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Classifica-tion

ACE Inhibitors

Beta Blockers

Ca+ Channel Blockers

K+ Channel Blockers

MOA

conversion of
A-I to A-II; vasodilator

decreases HR

decreases conduction

slows action potential


(fibrillation)

*atenolol
*carvedilol
*metoprolol
*sotalol

*verapamil
*diltiazem
*amlodipine
*nifedipine
*felodipine
*nicardipine

*amiodarone

Drug Names

*captopril
*enalapril
*lisinopril
*ramipril
*trandolapril
*fosinapril

Cardiac
Treat-ment

*Alpha's dine & sin


*clonidine, *prazosin
HTN, AV block, SVT,
A.fib/flutter, bradycardia,
impaired peripherial
circulation, stable angina

HTN, CAD, SVT,


A.fib/flutter, junctional
dysrhythmia, chronic stable
CAUTION - in asthma pt's angina
bronchospasms; & DM pts - can mask s/s
of hypoglycemia

hypoT, dizziness, fatigue,


headache, ARF, K+, angioedema,
Side Effects
skin rash, cough, loss of taste,
N/V/C, GI irritation

Nursing
Management

N/V, brady, P hypoT,


fatigue, bronchospasms,
hyperglycemia, head/dizz,
drowsiness, CHF, ED

*ortho BP, LFT's, weight


*assess BP, HR, skin, facial
(daily or weekly)
edema, K+ serum, renal tests
*hold if apical < 60
*hold SBP <100
*hold if SBP < 100
*ASA/NSAIDs may reduce
*avoid EtOH, OTC's, &
effectivness
hazardous tasks if dizzy; rise
*full effect on BP
slowly
may not be seen
*do not stop abruptly
*caution use with
for 3-6 wks
African Americans

HTN, a.fib/flutter,
SVT, junctional
dysthythmia, chronic
stable angina
CAUTION - in HF

AV block (prolonged PR interval),


bradycardia, hypoT, pulmonary
edema, CHF, headache, dizziness,
flushing, rash, fever,chills

*I/O, s/s of CHF,


pulm.edema/lungs, daily
weight, pain level
*BP & HR q3-4h
*hold if apical < 60
*hold if SBP < 100
*may cause 1 HB
*take with meals
*pines are for BP; varapimil
& diltiazem for dysrhythmias*

effects of digoxin
*propafenone
*procainamide
*ibutilide
*sotalol

A.fibw/RVR
SVT,
VT/VF
HF, AV block, pulmonary toxicity,
painful breathing, cough, SOB,
weakness in arms/legs, trouble
walking, dizziness,
lightheadedness

*assess BP, RR, apical & radial


pulses, renal & LFT
*hold HR>120 or <60
*safety/safety/safety
*keep all aptmts-MD, labs, etc. &
follow diet plan
*avoid EtOH, smoking, OTC's,
swallow whole, wax may be found
in stool

Classifica-tion

Direct Vasodilators

Statin Drugs

Antiplatelet

Anticoagulation

MOA

relax arteriolar smooth muscle,


causing
blood vessel dilation

inhibit synthesis of
cholesterol in liver

decrease platelet aggregation &


inhibit thrombus formation

prolong the formation


of blood clotting

*atorvastain
*lovastatin
*simvastatin
*fluvastatin

*ASA
*clopidogrel
bisulfate

Antidote = Vitamin K

*hydrazaline
*nitroglycerin

Drug Names

Cardiac
Treat-ment

Side Effects

(sublingual, patch, & paste)


*isosorbide mononitrate
*sodium nitroprusside

HTN, chronic stable


angina, HF after MI

headache, dizziness,
palpitations/tachy,
N/V, hypoT, flushing
*reactions lessen with prolonged
use/dose adjust

HDL
CAD
NVCD, elevated liver
enzymes, myopathy,
rhabdomylosis,
GI disturbances, rash

