Running head: INTERVENTIONS EXHIBIT
Therapeutic Interventions Exhibit #2
Fall 2013
Amanda Twining
1
INTERVENTIONS EXHIBIT
2
Millions of Americans are affected with coronary artery disease every year. It is also
referred to as coronary heart disease (CHD). Coronary artery disease (CAD) is the leading cause
of death in both men and women in the United States. CAD is an umbrella term used to describe
abnormal conditions that affect the coronary arteries, especially regarding reduced oxygen
supply to the heart, which can ultimately result in myocardial infarction. CAD is usually caused
by atherosclerosis, which are fatty plaque deposits in the arterial walls, specifically damaging the
tunica intima of the artery. This process occurs over the course of several years, and ultimately
leads to narrowing of the arteries. This damage can occur as early as childhood. Common signs
and symptoms of CAD include angina, dyspnea, palpitations, and fatigue. There are also several
risk factors which increase one’s likelihood of developing CAD, including smoking, diabetes
mellitus, hypertension, and familial disposition. These risk factors are also considered the
etiology of this disease (Mayo Clinic, 2012).
Along with the risk factors previously listed, high lipid blood levels also contribute to the
development of coronary artery disease, and are the most deadly risk factor. According to Lilley
(2014), lead contributor to Pharmacology and the Nursing Process, “The risk for CHD in
patients with cholesterol levels of 300 mg/dl is three to four times greater than that in patients
with levels of less than 200 mg/dl,” (2014, p. 446). For many patients, high cholesterol levels
are able to be lowered through diet and exercise alone. However, if after six months, the
patient’s cholesterol levels do not decrease after changing dietary and exercise habits, drug
treatment for hyperlipidemia may be started.
There are many drugs available for the treatment of hyperlipidemia; however,
hydroxymethylglutaryl-coenzyme a reductase inhibitors (HMG-CoA) are first line drugs for such
treatment (which is why this author chose this specific classification). These drugs are also
INTERVENTIONS EXHIBIT
3
called statins, as the specific drugs all end in “statin”. Fortunately for those prescribed with this
type of medication, adverse effects are uncommon. According to Karch (2014), author of
Lippincott’s Nursing Drug Guide, the most severe adverse effect is rhabdomyolysis (a
breakdown of muscle protein) with possible renal failure (due to urinary elimination of
myoglobin). Other lesser adverse effects include headache, blurred vision, flatulence, abdominal
pain, cramps, constipation, nausea, and vomiting (Lilley, 2014)
Drugs specific to HMG-CoA inhibitors include atorvastatin, fluvastatin, lovastatin,
pitavastatin, pravastatin, rosuvastatin, and simvastatin. The next seven paragraphs reflect the
work of Karsch in Lippincott’s Nursing Drug Guide (2014).
Atorvastatin, commonly referred to as Lipitor, reduces low density lipid (LDL)
cholesterol and triglycerides, while raising HDL cholesterol. Common side effects include
headache, flatulence, abdominal pain, cramps, constipation, and nausea; the most severe adverse
effects are liver failure and rhabdomyolysis with acute renal failure.
Fluvastatin is an antihyperlipidemic that reduces LDL cholesterol, and either raises high
density lipid (HDL) cholesterol or has no effect on it. It is indicated in patients who already have
CAD to slow the progression of the disease, as well as in children who have heterozygous
familial hypercholesterolemia. Common adverse effects in this medication include headache,
blurred vision, flatulence, abdominal pain, cramps, constipation, nausea, and most seriously,
rhabdomyolysis.
Lovastatin works much like fluvastatin, including almost identical indications. It is used
primarily as a preventative medication in patients “without symptomatic disease.” Common
adverse effects include headache, abdominal pain, flatulence, cramps, constipation and nausea.
INTERVENTIONS EXHIBIT
4
Pitavastatin lowers cholesterol, LDLs, and triglycerides while raising HDLs. It is
indicated to lower total cholesterol levels. Unlike previously listed statins, pitavastatin’s
common adverse side effect is back pain. Similar to the others, however, it can cause
rhabdomyolysis.
Pravastatin works much like fluvastatin and lovastatin. It is used to prevent a first
myocardial infarcation, reduce the risk of a stroke or transient ischemic attack in patients who
have had a myocardial infarction but normal cholesterol levels, and for children with
heterozygous familial hypercholesterolemia. Adverse effects include headache, blurred vision,
flatulence, abdominal pain, cramps, constipation, nausea and vomiting.
Rosuvastatin works similarly to pravastatin, fluvastatin, and lovastatin. An indication
that sets this medication apart from the others in the classification is its use in treatment of
patients with primary dysbetalpoproteinemia. Its other indications are similar to others in the
category. Common adverse effects include headache, nausea, diarrhea, pharyngitis, rhinitis,
sinusitis, and flulike symptoms. Severe adverse effects include liver failure, rhabdomyolysis,
myopathy, and myalgia.
