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 12
Drugs for
Cardiovascular
Diseases

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 12
Chapter Topics

• The cardiovascular system

• Angina
• Arrhythmia
• Heart failure
• Hypertension
• Myocardial infarction
• Blood clots
• Stroke
• Cholesterol abnormalities and related diseases
• Varicose veins
• Complementary and alternative therapies
© Paradigm Publishing, Inc. 3
 12
Learning
Objectives

• Describe the anatomy and physiology of the cardiovascular system.

• Describe the drugs and treatment for each type of heart disease.
• Recognize anticoagulant and antiplatelet drugs, and know their
functions.
• Explain stroke and the drugs used to treat it.
• Identify drugs used to treat hyperlipidemia, and understand its role in
heart disease and stroke treatment.

© Paradigm Publishing, Inc. 4

 The Cardiovascular System

• Cardiovascular system
– Circulates blood throughout the body, bringing oxygen
and nutrients to tissues and carrying away carbon dioxide
and toxic by-products
• Arteries
– Carry blood away from the heart to the tissues
• Veins
– Carry blood to the heart from the tissues
• Capillaries
– Tiny blood vessels where critical fluids, gases, and
nutrients are exchanged

© Paradigm Publishing, Inc. 5

The Cardiovascular System (continued)

© Paradigm Publishing, Inc. 6

 The Cardiovascular System (continued)

The heart
Term Definition
Sinoatrial (SA) node Group of specialized cells where a normal heartbeat starts
Depolarization The flow of positively charged sodium and calcium ions into
cells making the voltage positive
Repolarization The flow of positively charged potassium ions out of cells
making the voltage negative
Action potential An electronic burst; when an action potential arrives at a
myocardial cell, it depolarizes with an inflow of sodium and
calcium and repolarizes with an outflow of potassium.

© Paradigm Publishing, Inc. 7

 The Cardiovascular System (continued)

Causative factors of cardiovascular disease

• Predetermined factors
• Heredity
• Gender
• Increasing age

• Factors influenced by lifestyle modification

• Cigarette smoking
• High blood pressure
• High blood cholesterol levels
• Obesity
• Diabetes

© Paradigm Publishing, Inc. 8

Interactive
What roles do arteries, veins, and capillaries play in
the cardiovascular system?

© Paradigm Publishing, Inc. 9

Interactive
What roles do arteries, veins, and capillaries play in
the cardiovascular system?

Arteries carry blood away from the heart to the tissues.

Veins carry blood to the heart from the tissues.

Capillaries are very small blood vessels where fluids,

gases, and nutrients are exchanged.
© Paradigm Publishing, Inc. 10
 Angina
• Angina pectoris
– Definition
• Chest pain due to an imbalance between oxygen supply and oxygen
demand; does not cause irreversible changes
– Types of angina
• Stable angina
• Unstable angina
• Symptoms and risk factors of angina
– Symptoms
• Chest discomfort, sweating, dizziness, dyspnea
• Often triggered by exercise or emotional stress
– Risk factors
• Advanced age, coronary artery disease, hypertension, ↑ serum glucose
levels, ↑ serum lipoprotein levels, obesity, smoking, type A personality.

© Paradigm Publishing, Inc. 11

 Angina (continued)

• Antianginal drugs: beta blockers

– How they work
• Inhibit the action of catecholamines on beta receptors
• ↓ heart rate, ↓ myocardial contractility, ↓ blood pressure
– Nonselective beta blocker
• Blocks both beta-1 and beta-2 receptors
• Beta-1 associated with heart function, beta-2 with lungs
– Cardioselective beta blocker
• More selective for beta-1 than beta-2 receptors
– Therapeutic uses
• Angina, arrhythmias, hypertension, myocardial infarction, heart
failure

© Paradigm Publishing, Inc. 12

 Angina (continued)

