Deala, Donna Marie Toledo

Advanced Diploma in Medical Surgical- Group 1

SDL: COMMON CARDIAC DRUGS

CASE 1: Mr. Teo is a 68-year old retired accountant admitted with unstable angina. On admission, he was started on IV Nitroglycerin and
Diltiazem. He is scheduled to have coronary stenting procedure with adjunctive use of Antiplatelet agents.
NAME OF DRUG INDICATIONS ACTIONS SIDE EFFECTS NURSING
IMPLICATIONS
Nitroglycerin (IV)  Management of Mr. Teo’s unstable angina is due to  Headache  Blood pressure should
angina pectoris inadequate blood flow and oxygen  Dizziness be monitored because
Class: Nitrates (IV-immediate to his heart. If left untreated, this  Lightheadedness of risk for postural
treatment of may lead to heart attack.  Nausea hypotension
Other commonly used angina)  Flushing especially for IV
Nitrates: Nitrates, such as Nitroglycerin,  Low blood administration
Other Indications: relax the blood vessels through the pressure  Continuous ECG
Isosorbide Dinitrate (Isordil)  Treat release of nitric oxide. Thus  Difficulty with monitoring may be
Isosorbide Mononitrate hypertension causing vasodilation. Arterial breathing necessary for
(Imdur)  Control dilation causes increased cardiac  Dark urine monitoring
congestive heart output, venous dilation leads to  Bluish colored  Ask the patient if he is
failure venous pooling and reduction of lips, fingernails, taking any other
venous return thereby reduces palms drugs, look for
heart’s workload and need for possible drugs that
oxygen may interact with
Nitroglycerin.
For Mr. Teo’s case, Nitroglycerin e.g. Sildenafil
would also help relieve the pain (Viagra) can heighten
(which is caused by decrease blood the blood lowering
flow and oxygen) and decrease effect of Nitroglycerin
workload of his heart
Diltiazem  Treatment of
Class: Calcium Channel
Blockers
Other commonly used
Calcium Channel blockers:
Amlodipine (Norvasc),
Nifedipine (Adalat),
Verapamil (Calan)
Antiplatelet drugs  Stable angina
 Ishaemic heart
Aspirin (ASA)
When Calcium enters the cells, it  Headache  Ask the patient if he is
angina, high makes the heart contract and  Rash taking any other
blood pressure arteries narrow. Calcium channel  Hypotension drugs, look for
and abnormal blockers, such as diltiazem,  Drowsiness possible drugs that
heart rhythms prevents the entry of calcium in the  Dizziness may interact with
muscle cells. Thus, decreasing the  Nausea Diltiazem
force and rate of myocardial  Constipation e.g. Digoxin –
contractility. It then relaxes the  Edema (swelling Diltiazem can
muscle, causing dilation. It reduces of legs and feet) increase digoxin
the pressure that the arteries must blood levels
pump blood, leading to less work
for the heart and thus less oxygen Diltiazem with Anti-
required. Diltiazem reduces angina seizure medications
by decreasing the heart’s need for can increase toxicity
oxygen.
 Monitor the patient’s
blood pressure and
ECG as necessary
 Instruct the patient to
change positions
slowly since this may
cause hypotension
and lightheadedness
 Monitor for headache.
 Avoid driving after
taking the medicine
since it causes
dizziness
 Periodically assess for
rashes
Since Mr. Teo is undergoing  Bleeding  Watch out for any
coronary stenting, it is important  Dyspnea signs of bleeding, and
disease for him to take antiplatelet agents to  Headache immediately report to
help reduce the risk of myocardial  Dizziness the physician
 Clopidogrel (Plavix) –a  Acute coronary infarction and cardiovascular death.  Diarrhea or  Avoid strenuous
Thienopyridine syndrome Usually antiplatelets given are constipation activities that might
Dipyridamole (Persantine)  Prevent stent combination of Aspirin and  Stomach ache predispose to risk of
Ticlopidine (Ticlid) thrombosis thienopyridine  Nose bleeding bleeding
Prasugrel (Effient)  Easy bruising  Monitor FBC as
necessary
 Take the medication
as directed by the
physician. Do not
discontinue without
seeking advice from
the physician, as this
will increase the risk
for cardiovascular
events

CASE 2: Mr. Boon was admitted to the emergency department with the diagnosis of STEMI. He was initially given Aspirin and Prasugrel. Post
PCI, Mr. Boon was monitored in the coronary care high dependency unit with IV Integrelin in progress.

