NURSING PHARMACOLOGY
CARDIAC MEDICATIONS
________________________________________________________
ANTI-HYPERTENSIVE MEDICATIONS
ELEMENTS IN BLOOD PRESSURE CONTROL
✓ Heart
✓ Blood vessels
✓ Blood
✓ Baroreceptors (pressure receptors)
✓ Cardiovascular center in the medulla (brain).
HYPERTENSION
- Prolonged force on the vessels of the vascular
system.
- People with increased blood pressure are
susceptible to the development of coronary
artery disease (CAD), atherosclerosis, loss of
vision, decrease kidney function, and cerebral
function.
ANTIHYPERTENSIVE THERAPY
- Because an underlying cause of hypertension
is usually unknown, altering the body’s
regulatory mechanisms is the best treatment
currently available
- Drugs used to treat hypertension work to alter
the normal reflexes that control blood pressure.
- Treatment for essential hypertension does not
cure the disease but is aimed at maintaining the
blood pressure within normal limits to prevent
the damage that hypertension can cause.
- Several different types of drugs that affect
different areas of blood pressure control may
need to be used in combination to maintain a
patient’s blood pressure within normal limits.
SAFE MEDICATION ADMINISTRATION
- Several drugs that are used to treat
hypertension cannot be cut, crushed, or
chewed. This is very important information to
share with patients. Sometimes patients cut
tablets in half to facilitate swallowing or to get
twice the number of days for any given
prescription. Most drugs formulated for
extended release or sustained release are
delivered in a matrix system that slowly
dispenses the drug into the system. If the
coating of the matrix is cut, all of the drugs is
released at once, leading to the release of too
much drug at one time and, consequently, toxic
levels of the drug when first taking it. Then the
patient receives no drug as the day goes on.
1 #LabaRN
- Some antihypertensives to be aware of are
diltiazem, isradipine, nicardipine, nifedipine,
nisoldipine, and verapamil. (don’t cut)
GENERAL CLASSIFICATIONS
✓ ACE inhibitors
✓ Angiotensin II–receptor blockers (ARBs)
✓ Calcium channel blockers
✓ Diuretic agents
✓ Renin inhibitors
✓ Sympathetic nervous system drugs.
ACE INHIBITORS (-pril)
➢ Benazepril (Lotensin)
➢ Captopril (Capoten)
➢ Enalapril (Vasotec)
➢ Enalaprilat (Vasotec IV)
➢ Fosinopril (Monopril),
➢ Lisinopril (Prinivil, Zestril)
➢ Moexipril (Univasc)
➢ Perindopril (Aceon)
➢ Quinapril (Accupril)
➢ Ramipril (Altace)
➢ Trandolapril (Mavik)
ACTIONS/ INDICATIONS
- Otherwise known as “Angiotensin- Converting
Enzyme inhibitors”.
- It acts in the lungs to prevent ACE from
converting angiotensin I to angiotensin II, a
powerful vasoconstrictor and stimulator of
aldosterone release.
- This action leads to a decrease in blood
pressure and in aldosterone secretion, with a
resultant slight increase in serum potassium
and a loss of serum sodium and fluid.
- Commonly used in treatment of hypertension in
adults.
- These drugs are indicated for the treatment of
hypertension, alone or in combination with
other drugs.
- They are also used in conjunction with digoxin
and diuretics for the treatment of heart failure
and left ventricular dysfunction.
- Their therapeutic effect in these cases is
thought to be related to a decrease in cardiac
workload associated with the decrease in
peripheral resistance and blood volume.
- They are also approved for the treatment of
diabetic nephropathy.
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
- It is thought that the decrease in stimulation of
the angiotensin receptors in the renal artery will
slow the damage to the renal artery that occurs
in diabetes.
PHARMACOKINETICS
- All the ACE inhibitors are administered orally.
- Enalapril also has the advantage of parenteral
use (enalaprilat [Vasotec IV]) if oral use is not
feasible or rapid onset is desirable.
- These drugs are well absorbed, widely
distributed, metabolized in the liver, and
excreted in the urine and feces.
- They have been detected in breast milk, are
known to cross the placenta, and have been
associated with serious fetal abnormalities, and
so they should not be used during pregnancy.
CONTRAINDICATIONS
- Allergy to any of the ACE inhibitors to prevent
hypersensitivity reactions and with impaired
renal function, which could be exacerbated by
the effects of this drug in decreasing renal blood
flow.
- Patients with heart failure because the
change in hemodynamics could be detrimental
in some cases and in those with salt/volume
depletion, which could be exacerbated by the
drug effects
- Pregnant women because of the potential for
serious adverse effects on the fetus and during
lactation because of potential decrease in milk
production and effects on the neonate.
ADVERSE EFFECTS
- Reflex tachycardia, chest pain, angina, and
cardiac arrhythmias; gastrointestinal (GI)
irritation, ulcers, constipation, and liver injury;
renal insufficiency, renal failure, and
proteinuria; and rash, alopecia, dermatitis, and
photosensitivity.
DRUG- DRUG INTERACTIONS
- The risk of hypersensitivity reactions increases
if these drugs are taken with allopurinol.
- Risk of decreased antihypertensive effects if
taken with nonsteroidal anti-inflammatory
drugs; patients should be monitored.
DRUG- FOOD INTERACTIONS
- Absorption of oral ACE inhibitors decreases if
they are taken with food.
- They should be taken on an empty stomach 1
hour before or 2 hours after meals.
2 #LabaRN
NURSING CONSIDERATIONS
- Assessment for allergies to drug.
- Impaired kidney function
- Pregnancy or lactation
- Salt volume depletion
- Heart failure
- Assess for baseline body temperature and
weight; skin color, lesions, and temperature;
pulse, blood pressure, baseline
electrocardiogram, and perfusion; respirations
and adventitious breath sounds; bowel sounds
and abdominal examination; and renal function
tests, complete blood count with differential,
and serum electrolytes.
NURSING DIAGNOSES
- Nursing diagnoses related to drug therapy
might include the following
➢ Ineffective Tissue Perfusion (Total Body)
related to changes in cardiac output
➢ Impaired Skin Integrity related to
dermatological effects
➢ Acute Pain related to gastrointestinal
distress and cough
➢ Deficient Knowledge regarding drug
therapy
IMPLEMENTATION WITH RATIONALE
1. Encourage patient to implement lifestyle
changes, including weight loss, smoking
cessation, decreased alcohol and salt in the diet,
and increased exercise, to increase the
effectiveness of antihypertensive therapy.
2. Administer on an empty stomach 1 hour before or
2 hours after meals to ensure proper absorption
of the drug.
3. Alert the surgeon and mark the patient's chart
prominently if the patient is to undergo surgery to
alert medical personnel that the blockage of
compensatory angiotensin II could result in
hypotension after surgery that would need to be
reversed with volume expansion.
4. Give the parenteral form of enalapril only if an oral
form is not feasible; transfer to an oral form as
soon as possible to avoid an increased risk of
adverse effects.
5. Consult with the prescriber to reduce the dose in
patients with renal failure to account for their
decreased production of renin and lower-than-
normal levels of angiotensin II.
6. Monitor the patient carefully in any situation that
might lead to a drop in fluid volume (e.g.,
excessive sweating, vomiting, diarrhea,
dehydration) to detect and treat excessive
hypotension that may occur.
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

7. Provide comfort measures to help the patient

tolerate drug effects. These include small, DRUG NAME USUAL DOSAGE USUAL
frequent meals; access to bathroom facilities; INDICATIONS
bowel program as needed; environmental
controls; safety precautions; and appropriate skin
10-40 mg/d PO; Treatment of
care as needed.
reduce dose in hypertension,
8. Provide thorough patient teaching, including the ENALAPRIL geriatric patients HF, left
name of the drug, dosage prescribed, measures (VASOTEC) and patients with ventricular
to avoid adverse effects, warning signs of renal impairment; dysfunction in
problems, and the need for periodic monitoring 2.5 mg PO b.i.d. for adults
and evaluation, to enhance patient knowledge HF or left
about drug therapy and to promote compliance ventricular
9. Offer support and encouragement to help the dysfunction
patient deal with the diagnosis and the drug
regimen.
Short-term
treatment of
EVALUATION ENALAPRILAT 1.25 mg q6h IV acute
- Monitor patient response to the drug (VASOTEC IV) over 5 min hypertension
(maintenance of blood pressure within normal when
limits). oral therapy is
- Monitor for adverse effects (hypotension, not feasible
cardiac arrhythmias, renal dysfunction, skin
reactions, cough, pancytopenia, heart failure).
FOSINOPRIL Treatment of
- Evaluate the effectiveness of the teaching plan
(MONOPRIL) 20-40 mg/d PO hypertension,
(patient can name drug, dosage, adverse
adjunct therapy
effects to watch for, specific measures to avoid for HF,
them, and the importance of continued follow- for use in adults
up).
- Monitor the effectiveness of comfort measures
and compliance with the treatment regimen.
20-40 mg/d PO for Treatment of
hypertension, 5-20 hypertension,
LISINOPRIL mg/d PO for HF, 5- HF; treatment of
(PRINIVIL, 10 mg/d PO after stable patients
DRUG NAME USUAL DOSAGE USUAL
ZESTRIL) MI; decrease dose within 24 h after
INDICATIONS
in geriatric patients acute MI to
and patients with increase
renal impairment survival; for use
20-40 mg/d PO, Approved only
in adults
BENAZEPRIL reduce dose with for treatment of
(LOTENSIN) older patients and hypertension in
patients with renal adults
impairment
7.5-30 mg/d PO, Treatment of
MOEXIPRIL based on response; hypertension in
(UNIVASC) reduce dose in adults
patients with renal
25 mg PO b.i.d. to Treatment of
impairment and in
t.i.d. for hypertension;
geriatric patients
hypertension, 50- adjunct therapy
100 mg PO t.i.d. for for HF;
CAPTOPRIL heart failure (HF), treatment of left
(CAPOTEN) 50 mg PO t.i.d. for ventricular
Treatment of
ventricular dysfunction after
4 mg/d PO; reduce hypertension,
dysfunction, 25 mg myocardial
PERINDOPRIL dose in geriatric may be used
PO t.i.d. for diabetic infarction (MI),
(ACEON) patients and alone or
nephropathy; diabetic
patients with renal as combination
reduce dose in nephropathy: for
impairment drug to control
patients with renal use in adults
blood pressure,
impairment and in
for use in adults
geriatric patients

3 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

- Use for the treatment of heart failure in patients

DRUG NAME USUAL DOSAGE USUAL who are intolerant to ACE inhibitors.
INDICATIONS - Slows the progression of renal disease in
patients with hypertension and type 2 diabetes.
20-80 mg/d PO,
PHARMACOKINETICS
based on response Treatment of
QUINAPRIL for hypertension; hypertension, - Agents are all given orally.
(ACCUPRIL) 10-20 mg PO b.i.d. adjunctive - They are well absorbed and undergo
for HF; reduce treatment of HF, metabolism in the liver.
dose in patients for use in adults - Excreted in feces and in urine.
with renal - They cross the placenta.
impairment and in - It is not known whether they enter breast milk
geriatric patients
during lactation.

2.5-20 mg/d PO for Treatment of CONTRAINDICATIONS

RAMIPRIL hypertension, 5 mg hypertension, - Presence of hepatic or renal dysfunction, which
(ALTACE) PO b.id. for HF; adjunctive could alter the metabolism and excretion of
reduce dose in treatment of HF, these drugs.
geriatric patients for use in adults - Hypovolemia because of the blocking of
and patients with potentially life-saving compensatory
renal impairment
mechanisms.
- Pregnant due fetal abnormalities and death
1-2 mg PO q.i.d. for
(2nd or 3rd trimester).
hypertension; 4 Treatment of - Not be used during lactation because of the
TRANDOLAPRIL mg/d PO, titrate hypertension, potential for serious adverse effects in the
(MAVIK) slowly to that level HF, and after neonate.
for HF; reduce Ml; for use in - Women of childbearing age should be advised
dose in patients adults to use barrier contraceptives to avoid
with renal or pregnancy; if a pregnancy does occur, the ARB
hepatic impairment
should be discontinued immediately.

