Drugs for

Cardiovascular
Diseases

May Florence D. Bacayo, MSc.

1
may_florence@msu.edu.my
Topics
• The Heart and Causative Factors of Cardiovascular Disease
• Angina
• Arrhythmia
• Congestive Heart Failure
• Hypertension
• Myocardial Infarction
• Blood Clots
• Stroke
• High Cholesterol and Related Diseases

2
Learning Objectives
• Understand the cardiovascular system.
• Know the drugs and treatment for each type of
heart disease.
• Recognize anticoagulant and antiplatelet drugs and
know their functions.
• Discuss stroke and the drugs used to treat it.
• Identify drugs used to treat hyperlipidemia and
understand its role in heart disease and stroke
treatment.

3
The Heart and Causative Factors of
Cardiovascular Disease
• Heart has 3 functional parts
• Cardiac muscle (myocardium)
• Conducting system
• Blood supply

• Cardiovascular (CV) disease can involve any or all of

these parts

4
The Heart and Causative Factors of
Cardiovascular Disease
• Heart is a complicated organ
• Both predetermined and lifestyle factors contribute
to heart disease
• Proper diet, exercise, and rest can help heart
function

5
Heart’s Functional Anatomy

cardiac conducting blood

muscle system supply

6
Normal Heartbeat
• Begins in cell membranes of sinoatrial (SA) node
• Ion channels in cell membrane open
• Na+ and Ca + + ions flow into cell
• Voltage becomes positive (depolarization)
• Other channels open
• K+ ions flow out of cell
• Voltage becomes negative (repolarization)
• Electrical burst (action potential) propagates through conduction
system to myocardial cells
• Depolarizes with Na and Ca inflow
• Repolarizes with outflow of K
• Proteins in membrane cells continually restore K, Na, Ca balances

7
Internal Structures of the Heart

8
Conduction System
• Action potential first arrives at atria
• Atria contracts, pumping blood received from veins
into ventricles
• Then travels through the atrioventricular (AV) node
to reach ventricles
• Left ventricle pumps blood out into arteries

9
Conduction System of the Heart

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Predetermined Factors for
Cardiovascular Disease
• Heredity
• Children of parents with CV disease higher risk
• African Americans 2 to 3x more likely than other ethnic
groups to have hypertension
• Gender
• Men greater risk than women until age 55
• Increasing Age
Almost 55% of heart attack victims age 65+

11
Factors Influenced by Lifestyle
Modification
• Cigarette Smoking
• Smokers twice the risk of heart attack than nonsmokers
• High Blood Pressure
• Increases stroke and heart attack risk
• Lower blood pressure by diet, exercise, weight loss,
reduce salt, drugs

12
Factors Influenced by Lifestyle
Modification
• High Blood Cholesterol Levels
• Reduces blood flow to heart
• Diet low in cholesterol and fats, drugs
• Obesity
• Increases blood pressure, cholesterol levels, lead
diabetes, strains heart
• Diabetes
• Leads to vascular problems
• Diet, drugs

13
Terms to Remember
• sinoatrial (SA) node
• depolarization
• repolarization
• action potential
• atrioventricular (AV) node

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Angina Pectoris

• Also called angina

• Chest pain due to imbalance of oxygen supply and
demand
• Oxygen demand is related to heart rate, strength of
contraction, and resistance to blood flow

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Three Types of Angina
1. Stable
• Effort-induced pain from physical activity or emotional stress
• Relieved by rest
• Predictable and reproducible
2. Unstable
• Pain occurs with increasing frequency
• Diminishes patient’s ability to work
• Decreasing response to therapy
• May signal an oncoming MI
3. Variant
• Pain due to coronary artery spasm
• Pain may occur at certain times of the day, but is not stress induced

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Symptoms of Angina
• Severe chest discomfort: heaviness, pressure,
tightness, choking, squeezing
• Sweating
• Dizziness
• Dyspnea (shortness of breath)

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Risk Factors for Angina
• Increased
Advancedserum
age lipoprotein levels
• Obesity
Coronary artery disease
• Smoking
Hypertension
• Type
Increased
A personality
serum glucose levels (diabetes)

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Initiating Factors of an Attack
• Cold weather
• Emotions
• Heavy meals (blood to gut increases, decreases to
brain and heart)
• Hypoglycemia
• Pain
• Smoking (nicotine causes arterial constriction)

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Treatment Goals
• Reduce symptoms, prevent heart attack
• 3 major classes of drugs to treat angina
• Beta blockers
• Calcium channel blockers
• Nitrates
• Fourth type of drug is a metabolic modifier,
distinct from other 3 classes

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Discussion
Explain why some of these factors may initiate an
angina attack: cold weather, emotions, heavy meals,
hypoglycemia, pain, and smoking.
Cold weather and emotions cause tension in the
muscles and a decrease in blood flow to brain and
heart.

