EDGEWOOD COLLEGESchool of Nursing

N 312

CARDIAC DRUGS II

Lipid-Lowering AgentsWhat do your cholesterol numbers mean?

Total cholesterol LDL (bad) cholesterol-the main source of cholesterol buildup in the arteries HDL (good) cholesterol-helps keep cholesterol from building in the arteries

o protective Triglycerides-another form of fat in your blood

o Reflect your diet for the past several days o Tend to be dismissed

Total Cholesterol Level CategoryLess than 200 mg/dL Optimal200-239 mg/dL Borderline High240 mg/dL HIgh

LDL Cholesterol Level CategoryLess than 100 mg/dL Optimal100-129 mg/dL Near optimal130-159 mg/dL Borderline high160-189 mg/dL High190 mg/dL Very high

HDL Cholesterol Level Category> 60 Optimal Ideal Goal > 80< 40 Too low – considered a risk factor

HDL : LDL ratio < 0.4 optimal

HDL cholesterol, the higher the number the better. A level < 40mg/dL is low and is considered a major risk factor for developing cardiac disease.HDL levels > 60mg/dL help to lower your risk of heart disease. Aids incholesterol removal by returning from peripheral tissue back to liver.

LDL cholesterol is a major contributor to atherosclerosis. A level > 130mg/dLneeds intervention. If there is existing CAD a level > 100mg/dL should be lowered.

in HDL’s will risk for CAD. in LDL’s will risk for CAD.

Management of elevated LDL and cholesterol is diet and reducing risk factors.Diet recommended, 30% total fat, 10% saturated fat. Other risk factors:smoking, diabetes mellitus, HTN, obesity.

Lowering cholesterol in anyone at risk for heart disease saves lives. Drug therapy is always used in conjunction with diet therapy.

HMG CoA reductase inhibitors- these drugs interfere with the enzyme needed for synthesis of cholesterol.

I (Statins) most effective and newest therapy. Reduce LDL cholesterol significantly and elevate HDL cholesterol only about 2-5%. Also, reduces inflammation and enhances blood vessel dilation, decreasing risk of thrombosis. Contraindicated in liver disease. Liver function tests are needed on a regular basis while on therapy. Taken with other lipid lowering drugs may develop rhapdomyolysis. Best to take at night, when cholesterol synthesis is at its peak.

Rhapdomyolysis: when pt complains of leg pain or muscle pain; if develop this medication needs to be switched because worry of renal failure

Atorvastatin (lipitor)-can lower LDL levels by 60%-

lovastatin (mevacor) – 50% cheaper than lipitor

simvastatin (zocor)

atorvastatin calcium (lipitor)

II Bile Acid-binding resins- the resin makes the bile acids non-absorbable, preventingrecirculation of bile acid. The liver metabolizes more cholesterol to produce more bileacids resulting in reduction of cholesterol level. May decrease the absorption of other medications if given together. Drugs that bind and cannot be absorbed; thiazide diuretics,digoxin, warfarin, and some antibiotics), should take 1 hour before or after. Prolongeduse may cause deficiency in vit. A, D, E, & K.

-Bile acids are produced from cholesterol-blocks absorption of bile acids in the stomach into the circulation, therefore bile acids levels drops, and body will break down cholesterol in order to make-potential probs with medication: absorption problems (therefore usually don’t want to take with any other medications so it doesn’t interfere with absorption)-if on these for a long period of time has potential to reduce vitamin levels

-Pt’s may complain of GI problems-such as bloating or constipation

Cholestyramine (questran) – can be given if active liver disease. A powder form soneeds to be mixed with liquid. Can be given with meals. Bile acid-resins are not absorbed, may get GI symptoms; constipation, bloating.

III Niacin (nicotinic acid)- decreases serum levels of cholesterol, LDL, and triglycerides. Increases HDL’s better than any other drug. Also, acts as a vasodilator, so is used for PVD. If on other vasodilator medications may need to monitor for side effects. May cause flushing but should diminish over time. Due to its side effects it has limited use. Is hepatotoxic, shown to increase levels of homocysteine which will increase risk for CAD. Dose is much higher than what is used as a vitamin supplement. 3-9 grams/day vs. 25 mg/day. Should take with food.

-dose is 6X greater than normal Niacin-will increase HDL levels better than any other drug (so used for people who have low HDLs)-every effective but does cause facial flushing-can take bendril before it or else they have a nonflushing form available that they can substitutePrevention and Treatment of Thromboembolic Disorders

I Anticoagulants – most often used to prevent venous thrombosis

Heparin- rapid-acting anticoagulant. Helps antithrombin III inactivate thrombin, factor Xaand other factors so fibrin formation is suppressed. Cannot be given orally, given IV or SC. Onset of action IV is minutes. Half-life is 1.5 hours. Therapy is usually begun with a bolus and IV drip following. Prescribed in units not milligrams. Dose can varyfrom 100units, 5,000units every 12 hrs. to 1200units/hour. Depends on use. Given to treat pulmonary embolism, evolving stroke, deep vein thrombosis, open-heart surgery and renal dialysis. Careful monitoring is required. APTT-activated partial thromboplastin time is a lab test used to monitor heparin. Normal value is 20-35 secondsLaboratory values will vary from lab to lab.Heparin blood levels - Therapeutic goal for anticoagulant therapy is 1.5-2.5 times the control in seconds. Drug interactions; aspirin, ibuprofen).*Never give IM.Protamine sulfate is the antidote, used for heparin overdose.

