cardiac medications by theresa till rn, ed.d, ccrn

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  • Slide 1
  • Cardiac Medications By Theresa Till RN, Ed.D, CCRN
  • Slide 2
  • The Intima Controls the Destiny of the Cardiovascular System
  • Slide 3
  • Atherosclerosis Atherosclerosis results from the interaction between the intimal surface (endothelium), WBCs (macrophages), and fat (lipoprotein).
  • Slide 4
  • http://www.youtube.com/watch?v=n8P3n6GKBSY
  • Slide 5
  • http://www.youtube.com/watch?v=q RK7-DCDKEA&NR=1
  • Slide 6
  • Macrophage on Intima The macrophage determines that the fat on the intima is foreign and sends WBCs to the surface to destroy the fat. However, the intima is frequently also damaged.
  • Slide 7
  • Blood Vessel Layers
  • Slide 8
  • http://www.youtube.com/watch?v= zeS-0au8ij4&NR=1&feature=fvwp
  • Slide 9
  • Slide 10
  • Antiplatelets Decrease afterload because they cause the cells to be less sticky.
  • Slide 11
  • http://www.youtube.com/watch? v=YcNYxegDXa8
  • Slide 12
  • Platelet Activation
  • Slide 13
  • Clotting Cycle
  • Slide 14
  • Heparin Route: IV or SQ Onset: Immediate Duration: hours (about 4) Monitor: APTT, anti-Xa Antidote: Protamine Sulfate
  • Slide 15
  • Heparin-Induced Thrombocytopenia (HIT) 12 million patients exposed to heparin each year. Consider HIT whenever a hospitalized patient exposed to heparin experiences a drop in platelet count or develops new thrombi. HIT results in thrombosis despite anticoagulation due to immune complex aggregation in blood despite low or reduced platelet counts. Patients lose unaffected extremity due to thrombosis (fractured ankle, lose hand).
  • Slide 16
  • Definition of HIT Thrombocytopenia: 150,000 50% drop in platelet count from baseline (can still be within normal range and have HIT) Platelet recovery once UFH/LMWH stopped Patient with or without thrombosis
  • Slide 17
  • Treatment for HIT Stop heparin product Give direct thrombin inhibitor bivalirudin (Angiomax) lepirudin (Refludan) Argatroban (Acova) Fondaparinux (Arixtra) Once platelet count recovers, put patient on Coumadin.
  • Slide 18
  • Coumadin Route: Oral Onset: Slow (hours) Duration: Days Monitor: PT, INR Antidote: Vitamin K Keep dietary intake of Vitamin K consistent.
  • Slide 19
  • Properties of the Heart Inotropic (strength of cardiac contraction) Chronotropic (rate of cardiac contraction) Dromotropic (electrical excitability of the heart)
  • Slide 20
  • Hemodynamics of the Heart Preload amount of fluid in ventricles immediately before contraction. Afterload- amount of resistance the heart has to overcome to eject blood into the circulatory system. Contractility- amount of heart stretch
  • Slide 21
  • Preload Patients in HF have an increased preload. This increased fluid in the chambers of the heart result in increased stretching of the muscle. Degree of stretching can be measured by the BNP (Brain Naturetic Peptide). Blood test BNP > 100 suggestive of HF
  • Slide 22
  • http://www.youtube.com/watch?v=GnpL m9fzYxU
  • Slide 23
  • Hypertension Guidelines Category SBPDBP Normal 100
  • Slide 24
  • HTN 2X risk of CVA, MI if patient 20/10 over goal. 4X risk of CVA, MI if patient 30/20 over goal. Using combination therapy much sooner.
  • Slide 25
  • Dipper v. Non-Dipper Important to take BP different times during day----even at night. Normally, BP reduces when a person sleeps. However, some people have a BP that remains high throughout the day, which increases the risk of coronary artery disease.
  • Slide 26
  • Diuretics and Renal Absorption
  • Slide 27
  • Nitrates Tolerance is a big issue Safety is a big issue since they are powerful preload and afterload reducers (dilate blood vessels and drop BP)
  • Slide 28
  • Slide 29
  • Renin Angiotensin Aldosterone System (RAA)
  • Slide 30
  • Renin/Angiotensin System Renin Angiotensin I Angiotensin II (vasoconstriction) Aldosterone release from adrenals (sodium retention, potassium excretion and fluid retention). Opposite occurs with ACEI because block Angiotensin II so loose sodium/fluid and retain potassium.
  • Slide 31
  • Renin/Angiotensin/Aldosterone (RAA) System Angiotensin I converts to Angiotensin II which causes VASOCONSTRICTION Next, aldosterone is released that results in sodium retention and potassium excretion. When ACE inhibitors block the renin/angiotensin system, sodium is released and potassium is absorbed. Check for hyperkalemia.