*take on an empty stomach


*monitor LFT's prior to
*if headache develops treat
& q6-12wks after
w/ASA or acetaminpohen
start of therapy
*advise patient to take an
*use in adjunction with diet
Nursing
additional dose prior to anticipated therapy; restrictions of saturated
Managestress & have drug accessible at all
fat & cholesterol
ment
times *keep record of attacks
*review dietary habits, weight, &
*assess pregnancy status
exercise patterns
*avoid EtOH
*CK - if muscle pain or weakness
*do not mix w/other drugs
occurs

*warfarin
PT- 9.6-11.8seconds
INR- 2-3x norm (1.5-2.0)

*heparin, *enoxaprin
Antidote = Protamine Sulfate

aPTT therapeutic - 60-80

MI or re-infarction,
CAD, stroke
CONTRAINDICATED pregnancy
(3rd trimester), bleeding disorders or
thrombocytopenia
CAUTION
PUD, hepatic/renal disease

A.fib/flutter, MI, DVT,


PE, stroke
CONTRAINDICATED
thrombocytopenia
CAUTION
PUD, severe HTN, hemophelia

HR, BP, bruising, petechiae,


hematuria, bruising, epistaxis,
black/tarry stools, bleeding in
confusion, GI ulcers or upset,
urine/gums, vasculitis,
hemorrhage
hemorrhage

*take with food/milk


*advise patient of prolonged
bleeding time; notify HCP of
unusual bleeding
*may cause dizziness or
drowsiness
*inform HCP before undergoing
any procedures or new drug
therapy
*NO ASA or NSAIDs

*avoid all IM injections


*inspect & teach for abnormal
bleeding
*teach a diet consistent in vitamin
K is essential
*med ID bracelet, electric razor,
soft toothbrush
*contact HCP prior to taking any
OTC or
herbal therapy

Cardiotonics
decreasses conduction
of electrical impulses

*adenosine
*digoxin
(0.8 - 2 ng/mL)

*digitoxin

(14 - 26 ng/mL)

SVT, A.fib, CHF/HF


CONTRAINDICATED
heart block, V.tach/fib, pregnancy

CAUTION
advanced HF &
renal insuffieiency

digoxin toxicity:
KCL - IV or PO
early s/s - N/V/D, brady/tachy,
PVC's, bi/trigeminy
late s/s - visual changes

*assess BP, AP, lung sounds,


JVD, weight, sputum,
extremity edema, renal &
LFT's
*teach pt's s/s of
digoxin toxicity
*no herbal drugs
*K+ rich diet; monitor K+
levels

Anticholinergenic
antiparasympathetic; transient
phase of stimulation

*atropine

bradycardia,
Mobitz II

can't see, can't pee


can't spit, can't sh*t
tachycardia, agitation,
delirium, NVC, ED

*assess for tachycardia;


may lead to V.fib
*monitor I/O; may cause
urinary retention
*give IV over
1 minute

Dysrhythmia

EKG Characteristics

Causative Agents

Sinus
Bradycardia

< 60 bpm & regular

bb, CCB, MI, ICP/IOP,


hypothermia, hypoglycemia,

Sinus
Tachycardia

101 - 200 bpm & regular

exercise, fever, fear, anxiety, pain,


hypoT, hypovolemia, anemia, hypoxia,
hypoglycemia, hyperthyroid, MI, HF

Premature Atrial
Contraction
(PAC)

60 - 100 bpm & irregular;


P-wave may be hidden in the
preceding T-wave

stress, physical fatigue, caffeine, EtOH,


tobacco, electrolyte balances,
hyperthyroid, hypoxia, COPD, CAD

Supraventricular
Tachycardia
(SVT)

150 - 220 bpm & regular;


P-wave often hidden in the T-wave

hypokalemia, digitalis toxicity, ischemia,


CAD, cor pulmonale, rheumatic heart
disease

*a.flutter = F waves; a.fib = irregular*

HTN, CAD, cardiomyopathy, digoxin,


epinephrine, HF, EtOH intoxication,
caffeine, stress, cardiac surgery

1 AV Block

prolonged P-R interval;