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Drugs Used to Treat Angina
• Beta blockers
• Most generic names end in “lol”
• Nitrates
• Calcium channel blockers
• Many generic names end in “ipine”
• Metabolic modifier

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Beta Blockers
• Slow heart rate, decrease myocardial contractility,
lower blood pressure
• Reduce frequency and severity of attacks
• More beta-1 blocking, rather than beta-2, preferred
for heart conditions
• Also used to treat arrhythmias and hypertension,
and most commonly used after a myocardial
infarction

23
Drug List
• Drugs Used in Treatment of Angina
• Beta Blockers
• acebutolol
• atenolol
• betaxolol
• bisoprolol
• esmolol
• labetalol
• metoprolol
• nadolol
• nevbivolol
• pindolol
• propranolol
• sotalol
• timolol

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Side Effects of Beta Blockers
• Tiredness is most common
• Bradycardia primary side effect (slowed heart rate)
• May mask symptoms of hypoglycemia and
hyperthyroidism
• Diabetics should avoid

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Carvedilol
• Beta blocker approved for hypertension.
Nonselective
• Slows the heart and improves left ventricular
function
• Only beta blocker approved for heart failure
• Taking with food decreases dizziness

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Nebivolol
• Causes vasodilation by increasing production of
nitric acid
• Different action than other beta blockers
• Approved only for hypertension
• Reduces vascular resistance and large-artery
stiffness

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Sotalol
• Indicated for treatment of life-threatening
arrhythmias
• Side effects: bradycardia, depression, decreased
sexual activity

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Nitrates
• Most commonly used drugs for
angina
• Dilate coronary vessels, leading to
redistribution of blood to ischemic
tissues
• Reduce preload on the heart, which
reduces cardiac workload and
decreases afterload
• Helps with pulmonary edema in
CHF
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Drug List
• Drugs Used to Treat Angina
• Nitrates
• isosorbide dinitrate (Dilatrate-SR, Isordil)
• isosorbide mononitrate (Imdur, Ismo)
• nitroglycerin (Minitran, Nitrolingual, Nitrostat,
NitroDur)

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Nitrates and Erectile Dysfunction
Drugs
• Technicians—watch for patients who get
prescriptions for nitrates and ED drugs
• sildenafil
• vardenafil
• tadalafil
• Prescibers are often different prescriptions for
nitrates and for ED drugs
• Patient must tell prescriber this information, because
drugs could cause deadly interaction

31
Nitroglycerin

• Drug of choice for acute attacks,

taken sublingually
• May also be used as a prophylaxis
• Patch should be removed at night
• Patch-free time, or tolerance
develops
• Label should instruct patient on
procedure

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Side Effects of nitroglycerin
• Severe headache when patients first start using
• Orthostatic hypotension
• Flushing

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 Dispensing Issues of nitroglycerin

Warning!
• Stored and sold in original amber glass bottle
• Do not repackage
• Refill every 3 months
• Patient should discard any remaining drug

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Calcium Channel Blockers
• Inhibit calcium ions moving into cardiac muscle
cells
• Calcium triggers muscle contraction
• Reduces contractility of cell
• Relaxes vascular smooth muscle
• Used for most supraventricular tachy-arrhythmias

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Calcium Channel Blockers
• Constipation most
common side effect
• Some should be taken
with food
• Caffeine should be limited
• Also first-line therapy for
hypertension

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Drug List
• Drugs Used to Treat Angina
• Calcium Channel Blockers
• amlodipine
• diltiazem
• felodipine
• isradipine
• nicardipine
• nifedipine
• nisoldipine
• verapamil

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Verapamil
• Timed-release product designed for bedtime
dosing
• Approved for angina or hypertension
• Tablets release 4 to 5 hours after swallowing

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Drug List
• Drugs Used to Treat Angina
• Metabolic Modifier
• ranolozine (Ramexa)

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Metabolic Modifier: Ranolozine
• Indicated for chronic angina
• Helps heart to generate energy more efficiently
• Heart functions despite a decrease in oxygen
• Add-on therapy; should be used with amlodipine,
beta blockers, or nitrates
• Swallow whole, without regard to meals

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Terms to Remember
• angina pectoris
• stable angina
• unstable angina
• variant angina
• beta blocker
• bradycardia
• preload
• afterload
• calcium channel blocker
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Arrhythmia
• Variation from normal heart rhythm (70 to 80 beats
per minute)
• Occurs when
• Heartbeat is too slow or too fast
• Contractions of ventricles and atria not synchronized

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Normal Heart Rates and Rhythms
1. Normal heart rhythm generated by sinoatrial (SA)
node
2. Then propagated to myocardium
3. This causes atria to contract, filling the ventricles
4. Ventricles contract to eject blood into arteries

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Heart’s Conduction System

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Heart Rate Abnormalities
• Caused by ischemia, infarction, or alteration of body
chemicals
• Allows heart cells other than SA node to fire
automatically and become ectopic pacemakers
• Leads to premature contractions resulting in
tachycardia, flutter, or fibrillation
• ECG records conduction cycle of the heart
• Different types of arrhythmias show specific ECG
patterns
• Associated with degrees of danger or sudden death
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 Abnormal Heart Rhythms
Arrhythmia BPM ECG
tachycardia 150-250
bradycardia <60
atrial flutter 200-350
atrial fibrillation >350
prem. atrial cont. variable
prem. vent. cont. variable
vent. fibrillation variable

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Premature
Ventricular
Contraction

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Symptoms of Abnormal Heart
Rhythms
• Cyanosis
• Palpitations
• Weakness
• Syncope
• Sweating
• Lightheadedness
• Chest
• Visual
pain disturbances
• Hypotension
• Pallor