ADVERSE EFFECTS
ANGIOTENSIN RECEPTOR BLOCKERS (-sartan)
- Headache, dizziness, syncope, and weakness.
- Also called ARBs or angiotensin II- inhibitors
- Hypotension; GI complaints, including diarrhea,
are medicines that dilate (widen) blood vessels
abdominal pain, nausea, dry mouth, and tooth
and are used in the treatment of conditions
pain.
such as high blood pressure (hypertension),
- Symptoms of upper respiratory tract infections
heart failure, or kidney disease in people with
and cough; and rash, dry skin, and alopecia.
diabetes.

DRUG- DRUG INTERACTIONS

REPRESENTATIVE DRUGS
- The risk of decreased serum levels and loss of
➢ Azilsartan (Edarbi)
effectiveness increases if the ARB is taken in
➢ Candesartan (Atacand)
combination with phenobarbital, indomethacin,
➢ Eprosartan (Teveten)
or rifamycin.
➢ Irbesartan (Avapro)
- Decrease in antihypertensive effects if the drug
➢ Losartan (Cozaar)
is taken with ketoconazole, fluconazole, or
➢ Olmesartan (Benicar)
diltiazem.
➢ Telmisartan (Micardis)
➢ Valsartan (Diovan)
NURSING CONSIDERATIONS
THERAPEUTIC ACTIONS/ INDICATIONS - Assess for allergies
- Impaired kidney and liver function
- Selectively bind with the angiotensin II
- Pregnancy and lactation
receptors in vascular smooth muscle and in the
- Hypovolemia
adrenal cortex to block vasoconstriction and the
- Assess baseline VS, skin color, lesions, ECG,
release of aldosterone.
renal and liver function test, bowel sounds and
- These actions block the blood pressure– raising
adventitious breath sounds.
effects of the renin–angiotensin system and
lower blood pressure.

4 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

NURSING DIAGNOSES EVALUATION

- Nursing diagnoses related to drug therapy - Monitor patient response to the drug
might include the following (maintenance of blood pressure within normal
➢ Ineffective Tissue Perfusion (Total Body) limits).
related to changes in cardiac output - Monitor for adverse effects (hypotension,
➢ Impaired Skin Integrity related to cardiac arrhythmias, renal dysfunction, skin
dermatological effects reactions, cough, pancytopenia, heart failure).
➢ Acute Pain related to gastrointestinal - Evaluate the effectiveness of the teaching plan
distress and cough, skin effects, and (patient can name drug, dosage, adverse
headache effects to watch for, specific measures to avoid
➢ Deficient Knowledge regarding drug them, and the importance of continued follow-
therapy up).
- Monitor the effectiveness of comfort measures
IMPLEMENTATION WITH RATIONALE and compliance with the treatment regimen.
1. Encourage patient to implement lifestyle
changes, including weight loss, smoking
cessation, decreased alcohol and salt in the diet, DRUG NAME USUAL
DOSAGE USUAL INDICATIONS
and increased exercise, to increase the
effectiveness of antihypertensive therapy.
2. Administer without regard to meals; give with
Used alone or as a part
food to decrease GI distress if needed AZILSARTAN 80 mg/d of combination therapy
3. Alert the surgeon and mark the patient's chart (EDARBI) PO for treatment of
prominently if the patient is to undergo surgery hypertension in adults
to notify medical personnel that the blockage of
compensatory angiotensin II could result in
hypotension after surgery that would need to be CANDESARTAN 16-32 Used alone or as a part
reversed with volume expansion. (ATACAND) mg/d PO of combination therapy
for treatment of
4. Ensure that the female patient is not pregnant
hypertension in adults
before beginning therapy, and suggest the use
of barrier contraceptives while she is taking
these drugs EPROSARTAN 400-800 Used alone or as a part
5. Find an alternative method of feeding the baby if (TEVETEN) mg/d PO of combination therapy
the patient is nursing to prevent potentially for treatment of
dangerous blockade of the renin- angiotensin- hypertension in adults
aldosterone system in the neonate
6. Monitor the patient carefully in any situation that
might lead to a drop in fluid volume (e.g., Used alone or as a part
of combination therapy
excessive sweating, vomiting, diarrhea,
for treatment of
dehydration) to detect and treat excessive
hypertension in adults,
hypotension that may occur. IRBESARTAN 150-300 slowing progression of
7. Provide comfort measures to help the patient (AVAPRO) mg/d PO diabetic nephropathy
tolerate drug effects. These include small, with elevated serum
frequent meals; access to bathroom facilities; creatinine and
bowel program as needed; safety precautions of proteinuria in patients
central nervous system effects occur; with hypertension and
environmental controls; appropriate skin care as type 2 diabetes
needed; and analgesics as needed
8. Provide thorough patient teaching, including the
Used alone or as a part
name of the drug, dosage prescribed, measures of combination therapy
to avoid adverse effects, warning signs of for treatment of
problems, and the need for periodic monitoring hypertension in adults,
and evaluation, to enhance patient knowledge LOSARTAN 25-100 slowing progression of
about drug therapy and to promote compliance (COZAAR) mg/d PO diabetic nephropathy
9. Offer support and encouragement to help the with elevated serum
patient deal with the diagnosis and the drug creatinine and
proteinuria in patients
regimen.
with hypertension and
type 2 diabetes

5 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

PHARMACOKINETICS
DRUG NAME USUAL - Agents are all given orally.
DOSAGE USUAL INDICATIONS
- They are well absorbed and undergo
metabolism in the liver.
- Excreted in urine.
Used alone or as a part
OLMESARTAN 20–40 of combination therapy - They cross the placenta.
(BENICAR) mg/d PO for treatment of - Enter breast milk during lactation.
hypertension in adults - Nicardipine and clevidipine are available in an
(newest angiotensin II- intravenous form for short-term use
receptor blocker)
CONTRAINDICATIONS
- Patients with heart block or sick sinus
TELMISARTAN Used alone or as a part
syndrome, which could be exacerbated by the
(MICARDIS) 40-80 of combination therapy
mg/d PO for treatment of conduction-slowing effects of these drugs.
hypertension in adults - With renal or hepatic dysfunction, which could
alter the metabolism and excretion of these
drugs.
Used alone or as a part - Not be used during pregnancy unless the
80-320 of combination therapy benefit to the mother clearly outweighs any
VALSARTAN mg/d PO for treatment of potential risk to the fetus.
(DIOVAN) based on hypertension in adults,
response treatment of heart
ADVERSE EFFECTS
failure in patients who
are intolerant to ACE - CNS effect includes dizziness, light-
inhibitors headedness, headache, and fatigue.
- GI problems include nausea and hepatic injury
related to direct toxic effects on hepatic cells.
CALCIUM CHANNEL BLOCKERS (-dipine) - Cardiovascular effects include hypotension,
- Calcium channel blockers decrease blood bradycardia, peripheral edema, and heart
pressure, cardiac workload, and myocardial block. Skin flushing and rash
oxygen consumption. The effects of these
drugs on cardiac workload also make them very DRUG- FOOD INTERACTIONS
effective in the treatment of angina - Advise patients to avoid the use of
GRAPEFRUIT JUICE because it may lead to
REPRESENTATIVE DRUGS increased concentrations of calcium channel
✓ Amlodipine (Norvasc) blockers in the body leading to toxicity.
✓ Felodipine (Plendil)
✓ Isradipine (DynaCirc, DynaCirc CR) ASSESSMENT: History and Examination
✓ Nicardipine (Cardene, Cardene SR) - Assess for contraindications or cautions known
✓ Diltiazem (Cardizem, Dilacor CR) allergies to any of these drugs to avoid
✓ Nifedipine (Procardia XL) hypersensitivity reactions; impaired liver or
✓ Nisoldipine (Sular) kidney function, which could alter the
✓ Verapamil (Calan SR) metabolism and excretion of the drug; heart
block, which could be exacerbated by the
THERAPEUTIC ACTIONS/ INDICATIONS conduction depression of these drugs; and
- Inhibits the movement of calcium ions across current status of pregnancy or lactation
the membranes of myocardial and arterial because of the risk of adverse effects to the
muscle cells, altering the action potential and fetus or nursing baby.
blocking muscle cell contraction. - Perform a physical assessment to establish
- This effect depresses myocardial contractility, baseline status before beginning therapy and
slows cardiac impulse formation in the during therapy to determine the effectiveness
conductive tissues, and relaxes and dilates and evaluate for any potential adverse effects.
arteries, causing a fall in blood pressure and a - Inspect skin for color and integrity to identify
decrease in venous return. possible adverse skin reactions.
- Assess the patient’s complaint of pain,
including onset, duration, intensity, and location
and measures used to relieve the pain.
Investigate activity level prior to and after the

6 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

onset of pain to aid in identifying possible
contributing factors to the pain and its
progression.
- Assess cardiopulmonary status closely,
including pulse rate, blood pressure, heart rate,
and rhythm, to deter- mine the effects of
therapy and identify any adverse effects.
- Obtain an electrocardiogram as ordered to
assess for possible irregularities in rate or
rhythm.
- Monitor respirations and auscultate lungs to
evaluate changes in cardiac output
- Monitor the results of laboratory tests, including
renal function studies, to determine need for
possible dose adjustment and to identify
potential toxicity.
NURSING DIAGNOSES
- Nursing diagnoses related to drug therapy
might include the following
➢ Decrease Cardiac Output r/t hypotension
and vasodilation
➢ Risk for injury r/t central nervous system or
cardiovascular effects
➢ Ineffective Tissue Perfusion (Total Body)
related to changes in cardiac output
➢ Deficient Knowledge regarding drug
therapy
6. Provide thorough patient teaching including the
name of the drug and dosage prescribed;
measures to avoid adverse effects and prevent
anginal attacks; actions to take when an attack
occurs; warning signs of problems, and signs
and symptoms to report immediately; and the
need for periodic monitoring and evaluation to
enhance patient knowledge about drug therapy
and to promote compliance.
EVALUATION
- Monitor patient response to the drug (alleviation
of signs and symptoms of angina, prevention of
angina).
- Monitor for adverse effects (hypotension,
cardiac arrhythmias, GI upset, skin reactions,
headache).
- Monitor the effectiveness of comfort measures
and compliance with the regimen.
- Evaluate the effectiveness of the teaching plan
(patient can name drug, dosage, proper
administration, adverse effects to watch for,
specific measures to avoid them, and the
importance of continued follow-up).
DRUG NAME USUAL DOSAGE USUAL
INDICATIONS

IMPLEMENTATION WITH RATIONALE 5–10 mg/d PO, Used alone or in

1. Monitor the patient’s blood pressure, cardiac AMLODIPINE reduce dose in combination with
rhythm, and cardiac output closely while the (NORVASC) patients with other agents for
drug is being titrated or dose is being changed hepatic treatment of
to ensure early detection of potentially serious impairment and in hypertension and
adverse effects. geriatric patients angina in adults
2. Monitor blood pre because there is an
increased risk of hypotensive episodes.
Initially 1-2 mg/h
3. If a patient is on long-term therapy, periodically by IV infusion, Reduction of blood
monitor blood pressure and cardiac rhythm CLEVIDIPINE titrate quickly by pressure when
while the patient is using these drugs because (CLEVIPREX) doubling the dose oral therapy is not
of the potential for adverse cardiovascular every 90 s, usual possible or
effects. maintenance desirable
4. Provide comfort measures to help the patient dose 4-6 mg/h
tolerate drug effects. These include small,
frequent meals to alleviate gastrointestinal (GI)
Extended-release
upset; environmental controls, such as limiting
DILTIAZEM 60-120 mg PO preparation used
light, maintaining temperature, and avoiding (CARDIZEM, b.i.d. to treat
excessive noise and interruptions, which could DILACOR CR) hypertension in
aggravate stress and increase myocardial adults, other
demand; and taking safety precautions, such as preparations are
providing periodic rests and assisting with used for Angina
ambulation if dizziness occurs, to prevent
injury. Used alone or in
10-15 mg/d PO, do combination with
5. Offer support and encouragement to help the not exceed 10 mg/d
FELODIPINE other agents for
patient deal with the diagnosis and the drug in geriatric patients
(PLENDI) treatment of
regimen. or in patients with
hypertension in
hepatic impairment
adults

