DRUGS AFFECTING THE

CARDIOVASCULAR
SYSTEM
MARIVIC E. ILARDE MAN, RN
 OUTLINE OF THE DISCUSSION

1. Brief physiology of the Cardiovascular System

2. Classification of Cardiac Drugs
3. Effects of Drugs on the Heart
4. Uses of Cardiac Drugs
5. Nursing responsibilities
 HEART
4 chambers:
• Right atrium → Tricuspid Valve
• receives deoxygenated blood.
• Right ventricle → Pulmonic valve
• pumps blood to the pulmonary
artery.
• Left atrium → Mitral valve
• receives oxygenated blood.
• Left ventricle → aortic valve
• pumps blood into aorta for
systemic circulation.
 HEART
Cardiac output- the amount of blood ejected by each ventricle per min
CO= vol/min

• Factors that affect the CO

1. Stroke Volume: the volume of blood pumped by the ventricles per beat
SV= ml/beat
 contractility, preload and afterload

2. Heart Rate: the conduction system of the heart

HR=beats/min
 FACTORS THAT AFFECT CARDIAC
OUTPUT

CO= SV x HR
CO= SV (70ml/beat)x HR(65 beats/min)
CO= 4,550ml/min

The amount of blood passing through the heart is about 4-8 liters/min
 EFFECTS OF DRUGS ON HEART
1. Inotropic
• affects the force of contraction
• positive inotropic effect: ↑ myocardial contraction, ↑ renal blood
flow
2. Chronotropic
• interferes with the rate of heart beat
• positive chronotropic effect: ↑ heart rate
3. Dromotropic
• pertains to conduction
• positive dromotropic effect: speeds up conduction
 CARDIAC DRUGS

• Used in Hypertension
• Used in Angina Pectoris and Myocardial Infarction
• Used in Shock
• Used in Arrhythmias
• Used in CHF
 HYPERTENSION
excessive high blood pressure

Factors the affect BP:

1. Contraction of the LV
2. Peripheral Vascular resistance
3. Elasticity of the arterial walls
4. Blood volume
 BP HOMEOSTASIS

1. Baroreceptors
mechanoreceptors located in the carotid sinus and in the aortic arch.
 barareceptors sense pressure changes and respond to change in the
tension/stretch of the arterial wall.
The baroreflex mechanism is a fast response to changes in blood pressure.
BARORECPTORS
 HOW BARORECEPTORS REGULATE
BLOOD PRESSURE
BARORECEPTORS

BP decreases Baroreceptors signals to the adrenal medulla

releases cathecholamines activiate the Alpha and beta
receptors increase in the symphathetic activity
 activation of Beta 1 receptors HR & stroke volume
CO BP
 activation of Apha 1 receptors vasoconstriction and
vascular resistance increase in BP
 BP HOMEOSTASIS

2. RAAS Renin-Angiotensin-Aldosterone-System
it is regulated by the rate of renal blood flow
a classic endocrine system that helps to regulate BP and
extracellular volume of the body.
 ANTIHYPERTENSIVE DRUGS
• Goal: to decrease BP to normal
CLASSIFICATIONS OF ANTIHYPERTENSIVE DRUGS:
1. ACE-INHIBITORS
2. ANGIOTENSIN II – RECEPTOR BLOCKERS
3. CALCIUM CHANNEL BLOCKERS (CCB)
4. VASODILATORS
5. DIURETICS
6. RENIN INHIBITORS
7. SYMPHATETIC NERVOUS SYSTEM BLOCKER
A. BETA BLOCKERS
 ACE INHIBITORS
are heart medications inhibit ACE
increases the amount of blood the heart
pumps and lowers blood pressure
 raise blood flow, which helps to lower heart's
workload
 ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITOR
• no direct positive inotropic action
• reduce aldosterone secretion, salt and water
retention, and vascular resistance
• first line drugs for heart failure, along with
diuretics and digitalis
 ACE INHIBITORS
captopril ( Capoten ) → 1st ACE inhibitor
benazepril ( Cibacen )
perindopril ( Coversyl )
enalapril ( Renitec, Vasopress )
quinapril ( Accupril )
fosinopril ( BPNorm )
ramipril ( Tritace )
lisinopril ( Zestril )
trandolapril
moexipril ( Univasc )
…Pril =Chill =decrease BP
 NURSING RESPONSIBILITIES

1. The nurse should encourage the patient to implement lifestyle changes

such as weight reduction, smoking cessation, decreased intake of alcohol,
dietary restriction of salt/fats and increased exercise.

