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CARDIAC MEDICATIONS
I.
Antiplatelet Aggregation Therapy (Prevents platelet plug from forming which is first step in
clotting.)
A.
Oral:
i.
aspirin 81 mg—inhibits platelet aggregation within 30 minutes aspirin (Ecotrin)
(slower).
If patients have a history of bleeding ulcers or a recent bleed, ASA may be
contraindicated. With any type of GI history, ASA should be combined with
proton-pump inhibitors such as Protonix. Also, if MD or NP decide to give
ASA, it should be enteric coated with GI history. Decisions whether to use
ASA or not with a GI history is determined individually.
Aggrenox (combination of aspirin and persantine)
ii.
B.
Adenosine Diphosphate Receptor Antagonists (inhibit ADP pathway only)
. Onset of action 7 days so not used acutely
a. ticagrelor (Brilinta):BID. More effective than Plavix with similar risk of
bleeding. Only take with low dose ASA (81mg) daily. Faster onset and
elimination as it binds platelets reversibly. Must be stopped 5 days prior to
OR.
b. ticlodipine (Ticlid) 250 mg bid
c. clopidogrel (Plavix) - no risk of neutropenia
dosing 150-600mg loading dose, then 75 mg qd. Take when allergic to
aspirin. Must hold 5-7 days prior to surgery. Must be activated by
cytochrome P450 enzymes in liver thus delayed onset.
d. prasugrel (Effient) more effective than Plavix but more bleeding than
Plavix. Does not interfere with PPIs like Plavix. Avoid in patients ≥ 75
years old. Dose: 10mg daily. If weight is ≤ 60kg, give 5mg daily. Not
covered by many insurances.
e. cilostazol(Pletal)—used occasionally when pts. are allergic to Plavix.
Pletal is actually indicated for intermittent claudication.
f. NOTE: Antiplatelet meds are continued for 30 days after a bare metal
stent and for one year after a drug eluding stent. However, ASA is taken
indefinitely.
Parenteral: GPIIb/IIIa inhibitors (blocks all platelet aggregation). Used less
frequently.
abciximab (Reopro) IV—used after stents. Costly. Longer half- life. Higher risk of
bleeding
tirofiban (Aggrastat) IV--after stents or onset of C/P prior to cath
eptifibatide (Integrelin) IV--after stents or onset of C/P prior to cath
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II.
C.
May use one or combination to maximize antiplatelet effect
D.
If heparin used with IV antiplatelet drugs, ensure heparin dose is weight adjusted to
reduce incidence of bleeding and HIT.
Anticoagulants (Prevents blood from clotting, later step in clotting). Instruct patients
regarding high risk for injury with these drugs. Any fall or blow is significant and must
be reported.
A.
Oral
1.
warfarin (Coumadin)
- many food and drug interactions
- slow onset (days)
- difficult to dose
- Monitor INR, PT
- Only warfarin has antidote!
2.
dabigatran (Pradaxa)
- Direct thrombin inhibitor
- No need to monitor INR
- 150mg bid po, renal impairment 75mg bid
3.
rivaroxaban (Xarelto)
- Direct selective Factor Xa inhibitor
- No monitoring
- Used with atrial fibrillation, DVT & PE
- 20mg daily, ↓15mg daily for creatinine clearance of 30-50.
4. apixaban (Eliquis)
- Direct selective Factor Xa inhibitor
- No monitoring needed
- 5mg bid, reduce dose to 2.5 mg for increased risk
factors (elderly, poor
kidney function, etc).
5. Do not abruptly DC drug since ↑ risk of clotting
B.
Parenteral
1. Heparin (unfractionated heparin). Administer IV. Used less today because
action varies. Monitor APTT & ACT. Protamine sulfate reverses heparin.
Monitor for HIT. Most evident in first 2-5 days of treatement.
2. Low Molecular Weight Heparins (LMWH).Used more today since research shows
better outcomes with LMWH than unfractionated heparin. Give subcutaneously.