7 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

VASODILATORS
DRUG NAME USUAL DOSAGE USUAL - They are reserved for use in severe
INDICATIONS hypertension or hypertensive emergencies.
- Examples are Hydralazine (Apresoline),
Used alone or in
Minoxidil (Loniten), and Nitroprusside
ISRADIPINE 2.5- 10 mg PO combination with
(Nitropress).
(DynaCirc) b.i.d; 5- 10 mg/d thiazide diuretics
PO – controlled for treatment of
release hypertension in THERAPEUTIC ACTION
adults - Act directly on vascular smooth muscle to
20-40 mg PO cause muscle relaxation, leading to
t.i.d.; 0.5-2.2 mg/h vasodilation and drop in blood pressure.
IV based on Used alone or in - They do not block the reflex tachycardia that
response, switch combination with
occurs when blood pressure drops.
to oral form as other agents for
NICARDIPINE soon as feasible; treatment of
(CARDENE) reduce dose in hypertension and
DRUG NAME USUAL DOSAGE USUAL
geriatric patients angina, IV form for
INDICATIONS
and in patients short-term use
with hepatic or when oral route is
renal impairment; not feasible, for Adult: 20-40 mg
30-60 mg PO use in adults IM or IV repeated Treatment of
b.i.d.-sustained HYDRALAZINE as necessary severe
(APRESOLINE) Pediatric: 1.7-3.5 hypertension
release
mg/kg per 24 h IV
Extended-release
or IM in four to six
preparations only
divided doses
NIFEDIPINE 30-60 mg/d PO for the treatment
Treatment of
(Procardia XL) of hypertension in
Adult: 10-40 mg/d severe
adults, other
MINOXIDIL PO in divided hypertension
preparations are
(LONITEN) doses Pediatric unresponsive
used for angina
(<12 yl: 0.25-1 to other
mg/kg/d PO as a therapy
Extended-release
single dose
tablets used as
20–40 mg/d PO; monotherapy or as
Treatment of
reduce dose in part of
Adult and hypertensive
NISOLDIPINE geriatric patients combination
NITROPRUSSIDE pediatric crisis, also
(SULAR) and in patients therapy for
(NITROPRESS) patients: 3 used to
with hepatic treatment of
mcg/kg/min, do maintain
impairment hypertension in
not exceed 10 controlled
adults, other
mcg/kg/min hypotension
preparations are
during surgery
used for angina

Extended-release
formulations for PHARMACOKINETICS
120-240 mg/d PO, the treatment of - Nitroprusside is used intravenously;
VERAPAMIL reduce dose in the essential hydralazine is available for oral, intravenous,
(Calan SR) morning, hypertension, and intramuscular use.
extended-release other preparations - Minoxidil is available as an oral agent only.
capsules: 100-300 are used for
- These drugs are rapidly absorbed and widely
mg/d PO at angina and
distributed.
bodtimo treating various
arrhythmias in
- They are metabolized in the liver and primarily
adults excreted in urine.
- They cross the placenta and enter breast milk.

8 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
CONTRAINDICATIONS
- Caution should be used in patients with
peripheral vascular disease, CAD, heart failure,
or tachycardia, all of which could be
exacerbated by the fall in blood pressure.
- These drugs are also contraindicated with
pregnancy unless the benefit t to the mother
clearly outweighs the potential risk.
ADVERSE EFFECTS
- Dizziness, anxiety, and headache; reflex
tachycardia, heart failure, chest pain, and
edema; skin rash and lesions (abnormal hair
growth with minoxidil).
- GI upset, nausea, and vomiting.
- Cyanide toxicity (dyspnea, headache, vomiting,
dizziness, ataxia, loss of consciousness,
imperceptible pulse, absent reflexes, dilated
pupils, pink color, distant heart sounds, and
shallow breathing) may occur with
nitroprusside, which is metabolized to cyanide
and suppresses iodine uptake and can cause
hypothyroidism.
ASSESSMENT: History and Examination
- Assess for the following conditions, which could
be cautions or contraindications to use of the
drug: any known allergies to these drugs,
impaired kidney or liver function, pregnancy or
lactation because of the potential adverse
effects on the fetus or neonate, and
cardiovascular dysfunction, which could be
exacerbated by a fall in blood pressure.
- Assess baseline status before beginning
therapy to determine any potential adverse
effects; this includes body temperature and
weight; skin color, lesions, and temperature;
pulse, blood pressure, baseline
electrocardiogram, and perfusion; respirations
and adventitious breath sounds; bowel sounds
and abdominal examination; renal and liver
function tests; and blood glucose.
NURSING DIAGNOSES
- Nursing diagnoses related to drug therapy
might include the following
➢ Ineffective Tissue Perfusion (Total Body)
related to changes in cardiac output
➢ Impaired Skin Integrity related to
dermatological effects
➢ Acute Pain related to gastrointestinal
distress and cough, skin effects, and
headache
➢ Deficient Knowledge regarding drug
therapy
9 #LabaRN
IMPLEMENTATION WITH RATIONALE
1. Encourage the patient to implement lifestyle
changes, including weight loss, smoking
cessation, decreased alcohol and salt in the
diet, and increased exercise, to increase the
effectiveness of antihypertensive therapy.
2. Monitor blood pressure closely during
administration to evaluate for effectiveness and
to ensure quick response if blood pressure falls
rapidly or too much.
3. Monitor blood glucose and serum electrolytes
to avoid potentially serious adverse effects.
4. Monitor the patient carefully in any situation that
might lead to a drop in fluid volume (e.g.,
excessive sweating, vomiting, diarrhea,
dehydration) to detect and treat excessive
hypotension that may occur.
5. Provide comfort measures to help the patient
tolerate drug effects, including small, frequent
meals; access to bathroom facilities; safety
precautions if CNS effects occur; environmental
controls; appropriate skin care as needed; and
analgesics as needed.
6. Provide thorough patient teaching, including the
name of the drug, dosage prescribed,
measures to avoid adverse effects, warning
signs of problems, and the need for periodic
monitoring and evaluation, to enhance patient
knowledge about drug therapy and to promote
compliance
7. Offer support and encouragement to help the
patient deal with the diagnosis and the drug
regimen.
EVALUATION
- Monitor patient response to the drug
(maintenance of blood pressure within normal
limits).
- Monitor for adverse effects (hypotension, GI
distress, skin reactions, tachycardia, headache,
dizziness).
- Evaluate the effectiveness of the teaching plan
(patient can name drug, dosage, adverse
effects to watch for, specific measures to avoid
them, and the importance of continued follow-
up).
- Monitor the effectiveness of comfort measures
and compliance with the regimen.
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

RENIN INHIBITORS MECHANISM OF ACTION

MECHANISM OF ACTION
- Representative drug is Aliskiren (Tekturna).
- Inhibition of renin leads to decreased plasma
renin activity and inhibits the conversion of
angiotensinogen to angiotensin I.
- Inhibition of RAAS leads to decreased blood
pressure, decreased aldosterone release, and
decreased sodium reabsorption
PHARMACOKINETICS
- It is slowly absorbed from the GI tract, with peak
levels in 3 hours.
- It is metabolized in the liver, with a half- life of
24 hours, and is excreted in the urine.
- It crosses the placenta and enters the breast
milk.
CONTRAINDICATIONS
- It should be avoided in the second and third
trimesters of pregnancy and used in the first
trimester only if the benefit clearly outweighs
the risk.
- Women who are breastfeeding should find
another method of feeding the baby if this drug
is needed.
NURSING RESPONSIBILITIES
- Monitor potassium levels due to risk of
hyperkalemia.
- If combined with furosemide, there may be a
loss of diuretic effect
- Monitor client for cases of angioedema with
respiratory involvement.
- Report any dyspnea, or swelling of the face,
lips, or tongue
- Block vasoconstriction, decrease heart rate,
decrease cardiac muscle contraction, and tend
to increase blood flow to the kidneys, leading to
a decrease in the release of renin.
- These drugs have many adverse effects and
are not recommended for all people.
- They are often used as monotherapy.
b. ALPHA & BETA BLOCKERS
- Useful in conjunction with other agents and
tend to be somewhat more powerful, blocking
all of the receptors in the sympathetic system.
- Patients often complain of fatigue, loss of libido,
inability to sleep, and GI and genitourinary
disturbances.
- Representative drugs include
✓ Carvedilol (Coreg)
✓ Guanabenz (Wytensin)
✓ Labetalol (Normodyne, Trandate).
c. ALPHA-ADRENERGIC BLOCKERS
- Inhibit the postsynaptic alpha1-adrenergic
receptors, decreasing sympathetic tone in the
vasculature and causing vasodilation, which
leads to a lowering of blood pressure.
- However, these drugs also block presynaptic
alpha2-receptors, preventing the feedback
control of norepinephrine release
- The result is an increase in the reflex
tachycardia that occurs when blood pressure
decreases.
- These drugs are used to diagnose and manage
episodes of pheochromocytoma.
- Representative agents include
Phenoxybenzamine (Dibenzyline) and
phentolamine (Regitine).

SYMPHATETIC NERVOUS SYSTEM BLOCKERS d. ALPHA 1 BLOCKERS

- It can block the postsynaptic alpha1-receptor
a. BETA BLOCKERS (olol) sites.
✓ Acebutolol (Sectral) - This decreases vascular tone and promotes
✓ Atenolol (Tenormin) vasodilation, leading to a fall in blood pressure.
✓ Betaxolol (Kerlone) - These drugs do not block the presynaptic
✓ Bisoprolol (Zebeta) alpha2-receptor sites, and therefore, the reflex
✓ Carteolol (Cartrol) tachycardia that accompanies a fall in blood
✓ Metoprolol (Lopressor) pressure does not occur.
✓ Nadolol (Corgard) - It includes the following agents:
✓ Nebivolol (Bystolic) ✓ Doxazosin (Cardura),
✓ Penbutolol (Levator) ✓ Prazosin (Minipress)
✓ Pindolol (Visken) ✓ Terazosin (Hytrin).
✓ Propranolol (Inderal)
✓ Timolol (Blocadren)
e. ALPHA 2 AGONIST
- It stimulates the alpha2-receptors in the CNS
and inhibit the cardiovascular centers, leading