2. Give the drug on an empty stomach, either 1 hour before or 2 hours after
meals to ensure proper drug absorption

3. Stress the importance of NOT abruptly stopping the medication if

symptoms are improving.
 ANGIOTENSIN II – RECEPTOR BLOCKERS
 also known as angiotensin II receptor antagonists
ARBs reduce the action of the hormone angiotensin
II.
They are also used for chronic kidney disease and
prescribed following a heart attack.
 ANGIOTENSIN II – RECEPTOR
BLOCKERS ( … SARTAN )
EXAMPLE:
Losartan (Prototype)
Candesartan
Irbesartan
Valsartan
Telmisartan
 CALCIUM CHANNEL BLOCKERS

They work by slowing the movement of calcium into the cells

of the heart and blood vessel walls, which makes it easier for
the heart to pump and widens blood vessels.
As a result, the heart doesn't have to work as hard, and blood
pressure lowers
CCB calms the heart
 CALCIUM CHANNEL BLOCKERS
2 CLASSIFICATIONS:
1. Dihydropyridines:
• Selectively inhibit the L type of calcium Channels in the vascular smooth
muscle
• blocks the entry of Calcium into the vascular smooth muscle decreasing the
contraction and decrease BP.

Amlodipine (Norvasc)
Felodipine (Plendil)
Nicardipine
Nifedipine ( Calcibloc, Adalat) Long acting
 CALCIUM CHANNEL BLOCKERS
2. Nonhydropyridines
 non selectively block the cardiac cells on the SA and AV node that
decreases myocardial contractility , decrease the CO and HR
Diltiazem
Verapamil ( isoptin)

Side Effect:
1.excessive bradycardia
2. Cardiac conduction abnormality
3. Verapamil inhibits CC in the smooth muscle of the GIT : constipation
 VASODILATORS
medicines that dilate (open) blood vessels by relaxing the smooth muscle
 allows blood to flow more easily.
They affect the muscles in the walls of the arteries and veins, preventing the
muscles from tightening and the walls from narrowing.
As a result, blood flows more easily through the blood vessels.
 Used to treat severe hypertension
 VASODILATORS
Example:
• Hydrala
• Zine
• Diazoxide (Hyperstat)

• Hydralazine (Apresoline)

• Minoxidil (Loniten)

• Sodium Nitroprusside (Nitropress) (P)

• Tolazoline (Priscoline)
 CONTRAINDICATIONS
• The vasodilators are contraindicated in the presence of known allergy to the
drug
• with pregnancy and lactation because of the potential for adverse effects
on the fetus and neonate
• and with any condition that could be exacerbated by a sudden fall in blood
pressure, such as cerebral insufficiency
 NURSING CONSIDERATIONS

• Monitor blood glucose and serum electrolytes to avoid potentially serious

adverse effects.

• Monitor the patient carefully in any situation that might lead to a drop in fluid
volume (e.g., excessive sweating, vomiting, diarrhea, dehydration) to detect
and treat excessive hypotension that may occur.
 DIURETICS
also called water pills
increases the amount of water and sodium
excretion from the body as urine.
first line agent in
mild hypertension
Acetazolamide,
dorzolamide

Furosemide,
Ethacrymic Acid

Chlorthiazide
Hydrochlorthiazide

Spirinolactone,
Amiloride
Triamterene
 DIURETICS
• Nursing considerations:
1. monitor VS
2. monitor input and output
3. weigh the patient daily
4. monitor for adverse effects
 RENIN INHIBITOR
: inhibits/ antagonist renin production
: inhibits to the conversion of angiotensinogen to angiotensin 1
Results to relaxed blood vessels, improves cardiac output

EXAMPLE:
ALISKIREN
Enalliren
Remikiren
 SYMPATHETIC NERVOUS SYSTEM
BLOCKERS
• Blocks fight and flight response

1. BETA BLOCKERS (…olol)

AKA bete-adrenergic agents
block the hormones adrenaline and
noradrenaline in the sympathetic
nervous system.
symphatolytics

Example
Acebutolol
Atenolol
Betaxolol
Bisoprolol
Metoprolol
 BETA-BLOCKERS
Cardiac Effects
• Decrease contractility
(negative intropy)
• Decrease relaxation rate
(negative lusitropy)
• Decrease heart rate
(negative chronotropy)
• Decrease conduction velocity
(negative dromotropy)
Vascular Effects
• Smooth muscle contraction
(mild vasoconstriction)
 NURSING RESPONSIBILITIES

