CALCIUM CHANNEL BLOCKERS (CCB)
Maureen McGuinness, RN
(Ka
LEARNING OBJECTIVES
Upon completion of this power-point presentation, the student will be able to:
1) Describe the three classifications of calcium channel blockers and their
mode of action
2) Actively monitor patients for signs/symptoms and adverse reactions to
calcium channel blockers, in order to respond and maintain patient safety.
3) Verbalize the differences between verapamil/diltiazem and amlodipine;
describe their appropriate uses, in order to safely administer the
medication.
TYPE/CLASS
MECHANISM OF ACTION
INDICATIONS
CCB inhibit transport of calcium into myocardial and vascular
smooth muscle cells, resulting in inhibition of excitationcontraction coupling and subsequent contraction.
(Calcium channel blockers: classification, mechanism of action and indications, 2013)
CCB – CLASSIFICATION OF AGENTS
V binding site
D binding site
N binding site
(Calcium channel blockers: classification, mechanism of action and indications, 2013)
CCB - MECHANISM OF ACTION
CCB bind to specific
receptor sites
(Calcium channel blockers: classification, mechanism of action and indications, 2013)
CCB - MECHANISM OF ACTION
dihydropiridines
• Minimal effect on cardiac
conduction or heart rate,
• Potent actions
as arteriolar vasodilators
verapamil and diltiazem
• Slow AV conduction
• Decrease SA node
automaticity
• Decrease heart rate
(Calcium channel blockers: classification, mechanism of action and indications, 2013)
MECHANISM OF ACTION
• The mechanism of action of CCBs in hypertension is
based on their vasodilator properties
• The effectiveness of all agents is similar, with no
evidence to suggest that one drug is better than the
other
• The use of the once-daily administered drug, e.g.
amlodipine, felodipine and lercanidipine, is preferred to
aid compliance
• Calcium channel blockers also have a role in isolated
systolic hypertension in the elderly
(Salama, 2008).
INDICATIONS FOR USE
• Tissue selectivities differ between agents
• verapamil is more cardioselective
• dihydropyridines are relatively smooth muscle selective
• diltiazem has intermediate properties
• Clinical uses include hypertension, angina (by reducing
cardiac work and antidysrhythmic action), and in the case or
verapamil mainly in supraventricular arrhythmias.
• When prescribing refer to specific indication and license of the
specific calcium channel blocker as differences exist
(Salama, 2008).
COMMON TRADE NAMES
Cardizem (diltiazem); Norvasc (amlodipine);
Calan (Verapamil)
CARDIZEM (DILTIAZEM)
Therapeutic Class
• Antianginals, antiarrhythmics (class IV), antihypertensives
Indications
• Hypertension, Angina pectoris and vasospastic (Prinzmetal's)
angina, Supraventricular tachyarrhythmias and rapid ventricular
rates in atrial flutter or fibrillation
Evaluation/Desired Outcomes
• Decrease in BP, frequency and severity of anginal attacks
• Suppression and prevention of tachyarrhythmias
(Davis Drug Guide, 2013)
NORVASC (AMLODIPINE)
Therapeutic Class
• antihypertensives
Indications
• Alone or with other agents in the management of hypertension,
angina pectoris, and vasospastic (Prinzmetal's) angina
Evaluation/Desired Outcomes
• Decrease in BP, frequency and severity of anginal attacks
(Davis Drug Guide, 2013)
CALAN (VERAPAMIL)
Therapeutic Class
• Antianginals, antiarrhythmics (class IV), antihypertensives, vascular
headache suppressants
Indications
• Management of hypertension, angina pectoris, and/or vasospastic
(Prinzmetal's) angina
• Management of supraventricular arrhythmias and rapid ventricular rates in
atrial flutter or fibrillation
Evaluation/Desired Outcomes
• Decrease in BP and severity of anginal attacks
• Suppression and prevention of atrial tachyarrhythmias
(Davis Drug Guide, 2013)
CONTRAINDICATIONS
PRECAUTIONS
ADVERSE EVENTS
DIETARY AND HERBAL CONSIDERATIONS
CONTRAINDICATIONS
Cardizem (diltiazem)
Norvasc (amlodipine)
Calan (Verapamil)
• Hypersensitivity
• Hypersensitivity;
• Hypersensitivity
• Sick sinus syndrome
• Systolic BP <90 mm Hg.
• Sick sinus syndrome
• 2nd- or 3rd-degree AV
block (unless an artificial
pacemaker is in place)
• 2nd- or 3rd-degree AV
block (unless an artificial
pacemaker is in place)
• Systolic BP <90 mm Hg
• Systolic BP <90 mm Hg
• Recent MI or pulmonary
congestion
• HF, severe ventricular
dysfunction, or cardiogenic
shock, unless associated
with supraventricular
tachyarrhythmias;
• Concurrent use of rifampin.
