Drugs affecting Cardiovascular system

1. DRUGS AFFECTING
CARDIOVASCULAR SYSTEM

2. CARDIOTONICS

3. ?
• Cardiotonic agents are drugs used to
increase the contractility and output in a
hypodynamic heart without propotionate
increase in 02 consumption
• Commonly used in the treatment of heart
failure (HF)

4. • Cardiotonic (inotropic) drugs affect the
intracellular calcium levels in the heart
muscle, leading to increased contractility.
• This increase in contraction strength leads
to increased cardiac output, which causes
increased renal blood flow and increased
urine production

5. TYPES
1. Cardiac glycosides
2. Phosphodiesterase inhibitors

6. CARDIAC GLYCOSIDES
• Digoxin (Lanoxin) commonly used drug
• The cardiac glycosides were originally
derived from Digitalis purpurea (Common
Foxglove)

7. Foxglove plant
Digitalis lanata

8. Mechanism of action
• Digoxin increases intracellular calcium and
allows more calcium to enter myocardial
cells during depolarization. That results
1. Increased force of myocardial
contraction (a positive inotropic effect)
2. • Increased cardiac output and renal
perfusion

9. 3. Slowed heart rate, owing to slowing of the
rate of cellular repolarization (a negative
chronotropic effect)
4.Decreased conduction velocity through the
atrioventricular(AV) node

10. INDICATIONS
• Heart failure (HF)
• Atrial flutter
• Atrial fibrillation
• Paroxysmal atrial tachycardia

11. Dosage
• Digoxin is available for oral and parenteral
administration.
• Oral- 0.75–1.25 mg PO
• IV-0.125–0.25 mg IV
• Onset of action - 30–120 minutes when
taken orally, 5–30 minutes when given
intravenously

12. Contraindications
• hypersensitivity to digitalis preparations
• ventricular tachycardia or fibrillation
• heart block or sick sinus syndrome
• idiopathic hypertrophic subaortic stenosis
(IHSS)
• acute MI
• Renal failure

13. Adverse Effects
• headache, weakness, drowsiness and
vision changes
• Digitalis toxicity ( serious side effect)

14. Digitalis toxicity
• A serious syndrome that can occur when
digoxin levels are too high
• Normal level- 0.5 -2.0 ng/ml
signs and symptoms – anorexia, nausea,
vomiting, malaise, depression, irregular
heart rhythms including heart block, atrial
arrhythmias, and ventricular tachycardia

15. • Antidote- Digoxin immune Fab (DigiFab)

16. Nurses responsibilities
• Assess for contraindications or cautions
• Perform a physical assessment
• Assess cardiac status closely, including
pulse and blood pressure
• Monitor apical pulse for 1 full minute
before administering the drug

17. • Hold the dose if the pulse is less than 60
beats/min in an adult or less than 90
beats/min in an infant; retake the pulse in
1 hour. If the pulse remains low, document
it, withhold the drug, and notify the
prescriber
• Monitor the pulse for any change in quality
or rhythm

18. • Administer intravenous doses very slowly
over at least 5 minutes to avoid cardiac
arrhythmias and adverse effects.
• Avoid administering the oral drug with food
or antacids to avoid delays in absorption
• Obtain digoxin level as ordered; monitor
the patient for therapeutic digoxin level
(0.5–2 ng/mL)

19. • Maintain emergency equipment on
standby if digoxin toxicity develops
• Provide thorough patient teaching,
including the name of the drug, dosage
prescribed, technique for monitoring pulse
and acceptable pulse parameters, dietary
measures if appropriate, measures to
avoid adverse effects, warning signs of
possible toxicity and need to notify health
care provider

20. PHOSPHODIESTERASE
INHIBITORS
• milrinone (Primacor)
• This drugs block the enzyme
phosphodiesterase.This blocking effect
leads to an increase in myocardial cell
cyclic adenosine monophosphate (cAMP),
which increases calcium levels in the cell

21. INDICATIONS
• short-term treatment of HF that has not
responded to digoxin or diuretics alone or
that has had a poor response to digoxin,
diuretics, and vasodilators

