Week 8 Study Guides: Cardiac Medications and Metabolic Syndrome (complete) Flashcards
Meds in Nitrates class
nitroglycerin
isosorbide
hydralazine and nitrates (combined)
How do meds work for Heart failure?
Vasodilators, loop diuretics, Beta blocks
Vasodilators- decrease workload
Loop diuretics- Decreae blood volume
Beta blocks- decrease contractions and workload
Patient education with digoxin? Any specific or key instructions?
- take at the same time every day
- take 1 hour before or 2 hours after eating
- take apical HR before taking: report to provider if less than 60
- learn signs of digoxin toxicity
(Nausea, vomiting and vision changes) - cuz when a DIGit goes up your butt you’ll get nausea vomiting and vision changes..
(pulled this from online)
Meds in class of spironolactone
- spironolactone is a mineralcorticoid receptor antagonist
– AKA aldosterone receptor blocker
What specific actions does the nurse need to take with digoxin? Labs, vitals, nursing considerations?
Antidote? Check? Monitor? Caution in?
Antidote: digibind
- always check apical HR and call MD if less than 60
- monitor BUN/Cr and potassium
- rapid onset and absorption
- caution in:
– pregnancy and lactation
– pediatric and geriatric
– renal insufficiency
Patient education with calcium channel blockers: dihydropyridines? Any specific or key instructions?
- do not drink grapefruit juice
- increase fiber in diet
- always check HR prior to taking and make sure not less than 60
Mechanism of action of thiazide diuretics
- inhibit reabsorption of sodium and chloride from the distal tubules in the kidneys
- decrease peripheral resistance
- decrease preload
- better for sodium sensitive HTN as in african americans and older adults
Mechanism of action of digoxin
- increases intracellular calcium
- allows more calcium to enter myocardial cell during depolarization
- positive ionotropic effect (increase force of contraction)
- increased renal perfusion with a diuretic effect
– decrease in renin release - slowed conduction through AV node (decrease HR)
Uses of Beta Blockers
Used in treatment for heart failure; cause decreased contraction and workload
- hypertension but not first line
- decrease risk of sudden death after MI
- all patients after MI and PCI
- HR reduction in AFib
- palpitations
- heart failure
- migraines
- performance anxiety
- hyperthyroidism
Special uses:
- metoprolol: HR and post MI
- propranolol: social anxiety, headaches
Uses for digoxin
indications: heart failure and atrial fibrillation
not first-line treatment
Explain how diet and exercise break the circle of death
modify factors to break the cycle
- exercise and diet can break the obesity and insulin resistance portion of the circle of death
Uses of Alpha Blockers
not really used in blood pressure control; considered 3rd or 4th line treatment
- “almost work too well”
Key side effects of digoxin? Any black box warnings?
Has very narrow therapeutic margin:
- normal: 0.5-2.0
- desired level: 0.8
Digoxin toxicity:
- vision changes, N/V, dizziness
- increased risk of hypokalemia
- can be life-threatening
Meds in class: Entresto (Sacubitril plus Valsartan)
Class: angiotensin receptor-neprilysin inhibitor (ARNI)
Entresto (sacubitril + valsartan) is the only ARNI
Mechanism of action of ACE inhibitors
Prevents the conversion of angiotensin 1 to angiotensin 2
- works by vasodilation and by blocking RAAS/aldosterone
- helps prevent cardiovascular remodeling
Pathophysiology:
- decrease aldosterone production
- inhibit angiotensin 2 production
- decrease vasoconstriction
- interfere with RAAS
- keep vasodilation effects of bradykinin
Key side effects of ACE inhibitors? Any black box warnings?
