Lecture 12 Circulation

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Lecture 12 Circulation

• Antianginals
• Antihypertensives
• Anticoagulants

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Angina Pectoris

• Chest pain
• Lack of oxygen (ischemia) to heart muscle

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Coronary Arteries
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3 Types of Angina

• Stable- assoc. Coronary atherosclorisis
• Unstable- progressive
• Vasospastic- Prinzmetal or variant

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Preload Afterload
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Goal of TreatmentReducing Preload Afterload
Decrease Preload by Dilating Veins and
Decreasing blood return
Reduce Afterload by Dilating arteries
and Decreasing peripheral vascular resistance
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Antianginal Agents

• Decrease heart rate
• Decrease preload
• Decreased afterload
• decrease hearts contractility
• All in effort to dec. oxygen demand or
• Increase blood supply to cardiac muscle (or both)

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Nitrates- Nitroglycerin (Nitrobid, Nitrostat)

• SL- rapid absorption (for acute attack)
• PO- 50 absorbed (prophylactic)
• Transdermal patch or paste- slow absorption
  (prophylactic)
• IV- immediate action for acute attack

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Action

• relax vascular smooth muscle
• dilates coronary arteries
• reduces cardiac workload
• reduces myocardial demand for oxygen
• reduces or relieves chest pain

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Therapeutic Uses

• Immediate relief of angina (acute attack)
• Prevention of angina before exercise
  (anticipated attack)
• Long Term prevention (chronic angina)

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Drug Interactions

• Other Antianginals
• Antihypertensives
• Vasodilators
• ETOH

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Adverse Reactions

• Vasodilatation-HA, dizziness, flushing, syncope
• Postural hypotension
• Tachycardia
• Topical- skin rash, dermatitis, staining clothes

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Nursing Implications

• Do not use if angina due to enlarged heart
• Do not use with ICP or head trauma
• use caution w/ dehydration, diuretics, vascular
  depletion
• First dose pt sit or lie, check P BP a p

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Nursing Implications

• SL keep in air tight, light resistant bottle,
  replace q6 mon. (DO NOT swallow SL tab)
• Topical- remove old med and clean area
• May repeat SL q 5 min (up to 3 tabs) if no relief
  to ER
• Do not abruptly DC med (vasospasms)- consult MD

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Beta Adrenergic Blockers (Antianginals)

• Inderal (Propranolol)
• Not for acute attacks
• PO - 30 min. onset
• Used for long term prevention

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Action

• reduce BP
• blocks beta receptor site in cardiac muscle
• reduces HR
• reduces force of contractions
• reduces oxygen needs

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Drug Interactions

• Additive effect with Digoxin (reduced HR )
• Additive effect with Antihypertensive (low BP)
• Antiarrythmias
• Phenothiazines
• Aminophyline- opposite effect (antagonist)
• Cimetidine inhibits metabolism of Inderal

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Adverse Reactions

• Related to Cardiovascular system
• Low HR, low BP
• Angina, syncope
• CNS- dizzy, fatigue, confusion
• depression, insomnia
• Bronchoconstriction spasms
• Hypoglycemia- especially in diabetics

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Nursing Implications

• Not in pt w/ asthma, heart block, shock
• Caution in diabetes, CHF, COPD
• Hold if P lt60/min or systolic BP lt90 mmHg
• Teach pt to take at same time q day
• Do not DC abruptly (taper off to avoid HTN,
  angina, dysrhythmia or MI)

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Calcium Channel Blockers - Procardia (nifedipine)

• Used for prevention of angina (esp. if not
  responsive to other Rx)
• SL absorbed quickly (lowers BP)
• PO goes through first liver by-pass
• 90 protein bound

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Action

• blocks Calcium ion flow in myocardial muscles
  pacemaker
• decreases contractility
• decreases oxygen needs
• Acts at vascular smooth muscle
• decreased afterload oxygen needs by dec. HR
• Increases oxygen to heart by dilating coronary
  arteries

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Therapeutic Use

• Long term prevention of angina
• Not for acute attack
• Especially helpful in spasm type (Prinzmetal)

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Drug Interactions

• Beta Adrenergic blockers heart block, CHF
• Displaces protein bound Digoxin
• high protein bound drugs- increased effect of Rx
• Enhanced effect of Antihypertensives (lower BP)

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Adverse Reactions

• cardiovascular common serious
• low BP, slow P, sinus block
• worsening CHF, dizziness, flush, weak
• GI- N/V/D, muscle fatigue, cramps
• Worsening of angina
• Photosensitivity, Pruitus
• Nasal congestion, Mood changes

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Nursing Implications

• Caution in pt w/ low BP, CHF, sick sinus
• Caution in pt w/ renal or hepatic impairment
• Hold dose call MD if P , lt60/min or
• systolic BP lt 90 mm Hg

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Hypertension

• BP gt 140/90 on 3 separate readings
• Silent killer- no symptoms causes damage to vital
  organs
• heart, brain, kidney, eyes
• Primary- unknown cause
• Secondary- specific disease process
  (hyperthyroidism)

