ANTI-ANGINAL AGENTS

Drugs
Nitrates nitroglycerin

MOA and other information

Indications: acute angina, HTN, CHF, pulmonary edema Huge vasodilator Large PO 1st pass effect

S/Es and A/Es

HA Development of tolerance

Nursing Implications & Client Teachings

Acute tx; sublingual, max of 3 tabs in 15 mins Prophylactic: patch development of tolerance: 12 hrs on & 12 hrs off X: Viagra or Cialis are vasodilators & will cause severe hypotensive episodes if used w/ nitrates X: if bradycardia is present OR with CCBs Dont STOP abruptly rebound HTN Caution with DM may mask hypoglycemia

B-Blockers atenolol (Tenormin)

Indications: LT management of angina (not acute attack); HTN, post MI, dysrhythmias Cardioprotective exercise tolerance Best to use selective B-blockers with low lipid solubility CNS effects CCBs Indications: LT management & prevention of verapamil (Calan) angina/ prevention; HTN, dysrhythmias nifedipine (Procardia) vasodilators

CNS effects: depression, sexual dysfx, lethargy

Hypotension palpitations, reflex tachycardia GI: constipation, nausea, Bradycardia Other: peripheral edema, rash...

Causes heart block if used w/ -1 blocker Can contribute to CHF Interaction w/ grapefruit ( GI absorption)

Metabolic modifiers ranolazine (Ranexa)

Indications: chronic/irretractable angina as add on if other drugs aren't working Helps heart cells generate energy more efficiently

Caution with other agents that QT interval (erythromycin, amiodarone) & CYP3A4 inhibitors (verapamil, grapefruit juice) arrhythmias

ANTI-LIPEMICS
Drugs
Bile Acid Sequestrants Questran, Colestid, Welchol HMG-CoA Reductase Inhibitors "statins

MOA and other information

Prevent bile acid absorption from small intestines Bile acid necessary for cholesterol absorption NOT systematically absorbed/metabolized

S/Es and A/Es

Nursing Implications & Client Teachings

absorption of other vitamins / medications take them 1 hr before or 2 hrs after

GI effects: bloating, constipation, nausea, belching, heartburn these subsides over time rate of cholesterol production GI effects, rash, HA LDL & TG, HDL Myopathy early in tx (leg pain) HMG-CoA reductase = enzyme necessary for liver production rhabdomyolysis of cholesterol liver enzymes New indications: Prevents CHD, type II DM, less bone fractures in older adults, prevent MI & strokes, dementia lipoprotein lipase activity break downs lipids HDL metabolism Inhibits liver synthesis of VLDL & LDL inhibits release of free fatty acids from adipose tissue TGS by enhancing VLDL & LDL catabolism Indication: hypertriglycerdemia Flushing, pruritis GI distress Hepatotoxicity with released form GI effects, myopathy, rhadbomyolysis, cholelithiasis, blood dyscracias

Monitor LFTs w/in or after 4 mos. of tx

Nicotinic Acid Niacin = vit B3

Take ASA 30 mins prior to relieve flushing or try taking with ice H2O Monitor LFTs Combined with statins only in high risk pts Monitor LFTS, CBC d/c if CPK Ok to use with statins for efficacy

Fibric Acid Derivatives gemfibrozil (Lipid)

Cholesterol Absorption Inhibits intestinal absorption of cholesterol cholesterol Inhibitor goes to liver cholesterol stored in liver clearance of ezetimibe (Zetia) cholesterol from the blood

CHF AGENTS
Therapy
Pre-hospital Tx ACEis pril ARBs sartan B-blockers carvedilol (Coreg) metoprolol (Toprol XL) Cardiac glycoside Vasodilators Hydralazine (Apresoline) Loop diuretics furosemide (Lasix)

Drugs

MOA and other information

Vasodilation, PVR/SVR, less cardiac workload Prevents collagen deposition in heart, improve coronary artery blood flow, improve kidney fx 1st line drugs in CHF reduces mortality & improves QOL non-selective selective Inhibits Na+/K+ pump (refer to anti-dysrhythmic agent notes) afterload, reverses persistent vasoconstriction Controls pulmonary edema Added if ACEis alone don't control volume overload

Nursing Implications & Client Teachings

Should be used early in CHF

Start slow & never d/c abruptly s/s of CHF may seem to get worse at 1st use, will get better in the long

Acute Tx

Nitroglycerin SL, Loop diuretics, O2 hBNP Nesiritide (Natrecor) vasodilation reduces preload diuresis & renal excretion of Na+

Watch for K+ & Na+ imbalance Avoid NSAIDs Pts on fluid restriction; tolerance to Lasix develops X: lithium Monitor K levels before giving this

Outpatient Tx

ACEis or ARBs non-selective B-Blockers K+ sparing diuretics Loop diuretics Cardiac glycoside Take w/ food

For severe CHF not controlled by ACEis alone Appear to be tolerated with ARBs Watch K+ intake Monitor electrolytes Supplemented w/ KCl