Drugs Affecting the Cardiovascular System Flashcards by Kelsey Klipfel

Heart does not adequately pump blood (systolic) or fill with blood (diastolic)
Preload / Afterload / Contractility - meds target diff aspects of heart

Review patho: HF

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Inability/heart unable to meet metabolic (oxygen) demands of the body - not able push blood through body well enough
Right ventricular failure, left ventricular failure, congestive failure

Heart does not adequately pump blood (systolic) or fill with blood (diastolic)

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Increased preload (blood volume heart receives) causes increased workload on heart
Increased afterload (big thing is PVR) increases workload on heart
Heart enlarges (with HF), but weakens, resulting in poor contraction (contractility - strength heart with each beat)

Preload / Afterload / Contractility - meds target diff aspects of heart

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Reduce preload: Furosemide (diuretic), lisinopril

Increased preload (blood volume heart receives) causes increased workload on heart

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Reduce afterload (vascular resistance): metoprolol, lisinopril

Increased afterload (big thing is PVR) increases workload on heart

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Increase contractility: digoxin (Lanoxin)

Heart enlarges (with HF), but weakens, resulting in poor contraction (contractility - strength heart with each beat)

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Increases force of contraction, increasing cardiac output and renal perfusion; slows HR (end goal: slower but more powerful heart - each beat heart is stronger)

MoA: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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treat Heart failure

Indication: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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oral, IV (IV push over at least 5 minutes with tele monitor - risk for bradycardia); IV: higher risk for AE

Routes: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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Amiodarone and other antidysrhythmic drugs

Drug-drug: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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heart block (bradycardia and digoxin can cause bradycardia which why not want give if HR already slow), decreased renal function

Caution: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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GI effects, visual disturbances (green/yellow halo), arrhythmias (bradycardia)

AE: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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take apical pulse 1 full min prior to admin. (adequate HR to admin) Hold if HR less than 60 –notify provider - diff bradycardias and have HF and perfusion and BP goes way down - adequately count HR before given; use same brand consistently- diff brands have varied bioavailability (amt drug avaiable work in bloodstream); Toxicity rare but serious – monitor blood levels q 3 months, narrow therapeutic range

Nursing: - Cardiac glycoside: prototype: digoxin (Lanoxin)

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Pretty rare
Manifestations:
Reversal agent:

Digoxin toxicity

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Bradycardia - apparent
Headache
Dizziness
Confusion
Nausea/vomiting
Visual disturbances

Manifestations:- Digoxin toxicity

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Digoxin immune fab (creates antigen-antibody immunes complexes with drug – inactivates the drug)

Reversal agent:- Digoxin toxicity

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Atherosclerosis narrows coronary arteries: Stable and unstable plaques
Plaque rupture: Decreased blood flow; Decreased oxygen to cardiac tissue
Myocardial infarction: Tissue death

Coronary Artery Disease (CAD)

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Chest pain with exertion
Increased O2 demand of heart
Relieved with rest and nitroglycerin

Stable angina

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Chest pain at rest
Unrelieved with nitroglycerin
Possible myocardial infarction

Unstable angina

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Relaxes vascular smooth muscle; dilates coronary arteries to increase blood flow to myocardial tissue - restores blood flow and O2

MoA: - Antianginal Agents: Prototype: nitroglycerin (Nitrostat)

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Acute angina - given if experiencing angina; relief for angina; restores blood flow to heart tissue; short term solution to MI

Indication: - Antianginal Agents: Prototype: nitroglycerin (Nitrostat)

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Sublingual tablet (works quickly to resolve prob and restore flow; bypass first pass effect so directly into system and acts quickly) q 5 min up to 3 doses; onset: 1-3 min; dur.: 30-60 min

Route: - Antianginal Agents: Prototype: nitroglycerin (Nitrostat)

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erectile dysfunction meds in last 24 hrs (sildenafil/Viagra - causes hypotension - taking together causes unsafe drop in BP)

Caution: - Antianginal Agents: Prototype: nitroglycerin (Nitrostat)

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hypotension (relaxes vessels all over body; sig), headache, lightheaded and experience dizziness, tachycardia, sweating

Adverse effects: - Antianginal Agents: Prototype: nitroglycerin (Nitrostat)

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May administer 1 dose every 5 minutes up to 3 doses - imp keep track time; give enough time work before give extra doses If no relief after 2nd dose after 5 min, assume MI/cardiac event and call rapid response team and decide where to go Monitor blood pressure after administration - check BP 3-5 min later; if trend low can deviate and difference in what do; hypotensive increased risk for falls take additional actions High fall risk - may need lay them down; vasodilation