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Types of HTN

• Normal Less than 80 diastolic and 120 systolic
• Prehypertensive 80-89 diastolic and/or 120-139
  systolic
• Hypertension __ /90-99 no symptoms (or
  140-159SBP) Tx low Na, reduce Wt., Dc
  smoking
• ________ /gt100 few symptoms (or gt 160)
• Tx diuretics anti HTN
• _______ /gt115 symptomatic damage kidney, eyes
• Tx 3rd 4th step anti-HTN agent
• HTN crisis Malignant HTN ____/ 130-170 medical
  Emergency

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Step Approach Advised by American Heart Assoc.
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Sympatholytics

• Catapress (clonidine)-inhibits sympathetic
  transmitter outflow
• Aldomet (Methyldopa)- displaces norepinephrine
• Inhibit stimulation of sympathetic nervous system
• Decreases BP by peripheral vasodilatation
• Decreased Cardiac Output

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Therapeutic Uses

• Step 2 agent to control HTN
• Used in mild HTN
• Combined with Step 3 or 4 agents in severe HTN

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Drug Interactions

• With many drugs in this class (antiHTN)
• Beta Blockers- cause Hi BP (paradoxical response)
• Haldol (increases disorientation w/ Aldomet)
• Norepinephrine catecholamines- prolong presser
  response)

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Adverse Reactions

• Clonidine- anticholinergic effects, drowsy
• dry mouth, constipation, orhostatic hypotension,
  rebound HTN if Dc abruptly
• Methyldopa - sedation, dec. alertness, depression
• dry mouth, dark urine, sexual dysfunction, anemia

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Nursing Implications

• Teach pt about side effects
• Take at night to dec. drowsiness
• Check BP before, hold if SBP lt110 call MD
• Check CBC with long term therapy
• Use caution if pt has coronary insufficiency,
  recent MI, CVA, RF
• Mouth care, cool drinks, gum
• Do not stop abruptly (rebound BP, inc P,
  salivation)

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Vasodilating Agents

• Direct vasodilatation- Apresoline (hydralazine)
• Acts directly on arteries / or veins to relax
  peripheral smooth muscle
• Reduces BP and decreases peripheral vascular
  resistance
• Used as Step 3 Drug given w/ Diuretic or Beta
  Blocker
• Tx Malignant HTN w/ renal insufficiency or CHF
• or HTN crisis (IM or IV)

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Drug Interactions

• Additive Effect with other Anti HTN
• Additive effect with Nitrates
• Ca Channel Blocker
• Beta BLockers

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Adverse Reactions

• Cardiovascular Effects palpations, angina
• tachycardia, orthostatic hypotension
• GI effects- N/V, anorexia
• Lupus syndrome- joint pain, fever, rash
• Sodium and Fluid retention

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Nursing Implications

• Do not use in pt w/ Lupus, angina, recent MI
• Use cautiously in pt w/ liver dysfunction
• Take with meals to help absorption
• Teach pt to check for edema, signs of Lupus
• Test for Lupus w/ LE prep test regularly
• Warn pt to rise slowly
• I O, Daily Wt.

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Vasodilating Agents- Ca Channel Blockers

• cardiazem (diltiazem)
• Amlodipine (Norvasc)
• Vasodilates by preventing binding of Ca to its
  receptors
• prevents contraction of smooth muscles around
  vessels
• dilates vessels to reduce BP
• Used as Step 2 or 3 agent for moderate - severe
  HTN
• Drug interaction- Rx that affect hepatic
  microsomal system
• Beta Blockers-severe bradycardia

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Adverse Reactions

• Most serious Low BP and Slow P
• flushing, HA, edema
• sleepy, tremors, insomnia
• Nausea, rashes
• Increased liver enzymes

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Nursing Implications

• Not in pt w/ 2nd or 3rd degree Heart Block
• or impaired renal function
• Caution in pt w/ impaired hepatic function
• Assess for orthostatic hypotension, edema
• Teach to take own BP
• Inform may not feel well with Rx
• Do not stop abruptly, call MD for side effects

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Angiotensin-Antagonist Agents

• ACE angiotensin converting enzyme inhibitors
• Capoten (captopril)
• Vasotec (enalapril)
• Interrupts renin-angiotension-aldosterone system
• Inhibits enzyme action that converts Angiotension
  I to II
• Also prevents Na and Fluid retention

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Therapeutic uses

• Pt who fails to respond to other anti-HTN
• Step 4 (capoten)
• Step 12 (vasotec)
• Mild - Moderate HTN
• Renal insufficiency

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Drug Interactions

• Enhanced effect with diuretics
• Other anti-HTN
• Especially Beta Blockers

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Adverse Reactions

• Wide range from mild to severe
• cough
• Proteinuria, skin rash
• Low BP, tachycardia
• Loss of taste sensation
• GI distress
• Renal failure, neutropenia (capoten)