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Drug Treatment of Abnormal Heart
Rhythms
• Preventing life-threatening conditions by
restoring normal rhythm
• Acts on the myocardium where impulses are
conducted
• Some drugs influence heart rate
• Other drugs influence ion (Na, Ca) movement

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Depressant Closes Gate,
Stimulant Opens Gate

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Drug Classes to Treat Arrhythmias
• Class I. Membrane Stabilizing Agents
• Class II. Beta Blockers
• Class III. Potassium Channel Blockers
• Others

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Membrane Stabilizing Agents
(Class I)
• Slow the movement of Na ions into myocardial cells
• A stronger signal is needed for action potential

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Drug List
• Antiarrhythmic Agents
• Membrane-Stabilizing Agents (Class I)
• disopyramide
• flecainide
• lidocaine
• mexiletine
• moricizine
• phenytoin
• procainamide
• propafenone
• quinidine
• tocainide

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Phenytoin (Dilantin)

• Used on resistant arrhythmias and arrhythmias

caused by digoxin toxicity
• Adverse effects: cardiovascular collapse, and CNS
and respiratory depression
• Also anticonvulsant agent

54
Drug List
• Antiarrhythmic Agents
• Beta Blockers (Class II)
• acebutolol
• atenolol
• betaxolol
• bisoprolol
• carvedilol
• esmolol
• labetalol
• metoprolol
• nadolol
• nevbivolol

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Drug List
• Antiarrhythmic Agents
• Beta Blockers (Class II)
• pindolol
• propranolol
• sotalol
• timolol

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Potassium Channel Blockers
(Class III)
• Delay repolarization
• Block the flow of potassium across cell membranes

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Drug List
• Antiarrhythmic Agents
• Potassium Channel Blockers (Class III)
• amiodarone
• dofetilide

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Dofetilide
• Used to maintain normal sinus rhythm in patients
with atrial fibrillation/atrial flutter
• Drug itself can induce arrhythmias
• Available only to hospitals or to prescribers with
training of drug
• T.I.P.S. (Tikosyn Pharmacy Systems) allows retail
pharmacies to dispense drug

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Dofetilide
• Before dispensing, pharmacies must
• Educate their staff
• Document that the presciber is enrolled in the program
• Document that the patient has been properly initiated

© Paradigm Publishing, Inc. 60

Drug List
• Antiarrhythmic Agents
• Calcium Channel Blockers (Class IV)
• amlodipine
• diltiazem
• felodipine
• isradipine
• nicardipine
• nifedipine
• nisoldipine
• verapamil

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Other Antiarrhythmic Agents
• Have different mechanisms of action than other
classes

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Drug List
• Antiarrhythmic Agents
• Other Antiarrhythmic Agents
• atropine (none)
• digoxin (Lanoxicaps, Lanoxin)
• isoproterenol
• Antidote for Digoxin Toxicity
• digoxin immune Fab (Digibind)

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Atropine
• Used for bradycardia: heart rates less than 60 beats
per minute
• Used preoperatively to inhibit salivation and
secretions

64
Digoxin (Lanoxicaps, Lanoxin)
• Most important drug in managing atrial flutter,
fibrillation, and CHF
• Slows ventricular rate
• Increases force of contraction, refractory period,
and stimulation due to ion imbalance

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Side Effects of digoxin (Lanoxicaps,
Lanoxin)
• Used with caution,
possibility of systemic
accumulation of drug
• Patients may
experience digitalis
toxicity, or digtoxicity,
especially elderly
• Primary signs of
digtoxity: nausea,
vomiting, arrhythmias

66
Digoxin immune Fab (Digibind)
• Antidote for digitalis toxicity
• Antibody fragment
• Binds to digoxin
• Inactivates the drug
• Excreted by the kidneys

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Terms to Remember
arrhythmia
any variation from the normal heartbeat
tachycardia
excessively fast heart rate
membrane-stabilizing agent
a Class I antiarrhythmic drug that slows the
movement of ions into cardiac cells, thus reducing the
action potential and dampening abnormal rhythms and
heartbeats

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Congestive Heart Failure (CHF)
• Form of heart failure
• Heart pumps less blood than it receives
• Excess blood pools in the chambers and stretches the
walls of the heart

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Blood Flow Through Heart

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Fluid Accumulation in CHF
• Kidneys retain water and fluid accumulates in body
tissues
• In lungs when left side of heart fails
• In abdomen and lower extremities when right side
of heart fails

71
Discussion
Why is it dangerous for blood to pool in the
chambers of the heart?
There is decreased oxygen supply to tissues, and a
risk of blood clot formation and movement
throughout the body.

