Cardiovascular Medications

Diuretic Therapy

Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.

The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics.  Licorice root can potentiate potassium loss and increase the client’s risk for hypokalemia.  Use of licorice root should be reported to the PCHP.

When a client taking a diuretic experiences constipation, the nurse must consider the reason for taking the diuretic before offering a recommendation.  Increased fluid intake is usually contraindicated in clients with a history of heart failure.

Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives.  However, they are useful when combined with thiazide diuretics to reduce potassium (K⁺) loss.  Thiazide diuretics can cause hypokalemia when used as monotherapy.

The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics.  Hypokalemia can lead to dangerous ventricular dysrhythmias.

Anticoagulants

The anticoagulant heparin has to be administered intravenously or subcutaneously.  The duration is 2-6 hours intravenously and 8-12 hours subcutaneously.  It is measured by the aPTT (activated partial thromboplastin time) laboratory value.  Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days.  It is measured by prothrombin time (PT) or International Normalized Ratio (INR).

Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3.  A diet high in vitamin K may decrease warfarin’s anticoagulant effect.  Most antibiotics will increase INR by causing a vitamin K deficiency.

Clients taking a combination of antiplatelet agents (eg, aspirin, clopidogrel, ticagrelor, prasugrel) and anticoagulants (eg, warfarin, rivaroxaban, apixaban) are at very high risk for life-threatening bleeding complications.  The nurse should teach the client how to recognize and prevent signs and symptoms of increased bleeding.

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery.  However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place.

Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion.  KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

Nitrates

Nitroglycerin belongs to the group of medicines called nitrates. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its work load.

The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light.  The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken.  These instructions should be reinforced at each appointment.

Nitrate drugs are prescribed to treat angina.  The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension.

Ace Inhibitor

Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.

Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury.  These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin.

Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised.  The nurse should report this immediately to the health care provider.  Angioedema occurs more commonly in African American clients.

Major side effects of angiotensin-converting enzyme (ACE) inhibitors include:

• Symptomatic hypotension
• Intractable cough
• Hyperkalemia
• Angioedema (allergic reaction involving edema of the face and airways)
• Temporary increase in serum creatinine

Beta Blockers

Beta blockers, or “lols” (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure.  However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility

The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration.  Beta blockers are most useful for chronic heart failure.

The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol.  Wheezing may indicate bronchoconstriction or bronchospasm.  The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

Anthihypertensive

Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents.  Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.FOr Example, Metoprolol and Olanzapine. 

Clonidine is a very potent antihypertensive.  Abrupt discontinuation can result in serious rebound hypertensive crisis.  Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds).  Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.

Calcium Channel Blockers

Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina.  They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure.

Calcium channel blockers are utilized to treat hypertension and chronic stable angina.  Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension.  The nurse should report this client’s statement to the HCP.

Antiplateles Agent 

Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion.  They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage.  Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time.  Antiplatelet agents and Ginkgo biloba should not be taken together. 

If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use.  In this situation, the client would be at increased risk for bleeding.  This data should be reported to the prescribing health care provider before the client is discharged.

Statins 

Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels.

A therapeutic response to statin medication includes a decrease in a client’s LDL cholesterol, total cholesterol, and triglyceride levels to within normal range.  An increase in HDL cholesterol to within normal range is also an expected outcome.  Potential adverse effects include hepatic dysfunction and muscle injury.

The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.

Thrombolytics 

Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium.  This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely.  Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site).  Minor or major bleeding can be a complication.

Absolute contraindications to thrombolytic

• Prior intracranial hemorrhage
• Structural cerebrovascular lesion (eg, arteriovenous
  malformation, aneurysm)
• Ischemic stroke within 3 months (except within 3 hr)
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
• Significant head trauma within 3 months

Inotropic Agent

Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation.  Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies.  The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. 

Cardiac Glycoside

Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation.  Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate).  However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL).

Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate).  Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity.  General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.