Antianginal drugs: beta blockers

Medication
Acebutolol (Sectral)
Atenolol (Tenormin)
Carvedilol (Coreg)
Esmolol (Brevibloc)
Labetalol (Normodyne, Trandate)
Metoprolol (Lopressor, Toprol-
XL)
Nadolol (Corgard) and timolol
Nebivolol (Bystolic)
Propranolol (Inderal)
Sotalol (Betapace)
Side effects
Tiredness, bradycardia,
mask symptoms of
hypoglycemia and
hyperthyroidism, may
inhibit the
bronchodilating effects
of endogenous
catecholamines
Cautions and
considerations
Atenolol, metoprolol,
nadolol, propranolol, timolol:
↑ cardiac symptoms with
abrupt discontinuation
Sotalol: ↑ risk of arrhythmia
Acebutolol, atenolol,
betaxolol, bisoprolol,
metoprolol: preferred in
asthma and COPD
All: risk of cardiac problems
with abrupt discontinuation

© Paradigm Publishing, Inc. 13

 Angina (continued)

Antianginal drugs: nitrates

Medication How they Therapeutic Side effects Cautions and
work uses considerations
Isosorbide Relax Acute attacks Headaches, Short acting forms: not to be
dinitrate vascular and orthostatic swallowed; call 911 if no
(Dilatrate- smooth prophylaxis of hypotension, relief from one tablet within
SR, Isordil) muscle which angina flushing 5 minutes; maximum of 3
Isosorbide reduces doses in 15 minutes; keep
mononitrate preload sublingual nitroglycerin in
Nitroglycerin original container and protect
(Minitran, from light, heat, and
Nitrolingual, moisture; tablets good for 6
Nitrostat, months, write date on
Nitro-Dur) container.
Drug-free interval of at least
8 hours a day to prevent
tolerance

© Paradigm Publishing, Inc. 14

 Angina (continued)

Antianginal drugs: calcium channel blockers

Medication How they work Therapeutic uses Side effects Cautions and
considerations
Amlodipine (Norvasc) Prevent calcium Angina, Bradycardia, Risk of fluid
Diltiazem (Cardizem, from entering supraventricular hypotension, retention and
Dilacor XR) into cardiac tachyarrhythmias, heart block, palpitations;
Felodipine muscle cells hypertension, cardiac extended-release
Isradipine during isolated systolic failure, forms not be to
Nicardipine (Cardene) depolarization hypertension nausea, crushed or
Nifedipine (Adalat, by blocking the constipation, chewed; patient
Afeditab, Nifediac, slow channels headache, education
Procardia) dizziness, regarding
Nisoldipine (Sular) fatigue appearance of
Verapamil (Calan, ghost pill
Verelan) appearing in stool

© Paradigm Publishing, Inc. 15

 Angina (continued)

Antianginal drugs: metabolic modifier

Medication How it works Therapeutic uses Cautions and
considerations
Ranolazine (Ranexa) Assists the heart to Chronic angina in Risk of prolonging
generate energy more combination with the QT interval;
efficiently by allowing amlodipine, beta caution in kidney
it to function despite a blockers, or nitrates dysfunction and in
decrease in oxygen older adults

© Paradigm Publishing, Inc. 16

 Arrhythmia
Heart rates and rhythms

Term Definition
SA node Generates
normal cardiac
rhythm at 70 to
80 beats per
minute
Ectopic A pacemaker
pacemaker other than the
SA node
Tachycardia Excessively
high heart rate

© Paradigm Publishing, Inc. 17

 Arrhythmia (continued)

Membrane-stabilizing agents (Class I)

Medication How they Therapeutic Side effects Cautions and
work uses considerations
Disopyramide Slow the Atrial Disopyramide: dry To be reserved for
(Norpace) movement of arrhythmias mouth, urinary retention, life-threatening
Flecainide sodium into or ventricular constipation, blurred arrhythmias,
(Tambocor) myocardial arrhythmias vision caution in heart
Lidocaine cells reducing depending on Flecainide: dizziness, failure, quinidine
(Xylocaine) the ability to agent blurred vision, tremor, salts not
Mexiletine generate an nausea, vomiting interchangeable
Procainamide action Mexiletine: GI and
Propafenone potential. This neurologic symptoms,
(Rhythmol) dampens leukopenia,
Quinidine potential agranulocytosis
abnormal Quinidine:
rhythms and thrombocytopenia,
heartbeats. cinchonism

© Paradigm Publishing, Inc. 18

 Arrhythmia (continued)

Potassium channel blockers (Class III)