Normally, no routine lab tests to monitor since predictable response. However,
with obese patients can monitor serum anti-Xa level 4 hours after administration
to monitor effectiveness. Each of these meds has own instruction for use. Give
s/q & do not expel air and avoid dripping medication on needle. Monitor for HIT.
a. Dalteparin (Fragmin) qd
b. Enoxaparin (Lovenox). Used instead of Coumadin short term. Weight
based when acute event.
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c.. fondaparinux (Arixtra). May be hearing more about this drug. Given s/q
and indicated for DVT, PE, orthopedic cases. Given once daily. More risky
if patient has renal impairment but does not affect platelet count. Great
for patients at risk for HIT. Technically, classified as a synthetic selective
Factor Xa inhibitor.
3. Direct Thrombin Inhibitors: (patients with or at risk for HIT)
a. Bivalirudin (Angiomax)
Alternative to unfractionated heparin for angioplasty pts.
Lower risk of bleeding. Monitor APTT, ACT, platelet count. Used if patient
high risk for bleeding.
Expensive. Given IV. Rapid onset and offset.
Decreases need for GPIIb/IIIa Inhibitors.
Used in cath lab like heparin to decrease clotting.
If renal insufficiency, use protocol for renal impairment.
Administration: 1mg/kg bolus followed by 4 hour infusion
at 2.5mg/kg/hr.
Give before PTCA in conjunction with ASA to reduce risk of cardiac ischemia.
b. Lepirudin (Refludan)
c. Argatroban (Acova)
III.
Diuretics
A.
B.
Action: Decreases preload by decreasing vascular fluid volume.
Classifications
1.
Thiazide
Action: blocks reabsorption of sodium & chloride in early distal convoluted
tubule.
Common Drugs: hydrochlorothiazide (Hydrodiuril)
chlorothiazide (Diuril)
metolazone (Zaroxolyn)--works best if given 30 minutes prior
to loop diuretic.
chlorthalidone (Hygroten)—ALLHAT HTN study. More potent
than HCTZ and works better to ↓ BP.
2.
Loop
Action: acts on loop of Henle to block sodium reabsorption. Potassium is
excreted because Lasix interferes with Na/K pump.
Common Drugs: furosemide (Lasix) .
torsemide (Demadex) po IV longer acting, more potent than
Lasix
bumetanide (Bumex)
S.E.: ringing ears, lyte loss, hypotension
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3.
Potassium – sparing
Action: Increases the excretion of sodium and promotes retention of potassium
in distal convoluted tubule. Weaker than Lasix.
Common Drugs: amiloride (Midamor)
spironolactone (Aldactone)—spironolactone will be part of
CHF treatment due to its ability to block aldosterone. Breast
pain esp. seen with men is worse side effect.
triamterene (Dyrenium)
4. Aldosterone Receptor Blockers
Action: Blocks action of aldosterone so increases the excretion of sodium and
water and increases retention of potassium. Monitor for hyperkalemia.
a. eplerenone (Inspra): more selective, use only for HTN. Some dangerous drug
combinations (ketoconazole,erythromycin, verapamil) can cause toxicity.
b. spironolactone (Aldactone) less selective, used for CHF
5.
IV.
Nursing Implications of diuretics
a.
Monitor renal function (BUN, Creatinine)
b.
Monitor for hypokalemia. Digitalis toxicity occurs in presence of decreased
K+.
Diet alone cannot supple K+ loss.
Lasix modifies sodium/potassium pump so that patients lose both K+ and
Na+
c.
Monitor for hyperkalemia with K+ - sparing diuretics.
d.
Monitor for hypotension (fluid volume deficit)
e.
I/O, daily wt.
Direct Renin Inhibitor:
A.
aliskiren (Tekturna)
B.
Classification: Antihypertensive
C.
Indications: HTN but may also prove helpful for HF and nephropathy. Can be added
to other HTN meds (diuretics, ACEI, and ARBS).