22. DOSAGE
• Intravenous
• (PRIMACOR IV 10Mg/ml inj)
dose- 50 microgram/kg iv bolus followed
by 0.4-1.0 microgram/kg/min infusion

23. Contraindications
• hypersensitivity to phosphodiesterase
inhibitors
• severe aortic or pulmonic valvular disease
• acute MI

24. Adverse Effects
• ventricular arrhythmias (which can
progress to fatal ventricular fibrillation),
hypotension, and chest pain
• GI effects include nausea, vomiting,
anorexia, and abdominal pain
• Thrombocytopenia occurs frequently with
milrinone

25. • Precipitates form when these drugs are
given in solution with furosemide

26. Nurses responsibilities
• Assess for contraindications or cautions:
any known allergies to these drugs or to
avoid hypersensitivity reactions;
• acute aortic or pulmonic valvular disease,
• acute myocardial infarction
• ventricular arrhythmias

27. • Pregnancy and lactation
• Assess cardiac status closely, including
pulse and blood pressure
• Protect the drug from light to prevent drug
degradation
• Monitor input and output and record daily
weight

28. • Monitor platelet counts before and
regularly during therapy to ensure that the
dose is appropriate, inspect the skin for
bruising or petechiae to detect early signs
of thrombocytopenia
• Provide life-support equipment on standby

29. • Provide thorough patient teaching,
including the name of the drug, dosage
prescribed, measures to avoid adverse
effects, warning signs of problems, and
the need for periodic monitoring and
evaluation

30. ANTIANGINALS

31. ANGINA
• It is a pain syndrome due to induction of
an adverse oxygen supply/demand
situation in a portion of myocardium

32. • Antianginal drugs are used to help restore
the appropriate supply-and-demand ratio
in oxygen delivery to the myocardium.

33. How they act
• These drugs can work to improve blood
delivery to the heart muscle
• (1) by dilating blood vessels
(i.e.,increasing the supply of oxygen)
(2) by decreasing the work of the heart
(i.e.decreasing the demand for oxygen).

34. Classification
• Nitrates
a. short acting nitrates
Eg: Glyceryl trinitrate (Nitroglycerine)
b.Long acting nitrates
Eg; Isosorbide dinitrate (sorbitrate)
• betA-BLOCKERS
Eg; Atenelol, Propanalol

35. • Calcium channel blockers
a. phenyl alkamine
Eg: verapamil
b. benzothiazepine
Eg: Diltiazem
c. Dihydropyridines
Eg: Nifidipine, Amlodipine

36. • Potassium channel openers
Eg: Nicorandil
• OTHers
Eg: Ivabradine

37. Nitrates
• Nitrates are drugs that act directly on
smooth muscle to cause relaxation and to
depress muscle tone
• isosorbide dinitrate (Isordil)
• isosorbide mononitrate
• nitroglycerin

38. Mechanism of action
• The nitrates relax and dilate veins,
arteries, and capillaries, allowing
increased blood fl ow through the vessels
and lowering systemic blood pressure
because of a drop in resistance.
• Nitrates decreases the preload and
afterload

39. INDICATIONS
• LONG ACTING NITRATES
Taken before chest pain begins in situations in
which exertion or stress can be anticipated for
prevention of angina in adults; taken daily for
management of chronic angina
SHORT ACTING NITRATES
• Treatment of acute angina attack; prevention of
anginal attacks

40. AVAILABLE FORMS
• Nitroglycerin is available as
• sublingual tablet,
• Translingual spray,
• Intravenous solution
• Transdermal patch,
• Topical ointmentor paste,
• Transmucosal agent

41. DOSAGE
• Isosorbide nitrate- 2.5–5 mg SL
5-mg chewable tablet;
5–20 mg PO;
• Nitroglycerin- 5 mcg/min via IV infusion
pump every 3–5 min;
• 0.4-mg metered dose sublingual, up to
three doses in 15 min for acute attack

42. Contraindications
• Hypersensitivity
• Severe anemia
• Head trauma or cerebral hemorrhage
• pregnancy or lactation

43. Adverse effect
• Central nervous system (CNS)
headache, dizziness, and weakness
• Gastrointestinal (GI)
nausea, vomiting, and incontinence.
Cardiovascular
Hypotension
• Integumentary
flushing, pallor, increased perspiration.