• Concurrent IV beta blocker
therapy
(Davis Drug Guide, 2013)
PRECAUTIONS
Cardizem (diltiazem)
Norvasc (amlodipine)
Calan (Verapamil)
•
Severe hepatic impairment
(↓ dose recommended)
•
Severe hepatic impairment (↓
dose recommended)
•
Severe hepatic impairment
(↓ dose recommended)
•
Geri: ↓ dose; slower IV
infusion rate recommended;
↑ risk of hypotension; consider
age-related decrease in body
mass, ↓ hepatic/renal/cardiac
function, concurrent drug
therapy and other disease
states
•
Aortic stenosis;
•
•
History of HF;
History of serious ventricular
arrhythmias or HF;
•
OB: Lactation: Pedi: Safety not •
established;
•
Geri: (↓ dose recommended)
Geri: Dose ↓/slower IV
infusion rates recommended
(↑ risk of hypotension);
•
↑ risk of hypotension.
•
Severe renal impairment
•
Serious ventricular
arrhythmias or HF
•
OB: Lactation: Pedi: Safety not
established.
•
OB: Lactation: Safety not
established.
(Davis Drug Guide, 2013)
COMMON SIDE EFFECTS & ADVERSE EVENTS
System
Cardizem (diltiazem)
Norvasc
(amlodipine)
Calan (Verapamil)
CV
ARRHYTHMIAS, HF,
peripheral edema,
bradycardia, chest pain,
hypotension, palpitations,
syncope, tachycardia
peripheral edema,
angina,
bradycardia,
hypotension,
palpitations
ARRHYTHMIAS, HF,
bradycardia, chest pain,
hypotension, palpitations,
peripheral edema, syncope,
tachycardia
GI
↑ liver enzymes, anorexia,
constipation, diarrhea, dry
mouth, dysgeusia,
dyspepsia, nausea,
vomiting
gingival
hyperplasia,
nausea
↑ liver enzymes, anorexia,
constipation, diarrhea, dry
mouth, dysgeusia,
dyspepsia, nausea,
vomiting
GU
dysuria, nocturia, polyuria,
sexual dysfunction, urinary
frequency
* CAPITALS indicate life-threatening. Italics indicate most frequent
dysuria, nocturia, polyuria,
sexual dysfunction, urinary
frequency
(Davis Drug Guide, 2013)
COMMON SIDE EFFECTS & ADVERSE EVENTS
Norvasc
(amlodipine)
Calan (Verapamil)
flushing
dermatitis, erythema
multiforme, flushing,
photosensitivity,
pruritus/urticaria, rash,
sweating
System
Cardizem (diltiazem)
DERM
STEVENS-JOHNSON
SYNDROME, dermatitis,
erythema multiforme,
flushing, sweating,
photosensitivity,
pruritus/urticaria, rash
ENDO
gynecomastia,
hyperglycemia
gynecomastia,
hyperglycemia
HEMAT
anemia, leukopenia,
thrombocytopenia
anemia, leukopenia,
thrombocytopenia
METAB
weight gain
weight gain
MS
joint stiffness, muscle
cramps
joint stiffness, muscle
cramps
* CAPITALS indicate life-threatening. Italics indicate most frequent
(Davis Drug Guide, 2013)
COMMON SIDE EFFECTS & ADVERSE EVENTS
Norvasc
(amlodipine)
System
Cardizem (diltiazem)
NEURO
paresthesia, tremor
paresthesia, tremor
gingival hyperplasia
STEVENS-JOHNSON
SYNDROME, gingival
hyperplasia
MISC
Calan (Verapamil)
(Davis Drug Guide, 2013)
COMMON DIETARY CONSIDERATIONS
DIETARY
Cardizem
(diltiazem)
Norvasc
(amlodipine)
Calan (Verapamil)
Grapefruit juice ↑
levels and effect.
Grapefruit juice ↑
serum levels and
effect.
Grapefruit juice ↑
serum levels and
effect.
↑ caffeine levels with
caffeine-containing
herbs (cola nut,
guarana, mate, tea,
coffee).