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D.
Action:
Aliskiren directly blocks the action of renin at the top or beginning of the reninangiotensin-aldosterone (RAA) system which results in lower blood pressure. FIRST
NEW ANTIHYPERTENSIVE DRUG CLASSIFICATION IN TEN YEARS. Can be
taken alone or in combination with other drugs. Works well regardless of age or
gender. Will take time to determine overall efficacy compared to existing drugs used
for HTN.
E.
Dose: 150 mg or 300 mg once a day.
F.
Side effects: Well tolerated, hypotension, Can still cause cough
although less likely than ACEI or ARBS.
V.
or angioedema
Nitrates
A.
Common Drugs:
1.
Nitroglycerin (Sublingual, ointment, paste, patches, IV) slow to immediate
action. Remove patch at night, unless pt. has angina at night (adjust
accordingly).
2. isosorbide mononitrate (Imdur). Sustained release. Don’t crush.
NOTE:
Imdur given once every day and lasts 12 hours--NITRATE free period
of night (QD).
Ismo given in AM and again in seven hours then nitrate free period (BID), Ismo can be crushed.
Nitrate free period important. Can crush Ismo or Isordil to put down
NG or Peg tube.
B.
C.
Action:
1.
Primarily, the drugs vasodilate veins but have some dilation effect on arterioles.
This pooling of body fluids in periphery results in decreased preload (veins) &
afterload (arteries)
2.
Dilate coronary arteries.
Nursing Implications:
1.
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Observe for HYPOTENSION. Take BP and pulse before each dose.
Patients may c/o headache, flushing, and throbbing because of peripheral
vasodilation. Give ASA for headache. Patient should be lying down before
administering NTG (not sustained release) to avoid orthostatic BP drop. Inform
patient that headache is common side effect and should decrease with therapy.
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2.
VI.
Specific nursing actions
a.
NTG S/L If no relief call 911. NTG S/L must be stored in dark bottle, and
at room temperature. May use now until expiration on the bottle, as long
as they have stored medication properly. Don't refrigerate; moisture &
heat destroys drug. Burning under tongue no longer an indication of drug
potency. Many cardiologists today teach patients who have a cardiac
history to seek treatment after obtaining pain relief after taking only one
nitroglycerin sublinqual pill.
b.
NTG ointment - messy, less accurate, wear gloves. Rotate sites to avoid
skin irritation. Don't rub in ointment. Apply occlusive dressing.
c.
Transderm NTG - patches, time-release, don't touch backing. On in AM, off
in PM to avoid NTG tolerance.
d.
NTG IV - used with unstable angina, frequently while waiting for PTCA or
CABG. BP every15 min. Titrate drip to D.O. (usually SBP 90-100 )
e.
NTG lingual spray: usually 1-2 sprays q 5 minutes for 15minutes. Instruct
patient to lift tongue and spray dose under tongue. Highly flammable--no
smoking.
f.
Nitrates & Viagra—drug interaction. Combination is contraindicated.
Potentiates hypotension.
Cardiac Glycosides
A.
Common Drug: digoxin (Lanoxin)
B. Action: Positive inotropic agent; negatively dromotropic &
chronotropic.
C.
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negatively
Nursing Implications
1.
Given po, IV - never IM (irradically absorbed)
2.
Excreted via kidneys so watch patients who are renally compromised.
3.
Take pulse before each dose. Contact Dr. if < 60/min.
4.
Report S.E. of digitalis toxicity:
Visual disturbances, anorexia, nausea, vomiting,
decreased pulse, dysrhythmias
5.
Serum digitalis levels should be taken regularly by Dr. to avoid digitalis toxicity.
(therapeutic range 1-2ng/ml) Dig. toxicity occurs more commonly with
hypokalemia, hypocalcemia and hypomagnesemia. Do not cardiovert if patient
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digitalis toxic. Dr. usually "HOLDS" digitalis on the day of cardioversion.