Nursing actions in acute care - Nitro: nursing and teaching

Administration as above (after 2nd dose call 911): May administer 1 dose every 5 minutes up to 3 doses - keep track time; enough time work before give extra doses; If no relief after 2nd dose after 5 min, assume MI/cardiac event and call 911 Med must be stored in a dry, dark place – exposed to sunlight decompose and alter med - keep in dark glass container; need med to work when need it Refill medication when it is near expiration/expires

Teaching - Nitro: nursing and teaching

The nurse would instruct a client taking digoxin to do which of the following? A.Make up a missed dose the next day B.Report changes in heart rate C.Avoid exposure to the sun D.Switch to another brand if less expensive

Answer: B Rationale: Digoxin can cause arrhythmias (bradycardia)

The nurse is preparing to administer digoxin to a client with an apical pulse of 48 beats per minute. What action should the nurse take next? A.Give the drug and notify the primary care provider that the heart rate is low. B.Retake the pulse in 15 minutes and give the drug if the heart rate is unchanged. C.Retake the pulse in 1 hour and hold the drug if the heart rate is unchanged. D.Hold the drug and notify the primary care provider that the heart rate is below 60 beats per minute.

Answer: D Rationale: The best action is to hold the dose and notify the provider. Digoxin cannot be safely given to a patient who is bradycardic.

What is the mechanism of action of nitroglycerin? A.Increase preload on the heart. B. Increase the afterload on the heart. C. Dilate coronary arteries. D. Decrease fluid volume.

Answer: C Rationale: Nitroglycerin dilates the coronary arteries to increase blood flow and therefore oxygenation to tissues.

Changes to automaticity or conductivity of heart cells: Change in HR Uncoordinated heart muscle contractions Altered movement of impulses Atrial fibrillation Tachycardias

Review patho: arrhythmias

Dyssynchronous firing of atria Uncoordinated with ventricles Most common arrhythmia Acute and chronic Slow HR: Metoprolol, diltiazem, amiodarone

Atrial fibrillation

Ventricular fibrillation Ventricular tachycardia Medical emergencies Controls V arrhythmia- Lidocaine

Tachycardias

Delineate into classes Antiarrythmic drug Class I: Na channel blockers Class II: beta-adrenergic blockers Class III: K channel blockers Class IV: Ca channel blockers

Antidysrhythmic drugs

IV Lidocaine Life-threatening ventricular arrhythmias during MI/cardiac surgery

Class I: Na channel blockers

Metoprolol afib/flutter Suprventricular and ventricular dysrhythmia HTN

Class II: beta-adrenergic blockers

Amiodarone afib/flutter vtach/fib

Class III: K channel blockers

Diltiazem Supraventricular tachycardias afib/flutter HTN

Class IV: Ca channel blockers

Altering action potentials: All have potential adverse effects: Drug-drug: Contraindications:

Antidysrhythmic drugs: gen considerations

Bradycardia, heart blocks, arrhythmias, and hypotension (all can cause low HR, slow down HR lower BP at same time because decreasing CO) Probs at Greater risk with IV administration With IV: need be on Tele monitor (monitor rhythm closely), closely monitor BP (arterial line/cuff and check BP frequently)

Altering action potentials: All have potential adverse effects:

Two Antidysrhythmic drugs together (dangerous - sig increased risk of bradycardia), antihypertensives (lower HR and on these sig impact CO which lowers and on this lowers BP so can get too low BP)

Drug-drug:

Bradycardia (potentially lower HR), hypotension (potentially lower BP), heart block (lack of cardiac conduction somewhere in part cardiac tissue; diff grades and some more severe than others; type of bradycardia) - not give if already have low BP/HR because would drop them more

Contraindications:

Treatment of life-threatening ventricular arrhythmias during MI or cardiac surgery; small use for IV

Indication: - Sodium Channel Blockers: Prototype: Lidocaine

IV (topical lidocaine low risk systemic) - dangerous drug; POTENT

Routes: - Sodium Channel Blockers: Prototype: Lidocaine

IV-immediate; Peak: IV-Immediate; Duration: IV-20 min

Onset: - Sodium Channel Blockers: Prototype: Lidocaine

Dizziness, headache, cardiac arrest, respiratory depression, anaphylaxis

AE: - Sodium Channel Blockers: Prototype: Lidocaine

Have resuscitation equipment available potentially cause cardiac arrest - sig bradycardia