- generally well tolerated and absorbed
- hyperkalemia
- dizziness
-
cough (“ACE cough”)
– related to kinins and activation of arachidonic pathway and prostaglandin production
– begins 1-2 weeks of initiation; typically resolves within few days of stopping med - angioedema
BLACK BOX WARNING:
- serious fatal abnormalities: not given in pregnancy and caution in childbearing-age women
- esp in 3rd trimester
- contraception very important
Medications in loop diuretics class
- furosemide (Lasix)
- bumetanide
- torsemide
Mechanism of action of ARBs
- bind with AG-2 receptors in vascular smooth muscle and adrenal cortex to stop vasoconstriction and aldosterone production
- blocks AG-2 from binding at receptor sites in brain, kidneys, heart, periphery, and adrenal tissue
Explain how ACE inhibitors improve endothelial dysfunction
ACE inhibitors block the converting enzyme - stopping angiotensin 1 from becoming angiotensin 2
- which stops the stimulation of aldosterone secretion
– blocking the increased water and sodium retention
– blocking increased preload
- stops constriction of vascular smooth muscle
– stops increased afterload
inappropriate RAAS activation from increased angiotensin 2 causes endothelial dysfunction and vascular remodeling (and elevated BP & atherosclerosis) so inhibiting AG2 stops this
Meds in Beta Blockers class?
“-lol ending”
- carvedilol
- metoprolol
- bisoprolol
- labetalol
- atenolol
Selective Beta 1:
- metoprolol
- atenolol
- esmolol
- bisoprolol
Non selective:
- propranolol
- carvedilol
- nasolol
- sotalol
Mechanism of action of calcium channel blockers: dihydropyridines
- more vascular selection
- more of a direct effect on vasodilation and less reduction of calcium
- no effect on AV contraction; may increase HR due to vasodilation
overall patho of CCBs:
- decrease cardiac workload and myocardial O2 consumption
- inhibits movement of calcium across membranes of myocardial/arterial muscle cells
- alter action potential and block muscle cell contractions
- decrease contractility and slows AV conduction
- relax and dilate arteries
Uses of ACE inhibitors
First-line treatment for heart failure and hypertension; decrease the workload of overworked cardiac muscle
Indications:
- HTN
- HF
- DM
- post MI and PCI
Explain how metformin improves endothelial dysfunction
Online: Metformin improves endothelial dysfunction primarily by activating the AMP-activated protein kinase (AMPK) pathway, which leads to increased nitric oxide (NO) production, reduced oxidative stress, decreased inflammation, and inhibition of endothelial cell apoptosis
- thereby enhancing vascular function and protecting against damage to the endothelial lining of blood vessels.
Key side effects of spironolactone? Any black box warnings?
- can cause gynecomastia
Uses of ARBs
first-line treatment of hypertension; when ACE inhibitor cannot be used
Key side effects of Alpha Blockers? Any black box warnings?
adverse effects are significant
- first dose effect!
- orthostatic hypotension
- vertigo, syncope, dizziness
- tachycardia
- sexual dysfunction
Meds in class of calcium channel blockers: dihydropyridines
- amlodipine
- felodipine
- nifedipine
What are the characteristics of metabolic syndrome?
- hypertension
- obesity (especially apple shape; abdominal fat)
- abnormal cholesterol levels (hyperlipidemia)
- chronic inflammation
- insulin resistance
Patient education with calcium channel blockers: non-dihydropyridines? Any specific or key instructions?
- increase fiber in diet
- always check heart rate before taking and make sure not less than 60
- do not drink grapefruit juice
Key side effects of loop diuretics? Any black box warnings?
- hyponatremia
- hypokalemia
- hypovolemia
- hypomagnesemia
- hyperglycemia
- ototoxicity
Explain how HTN and metabolic syndrome lead to the development of coronary artery disease, cerebral vascular disease, and peripheral arterial disease
- LDL deposits cholesterol between layers in the artery wall
- inflammatory cells (macrophages) engulf deposited cholesterol - inflammatory resp.
– macrophages become giant foam cells
– a fatty streak develops between layers of artery wall - foam cells continue to expand the core of the plaque
– a fibrous outer cap forms from converted smooth muscle cells and other elements - large unstable plaque within thin fibrous cap and can rupture
- a blood clot (thrombus) forms at site of plaque rupture
- can lead to blockage and blocked artery starts to die
Patient education with Beta Blockers? Any specific or key instructions?
- ALWAYS check apical heart rate before taking
- NEVER stop abruptly: need to taper off
– SNS will surge and go to an extreme if stopped abruptly
Key side effects of calcium channel blockers: dihydropyridines? Any black box warnings?