NAME OF DRUG INDICATIONS ACTIONS SIDE EFFECTS NURSING

IMPLICATIONS
Aspirin  Management of The use of aspirin has been shown  Heartburn  Must be taken with
acute coronary to reduce mortality from MI.  GI upset meals to avoid GI
Class: Salicylate syndrome Occlusive coronary thrombus (vomiting, upset
originates from an adhesion of a stomach pain)  Watch out for
Other commonly used: Other Indications: small collection of activated  Nausea bleeding, easy
Magnesium salicylate  Anti- platelets at the site of intimal  Drowsiness bruising or gum
thrombotic/reduction disruption in an unstable  Tinnitus bleeding
of risk for stroke atherosclerotic plaque. Aspirin  Rash, urticaria  Report side effects
 Inflammatory irreversibly interferes with such as: ringing of
conditions function of cyclooxygenase and ears, abdominal pain,
inhibits the formation of bloody stools

Prasugrel
Class: Thienopyridine
Other commonly used:
Clopidogrel, Ticlopidine
Integrelin (IV)
Class: Glycoprotein IIb/IIa
Inhibitor
(rheumatic fever, thromboxane A2. Within minutes,
rheumatoid arthritis) aspirin prevents additional platelet
 Relieve mild to activation and interferes with
moderate pain platelet adhesion and cohesion.
 Prevention of In STEMI, there is narrowing and  Dizziness  Health education:
atherosclerotic blockage of the artery. It may also  Excessive Don’t take this drug
events in patients be due to rupture of tiredness if active bleeding is
with recent MI of atherosclerotic plaque causing  Cough present such as
stroke blood clots to form inside the  Pain in the back, stomach ulcer,
 Prophylaxis of artery, leading to obstruction in arms and legs stroke, TIA
thrombotic events in the artery.  Bleeding  Watch out for signs
acute coronary  Dyspnea of bleeding, such as
syndrome Thienopyridines, such as  hyperlipidemia black or bloody
Prasugrel, are ADP receptor stools, cough out
inhibitors that block platelet blood or vomit that is
aggregration. Thus, preventing coffee gound
blot clot formation  Be extra careful
when doing outside
activities that may
pose you at risk for
bleeding
 Monitor for signs of
thrombotic
thrombocytic
purpura (fever,
haemolytic anemia,
renal dysfunction,
neurologic findings)
 Monitor FBC
 Treatment of heart Inhibits glycoprotein receptors in  Bleeding  Watch out for signs
attacks the platelet thereby preventing  Abdominal pain of bleeding
 Unstable angina platelet aggregation.  Back pain  Monitor FBC
 Confusion
 Other commonly used:  Patients undergoing It decreases the size of the blood  Coughing out of
Abciximab (Reopro) PTCA with or clot (which blocks the coronary blood
without stenting arteries) thereby, increasing blood  Dizziness
flow. It also limits damage to the  Difficulty of
heart muscle breathing

*most potent antiplatelet agents;