Nursing: - Sodium Channel Blockers: Prototype: Lidocaine

Blocks potassium channels, delays repolarization; slows HR

MoA: - Potassium Channel Blockers: Prototype: Amiodarone

v-tachycardia and v-fibrillation - lifethreatening - given IV push and ACLS; chronic Atrial fib or flutter; used in variety ways

Indications: - Potassium Channel Blockers: Prototype: Amiodarone

Maintenance for chronic afib: oral scheduled - goal: HR less than 110 - too high lose CO; Acute: treat vtach/fib/afib with RVR (infusion; can give loading dose) - loading dose then switched over when appropriate: IV push/infusion/drip on tele floors/ICU/ER/ACLS (adv care life support)

Dose: - Potassium Channel Blockers: Prototype: Amiodarone

Increase digoxin levels (up to 50-70% - issue since has narrow therapeutic window - toxic on med); decreases metabolism of warfarin requiring lower doses - more left in bloodstream so higher risk for bleeding (up to 50% increase in INR); if taken with this drug decreases doses of either drug by 50%

Drug-Drug: - Potassium Channel Blockers: Prototype: Amiodarone

GI effects (n/v/d), corneal microdeposits (photophobia, visual halos, dry eyes) - long term: higher risk to develop, fatigue, dizziness, photosensitivity; highly lipophilic drug: VERY attracted fat tissues

AE: - Potassium Channel Blockers: Prototype: Amiodarone

Hepatotoxicity, pulmonary toxicity, pro-arrhythmias

Black box: - Potassium Channel Blockers: Prototype: Amiodarone

Teach - no grapefruit juice (liver enzyme interaction and not metabolize so more in bloodstream), use barrier sunblock (photosensitivity - barrier sunblocks; avoid sun); tele monitoring (if getting IV - closely monitor rhythm), monitor electrolytes

Nursing: - Potassium Channel Blockers: Prototype: Amiodarone

A client who is taking an antiarrhythmic drug will need which of the following? A.Constant cardiac monitoring until stabilized. B.Frequent blood tests including blood levels. C.An antidepressant to combat the adverse effect of depression. D.Dietary changes to prevent irritation of the heart muscle.

Answer: A Rationale: If a patient is unstable, they will likely need an IV antidysrhythmic medication which requires cardiac monitoring.

Decrease PVR Normal blood pressure = CO + SVR (aka PVR) Decrease blood volume

HTN

Beta-blockers (SNS) Calcium-channel blockers Direct vasodilators ACE-Inhibitors ARB’s

Decrease PVR

ACE-Inhibitors ARB’s Diuretics

Decrease blood volume

Lisinopril: ACE inhibitor; inhibiting ACE being able convert angiotensin I to angiotensin II - blocking part cascade of RAAS - cannot have vasoconstriction/aldosterone release Losartan: angiotensin receptor blocker; blocks receptor sites for angiotensin II - cannot exert actions Blocking RAAS: end up with not vasoconstrict as well (decreases PVR) and not release as much aldosterone and then reabsorb less Na and H2O decreasing blood volume

Review BP/RAAS

Uncontrolled hypertension can cause which of the following problems? Select all that apply. A.Loss of vision B.Stroke C.Acceleration of atherosclerosis D.Kidney disease E.Diabetes mellitus type 2

Answer: A, B, C, D Rationale: Uncontrolled hypertension can accelerate atherosclerosis and cardiovascular disease. Diabetes can contribute to worsening hypertension, but it is hypertension does not cause diabetes.

Angiotensin converting enzyme (ACE) inhibitor Angiotensin receptor blocker (ARB) Calcium-channel blocker Vasodilator Thiazide diuretics

Antihypertensive drugs (all treat HTN)

-pril Blocks ACE, the enzyme responsible for converting angiotensin I to angiotensin II in the lungs; prevents vasoconstriction and aldosterone release (RAAS)

Angiotensin converting enzyme (ACE) inhibitor

-sartan Blocks binding to specific receptors in the blood vessels and adrenal gland; prevents vasoconstriction and aldosterone release (RAAS)

Angiotensin receptor blocker (ARB)

Diltiazem (Cardizem); Amlodipine -pine Inhibit the movement of Ca ions across the membranes of myocardial and arterial muscle cells blocking muscle cell contraction - slow down HR and BP - antiarrhythmic/antihypertensive; decrease BP, cardiac workload, and myocardial O2 consumption

Calcium-channel blocker

Nitroprusside; Hydralazine Act directly on vascular smooth muscle to cause relaxation

Vasodilator

-thiazide Increase Na and water excretion from the kidney; first line treatment for HTN; get rid more blood volume via water decreasing BP