1. Monitor BP, ECG

2. Monitor I&O
3. Monitor compliance
4. Advise to change position slowly to prevent
orthostatic hypotension
 ALPHA-ADRENERGIC BLOCKERS
• A substance that relaxes muscle tissue in blood vessels, which improves the
flow of urine and blood.
• Also called Alpha-adrenergic antagonist

EXAMPLE:
PHENTOLAMINE
PHENOXYBENZAMINE

Pharmacodynamics:
 Inhibits the postsynaptic alpha1-adrenergic receptors, preventing the
feedback control of norepinephrine release
 ALPHA- AND BETA- BLOCKERS
have a combined effect. They block the binding of catecholamine
hormones to both alpha- and beta-receptors.
Therefore, they can decrease the constriction of blood vessels like alpha-
blockers do.
They also slow down the rate and force of the heartbeat like beta-
blockers do.
EXAMPLE:
• Carvedilol
Labetalol
Guanabenz
 ALPHA-1 ADRENERGIC BLOCKERS
The alpha-1 adrenergic receptor antagonists are a family of agents that
bind to and inhibit type 1 alpha-adrenergic receptors and thus inhibit
smooth muscle contraction.
(also called alpha-blockers)

• EXAMPLE
Doxazosin
Prazosin
Terazosin
• Indications:
 hypertension
benign prostatic hypertrophy (BPH)
 ALPHA-2 ADRENERGIC AGONIST

• sympathomimetic agents that selectively stimulates alpha adrenergic

receptors and sends a feedback mechanism for modulating the release of
norepinephrine.

• EXAMPLE:
Clonidine
Guanfacine
Methyldopa
 ALPHA-2 ADRENERGIC AGONIST
• Pharmacodynamics:
stimulates the alpha2-adrenergic receptors in the
CNS and inhibit the cardiovascular centers
decrease in sympathetic outflow from the CNS
decrease in norepinephrine release
 weakening the sympathetic nervous system effects that results in
increase in the reflex tachycardia
ADVERSE EFFECTS AND TOXICITY ASSOCIATED
WITH ANTIHYPERTENSIVE DRUGS
Syncope, dizziness,
headache

Alopecia, rash

cough
ADVERSE EFFECTS AND TOXICITY ASSOCIATED
WITH ANTIHYPERTENSIVE DRUGS

Renal damage
proteinuria
Renal failure

Tachycardia
Heart failure
Arrythmias
hypotension
ADVERSE EFFECTS AND TOXICITY ASSOCIATED
WITH ANTIHYPERTENSIVE DRUGS

Constipation
GI upset

Loss of libido
 2. ANGINA PECTORIS
 refers to a strangling or pressure-like pain caused by cardiac ischemia.
The pain is usually located substernally, sometimes with radiation to the neck,
shoulder and arm, or epigastrium.
Drugs used in angina exploit two main strategies: reduction of
oxygen demand and increase of oxygen delivery to the myocardium.
 DRUGS USED FOR ANGINA
1. NITRATES: NITROGLYCERINE
2. BETA BLOCKERS
3. CALCIUM CHANNEL BLOCKERS
 NITROGLYCERINE
EXAMPLE
Isosorbide dinitrate
Isosorbide mononitrate

• Pharmacodynamics:
relaxes vascular smooth muscle with a resultant decrease in
venous return and decrease in arterial blood pressure,
reducing the left ventricular workload and decreasing
myocardial oxygen
 drug of choice for treating an acute anginal attack
 BETA-BLOCKERS
EXAMPLE:
Metoprolol
Nadolol
Propranolol

• Pharmacodynamics:
competitively blocks beta-adrenergic receptors in the heart and
kidneys, decreasing the influence of the sympathetic nervous
system on these tissues and the excitability of the heart;
decreases cardiac output, which results in a lowered blood
pressure and decreased cardiac workload
 CALCIUM CHANNEL BLOCKERS
EXAMPLE:
Diltiazem

• Pharmacodynamics:
inhibits the movement of calcium ions across the membranes of myocardial
and arterial muscle cells
 alters the action potential and blocking muscle cell contraction
depresses myocardial contractility
slows cardiac impulse formation in the conductive tissues, and relaxes and
dilates arteries
fall in BP and a decrease in venous return
decreases the workload of the heart and myocardial oxygen consumption
 3. ARRHYTHMIA
 irregular rhythm of the heart