10 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
to a decrease in sympathetic outflow from the
CNS and a resultant drop in blood pressure.
- Associated with many adverse CNS and GI
effects, as well as cardiac dysrhythmias.
- It includes Clonidine (Catapres), Guanfacine
(Tenex), and methyldopa (generic).
KEY POINTS:
- Hypertension is a sustained state of higher-than
normal blood pressure that can lead to blood
vessel damage, atherosclerosis, and damage
to small vessels in end organs.
- The cause of essential hypertension is
unknown; treatment varies among individuals.
- Drug treatment of hypertension aims to change
one or more of the normal reflexes that control
blood pressure.
- Sodium levels and fluid volume are decreased
by diuretic agents.
- ACE inhibitors prevent the conversion of
angiotensin I to angiotensin II, leading to a fall
in blood pressure.
- ARBs prevent the body from responding to
angiotensin II, causing a loss of effectiveness of
the renin angiotensin system.
- Calcium channel blockers interfere with the
ability of muscles to contract, which leads to
vasodilation, which in turn reduces blood
pressure.
11
ANTI-HYPOTENSIVE MEDICATIONS
HYPOTENSION
- Vital centers in the brain and the rest of the
tissues of the body may not receive sufficient
oxygenated blood to continue functioning.
- It puts the body in serious jeopardy; it is often
an acute emergency situation, with treatment
required to save the patient’s life.
VASOPRESSORS/ SYMPHATOMIMETICS
- Otherwise known as “Symphatetic Adrenergic
Agonist”.
- React with sympathetic adrenergic receptors to
cause the effects of a sympathetic stress
response: increased blood pressure, increased
blood volume, and increased strength of
cardiac muscle contraction.
- These actions increase BP and may restore
balance to the cardiovascular system while the
underlying cause of the shock (e.g., volume
depletion, blood loss) is treated.
- First choice for treating severe hypotension or
shock.
REPRESENTATIVE AGENTS
✓ Dobutamine (Dobutrex)
✓ Dopamine (Intropin)
✓ Ephedrine (generic)
✓ Epinephrine (Adrenalin, EpiPen)
✓ Isoproterenol (Isuprel)
✓ Norepinephrine (Levophed)
✓ Phenylephrine (Neo-Synephrine)
ADVERSE EFFECTS
- Decreased GI activity with nausea and
constipation, increased respiratory rate and
changes in BP, headache, and changes in
peripheral blood flow with numbness, tingling,
and even gangrene in extreme cases.
- It should be used with caution with any disease
that limits blood flow, with tachycardia, or with
hypertension.
ALPHA SPECIFIC ADRENERGIC AGENTS
- Midodrine (ProAmatine) is used to treat
orthostatic hypotension— hypotension that
occurs with position change—that interferes
with a person’s ability to function and has not
responded to any other therapy.
THERAPEUTIC ACTIONS
- It activates alpha-receptors in arteries and
veins to produce an increase in vascular tone
and an increase in blood pressure.
- It is indicated for the symptomatic treatment of
orthostatic hypotension.
#LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
PHARMACOKINETICS
- Rapidly absorbed from the GI tract, reaching
peak levels within 1 to 2 hours.
- It is metabolized in the liver and excreted in the
urine with a half-life of 3 to 4 hours.
- Caution should be used during lactation.
CONTRAINDICATIONS
- Contraindicated in the presence of supine
hypertension, CAD, or pheochromocytoma
because of the risk of precipitating a
hypertensive emergency.
- Acute renal disease, urination retention,
pregnancy, and lactation.
- with visual problems
ADVERSE EFFECTS
- Piloerection, chills, and rash
- Hypertension and bradycardia
- Dizziness, vision changes, vertigo
- Headache; and problems with urination.
DRUG- DRUG INTERACTIONS
- There is a risk of increased effects and toxicity
of cardiac glycosides, beta- blockers, alpha-
adrenergic agents, and corticosteroids if they
are taken with midodrine.
- Dose adjustment is necessary.
ASSESSMENT: HISTORY AND EXAMINATION
- Assess for the following conditions, which could
be contraindications or cautions: any known
allergy to midodrine to prevent hypersensitivity
reactions; impaired kidney or liver function,
which could interfere with metabolism and
excretion of the drugs; pregnancy or lactation
because of the potential adverse effects on the
fetus or neonate; cardiovascular dysfunction;
visual problems; urinary retention; and
pheochromocytoma, which could be
exacerbated by the effects of the drugs.
- Assess baseline status before beginning
therapy to determine any potential adverse
effects; this includes body temperature and
weight; skin color, lesions, and temperature;
pulse, blood pressure, orthostatic blood
pressure, and perfusion; respiration and
adventitious sounds; bowel sounds and
abdominal examination; and renal and liver
function tests.
12
NURSING DIAGNOSES
- Nursing diagnoses related to drug therapy
might include the following:
➢ Ineffective Tissue Perfusion (Total Body)
related to changes in cardiac output
➢ Disturbed Sensory Perception (Visual,
Kinesthetic, Tactile) related to central
nervous system (CNS) effects
➢ Acute Pain related to gastrointestinal
distress, piloerection, chills, or headache
➢ Deficient Knowledge regarding drug
therapy
IMPLEMENTATION WITH RATIONALE
1. Monitor blood pressure carefully to monitor
effectiveness and blood pressure changes.
2. Do not administer the drug to patients who are
bedridden, but only to patients who are up and
mobile, to ensure therapeutic effects and
decrease the risk of severe hypertension.
3. Monitor heart rate regularly when beginning
therapy to monitor for bradycardia, which
commonly occurs at the beginning of therapy; if
bradycardia persists, it may indicate a need to
discontinue the drug.
4. Monitor patient with known visual problems
carefully to ensure that the drug is discontinued
if visual fields change.
5. Encourage the patient to void before taking a
dose of the drug to decrease the risk of urinary
retention problems.
6. Provide comfort measures to help the patient
tolerate drug effects, including small, frequent
meals; access to bathroom facilities; safety
precautions if CNS effects occur; environmental
controls; appropriate skin care as needed; and
analgesics as needed.
EVALUATION
- Monitor patient response to the drug
(maintenance of blood pressure within normal
limits).
- Monitor for adverse effects (hypertension,
dizziness, visual changes, piloerection, chills,
urinary problems).
- Evaluate the effectiveness of the teaching plan
(patient can name drug, dosage, adverse
effects to watch for, specific measures to avoid
them, and the importance of continued follow-
up).
- Monitor the effectiveness of comfort measures
and compliance with the regimen.
#LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
CARDIOTONIC MEDICATIONS
CARDIOTONIC MEDICATIONS
- Drugs used to increase the contractility of the
heart muscle for patients experiencing heart
failure.
MECHANISM OF ACTIONS
- Inotropic drugs affect the intracellular calcium
levels in the heart muscle, leading to increased
contractility.
- This increase in contraction strength leads to
increased cardiac output, which causes
increased renal blood flow and increased urine
production.
- Increased renal blood flow decreases renin
release, interfering with the effects of the
RAAS, and increases urine output, leading to
decreased blood volume.
- The result is a decrease in the heart’s workload
and relief of HF.
CARDIAC GLYCOSIDES
- Originally derived from the foxglove or digitalis
plant.
- These plants were once ground up to make
digitalis leaf.
- Digoxin (Lanoxin) is the drug most often used
to treat heart failure.
ACTIONS & INDICATIONS
- Digoxin increases intracellular calcium and
allows more calcium to enter myocardial cells
during depolarization.
- This results to increased force of myocardial
contraction (positive inotropic effect).
- Increased cardiac output and renal perfusion.
- Slowed heart rate, owing to slowing of the rate
of cellular repolarization (negative chronotropic
effect)
- Decreased conduction velocity through the
atrioventricular (AV) node.
- Indicated for the treatment of HF, atrial flutter,
atrial fibrillation, and paroxysmal atrial
tachycardia.
- It has a very narrow margin of safety.
PHARMACOKINETICS
- It can be for oral and parenteral administration.
- It has a rapid onset of action and rapid
absorption (30–120 minutes when taken orally,
5–30 minutes when given intravenously).
- Primarily excreted unchanged in the urine.
- Because of this, caution should be exercised in
the presence of renal impairment because the
drug may not be excreted and could
accumulate, causing toxicity.
13
CONTRAINDICATIONS
- Patients with ventricular tachycardia or
fibrillation, which are potentially fatal
arrhythmias and should be treated with other
drugs.
- Heart block or sick sinus syndrome, which
could be made worse by slowing of conduction
through the AV node.
- Renal insufficiency because the drug is
excreted through the kidneys and toxic levels
could develop.
- Idiopathic hypertrophic subaortic stenosis
(IHSS) because the increase in force of
contraction could obstruct the outflow tract to
the aorta and cause severe problems.
- Acute MI because the increase in force of
contraction could cause more muscle damage
and infarct
- Electrolyte abnormalities (increased calcium,
decreased potassium, decreased magnesium),
which could alter the action potential and
change the effects of the drug.
ADVERSE EFFECTS
- Headache, weakness, drowsiness, and vision
changes (a yellow halo around objects).
- GI upset, anorexia, arrhythmias, ventricular
tachycardia, malaise, depression.
- ANTIDOTE: Digoxin Immune Fab (DigiFab).
Digoxin immune Fab (DigiFab)
- is an antigen-binding fragment (Fab) derived
from specific antidigoxin antibodies. These
antibodies bind molecules of digoxin, making
them unavailable at their site of action. The
digoxin antibody-antigen complexes
accumulate in the blood and are excreted
through the kidney. Digoxin immune Fab is
used for the treatment of life-threatening
digoxin intoxication (serum levels >10 ng/mL
with serum potassium >5 mEq/L in a setting of
digoxin intoxication) and potential life-
threatening digoxin overdose.
- The amount of digoxin immune Fab that is
infused intravenously is determined by the
amount of digoxin ingested or by the serum
digoxin level if the ingested amount is unknown.
The patient's cardiac status should be
monitored continually while the drug is given
and for several hours after the infusion is
finished. Because there is a risk of
hypersensitivity reaction to the infused protein,
life-support equipment should be on standby.
- Serum digoxin levels will be very high and
unreliable for about 3 days after the digoxin
immune Fab infusion because of the high levels
of digoxin in the blood. The patient should not
be redigitalized for several days to 1 week after
#LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
digoxin immune Fab has been use because of
the potential of remaining fragments in the
blood.
DRUG- DRUG INTERACTIONS
- Increased therapeutic effects and toxic if it is
taken with verapamil, amiodarone, quinidine,
quinine, erythromycin, tetracycline, or
cyclosporine.
- If combined with any of these drugs, it may be
necessary to decrease the digoxin dose to
prevent toxicity.
- The risk of cardiac arrhythmias could increase
if these drugs are taken with potassium-losing
diuretics. Check potassium levels regularly.
- Less effective if it is combined with thyroid
hormones, metoclopramide, or penicillamine,
and increased digoxin dose may be needed.
- Absorption of oral digoxin may be decreased if
it is taken with cholestyramine, charcoal,
colestipol, antacids, bleomycin,
cyclophosphamide, or methotrexate.
- If it is used in combination with any of these
agents, administer 2 to 4 hours apart.
- St. John’s wort and psyllium have been shown
to decrease the effectiveness of digoxin.
- Increased digoxin toxicity has been reported
with ginseng, hawthorn, and licorice.
NURSING DIAGNOSES
- Nursing diagnoses related to drug therapy
might include the following:
➢ Risk for Imbalanced Fluid Volume related
to increased renal perfusion secondary to
effects of the drug
➢ Decreased Cardiac Output related to
ineffective cardiac muscle function
➢ Ineffective Tissue Perfusion (Total Body)
related to change in cardiac output
➢ Impaired Gas Exchange related to
changes in cardiac output
➢ Deficient Knowledge related to prescribed
drug therapy
NURSING CONSIDERATIONS
- Monitor apical pulse for 1 full minute before
administering the drug.
- Hold the dose if the pulse is less than 60
beats/min in an adult or less than 90 beats/min
in an infant.
- If the pulse remains low after one hour, withhold
the drug, and notify the prescriber because this
could indicate digoxin toxicity.
- Administer IV doses very slowly over at least 5
minutes to avoid cardiac arrhythmias.
- Avoid IM doses are painful.
- Weight daily to rule out fluid retention and check
for edema
14
- Have the cardiac monitor standby, have
potassium salts and lidocaine for arrhythmias,
phenytoin for seizure, atrophine to increase
heart rate.
- Monitor the patient for therapeutic digoxin level
(0.5–2 ng/mL).
- Small, frequent meals to help alleviate GI upset
or nausea, access to bathroom privileges due
to increased urination related to increased
cardiac output.
- Must have adequate room lighting due to vison
changes (yellow halo around objects).
PHOSPHODIESTERASE INHIBITORS
- It belongs to a second class of drugs that act as
cardiotonic (inotropic) agents.
- These include milrinone (Primacor).
- Indicated for the short-term treatment of HF that
has no or poor response to digoxin, diuretics,
and vasodilators.
MECHANISM OF ACTION
- It blocks the enzyme phosphodiesterase that
leads to an increase in myocardial cell cyclic
adenosine monophosphate (cAMP), which
increases calcium levels in the cell.
- Increased cellular calcium causes a stronger
contraction and prolongs the effects of
sympathetic stimulation, which can lead to
vasodilation, increased oxygen consumption,
and arrhythmias.
- Because these drugs have been associated
with the development of potentially fatal
ventricular arrhythmias, their use is limited to
severe situations.
PHARMACOKINETICS
- Inamrinone and milrinone are available only for
intravenous use.
- These drugs are widely distributed after
injection.
- They are metabolized in the liver and excreted
primarily in the urine.
CONTRAINDICATIONS
- They also are contraindicated in the following
conditions: severe aortic or pulmonic valvular
disease.
- Acute myocardial infarction, fluid volume deficit,
and ventricular arrhythmias.
- Caution in giving to elderlies.
ADVERSE EFFECTS
- Ventricular arrhythmias, ventricular fibrillation,
hypotension, and chest pain.
- Nausea, vomiting, anorexia, and abdominal
pain.
#LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