44. Nurses responsibilities
• Assess for contraindications
• Assess cardiopulmonary status closely,
including pulse rate, blood pressure, heart
rate, and rhythm (30min)
• Always check the expiration date on the
bottle and protect the medication from
heat and light
• Instruct the patient that a sublingual dose
may be repeated in 5 minutes if relief is

45. is not felt, for a total of three doses; if pain
persists, the patient should go to an
emergency room
•Rotate the sites of topical form
•Taper the dose gradually (over 4 to 6
weeks) after long-term therapy

46. BETA BLOCKERS
• Beta-adrenergic blockers are used to
block the stimulatory effects of the
sympathetic nervous system.
• Eg- Atenelol
Propanalol
Metoprolol

47. Mechanism of action
• The beta-blockers competitively block
beta-adrenergic receptors in the heart and
decreasing the influence of the SNS on
these tissues. The result is a decrease in
the excitability of the heart, a decrease in
cardiac output, a decrease in cardiac
oxygen consumption, and a lowering
of blood pressure.

48. INDICATIONS
• Long-term management of angina
pectoris.
• To prevent reinfarction in stable patients 1
to 4 weeks after an MI

49. CONTRAINDICATIONS
• Bradycardia, heart block, and cardiogenic
shock
• Pregnancy and lactation
• Cautious administration to Asthma,
chronic obstructive pulmonary disease, or
thyrotoxicosis

50. DOASGE
• ORAL- 50-100 mg
• INTRAVENOUS - 5mg -15mg

51. NURSES RESPONSIBILITY
• Assess for contraindications or cautions
• Do not stop these drugs abruptly after
chronic therapy, but taper gradually over 2
weeks
• Monitor blood pressure, pulse, rhythm,
and cardiac output regularly
• Continuously monitor any patient receiving
an intravenous form of these drugs

52. CALCIUM CHANNEL BLOCKERS
• amlodipine (Norvasc),
• diltiazem (Cardizem)
• nicardipine (Cardene)
• nifedipine
• verapamil (Calan, Isoptin).

53. MECHANISM OF ACTION
• Calcium channel blockers inhibit the
movement of calcium ions across the
membranes of myocardial and arterial
muscle cells, altering the action potential
and blocking muscle cell contraction.
• This will results loss of smooth muscle
tone, vasodilation, and decreased
peripheral resistance occur

54. • Decreases the preload and afterload
which results in decreases cardiac
workload and oxygen consumption.

55. INDICATIONS
Treatment of
•Prinzmetal angina
•Chronic angina
•Effort associated angina
•Hypertension.
•Verapamil is also used to treat cardiac
tachyarrhythmias because it slows
conduction more than the other calcium
channel blockers do

56. Contraindications
• Hypersensitivity
• Pregnancy and lactation
Caution should be used with
• heart block or sick sinus syndrome
• Renal or hepatic dysfunction
• Heart Failure ,

57. Adverse Effects
• CNS -dizziness, light-headedness,
headache, and fatigue.
• GI- nausea and hepatic injury related to
direct toxic effects on hepatic cells.
Cardiovascular -hypotension, bradycardia,
peripheral edema, and heart block.
• Skin- flushing and rash

58. NURSES RESPONSIBILITIES
• Assess for contraindications
• Inspect skin for color and integrity
• Monitor blood pressure very carefully
• Provide thorough patient teaching

59. Potassium channel openers
• Potassium channel openers activates the
ATP sensitive potassium channels thereby
hyperpolarising the vascular smooth
muscles.
• This results in reduction in vascular tone
• That will lead to a decrease in preload and
afterload
• EG- Nicorandil

60. Dosage
• Oral- 5-20mg

61. INDICATIONS
• Prevention and long term treatment of
chronic stable angina pectoris
• Reduction in the risk of acute coronary
syndromes in patients with chronic stable
angina

62. contraindications
• Hypersensitivity
• Cardiogenic shock
• hypotension

63. Side effects
• Flushing
• Palpitation
• Weakness
• Headache
• Dizziness
• vomiting

64. Nurses responsibility
• Assess the hypersensitivity and
contraindications
• Regular monitoring of vital signs
• Health education
• asses the oral cavity for oral ulcers