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Congestive Heart Failure (CHF)
• Occurs in 10% of population over 75
• Can result in death through progressive heart
damage or sudden death
• Overworking of the heart leads to cardiomegaly
and myocardial hypertrophy

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Primary Causes of Congestive Heart
Failure
• Cardiomyopathy
• Coronary artery disease
• Hypertension

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Secondary Causes of Congestive
Heart Failure
• High salt intake
• Noncompliance with treatment
• Side effects of drug therapy
• Kidney failure
• Stress
• Infection and inflammation
• Cigarette smoking
• Obesity

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Drugs to Treat CHF or HF
• Vasodilators
• Angiotensin-converting enzyme (ACE) inhibitors
• Human B-type natriuretic peptide
• All 3 medications counteract
• Contraction of small blood vessels which reduces stress
on heart
• Fluid retention

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Vasodilators
• Cause blood vessels to dilate
• Reduce resistance against which the heart must
work

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Drug List
• Agents for Treating Heart Failure
• (Not Previously Discussed)
• Vasodilators
• milrinone
• nitroprusside
• isosorbide-hydralazine

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Isosorbide-hydralazine
• Combination drug (both vasodilators) used to
supplement standard therapy in African American
population
• First drug approved for specific race
• Can cause headaches and dizziness
• Also approved for a form of angina

79
ACE Inhibitors
• Inhibits conversion of angiotensin I to angiotensin II
• Lowers blood pressure and stress on the heart
• Used for hypertension, HF, post-MI
• Considered to preserve potassium

80
Drug List
• Agents for Treating Heart Failure
• ACE Inhibitors
• benazepril
• captopril
• enalapril
• fosinopril
• lisinopril
• moexipril
• perindopril
• quinapril
• ramipril
• trandolapril

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Drug •List
Agents for Treating Heart Failure
• (Not Previously Discussed)
• ACE Inhibitors
• moexipril (Univasc)
• perindopril (Aceon)
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)

82
 Dispensing Issues of ACE
Inhibitors
Warning!
• If same prescriber writes prescription for ACE
inhibitor and potassium, labs are probably
being checked
• If more than one prescriber, all need to be
aware of possible K interactions

83
 Dispensing Issues of ACE
Inhibitors
Warning!
• Stand slowly to prevent orthostatic
hypotension
• Avoid salt substitutes
• Given with caution to patients taking lithium

84
Side Effects of ACE Inhibitors
• Dry, non-productive cough
• Dizziness during first few days

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Drug List
• Agents for Treating Heart Failure
• Human B-Type Natriuretic Peptide (hBNP)
• nesirtide

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Human B-Type Natriuretic Peptide (hBNP):
nesirtide (Natrecor)
• DNA recombinant technology
• Causes relaxation of vascular smooth muscle,
lowering blood pressure
• Improves circulation, shortness of breath, and
fatigue in acute HF
• Only used in hospitalized patients

87
Terms to Remember
congestive heart failure (CHF)
a condition in which the heart can no longer
pump adequate blood to the body’s tissues
cardiomegaly
enlargement of the heart due to overwork from
overstimulation
myocardial hypertrophy
thickening of the heart muscle in response to
overstimulation

88
Hypertension and Blood Pressure
• Blood pressure: product of cardiac output (CO) and
total peripheral resistance (TPR)
• Vasoconstriction increases TPR
• CO (product of heart rate and stroke rate) is
determined by
• Preload: blood delivered to the heart
• Afterload: shortening of cardiac muscle
• Contractility: capacity of muscle to shorten

89
Blood Pressure
• Systolic Blood Pressure
• Pressure when the heart ejects blood
• Cardiac output is the major determinant
• Diastolic Blood Pressure
• Pressure when the heart relaxes and fills
• TPR largely determines diastolic pressure
• 120 mm Hg systolic, 80 mm Hg diastolic
• Written as “120/80” Read as “120 over 80”

90
Hypertension
• A disease in which
• Systolic blood pressure is greater than 140 mm HG
• Diastolic pressure is greater than 90 mm Hg

91
 Staging of Blood Pressure
Category Systolic Diastolic

Normal <120 <80

Prehypertension 120-139 80-89
Hypertension
Stage 1 140-159 90-99
Stage 2 >160 >100

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Factors Leading to Hypertension
• Obesity
Family history
• Adrenal
Cigarettetumor
smoking
• Medications:
High-fat diet OC, corticosteroids, NSAIDs, nasal
• decongestants,
Kidney disease appetite suppressants
• Decreased pressure peripherally

93
Untreated Hypertension
• Cardiovascular disease can develop
• Enlargement of the heart
• Cardiac hypertrophy
• Thickening of the cardiac wall
• Reduced cardiac output
• HF results in cold extremities, edema, and
accumulation of fluid in the lungs

94
Untreated Hypertension
• Renal insufficiency can occur
• Increased pressure causes reduction in renal blood flow
and function
• Accelerated cardiac and peripheral vascular disease
can occur
• Higher the pressure, greater the risk

95
Treatment for Reducing Blood
Pressure
Step 1. Change lifestyle
Step 2. Monotherapy (first-line drug)
Step 3. Add a diuretic if not in Step 2
Step 4. Add a third agent synergistic with others

96
Step 1. Modify Lifestyle Factors

1. High sodium intake to moderate sodium intake

2. Excess consumption to weight reduction
of calories
3. Physical inactivity to regular aerobic activity
4. Excess ETOH to moderate ETOH
5. Nicotine usage to nicotine cessation
6. High stress to control stress

97
 Step 2. Monotherapy
A single drug, usually
• Diuretic
• Beta blocker
• ACE inhibitor
• Angiotensin II receptor antagonist
• Calcium channel blocker

98
 Steps 3 and 4

Step 1. Lifestyle modifications

Step 2. Monotherapy
Step 3. Add a diuretic if not added in Step 2
Step 4. Add a third agent synergistic with other two
in reducing blood pressure