PTT (partial thrombo plastin time (sp)—Lab test used to test heparin

Enoxaparin (lovenox)- low-molecular weight heparin. Used for prophylaxis purposes;for DVT after hip, abdominal surgery. APTT is not used for monitoring. Given SC.Adverse affects same as heparin. Advantage is can be given at home.

--safer for patient

symptoms of DVT-calf pain-redness-swelling-test: dorsiflexsion (if have pain with that is +)

Heparin is giving SQ because of bruising

HIT – heparin induced thrombocytopenia

Warfarin (coumadin)- long-term oral anticoagulant. Does not affect clot alreadypresent but used as a preventive. Used for those needing long-term prophylaxis such as;patients with prosthetic valves, those with atrial fibrillation, and prevention of PE.Blocks vitaminK, therefore synthetic vitamin K is used for warfarin overdose. For mild bleeding given orally, for severe bleeding, 5-50mg. vit K given IM or SC.The prothrombin time (PT) (INR) is the lab test used to monitor warfarin therapy.INR, international normalized ratio to be therapeutic should be 2.0-3.0 while some patients need an INR 3-4.5. Monitoring is done daily initially, then once/week for 1-2months, every 2-4 weeks after that. Onset of drug takes several days, after discontinuing drug; effects may still be present for 2-5 days.Patient education – diet, medications, risk for bleeding. Very effective if pts. are in a setting where an anticoagulant management service is present.

Genetic markers – identified as cause for variable response

**INR (international normalized ratio)PT measures seconds it takes the blood to clot…INR therapeutic is usually 2-3; sometimes physicians want it higher-INR 1 or less is considered normal-long half life so slow onset-fluids with high amount of vitamin K—leafy veggies, salads-reversible for warfarin-Vitamin K-discovered that certain individuals react very different to dose and have a problem with bleeding (screening test)

DTI-direct thrombin inhibitor- new drug group, approved 2011. A good alternative to Warfarin anticoagulant therapy. Does not require therapeutic INR monitoring.

Dabigatran etexialte (pradaxa)- the first oral DTI in the US. Indicated to reduce risk of stroke and systemic embolism from atrial fibrillation. Advantages: oral route, rapid onset of action, and predictable anticoagulant. Is not an inducer or inhibitor of cytochrome P450 isoenzymes.

II Antiplatelets- suppresses platelet aggregation, used primarily to prevent thrombosisin arteries.

Aspirin-used for prophylaxis of MI, reinfarction and stroke. Dosing 60mg. –325mg./day. May cause GI irritation and increased bleeding.--cheapest and most commonly used

Clopidogrel (plavix) – inhibits platelet aggregation. May prolong bleeding time. The first one approved and is used the most. Does have a delayedonset and variable response because it can be activated by cytochrome P450 enzymes in the liver.--should not be used with prilosec (this combo reduces amount of plavix by 50%; wont get full benefits of plavix)-two GERD meds can take: pepsid and zantec

Ticlopidine (ticlid)- effects are similar to aspirin. Used for patients allergic orunable to tolerate aspirin. Can cause thrombocytopenia (lowering of platelets)

If platelets less than 90,000, do not give plavix, because if have low platelets this could increase patient’s change of bleeding

All platelet meds should be stopped a week before surgery because of bleeding

Dipyridamole (persantine)- usually used for prevention after heart valve surgery and used with warfarin. Also dilates coronary arteries.

All of these should be stopped 7 days prior to surgery.

III Thrombolytics-used to remove thrombi already formed, also known as fibrinolytics.Most optimal to use within 6 hours of the event.

-short half life-usually given in emergency room-if patient recognizes signs and symptoms…if 6 hours within stroke of heart attack can use-if any recent falls of surgeries patient is not a candidate because it will destroy any other clot in body-used for acute heart attack, stroke, occluded blood vessel

Binds with plasminogen to convert it to plasmin to digest fibrin meshwork of clot. Used for acute coronary thrombosis (MI), massive pulmonary emboli, stroke, for DVT and peripheral arterial clot. Given IV directly into occluded vessel if possible. Half-life is very short. Careful screening needs to be done prior to therapy. Adverse effects; bleeding

(intracranial 1%), allergic reaction, hypotension, fever. Can be used to dissolve clots in central lines and AV cannulas.

Alteplase (tPA) tissue type plasminogen activator- does not cause hypotension or allergic reaction. In 2009, the window for tPA administration for eligible patients was extended from 3-4.5 hours where the clot dissolving can reverse the effects of a stroke. Amazing!

Exclusion Criteria: Age older than 80 INR < 1.7 NIHSS stroke scale > 25 History of both diabetes and stroke

Alterations to adjust HDL and LDL-Diet to a certain extend-Exercise-Smoking cessation (smoking causes LDL to be high)

*Research has shown support groups or coaches are the best way for people to make successful lifestyle changes

Anticoagulant- medication that is going to prevent future clots from occurring; cannot break down an existing clot-used as preventative measure or preventing an already exisiting clot from getting larger

antiplatelets-work on platelets (RBCs tend to clump together and go to site of injury); work on making them not clump together, instead slippery, helps avoid clots

thrombolytics- clot busting medications; will break down exisiting clots

Questions

**Warfarin therapy is monitored by measuring the PT expressed as an INR. A patient has an mechanical artificial valve. You would expect the target INR to be:

If not on warfarin, INR should be less than one

Mechanical artificial valve usually want a little higher than therapeutic, like 3-3.5