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PART I

Angiotensin II-Receptor Blockers

 ARBs are antihypertensive agents that exert their action by blocking vasoconstriction
and release of aldosterone through selective blocking of angiotensin II receptors in
vascular smooth muscles and adrenal cortex.

Therapeutic Action

 The main action is to block the blood pressure raising effect of the renin-angiotensin-
aldosterone system (RAAS).

Indications

 Like ACE inhibitors, they can also be used alone for treatment of hypertension or in
combination with other antihypertensive agents.
 Utilized in treatment of heart failure for patients who do not respond to ACE
inhibitors.
 By blocking the effects of angiotensin receptors in vascular endothelium, these drugs
are able to slow down the progress of renal disease in patients with type 2 diabetes
and hypertension.

 Children: safety and efficacy of ARBs has not been established in this age group.
 Adults: ARBs are not allowed during pregnancy.
 Older adults: are more susceptible to drug toxicity because of underlying conditions
that would interfere with metabolism and excretion of drug. Renal and hepatic
function should always be monitored.

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Pharmacokinetics

Route Onset Peak Duration

Oral Varies 1-3 h 24 h

Metabolism: liver
Excretion: urine and feces

Contraindications and Cautions

 Allergy to ARBs. Prevent severe hypersensitivity reactions.

 Renal and hepatic impairment. Can alter metabolism and excretion of drugs which
can increase the risk for toxicity.
 Hypovolemia. Can be exacerbated by the drug’s action on blocking important life-
saving compensatory mechanisms.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and
potential termination of pregnancy between second and third trimester. It is still not
known whether ARBs can enter breast milk but it is generally not allowed in lactating
women because of potential adverse effects to the neonate.

Adverse Effects

 CNS: headache, dizziness, syncope, weakness

 Respiratory: symptoms of upper respiratory tract infections (URTI), cough
 GI: diarrhea, abdominal pain, nausea, dry mouth, tooth pain
 EENT: rash, alopecia, dry skin

Interactions

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 Phenobarbital, indomethacin, rifamycin: loss of effectiveness of ARBs
 Ketoconazole, fluconazole, diltiazem: decreased antihypertensive effects of ARBs

Nursing Considerations

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug like drug allergy,
hypovolemia, and renal impairment, to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory
tests like renal and hepatic function tests, and serum electrolyte to assess patient’s
response to therapy.

Nursing Diagnoses

Suggested Nursing Diagnosis related to drug treatment

 Ineffective tissue perfusion related to fluid excretory effect of the drug

 Impaired skin integrity related to dermatological effects of the drug
 Risk for injury related to CNS side effects of the drug

Vital nursing interventions done in patients who are taking ARBs:

 Educate patient on importance of healthy lifestyle choices which include regular

exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect
of antihypertensive therapy.

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 Administer drug with food to prevent GI distress associated with drug intake.
 Monitor renal and hepatic function tests to alert doctor for possible development of
renal and/or hepatic failure as well as to signal need for reduced drug dose.
 Provide comfort measures such as quiet environment, teach relaxation techniques,
to help patient tolerate drug effects.
 Educate patient and family members about drug’s effect to the body and
manifestations that would need reporting to enhance patient knowledge on drug
therapy and promote adherence.

Calcium-Channel Blockers

 Calcium-channel blockers as antihypertensive agents decrease blood pressure,

cardiac workload, and myocardial consumption of oxygen.
 Since these drugs can significantly decrease cardiac workload, they are effective in
treatment of angina.

Therapeutic Action

 These drugs inhibit the movement of calcium ions across myocardial and
arterial muscle cell membranes. As a result, action potential of these cells are altered
and cell contractions are blocked.
 Resultant effects include: depressed myocardial contractility, slow cardiac impulse in
conductive tissues, and arterial dilation and relaxation.

Indications

 Like ACE inhibitors and ARBs, they can also be used alone for treatment of
hypertension or in combination with other antihypertensive agents.
 Extended-release preparations are usually indicated for hypertensions in adults.
 Children: calcium-channel blockers is the drug group that is first considered in cases
of hypertension in this age group that needs drug therapy.
 Adults: these drugs are not allowed during pregnancy.
 Older adults: are more susceptible to drug toxicity because of underlying conditions
that would interfere with metabolism and excretion of drug. Renal and hepatic
function should always be monitored.

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Pharmacokinetics

Route Onset Peak Duration

Oral and
30-60 min 6-11 h 12 h
extended release

Metabolism: liver
Excretion: urine

Contraindications and Cautions

 Allergy to calcium-channel blockers. Prevent severe hypersensitivity reactions.

 Heart block (sick sinus syndrome). Can be exacerbated by conduction-slowing effect
of the drug.
 Renal and hepatic impairment. Can alter metabolism and excretion of drugs which
can increase the risk for toxicity.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and should
not be used unless the benefit to the mother clearly outweighs the risk to the fetus.
It is not clear whether this drug can enter breast milk so another method of feeding
is implemented for lactating mothers who are taking this drug.

Adverse Effects

 CNS: headache, dizziness, light-headedness, fatigue

 CV: hypotension, bradycardia, peripheral edema, heart block
 GI: nausea, hepatic injury
 EENT: rash, skin flushing

Interactions

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 Increased serum level and toxicity of cyclosporine if taken with diltiazem.
 Grapefruit juice can increase serum level and toxicity of calcium-channel blockers.

Nursing Considerations

Important nursing considerations when administering calcium-channel blockers:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug such as headache, rash, and
bradycardia, to prevent potential adverse effects.
 Monitor cardiopulmonary status closely as the drug can cause severe effects on
these two body systems.