6. Digoxin use in women with HF may  death rate.
Lower doses of dig in HF are now recommended, 0.125 mg
VII. Positive Inotropic Drugs
A.
dopamine 2-10 mcg/kg/min
B.
dobutamine 2.5-10 mcg/Kg/min
VIII. Natriuretic Peptide
IX.
A.
nesiritide (Natrecor)—beta type
B.
IV medication with vasodilatory and diuretic effects, which improve circulation, SOB
and fatigue in acute HF patients.
C.
Alternative for dobutamine, milrinone therapy and less likely to  HR or cause
arrhythmias
D.
Can cause more prolonged hypotension
E.
Very expensive
Angiotensin - Converting Enzyme Inhibitors (ACEI)
“Give them an ACEI and they’ll cough in your face.”
A.
Indications: Remodeling (shrinking) left ventricle. After MI, ventricle dilates and
thins which increases mortality.
Treats hypertension especially good for patients prone to CHF.
Three drugs in one: diuretic decreases aldosterone release which increases
sodium excretion
preload - venodilator
afterload - arteriodilator
B.
Common Drugs:
1. captopril (Capoten) 12.5-50 mg 2-3 times daily
2. lisinopril (Prinivil, Zestril) Adverse taste occasionally occurs. 5-40 mg /day. NOT
effected by food.
3. enalapril (Vasotec) Adverse taste occasionally.
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4. Other drugs:
X.
benazepril (Lotensin)
fosinopril (Monopril)
quinapril (Accupril)
ramipril (Altace)
moexipril (Univasc) (cheaper) take on empty stomach
trandolapril (Mavik)--similar to lisinopril
perindopril (Aceon)
Angiotensin II Receptor Blockers (ARB): less chance of cough secondary to no
bradykinin breakdown.
A.
losartan (Cozaar) is an angiotensin II receptor blocker.
valsartan (Diovan) - 80mg -320 mg QD
irbesartan (Avapro), QD 150-300 mg QD
cardesartan (Atacand) 16-32 mg QD
azilsartan (Edarbi) 40-80 mg QD
B. Action – vasodilates by working on angiotensin system. Causes renal
retention of potassium & increased excretion of sodium & water. Monitor
kidney function. Because of this effect, patients on diuretics may not need
potassium supplements. Watch for increased potassium levels.
C. Nursing Implications for ACEI and ARB
1. Two ACEI should not be given at same time. This should always be
questioned. Should also question ACEI and ARB given at same time.
No evidence for improved outcomes.
2. Angioedema, uncommon side effect of ACEI. May occur during first
week of therapy, or years later. If patient has swelling of tongue or
throat, go to ER. More common in blacks than whites. ARB’s can also
cause angioedema. Caution should be used if changing a patient who
developed angioedema from ACEI to an ARB.
XI. Calcium Channel Blockers
Classes 1.
Dihydropyridine (these do not decrease contractility but can cause reflex
tachycardia). Side effects secondary to vasodilation.
A. nifedipine (Procardia) (Adalat)
B. nicardipine (Cardene)
C. amlodipine (Norvasc)
D. isradipine (Dynacirc)
E. felodipine (Plendil)
F. clevidipine (Cleviprex) (Ultra short-acting, IV, lipid load restrictions,
contraindicated if allergic to soy or eggs)
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2.
3.
Diphenylalkylamine
verapamil (Calan) Dysrhythmic, decreases contractility,
Benzothiazepine
diltiazem (Cardizem) Dysrhythmic, decreases contractility
NOTE: Often see two different classes of calcium blockers used together
(i.e. nifedipine & diltiazem)
A.
B.
Action: Varies depending on drug (dysrhythmic, vasodilator, relaxes coronary
artery spasm (Prinzmetal angina--especially Cardizem).