- peripheral edema (common)
- headache
- flushing
- lightheadedness
- dizziness
- can have increased HR (double check. It should cause decrease)
- GI side effects
Key side effects of nitrates? Any black box warnings?
- when taking: tingles or burns under tongue
- headache
- dizziness
What specific actions does the nurse need to take with ARBs? Labs, vitals, nursing considerations?
Do not give with, monitor what
- do not give with an ACE inhibitor
- drug interactions with diltiazem, oral anti-fungals
- monitor renal function
- some drug interactions related to the cytochrome P450
- can be given with or without foods
Labs: creatinine; can increase due to possible decreased GFR; LFTs
Vitals: I&Os, BP
Mechanism of action of calcium channel blockers: non-dihydropyridines
- negative ionotropic effects (decrease force of contraction)
- slow AV conduction and rate of SA node
overall patho of CCBs:
- decrease cardiac workload and myocardial O2 consumption
- inhibits movement of calcium across membranes of myocardial/arterial muscle cells
- alter action potential and block muscle cell contractions
- decrease contractility and slows AV conduction
- relax and dilate arteries
What specific actions does the nurse need to take with calcium channel blockers: non-dihydropyridines? Labs, vitals, nursing considerations?
- always check HR prior to giving; call MD if less than 60
- be aware of conduction issues
- avoid use in those with heart failure
- avoid grapefruit juice (especially with diltiazem)
- check orthostasis
no lab monitoring
vitals: HR
Uses of thiazide diuretics
treat hypertension; first-line medication
Meds in class of ACE inhibitors
(A-pril)
end in -pril
- lisinopril
- enalapril (can be given IV)
- ramipril
- captopril
Patient education with Alpha Blockers? Any specific or key instructions?
- let them know about first dose effect and that adverse effects are significant
What specific actions does the nurse need to take for loop diuretics? Any labs, vitals, nursing considerations?
- monitor potassium level!
– monitor other electrolytes too, but potassium very important - monitor I&Os
- monitor blood sugar
What specific actions does nurse need to take with spironolactone? Labs, vitals, nursing considerations?
- monitor potassium (can cause hyperkalemia)
- monitor LFTs
- monitor BUN/Cr
- do not give in renal insufficiency
Patient education with ARBs? Any specific or key instructions?
- avoid during pregnancy
- do not take with ACE inhibitor
- can take with or without food
Mechanism of action of nitrates
Actions:
- arterial and venous dilator (potent vasodilator)
- decreases preload and afterload
- increases oxygen demand to heart; decrease myocardial oxygen demand
Pharmacokinetics:
- very rapidly absorbed
- tolerance develops easily; need drug-free period
- drug-drug interaction with Sildenafil (viagra)
Key side effects of Beta Blockers? Any black box warnings?
- hypotension
- bradycardia (why you check apical HR)
- bronchospasm (don’t want to give to COPD or asthma pt)
- exacerbation of peripheral vascular disease
- fatigue
- depression
- impotence
- sleep issues
adverse effects:
- worsening of HF especially when first started; why you need to start at low dose
Patient education with Entresto (Sacubitril plus Valsartan)? Any specific or key instructions?
- contraindicated in pregnancy
- DO NOT TAKE WITH NSAIDs (NSAIDs vasoconstrict so counteracts)
Explain how beta blockers improve endothelial dysfunction
Online: Beta-blockers, particularly newer “third-generation” ones like nebivolol and carvedilol, can improve endothelial dysfunction by enhancing the production of nitric oxide (NO) from endothelial cells, which helps relax blood vessels and improve blood flow, primarily through their antioxidant properties and by modulating the activity of the enzyme endothelial nitric oxide synthase (eNOS)
- essentially promoting better vascular function beyond just lowering heart rate and blood pressure.
Meds in ARBs class (angiotensin II receptor blockers)
end in -sartan
- losartan
- irbesartan
- valsartan
Uses of Entresto (Sacubitril plus Valsartan)
Used for systolic heart failure to improve symptoms and reduce remodeling
What specific actions does the nurse need to take with Beta Blockers? Labs, vitals, nursing considerations?