(Davis Drug Guide, 2013)
COMMON HERBAL CONSIDERATIONS
Herbs
Cardizem
(diltiazem)
Norvasc
(amlodipine)
Arnica
May  effectiveness of antihypertensives
Astragalus, Barberry
May ↑effectiveness of antihypertensives
Bayberry
May block effects of antihypertensives
Black cohosh root
May lower blood pressure
Cats claw, parsley
seeds,
Increased hypotension when taken with antihypertensives
Chinese angelica
Monitor patients on antihypertensives for toxic effects
Coleus forskolin
Use caution when taking with antihypertensives, severe additive
effects can occur
DHEA
Risk of interactions with calcium channel blockers
Calan (Verapamil)
(Karch, 2013)
COMMON HERBAL CONSIDERATIONS
Herbs
Cardizem
(diltiazem)
Norvasc
(amlodipine)
DHEA
Risk of interactions with calcium channel blockers
Goldenseal
May interfere with antihypertensives
Guayusa, melatonin,
mistletoe leaves, rue
extract
Advise caution with antihypertensives
Mau huang
Warn against use with antihypertensives
Calan (Verapamil)
(Karch, 2013)
NURSING CONSIDERATIONS
NURSING CONSIDERATIONS
VERAPAMIL AND DILTIAZEM
•
•
•
•
•
•
Monitor BP and pulse before, during titration and periodically during therapy.
Monitor ECG periodically during prolonged therapy.
Monitor intake and output ratios and daily weight.
Assess for rash and signs of HF.
Monitor patient compliance with medication regimen.
Monitor routine serum digoxin levels for signs and symptoms of digoxin
toxicity.
• For treatment of Angina monitor for location, duration, intensity, and
precipitating factors of patient's anginal pain
• For treatment of Arrhythmias monitor EKG report bradycardia or prolonged
hypotension promptly
(Davis Drug Guide, 2013)
LAB CONSIDERATIONS:
VERAPAMIL AND DILTIAZEM
• Total serum calcium concentrations are not affected by calcium channel
blockers.
• Monitor serum potassium periodically. Hypokalemia ↑ risk of arrhythmias
and should be corrected.
• Monitor renal and hepatic functions periodically during long-term therapy.
May cause ↑ hepatic enzymes after several days of therapy, which return to
normal on discontinuation of therapy.
(Davis Drug Guide, 2013)
NURSING CONSIDERATIONS:
AMLODIPINE
• Monitor BP and pulse before therapy, during dose titration, and periodically
during therapy. Monitor ECG periodically during prolonged therapy.
• Monitor intake and output ratios and daily weight. Assess for signs of HF
(peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous
distention).
• Angina: Assess location, duration, intensity, and precipitating factors of
patient's anginal pain.
Lab Test Considerations:
• Total serum calcium concentrations are not affected by calcium channel
blockers.
(Davis Drug Guide, 2013)
QUESTIONS
QUESTION # 1
1) Mr. Jones is being discharged from the hospital with a new prescription for
Norvasc (amlodipine) for hypertension. He is concerned about the side effects.
The nurse explains common side effects include: (Choose the best answer).
a) ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain,
hypotension, palpitations, syncope, tachycardia
b) Peripheral edema, angina, bradycardia, hypotension, palpitations, gingival
hyperplasia, nausea, flushing
c) Dermatitis, erythema multiforme, flushing, photosensitivity, pruritus/urticaria,
rash, sweating
d) ↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia,
dyspepsia, nausea, vomiting
Answer B
Rationale: Norvasc (Amlodipine) is a third generation dihydropiridines which has
minimal effect on cardiac conduction or heart rate, while having potent actions
as arteriolar vasodilators.
QUESTION # 2
2) Mrs. Francis is currently receiving calcium channel blockers for angina. The
nurse understands that she must: (Select all that apply).
a) Perform a physical assessment to establish baseline status before
beginning therapy and during therapy
b) Inspect skin color and integrity
c) Monitor laboratory test results, including liver and renal function tests
d) All of the above
Answer: D
a) Rationale: Establish baseline to determine the effectiveness and
evaluate for any potential adverse events. Inspect skin color and
integrity to identify possible adverse skin reactions. Monitor lab results
to determine the need for possible dose adjustments.
QUESTION # 3
3) After teaching a patient who is receiving verapamil for long-term treatment
of angina, the nurse determines that the patient has understood the
teaching when the patient identifies what potential adverse effect? (Select
all that apply)
a)
b)
c)
d)
Hypotension
Palpitations
Anorexia
Increased exercise tolerance
Answer: A, B, C
Rationale: Hypotension, palpations and anorexia are all symptoms of
adverse reactions, increased exercise tolerance is not.
REFERENCES
Calcium channel blockers: classification, mechanism of action and indications. (2013).
Retrieved November 21, 2013, from Pharmacology Corner:
http://pharmacologycorner.com/calciumDavis Drug Guide. (2013, August 20). Retrieved from Nursing Central:
http://nursing.unboundmedicine.com/nursingcentral/ub
Karch, A. M. (2013). Focus on nursing pharmacology. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkin.
Salama, R. (2008). Calcium channel blockers: uses and prescribing rationale. Nurse
Prescribing, 6(4), 168-172.