Medication How they work Therapeutic uses Cautions and considerations
Amiodarone Delay Amiodarone: Amiodarone: reserve for life-
(Cordarone, repolarization atrial and threatening arrhythmias; risk of
Nexterone, Pacerone) of atrial and ventricular liver toxicity, exacerbations of
Dofetilide (Tikosyn) ventricular arrhythmias arrhythmias, pulmonary toxicity
Dronedarone (Multaq) fibers by Dofetilide: atrial Dofetilide: must be started in
blocking the fibrillation/flutter setting with clinical monitoring,
flow of in patients who caution in renal impairment
potassium have been Dronedarone: not to be used in
across cell cardioverted patients with symptomatic heart
membranes Dronedarone: failure, may increase mortality in
atrial fibrillation patients with permanent atrial
fibrillation

© Paradigm Publishing, Inc. 19

 Arrhythmia (continued)

Other agents
Medication Description
Beta blockers (Class II) • See previous discussion in this chapter and Table 12.1
Calcium channel blockers • See previous discussion in this chapter and Table 12.3
(Class IV)
Atropine • Used in bradycardia or heart rates below 60 beats per minute
• Low doses may worsen bradycardia, high doses may cause
cardioacceleration.
Digoxin (Digitek, Digox, • Used in atrial fibrillation or flutter
Lanoxin) • Risk of digitalis toxicity which presents with nausea, vomiting,
arrhythmias
• Antidote for digitalis toxicity is digoxin immune Fab (DigiFab)
Isoproterenol (Isuprel) • Used for ventricular arrhythmias, bradyarrhyrthmias, and to third-
degree AV block

© Paradigm Publishing, Inc. 20

 Heart Failure
• Definition
– A chronic, progressive condition in which the heart is no longer
able to pump enough oxygen-rich blood to meet the body’s needs
• Symptoms
– Shortness of breath, fatigue, edema, exercise intolerance
• Goals of therapy
– Prolong survival, relieve symptoms, improve quality of life,
prevent progression of disease
• Drug therapy
– ACE inhibitors
– Beta blockers
– Diuretics
– Digoxin
© Paradigm Publishing, Inc. 21
 Heart Failure (continued)

Treatment of heart failure: vasodilators

Medication How it works Therapeutic uses Side effects Cautions and
considerations
Isosorbide Reduces the Supplement Headaches Hydralazine: risk of lupus-
dinitrate- resistance standard therapy, and like syndrome, fluid
hydralazine against which alternative for dizziness retention, peripheral
(BiDil) the heart must patients unable to neuritis
work take an ACE Combination: caution in
inhibitor patients with coronary
artery disease

© Paradigm Publishing, Inc. 22

 Heart Failure (continued)

Treatment of heart failure: ACE inhibitors

Medication How they work Therapeutic Side effects Cautions and
uses considerations
Benazepril Inhibits the ↓ risk of Persistent Hypotension,
(Lotensin) conversion of cardiovascular cough, hyperkalemia,
Captopril (Capoten) angiotensin I to events angioedema, potassium
Enalapril (Epaned, angiotensin II, a dizziness, ↑ supplements to
Vasotec) potent potassium be avoided in
Fosinopril (Monopril) vasoconstrictor levels patients taking
Lisinopril (Prinivil, potassium-
Zestril) sparing diuretics,
Moexipril (Univasc) downward dose
Perindopril (Aceon) adjustment in
Quinapril (Accupril) patients with
Ramipril (Altace) kidney problems
Trandolapril (Mavik)

© Paradigm Publishing, Inc. 23

 Heart Failure (continued)

Treatment of heart failure: other agents

Medication class
Aldosterone antagonists
Beta blockers
Antiarrhythmic medications
Neprilysin inhibitor-angiotensin
receptor blocker
Description
•Spironolactone, a potassium-sparing diuretic
•Discussed in Chapter 11
•Discussed earlier in chapter with angina
•Digoxin (Digitek, Digox, Lanoxin)
•Discussed earlier in chapter with arrhythmias
•Sacubitril/Valsartan (Entresto)
•Needs to be started 36 hours after the last dose of
ACE inhibitor/ARB (due to increased risk of
angioedema)
•Similar side effect profile to ACE inhibitors

© Paradigm Publishing, Inc. 24

 Hypertension

• Blood pressure
– The product of cardiac output and total peripheral resistance
• Cardiac output (CO = HR x SV)
– Preload
– Afterload
– Contractility
• Systolic blood pressure
– The pressure when the heart ejects blood
• Diastolic blood pressure
– The pressure when the heart relaxes and fills
• Blood pressure notation
– Systolic “over” diastolic pressure
© Paradigm Publishing, Inc. 25
 Hypertension (continued)