- always start at very low doses b/c can make HF worse
- always check apical heart rate and call MD if less than 60
- caution use in chronic lung disease b/c may increase risk of asthma attacks (blocks B2 receptor)
- may mask hypoglycemic episodes so monitor diabetics
- caution in those with brady arrhythmias b/c will drop HR
- check for orthostasis
- make sure patient is given medication even when NPO
- assess for side effects
Labs: glucose level especially is patient is diabetic; no other major lab concerns
Vitals: HR (check apical)
What specific actions does the nurse need to take with ACE inhibitors? Labs, vitals, nursing considerations?
Be aware of…
- be aware of renal function and potassium
- assess orthostasis
- awareness of administration to childbearing women
- NO NSAID use
- should be taken on empty stomach
Labs: potassium, BUN, Cr
Vitals: BP
Patient education with spironolactone? Any specific or key instructions?
- take with meals
- avoid taking with:
– ACE inhibitors/ARBs
– heparin
– NSAIDs
What specific actions does the nurse need to take with thiazide diuretics? Labs, vitals, nursing considerations?
- anyone with allergy to sulfa should not take
- should not be given to patients with history of gout
- avoid in renal failure
- digoxin toxicity
- may decrease effect of diabetic medications
- lithium toxicity
- give early in morning b/c urination
Check potassium, glucose, BP, HR
Uses of calcium channel blockers: non-dihydropyridines
What do they treat
- hypertension
- angina
- arrhythmias (AFib, SVT)
- migraines (verapamil)
Uses of calcium channel blockers: dihydropyridines
What do they treat
- hypertension
- angina
- rate control in AFib
- SVT
- Raynaud’s phenomenon
What specific actions does the nurse need to take with nitroglycerine? Labs, vitals, nursing considerations?
- must stay in original bottle and be protected from light
- watch BP before and after giving
- always wear gloves when administering (absorbed rapidly)
Routes (essentially every route): SL, translingual, transmucosal, OR, OR-SR, IV, topical, transdermal
What specific actions does the nurse need to take with nitrates? Labs, vitals, nursing considerations?
Very rapidly absobed
Tolerance developes easily
Must have drug free periods
**do not take with sildenafil
Key side effects of Entresto (Sacubitril plus Valsartan)? Any black box warnings?
Comno med
- angioedema
- hypotension
- hyperkalemia
- renal failure
- cough
Mechanism of action of loop diuretics
Inhibit reabsorption of sodium or chloride at the loop of Henle
- decrease workload on heart (less water in body)
- decrease pulmonary congestion
- decrease preload, stroke volume, cardiac output
Patient education with ACE inhibitors? Any specific or key instructions?
- do not give to pregnant women! do not take if pregnant, especially if in 3rd trimester
- take on an empty stomach
- no NSAID use
Key side effects of calcium channel blockers: non-dihydropyridines? Any black box warnings?
- bradycardia (can really drop)
- decreased cardiac output
- GI side effects
- should not be used in those with heart block
Meds in Alpha Blockers class
- doxazosin (cardura)
- prazosin (minipress)
Mechanism of action of Beta Blockers
Block the beta-receptors in the sympathetic nervous system, decreasing calcium flow into the myocardial cells, and causing decreased contraction and workload
- decreases catecholamine stimulation
- decreases myocardial energy demands
- reduces remodeling
blocks SNS responses
- decrease HR
- decrease BP
- decrease muscle contraction
- increase blood flow to the kidneys
- decrease renin release
Key side effects of ARBs? Any black box warnings?
angiotensin receptor blocker
- cough (less than an ACEI)
- hyperkalemia (less than ACEI)
- headaches
- dizziness and syncope
- GI complaints
- xerostomia (dry mouth)
- alopecia
What specific actions does the nurse need to take with calcium channel blockers: dihydropyridines? Labs, vitals, nursing considerations?