Nursing Diagnoses

 Decreased cardiac output related to hypotension and vasodilating effect of the drug
 Risk for injury related to cardiovascular and CNS adverse drug effects

Vital nursing interventions done in patients who are taking calcium-channel blockers:

 Educate patient on importance of healthy lifestyle choices which include regular

exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect
of antihypertensive therapy.
 Monitor blood pressure and heart rate and rhythm to detect possible development
of adverse effects.

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 Provide comfort measures for the patient to tolerate side effects such as small
frequent meals for nausea, limiting noise and controlling room light and temperature
to prevent aggravation of stress which can increase demand to the heart.
 Educate patient and family members about drug’s effect to the body and
manifestations that would need reporting to enhance patient knowledge on drug
therapy and promote adherence.
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.

Vasodilators

 Direct vasodilators are used when the previous drugs mentioned are not effective.
 These antihypertensive agents are reserved for severe hypertension and
hypertensive emergencies.

Therapeutic Action

 These antihypertensive agents exert their effect by acting directly on smooth

muscles. Consequently, there will be muscle relaxation and vasodilation. Both of
these will cause drop in blood pressure.

Indications

 As mentioned, these drugs are only used for hypertension cases that do not respond
to other drug therapies.
 Nitroprusside is used in maintaining controlled hypotension during surgery.
 Nitroprusside is administered intravenously; hydralazine is available for oral,
intravenous, and intramuscular use; and minoxidil is available for oral use only.

Pharmacokinetics

Route Onset Peak Duration

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IV 1-2 min Rapid 1-10 min

Metabolism: liver
Excretion: urine

Contraindications and Cautions

 Allergy to direct vasodilators. Prevent severe hypersensitivity reactions.

 Cerebral insufficiency. Can be exacerbated by drug’s action to cause sudden drop in
blood pressure.
 Peripheral vascular disease, CAD, heart failure, tachycardia. These conditions can
be exacerbated by sudden drop in blood pressure.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and should
not be used unless the benefit to the mother clearly outweighs the risk to the fetus.
The drug can enter the breast milk and can cause potential adverse effects to the
neonate. If needed by lactating mothers, another method of feeding is instituted.

Adverse Effects

 CNS: headache, dizziness, anxiety

 CV: reflex tachycardia, heart failure, edema, chest pain
 GI: nausea, vomiting, GI upset
 EENT: rash, lesions ; minoxidil is associated with abnormal hair growth
 Nitroprusside is metabolized into cyanide so it can cause cyanide
toxicity characterized by dyspnea, ataxia, loss of consciousness, distant heart sounds,
and dilated pupil.
 Nitroprusside suppresses iodine uptake which leads to development
of hypothyroidism.

Interactions

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 Each drug in this group act differently on the body so each drug should be checked
for potential drug-to-drug and drug-to-food interactions.

Nursing Considerations

Important nursing considerations when administering direct vasodilators:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug such as drug allergy, CAD,
cerebral insufficiency, to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory
tests like renal and hepatic function tests, and serum electrolyte to assess patient’s
response to therapy.

Nursing Diagnoses

 Decreased tissue perfusion related to changes in volume of blood pumped out by

the heart
 Acute pain related to GI distress, headache, and skin effects of the drug

Vital nursing interventions done in patients who are taking vasodilators:

 Educate patient on importance of healthy lifestyle choices which include regular

exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect
of antihypertensive therapy.
 Monitor blood pressure and heart rate and rhythm closely to evaluate for
effectiveness and ensure quick response if blood pressure falls rapidly or too much.
 Provide comfort measures for the patient to tolerate side effects like small frequent
meals for nausea, limiting noise and controlling room light and temperature to
prevent aggravation of stress which can increase demand to the heart.

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 Monitor patient for any manifestations that could decrease fluid volume inside the
body such as vomiting, diarrhea, excessive sweating, to detect and treat excessive
hypotension.
 Educate patient and family members about drug’s effect to the body and
manifestations that would need reporting to enhance patient knowledge on drug
therapy and promote adherence.
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.

Classification Generic Name Brand Name

benazepril Lotensin

Angiotensin-Converting captopril Capoten

Enzyme (ACE) Inhibitors enalapril Vasotec IV

quinapril Accupril

irbesartan Avapro

Angiotensin II-Receptor losartan Cozaar

Blockers (ARBs) telmisartan Micardis

valsartan Diovan

amlodipine Norvasc

diltiazem Diltiazem
Calcium-channel
nicardipine Cardene
blockers
nifedipine Adalat, Procardia

verapamil Calan, Isoptin

Vasodilators hydralazine Apresoline

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minoxidil Loniten

nitropruisside Nitropress

Others: 

Renin inhibitor aliskiren Tekturna

PART II

Antianginal drugs

-  are used primarily to restore the balance between the oxygen supply and
demand of the heart. These drugs dilate the coronary vessels to increase the
flow of oxygen to the ischemic regions. Other than that, they also decrease the
workload of the heart so the organ would have less demand for oxygen.

Coronary Artery Disease

Coronary Artery Disease (CAD) is the narrowing of blood vessels supplying oxygen and
nutrients to the heart, primarily due to the development of fatty tumors (atheromas) in the
lumen of blood vessels in a process called atherosclerosis.