A. Pathophysiology:
 involves changes to the automaticity or conductivity of the heart
cells
 CLASS 1 ANTIARRHYTHMIC DRUGS
• Drugs used for Arrhythmia:
 CLASS I ANTIARRHYTHMIC DRUGS
Class Ia:
Procainamide
Quinidine
Class Ic
Flecainide
Propafenone
 Class Ib
Lidocaine
Mexiletine
 CLASS 1 ANTIARRHYTHMIC DRUGS
• Pharmacodynamics:
blocks sodium channels
decreases depolarization, decreasing automaticity of the
ventricular cells
 increases ventricular fibrillation threshold

• Indications:
management of acute ventricular arrhythmias during
cardiac surgery or MI
 CLASS II ANTIARRHYTHMIC DRUGS
• EXAMPLE
Acebutolol
Esmolol
Propranolol

• Pharmacodynamics:
competitively blocks beta-adrenergic receptors in the
heart and kidney, has a membrane-stabilizing effect, and
decreases the influence of the sympathetic nervous system
 CLASS III ANTIARRHYTHMIC DRUGS
EXAMPLE
Amiodarone
Dofetilide

• Pharmacodynamics:
acts directly on heart muscle cells to prolong repolarization and the
refractory period, increasing the threshold for ventricular fibrillation; also acts
on peripheral smooth muscle to decrease peripheral resistance
 CLASS IV ANTIARRHYTHMIC DRUGS
• EXAMPLE:
Diltiazem
Verapamil
• Pharmacodynamics:
blocks the movement of calcium ions across the cell membrane, depressing
the generation of action potentials, delaying phases 1 and 2 of
repolarization, and slowing conduction through the AV node.

• Indications:
 Treatment of paroxysmal supraventricular tachycardia
atrial fibrillation
 atrial flutter.
 HEART FAILURE
 a condition where the heart is not pumping
effectively and blood backs up so the system
becomes congested
results from conditions that impair the ability of the
heart to fill with, or to pump out, sufficient blood.
• Either side of the heart may be affected, or both
sides may be affected in some patients.
 AGENTS USED FOR HEART FAILURE
CARDIOTONIC DRUGS ( INOTROPIC DRUGS )
drugs that affect the intracellular calcium levels in the heart muscle that
results in;
1. increased contractility, increase in contraction, increased cardiac output
2. increased renal blood flow, increased urine production, decreases renin
release
3. interfering with the effects of the renin–angiotensin–aldosterone system
o increases urine output
o decreased blood volume
4. decrease in the heart’s workload
5. relief of HF
 CARDIOTONIC DRUGS ( INOTROPIC
DRUGS )
CARDIAC GLYCOSIDES
1. Digoxin ( Lanoxin )
derived from digitalis plant
 most often used drug to treat HF

They increase the level of CALCIUM inside the cell by inhibiting the Sodium-
Potassium pump.

More calcium will accumulate inside the cell during cellular depolarization
 CARDIAC GLYCOSIDES