If R is far from P = 1st

digoxin toxicity, bb, CCB,


MI, CAD

2 AV Block;
Wenkenbach

P-wave = longer, longer, longer,


DROP = Wenkenbach

digoxin toxicity, bb, CAD

2 AV Block;
Mobitz II

If some QRS's don't get


through = Mobitz II

digoxin toxicity, CAD, anterior MI,


rheumatic heart disease

3 AV Block;
complete

If P's & Q's don't


agree = 3rd

severe heart disease, CAD, MI,


myocarditis, CM, bb, CCB,
scleroedema, amyloidosis

PVC

PVC's occur at variable rates; unifocal or


multifocal, couplets, bi/tri/quadrigeminy;
3+ sequential PVC's = VT

caffeine, EtOH, nicotine, amniophylline,


epinephrine, digoxin, isoproterenol, hypoxia,
fever, emotional stress, exercise,
MI, HF, CAD, MV prolapse

V.Tach/V.Fib

150 - 250 bpm;


QRS's are wide & distorted;
not measurable in v.fib

hyperkalemia, drug toxicity, acidosis,


CM, MI, CAD, MV prolapse, HF,
cardiac cath, CNS disorders

A.Flutter/
A.Fib

A: 200 - 600 bpm;


V: > or < 100 bmp

Treatments
O2, atropine, pacemaker,
drug dosage adjusted or discontinued
O2, bb, treat underlying cause,
antipyretics-fever, analgesics-pain

remove cause, bb, observation


O2, remove cause, IV adenosine,
amiodarone, bb, CCB,
cardioversion, observation
O2, digoxin, bb, CCB, warfarin,
cardioversion, ablation
A.fib w/RVR*amiodarone, propafenone

O2, check meds/labs, call HCP *if new


onset, continue to monitor
O2, temp pacemaker, ERT, VS, atropine,
check meds/labs,
call HCP, permanent pacemaker
O2, temp pacemaker, ERT,
VS, meds/labs, call HCP,
*permanent pacemaker
O2, ERT, VS, meds/labs, call HCP,
*permanent pacemaker ASAP

O2, bb, amiodarone,


procainamide, lidocaine

CPR, defibrillate,
epinephrine

Dx Tests

Description & Purpose

EKG recording for 24-48 hours correlating


rhythm changes w/symptoms in diary; recorder
Holter Monitoring
is used to store, recall, print & analyze info for
rhythm disturbances

Echocardiogram

ultrasound of chest & heart; measures


EF% - IV contrast may be used to enhance
images; also records direction of
blood flow across valves

Pharmacologic
Echo

sused as substitute for exercise stress test in


people unable to exercise; dobutamine or
dipyridamole infused via IV & dose increased in
5 min intervals to detect abnormalaties

Transesophageal
Echocardiogram
(TEE)

probe w/ultrasound transducer is swallowed &


passes down esophagus; contrast may be
injected IV for evaluating blood flow if atrial or
ventricular septa defect is suspected

Exercise Stress
Test

exercise tolerance, ADL's, rhythm


disturbances, EKG changes;
contraindications acute CV disease,
recent MI (2 weeks), angina

Exercise Nuclear
Imaging

nuclear images are taken at rest & after exercise;


injection given at max HR on bicycle/treadmill &
continue for 1 min to circulate; scanning done
15-60min after exercise; resting scan 60-90min
after initial infusion or 24 hours later

Pharmacologic
Nuclear Imaging

dipyridamole or adenosine to promote


vasodilation when unable to exercise

Nuclear
Cardiology

IV injection of radioisotopes; measures blood


flow to heart at rest & while your heart is
working harder as a result of
exertion or medication; HCP suspects CAD

Single-photon
Emission Computed
Tomography (SPECT)

used to evaluate myocardium at risk for MI;


small amounts of radioactive isotope injected
via IV; detects coronary artery blood flow,
intracardiac shunts, motion of ventricles,
EF% & size of heart chambers