The last drug in this classification is simvastatin, which works much like rosuvastatin,
pravastatin, fluvastatin, and lovastatin. Along with typical indications to reduce cholesterol
levels along with diet and exercise, it is also used to reduce the need for bypass surgery and
angioplasty in patients with CAD. Common adverse side effects include headache, flatulence,
diarrhea, abdominal pain, cramps, constipation, and nausea. Severe adverse effects include liver
failure, rhabdomyolysis, and acute renal failure.
As may be inferred from their name, HMG-CoA reductase inhibitors block HMG-CoA
reductase. This is the enzyme that controls the rate of cholesterol production. By competitively
INTERVENTIONS EXHIBIT
5
blocking the sites for these receptors, serum levels of cholesterol, LDL cholesterol and
triglycerides are reduced and excreted. Statins also have a huge impact on survival rates for
those who have had a myocardial infarction, or are at risk for one. According to an article in the
European Heart Journal, with statin use, “the risk of sudden cardiac death was reduced by 10%
compared with a reduction in the risk of other (non-sudden) cardiac deaths of about 20%,”
(Rahimi, et al, 2012). Thus, statins are significantly cardio protective. Another study found that
primary prevention with statin use is “cost effective” and could “improve patient quality of life”
(Taylor, et al 2013).
Likewise, an advantage to HMG-CoA reductase inhibitor use is its effect on elevating
HDL cholesterol levels. According to Lilley (2014), these levels can raise by 2% to 15%, thus
making them a negative risk factor for cardiovascular disease. An article in the International
Journal of Current Scientific Research highlights the effect of HDLs, stating, “HDL’s protective
function has been attributed to its active participation in the reverse transport of cholesterol,”
(2011). Therefore, as a patient takes a statin, there are several mechanisms ensuring cardio
protection.
Any drug treatment for hyperlipidemia is only selected after diet and exercise alone are
proved to be ineffective because pharmacological treatment is a long term commitment. Many
patients are genetically predisposed to high LDL and triglyceride levels (even if they are
otherwise very active, and eat healthily). The patient must be educated on several factors while
taking drugs from this classification; it must also be determined that the patient is not allergic to
this classification of medication. Statins must be taken at bedtime, as the “highest rates of
cholesterol synthesis are between midnight and 5am,” (Karch, 2014, p. 48). It is important to let
women of childbearing age know to use contraceptives while on these medications, as all HMG-
INTERVENTIONS EXHIBIT
6
CoA inhibitors are category X pregnancy drugs. The patient should also consult with a dietician
before beginning medication. Just because the medication will lower cholesterol levels does not
mean that the patient should eat whatever he wants; the medication is intended to be an adjunct
therapy along with dietary and exercise changes. It is also noted that patients should avoid
consuming large amounts of grapefruit juice while on this classification of medication. Patients
should report any unexplained muscle pain to their prescribers, as this could indicate the most
serious adverse effect of rhabdomyolysis. Liver function tests should also be ordered regularly as
the medication acts directly on the liver. (Karsh 2014).
HMG-CoA reductase inhibitors are an important classification for the prevention and
treatment of coronary artery disease. Studies have shown that low cholesterol, LDL and
triglyceride levels, and high HDL levels promote cardiovascular health. The medications of this
class ensure that all these therapeutic effects will take place in a cost effective manner, and will
improve the patient’s quality of life, in use as adjunct therapy to changes in dietary and exercise
routines. Patients who have had previous myocardial infarctions, or are at high risk for one due
to genetics, diabetes mellitus, failure to cease smoking, or especially high cholesterol levels
would benefit greatly from the use of statins as a preventative measure.
INTERVENTIONS EXHIBIT
7
References
Karch, A.M. (2014). 2014 Lippincott’s Nursing Drug Guide. Lippincott Williams&Wilkins.
Lilley, L.L., Rainforth Collins, S., Snyder, J.S. (2014). Pharmacology and the Nursing Process.
Elsevier.
Mayo Clinic Staff. (2012). “Coronary Artery Disease”. Mayo Foundation for Medical Education
And Research.
Pichandi, S., Pasupathi, P., Raoc, YY., J, F., Ambika, A., Ponnusha, B.S., …& Virumandye, R.
(2011). The role of statin drugs in combating cardiovascular diseases. International
Journal of Current Scientific Research.
Rahimi, K., Majoni, W., Merhi, A., Emberson, J. (2012). Effects of statins on ventricular
tachyarrhythmia, cardiac arrest, and sudden cardiac death: A meta-analysis of published
and unpublished evidence from randomized trials. European Heart Journal, vol 33,
pp 1571-1581.
Taylor, F., Huffman, M.D., Macedo, A.F., Moore, T.HM., Burke, M., Smith, G.D., …&Ebrahim,
S. (2013). Statins for the primary prevention of cardiovascular disease. Cochrane Heart
Group.