• Negative chronotropic effect- the heart rate is slowed due to decreased

rate of cellular repolarization

• Bradycardia

• Decreased conduction velocity through the AV node

 CARDIAC GLYCOSIDES
• Nursing considerations:
1. monitor apical pulse for 1 full minute before administering the drug
to monitor for adverse effects.
2. hold the dose if the pulse is less than 60 beats/min in an adult or less
than 90 beats/min in an infant; retake the pulse in 1 hour. If the pulse
remains low, document it, withhold the drug, and notify the
prescriber because the pulse rate could indicate digoxin toxicity
3. monitor the pulse for any change in quality or rhythm to detect
arrhythmias or early signs of toxicity
4. monitor the patient for therapeutic digoxin level (0.5–2 ng/mL)
5. Patient teaching on the antidote in case of toxicity: DIGOXINE
IMMUNE FAB
 VASODILATORS
1. Ace inhibitors … pril (captopril, enalapril)
2. Nitrates: nitroglycerine
• Pharmacodynamics:
 relax vascular smooth muscle that results in
• a decrease afterload
• a venous pooling: a decrease preload of
the heart, decrease workload,
(+) inotropic effect
 DRUGS FOR CIRCULATORY DISORDERS
Five major groups:
1. antilipidemics - hypolipidemics; antihyperlipidemia; increase blood lipid
concentration.
2. Anticoagulants - prevent the formation of clots that inhibit the circulation
3. thrombolytics - dissolve blood clots that have already formed
4. antiplatelets (antithrombotics) - prevent platelets aggregation (clumping
together of platelets to form a clot)
5. Peripheral vasodilation - promote dilation of blood vessels narrowed by
vasospasm
 ANTIHYPERLIPIDEMIC AGENTS
1. HMG CoA reductase inhibitors (statins)
Action: blocks HMG CoA reductase  inhibits cholesterol biosynthesis in the
liver ↓ total cholesterol, ↓ LDL, ↑ HDL
Drugs: lovastatin
fluvastatin(Lescol)
pravastatin (Lipostat)
atorvastatin(Lipitor)
simvastatin (Zocor, Vidastat)
Side effects: myopathy, increase liver enzymes
Contraindication: active or chronic liver disease
• use in caution in patient taking cyclosporine, macrolide antibiotics,
antifungal agents
• may increase statin serum level
 2. BILE ACID SEQUESTRANTS
Action: binds with bile acids in the intestine
Drugs: cholestyramine
cholestipol
Side effects: gastrointestinal distress, constipation, decreased
absorption of other drugs
Contraindication:
• cannot be used in patients with elevated triglyceride (>400mg/dl)
 PARENTERAL (SC OR IV)
A. Heparin
• Combines with antithrombin III -> inactivates thrombin inhibits conversion of
fibrinogen to fibrin (clot)  clot is prevented
• Poorly absorbed through Gl mucosa -> give SC or IV
• Can be used to prevent clot from forming (SC) or to treat acute thrombosis
(IV)
 HEPARIN
Side effects:
• Prolongs clotting time (monitor partial thromboplastin time or PTT and
activated partial thromboplastin time or aPTT)
• Thrombocytopenia (decrease in platelet count)
• Bleeding  antidote: protamine sulfate
• Before discontinuing, oral therapy is begun (warfarin)
 B. LOW MOLECULAR WEIGHT HEPARINS
• Lower risk of bleeding than heparin
Use: to prevent thromboembolism
• Frequent laboratory is not required
Drug examples: enoxaparin sodium (Clexane)
dalteparin sodium (Fragmin)
ardeparin
nadroparin calcium (Fraxiparine)
tinzaparin sodium (Innohep)
• average treatment duration : 7-14 days
Side effect:
• bleeding is rare  antidote: protamine sulfate
• contraindicated for strokes (hemorrhagic), peptic ulcers and blood anomalies
 ORAL ANTICOAGULANTS
Drug examples:
warfarin (Coumadin) →most prescribed
dicumarol
anisindione → more side effects noted
Action:
• inhibit hepatic synthesis of vitamin K → affect vitamin K dependent clotting factors
• well absorbed in Gl mucosa but food will delay absorption
• long half-life and highly-protein bound →cumulative effect →bleeding and other
side effects
Side effects:
• bleeding: monitor prothrombin time (PT) and International Normalized Ratio (INR)
• antidote for side effects: parenteral vitamin K
• for severe bleeding may give fresh-frozen plasma or platelets
 ANTIPLATELETS
Action: used to prevent thrombosis in the arteries by suppressing platelet
aggregation
Indications:
• for prophylaxis against myocardial infarction and stroke
Drugs: aspirin (Aspilet)
dipyridamole (Persantin)
ticlodipine (Ticlid)
clopidogrel (Plavix)
Platelet glycoprotein (GP) IIb/IIIa receptor antagonists
abciximab – drug of choice for angioplasty
eptifitabide
tirofiban (Aggrastat)
dipyridamole + aspirin (Aggrenox)
 PERIPHERAL VASODILATORS
Peripheral Vascular Disease
S/Sx: numbness and coolness of extremities, intermittent claudication, leg
ulcers
• caused by arteriosclerosis and hyperlipidemia
• e.g. Raynaud’s disease, arteriosclerosis obliterans, cerebrovascular
insufficiency
Action of peripheral vasodilators: increased blood flow to the extremities
• acts directly on vascular smooth muscle (isoxsuprine)
Drugs: tolazoline
isoxsuprine (Duvadilan)
nicotinyl alcohol
papaverine
prazosin (Minipress)
nifedipine (Adalat, Calcibloc)