Dx Tests

Description & Purpose

Cardiac
Catheterization

contrast injected to examine structure & motion


of heart & coronary arteries;
also provides information to determine
need for angioplasty or stenting
small amount of blood removed, mixed w/radioactive

Multigated
isotope & reinjected; EKG's used for timing, images
Acquisition Scan acquired during cardiac cycle; indicated for MI, HF,
valvular HD,
(MUGA)
cardiotoxic drugs on the heart

Magnetic
Resonance
Angiography
(MRA)

used for vascular occlusive disease &


AAA; same as MRI but with use
of gadolinium as IV contrast

Cardiac CT Scan

evaluates heart muscle, coronary artery


circulation, pulmonary veins, thoracic
aorta, pericardium; IV contrast

Electrophysiology Study
(EPS)

invasive study to record cardiac electrical


conduction using catheters via femoral &
jugular veins into right side of heart;
dysrhythmia can be induced & terminated

Peripherial
Arteriography &
Venography

injection of contrast into veins or arteries


followed by serial x-rays to detect
atherosclerotic plaques, occlusions,
aneurysms, or trauma

Dx Labs

Description & Purpose

Troponin - I

* earliest increase 4-6 hours, peak hours 10-24 hrs


* duration of increase 4-7 days
* specificity 95%; sensitivity at peak 98%

Creatine Kinase
(CK)

* earlies increase 4-8 hrs; peak hours 24-36 hrs


* duration of increase 36-48 hours
* specificity 57-88%; sensitivity at peak 93-100%

CK-MB

* earliest increase 3-4 hours; peak hrs 15-24 hrs


* duration of increase 24-36 hours
* specificity 93-100%; sensitivity at peak 94-100%

Myoglobin

99-100% sensitive for MI;


serum concentration rise 30-60min after MI
male: 5.2-12.9 umol/L; female: 3.7-10.4 umol/L

Nursing Considerations
encourage to stimulate conditions that produce
symptoms; keep an accurate diary of activities
& symptoms; no bath or shower

assess for allergy to shellfish; supine position


on left side of equipment;
no contraindications to procedure unless
contrast is being used
start IV infusion; monitor VS before/during/after
until baseline achieved; aminophylline given to
prevent or reverse
side effects of dipyridamole
NPO 6 hours prior; IV sedation & throat
anesthetized; designated driver needed;
bite block placed-suctioning as needed;
no eating/drinking until gag reflex returns
pt to wear comfortable clothes/shoes & walk as
quickly as possible; hold bb & caffeine
24 hrs prior to procedure; no smoking 3 hrs
prior; test is terminated for chest discomfort

explain to eat only a light meal between


scans; certain medications may need to
be held for 1-2 days before the scan
hold all caffeine products
12 hours prior to procedure;
hold bb & CCB 24 hours prior
establish IV line - pt will have to lie still on back
with arms extended for 20 minutes;
repeat scans are performed within a few
minutes to hours after the injection

establish IV line; ECG monitoring


Nursing Considerations

withhold food/fluids 6-18 hours; give sedative;


instruct patient to deep breath when dye is
injected; assess circulation, peripherial pulses,
color, & sensation q15min/1 hour after

establish IV line, EKG monitoring;


procedure involves little risk

contraindicated w/allergies to
contrast or implanted metal devices

procedure is quick & involves little to no


risk; assess for shellfish allergies
discontinue antidysrhythmic meds
several days prior to study; NPO 6-8h, IV
sedation if needed; frequent VS &
continuous EKG after procedure
check for iodine allergy; mild sedative;
check extremity puncture, pulsation,
warmth, motion, swelling, bleeding;
Nursing Considerations
< 0.5 ng/mL - normal
0.5 - 2.3 ng/mL - suspicious for MI injury
> 2.3 ng/mL - positive for MI injury

cardiac biomarker used to


diagnose MI & necrosis
explain the purpose of serial sampling
(e.g. 3x q6-8h); normal is 0.3 mcg/L
in conjunction with serial EKG's
cleared from circulation rapidly &
most diagnostic if measured within
first 12 hours of onset of chest pain