Nursing Implications
Check pulse and BP before administration. Monitor PR, QRS, and QT intervals if
dysrhythmic. Reflex tachycardia can occur with “dipines.” Monitor for ankle swelling.
Ghost shell in stool common with procardia. Don’t give procardia sl. Constipation
common with cardizem. Floss! Gum overgrowth. Great for kidney patients because
increases flow to kidneys. Use with great care when patients are on digoxin because
there is increased risk for digitalis toxicity with calcium channel blockers.
XII. Beta Adrenergic Blockers
A.
Taper doses when discontinuing.
Common Drugs:
1.
2.
3.
4.
atenolol (Tenormin)
metoprolol (Lopressor)
nadolol (Corgard)
propanolol (Inderal) used more for migraines than cardiac purposes. Impotence
common.
5. acebutolol (Sectral) less commonly used.
6. esmolol (Brevibloc) - used commonly post-cabg to decrease fast heart rate
7. pindolol (Visken)
8. sotalol (Betapace)
9. nebivolol (Bystolic): also approved for CHF
10. carvedilol (Coreg) for CHF (FDA approved for CHF) in small doses. Dose
3.125mg bid increased gradually. Small doses prevent heart failure yet blocks
SNS stimulation. If adequate dose achieved can  mortality by 35%.
B.
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Action: Negatively inotropic, negatively chronotropic so BP, HR & contractility are all
decreased. Initially, a decrease in cardiac output; eventually a decrease in
peripheral resistance. The decreased inotropic action can actually place a patient in
iatrogenic CHF. In addition, beta blockers reduce speed of impulse conduction
through the AV node. After months of BB treatment, heart size decreases (by 
cardiac muscle remodeling) which preserves or improves EF.
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C.
Nursing Implications
1. In General Do Not give these drugs to patients with acute asthma, COPD
(constricts bronchioles), CHF, or heart block (slows impulses. Beta blockers
(even BB eye drops) can mask symptoms of hypoglycemia (i.e.
tachycardia, sweating). Rely on accuchecks. Beta blockers can also inhibit the
release of insulin making glucose control more difficult.
2. Take BP and pulse before each dose.
3.
XIII.
Side effects: bradycardia, hypotension, wheezing,
depression, sexual dysfunction, chasing nightmares, fatigue and reversible hair
loss.
Antianginal
A.
Newer Drug: ranolazine (Ranexa)
B.
Indication: Used for chronic angina pectoris that does not respond to nitrates, beta
blockers, and amlodipine. It is also an option for patients who cannot take full doses
of conventional anti-anginal drugs due to decreased blood pressure and decreased
heart rate.
C.
Action:
Ranexa's mechanism of action is not fully understood. The drug has been shown to
exert its anti-anginal and anti-ischemic effects without reducing heart rate or blood
pressure. It is suspected that the drug exerts some of its effects by eliciting changes
in cardiac metabolism.
D
Dose:
Initial: 500 mg po BID
Maximal dose: 1000 mg po BID
E.
Side effects:
F.
Contraindications: 1) Continuing drugs that ↑ QT interval (amiodarone, quinidine)
Does NOT decrease BP or HR.
Prolonged QT interval
Syncope
Increases blood levels of simvastatin and digoxin.
Decreases blood levels of antidepressants and antipsychotics .
2) Potent CYP3A inhibitor: If given with diltiazem, verapamil,
“azoles,” antifungals → ↑ arrhythmia risk.
3) hepatic dysfunction
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XIV.
Alpha Blockers
A.
Action: Prevents vasoconstriction of blood vessels by blocking alpha receptors.
B.
Evidence states this drug classification should be avoided with hypertension since
there is increase risk of developing CHF or CVA. Best to treat HTN with diuretic
initially. This classification is still used for BPH.
--May see patients on alpha blocker + Procar for BPH—additive effect if alpha block
not effective.
C.
Alpha Adrenergic Blockers
prazosin (Minipress)
terazosin (Hytrin)
doxazosin (Cardura) high risk for postural hypotension.
phentolamine (Regitine)
phenoxybenzamine (Dibenzyline)
D.