• Definition
– Elevated blood pressure
• When to treat
– >150/90 in patients > 60 years old
– >140/90 in patients < 60 years old
– >140/90 in diabetes or kidney disease
• Risk factors
– Definitive factors: family history, cigarette smoking, high-fat diet
– Additional factors: kidney disease, decreased pressure or delayed
pulse in lower extremities, obesity, adrenal tumor, use of certain
medications

© Paradigm Publishing, Inc. 26

 Hypertension (continued)

• Untreated hypertension
– Cardiovascular disease
– Heart failure
– Renal insufficiency
– Accelerated cardiac and
peripheral vascular disease
• Hypertension therapy
– Modify lifestyle factors.
– Monotherapy
– Add an additional drug.
– Add a third agent.

© Paradigm Publishing, Inc. 27

 Hypertension (continued)

Antihypertensive therapeutics: angiotensin receptor blockers

Medication How they work Therapeutic Side effects Cautions and
uses considerations
Azilsartan (Edarbi) Block Alternative for Cough not a Hypotension,
Candesartan angiotensin II patients who typical side special dosing in
(Atacand) receptors, cannot tolerate effect patients with
Eprosartan (Teveten) thereby ACE inhibitors kidney or liver
Irbesartan (Avapro) preventing impairment
Losartan (Cozaar) constriction and
Olmesartan (Benicar) causing blood
Telmisartan vessels to relax
(Micardis)
Valsartan (Diovan)

© Paradigm Publishing, Inc. 28

 Hypertension (continued)

Antihypertensive therapeutics: central nervous system agents

Medication How they work Side effects Cautions and
considerations
Clonidine (Catapres, Stimulate the alpha- Clonidine: Clonidine and guanfacine:
Catapres-TTS, 2 adrenergic bradycardia, caution in cardiovascular
Duraclon) receptors in the brain hypotension, disease, kidney impairment;
Guanfacine (Tenex) leading to decreased respiratory not recommended in older
heart rate, cardiac depression adults; gradual
output, total Guanfacine: discontinuation
peripheral drowsiness, recommended
resistance, plasma fatigue, dry Clonidine patches: to be
renin activity and mouth, removed prior to MRIs,
blunting of depression, fluid cardioversion, defibrillation
baroreceptor reflexes retention, skin Guanfacine: caution in liver
rash, exfoliation dysfunction

© Paradigm Publishing, Inc. 29

 Hypertension (continued)

Antihypertensive therapeutics: other agents

Medication class Description
Diuretics •Reduce cardiac output by increasing the elimination of urine and
reducing fluid volume
•Discussed in Chapter 11
Peripheral acting agents •Indirectly cause vasodilation and hypotension
(alpha blockers) •Discussed in Chapter 11
Direct renin inhibitor •Aliskiren (Tekturna)
•Inhibits renin, which controls the first rate-limiting step of the renin-
angiotensin-aldosterone system
•Main side effect is diarrhea.
•Risk of teratogenicity, hypersensitivity, angioedema, caution in
kidney impairment
Combination drugs •Have additive effects
•Cost savings by taking two drugs separately instead of combination
product

© Paradigm Publishing, Inc. 30

 Myocardial Infarction

• Definition
– Occurs when the flow of oxygenated blood to a section of the heart is blocked
• Causes of a heart attack
– Narrowing of the lumen of one or more coronary arteries by 70 percent or
more
• Risk factors
– History of angina, alcohol consumption, reduced pulmonary vital capacity,
cigarette smoking, atherosclerosis
• Symptoms of myocardial infarction
– Most common symptoms: chest pain or discomfort, upper body discomfort,
shortness of breath
– Other symptoms: cold sweat, unusual fatigue, nausea and vomiting, light-
headedness, dizziness

© Paradigm Publishing, Inc. 31

 Myocardial Infarction (continued)

• Treatment of myocardial
infarction
– Immediate goals of treatment
• Open blocked arteries, control
blood pressure, regulate heart
rhythm.
– Acute phase
• Oxygen, nitroglycerin, aspirin
– Chronic therapy
• Anticoagulants, antiplatelets,
beta blockers, ACE inhibitors,
medications to treat cholesterol