- Thrombocytopenia and burning in the IV site. ANTI-ANGINAL MEDICATIONS

- Hypersensitivity reactions associated with
these drugs include vasculitis, pericarditis,
pleuritis, and ascites.
DRUG- DRUG INTERACTIONS
- Precipitates form when these drugs are given in
solution with furosemide.
- Avoid this combination in solution.
- Use alternate lines if both of these drugs are
being given intravenously.
NURSING ACTIONS
- Protect the drug from light to prevent drug
degradation.
- Assess skin for signs of thrombocytopenia.
- Check platelets regularly to check dose
adequacy.
- Watch closely BP and HR for toxicity.
- Check IV site for burning or irritation.
- Drugs used to restore the appropriate supply-
and- demand ratio in oxygen delivery to the
myocardium.
NITRATES
- Drugs that act directly on smooth muscle to
cause relaxation and to depress muscle tone.
- Because the action is direct, these drugs do not
influence any nerve or other activity, and the
response is usually quite fast.
- It includes
✓ amyl nitrate (generic)
✓ isosorbide dinitrate (Isordil)
✓ isosorbide mononitrate (Imdur, Monoket)
✓ nitroglycerin (Nitro-Bid, Nitrostat).
DRUG NAME USUAL DOSAGE USUAL
INDICATIONS

AMYL NITRATE 0.3 mL by Relief of acute

(GENERIC) inhalation of vapor, anginal pain in
may be repeated in adults
3–5 min

• 2.5–5 mg
sublingual Taken before
(SL) chest pain
ISOSORBIDE • 5 mg begins in
DINITRATE chewable situations in
(ISORDIL) tablet which exertion
• 5–20 mg PO or stress can
• maintenance be anticipated
10–40 mg PO for prevention
q6h or 40–80 of angina in
mg PO adults; taken
sustained daily for
release q8– management
12h of chronic
• Acute angina
prophylaxis:
5–10 mg SL or
chewable
tablets q2–3h

15 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

DRUG NAME USUAL DOSAGE USUAL • doses as high

INDICATIONS as 26 mg PO
q.i.d. have
been used
• 0.5 inches q8h
• 2.5–5 mg for topical
sublingual Taken before application, up
(SL) chest pain to 4–5 inches
ISOSORBIDE • 5 mg begins in (1 inch = 15
MONONITRATE chewable situations in mg) have been
(IMDUR, tablet which exertion used
MONOKET) • 5–20 mg PO or stress can • one pad (60–
• maintenance be anticipated 75 mg) has
10–40 mg PO for prevention been used
q6h or 40–80 of angina in • one pad
mg PO adults; taken transdermal
sustained daily for system per day
release q8– management • 1 mg q3–5h
12h of angina while awake
• Acute for
prophylaxis: transmucosal
5–10 mg SL or system
chewable
tablets q2–3h

THERAPEUTIC ACTIONS
• 5 mcg/min via - Nitrates relax and dilate veins, arteries, and
IV infusion capillaries, allowing increased blood flow through the
pump every 3– vessels and lowering systemic blood pressure
5 min. because of a drop in resistance.
• one tablet SL - Therefore, the blood supply through any healthy
every 5 min for vessels in the heart increases, possibly helping the
acute attack, heart to compensate.
up to three - The main effect seems to be related to the drop in
tablets in 15 blood pressure that occurs.
min - The vasodilation causes blood to pool in veins and
• 0.4-mg capillaries, decreasing preload, while the relaxation
metered dose of the vessels decreases afterload.
translingual, - It greatly reduces the cardiac workload and the
up to three demand for oxygen, thus bringing the supply and
doses in 15 demand ratio back into balance.
NITROGLYCERIN min for acute Nitrate of - Indicated for the prevention and treatment of attacks
(NITROBID, attacks choice for of angina pectoris.
NITROSTAT, treatment of
OTHERS) Prevention: acute angina
PHARMACOKINETICS
• one tablet attack;
prevention of - Nitroglycerin is available as a sublingual tablet, a
(0.3–0.6 mg)
anginal translingual spray, an intravenous solution (for bolus
sublingually 5–
attacks injection or infusion), a transdermal patch, a topical
10 min before
ointment or paste, or a transmucosal agent
activities that
- Slow-release forms also are available for use in
might
preventing anginal attacks.
precipitate an
- Amyl nitrate is supplied as a capsule that is broken
attack:
and waved under the patient’s nose for inhalation
• 2.5–9 mg PO
and has an onset of action of about 30 seconds.
of sustained
- Isosorbide dinitrate and isosorbide mononitrate are
release (SR)
available in oral form; has an onset of action in 14 to
tablet q8–12h
45 minutes, or up to 4 hours if the sustained-release
(SR) form is used.
- The drug may have a duration of action of 4 to 6
hours, or 6 to 8 hours if the SR form is used
- Nitrates are very rapidly absorbed, metabolize in the
liver, and excreted in urine.

16 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS
SUBLINGUAL ADMINISTRATION
- Patients often prefer this route of administration,
opting to administer the drug themselves even in the
institutional setting. Make sure that the drug is given
correctly:
✓ Check under the tongue to make sure there are
no lesions or abrasions that could interfere with
the absorption of the drug. Have the patient
take a sip of water to moisten the mucous
membranes so the tablet will dissolve quickly.
Then instruct the patient to place the tablet
under the tongue, close the mouth, and wait
until the tablet has dissolved.
✓ Caution the patient not to swallow the tablet; its
effectiveness would be lost if the tablet entered
the stomach. If the patient uses translingual
drugs often, encourage the patient to alternate
sides of the tongue—placing it under the left
side for one dose and under the right side for
the other dose.
✓ Here’s a tip to help in administering sublingual
medications to patients who cannot do it
themselves or who cannot open their mouths:
Use a tongue depressor to move the tongue
aside and place the tablet or slide the tablet
down through a straw to the underside of the
tongue.
TRANSBUCCAL ADMINISTRATION
- Make sure that the tablet the patient is going to use
is designed for buccal administration:
✓ Check the inside of the cheeks to be sure there
are no ulcerations or abrasions that could
interfere with the absorption of the drug. Have
the patient place the tablet between his or her
gums and cheek pocket and then hold it in
place until the tablet dissolves.
✓ Again, caution the patient not to swallow the
tablet, and instruct the patient to rotate the site
of placement from side to side with each dose
TRANSDERMAL ADMINISTRATION:
- Errors have been reported with inappropriate use of
nitroglycerin patches and nitroglycerin paste. Make
sure to discuss safe administration with the patient:
✓ It is very important, even if it seems like
common sense, to teach patients to remove the
old transdermal system and to wash the area
before placing a new system to prevent
adverse effects such as severe hypotension.
✓ Urge patients who are given tubes of
nitroglycerin paste to label tubes clearly in large
letters and to store them safely away from other
people in a secure place. This prevents
accidental misuse of nitroglycerin paste for
hand cream, which can result in a toxic dose of
the drug.
17
CONTRAINDICATIONS
- Severe anemia because the decrease in cardiac
output could be detrimental in a patient who already
has a decreased ability to deliver oxygen because of
a low RBC count
- Head trauma or cerebral hemorrhage because the
relaxation of cerebral vessels could cause
intracranial bleeding.
- Caution for patients with hypotension,
hypovolemia, and conditions that limit cardiac
output (e.g., tamponade, low ventricular filling
pressure, low pulmonary capillary wedge pressure).
- patients with renal and liver disease, pregnant and
lactating mothers.
ADVERSE EFFECTS
- Headache, dizziness, and weakness, nausea,
vomiting, and incontinence.
- Hypotension, reflex tachycardia that occurs when
blood pressure falls; syncope; and angina, which
could be exacerbated by the hypotension and
changes in cardiac output.
- Skin flushing, pallor, and increased perspiration.
local hypersensitivity reactions.
DRUG-DRUG INTERACTIONS
- Risk of hypertension and decreased antianginal
effects if these drugs are given with ergot derivatives.
- Risk of decreased therapeutic effects of heparin if
combined with this drug. Dose adjustments should
be made.
- Not be combine with sildenafil, tadalafil, or vardenafil,
drugs used to treat erectile dysfunction, because
serious hypotension and cardiovascular events
could occur.
NURSING ACTIONS
- Check skin quality for transdermal or topical use; oral
mucosa for sublingual or buccal forms used.
- Assess the patient’s complaint of pain, including
onset, duration, intensity, location, and measures
used to relieve it.
- Investigate activity level prior to and after the onset
of pain.
- Assess the patient’s neurological status, including
level of alertness, affect, and reflexes.
- Monitor respirations and auscultate lungs closely.
- Obtain an electrocardiogram as ordered.
- Protect the medication from heat and light because
these drugs are volatile and lose their potency.
- Instruct the patient that a sublingual dose may be
repeated in 5 minutes if relief is not felt, for a total of
three doses if MI persist.
- Rotate the sites of topical forms to decrease the risk
of skin abrasion and breakdown.
- Make sure that translingual spray is used under the
tongue and not inhaled.
- Break an amyl nitrate capsule and wave it under the
nose of the angina patient to provide rapid relief
using the inhalation form of the drug; this may be
repeated with another capsule in 3 to 5 minutes if
needed.
#LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