  • Slide 32
  • Ace Inhibitors Preload reducer (decreases venous volume) Afterload reducer (decreases arterial volume) Diuretic
  • Slide 33
  • ACE Inhibitors
  • Slide 34
  • Renin-angiotensin-aldosterone system (RAAS): http://pearsonium.com/RAASystem/ind ex.html
  • Slide 35
  • Calcium Channel Blockers Block the calcium influx into the blood vessel thus preventing actin and myosin from sliding over each other. Net vasodilation Also, great for Prinzmetal angina (spasm). Some are powerful dysrhythmics
  • Slide 36
  • Calcium Channel Blockers Actin/Myosin
  • Slide 37
  • Beta Blockers Decreases Heart Rate (Blunts HR) Decreases Heart Contraction Decreases Excitability of Heart CARE WITH DIABETICS AND ASTHMATICS
  • Slide 38
  • Cholesterol Remember that cholesterol can be elevated if a person is hypothyroid. Physicians should do a thyroid panel (T3,T4, TSH) before starting a patient on hypolipemics. Many times once the thyroid problem is corrected, the cholesterol returns to normal.
  • Slide 39
  • New Statin Guidelines ACC/AHA Individuals who need statins are Diabetics History of Heart Disease LDL >1 90 Patients with an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75 years of age (the report provides formulas for calculating 10- year risk).
  • Slide 40
  • New Statin Guidelines Websites http://circ.ahajournals.org/content/early/2013/11/11/01.cir.00004377 38.63853.7a.full.pdf Research article explaining new guidelines http://my.americanheart.org/professional/StatementsGuidelines/Pr evention-Guidelines_UCM_457698_SubHomePage.jsphttp://my.americanheart.org/professional/StatementsGuidelines/Pr evention-Guidelines_UCM_457698_SubHomePage.jsp Calculator http://newsroom.heart.org/news/acc-aha-publish-new-guideline- for-management-of-blood-cholesterolhttp://newsroom.heart.org/news/acc-aha-publish-new-guideline- for-management-of-blood-cholesterol Guidelines
  • Slide 41
  • Controversy Regarding Statin Guidelines http://www.doctoroz.com/episode/controversial-new- statin-guidelines Part 1 http://www.doctoroz.com/episode/controversial-new- statin-guidelines http://www.doctoroz.com/episode/controversial-new- statin-guidelines?video_id=2859817307001 Part 2 http://www.doctoroz.com/episode/controversial-new- statin-guidelines?video_id=2859817307001
  • Slide 42
  • Cholesterol
  • Slide 43
  • HDL/LDL Ratio
  • Slide 44
  • Hyperlipidemia Total Cholesterol Want < 200 HDL Good Fat Want >40 M >50 F LDL Bad Fat Want < 130 if healthy Want < 100 if high risk (some MD want 70) Triglycerides Want < 150 Hypothyroidism can lead to increased cholesterol. TC/HDL Ratio Want < 4.5
  • Slide 45
  • TC/HDL Ratio Examples: Patient A: Total cholesterol 240, HDL 80 240/80 =3 (Low Risk for CAD) Patient B: Total Cholesterol 240, HDL 30 240/30= 8 (High Risk for CAD)
  • Slide 46
  • Metabolic Syndrome Clustering of obesity, dyslipidemia, hypertension, and insulin resistance exponentially increase the risk of CAD.
  • Slide 47
  • http://www.oprah.com/oprahshow/ Dr-Oz-Explains-What-Diabetes- Does-to-Your-Body-Video
  • Slide 48
  • Metabolic Syndrome (continued) Three of five = increased risk of CAD Waist circumference M >40 and F >35 TG > 150 HDL Men 110
  • Slide 49
  • Dysrhythmics
  • Slide 50
  • http://www.youtube.com/watch?v= XV11kplLoxw&feature=related http://www.youtube.com/watch?v=xL zRFAT9uFA
  • Slide 51
  • Normal Electrical Conduction System through the Heart When impulses do not travel normal electrical pathway, dysrhythmias occur.
  • Slide 52
  • Electrical System
  • Slide 53
  • 1)P Wave = atrial contraction 2) PR Interval = 0.12-0.20 (SA Node AV Node) 3) QRS complex =ventricular contraction ( 0.12) 4) ST segment (should be flat or isoelectric) 5) T wave = ventricular relaxation 6) QT Interval = ventricular contraction and relaxation ( 0. 40)
  • Slide 54
  • Smoking Disconnect remains between trial evidence and clinical practice. 25% of Americans smoke yet people have known since the 1960s that smoking causes cancer. Cardiologists are writing no smoking prescriptions to reinforce importance of abstinence.