Major side effect: postural hypotension
XV. Morphine
XVI.
A.
Action: Decreases preload and afterload. Analgesic/Sedative.
Negatively inotropic.
B.
Nursing Implications: Usually given IV with chest pain. Respiratory depression
major side effect. Take respirations before giving and after each 1-2mg IV. Dilute.
Give morphine 1mg/1min IV.
Dysrhythmics:
A.
Action - Decreases dromotropic effect of the heart. Different
drugs work in different areas of the conduction system.
B.
Drugs for Atrial Dysrhythmias
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1.
digoxin (Lanoxin): If patient is Dig. toxic, this state can cause all types of
dysrhythmias.
2.
verapamil (Calan, Isoptin, Covera HS), diltiazem (Cardizem, Tiazac, Dilacor XL)
IV for 24o.
3.
quinidine (Quinidex, Quiniglute)
These drugs cause diarrhea.
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4.
procainamide (Pronestyl), (lupus like syndrome, joint pain, can see capsule in
stool)
5.
Dilantin (esp. with digitalis toxicity)
6.
adenosine (Adenocard) (helps distinguish SVT vs. VT) by product of ATP.
Used with WPW & Paroxysmal SVT.
Given IV - 10 seconds is 1/2 life. Dose 6mg bolus over 1-2 seconds; if SVT
doesn't resolve, rebolus 12 mg IVP.
Adenosine converts PSVT to NSR by blocking pathways to AV node. Similar to
Verapamil. Neg dromotropic, chronotropic and inotropic. Afterload reducer,
Dysrhythmic.
7. amiodarone (Cordarone) PO, IV. Watch for bradycardia/hypotension with IV use
in hospital.
8. dronedarone (Multag). Less toxic than amiodarone but may have liver toxicity.
Do not use with CHF patients (double mortality). Less effective than amiodarone.
8.
ibutilide (Corvert). Pharmacologic cardioversion. Watch QT interval if other
dysrhythmics are given. Not as impressive as expected.
9.
dofetilide (Tikosyn)—close monitoring by drug company due to potential to
cause torsades (ventricular tachycardia). Many drug interactions. Only certain
hospitals and retail pharmacies are allowed to dispense. Only used for
refractory atrial dysrhythmias. Excreted renally. Creatinine clearance and GFR
must be done prior to initiation of drug and periodically because if too high level
of drug in body, patient at increased risk for torsades. Check QT interval.
Generally, if GFR is greater than 60, 500 mg given.
if GFR is 40-60, 250 mg given.
If GFR is less than 40, 125 mg given.
C.
Drugs for Ventricular Dysrhythmias (Check QRS & QT interval. If increasing, notify
Dr.)
1.
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amiodarone (Cordarone)
Drug frequently used before AICD. Used for atrial and ventricular dysrhythmias.
Recent requirement is that patients have opthalmic follow-up. Baseline CXR
and PFT needed. Smurf syndrome. Guidelines for ACLS = 300 mg IV bolus for
pulseless VT outside hospital.Amiodarone can predispose the patient to retinal
deposits and damage, pulmonary fibroisis, and increased or decreased thyroid
function.
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2. lidocaine (Xylocaine): IV
S.E.: toxicity occurs quickly. Confusion (increased levels).DC
3. procainamide (Pronestyl); po or IV
Procan SR extended release
Procanbid - BID dosing - Do not cut/break.
S.E.: diarrhea, GI upset, lupus increased levels, leukopenia,
thrombocytopenia.
D.
Nursing Implications for dysrhythmic drugs
1 Maintain therapeutic blood level of cardiac meds by spacing meds regularly
throughout day like antibiotics.
2. Take pulse and BP before each dose. Dysrhythmics are negatively dromotropic
so pulse is usually decreased.
Call Dr. if pulse below 60 but don't automatically hold.