99
Pharmacologic Antihypertensive
Therapies
Drug Class Mechanism of Action
Diuretics First-line therapy. Reduce
total peripheral resistance
Selective Aldosterone Act as diuretics, decrease
Receptor Antagonists blood pressure
Calcium Channel First-line therapy. Reduce
Blockers peripheral resistance
ACE Decrease blood pressure,
reduce peripheral resistance

100
Pharmacologic Antihypertensive
Therapies
Drug Class Mechanism of Action
ARBs Block vasoconstriction of
angiotensin II receptors

Beta Blockers Decrease heart rate and blood

pressure

CNS Agents Decrease heart rate, reduce

total peripheral resistance

101
Pharmacologic Antihypertensive
Therapies
Drug Class Mechanism of Action
Peripheral Block constriction of blood
Acting Agents vessels, leading indirectly to
(Alpha Blockers) vasodilation and hypotension
Vasodilators Relax arterial smooth muscle,
lower peripheral resistance via
direct mechanism
Combination Second-line drugs. Additive
Drugs effects lower blood pressure.

102
Treatment Effectiveness of Three
Classes
Beta blockers, calcium channel blockers, and ACE
inhibitors all equally effective in treating
hypertension

103
Calcium Channel Blockers

• Reduce blood
pressure by arteriolar
dilation
• Leads to reduced
peripheral resistance

104
ACE Inhibitors
• Reduce blood pressure by competitive inhibition of
angiotensin-converting enzyme (ACE)
• Prevent conversion of angiotensin I to angiotensin
II, a potent vasoconstrictor

105
Drug List
Antihypertensive Therapeutic Agents
• Calcium Channel Blockers
• ACE Inhibitors

106
Angiotensin Receptor Blockers
(ARBs)
• Reduce blood pressure by
blocking angiotensin II at its
receptors
• Bound angiotension II
cannot exert its effects
• ARBs: less coughing and
angioedema than ACEIs
• Most generic names end in
“sartan”

107
 Dispensing Issues of ARBs and
ACEs
Warning!
• Pharmacy technician—if patient has
prescriptions for both drug classes from two
different prescribers, make pharmacist or
prescribers aware

108
Drug List
• Antihypertensive Therapeutic Agents
• Angiotensin Receptor Blockers (ARBs)
• candesartan
• eprosartan
• irbesartan
• losartan
• olmesartan
• telmisartan
• valsartan

109
Central Nervous System (CNS)
Agents
• Stimulate alpha-2 adrenergic receptors in the brain
• Results in decreased heart rate and cardiac output,
and lowered total peripheral resistance

110
Drug List
• Antihypertensive Therapeutic Agents
• Beta Blockers
• CNS Agents
• clonidine
• guanfacine
• methyldopa

111
Peripheral Acting Agents (Alpha
Blockers)
• Block alpha
constriction of
blood vessels
• Leads indirectly
to vasodilation
and hypotension

112
Drug List
• Antihypertensive Therapeutic Agents
• Peripheral Acting Agents (Alpha Blockers)
• alfuzosin
• doxazosin
• phentolamine
• prazosin
• terazosin

113
Terazosin
• Blocks impulses at vascular smooth muscle

114
Vasodilators
• Direct relaxant effect on arterial smooth muscle
• Leads to reduction in peripheral resistance
• Also used for congestive heart failure

115
Drug List
• Antihypertensive Therapeutic Agents
• Vasodilators
• epoprostenol
• fenoldopam
• hydralazine
• isosorbide-hydralazine
• milrinone

116
Drug List
• Antihypertensive Therapeutic Agents
• Vasodilators
• minoxidil
• nitroprusside
• treprostinil
• sildenafil
• Direct Renin Inhibitors (DRIs)
• aliskiren

117
Sildenafil
• Reduces blood pressure by vasodilator effects
• Reduces pulmonary arterial pressure and
pulmonary vascular resistance
• Do not use with nitrates

118
 Dispensing Issues of sidenafil

Warning!
• Two different names for sildenafil
• Be sure patient is not on both drug forms, or
on both Revatio and Levitra or Cialis
• Revatio: white round tablet; 20 mg
• Viagra: blue, diamond-shaped tablet; 25, 50, or
100 mg

119
Aliskiren
• Inhibits renin, which controls first rate-limiting step
of the renin-angiotensin-aldosterone system
• Indicated for treatment of hypertension
• Do not take with meals
• Primary side effect is diarrhea

120
Combination Drugs
• Additive effect to relax blood vessels and lower
pressure
• Two low doses of different drugs usually cause
fewer side effects than increasing the dose of either
drug

121
Drug List
• Antihypertensive Therapeutic Agents
• Combination Drugs
• amlodipine-benazepril
• amlodipine-valstran
• benazepril-hydrochlorothiazide
• enalapril-diltiazem
• enalapril-hydrochlorothiazide
• irbesartan-hydrochlorothiazide
• losartan-hydrochlorothiazide
• trandolapril-verapamil
• valsartan-hydrochlorothiazide

122
Amlodipine-valsartan
• Calcium channel blocker and ARB
• ARB decreases edema and lowers blood pressure
• Approved only to treat hypertension
• Can be used as monotherapy when the two classes
need to be combined