- Keep a record of the number of sprays used if a cardiac oxygen consumption, and lowering of blood
translingual spray form is used. pressure.
- Have emergency life support equipment readily - Indicated for the long-term management of angina
available. pectoris caused by atherosclerosis.
- Taper the dose gradually (over 4 to 6 weeks) after - sometimes used in combination with nitrates to
long-term therapy because abrupt withdrawal could increase exercise tolerance.
cause a severe reaction, including MI. - Not indicated for the treatment of Prinzmetal angina
- Give SR forms with water and caution the patient not because they could cause vasospasm due to
to chew or crush them. blocking of beta-receptor sites.
- Propranolol and metoprolol can also be used to
BETA-ADRENERGIC BLOCKERS prevent reinfarction in stable patients 1 to 4 weeks
- Used to block the stimulatory effects of the after an MI.
sympathetic nervous system. - This effect is thought to be caused by the
- The beta-blockers recommended for use in angina suppression of myocardial oxygen demand for a
include prolonged period.
✓ metoprolol (Toprol)
✓ propranolol (Inderal)
✓ nadolol (Corgard). PHARMACOKINETICS
- Absorbed from the GI tract after oral administration
and undergo hepatic metabolism.
DRUG NAME USUAL USUAL - Reach peak levels in 60 to 90 minutes and have
DOSAGE INDICATIONS varying duration of effects, ranging from 6 to 19
hours.
- Food has been found to increase the bioavailability
• 100 mg/d of propranolol, but this effect has not been found with
METOPROLOL PO as single Treatment of other beta-adrenergic blocking agents.
(TOPROL, dose, angina in adults;
TOPROL XL) extended- prevention of
release reinfarction CONTRAINDICATIONS
tablet within 3–10 d
- Patients with bradycardia, heart block, and
• 100–400 after myocardial
cardiogenic shock because blocking of the
mg/d PO in infarction (MI)
sympathetic response could exacerbate these
two divided diseases.
doses - Patients with diabetes, peripheral vascular disease,
regular asthma, COPD, or thyrotoxicosis because the
release blockade of the sympathetic response blocks normal
reflexes that are necessary for maintaining
homeostasis in patients with these diseases.
40–80 mg/d PO
NADOLOL Long-term ADVERSE EFFECTS
(CORGARD) management of
- Dizziness, fatigue, emotional depression, and sleep
angina in adults
disturbances, gastric pain, nausea, vomiting, colitis,
and diarrhea, HF, reduced cardiac output, and
arrhythmias, bronchospasm, dyspnea, and cough,
• 10–20 mg
decreased exercise tolerance and malaise are also
PO t.i.d. to Long-term
common complaints.
PROPRANOLOL q.i.d., titrate management of
(INDERAL) based on angina and
DRUG- DRUG INTERACTIONS
patient prevention of
response reinfarction in - A paradoxical hypertension occurs when clonidine is
• 160 mg/d is patients 1– 4 wk given.
often after MI in - Increased rebound hypertension with clonidine
needed for adults withdrawal may also occur; it is best to avoid this
maintenance combination.
- A decreased antihypertensive effect occurs when
betablockers are given with NSAIDs; closely monitor
THERAPEUTIC ACTIONS and adjust dose.
- An initial hypertensive episode followed by
- Competitively block beta-adrenergic receptors in the bradycardia occurs if these drugs are given with
heart and juxtaglomerular apparatus, decreasing the epinephrine, and a possibility of peripheral ischemia
influence of the sympathetic nervous system on exists if betablockers are taken in combination with
these tissues. ergot alkaloids.
- The result is a decrease in the excitability of the - Blood glucose imbalance is noted if these drugs are
heart, a decrease in cardiac output, a decrease in given with insulin or antidiabetic agents.

18 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

PIPERAZINEACETAMIDE AGENT NURSING ACTIONS

- Ranolazine (Ranexa) is available in an extended- - Patients must be cautioned not to cut, crush, or chew
release tablet form for oral use. the tablets, which need to be swallowed whole.
- Approved as a first-line treatment for angina or for - Safety precautions may be needed if dizziness is an
use in combination with nitrates, beta-blockers, or issue.
amlodipine.
ANTI - ARRHYTHMIC MEDICATIONS
DRUG NAME USUAL USUAL
DOSAGE INDICATIONS
ANTI ARRHYTMIC AGENTS
- Drugs used to use affect the action potential of the
cardiac cells by altering their automaticity,
• 500 mg Treatment of chronic
RANOLAZINE angina in adults, as conductivity, or both.
PO b.i.d.,
(RANEXA) to a primary therapy or in
combination with CLASS I ANTI-ARRHYTHMICS
maximum
1,000 mg nitrates, amlodipine, - Drugs that block the sodium channels in the cell
PO b.i.d. or beta-blockers membrane during an action potential.
- Sub classes includes:
✓ Class Ia: disopyramide (Norpace),
THERAPEUTIC ACTION procainamide (Pronestyl), and quinidine
(generic).
- Added benefits of decreasing blood glucose levels ✓ Class Ib: lidocaine (Xylocaine) and mexiletine
when used in diabetic patients and decreasing the (Mexitil).
incidence of ventricular fibrillation, atrial fibrillation, ✓ Class Ic: flecainide (Tambocor) and
and bradycardia in chronic angina patients. propafenone (Rythmol)
- It does prolong the QT interval, it does not decrease
HR or BP, but it does decrease myocardial workload,
bringing the supply and demand for oxygen back into
DRUG NAME USUAL DOSAGE USUAL
balance.
INDICATION
S
PHARMACOKINETICS
- It is rapidly absorbed, reaching peak levels in 2 to 5 Class Ia
hours.
- It is metabolized in the liver with a half-life of 7 hours • Adult: 400–
and is excreted in urine and feces. 800 mg/d PO
in divided Treatment of
doses q6–12h. life-
CONTRAINDICATIONS DISOPYRAMIDE use lower threatening
- With preexisting prolonged QT interval or in (NORPACE) doses with ventricular
combination with drugs that would prolong QT older patients arrhythmias
intervals. • Pediatric: 6–
- Hepatic and renal impairment, pregnant, and 30 mg/kg/d PO
lactating. in divided
doses q6h,
DRUG- DRUG INTERACTIONS base dose on
- Can occur with ketoconazole, diltiazem, verapamil, age
macrolide antibiotics, and HIV protease inhibitors;
these combinations should be avoided because
ranolazine levels may become extremely high. • Adult: 0.5–1 g Treatment of
- Digoxin levels may become high if the two drugs are intramuscular life-
combined; adjust dose. (IM) q4–8h; threatening
- Decrease dose of tricyclic antidepressants and 500- 600 mg ventricular
antipsychotic drug if these agents are taken with intravenous arrhythmias:
ranolazine. PROCAINAMIDE (IV) over 25– favorable
- Grapefruit juice should be avoided. (PRONESTYL) 30 min, then drug with
2–6 mg/min IV which to start
• Pediatric: 20– treatment
ADVERSE EFFECTS 30 mg/kg/d IM because it is
in divided available in
- Dizziness, headache, nausea, and constipation are
doses IM, IV, and
the most commonly experienced.
oral forms
(can be

19 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

q4–6h; 3–6 switched to

mg/kg IV over oral form) • 150–300 mg Treatment of
5 min, then PO based on life-
20–80 patient threatening
mcg/kg/min IV PROPAFENONE response; start ventricular
(RYTHMOL) with lower arrhythmias in
dose and adults;
• 400–600 mg increase slowly prevention of
PO q2–3h with older PAT in
• 600 mg IM, Treatment of patients symptomatic
then 400 mg atrial patients with
QUINIDINE IM q2h as arrhythmias in no structural
(GENERIC) needed adults heart defect
• 330 mg IV at a
rate of 1
mL/min MECHANISM OF ACTION
- Class I stabilize the cell membrane by binding to
Class lb sodium channels, depressing phase 0 of the action
potential and changing the duration of the action
• Adult: 300 mg Treatment of potential
of 10% life- - Class Ia drugs depress phase 0 of the action
solution IM, threatening potential and prolong the duration of the action
50–100-mg IV ventricular potential.
bolus at the arrhythmias - Class Ib drugs depress phase 0 somewhat and
rate of 20–50 during actually shorten the duration of the action potential.
LIDOCAINE mg/min, 1- to myocardial - Class Ic drugs markedly depress phase 0, with a
(XYLOCAINE) 4-mg/min IV infarction or resultant extreme slowing of conduction, but have
infusion cardiac little effect on the duration of the action potential.
• Pediatric: surgery; also - These drugs are local anesthetics or membrane-
safety and used as bolus stabilizing agents.
efficacy not injection - They bind more quickly to sodium channels that are
established. 1 in open or inactive ones that have been stimulated and
mg/kg IV emergencies are not yet repolarized.
followed by IV when
infusion 30 monitoring is
mcg/kg/min not available PHARMACOKINETICS
has been to document
- Disopyramide is available in oral form.
recommended exact
Procainamide is available in intramuscular and
arrhythmia
intravenous forms.
- Quinidine is also available for oral, IM, or IV
• 200 mg PO Approved
administration and is administered to adults only.
MEXILETINE q8h up to only for use in
- Lidocaine is administered by the IM or IV route and
(MEXITIL) 1,200 mg/d PO life- can also be given as a bolus injection in emergencies
may be threatening when monitoring is not available to document the
needed ventricular exact arrhythmia.
arrhythmias in - Mexiletine is an oral drug administered to adults
adults
only.
- Flecainide and propafenone are available in oral
Class lc form.

• 50–100 mg PO Treatment of
life-threatening
q12h; reduce CONTRAINDICATIONS
ventricular
dose as
arrhythmias in - Patient with bradycardia or heart block unless an
needed with adults; artificial pacemaker is in place because changes in
FLECAINIDE older patients prevention of conduction could lead to complete block.
(TAMBOCOR) or patients with paroxysmal
- Heart failure, hypotension, or shock, which could
renal atrial
tachycardia
be exacerbated by effects on the action potential.
impairment
(PAT) in - Electrolyte disturbances, which could alter the
symptomatic effectiveness of these drugs.
patients with no
structural heart
defect

20 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

ADVERSE EFFECTS
- Dizziness, drowsiness, fatigue, twitching, mouth • Loading dose Short-term
numbness, slurred speech, vision changes, and of 500 management of
tremors that can progress to convulsions. ESMOLOL mcg/kg/min IV, supraventricular
- GI symptoms include changes in taste, nausea, and (BREVIBLOC) then 50 tachycardia
vomiting. mcg/kg/min for (SVT) in adults
- Hypotension, vasodilation, and the potential for 4 min, maintain and tachycardia
cardiac arrest. with IV infusion that is not
- Respiratory and bone marrow depression. 100 responding to
- Moricizine, a class Ia drug, is found to increase mcg/kg/min other measures
cardiac deaths because of its proarrhythmic effects.
- Flecainide is a class Ic drug that was found to
increase the risk of death. • 10–30 mg PO Treatment of
t.i.d. to q.i.d.; supraventricular
1–3 mg IV for tachycardias
DRUG- DRUG INTERACTIONS PROPRANOLO life-threatening caused by
L (INDERAL) arrhythmias, digoxin or
- Risk for arrhythmia increases if these agents are
may repeat in catecholamines
combined with other drugs that are known to cause
2 min, then do in adults; also
arrhythmias, such as digoxin and the beta-blockers.
not repeat for used as an
- Because quinidine competes for renal transport sites
4h antihypertensive,
with digoxin, the combination of these two drugs can
antianginal, and
lead to increased digoxin levels and digoxin toxicity.
antimigraine
- Serum levels and toxicity of the class Ia
headache drug
antiarrhythmics increase if combined with cimetidine.
- Risk of bleeding effects if they are combined with oral
anticoagulants.

THERAPEUTIC ACTIONS
DRUG- FOOD INTERACTIONS - Competitively block beta receptor sites in the heart
and kidneys.
- Requires a slightly acidic urine for excretion.
- The result is a decrease in heart rate, cardiac
- Avoid foods that alkalinize the urine like citrus juices,
excitability, and cardiac output, a slowing of
vegetables, antacids, milk products, which could
conduction through the AV node, and a decrease in
lead to increased quinidine levels and toxicity.
the release of renin.
- Grapefruit juice leads to increased serum levels and
- These effects stabilize excitable cardiac tissue and
toxic effects.
decrease blood pressure, which decreases the
heart’s workload and may further stabilize hypoxic
CLASS II ANTIARRHYTHMICS
cardiac tissue.
- These are beta-adrenergic blockers that block beta-
- These drugs are indicated for the treatment of
receptors, causing a depression of phase 4 of the
supraventricular tachycardias and PVCs
action potential.
- Several beta-adrenergic blockers, such as
✓ acebutolol (Sectral)
PHARMACOKINETICS
✓ esmolol (Brevibloc)
✓ propranolol (Inderal). - Acebutolol is an oral drug. Esmolol is administered
IV. Propranolol may be administered orally or IV.
DRUG NAME USUAL DOSAGE USUAL - Food has been found to increase the bioavailability
INDICATIONS of propranolol.

