin toxicity *avoid EtOH, smoking, *no herbal drugs OTC's, swallow whole, wax may be found in stool *K+ rich diet; monitor K+ levels Classification Direct Vasodilators Statin Drugs Antiplatelet Anticoagulation Anticholinergenic 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 antiparasympathetic; transient phase of stimulation *atorvastain *lovastatin *simvastatin *fluvastatin *ASA *clopidogrel bisulfate Drug Names Cardiac Treatment Side Effects *hydrazaline *nitroglycerin (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 *warfarin Antidote = Vitamin K PT- 9.6-11.8seconds INR- 2-3x norm (1.5-2.0) *heparin, *enoxaprin *atropine 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 bradycardia, Mobitz II HR, BP, bruising, NVCD, elevated liver hematuria, bruising, can't see, can't pee petechiae, black/tarry enzymes, myopathy, epistaxis, confusion, GI can't spit, can't sh*t stools, bleeding in rhabdomylosis, ulcers or upset, tachycardia, agitation, urine/gums, vasculitis, GI disturbances, rash hemorrhage delirium, NVC, ED hemorrhage *take on an empty stomach *take with food/milk *avoid all IM injections *monitor LFT's prior to *if headache develops treat *advise patient of & q6-12wks after *inspect & teach for w/ASA or acetaminpohen prolonged bleeding time; start of therapy abnormal bleeding notify HCP of unusual *advise patient to take an *use in adjunction with *teach a diet consistent in bleeding Nursing additional dose prior to diet therapy; restrictions of vitamin K is essential Manage- anticipated stress & have *may cause dizziness or saturated fat & cholesterol *med ID bracelet, electric ment drug accessible at all times drowsiness *review dietary habits, razor, soft toothbrush *keep record of attacks *inform HCP before weight, & exercise patterns *contact HCP prior to *assess pregnancy status undergoing any procedures *CK - if muscle pain or taking any OTC or *avoid EtOH or new drug therapy weakness occurs herbal therapy *do not mix w/other drugs *NO ASA or NSAIDs *assess for tachycardia; may lead to V.fib *monitor I/O; may cause urinary retention *give IV over 1 minute Dx Tests Description & Purpose Nursing Considerations Holter Monitoring EKG recording for 24-48 hours correlating rhythm changes w/symptoms in diary; recorder is used to store, recall, print & analyzeinfo for rhythm disturbances encourage to stimulate conditionsthat produce symptoms; keep an accurate diary of activities & symptoms; no bath or shower Echocardiogr am ultrasound of chest & heart; measures EF% - IV contrast may be used to enhance images; also records direction of blood flow across valves assess for allergy to shellfish; supine position on left side of equipment; no contraindications to procedure unless contrast is being used Used as substitute for exercise stresstest in people unable to exercise; dobutamine Pharmacologi or dipyridamole infused via IV & dose c Echo increased in 5 min intervals to detect abnormalities start IV infusion; monitor VS before/during/after until baseline achieved; aminophylline given to prevent or reverse side effects of dipyridamole Transesophag eal Echocardiogr am (TEE) throat anesthetized; designated driver needed; bite block placed-suctioning as needed; no eating/drinking until gag reflex Exercise Stress Test Exercise Nuclear Imaging Pharmacologi c Nuclear Imaging Nuclear Cardiology 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 tolerance, ADL's, rhythm disturbances, EKG changes; contraindications acute CV disease, recent MI (2weeks), angina pt to wear comfortable clothes/shoes & walk as quickly as possible; hold bb& caffeine 24 hrs prior to procedure; no smoking3 hrs prior; test is terminated for chest discomfort 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 explain to eat only a light meal between scans; certain medications may need to be held for 1-2 days before the scan dipyridamole or adenosine topromote vasodilation when unable to exercise hold all caffeine products 12 hours prior to procedure; hold bb & CCB 24 hours prior IV injection of radioisotopes; measures blood flow to heart at rest & while your heart is working harderas a result of exertion or medication; HCP suspects CAD establish IV line - pt will have to lie still on back with arms extended for20 minutes; repeat scans are performed within afew minutes to hours after the injection Single-photon Emission Computed Tomography (SPECT) for MI; small amounts of radioactive isotope injected