XVII.
Hypolipemic drugs: The objective of drug therapy is to lower LDL - cholesterol and raise
HDL - cholesterol. Higher doses of statins used to achieve this effect (ie Zocor 40mg
HS). Care with high dose statins since they can cause myopathy. Zocor 80mg can be
taken only if patient has taken this dose for one year without myopathy. Drug therapy is
recommended only after 6 months of diet modification. Most hypolipemic drugs exert
maximum effect within 30 days.
1.
Bile acid-binding resins (work in intestine)
a.
Common drugs: cholestyramine (Questran) 2-8 Gm bid (powder)
colestipol (Colestid) tabs or granules—2-16 Gm qd bid
colesevelam (Welchol)—more potent bile acid resin. Should
not bind with other drugs. 625 mg 3 tabs bid.
b.
Mechanism of action: The drug combines with bile salts and both are evacuated
in the stool. Reduction in available bile salts leads to the breakdown of serum
LDL to make more bile salts. This results in a decreased serum LDL. Bile salts
are necessary for the breakdown of fat.
c.
Nursing Implications
1.
2.
3.
4.
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Binds to all drugs. Important to give 1 hr. after other drugs or 4-6 hrs.
before other drugs.
Inconvenient (mix) take 3X/day.
Inexpensive
side effects: cramps, constipation, flatulence (increase fruits and
vegetables)
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2.
HMG - CoA reductase inhibitors
a.
Common drugs:
NOTE: Take Altocor, Zocor, Lescol & Mevacor in the evening since cholesterol
synthesis peaks at midnight.
lovastatin ER (Altocor)
simvastatin (Zocor): Drug interaction: to ↓ chance of rhabodomyolysis, the
maximum recommended dose is Zocor 10mg with diltiazem, & verapamil.
Zocor 20mg with amiodarone, amlodipine, ranolazine
fluvastatin (Lescol)
pitavastatin (Livalo)
NOTE: Can take Lipitor, Crestor, & Pravachol at any time due to long half life.
atorvastatin (Lipitor): NOW GENERIC
pravastatin (Pravachol)
NOTE: Pravachol has received FDA approval as primary preventative of heart
attack.
rosuvastatin (Crestor)
- 10mg lowers LDL ~ 50% (equal to Lipitor 40 mg)
- works best to  HDL
- only statin in which you must monitor for renal function if they are on
high dose (40mg)
b.
Mechanism of action: These drugs inhibit cholesterol synthesis and increase
the number of LDL receptors on the cell. This decreases circulating serum LDL.
c.
Nursing Implications
1. Well tolerated; mild GI distress
2. Do slit lamp exam every 6 months.
3. Can cause liver damage. Check LFT—risk is the same for all statins.
Check CPK; can also cause muscle damage in 10% of patients. Can lead
to rhabdomyolysis (tea-colored urine).
4. Taking OTC coenzyme QT as a supplement to reduce cholesterol is
controversial at this time.
5. Vitamin D (400-1000IU) daily is also being tried for muscle pain associated
with statins. Low Vitamin D levels contribute to myalgias.
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3.
Cholesterol Absorption Inhibitor
--ezetimibe (Zetia) 10 mg. daily
--works in the gut wall to prevent cholesterol absorption thru the intestinal villa
--may be used alone or with a statin
NOTE:No evidence that combining statins with fibrates, niacin, or fish oil reduces
cardiac risk. Save these drugs for people who cannot tolerate statins.
4.
Nicotinic acid (Niacin): This drug directly lowers serum LDL and triglyceride levels
and raises HDL. This vitamin actually stops the liver from making LDL. Flushing is
a common side effect. Taking niacin with ASA and with food decreases flushing.
Sustained release is best. Niaspan - newer sustained release niacin. Lower doses
may decrease liver side effects. Take HS. Titrate slowly to achieve 1000-2000 mg.
daily.
5.