 This pathologic process attracts platelets and clotting factors to the area, causing a

much larger obstruction to the vessels. The vessels also lose their natural ability to be
elastic, resulting to inability to dilate and constrict. The heart stimulates the blood
vessels to deliver more blood but blood delivery is limited by narrow vessel
diameter, resulting to low oxygen supply of the heart.
 As a consequence of hypoxia, pain (angina) is felt.
 There are two types of angina:
 classic angina (of exercise), which occurs due to diminished coronary blood flow to
the heart; and
 vasospastic/Prinzmetal’s/variant angina, which is caused by reversible vasospasm
even at rest. Both types decrease oxygen supply of the heart.

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Nitrates

 Nitrates are antianginal agents that provide fast action to directly relax smooth
muscles and depress muscle tone without affecting nerve activity.
 Nitrates reduce preload and myocardial muscle tension by dilating the veins. Also,
they reduce afterload by dilating the arteries. Both of these actions lower oxygen
demand by decreasing the workload of the heart.

Therapeutic Action

 The main effect is drop in systemic blood pressure.

 It compensates by increasing blood flow to healthy arteries and veins because
affected vessels already lose their elasticity.

Indications

 Children: May be used only for congenital heart defects and cardiac surgery because

they can cause potentially dangerous changes in blood pressure.
 Adults: Should be educated on drug’s various forms and their proper administration,
storage, effectiveness, and manifestations that would warrant prompt medical help.
Lifestyle modifications such as smoking cessation, low-fat diet, and weight loss
should be encouraged to promote effectiveness of Antianginal therapy.
 Older adults: Safety measures should be instituted as they are prone to adverse
effects like arrhythmias and hypotension. They should receive initial low dose
because of probably hepatic and renal impairments which can interfere with
metabolism and excretion of drugs.
 Use during pregnancy is not established.
 Sublingual nitroglycerin is most effective for recurrent variant angina.
 Continuous infusion or transdermal patch for unstable angina.

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Pharmacokinetics

Route Onset Duration

IV 1-2 min 3-5 min

Sublingual tablet 1-3 min 30-60 min

Translingual spray 2 min 30-60 min

Transmucosal tablet 1-2 min 3-5 min

Oral SR tablet 20-45 min 8-12 h

Topical Ointment 30-60 min 4-8 h

Transdermal 30-60 min 24 h

Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

 Allergy to nitrates – prevent hypersensitivity reactions

 Severe anemia – decreased cardiac output (CO) caused by nitrates is dangerous for
blood with low-oxygen binding capacity
 Head trauma and cerebral hemorrhage – relaxation of cerebral vessels can lead to
intracranial bleeding
 Pregnancy and lactation – potential harm to fetus
 Hepatic and renal disease – alteration in drug metabolism and excretion
 Conditions that can limit CO like hypovolemia, hypotension, etc.

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Adverse Effects

 CNS: throbbing headache, dizziness, weakness

 GI: nausea, vomiting, incontinence
 CV: hypotension, reflex tachycardia, syncope
 EENT: pallor, flushing, sweating
 Large dose leads to methemoglobinemia and cyanosis.

Interactions

 Ergot derivatives: risk for hypertension; decreased antianginal effect

 Heparin: decreased therapeutic effect of nitrates
 PDE-5 inhibitors: risk for severe hypotension

Nursing Management

Nursing Assessment

 Presence of mentioned contraindications and cautions

 Skin color and integrity, especially for transdermal or topical forms of nitrates
 Pain and activity level
 Neurological status (level of consciousness, affect, reflexes,
 Cardiopulmonary status (BP; take heart rate in full minute
 Electrocardiogram as ordered
 Laboratory tests like CBC, liver and kidney function tests,

Nursing Diagnoses

 Decreased cardiac output related to vasodilation and hypotensive effects of the drug
 Risk for Injury related to adverse effects on neurological and cardiovascular status
 Ineffective Tissue Perfusion related to low oxygen supply to myocardial cells

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Implementation with Rationale

 Instruct patient not to swallow sublingual preparations to ensure therapeutic effects.

Take three tablets with a 5-minute interval, for a total of three doses. If the pain
does not subside, seek medical help.
 Ask for presence of burning sensation to ensure drug potency.
 Protect drug from sunlight to maintain drug potency.
 For sustained release forms, take drug with water and do not crush for these
preparations need to reach GIT intact.
 Rotate injection sites and provide skin care as appropriate to prevent skin abrasion
and breakdown.
 Avoid abrupt stop of long-term therapy. Taper doses for 4-6 weeks to
prevent myocardial infarction.
 Provide comfort measures: small frequent meals, appropriate room temperature and
lights, noise reduction, ambulation assistance, reorientation, and skin care.

Beta-Adrenergic Blockers

 Beta-adrenergic blockers are drugs which block or lyse the effects of sympathetic

stimulation. Hence, they are also called as sympatholytics.

Therapeutic action

 Main effects include decreased blood pressure, contractility and heart rate by
blocking the beta-receptors in the heart and juxtaglomerular apparatus of the
kidneys. These combined effects reduce the oxygen demand of the heart.
 Usually used in therapy with nitrates because of reduced adverse effects and
increased exercise tolerance.
 Not indicated for variant angina because therapeutic effect of drugs can cause
vasospasm.

Indications

 Nadolol is used for management of chronic angina. It is the drug of choice in angina
patients with hypertension.

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 Propranolol is the prototype drug of this class. It is used for treatment of angina and
syncope.
 Nebivolol, the newest adrenergic blocking agent does not produce the same adverse
effects seen in propranolol.

Pharmacokinetics

Route Onset Peak Duration

Oral 15 min 90 min 15-19 h

IV Immediate 60-90 min 15-19 h

Metabolism: liver
Excretion: kidney (urine)

 Food increases bioavailability of propranolol.