Thiazide diuretics

-olol Block vasoconstriction, decrease HR, decrease cardiac muscle contraction, increase blood flow to the kidneys (block beta 1 and beta 2 receptors - activated affect BP; normal action increase HR and BP) - block less vasoconstriction and slower HR

Beta adrenergic blocker - Antihypertensive drugs: adrenergic blocking agents

Take BP prior to admin! (all can cause hypotension - primary AE - given too much; need know where start) If dosed once daily, give in the AM - BP much higher in day when doing things than HS - most help to control BP, esp for diuretic Do not abruptly discontinue (esp. Beta adrenergic blocking agents) IV push medications PRN medications require evaluation

Administration Considerations for Antihypertensive Drugs (Acute Care)

Do NOT split, crush or chew extended-release tablets (ER, XL)

If dosed once daily, give in the AM - BP much higher in day when doing things than HS - most help to control BP, esp for diuretic

Once taken away body goes into overdrive Risk for reflex HTN - can get really high BP

Do not abruptly discontinue (esp. Beta adrenergic blocking agents)

Administer over a minimum of 2 minutes - not want too quick to drop BP; Telemetry monitor: some can affect HR and BP

IV push medications

IVP: recheck BP in 5-10 min to make sure coming down way want PO: recheck BP in 1 hour

PRN medications require evaluation

Blocks ACE, the enzyme responsible for converting angiotensin I to angiotensin II in the lungs; decreases vascular resistance, prevents aldosterone secretion, prevents breakdown of bradykinin (potent vasoconstrictor)

MoA: - ACE-Inhibitor: Prototype: lisinopril

ACE-inhibitors, ARB’s, K+ sparing-diuretics, NSAIDs (toxic to kidneys)

Contra/Caution: - ACE-Inhibitor: Prototype: lisinopril

Common-Persistent dry cough (annoying and decrease compliance if cont have it), orthostatic hypotension, hyperkalemia; Rare-angioedema

AE: - ACE-Inhibitor: Prototype: lisinopril

monitor K+ (increase K levels), renal function - toxic to kidneys overtime

Nursing: - ACE-Inhibitor: Prototype: lisinopril

A = Angioedema C = Cough E = Elevated potassium

ACE acronym for AE (of ACE-I)

Blocks binding of angiotensin II to specific receptors in blood vessels and adrenal gland; used as alternate to ACE-inhibitors

MoA: - Angiotensin-receptor blocker (ARB): Prototype: losartan (Cozaar)

ACE-inhibitors, ARB’s, K+ sparing-diuretics, NSAIDs (toxic to kidneys)

Contra/Cautions: - Angiotensin-receptor blocker (ARB): Prototype: losartan (Cozaar)

GI effects (n/v/d)

AE: - Angiotensin-receptor blocker (ARB): Prototype: losartan (Cozaar)

Act directly on vascular smooth muscle (venous and arterial) to cause relaxation/vasodilation; persistent HTN hard treat

MoA: - Direct Vasodilator: Prototype: nitroprusside (Nitropress)

Maintenance: oral or transdermal; Acute HTN crisis: IV push

Route: - Direct Vasodilator: Prototype: nitroprusside (Nitropress)

PVD (veins already dilated), CAD, HF (more sig hypotension and not adequately perfuse because low CO), tachycardia, hypotension

Caution: - Direct Vasodilator: Prototype: nitroprusside (Nitropress)

Hypotension (sig vasodilation), reflex tachycardia, bradycardia - cardiac monitor if IV

AE: - Direct Vasodilator: Prototype: nitroprusside (Nitropress)

Inhibits flow of calcium ions into myocardial cells and vascular smooth muscle; slows HR, lowers BP

MoA: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

HTN, A-fib, A-flutter, supraventricular tachycardias

Indication: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

Maintenance (afib and HTN): oral ; acute (afib with RVR): IV infusion

Route: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

hypotension, acute MI, pulmonary congestion

Caution: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

Hypotension, bradycardia/heart block, peripheral edema - must monitor for; deals with relaxation of arteries and not change pressure of veins - fluid pushed out into peripheral tissues

AE: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

teach- avoid grapefruit juice (increases levels)

Nursing: - Calcium-channel blocker: Prototype: diltiazem (Cardizem)

Block beta-1 and beta-2 receptors of the SNS; slows HR and lowers BP

MoA: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

HTN, Heart failure, s/p MI, A-fib/flutter, angina

Indications: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

Maintenance (afib/HTN): oral; acute HTN or dysrhythmias: IV push

Route: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

Beta-agonist inhaler (albuterol) - opposing MoA: trouble is albuterol less effective because metoprolol blocking receptors for albuterol