Fibric Acid Derivatives:
Gemfibrozil (Lopid): This drugs decreases levels of VLDL and raises HDL. It can
reduce triglycerides by 50% Take 30 minutes prior to AM & PM meal. Monitor
liver function tests (CPK, SGOT, SGPT) Monitor CBC; med can decrease counts.
600 mg BID
Fenofibrate (Tricor) 54 mg - alternative to Lipitor, Niacin to decrease TG.
Recommended dose 3 caps/day. Tricor 160mg qd—sustained release.
NOTE: Warning about using statins with Lopid due to enhanced incidence of
skeletal muscle damage. Monitor pts. for unusual muscle pain, tenderness
and weakness.
-- LDL 20%, TG – 10%
6.. Sea Omega (omega-3 fatty acid)
- used to reduce triclycerides
-  sudden cardiac death by 45% for patients p MI  2o to  antiarrhythmic
effects
- also has antiplatelet + anti-inflammatory effects.
- Omacor: prescription sea omega
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XVIII.
General Rules to Remember
A.
If pulse or blood pressure is low, hold cardiac medication PLUS call Dr. Many times
the cardiologists’ goal is to have a slow pulse or low blood pressure. Remember,
many of these vasodilators will decrease afterload so the heart doesn't have to work
so hard.
B.
If your patient goes for a test/surgery and is required to be NPO, don't automatically
assume pt. should be taken off cardiac meds. Call doctor and verify it.
C.
If patients are experiencing untoward side effects, (impotence, dry mouth,
constipation, dizziness, leg swelling, fatigue, etc.) inform Dr. Many times a different
drug will better suit the patient. Side effects
esp. hypotension, fatigue and
impotence can cause pt. to stop taking drug.
D.
Warn patient not to take self off cardiac med (CHF, VT can occur). Call Dr.
E.
JNC-8 Blood Pressure Guidelines:
a. Patient’s < age 60: BP < 140/90
b. Patients age 60-79 < 150/90 (without renal disease or diabetes or < 140/90 with
renal disease or diabetes).
c. However, don’t back off of BP meds due to lower BP if patient is doing well on
them.
F.
Don't crush extended release tabs. Can break "scored" extended release tabs in
half.
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17
References
American College of Cardiology. (2007). Cardiac Medications. Retrieved on July 8, 2007 from,
http://www.acc.org/
American College of Cardiology Foundation and the American Heart Association (2005). ACC/AHA
2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.
Retrieved on July 23, 2007 from
http://westernhealth.com/providers/downloads/hf_fulltext.
American Heart Association. (2007). Hypertension: New Concepts and New Agents. Retrieved on
July 23, 2007 from,
http://www.americanheart.org/presenter.jhtml?identifier=3045537
Gahart, B.L. & Nazareno, A. R. (2014). 2014 Intravenous Medications. St. Louis, MO: Elsevier
Mosby.
Lehne, R. A. (2012). Pharmacology for Nursing Care. St. Louis, MO: Saunders.
Lilley, Rainforth Collins, Harringtion, & Snyder (2012). Pharmacology and the Nursing Process. St.
Louis, Mosby.
National Cholesterol Education Program. (2007). Adult Treatment Panel III Guidelines at a Glance:
Quick Desk Reference. Retrieved on July 14, 2007 from,
http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf
National Heart. Lung, and Blood Institute. (2003). The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Retrieved
on July 23, 2007 from,
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
Pharmacist’s Letters
2/2014, JNC-8.. Volume 30, No. 2, p.7.
1/2014 Lipid Guidelines. Volume 30, No. 1, p.1-2.
7/2013 Tricor and Statins, Volume 29, No. 7, p. 38.
3/2013 ARBs and ACEI: No benefit. Volume 29, No. 3, p. 13.
Well, B.G. et.al. (2006). Pharmacotherapy. New York: McGraw-Hill
Vallerand, A.H., et al., Davis’s Drug Guide for Nurses. F.A.Davis, 2013.
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