 Propranolol is the only drug under this class that can cross the blood-brain barrier.

Contraindications and Cautions

 Bradycardia, heart block, and cardiogenic shock – blocking effect of drugs

exacerbates these conditions
 Pregnancy and lactation – potentially harmful effects to the fetus or neonate
 Diabetes, chronic obstructive pulmonary disease (COPD), thyrotoxicosis, and
peripheral vascular diseases – blocking effect prevents maintaining homeostatic
requirements of these diseases

Adverse Effects

 CNS: emotional depression, dizziness, fatigue, sleep disturbances

 GI: gastric pain, nausea, vomiting, colitis, diarrhea
 CV: heart failure, reduced cardiac output, arrhythmia
 Respiratory: dyspnea, cough, bronchospasm

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Interactions

 Clonidine: increased rebound hypertension

 NSAIDs: decreased antihypertensive effects
 Epinephrine: hypertension followed by bradycardia
 Ergot alkaloids: peripheral ischemia
 Insulin and oral hypoglycemic agents: alteration in blood glucose levels without the
patient experiencing manifestations of hypo- or hyperglycemia

Nursing Considerations

Nursing Assessment

 Assess for presence of mentioned contraindications and cautions.

 Assess neurological status to determine presence of neurological adverse effects.
Focus on level of orientation and sensory function.
 Monitor blood pressure and heart rate accurately. Be sure to count the heart rate in
one full minute.
 Auscultate lungs to determine presence of possible respiratory adverse effects.
 Check color and sensation of extremities. Measure capillary refill. This is to evaluate
presence of insufficiencies in the peripheral vascular system.
 Monitor laboratory test results like electrolyte levels and renal function tests to
ascertain risk for arrhythmia and discern whether dose adjustment is needed.

Nursing Diagnosis

 Decreased Cardiac Output related to decreased heart rate, blood pressure, and
contractile properties of the heart
 Ineffective Tissue Perfusion related to decreased blood flow to the heart
 Risk for Injury related to possible alterations in CNS while on drug therapy

Implementation with Rationale

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 Give drug as ordered following safe and appropriate administration to ensure
therapeutic effects.
 Provide comfort measures: ambulation assistance, raised siderails, appropriate room
light and temperature, and rest periods
 Monitor cardiopulmonary status closely to detect possible alterations in vital signs
which signal need for dose adjustment and to prevent related adverse effects.
 Educate client about the need to not abruptly stop therapy as this can lead to
rebound hypertension and myocardial infarction.

Calcium-Channel Blockers

Calcium-channel blockers are drugs which block heart contraction by inhibiting

movement of calcium ions, thereby altering arterial and cardiac muscle action
potentials.

 They basically produce vasodilation and relief of spasm.

 They do not increase lipid levels.
 Serve as a substitute for classic and variant angina when beta-blockers and nitrates
are contraindicated.

Therapeutic Action

 By blocking contractions, loss of muscle tone and vasodilation occur, consequently

decreasing peripheral resistance.
 Relieves vasospasm in variant angina, thereby increasing blood flow to the heart.
 Can block atherosclerotic process in endothelial cells
 Indications
 Treatment of variant angina, chronic angina and effort-associated angina

Pharmacokinetics

Route Onset Peak Duration

Oral 30-60 min 2-3 h 2-4 h

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SR, ER 30-60 min 6-11 h Varies

IV Immediate 2-3 min Varies

Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

 Allergy to drugs
 Heart block and sick sinus syndrome – conduction problems in these disease may be
exacerbated by slow conduction effect of drugs
 Renal and hepatic dysfunctions – alteration with metabolism and excretion of drugs
 Heart failure – worsened by decreased cardiac output effect of the drug

Adverse Effects

 CNS: dizziness, lightheadedness, fatigue, and headache

 GI: nausea, hepatotoxicity effect of the drug
 CV: hypotension, bradycardia, peripheral edema
 EENT: flushing, rash

Interactions

 Cyclosporine with diltiazem: increased serum level and toxicity of cyclosporine

 Cyclosporine with verapamil: heart block and digoxin toxicity. Verapamil increases
level of digoxin.
 Digoxin with verapamil: depressed myocardial conduction
 General anesthesia with verapamil: serious respiratory distress

Nursing Considerations

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Nursing Assessment

 Assess for presence of mentioned contraindications and cautions.

 Inspect skin color and integrity to determine presence of adverse effects on skin.
 Assess the patient’s complaint of pain and the activity level prior to and after the
onset of pain to aid in identifying possible contributing factors to the pain and its
progression.
 Monitor cardiopulmonary status closely as the drug can cause severe effects on
these two body systems.

Nursing Diagnosis

 Decreased Cardiac Output related to hypotension and vasodilating effect of the

drugs
 Risk for Injury related to cardiovascular and CNS adverse drug effects

Implementation with Rationale

 Monitor blood pressure and heart rate and rhythm to detect possible development
of adverse effects.
 Provide comfort measures for the patient to tolerate side effects such as small
frequent meals for nausea, limiting noise and controlling room light and temperature
to prevent aggravation of stress which can increase demand to the heart,
 Educate client on measures to avoid angina attacks such as diet changes, rest
periods,
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.