most expensive

CASE 3: Mdm Wee is admitted to the HDU for cardiogenic shock. She was started on Inotropic Drugs and Morphine. Vasodilators were also
started for Mdm Wee.
NAME OF DRUG INDICATIONS ACTIONS SIDE EFFECTS NURSING
IMPLICATIONS
Inotropic Drugs Positive Inotropes: Positive Inotropes: Strengthens  Hypotension  Monitor the BP,
Congestive Heart failure, the heart’s contractions, making it  Irregular heart rate, ECG,
Cardiomyopathy, Recent more effective in pumping blood heartbeat cardiac output and
Positive Inotropes: Heart Attack, Cardiogenic with fewer heartbeats  Shortness of urinary output
Digoxin, Dopamine, Shock breath  Palpate peripheral
Dobutamine In the case of Mdm Wee, her  Palpitations pulses and
Negative Inotropes: heart was severely damaged that it  Sweating appearance of
Hypertension, Chronic Heart was unable to pump enough blood  Vision problems extremities routinely
Negative Inotropes: Beta- failure, Arrhythmias, Angina supply to the body. Inotropes  Headache  Monitor electrolytes,
Blockers, Calcium Channel makes the contractions more  Lightheadedness BUN, Creatinine,
blockers, Anti-arrhythmic effective, thus increasing the  Loss of appetite prothrombin time
efficiency of the heart in pumping  Fatigue  Monitor peripheral
blood.  Diarrhea line for presence of
 Skin rash phlebitis
 Bleeding
Negative Inotropes: Slows the gum/nose
heart rate and makes the heart bleeding
contractions weak  phlebitis
Morphine Treatment of pain Suffering from cardiogenic shock,  Dizziness  Should not be given
Mdm Wee also may be  Respiratory in patients receiving
Class: Opiates experiencing sharp, stabbing pain. depression MAOI within 14
Morphine acts as analgesia in  Hypotension days prior
Other commonly used: cardiogenic shock.  Drowsiness  Assess for level of
Vicodin, Methadone,  Nausea consciousness, blood
Hydrocodone, Demerol, Morphine also reduces  Vomiting pressure, heart rate
Naloxone sympathetic stimulation, and  Stomach pain and respirations
decreases the heart’s preload,  constipation before and after
making the demand for oxygen  Loss of appetite administration
less and decrease workload for the  Sweating  Watch out for
heart.  Dry mouth physical and
 Headache psychological
 Mood changes dependence and
 Confusion tolerance
 Difficulty of  Assess bowel
urination function routinely
 Small pupils  Ensure adequate
fluids
 Avoid sudden
changes in position
that may cause
hypotension
Vasodilators Hypertension, Heart failure, Relaxes the blood vessels, causing  Lightheadedness  Monitor BP and HR
Angina dilation. Dilation of arterial  Dizziness routinely
Alpha-adrenergic vessels leads to reduction  Headache  Avoid sudden
Blockers : in systemic vascular resistance  Increased or position changes
Doxazosin (Cardura); which leads to a fall in arterial irregular heart
Prazosin (Minipress); blood pressure. Dilation of venous rate
Terazosin (Hytrin) vessels decreases venous blood  Difficulty of
pressure. breathing
Angiotensin converting
enzymes (ACE):
Captopril; Enalapril
 Angiotensin Receptor
Blockers : Candesartan,
Losartan, Irbesartan;
Telmisartan, Valsartan

Central alpha-adrenergic
agonist: Clonidine
(Catapres);

Calcium Channel
Blockers: Amlodipine;
Nifedipine

Direct Vasodilators:
Hydralazine; Minoxidil

Nitrodilators: Isosorbide
Dinitrate; Isosorbide
Mononitrate; Nitroglycerin

CASE 4: Mrs. Soon who has history of congestive heart failure is admitted to the coronary HDU. She was previously on digoxin. On admission,
she is started on diuretics. Tab Captopril was subsequently changed to Losartan. Metoprolol was also started for Mrs. Soon.
NAME OF DRUG INDICATIONS ACTIONS SIDE EFFECTS NURSING
IMPLICATIONS
Digoxin Heart failure, atrial Digoxin increases the strength and  Nausea,  For patients taking
fibrillation efficiency of heart contractions, and vomiting diuretics and
CLASS: Cardiac glycosides is useful in the treatment of heart  Loss of appetite laxatives, may cause
 failure and control the rate and  Fast, slow or hypokalemia,
rhythm of the heart. It inhibits the uneven heart increasing the risk of
activity of an enzyme (ATPase) that rate toxicity
controls movement of calcium,  Black tarry  Monitor apical pulse
sodium, and potassium into heart stools for 1 full minute
muscle. Calcium controls the force  Confusion, before administering
of contraction. Inhibiting ATPase hallucination  Monitor ECG if on IV
increases calcium in heart  Blurring of administration
muscle and therefore increases the vision  Observe IV site for
force of heart contractions.  Headache infiltration and
 Dizziness extravasation
 Electrolyte  Monitor for intake
imbalances with and output, peripheral
acute digoxin edema
toxicity

Diuretics High blood pressure, Diuretics act by diminishing  Blurred vision  Monitor the blood
congestive heart failure, sodium reabsorption at different  Hearing loss pressure, may further
Thiazide Diuretics: kidney and liver sites in the nephron, thereby  Tinnitus increase the risk of
Hydrochlorothiazide problems, glaucoma increasing urinary sodium and  Hypotension hypotension if the
Loop Diuretics: water losses. This further helps in  Anorexia, patient is on
Bumetanide, Furosemide lowering the blood pressure and constipation, hypertensive
Potassium-Sparing thus making it easier for the heart to diarrhea medications or
Diuretics: Spironolactone pump  Dehydration alcohol intake
 Muscle cramps  Assess fluid status,
 Paresthesia monitor weight, an
 Fever intake and output
 Assess for presence of
edema
 Assess patients
receiving digoxin for
anorexia, nausea,
vomiting, muscle
cramps, paresthesia
 and confusion.
(higher risk of digoxin
toxicity because of
potassium-depleting
effect)