123
 Dispensing Issues of amlodipine-
valsartan
Warning!
• Other combination products that contain these
drugs
• Pharmacy technician—make sure patient is not
receiving same drug from two different
sources

124
Terms to Remember
• blood pressure (BP)
• preload
• afterload
• contractility
• systolic blood pressure
• diastolic blood pressure
• hypertension

125
Myocardial Infarction
• Also called heart attack
• Occurs when prolonged decrease in oxygen
delivered to a region of cardiac muscle, and muscle
dies
• If healing occurs, scars form, and less contractility
of heart muscle
• Leading cause of death in industrialized nations

126
Causes of Heart Attack
• Prolonged decrease in oxygen supply
• Occurs if one or more of the 3 major arteries is
narrowed by 70% or more
• Risk factors
• History of angina, alcohol consumption, reduced
pulmonary vital capacity, cigarette smoking,
atherosclerosis

128
Lifestyle Changes to reduce MI Risk
• Decrease
Eliminate alcohol
smokingconsumption
• Control
Reduce hypertension:
diabetes diet, medication, both
• Use
Exercise
aspirin
moderately
therapy
• Reduce
Adjust calories
dietary for
cholesterol
ideal bodyand
weight
triglycerides

129
Symptoms of a Heart Attack
• Oppressive or burning tightness or squeezing in the
chest
• Feeling of choking
• Sense of “impending doom”
• Substernal pain with radiations to the neck, throat,
jaw, shoulders, and one or both arms
• Pain can last 30 minutes to several hours

130
Treatment of Myocardial Infarction
• Aimed at allowing the heart to rest and undergo
normal healing
• Beta blockers combined with 81 mg aspirin
frequently prescribed to reduce risk of death or
recurrence
• Beta blocker slows action of heart
• Aspirin prevents blood clot formation

131
Terms to Remember
myocardial Infarction (MI)
a heart attack; occurs when a region of
the heart muscle is deprived of oxygen

132
Blood Clots
• Blood clots also called thrombi (singular: thrombus)
• Develop from abnormalities in
• Blood coagulation
• Blood flow
• Platelet adhesiveness
• Vessel walls

133
Clotting Cascade
• Damage to tissue cells activates a pathway of
coagulation, or clotting cascade
• If any factor in the cascade is missing, blood will not
clot (hemophilia)

134
Clotting Cascade

135
Venous Thrombi
• Usually form in areas of slow blood flow, surgical or
vein injuries, or large venous sinuses (pockets
formed by valves in deep veins)
• If a piece of clot breaks off, can travel to the lung
causing pulmonary embolism (PE)

136
Deep Vein Thrombosis (DVT)
• DVT above the knee is the most serious
• May be fatal

137
Risk Factors for DVT
• Major
Age over
illness
40
• Obesity
Bed rest for over 4 days
• Pregnancy
Estrogen combined with nicotine
• Previous
High-doseDVT
estrogen therapy
• Surgery
• Trauma
• Varicose veins

138
Classes of Drugs to Reduce Risk of
Blood Clots
• Anticoagulant: prevents clot formation by inhibiting
clotting factors
• Antiplatelet: reduces the risk of clot formation by
inhibiting platelet aggregation
• Third class of drugs, fibrinolytics, dissolve clots
already formed

139
Laboratory Testing
• Certain lab tests must be done on patients on
anticoagulant therapy
• Prevent future embolisms and minimize risk of
hemorrhage

140
Most Frequently Used Laboratory
Tests
• Partial thromboplastin time (PTT), affected by
heparin
• Prothrombin Time (PT), affected by warfarin
• International Normalized Ration (INR)
• Most important indicator
• Hematocrit: proportion of blood sample that is red
blood cells

141
Therapy for DVT
• Low-dose heparin, adjusted-weight heparin, or low-
molecular weight heparin and warfarin (Coumadin)
• Purpose is to prevent fatal blood clotting while
ensuring adequate coagulation

142
Drug List
• Anticoagulant Agents and Antidotes
• Anticoagulant Agents
• bivalirudin
• fondaparinux
• heparin
• lepirudin
• warfarin

143
Drug List
• Anticoagulant Agents and Antidotes
• Low-Molecular-Weight Heparins
• dalteparin
• enoxaparin
• Tinzaparin
• Antidote for Heparin
• protamine sulfate (none)
• Antidote for Warfarin
• phytonadione (Vitamin K)

144
Heparin
• Inhibits thrombin formation, preventing clots from
forming
• Does not dissolve existing clots
• Prophylaxis for DVT

145
Lepirudin
• Alternate anticoagulant for patients who cannot
tolerate heparin
• Directly inhibits thrombin
• Most important side effect is excessive bleeding

146
 Dispensing Issues of Heparin

Warning!
• Technicians—dispense needles with heparin
only for subcutaneous injections
• Prescriber may not specify type
• Technicians—for correct dosage amount, must
convert PPT units to milliliters

147
Warfarin (Coumadin)
• Prevents production of vitamin K-dependent
clotting factors
• Prevents future clots, no effect on existing clots
• Do not take with aspirin or NSAIDs

148
Low-molecular-weight heparins
• Given 12 hours after surgery
• Advantages
• Reduced bleeding
• Reliable dose response
• Longer plasma half-life
• No effect on platelets