© Paradigm Publishing, Inc. 32

 Blood Clots

• Thrombus
– Blood clots transported in the blood
• Pulmonary embolism (PE)
– A piece of a clot which breaks off and travels to the lung blocking the
pulmonary artery
• Deep vein thrombosis (DVT)
– Venous thrombi which form in areas of low-velocity blood flow, surgical
or other vein injury, or large venous sinuses
• Anticoagulant
– Prevents clot formation by inhibiting clotting factors
• Antiplatelet
– Reduces the risk of clot formation by inhibiting platelet aggregation

© Paradigm Publishing, Inc. 33

 Blood Clots (continued)

Laboratory test Drug affected by

Partial Heparin
thromboplastin
time (PTT)

Prothrombin time Warfarin

(PT)
International Warfarin
normalized ratio
(INR)

© Paradigm Publishing, Inc. 34

 Blood Clots (continued)

Anticoagulant agents: direct thrombin inhibitors

Medication How they work Therapeutic Side effects Cautions and
Uses considerations
Bivalirudin Patients with Dabigatran:
(Angiomax) unstable angina increased risk of
undergoing thrombotic events if
Bind directly to angioplasty Nausea, discontinued
thrombin, can headache, back prematurely; risk of
Dabigatran inhibit circulating Prevention and pain, bleeding
(Pradaxa) treatment of spinal or epidural
thrombin as well due to excessive hematoma; caution
as thrombin DVT and PE; anticoagulation
prevention of in older adults,
bound to fibrin kidney impairment
stroke in
nonvalvular
atrial fibrillation

© Paradigm Publishing, Inc. 35

 Blood Clots (continued)
Anticoagulant agents: heparin
How it works Therapeutic Side effects Cautions and
Uses considerations
Inhibits thrombin Low-dose: Bruising, bleeding Risk of heparin-
formation, thereby prophylaxis of due to excessive induced
reducing the ability DVT and PE in anticoagulation, thrombocytopenia
of blood to clot and patients at risk thrombocytopenia (HIT), patients to
preventing the report bleeding or skin
formation of a new Heparin flushes: rashes to prescribers
clot keep IV lines right away
open

Antidote for heparin

Medication Description
Protamine sulfate 1 mg neutralizes ~100 units of heparin

© Paradigm Publishing, Inc. 36

 Blood Clots (continued)
Anticoagulant agents: low-molecular-weight heparin
Medications Therapeutic Uses Side effects Cautions and
considerations
Enoxaparin Prevention of Hemorrhage,
(Lovenox) thrombosis after thrombocytopenia Dose adjustment
surgery, treatment of required in impaired
DVT with or without renal function,
pulmonary embolism contraindicated in some
Dalteparin Prevent cases of severe kidney
(Fragmin) thromboembolism problems

© Paradigm Publishing, Inc. 37

 Blood Clots (continued)
Anticoagulant agents: factor Xa inhibitors
Medication How they work Therapeutic Uses Cautions and
considerations
Apixaban Prevention and treatment of
(Eliquis) DVT; stroke prevention in Risk of spinal or
nonvalvular atrial fibrillation epidural
hematoma,
Edoxaban Block the activity Treatment of DVT and PE; increased risk of
(Savaysa) of factor Xa and stroke prevention in thromboembolic
prevent blood nonvalvular atrial fibrillation events with
clots from premature
developing or discontinuation,
Fondaparinux getting worse Prevention and treatment of caution and
(Arixtra) DVT potential for dose
Rivaroxaban Stroke prevention in adjustment in
(Xarelto) nonvalvular atrial fibrillation kidney impairment
and after hip or knee surgery

© Paradigm Publishing, Inc. 38

 Blood Clots (continued)
Anticoagulant agents: vitamin K antagonists
Medications How it works Therapeutic Cautions and considerations
Uses
Warfarin Inhibits the Prevention of Administration of dose: same time
(Coumadin) vitamin K- future clots each day
dependent Diet: avoid varying the amount of
clotting factors II, vitamin K consumed, warfarin doses
VII, IX, and X can be adjusted according to diet.
Alcohol: excessive intake increases
warfarin’s effects to unsafe levels,
moderate intake (one to two drinks a
day) does not affect anticoagulation
therapy.