Antianginal Drugs: Generic and Brand Names

Classification Generic Name Brand Name

Nitrates and Nitrites amyl nitrate Vaporole

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Classification Generic Name Brand Name

Isosorbide mononitrate Imdur, Monoket

Isosorbide dinitrate Isordil, Sorbitrate

Nitroglycerin Nitro-Bid, Nitrostat

acebutolol Sectral

esmolol Brevibloc

metoprolol Toprol, Toprol XL

Beta-adrenergic
blockers
nadolol Corgard

propranolol Inderal, Lopressor

timolol Blocadren

amlodipine Norvasc

diltiazem Diltiazem, Diltiazem SR

Calcium-channel
nicardipine Cardene
blockers

nifedipine Adalat, Procardia

verapamil Calan, Isoptin

Others:

Piperazineacetamides ranolazine Ranexa

Nonnitrate coronary dipyridamole Persantine

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Classification Generic Name Brand Name

vasodilators

Antihyperlipidemic Drugs 

- lower serum levels of cholesterol and various lipids. They are also called as lipid-
lowering agents; these drugs provide effective treatment for hyperlipidemia
(increased lipid level in the blood). The incidence of coronary artery disease
(CAD), the most common cause of death among adults, is higher in people with
hyperlipidemia. High level of lipids and triglyceride is associated with metabolic
syndrome consist of insulin resistance, abdominal obesity, hypertension, and
proinflammatory and prothrombotic states.

Antihyperlipidemic: Generic and Brand Names

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Classification Generic Name Brand Name

cholestyramine Questran

Bile Acid
Sequestrants colesevelam Welchol

colestipol Colestid

atorvastatin Lipitor

fluvastatin Lescol

HMG-CoA lovastatin Mevacor

Reductase
Inhibitors pitavastatin Livalo

pravastatin Pravanchol

simvastatin Zocor

Cholesterol
Absorption ezetimibe Zetia
Inhibitor

Others: 

fenofibrate TriCor

Fibrates finofibric acid Tripilix

gemfibrozil Lopid

Vitamin B niacin Niaspan

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Coronary Artery Disease (CAD)

 Due to various reasons, fatty streaks begin to develop in the endothelium

of coronary arteries. Over time, these fatty streaks develop into plaques (atheromas)
and injure the lining of blood vessels. The inflammatory reaction begins, and it
attracts white blood cells and platelets to the area. These cells collect on the injured
vessels and cause the atheroma to grow bigger, further narrowing the diameter of
blood vessels, and therefore, limiting the blood flow.
 The injury decreases the flexibility of the vessels, rendering it less distensible and less
reactive to neurochemical stimuli. Coronary arteries are now unable to balance
oxygen demand and blood supply.
 If not acted promptly, this can lead to total vessel blockage and vessel rupture. CAD
is the leading cause of death worldwide, and its incidence is high in people with
hyperlipidemia.
 The cause of CAD remains unknown, but certain risk factors were identified, and
these include increasing age, male gender, sedentary lifestyle, smoking, obesity,
high-fat diet, high-stress levels, menopause, and medical conditions
like hypertension, gout, and diabetes.

Bile Acid Sequestrants

 These drugs are used to normalize high serum level of cholesterol.

Therapeutic Action

 Bile acid sequestrants exert their effect in the intestines by binding into bile acids
which contain a high level of cholesterol.
 The resultant insoluble complex formed by this combination is then excreted through
feces.
 As this happens, more LDL segments from the circulation will be absorbed by the
intrahepatic circulation to make more bile acids.

Indications

 Bile Acid Sequestrants are used as the treatment for primary hypercholesterolemia

(high cholesterol and high LDL) as an adjunct to diet and exercise.

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 Cholestyramine is also used to treat pruritus associated with partial biliary
obstruction.
Children

 Familial hypercholesterolemia treatment in children is limited to tight dietary

restrictions of calorie and fats because lipids in children are important for the
development of the nervous system. In cases that are unresponsive to dietary
restrictions, other classes of antihyperlipidemic are used.
Adults

 Bile acid sequestrants are used in combination with HMG-CoA reductase inhibitors
for patients whose lipid levels are challenging to normalize with the use of HMG-CoA
reductase inhibitors alone.
 Pregnant women, bile acid sequestrants are the drug of choice in lowering
cholesterol and lipid levels.
Older adults

 The impact of lipid-lowering agents in older adults is not supported by any outcome
data. Instead, in taking care of this age group, reinforcement of lifestyle changes is
given focus.
 Older adults are instructed on drugs that can’t be cut, crushed, and chewed.

Pharmacokinetics

 Not absorbed systemically and is excreted in the feces.

Contraindications and Cautions

 Allergy to bile acid sequestrants. Prevent severe hypersensitivity reactions.

 Complete biliary obstruction. Prevent bile from being secreted into the intestines.
 Abnormal intestinal function. Aggravated by the presence of bile acid sequestrants.
 Pregnancy and lactation. Potential decrease in absorption of fat and fat-soluble
vitamins can be detrimental to fetus or neonate.

Adverse Effects

The adverse effects of bile acid sequestrants nurses need to watch out for are as follows:

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 CNS: headache, anxiety, fatigue, drowsiness
 GI: GI upset, constipation, fecal impaction, nausea, aggravated hemorrhoids
 Hema: increased bleeding time, decreased production of clotting factors
 Musculoskeletal: muscle aches, muscle pains
 Other: rash, fat-soluble vitamin deficiencies

Interactions

 Bile acid sequestrants delay the absorption of thiazide diuretics,

corticosteroids, digoxin, warfarin, and thyroid hormones. Therefore, if needed, these
drugs are taken 1 hour before or 4-6 hours after a meal.

Nursing Considerations

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to prevent potential adverse effects.