What is important to consider with CCBs
CA-Pines (California pine trees)
- always check HR prior to giving; call MD if less than 60
- be aware of conduction issues
- avoid use in those with heart failure
- avoid grapefruit juice
- check orthostasis
no lab monitoring
vitals: HR
Amlodipine
Felodipine
Nifedipine
Meds in class of calcium channel blockers: non-dihydropyridines
- verapamil
- diltiazem
both can be given IV
Key side effects of thiazide diuretics? Any black box warnings?
- anyone with sulfa allergy should not take
- hypokalemia
- hyperglycemia (watch w/ diabetics)
- can cause exacerbation of gout
– increases uric acid - other electrolyte imbalances (calcium)
- orthostasis
Patient education with nitrates? Any specific or key instructions?
- can 1 every 5 minutes up to 3 taken - pain continues call 911
- DO NOT take with viagra (sildenafil)
- must be sitting or lying when taking it
- keep medication in original bottle to protect from light
Patient education for loop diuretics? Any specific or key instructions?
- change position slowly due to potential orthostatic changes
- report weight gain of more than three pounds in a day
- enjoy potassium-rich foods especially because hypokalemia is a big risk (raisins are great source)
(pulled this from online)
MONITOR I & O
MONITOR POTASSIUM level
Bumentanide
furosemide
Torsemide
Uses of nitrates?
prevention and treatment of attacks of angina pectoris and heart failure
Meds in class with digoxin
Class name: digitalis glycosides
- digoxin
- deslanoside
- mitildigoxin
Explain how the “circle of death” plays into increasing blood pressure and blood sugar in metabolic syndrome
obesity and high-fat diet coupled with sedentary lifestyle cause buildup of adipose tissue, brought on by macrophages and lymphocytes, and produce low-grade chronic inflammatory state
- from obesity and inflammation, cells fail to make effective use of insulin
- blood sugar increases
- beta cells in pancreas secrete insulin
- insulin resistance: insulin is not able to reduce blood sugar
– compensatory insulin fails and person remains hyperglycemic
insulin resistance causes:
- increased catecholamines
- stimulates sodium reabsorption and increases BP
– BP can decrease with meds that improve insulin sensitivity
- endothelial dysfunction
- RAAS and SNS dysfunction
- smooth muscle proliferation -> hypertrophy and TOD
Uses of loop diuretics
Decrease blood volume, which decreases venous return and blood pressure
What specific actions does the nurse need to take with Alpha Blockers? Labs, vitals, nursing considerations?
- need to monitor patient very closely after giving first dose
- avoid use in older adults due to increased sedation and confusion
vitals: BP and HR
Meds in class of thiazide diuretics
- hydrochlorothiazide (HCTZ)
- chlorthalidone
Mechanism of action of spironolactone
blocks the exchange of sodium for potassium in the distal tubules
- potassium sparing
Patient education with thiazide diuretics? Any specific or key instructions? (Lifestyle type of recommendations)
- adherence!
- watch diet, exercise
- decrease alcohol, stop smoking
- avoid NSAIDs which increase BP
Mechanism of Action of Alpha Blockers
- inhibit alpha synapse at the alpha adrenergic receptors (blocks SNS)
- prevent feedback of norepinephrine
What specific actions does the nurse need to take with Entresto (Sacubitril plus Valsartan)? Labs, vitals, nursing considerations?
idk?
monitor potassium, BUN, Cr, BP
Mechanism of action of Entresto (Sacubitril plus Valsartan)
Increase:
- naturetic peptides (like BNP)
- bradykinin (vasodilation)
- other mediators which increase vasodilation
Uses of spironolactone
Indications: hypertension and heart failure
- used when one drug is not enough to treat symptoms
Cardiac output
Stroke Volume X HR
Normally, 4-8L /min
Stroke Volume
Cannot directly meausre so we measure cardiac output via: preload, afterload, and contractility
Preload
At the end of diastole, or when L ventricle is filled/ mitral valve closed.
More stretching = more blood which is good. But excessive stretching can lead to heart failure
Preload = stretching
Normal ejection fraction
55-70%
anything below 40% is abnormal
Meds to check for apical HR
Beta blockers: Carvedilol, metoprolol, bisopropolol
DIGOXIN
Calcium channel blockers