© Paradigm Publishing, Inc. 39

 Blood Clots (continued)
Antidote for warfarin
Medication Description
Phytonadione or vitamin K1 Charts available indicating amount to be given based in
(Mephyton) INR
Fresh whole blood Contains the clotting factors necessary to stop blood loss

Common Drugs that Interact with Warfarin

Amiodarone Fluvastatin Rifampin
Carbamazepine Gemfibrozil Rosuvastatin
Cimetidine Levothyroxine Simvastatin
Fenofibrate Lovastatin Sulfamethoxazole
Fluconazole Metronidazole Tamoxifen
Fluoxetine Phenytoin Voriconazole

© Paradigm Publishing, Inc. 40

 Blood Clots (continued)
Antiplatelet agents: general antiplatelet drugs
Medication How it works Therapeutic Uses Cautions and
considerations
Aspirin Irreversibly inhibits Approved for Risk of mild salicylate
cyclooxygenase, an reduction of intoxication, risk of Reye’s
enzyme that promotes recurrent TIAs or syndrome in children given
clotting strokes aspirin after exposure to
chickenpox or other viral
infections

Cilostazol Reversibly inhibits Symptomatic Not to be used in patients

(Pletal) platelet management of with heart failure
phosphodiesterase, peripheral vascular
thereby inhibiting platelet disease
aggregation
Clopidogrel Blocks adenosine Prevent recurrence of Risk of thrombocytopenia
(Plavix) diphosphate receptors, atherosclerotic and neutropenia
thereby preventing events
fibrinogen binding
(P2Y12 inhibitor)

© Paradigm Publishing, Inc. 41

 Blood Clots (continued)
Antiplatelet agents: general antiplatelet drugs
Medication How it works Therapeutic Uses Cautions and
considerations
Prasugrel Not provided Taken with aspirin to reduce Risk of significant or fatal
(Effient) cardiovascular death, MI, bleeding, not
(PY212 inhibitor) and stroke after stent recommended in patients >
placement 75 years or those likely to
undergo coronary arter
bypass surgery

Ticagrelor Blocks platelet Decreases cardiovascular Risk of bleeding,

(Brilinta) aggregation events in patients who have maximum of aspirin 100
(PY212 inhibitor) coronary syndromes mg recommended
concurrently

© Paradigm Publishing, Inc. 42

 Blood Clots (continued)
Glycoprotein antagonists
Medication How they work Therapeutic Uses Cautions and
considerations
Abciximab Risk of bleeding, caution
(ReoPro) in older adults

Reversibly bind to a
receptor on platelets, Indicated for acute coronary
Eptifibatide preventing platelet syndrome and given during Risk of bleeding, caution
(Integrilin) aggregation as well invasive procedures to in kidney impairment
as the binding of prevent artery closure
fibrinogen
Tirofiban Risk of bleeding and
(Aggrastat) thrombocytopenia; dose
reduction in kidney
impairment

© Paradigm Publishing, Inc. 43

 Blood Clots (continued)
Fibrinolytic agents
Medication How they work
Alteplase (Activase) Dissolves clots by binding
Reteplase (Retavase) to the clot protein formed
Tenecteplase by fibrin
(TNKase)
Cautions and considerations
Risk of bleeding and hemorrhage;
caution in patients with conditions
that increase the risk of bleeding;
caution in older adults

© Paradigm Publishing, Inc. 44

Interactive
Determine whether each of the following drugs is an
anticoagulant or an antiplatelet.

Heparin

Apixaban (Eliquis)

Prasugrel (Effient)

© Paradigm Publishing, Inc. 45

Interactive
Determine whether each of the following drugs is an
anticoagulant or an antiplatelet.