via IV; detects coronary artery blood flow, intracardiac shunts,motion of ventricles, Dx Tests Description & Purpose establish IV line; ECGmonitoring Nursing Considerations contrast injected to examine structure & motion of heart &coronary Cardiac arteries; also provides information to Catheterizatio determine need for angioplasty or n stenting small amount of blood removed, mixed w/radioactive isotope & reinjected; EKG's used for timing, images acquired during cardiac cycle; indicated for MI, HF, valvular HD, cardiotoxic drugs on the heart Multigated Acquisition Scan (MUGA) used for vascular occlusive disease & AAA; same as MRIbut with use of gadolinium as IV contrast Magnetic Resonance Angiography (MRA) Cardiac CT Scan Electrophysiology Study (EPS) 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, EKGmonitoring; procedure involves little risk contraindicated w/allergies tocontrast or implanted metal devices evaluates heart muscle, coronary artery procedure is quick & involveslittle to no circulation, pulmonary veins, thoracic risk; assess for shellfish allergies aorta,pericardium; IV contrast discontinue antidysrhythmic invasive study to record cardiac electrical conduction using cathetersvia meds several days prior to study; NPO femoral & jugular veins into rightside of 6-8h, IV sedation if needed; frequent VS heart; dysrhythmia can be induced & & continuous EKG after procedure terminated Peripherial Arteriography & Venography injection of contrast into veins or arteries followed by serial x- rays to detect atherosclerotic plaques, occlusions, aneurysms,or trauma check for iodine allergy; mildsedative; check extremity puncture, pulsation, warmth,motion, swelling, bleeding; Dx Labs Description & Purpose Nursing Considerations 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 < 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 todiagnose MI & necrosis explain the purpose of serial sampling (e.g. 3x q6-8h); normal is 0.3mcg/L in conjunction with serial EKG's most diagnostic if measuredwithin first 12 hours of onset of chest Dysthymia EKG Characteristics Causative Agent Treatment Bb, CCB, MI, ICP/IOP, Hypothermia, Hypoglycemia, O2, atropine, pacemaker, drug dosage adjusted or discontinued Exercise, fever, fear, anxiety, pain, hypovolemia, anemia, hypoxia, hypoglycemia, hyperthyroid, MI, HF O2, beta blocker, treat underlying cause, antipyretics-fever, analgesics-pain Premature Atrial 60 - 100 bpm & irregular; Contraction (PAC) P-wave may be hidden Stress, caffeine, tobacco, hyperthyroid, hypoxia, COPD, CAD, electrolytes imbalance Remove cause, observation, Beta blocker therapy (BB) Supraventricular 150 - 220 bpm & regular; Tachycardia (SVT) P-wave often hidden in the T- Hypokalemia, dig toxicity, ischemia, CAD, rheumatic heart disease O2, remove cause, IV, bb, adenosine, amiodarone, cardioversion, observation A: 200 - 600 bpm; V: > or < 100 bmp *a.flutter = F waves; a.fib = irregular* HTN, CAD, cardiomyopathy, digoxin, epinephrine, HF, caffeine, stress, cardiac surgery Prolonged P-R interval; If R is far from P = 1st° Digoxin toxicity, bb, MI, CAD O2, digoxin, bb, warfarin, cardioversion, ablation A.fib w/RVR*amiodarone, propafenone O2, check meds/labs, call HCP *if new onset, observation 2° AV Block; Wenkenbach P-wave = longer, longer, longer, DROP = Wenkenbach Digoxin toxicity, Beta Blocker, CAD O2, temp pacemaker, ERT, VS, atropine, check meds/labs, call HCP, permanent pacemaker 2° AV Block; Mobitz II If some QRS's don't get through = Mobitz II Digoxin toxicity, CAD, anterior MI, rheumatic heart disease O2, temp pacemaker, ERT, VS, meds/labs, call HCP, *permanent pacemaker 3° AV Block; If P's & Q's don't agree = 3rd ° Heart disease, CAD, MI, myocarditis, MI, scleroedema, amyloidosis O2, ERT, VS, meds/labs, call HCP, *permanent pacemaker ASAP PVC's occur at variable rates; unifocal or multifocal, couplets,bi/tri/quadrigeminy; 3+ sequential PVC's = VT caffeine, nicotine, HF, CAD, amniophylline, epinephrine, digoxin, isoproterenol, hypoxia, fever, stress, exercise, MI, MV prolapse Hyperkalemia, drug toxicity, acidosis, CM, MI, CAD, MV prolapse, HF, cardiac cath, CNS disorders O2, bb, amiodarone, procainamide, lidocaine Sinus Bradycardia Sinus Tachycardia < 60 bmp & regular 101 - 200 bpm & regular in the preceding T-wave wave A.Flutter A.Fib 1° AV Block complete PVC V.Tach/V.Fib 150 - 250 bpm; QRS's are wide & distorted; not measurable in v.fib CPR, defibrillate, epinephrine