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Nursing Implications

• Assess for Hx of decreased renal function, low
  WBC
• More effective w/ diuretic
• Use w/ caution in pt w/ Lupus, renal disease, Hi
  K
• elderly, recent MI, cardiovascular disease
• Question pt re. before during Tx orthostatic
  changes
• Monitor WBC, proteinuria, liver kidney
  function, K

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Angiotension II Receptor Antagonist (A2RB)

• Selectively antagonizes Angiotension 2 receptor
  sites so they can not cause vasoconstriction
• Losartan (Cozaar)
• Valsartan (Diovan)
• Side effects- dizziness, fatigue
• Nursing care- Check BP, renal function
• Usually does not cause cough like ACE inhibitors

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Thrombus/Embolus

• Venous status clots (DVT)
• Damage to vein thrombin adheres to area
  thrombus
• Part of clot breaks off embolus
• Body has natural heparin to dissolve clot

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Anticoagulant Agents - Parenteral

• Heparin - prevents clot from enlarging
• Lovenox- (enoxaparin) Low Molecular Weight
  Heparin
• Inactivates thrombin, inhibits coagulation
• Decreases platelet adhesiveness
• Given SQ for prevention of clots
• IV bolus continuous drip for Tx of clot

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Therapeutic Uses

• Prevention or treatment of thromboembolisms r/t
• Cardiac or Vascular surgery, Acute MI
• Atrial Fibrillation
• Prostate or Orthopedic surgery
• Prolonged bedrest

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Drug Interactions

• Oral anticoagulants synergistic effect (blood
  thinner)
• Antiplatelet Rx (ASA) additive effect
• Oral contraceptives antagonistic effect
• Antihistamines, nicotine phenothiazines, PCN
• Very acidic - Do not mix in IV with other Rx,
  ONLY NS

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Adverse Reactions

• Bleeding- urine, stool, GI tract, brain
• thrombocytopenia
• hair loss
• osteoporosis (spontaneous Fx)
• Antidote is Protamine Sulfate

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Lab Tests to Monitor

• APTT or PTT (activated or partial thromoplastin
  time)
• Therapeutic range 1 1/2 to 2 1/2 times control
• Call MD if PTT gt 3 x control
• platelet count (lowered)
• Hct Hgb drops (indicates bleeding)

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Heparin
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Nursing Implications

• Do not use if actively bleeding, bleeding
  disorder
• ETOH ism, GI ulcer, spinal or eye surgery,
  pregnant
• Use w/ caution in hepatic or renal disease,
  elderly
• Assess for bleeding- gums, nose, urine, stool,
  emesis, wounds
• Avoid IM injections, use soft toothbrush, no ASA,
  no rectal temps
• SQ injections - use TB syringe, 1/2, 27g
  Administer in abdomen gt 2 from umbilicus, do not
  aspirate or rub

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Nursing Implications Cont

• Use infusion pump for IV
• Protect pt from injury (pad rails)
• Prescribed in units (not milligrams)
• Teach pt home care- sx of bleeding, need for
  testing
• Do not use straight edge razor

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Oral Anticoagulants - Coumadin (Warfarin)

• 99 protein bound
• Onset 24-72 hr Duration 2-5 days
• Indirectly interferes w/blood clotting by
  depressing hepatic synthesis of Vit K
• Vitamin K antagonist
• Prevents clot formation
• Limits growth of existing clot

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Therapeutic Uses

• Often in conjunction with Heparin (quicker
  acting)
• Long term anticoagulation
• DVT or prophylactic
• Heart valve replacement
• Chronic Atrial Fibrillation

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Drug Interactions

• Many drugs can interact and cause Serious side
  effects
• Especially highly protein bound drugs
• dilantin, Lasix, barbiturates
• ASA, Heparin, NSAIDs additive effect (thinner
  blood)
• Foods high in Vitamin K will increase clotting
• ETOH will increase bleeding

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Adverse Reactions

• Bleeding complications
• Range form minor to severe
• Treatment of reaction range from
• DC Coumadin, po, IM, IV Vit K to transfusion of
  plasma or blood
• Rare- anorexia, itching, hair loss

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Lab Test to Follow

• PT - Protime (Prothrombin) or INR (international
  normalizing ratio)
• Therapeutic range 1.2 to 1.5 times control of PT
• or INR values 2-3 times control
• Call MD if gt 2 times control on PT or
• INR value gt 4 times control

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Coumadin
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Nursing Implications

• Do not use if active or past GI bleed,
  thrombocytopenia, Malignant HTN
• recent neuro or eye surgery, ETOHism, kidney or
  liver disease, pregnant, lactating
• Vitamin K is antidote (aquamephyton)
• Assess for sx bleeding
• Assess for sx of clot formation- Homans sign
• Assess for sx PE SOB, CP, dec. O2, Inc.
  RR
• Dose individual according to PT

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Nursing Implications Con't

• Teach pt to keep log of dose and lab results
• Do not use OTC Rx other Rx that interact
• Avoid ETOH and High Vitamin K foods
• Report sx bleeding
• Wear ID band
• Avoid activities that could cause bleeding