65. OTHERS- IVABRADINE
• Ivabradine is a newer type of drug
• Mechnism of action- it acts by reducing
the heart rate by specific inhibition of the
funny
channel (cyclic nucleotide-gated)
• It specifically inhibits the cardiac
pacemaker and therby reducing heart
rate

66. indications
• Chronic stable angina patients with normal
sinus rhythm
• Chronic heart failure

67. Dosage
• Oral- 2.5-5mg

68. Contraindications
• Resting heart rate less than 70
• Cardiogenic shock
• Acute M I
• Sick sinus syndrome
• Severe hepatic injury
• Pregnency and lactation

69. Side effects
• Blurred vision
• Bradycardia
• Syncope
• Headache
• Constipation
• Muscle cramps

70. Nurses responsibility
• Check for hypersensitivity and
contraindications
• Assess the pulse rate and blood pressure
• Check the liver function test regularly
• Check for visual disturbances
• Health education

71. ANTIHYPERTENSIV

72. ?
HYPERTENSION

73. •REGULATORS OF BLOOD
PRESSURE ?

74. • Antihypertensives are the drugs that used
to treat hypertension

75. CLASSIFICATIONS
• DIURETICS
LOOP DIURETICS
Eg- furosemide
THIAZIDE DIURETICS
Eg- Hydrochlorothiazide
POTASSIUM SPARING DIURETICS
Eg- Spirinolactone

76. ADRENERGIC inhibitors
•CENTRALLY ACTING α- ADRENERGIC
ANTAGONISTS
Eg- Clonidine
•PERIPHERALLY ACTING α- ADRENERGIC
ANTAGONISTS
Eg- Reserpine
• α- ADRENERGIC BLOCKERS
Eg-Prazocin

77. • β- ADRENERGIC BLOCKERS
Eg- Atenelol
• Calcium Channel Blockers
Eg- Amlodipine
Nifidipine

78. ANGIOTENSIN INHIBITORS
• ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITORS
Eg- Captopril, Enalapril
• Angiotensin II–Receptor
Blockers
Eg- Losartan
Telmisartan

79. • DIRECT VASODILATORS
Eg- Nitroglycerin
Sodium nitroprusside

80. DIURETICS
Drugs that increase the production of urine

81. LOOP DIURETICS
They inhibit the sodium and chloride
reabsorption in the thick segment of the
ascending limb of the loop of Henle as well
as in the proximal convoluted tubule and the
distal diluting site
Eg- furosemide( Lasix)

82. Dosage
• 40 mg PO t.i.d

83. Thiazide diuretics
Inhibit sodium and chloride reabsorption
in the distal convoluted tubule
•These drugs are the first-line drugs used to
manage essential hypertension when drug
therapy is needed

84. • Eg- Hydrochlorothiazide
• Dosage- 25–100 mg/d

85. Potassium Sparing Diuretics
• The potassium-sparing diuretics are not
as powerful as the loop diuretics, but they
retain potassium instead of wasting it
• Eg- spironolactone (Aldactone)
amiloride (Midamor)

86. Mechanism of action
• Spironolactone acts as an aldosterone
antagonist, blocking the actions of
aldosterone in the distal tubule.
• It decreases the elimination of potassium

87. Dosage
• 50–100 mg/d PO

88. CONTRAINDICATIONS
• Hypersensitivity
• Fluid and electrolyte imbalances
• Severe renal failure
cautious administration with
Systemic lupus erythematous( SLE)
Gout
Pregnancy and lactation

89. SIDE EFFECTS
• Common side effects
GI upset
fluid and electrolyte imbalances
hypotension
electrolyte disturbances

90. • Side effects ( thiazide and loop diuretics)
1.hypokalemia
weakness, muscle cramps, and
arrhythmia
2. hypercalcemia
3. decreased excretion of uric acid

91. • Side effects ( potassium sparing diuretics)
1. Hyperkalemia
lethargy, confusion, ataxia, muscle
cramps, and cardiac arrhythmias.