• 200–600 mg Management of
PO b.i.d., premature CONTRAINDICATIONS
based on ventricular - The presence of sinus bradycardia (rate less than 45
patient contractions in beats/min) and AV block.
response. use adults. - With cardiogenic shock, HF, asthma, or respiratory
ACEBUTOLOL lower doses intraoperative depression.
(SECTRAL) with older and - With diabetes and thyroid dysfunction.
patients; postoperative
decrease dose tachycardia; also
by 50% in used as an
patients with antihypertensive
renal or
hepatic
impairment

21 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

ADVERSE EFFECTS
- Dizziness, insomnia, and fatigue. hypotension, SOTALOL • 80 mg/d PO Treatment of
bradycardia, AV block, arrhythmias, and alterations (BETAPACE, may be titrated adults with life-
in peripheral perfusion, bronchospasm, and BETAPACE AF) to 240–320 threatening
dyspnea. mg/d PO. ventricular
- Nausea, anorexia, constipation, diarrhea, loss of reduce dose in arrhythmias not
libido, decreased exercise tolerance, and alterations patients with responding to any
in blood glucose levels. renal another drug.
impairment Maintenance of
• 80–120 mg PO normal sinus
DRUG - DRUG INTERACTIONS daily to b.i.d. rhythm after
based on conversion of
- Adverse effects increases if these drugs are taken
patient atrial arrhythmias
with verapamil.
response in adults
- Possibility of increased hypoglycemia if taken with
insulin.

THERAPEUTIC ACTIONS
CLASS III ANTIARRHYTHMICS
✓ Amiodarone (Cordarone) - Block potassium channels and slow the outward
✓ dofetilide (Tikosyn) movement of potassium during phase 3 of the action
✓ ibutilide (Corvert) potential, prolonging it.
✓ sotalol (Betapace, Betapace AF) - Amiodarone is the drug of choice for treating
ventricular fibrillation or pulseless ventricular
tachycardia in cardiac arrest situations
DRUG NAME USUAL DOSAGE USUAL
INDICATIONS
PHARMACOKINETICS
- Amiodarone is available in an oral or IV form.
• 800–1,600 Treatment of Dofetilide and sotalol are administered only in oral
mg/d PO in adults with life- form. Ibutilide is given IV.
divided doses threatening - Absorption of sotalol is decreased by the presence
for 1–3 wk, ventricular of food.
AMIODARONE then 600–800 arrhythmias not
(CORDARONE) mg/d PO for 1 responding to
mo; reduce to any other drug; CONTRAINDICATIONS
400 mg/d PO if preferred - Ibutilide and dofetilide should not be used in the
rhythm is antiarrhythmic in presence of AV block.
stable, 1,000 Advanced Cardiac - Presence of shock, hypotension, or respiratory
mg IV over 24 Life Support depression; with a prolonged QTc interval.
h, then 540 mg protocol
IV at 0.5
mg/min for 18– ADVERSE EFFECTS
96 h
- Nausea, vomiting, and GI distress; weakness and
dizziness; and hypotension, HF, and arrhythmia.
- Amiodarone has been associated with a potentially
• 125–500 mcg Conversion of
fatal liver toxicity, ocular abnormalities, and the
PO b.i.d. atrial fibrillation
development of very serious cardiac arrhythmias.
DOFETILIDE based on (AF)/flutter to
(TIKOSYN) creatinine normal sinus
DRUG - DRUG INTERACTIONS
clearance rhythm.
maintenance of - Serious toxic effects if taken with digoxin or
normal quinidine.
sinus rhythm after - Increased risk of proarrhythmias if taken with
conversion for antihistamines, phenothiazines, or tricyclic
adults antidepressants.
- Serious adverse effects if dofetilide is combined with
ketoconazole, cimetidine, or verapamil.
• 1 mg infused Conversion of - Sotalol may have a loss of effectiveness if it is
IBUTILIDE IV over 1 min, recent-onset combined with NSAIDs, aspirin, or antacids.
(CORVERT) may be AF/flutter in adults
repeated in 10 (Most effective if
min if needed the duration of
AF/flutter is <90 d)

22 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

CLASS IV ANTIARRHYTHMICS DRUG - DRUG INTERACTIONS

- Blocks the movement of calcium ions across the cell - Verapamil has been associated with increased risk
membrane, depressing the generation of action of cardiac depression with beta-blockers.
potentials and delaying phases 1 and 2 of - Additive AV slowing with digoxin.
repolarization, which slows automaticity and - Increased serum levels and toxicity of digoxin,
conduction. carbamazepine, prazosin, and quinidine.
- It includes - Increased respiratory depression with atracurium,
✓ diltiazem (Cardizem) pancuronium, and vecuronium; and decreased
✓ verapamil (Calan, Covera-HS). effects if combined with calcium products or rifampin.
- Severe cardiac effects if these drugs are given IV
within 48 hours of IV beta-adrenergic drugs.
DRUG NAME USUAL DOSAGE USUAL - Diltiazem can increase the serum levels and toxicity
INDICATIONS of cyclosporine if the drugs are taken concurrently.

A. OTHER ANTIARRHYTHMICS
• 0.25 mg/kg IV a) adenosine (Adenocard), digoxin, and dronedarone
bolus, then a (Multaq).
DILTIAZEM second bolus of IV to treat ➢ Adenosine is another antiarrhythmic agent that
(CARDIZEM) 0.35 mg/kg IV if paroxysmal is used to convert supraventricular tachycardia
needed; maintain SVT in adults to sinus rhythm if vagal maneuvers have been
with continuous ineffective.
infusion of 5–10 ➢ It is often the drug of choice for terminating
mg/h for up to supraventricular tachycardias, including those
24h associated with the use of alternative
conduction pathways around the AV node (e.g.,
Wolff–Parkinson–White syndrome).
• Adult: 5–10 mg IV to treat ➢ This drug slows conduction through the AV
IV over 2 min, paroxysmal node, prolongs the refractory period, and
VERAPAMIL may repeat with supraventricular decreases automaticity in the AV node.
(CALAN, 10 mg in 30 min tachycardia; b) Digoxin is also used to treat atrial arrhythmias.
COVERA-HS) if needed temporarily ➢ This drug slows calcium from leaving the cell,
• Pediatric: 0.1– controls the prolonging the action potential, and slowing
0.3 mg/kg IV ventricular conduction and heart rate.
over 2 min; do response to ➢ The drug exerts a positive inotropic effect,
not exceed 5 mg rapid atrial rates leading to increased cardiac output, which
per dose, may increases perfusion of the coronary arteries and
repeat in 30 min may eliminate the cause of some arrhythmias as
if needed hypoxia is resolved and waste products are
removed more effectively.
c) Dronedarone has properties of all four classes of
antiarrhythmics.
PHARMACOKINETICS ➢ It is an oral drug that is taken twice a day.
- Diltiazem is administered intravenously. Grapefruit juice should be avoided while taking
- When used as an antiarrhythmic, verapamil is used this drug. The most common adverse effects
intravenously. seen with dronedarone are HF, prolonged QT
- These drugs are well absorbed after IV interval, nausea, diarrhea, and rash.
administration.
- They are highly protein bound.
DRUG NAME USUAL DOSAGE USUAL
INDICATIONS
CONTRAINDICATIONS
- Sick sinus syndrome or heart block (unless an
• 6 mg IV as a
artificial pacemaker is in place).
rapid bolus Treatment of
- Caution should be used in cases of idiopathic
ADENOSINE over 1–2 s, supraventricular
hypertrophic subaortic stenosis, HF or hypotension
(ADENOCARD) may repeat tachycardias,
because of the hypotensive effects of these drugs.
with 12-mg IV including those
bolus after 1– caused using
2 min if alternate
ADVERSE EFFECTS
needed, may conduction
- Dizziness, weakness, fatigue, depression, and be repeated a pathways in
headache. second time if adults
- GI upset, nausea, and vomiting can occur. needed
- Hypotension, HF, shock, arrhythmias, and edema.

23 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

LIPID LOWERING MEDICATIONS

• Adult: 0.75–
1.25-mg PO - Drugs lower serum levels of cholesterol and various
DIGOXIN loading dose, lipids.
(LANOXIN) then 0.125– Treatment of - These include bile acid sequestrants, HMG-CoA
0.25 mg/d PO atrial flutter, AF, reductase inhibitors, and a cholesterol absorption
or 0.125– PAT inhibitor.
0.25-mg IV
loading dose, BILE ACID SEQUESTRANTS
and then - Used to decrease plasma cholesterol levels.
0.125–0.25 - Three bile acid sequestrants currently in use are
mg/d PO ✓ Cholestyramine (Questran)
• Pediatric: ✓ Colestipol (Colestid)
10–50- ✓ Colesevelam (WelChol).
mcg/kg
loading dose
PO or 8–50- DRUG NAME USUAL DOSAGE USUAL
mcg/kg INDICATIONS
loading dose
IV, based on
age, then
• 4 g PO one to Adjunctive
maintenance
two times per treatment of
dose of 25%– CHOLESTYRAMINE day, maximum primary
35% of (QUESTRAN) dose 24 g/d; hypercholester
loading dose
must be mixed olemia;
with water or treatment of
other pruritus
• 400 mg PO Treatment of
noncarbonated associated
b.i.d with the paroxysmal or with partial
fluids
morning and persistent AF or biliary
DRONEDARONE evening atrial flutter in obstruction
(MULTAQ) meals patients with
multiple risk
• Three 625 mg Adjunctive
factors for
tablets taken treatment with
coronary artery
COLESEVELAM twice a day diet and
disease who are
with meals, or exercise to
currently in
six tablets reduce low-
sinus rhythm or
taken once density
scheduled for
daily with a lipoproteins
conversion
meal (LDLs) in
patients with
familial
hypercholester
olemia; may be
combined
with an HMG-
CoA reductase
inhibitor

• Granule form: Adjunctive

5–30 g/d PO; treatment of
may be taken in
primary
divided doses;
COLESTIPOL hypercholester
must be mixed in
(COLESTID) water or other olemia
liquid
• Tablet form: 2–
16 g/d PO taken
once or in
divided doses;
tablets must not
be cut, crushed,
or chewed

24 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

THERAPEUTIC ACTIONS DRUG- DRUG INTERACTIONS

- Binds with bile acids in the intestine to form an - Malabsorption of fat-soluble vitamins occurs when
insoluble complex that is then excreted in the feces. they are combined with these drugs.
- Bile acids contain high levels of cholesterol.
- As a result, the liver must use cholesterol to make - These drugs decrease or delay the absorption of
more bile acids. thiazide diuretics, digoxin, warfarin, thyroid
- The hepatic intracellular cholesterol level falls, hormones, and corticosteroids.
leading to an increased absorption of cholesterol - Any of these drugs should be taken 1 hour before or
containing LDL segments from circulation to 4 to 6 hours after the bile acid sequestrant.
replenish the cell’s cholesterol.
- The serum levels of cholesterol and LDL decrease A. HMG-CoA REDUCTASE INHIBITORS (-statin)
as the circulating cholesterol is used to provide the ✓ Atorvastatin (Lipitor)
cholesterol that the liver needs to make bile acids. ✓ Fluvastatin (Lescol
- These drugs are used to reduce serum cholesterol in ✓ Lovastatin (Mevacor)
patients with primary hypercholesterolemia ✓ Pitavastatin (LIvalo)
(manifested by high cholesterol and high LDLs) as ✓ Pravastatin (Pravachol)
an adjunct to diet and exercise. ✓ Rosuvastatin (Crestor)
- Cholestyramine is also used to treat pruritus ✓ Simvastatin (Zocor)
associated with partial biliary obstruction.