 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy and evaluate potential adverse
effects.
 Obtain baseline status for weight while noting recent manifestations that increases
or decreases to determine patient’s fluid status.
 Assess neurological status, particularly orientation and alertness to determine any
CNS effects.
 Assess bowel elimination patterns, including frequency of stool passage and stool
characteristics to monitor the development of constipation and possible fecal
impaction.
 Assess closely patient’s heart rate and blood pressure to identify cardiovascular
changes that may warrant change in drug dose
 Inspect abdomen for distention and auscultate bowel sounds to assess for changes
in GI motility.

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 Monitor results of laboratory tests, particularly serum cholesterol and lipid levels to
evaluate the effectiveness of drug therapy.

Nursing Diagnoses

 Acute pain related to CNS and GI effects

 Risk for injury related to CNS drug effects and potential for bleeding
 Altered elimination pattern related to constipation

Implementation with Rationale

Vital nursing interventions done in patients who are taking bile acid sequestrants:

 Administer powdered agents already mixed with fluids to ensure drug

effectiveness.
 Instruct client not to chew, crush, and cut tablets because these drugs are meant to
be broken down in the intestines and premature crushing will render active
ingredients ineffective.
 Administer drug before meals to ensure that drug is in the GI tract together with
food.
 Administer other drugs 1 hour before or 4-6 hours after bile acid sequestrantsto
avoid drug interactions.
 Arrange for a bowel program to effectively address constipation if it ever occurs.
 Instruct patient to increase oral fluid intake and dietary fiber intake to prevent
constipation.
 Provide comfort measures small frequent meals for GI upset and instituting safety
measures for drowsiness and weaknesses to help patient tolerate drug effects.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding of drug therapy and
thereby promote adherence to drug regimen.

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HMG-CoA Reductase Inhibitors

 This drug group increases the cell absorption of LDL by blocking the enzyme (HMG-
CoA reductase) regulating the rate-limiting step in the synthesis of cholesterol. With
this alteration in fat metabolism, HDL increases slightly.
 Drugs under this classification are chemically-modified compounds from the
products of fungi.

Therapeutic Action

 In a sense, HMG-CoA reductase inhibitors block the completion of cholesterol

synthesis in the body.
 These are primarily indicated as adjunct medicine with diet and exercise for
treatment of high cholesterol and LDL levels in the blood.

Indications

 Pravastatin, lovastatin, and simvastatin are indicated for patients with documented
CAD to slow progression of the disease.
 Together with these three agents, atorvastatin is used as prophylaxis for
first myocardial infarction attack for patients with multiple risk factors for CAD.
Children

 Treatment for familial hypercholesterolemia for this age group is strictly limited to
tight dietary restrictions from fats and calories because lipids in this age group are
important for the development of nervous system.
Adults

 HMG-CoA reductase inhibitor is the drug of choice for patients who have multiple
risk factors or have already developed CAD.
 The importance of lifestyle changes such as dietary restrictions, regular exercise, and
smoking cessation should be emphasized to this age group.

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 This class is well-tolerated and is less expensive compared to other classes with the
same therapeutic effect. For cases who are slow to respond to this class alone,
combination therapy with niacin, fibrate, and bile acid sequestrants is instituted.
  PREGNANCY CATEGORY X  For women who are pregnant, this drug class is
contraindicated pregnancy category X.
Older adults

 Are more susceptible to drug toxicity because of underlying conditions that would
interfere with metabolism and excretion of drug.
 Importance of mentioned lifestyle changes should also be emphasized.

Pharmacokinetics

Route Onset Peak Duration

Oral Slow 1-2 h 20-30 h

Metabolism: liver
Excretion: bile

Contraindications and Cautions

 Allergy to HMG-CoA reductase inhibitors. Prevent severe hypersensitivity reactions.

 Active liver disease. Exacerbated by drug’s therapeutic effect and has potential to
lead to severe liver failure.
 Pregnancy, lactation. Potential for drug adverse effects to fetus or neonate.
 Impaired endocrine function. Problems can arise due to alteration in the formation
of steroid hormones.
 Renal impairment. Caution is given to patients taking other statins and close
monitoring in instituted. Atorvastatin is not affected by renal diseases.

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Adverse Effects

 CNS: headache, dizziness, insomnia, fatigue, blurred vision, cataract development

 CV: increased risk for cardiovascular effects with simvastatin started at 80 mg for
new patients
 GI: flatulence, nausea, vomiting, cramps, abdominal pain, constipation
 Hepatobiliary: increase liver enzymes, acute liver failure with use of atorvastatin and
fluvastatin

Interactions

 Cyclosporine, erythromycin, gemfibrozil, niacin, antifungal drugs: increased risk for

rhabdomyolysis
 Digoxin, warfarin: increased serum levels and resultant toxicity of HMG-CoA
reductase inhibitors
 Oral contraceptives: increased serum estrogen
 Grapefruit juice: increased serum levels and resultant toxicity

Nursing Considerations

Important nursing considerations when administering HMG-CoA reductase inhibitors:

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug such as hypersensitivity,

acute liver disease, pregnancy to prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy, and evaluate potential adverse
effects.
 Obtain baseline status for weight while noting recent manifestations that increases
or decreases to determine patient’s fluid status.

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 Assess neurological status with particular focus on consciousness, reflexes, and
affect.
 Assess closely patient’s heart rate and blood pressure to identify cardiovascular
changes that may warrant change in drug dose.
 Assess bowel patterns to determine possibility of developing constipation and
resultant fecal impaction.