Heparin
• Anticoagulant
Apixaban (Eliquis)
• Anticoagulant
Prasugrel (Effient)
• Antiplatelet
© Paradigm Publishing, Inc. 46
 Stroke

• Definition of stroke
– The result of an event that interrupts the oxygen supply to a
localized area of the brain
• Transient ischemic attack (TIA)
– Temporary neurologic changes during a brief period of time
• Symptoms of stroke
– Sudden numbness or weakness of the face, arm or leg; sudden
confusion, difficulty speaking, or understanding speech;
sudden trouble seeing in one or both eyes; sudden dizziness,
loss of balance or coordination; sudden severe headache with
no known cause

© Paradigm Publishing, Inc. 47

https://www.mass.gov/service-details/stroke-signs-and-symptoms-act-fast

© Paradigm Publishing, Inc. 48

 Stroke (continued)
Types of stroke
Type of stroke Description

Ischemic Obstruction to blood flow in a

stroke cerebral blood vessel.
Sources of ischemia include
• Newly formed thrombus
becoming lodged at its site
of origin
• Emboli moving from one
cerebral vessel to another
• Cardiogenic emboli

Hemorrhagic Primary rupture of a cerebral

stroke blood vessel
https://www.healthline.com/health/stroke
49

© Paradigm Publishing, Inc.

 Stroke (continued)

Risk factors for stroke

Modifiable Not modifiable
• Cigarette smoking • Age
• Coronary artery disease • Gender
• Diabetes • Genetic predisposition
• Excessive alcohol intake • Prior stroke
• Hyperlipidemia • Race
• Hypertension
• Obesity
• Physical inactivity

© Paradigm Publishing, Inc. 50

 Stroke (continued)

Stroke management
Medication class Role in therapy
Antiplatelet agents •Prevent recurrent thrombotic stroke
•Prevent initial episodes in high-risk patients
Anticoagulant agents •Prevent existing clots from expanding
Fibrinolytic agents •Dissolve existing thrombi
Aspirin-dipyridamole •Prevent recurrence of stroke or TIA
(Aggrenox)

© Paradigm Publishing, Inc. 51

 Cholesterol Abnormalities
and Related Diseases

Hypercholesterolemia
• An excessive amount of cholesterol in
the blood

Hyperlipidemia
• A condition in which the levels of one
or more of the lipoproteins are
elevated

Dyslipidemia
• A condition where levels of
atherogenic lipoproteins are elevated
and/or levels of antiatherogenic
lipoproteins are decreased

© Paradigm Publishing, Inc. 52

 Cholesterol Abnormalities
and Related Diseases (continued)
• Causes of dyslipidemia
– Inherited
– Diet high in saturated fat
• Lipoproteins
– High-density lipoproteins (HDL)
• Transport cholesterol back to the liver for excretion
• The “good cholesterol”
– Low-density lipoproteins (LDL)
• Bring cholesterol to body cells, may be deposited in arteries
• The “bad cholesterol”
– Triglycerides
• Neutral fats made from carbohydrates for storage in fat cells
© Paradigm Publishing, Inc. 53
 Cholesterol Abnormalities
and Related Diseases (continued)
Drugs for dyslipidemia: HMG-CoA reductase inhibitors
Medication How they work Side effects Cautions and
considerations
Atorvastatin Inhibit the enzyme that GI upset, Risk of rhabdomyolysis
(Lipitor) catalyzes the rate- headache, with acute kidney failure,
Fluvastatin limiting step in rhabdomyolysis myopathy, liver function
(Lescol) cholesterol biosynthesis abnormalities, increases
Lovastatin in blood glucose; dose
(Mevacor) adjustment may be
Pitavastatin necessary in patients with
(Livalo) kidney dysfunction.
Rosuvastatin
(Crestor)
Simvastatin
(Zocor)

© Paradigm Publishing, Inc. 54

 Cholesterol Abnormalities
and Related Diseases (continued)
Drugs for dyslipidemia: fibric acid derivatives
Medication How they Side effects Cautions and
work considerations
Fenofibrate Gas, diarrhea, constipation
(TriCor)

Not to be used in
Increase the patients with
Fenofibric acid excretion of Unexplained muscle pain leading to gallbladder
(Trilipix) cholesterol in kidney failure (serious side effect) problems, caution
bile in combination with
statins
Gemfibrozil Abdominal pain, diarrhea, nausea,
(Lopid) vomiting, vertigo, headache,
alteration in taste, skin rash

© Paradigm Publishing, Inc. 55

 Cholesterol Abnormalities
and Related Diseases (continued)
Drugs for dyslipidemia: bile acid sequestrants
Medication How they work Side effects Cautions and
considerations
Cholestyramine Constipation, Caution if triglyceride
(Questran, nausea, vomiting level > 300 mg/dL,
Prevalite) potential for decreased
Colesevelam Constipation absorption of fat-
(Welchol) Block cholesterol soluble vitamins and in
absorption and patients with fat-
Colestipol decrease cholesterol Gastrointestinal soluble vitamin
(Colestid) synthesis including deficiencies, risk of
constipation exacerbating
constipation and
causing fecal
impaction