DRUG NAME USUAL DOSAGE USUAL

PHARMACOKINETICS INDICATIONS
- Bile acid sequestrants are not absorbed
systemically.
- They act while in the intestine and are excreted • 10 mg/d PO Adjunctive therapy
directly in the feces. with a for reduction of
- Their action is limited to their effects while they are possible dose increased
present in the intestine. range of 10– cholesterol and LDL
- Cholestyramine is a powder that must be mixed with 80 mg/d; may levels, triglycerides;
liquids and taken up to six times a day. be taken at prevention of
- Colestipol is available in both powder and tablet form ATORVASTATIN any time of coronary artery
and is taken only four times a day. (LIPITOR) day disease (CAD) in
- Colesevelam is available in tablet form and is taken • Children adults with
once or twice a day. (10–17 y): 10 multiple risk factors;
mg/d PO, approved to lower
maximum cholesterol
CONTRAINDICATIONS dose 20 mg/d levels in children
10–17y of age who
- Complete biliary obstruction, abnormal intestinal
meet specific
function, and pregnancy or lactation because the
criteria with genetic
potential decrease in the absorption of fat and fat-
hyperlipidemias
soluble vitamins could have a detrimental effect on
the fetus or neonate.

• 20–80 mg Adjunctive therapy

ADVERSE EFFECTS PO, taken at for reduction of
bedtime; >2 h increased
- Headache, anxiety, fatigue, and drowsiness, which cholesterol and LDL
FLUVASTATIN after a bile
could be related to changes in serum cholesterol levels; to slow the
(LESCOL) acid
levels. progression of
sequestrant if
- Nausea, constipation that may progress to fecal CAD in patients with
this
impaction, and aggravation of hemorrhoids. known CAD;
combination
- Increased bleeding times related to a decreased reduction of the risk
is being used
absorption of vitamin K and consequent decreased of undergoing
production of clotting factors. revascularization
- Vitamin A and D deficiencies related to decreased procedure
absorption of fat-soluble vitamins; rash; and muscle
aches and pains.
• 20 mg/d PO Adjunctive therapy
taken with the for reduction of
evening meal. increased
LOVASTATIN
(MEVACOR) maximum cholesterol and LDL
dose 80 levels; to slow the
mg/d. do not progression of CAD;
exceed 20
25 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

mg/d if patient primary prevention

is taking of CAD in patients • 5–80 mg/d Prevention of first MI
immunosuppr with elevated lipid PO taken in patients with
essives or levels, approved for once a day in known
has renal use with adolescents the evening; hypercholesterolemi
impairment boys and girls who SIMVASTATIN start with 5 a and CAD;
• Boys and girls are at least 1y past (ZOCOR) mg/d in adjunctive therapy
1y menarche and have elderly for reduction of
postmenarch specific genetic patients and increased
e: 20 mg/d disorders in patients cholesterol and LDL
PO, may leading to high with hepatic levels: approved to
increase to 80 cholesterol levels or renal lower cholesterol
mg/d impairment levels in children
• (10–17 y): 10 10–17y of age who
mg/d PO, up meet specific criteria
• Initially, 2 Treatment of primary to 40 mg/d with genetic
PITAVASTATIN hyperlipidemia or based on hyperlipidemias
mg/d PO,
(LIVALO)
range 1–4 mixed dyslipidemias response
mg/d PO in adults

THERAPEUTIC ACTIONS
• 10–40 mg/d Only statin with - The early rate-limiting step in the synthesis of cellular
PO taken at outcome data to cholesterol involves the enzyme HMG-CoA
bedtime. show effectiveness reductase.
• start with 10 in decreasing CAD - If this enzyme is blocked, serum cholesterol and LDL
mg/d in and incidence of levels decrease because more LDLs are absorbed
elderly myocardial by the cells for processing into cholesterol.
patients and infarction (MI); - This medications block HMG-CoA reductase from
patients with prevents first MI completing the synthesis of cholesterol.
PRAVASTATIN hepatic or even in patients - They are chemical modifications of compounds
(PRAVACHOL) who do not have a
renal produced by fungi.
impairment documented - Indicated as adjuncts with diet and exercise for the
• (8–13 y): 20 increased treatment of increased cholesterol and LDL levels
mg/d PO cholesterol that are unresponsive to dietary restrictions alone.
• (14–18 y): 40 concentration (an - Pravastatin, lovastatin, and simvastatin are indicated
mg/d PO effect possibly for patients with documented CAD to slow
related to blocking of progression of the disease.
the formation of - These three agents and atorvastatin are used to
foam cells in injured prevent a first myocardial infarction (MI) in patients
arteries); adjunctive who have multiple risk factors for developing CAD.
therapy for reduction
of increased
cholesterol and LDL PHARMACOKINETICS
levels; approved
- The peak effect of these drugs is usually seen within
for use with children
2 to 4 weeks.
>8y of age with
- These drugs are most effective when taken at night
genetically
when the liver is processing the most lipids.
linked
hyperlipidemia, as
an adjunct to diet in
CONTRAINDICATIONS
exercise
- Statins also are contraindicated in patients with
active liver disease or a history of alcoholic liver
• 10 mg/d PO Adjunctive therapy for disease.
reduction of increased - Labeled as pregnancy category X
initial dose
cholesterol and LDL - Atorvastatin levels are not affected by renal disease,
range; 5–40
levels, triglycerides;
mg/d but patients with renal impairment who are taking
with diet to slow the
other statins require close monitoring.
ROSUVASTATIN progression of
(CRESTOR) atherosclerosis; raises
high-density lipoprotein
(HDL) slightly better
than
the other statins and at
a lower price

26 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

ADVERSE EFFECTS PHARMACOKINETICS

- Flatulence, abdominal pain, cramps, nausea, - Ezetimibe is absorbed well after oral administration,
vomiting, and constipation, headache, dizziness, reaching peak levels in 4 to 6 hours.
blurred vision, insomnia, fatigue, and cataract - It is metabolized in the liver and the small intestine,
development and may reflect changes in the cell with a half-life of 22 hours.
membrane and synthesis of cholesterol.
- Rosuvastatin is associated with rhabdomyolysis, a
breakdown of muscles. CONTRAINDICATIONS
- If it is used in combination with a statin, it should not
be used during pregnancy or lactation or with severe
DRUG- DRUG INTERACTIONS liver disease because of the known effects of statins,
- Rhabdomyolysis increases if combined with including possible liver problems and renal failure.
erythromycin, cyclosporine, gemfibrozil, niacin, or
antifungal drugs.
- Increased serum levels and toxicity can occur if ADVERSE EFFECTS
taken with digoxin or warfarin. - Mild abdominal pain and diarrhea, headache,
- Monitor serum digoxin levels and/or clotting times. dizziness, fatigue, upper respiratory tract infection
- Increased estrogen levels if taken with oral (URI), back pain, and muscle aches and pains.
contraceptives.
- Serum levels and the risk of toxicity increase if these
drugs are combined with grapefruit juice. DRUG- DRUG INTERACTIONS
- Elevated serum levels increases if it is given with
cholestyramine, fenofibrate, gemfibrozil, or antacids.
CHOLESTEROL ABSORPTION INHIBITORS
- It should be taken at least 2 hours before or 4 hours
- Ezetimibe works in the brush border of the small
after the other drugs.
intestine to decrease the absorption of dietary
- Toxicity increases if combined with cyclosporine; if
cholesterol from the small intestine.
combined with fibrate, the risk of cholelithiasis
- Less dietary cholesterol is delivered to the liver, and
increases.
the liver increases the clearance of cholesterol from
- Warfarin levels increase in a patient who is also
the serum to make up for the drop in dietary
taking ezetimibe.
cholesterol, causing the total serum cholesterol level
to drop.
FIBRATES
- Stimulate the breakdown of lipoproteins from the
DRUG USUAL
tissues and their removal from the plasma.
NAME DOSAGE USUAL INDICATIONS
- They lead to a decrease in lipoprotein and
triglyceride synthesis and secretion.
- Peak effects are usually seen within 4 weeks, and
Adjunct to diet and exercise
the patient’s serum lipid levels should be reevaluated
to reduce cholesterol as
EZETIMIBE at that time.
10 mg/d monotherapy or combined
(ZETIA) - Fenofibrate (TriCor) inhibits triglyceride synthesis in
PO with an HMG-CoA inhibitor or
the liver, resulting in reduction of LDL levels;
a bile acid sequestrant,
increases uric acid secretion; and may stimulate
adjunct to diet to reduce
triglyceride breakdown.
elevated sitosterol and
- It is used for adults with very high triglyceride levels
campesterol levels in
who are not responsive to strict dietary measures
homozygous sitosterolemia
and who are at risk for pancreatitis.
(to reduce elevated sitosterol
- Gemfibrozil (Lopid) inhibits peripheral breakdown of
and campesterol levels, the
lipids, reduces production of triglycerides and LDLs,
enzymes that are elevated
and increases HDL concentrations.
when patients have this rare
- Associated with GI and muscle discomfort.
disorder); used in
- Not be combined with statins due to an increased risk
combination with atorvastatin
of rhabdomyolysis.
or simvastatin as treatment
- Fenofibric acid (Trilipix), a peroxisome proliferator
for homozygous familial
receptor alpha activator.
Hypercholesterolemia
- Increases breakdown of lipids, elimination of
triglyceride-rich particles from the plasma, and
reduction in the production of an enzyme that
naturally inhibits lipid breakdown.
- Patients complaining of gallstone-type pain should
be screened carefully.
- Caution must be used with warfarin anticoagulants;
increased bleeding can occur.

27 #LabaRN
NURSING PHARMACOLOGY | CARDIAC MEDICATIONS

- Vitamin B3, known as niacin (Niaspan) or nicotinic

acid, inhibits the release of free fatty acids from 1,200 mg/d PO Treatment of very
adipose tissue, increases the rate of triglyceride GEMFIBROZIL divided into two high triglyceride
removal from plasma, and generally reduces LDL (LOPID) doses and taken levels with
and triglyceride levels and increases HDL levels. before the abdominal pain and
- It may also decrease the levels of apoproteins morning and potential pancreatitis
needed to form chylomicrons. evening meals in adults
- Associated with intense cutaneous flushing, nausea,
and abdominal pain. VITAMIN B
- Increases serum levels of uric acid and may
predispose patients to the development of gout. • 1.5–2 g/d Treatment of
- It is given at bedtime to make maximum use of PO in hyperlipidemia not
nighttime cholesterol synthesis, and it must be given divided responding to diet
4 to 6 hours after the bile sequestrant to ensure NIACIN doses for and weight loss; to
absorption. (NIASPAN) tablets. slow progression of
- Rimonabant is an endocannabinoid blocker that has • 500–2,000 CAD when
been used as a weight loss agent. mg/d PO for combined with a bile
- It reduces weight and abdominal adiposity and extended- acid sequestrant
improve lipid profiles while increasing insulin release
sensitivity and reducing the pro inflammatory and tablets taken
prothrombotic markers. at bedtime
- Research is being done on the effects of blocking the
endocannabinoid system, resulting in weight loss,
improved lipid profiles, and decreased
proinflammatory and prothrombotic states.
- Questions have not been answered about the safety
or effectiveness of drugs that block this system.

DRUG NAME USUAL USUAL

DOSAGE INDICATIONS

67 mg/d PO Treatment of very

given with a high triglyceride
meal; may be levels in adults who
FENOFIBRATE increased up to are at risk for
(TRICOR) 67 mg PO t.i.d. pancreatitis if not
as needed; responsive to dietary
monitor patients measures
with impaired
renal function
and the elderly
very carefully

45–135 mg/d PO Treatment of

hypertriglyceridemia
or to reduce lipid
FENOFIBRIC levels in mixed
ACID hyperlipidemia not
(TRILIPIX) responsive to other
therapies: with a
statin to reduce
triglyceride levels
and raise HDL levels
in mixed
hyperlipidemias
with high risk for
CAD

28 #LabaRN