Nursing Diagnoses

 Disturbed sensory perception related to CNS effects

 Risk for injury related to CNS effect

Implementation with Rationale

Vital nursing interventions done in patients who are taking HMG-CoA reductase inhibitors:

 Administer drug at bedtime to maximize effectiveness of the drug because peak of

cholesterol synthesis is from midnight to 5 AM. However, atorvastatin can be given
at any hour of the day.
 Monitor serum cholesterol and LDL levels to determine effectiveness of drug
therapy.
 Monitor results of liver functions tests to determine possible liver damage.
 Ensure patient has initiated a 3-6 month diet and exercise program before initiating
drug therapy to ensure need for drug therapy.
 Emphasize the importance of lifestyle changes to the patient to decrease risk of CAD
and promote drug effectiveness.
 Provide comfort and safety measures to help patient tolerate drug side effects.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

Cholesterol Absorption Inhibitors

 Cholesterol absorption inhibitors are one of the new class of drugs approved (2003)
to lower serum cholesterol levels.

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 A controversy is linked to this drug because a study in 2008 failed to show positive
benefits of combining this class to statins. Further studies are needed to validate this
alleged lack of effect of cholesterol-lowering agents.

Therapeutic Action

 Acting on the brush border of intestines, cholesterol absorption inhibitors block the
absorption of dietary cholesterol. Consequently, less cholesterol goes to the liver and
it increases the cholesterol clearance to make up for the drop.

Indications

Cholesterol absorption inhibitors are indicated as follows:

 Adjunct to diet and exercise as a monotherapy or in combination with HMG-CoA

inhibitors or bile acid sequestrants.
 Used in combination with statins to treat homozygous familial hypercholesterolemia.
Children

 Not indicated for this age group.

Adults

 Used in combination with HMG-CoA inhibitors or bile acid sequestrants.

 The importance of lifestyle changes (e.g. dietary restrictions, regular exercise, and
smoking cessation) should be emphasized to this age group.
 Effect to fetuses and neonates is not known.
Older adults

 Are more susceptible to drug toxicity because of underlying conditions that would
interfere with metabolism and excretion of drug.
 Importance of mentioned lifestyle changes should also be emphasized.

Pharmacokinetics

Route Onset Peak

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Oral Moderate 4-12 h

Metabolism: liver, small intestine

Excretion: urine, feces

Contraindications and Cautions

Cholesterol absorption inhibitors are contraindicated with the following:

 Allergy to cholesterol absorption inhibitors. Prevent severe hypersensitivity

reactions.
 Liver disease, pregnancy, lactation: not used if combined with statins because of the
effects of statins to these health conditions. Effect of this class to fetuses and
neonates is not known.

Adverse Effects

The adverse effects of cholesterol absorption inhibitors are as follows:

 CNS: headache, dizziness, fatigue

 Respiratory: upper respiratory tract infection (URI)
 GI: mild abdominal pain, diarrhea
 Musculoskeletal: muscle aches and pains, back pain

Interactions

Assess the interaction of the drug with the following:

 Cholestyramine, fenofibrate, antacid, gemfibrozil: elevated serum level of

cholesterol absorption inhibitors
 Cyclosporine: increased toxicity of cholesterol absorption inhibitors
 Fibrates: increased risk for development of cholelithiasis

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 Warfarin: increased serum warfarin levels

Nursing Considerations

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug such as hypersensitivity,

acute liver disease, pregnancy etc. To prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy. To establish
baseline status, determine effectivity of therapy and evaluate potential adverse
effects.
 Assess neurological status. Give  with a particular focus on orientation and reflexes
to determine CNS drug effects.
 Assess closely patient’s heart rate and blood pressure. To identify cardiovascular
changes that may warrant a change in drug dose.
 Assess bowel patterns. To determine the possibility of developing constipation and
resultant fecal impaction.
 Monitor laboratory test results of serum cholesterol, LDL, and liver function.  To
determine the potential for drug adverse effects and monitor effectiveness of
therapy.

Nursing Diagnoses

 Disturbed sensory perception related to CNS effects

 Acute pain related to side-effect of drugs as evidenced by headache, myalgia, and GI
distress
 Risk for injury related to CNS effects

Implementation with Rationale

Vital nursing interventions done in patients who are taking cholesterol absorption inhibitors:

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 Monitor serum cholesterol and LDL levels. To determine the effectiveness of drug
therapy.
 Monitor results of liver functions tests. To determine possible liver damage.
 Ensure patient has initiated a 3-6 month diet and exercise program before initiating
drug therapy. To ensure the need for drug therapy.
 Emphasize the importance of lifestyle changes. To the patient to decrease the risk
of CAD and promote drug effectiveness.
 Provide comfort and safety measures. To help patient tolerate drug side effects.
 Educate patient on drug therapy.  Include in the teaching plan the drug name, its
indication, and adverse effects to watch out for to enhance patient understanding of
drug therapy and thereby promote adherence to the drug regimen.

Cardiotonic-inotropic drugs 
are particularly useful for patients with heart failure (HF), wherein the heart is not able to
effectively pump the blood towards different body organs. A result, cells of the body are
deprived of oxygen and nutrients. Cardiotonic agents are drugs used to increase the
contractility of the heart

Generic and Brand Names

Classification Generic Name Brand Name

deslanoside Cedilanid-d

Cardiac glycosides digitoxin Crystodigin

digoxin Lanoxin, Lanoxicaps

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Classification Generic Name Brand Name

amrinone, inamrinone Inocor

cilostazol Pletal
Phosphodiesterase
inhibitors
milrinone Primacor

enoximone Perfan

Heart Failure (HF)

Heart failure is a syndrome characterized by dysfunction of cardiac muscles.