© Paradigm Publishing, Inc. 56

 Cholesterol Abnormalities
and Related Diseases (continued)
Drugs for dyslipidemia: other cholesterol-lowering agents
Medication How they work Side effects Cautions and
considerations
Ezetimibe Inhibit absorption of Caution in liver and
(Zetia) cholesterol in the small kidney disease
intestine
Niacin Inhibits VLDL synthesis Extreme skin
(Niacor) by the liver and lowers flushing, nausea, May increase blood
triglyceride and LDL vomiting, diarrhea, glucose levels
levels ↑ uric acid levels
Niacin Inhibits VLDL synthesis Less flushing than
May increase blood
(Niaspan) by the liver with immediate-
glucose levels
release form
Psyllium Provides the same effect
(Fiberall, as a high-fiber diet, see
Metamucil) Chapter 10.

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 Cholesterol Abnormalities
and Related Diseases (continued)
• Omega-3 fatty acids
– Lovaza and Vescepa derived from fish
– Adjunct to diet for triglyceride lowering
• Combinations
– Amlodipine-atorvastatin (Caduet)
– Niacin-lovastatin (Advicor)
– Niacin ER-simvastatin (Simcor)

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Interactive
Which classes of drugs are used in the treatment
of hyperlipidemia?

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Interactive
Which classes of drugs are used in the treatment
of hyperlipidemia?

• HMG-CoA reductase inhibitors (statins)

• Fibric acid derivatives
• Bile acid sequestrants
• Others such as ezetimibe, niacin, and pysllium

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 Complementary and
Alternative Therapies
• Plant sterol esters
– Found to significantly lower LDL cholesterol
– Adjunct to diet and drug therapy for hyperlipidemia
– Beta-sitoserol found in margarine and juice
• Red yeast rice
– Fermented rice product used in recipes and medications to lower cholesterol and improve
cardiovascular health
– Contains monacolins, agents with HMG-CoA reductase inhibitor activity
• Alpha tocopherol (vitamin E)
– Antioxidant used for cardiovascular disease, cancer, diabetic neuropathy; effectiveness not
proven
• Garlic
– Possible effectiveness in treating atherosclerosis, hypertension, some cancers, and skin
fungal infections
– Must contain allicin, the active ingredient
– Drug interactions with warfarin and protease inhibitors
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 12
Chapter
Summary

• Angina pectoris is an imbalance between oxygen supply to the heart and oxygen
demand from the heart.
• Drugs used to treat angina include beta blockers, nitrates, calcium channel blockers,
and a metabolic modifier.
• Normal heart rhythm is generated by the SA node.
• The classes of drugs used to treat arrhythmias are class I (membrane-stabilizing
agents, class II (beta blockers), class III (potassium channel blockers), and class IV
(calcium channel blockers).
• Heart failure occurs when the pumping ability of the heart can no longer sustain the
blood flow needs of the body.
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 12
Chapter
Summary

• Medications used for heart failure include vasodilators, ACE inhibitors, and human
B-type natriuretic peptide.
• Drugs commonly used for hypertension include ACE inhibitors, angiotensin II
receptor antagonists, beta blockers, calcium channel blockers, and diuretics.
• MI occurs when there is a prolonged decrease in oxygen delivery to a region of
cardiac muscle, which dies.
• Beta blockers and low-dose aspirin are prescribed to reduce the risk of death or
recurrent following an MI.

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 12
Chapter
Summary

• Blood clots in the bloodstream can cause life-threatening pulmonary embolism and
other serious damage.
• Anticoagulants, antiplatelets, glycoprotein antagonists, and fibrinolytic agents are
used in the management of blood clots.
• A stroke may be caused by either a cerebral hemorrhage or a cerebral infarction.
• Antiplatelets and anticoagulants are used in the management of stroke.
• The liver packages triglycerides, cholesterol, and carrier proteins as lipoproteins
which circulate in the blood.
• Drugs are used as an adjunct to diet to treat dyslipidemia.

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