Captopril Congestive heart failure, Captopril inhibits the release of  Dizziness  monitor BP and pulse
hypertension, kidney ACE (Angiotensin Converting  Lightheadedness frequently
Class: ACE Inhibitor problems caused by Enzyme). ACE is the enzyme that  Salty or metallic  assess for signs of
Diabetes converts Angiotensin I to taste angioedema such as
Other commonly used: Angiotensin II, which is a potent  Cough swelling of face, eyes,
Enalapril, Lisinopril endogenous vasoconstrictor.  Fast heartbeat lips, tongue, difficulty
Angiotensin II also stimulates  Excessive of breathing
aldosterone secretion from the tiredness  monitor for weight
adrenal cortex, thereby contributing  Chest pain  monitor FBC
to sodium and fluid retention.  Hoarseness  Watch out for cough
 Stomach pain
Thus, lowers BP  Itching
 Rashes
 angioedema

Losartan Hypertension; Heart Relaxes blood vessels so that blood  Fatigue  Avoid sudden
failure can flow more easily  Hypoglycaemia changes in position
Class: Angiotensin II  Chest pain especially from lying
receptor antagonist Other Indications:  Diarrhea to sitting
 Orthostatic  Assess for signs of
Other commonly used: Protect the kidneys from Hypotension angioedema (facial
Candesartan, Irbesartan, damage caused by  Back pain, swelling, dyspnea)
Telmisartan, Valsartan Diabetes; Lower risk of myalgia  Schedule activities in
stroke in hypertensive a day, to avoid fatigue
patients
Metoprolol Hypertension, heart Blocks stimulation of Beta 1  tiredness  Avoid sudden
failure, angina adrenergic receptors. Thus  mild dizziness changes in position
Class: Beta-blocker decreasing blood pressure and heart  rash  Monitor the BP and
rate HR
 Other commonly used: Other Indications:  breathing  Monitor intake and
Atenolol, propranolol, Tachyarrhythmias; problems output and weight
bisoprolol Migraine  diarrhea or  Assess routinely for
constipation signs and symptoms
 slower heart rate of heart failure
(crackles, dyspnea,
weight gain, jugular
vein distention,
peripheral edema)

CASE 5: Inotropic and Anti-arrhythmic drugs are commonly prescribed in the treatment of patients with myocardial infarction, coronary
artery disease, and cardiac emergencies.
NAME OF DRUG INDICATIONS ACTIONS SIDE EFFECTS NURSING
IMPLICATIONS
Inotropic Myocardial Infarction, Stimulates Beta 1 adrenergic  Headache  monitor for BP, heart
coronary artery disease, receptors with relatively minor  Hypertension rate, pulse pressure,
Positive Inotropes: cardiac emergencies effect on heart rate or peripheral  Increased heart cardiac output,
Digoxin, Dopamine, blood vessels. Thus, increasing the rate urinary out
Dobutamine cardiac output without significantly  PVCs  monitor for peripheral
increasing the heart rate  Nausea pulses and assess
 Vomiting appearance of
Negative Inotropes: Beta-  Shortness of extremities
Blockers, Calcium Channel breath  monitor ECG for
blockers, Anti-arrhythmic  Palpitations presence of
arrhythmias
 watch out for
hypertension or
hypotension

Anti-arrhythmic Anti-arrhythmic drugs directly or Anti-arrhythmics: Anti-arrhythmics:

Class I : Na channel indirectly alter membrane ion  Chest pain  Monitor for the
blockers conductances, which in turn alters  Fainting improvement or
Lidocaine; procainamide; the physical characteristics of  Worsening worsening of
propafenone cardiac action potentials. It mainly arrhythmias arrhythmias
decreases or increases conduction  Blurred vision  Monitor the BP, heart
Class II: Beta blockers velocity, alter the excitability of  Swelling feet or rate and ECG
Propranolol; metoprolol; cardiac cells by changing the legs  Monitor the intake
atenolol duration of the effective refractory  Dizziness and output; monitor
period and suppress abnormal  Cough for signs of edema
Class III: K channel automaticity  Abnormally fast
blockers or slow heart
Amiodarone; Sotalol; rate
Ibutilide

Class IV: Slow Ca

chanenel blockers
Verapamil; Diltiazem

Class V: Variable
Mechanism
Digoxin, Adenosine,
Magnesium sulfate
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