149
Tinzaparin
• Should not be interchanged with the other low-
molecular-weight heparins
• Given 1x daily

150
Antidote for Heparin
• Protamine sulfate is antidote for heparin
• 1 mg neutralizes 90 to 120 units of heparin

151
Antidote for Warfarin
• Phytonadione (Vitamin K) is antidote for Warfarin
• Charts are available to indicate amount to
administer based on PTT

152
Antiplatelet Agents
• Interfere with chemical reactions that cause
platelets to be sticky
• Aspirin prescribed to prevent strokes and MIs
• Glycoprotein antagonists administered during
invasive procedures to prevent artery closure

153
Drug List
• Antiplatelet Agents
• General Antiplatelet Agents
• aspirin
• clopidogrel
• ticlopidine
• Glycoprotein Antagonists
• abciximab
• eptifibatide
• tirofiban

154
Eptifibatide
• Mimics native protein sequences in the platelet
receptors
• Used in conjunction with heparin and aspirin

155
Fibrinolytic Agents
• Fibrinolytics dissolve clots by binding to the clot
protein formed by fibrin
• Used for massive PE and MI
• All fibrinolytics supplied as a powder
• When reconstituting, vial should be gently swirled, not
shaken

156
Drug List
• Fibrinolytic Agents
• alteplase
• reteplase
• tenecteplase
• urokinase

157
Terms to Remember
• thrombus
• clotting cascade
• pulmonary embolism (PE)
• anticoagulant
• atiplatelet
• partial thromboplastin time (PTT)
• prothrombin time (PT)
• International Normalized Ratio (INR)
• hematocrit
• fibrinolytic
158
Stroke
• Brain is very oxygen-enriched organ
• If cerebral circulation stops, brain runs out of
oxygen within 10 seconds. Brain tissue dies, does
not regenerate
• Stroke: interruption of oxygen supply

159
Types of Strokes
• Transient ischemic attack (TIA)
• Temporary warning signs over brief period of time
• Strong predictor of imminent stroke
• Reversible ischemic neurologic deficit (RIND)
• Reverses spontaneously, but less rapidly than a TIA
• Lasts more than 24 hours
• Resolves in less than 21 days

161
Causes of Stroke: Primary Events
• Ischemic Stroke
• Results of obstruction to flow due to thrombus or
emboli lodging in a blood vessel
• Cerebral Hemorrhage
• Primary rupture of a blood vessel
• Signs: sudden severe headache, stiff neck, stupor, or a
combination
• Long-lasting and irreversible effects

162
Modifiable Stroke Risk Factors
• Hyperlipidemia
Cigarette smoking
• Hypertension
Coronary artery disease
• Obesity
Diabetes
• Physical
Excessiveinactivity
alcohol intake

163
Not Modifiable Stroke Risk Factors

• Age
• Gender
• Genetic predisposition
• Prior stroke
• Race

164
Stroke Management Options
• Emphasis on prevention
• Antiplatelet therapy
• Anticoagulant therapy
• Fibrinolytic intervention
• Cerebrovascular surgery
• Nonpharmacologic therapy
• Poststroke management
• Cause of stroke determines therapy

165
Antiplatelet Agents
• Prevent platelet activation and formation of
platelet plug
• Interfere with platelet aggregation induced by ADP, or
• Interfere with synthesis of thromboxane
• Most often used to prevent initial and recurrent
thrombotic stroke

166
Anticoagulant Agents
• Interfere with synthesis or activation of the
coagulation factors in blood
• May prevent existing clots from expanding
• Does not reduce existing clots
• Routinely used to treat DVT and PE, and prevention
of stroke

167
Fibrinolytic Agents
• Dissolve existing emboli or thrombi
• Indications
• DVT
• Acute peripheral occlusion
• Acute MI with embolization
• PE
• Coronary embolus

168
Drug List
• TIA and Stroke Prevention Drugs
• aspirin-dipyridamole
• dipyridamole
• pentoxifylline

169
Terms to Remember
stroke
the result of an event (finite, ongoing,
protracted occurrences) that interrupts oxygen supply
to an area of the brain
transient ischemic attack (TIA)
temporary neurologic change that occurs when part
of the brain lacks sufficient blood supply over a
brief period of time

170
Terms to Remember
reversible ischemic neurologic deficit (RIND)
a neurologic change, caused by a temporary
storage of oxygen, that reverses spontaneously
but less rapidly than a TIA
ischemic stroke
a cerebral infarction, in which a region of the
brain is damaged by being deprived of oxygen

171
High Cholesterol and Related
Diseases
• High blood cholesterol is major risk factor for heart
attacks and strokes
• Hypercholesterolemia: excessive amount of
cholesterol in blood
• Hyperlipidemia: levels of one or more of the
lipoproteins are elevated

172
Cholesterol
• Cholesterol in all foods of animal origin, but not in
foods of plant origin
• Some cholesterol needed for good health
• Used to make cell membranes, steroid hormones,
and bile acids

173
Hypercholesterolemia
• Can be inherited or can develop from
environmental factors
• Food fats contain mix of 3 fatty acids: saturated,
monounsaturated, polyunsaturated
• Saturated has greatest effect on raising blood
cholesterol levels