Drug-drug: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

bradycardia, hypotension, masks signs of hypoglycemia - blocking SNS sites when tries activate cannot since blocking receptors so not same s/s so monitor BG closely

Contra/Cautions: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

Bradycardia, hypotension, bronchospasm, pulmonary edema, weakness - blocking SNS, fatigue - blocking SNS, decreased exercise tolerance - good job keeping HR low so not exercise high level because keeps HR down, alterations in blood glucose

Adverse effects: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

monitor hypoglycemia closely in diabetes mellitus - masking s/s; immediate and extended release (XL, XR) prescribed

Nursing: - Beta Adrenergic Blocker: Prototype: metoprolol (Toprol)

Physical assessment with focus CV (#1 priority), respiratory, and neuro assessments Labs: electrolytes (not in an imbalance), kidney, and liver function - track to ensure kidney func not worsening which happens with HTN Assess cardiac rhythm (if on tele monitor - not induced secondary rhythm and in correct rhythm) Best prac: Always assess HR and BP prior to administration in acute care since work together Blood pressure parameters (general): Heart rate parameters (general):

Care Plan for Antiarrhythmic and Antihypertensive Drugs: Assessment

Will be Hold parameters

Best prac: Always assess HR and BP prior to administration in acute care since work together

High: Greater than 180 SBP and/or 110 DBP >>> Call MD - may need additional BP meds Low: Less than 90 SBP and/or 60 DBP >>> Hold and call MD

Blood pressure parameters (general):

Hold if HR < 60 bpm

Heart rate parameters (general):

Monitor cardiac rhythm closely with admin of IV antiarrhythmic agent If appropriate Consult prescriber to switch from IV to oral if indicated ASAP - risk bradycardia and other AE much more likely - lot safer for pat Educate client:

Nursing Care Plan: Antiarrhythmic Interventions

Ensure emergency life support equipment readily available

Monitor cardiac rhythm closely with admin of IV antiarrhythmic agent

Medication: dosing, timing, drug specific AE Do not abruptly discontinue medication (pt will take scheduled) - risk developing comps NEED TO DO THIS: How to assess pulse, blood pressure and s/s bradycardia and hypotension (fatigue, lightheadness, syncope, frequent falling) Need for follow-up and monitoring Periodically assess cardiac rhythm with oral agents (yearly as baseline to see how doing) - probs - do more often or go home on monitor

Educate client:

Monitor for any situation which may lead to decreased fluid volume - much more hydrated when hot out - decreased fluid volume and risk hypotension; adequately hydrated all time and alert for any changes in fluid volume Reduce risk for falls (risk for orthostatic hypotension) Consult with prescriber to switch from IV to oral if indicated - minimize risk hypotension Educate client:

Nursing Care Plan: Antihypertensive Interventions

Lifestyle change - HTN - lower BP outside meds: weight loss, smoking cessation, decreased alcohol/salt intake Medication: dosing, timing, drug specific AE Do not abruptly discontinue (pt will take scheduled) - reflex HTN NEED TO DO THIS: How to assess pulse, blood pressure and s/s bradycardia or hypotension Educated on any Need for follow-up and monitoring: seen more often until stable

Educate client:

Therapeutic response (depends on indication/MoA) Adverse effects Teaching (was it effective?)

Care Plan for Antiarrhythmic and Antihypertensive Drugs: Evaluation

BP goal for most clients: SBP < 140 mm Hg, DBP < 90 mm Hg: Multiple antihypertensives may be needed to achieve target goal HR goal for A-fib: < 110 bpm = COMMON: Caution: drug-drug interaction multiple meds that slow HR

Therapeutic response (depends on indication/MoA)

Bradycardia (Antiarrhythmic), hypotension (Antihypertensive), drug specific

Adverse effects

Safety and efficacy of meds not widely studied; most not need these meds; afib and HTN later in life because not taking very much

Children - Drug therapy across the lifespan: cardiac drugs

Consider drug-drug interactions, co-morbidities; appropriate education

Adults - Drug therapy across the lifespan: cardiac drugs

Many meds are Pregnancy Category D; consider risk vs. benefit

Pregnancy- Drug therapy across the lifespan: cardiac drugs

More susceptible to AE of hypotension, bradycardia, toxic effects due to underlying disease that may interfere with metabolism and excretion High fall risk - implement fall precautions Monitor closely

Older Adults- Drug therapy across the lifespan: cardiac drugs