174
Lipoproteins
• Liver packages triglycerides, cholesterol, and carrier
proteins in spherical particles called lipoproteins;
circulate in blood
• High-density lipoproteins (HDL)
• Low-density lipoproteins (LDL)
• Triglycerides: neutral fats for storage in fat cells that
release fatty acids in blood

175
HDL and LDL
• HDL: Good cholesterol
• Carry 20 to 30% of the total serum cholesterol
• LDL: Bad cholesterol
• Carry 60 to 70% of the total serum cholesterol

176
Atherosclerosis
• LDL not used by cells may be deposited in artery
walls, eventually clogging them
• Atherosclerosis: narrowing of arteries due to
deposits of cholesterol and fat on the inner surface
of blood vessel
• Can result in stroke, MI, or limbs lost to gangrene
• High HDL lowers risk of atherosclerosis

177
(a) Normal
Artery

(b) Clogged
Artery

178
Treatment of Hyperlipidemia
• Reduce amount of saturated fats
• Total fat intake should not exceed 30% of total
calories
• Goal: to decrease total cholesterol levels,
specifically LDL levels
• Proper diet control and adjunct of cholesterol
(lipid)-lowering drugs

179
HMG-CoA Reductase Inhibitors
(Statins)
• Inhibit enzyme responsible for cholesterol
biosynthesis
• Side effects: GI upset and headache
• Take at night (most cholesterol formed at night)
• Generic name ends in “statin”

180
Statins
• Some combinations of these drugs are synergistic
and some may be dangerous
• Report any symptom of muscle pain to physician
immediately
• Thiazide diuretics, loop diurectics, and
glucocorticoids increase lipid profile unfavorably

181
Drug List
• Lipid-Lowering Agents
• HMG-CoA Reductase Inhibitors
• atorvastatin
• fluvastatin
• lovastatin
• pravastatin
• rosuvastatin
• simvastatin

182
Atorvastatin
• Potent lipid-lowering drug
• Lowers LDLs significantly
• Lowers triglycerides

183
Simvastatin
• Take at bedtime
• Report muscle pain accompanied by fever
• Store in well-sealed containers

184
Statin Equivalency Chart

Generic Name Brand Name Equiv. Dose

atorvastatin Lipitor 20 mg
rosuvastatin Crestor 5 mg
fluvastatin Lescol 160 mg
lovastatin Mevacor 80 mg
pravastatin Pravachol 80 mg
simvastatin Zocor 40 mg

185
Fibric Acid Derivatives
• Exact mechanism of action is unknown
• Increase excretion of cholesterol in bile, thereby
increasing the risk of gallstones
• Report muscle pain

186
Drug List
• Lipid-Lowering Agents
• Fibric Acid Derivatives
• clofibrate
• fenofibrate
• gemfibrozil

187
Fenofibrate
• Increases breakdown of very low-density
lipoproteins (VLDLs)
• Should be used with dietary modification
• Primary side effects are GI disturbances

188
Gemfibrozil
• Lowers triglyceride and VLDL levels
• Increases HDL levels

189
Side Effects of gemfibrozil
• Abdominal pain • Vertigo
• Diarrhea • Headache
• Nausea • Alteration in taste
• Vomiting • Skin rash

190
Bile Acid Sequestrants
• Form a nonabsorable complex with bile acids in the
intestine
• If second medication is used, take 1 hour before or
4 to 6 hours afterward
• Constipation primary side effect

191
Drug List
• Lipid-Lowering Agents
• Bile Acid Sequestrants
• cholestyramine
• colesevelam
• colestipol

192
Drug List
• Lipid-Lowering Agents
• Other Cholesterol-Lowering Agents
• ezetimibe
• niacin
• psyllium
• Omega-3 fatty acid

193
Niacin
(Vitamin B3)
• Inhibits synthesis of VLDL and lowers triglyceride
and LDL levels
• May cause extreme skin flushing, preventatives are
available
• Most effective drug to increase HDL levels

194
Ezetimibe
• Lowers total cholesterol by inhibiting absorption in
the small intestine
• Also increases HDL levels

195
Omega-3 Fatty Acids
• In form of fish oil supplements, decrease
triglycerides
• Used as alternative or adjunct with niacin, statins,
or fibric acid derivatives
• In flaxseed may decrease heart disease, but not
triglycerides

196
Omega-3 Fatty Acid
• Derived from fish
• Interferes with ability of
liver to synthesize
triglycerides
• Indicated as adjunct to
diet
• Soft gelatin capsule
with light-yellow oil

197
Combinations
• Manufacturers have combined drugs with
synergistic mechanisms of action to lower
cholesterol

198
Drug List
• Lipid-Lowering Agents
• Combinations
• amlodipine-atorvastatin
• niacin-lovastatin
• niacin (ER)-simvastatin
• pravastatin-buffered aspirin ``

199
Discussion
What are some ways that people can lower their
cholesterol levels?
Eat less fat, particularly saturated fat; exercise,
take medications as directed

200
Terms to Remember
• hypercholesterolemia
• hyperlipidemia
• lipoproteins
• high-density lipoproteins (HDL)
• low-density lipoproteins (LDL)
• trigylcerides
• atherosclerosis
• very low-density lipoproteins (VLDLs)

201