 It can occur in a number of heart conditions which can overwork the heart muscles. 
 Coronary artery disease (CAD), which leads to insufficient blood supply for the
myocardium and is also the most common cause of HF;
 Cardiomyopathy, which leads to enlargement of the heart and myocardial fatigue;
and
 Valvular heart diseases, which can cause reflux and overloading of blood to the
ventricles which consequently over stretches the myocardium.
 Clinical manifestations depend on the side of the heart which failed:
Left-sided HF

 Primarily reflects pulmonary manifestations because the left ventricle cannot push
blood towards the peripheral systems.
 As a result, a engorgement of pulmonary veins, which leads to difficulty of breathing.

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 Other manifestations include: tachypnea (rapid breathing), dyspnea (discomfort
associated with breathing), and orthopnea (increased difficulty of breathing when
lying down).
 Patient also experiences coughing and hemoptysis (coughing up of blood). In severe
cases, pulmonary edema (filling up of fluid in the lung spaces) occurs which is life-
threatening because it interferes with gas exchange.
Right-sided heart failure

 Occurs when the right side of the heart has the need to exert more force in order to
push blood towards the pulmonary circulation.
 This side is usually a low-pressure system so when this happens, the pressure in this
side rises and venous return can’t enter.
 Neck veins become distended and central venous pressure is increased. Organs
like liver and spleen are enlarged because they are congested with blood.
 Dependent areas like the limbs develop pitting edema because fluid pools in these
areas.

Cardiac Glycosides

 Cardiac glycosides are cardiotonic agents from foxglove or digitalis plants. They exert
their effects on the cardiac muscles by affecting levels of intracellular calcium. In
turn, the contractility of the muscles is increased.

Therapeutic Action

 Allows more calcium to enter during contraction, therefore increasing the force of
contraction – positive inotropic effect.
 Consequently, there is increased cardiac output and renal perfusion. A good blood
supply to the kidney decreases renin release. This downplays the activity of renin-
angiotensin-aldosterone system (RAAS) which causes more fluid to be excreted in
the body through urine. A decrease in blood volume eases the workload of the heart.
 Another mechanism of this drug is to decrease the workload of the heart and slow
down relaxation of the cells. Therefore, this drug can increase the strength of
contractility without increasing the rate of contraction (negative chronotropic
effect).

Indications

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 Primarily indicated for decreasing workload of the heart and relieving HF.
 Digoxin is especially indicated for atrial flutter, atrial fibrillation, and paroxysmal
atrial tachycardia.
Children

 Widely used in the treatment of heart defects in children but the margin of safety for
drug dosage is small so the nurse should recalculate and re-validate the dose with
another nurse before administration.
 Serum level of digoxin and signs of digitalis toxicity should be monitored carefully.
Adults

 This age group should be educated on manifestations that should be reported

signifying drug toxicity.
 Also, adults are cautioned against utilization of different brands of digoxin as
differences in bioavailability can increase the chance of toxicity.
 It is important for these patients to be taught how to take their own heart rate and
assess its regularity.
 Safety of this drug for pregnant women is not established. As for lactating women,
although digoxin enters breast milk, it has not been associated with adverse effects
in neonates but caution is still exercised.
Older adults

 Older adults are more susceptible to drug toxicity because of underlying conditions
that would interfere with metabolism and excretion of drug.
 Renal and hepatic function should always be monitored.
 Relatives should be instructed on how to take heart rate and assess its regularity.
 Careful attention should be given to other drugs taken by older adult patients as well
as their alternative therapies.

Pharmacokinetics

Route Onset Peak Duration

Oral 30-120 min 2-6 h 6-8 d

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IV 5-30 min 1-5 h 4-5 d

Metabolism: N/A
Excretion: urine (unchanged)

Contraindications and Cautions

 Allergy to any component of digitalis preparation. Prevent severe hypersensitivity

reactions.
 Ventricular tachycardia or fibrillation. These are potentially fatal arrhythmias and
should be treated with another drug.
 Heart block (sick sinus syndrome). Can be worsened by drug’s effect on slowing
conduction through AV node
 Idiopathic hypertrophic subaortic stenosis (IHSS). Obstruction of outflow tract to
the aorta can result from increasing the force of contraction and this can lead to
other severe problems.
 Acute myocardial infarction (MI). Increasing the force of contraction can damage
the heart muscles more.
 Renal insufficiency. Drug is excreted through urine and the existing renal
insufficiency can contribute to development of drug toxicity.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus or
neonate.

Adverse Effects

 CNS: headache, weakness, drowsiness, vision changes (most commonly reported is

seeing yellow halo around objects)
 CV: arrhythmias
 GI: GI upset, anorexia
  NURSING ALERT!  Signs and symptoms of digitalis toxicity: anorexia, nausea,
vomiting, malaise, depression, irregular heart rhythms such as heart block, heart
arrhythmias, and ventricular tachycardia

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Interactions

 Digoxin immune Fab or DigiFab: antidote; these antibodies bind molecules of

digoxin, making them unavailable at site of action. Used when serum digoxin is >10
ng/mL and serum potassium is >5 mEq/L.
 Verapamil, amiodarone, quinine, erythromycin,
tetracycline, cyclosporine:increased therapeutic and toxic effects of digoxin.
Combination of digoxin with any of these drugs would warrant decrease in dose of
digoxin to prevent toxicity.
 Potassium-losing diuretics: increased risk of cardiac arrhythmias
 Thyroid hormones, metoclopramide, penicillamine: decreased therapeutic effects
of digoxin. Increasing the dose of digoxin is important.
 Cholestyramine, charcoal, colestipol, antacids, bleomycin,
cyclophosphamide, methotrexate: decreased absorption of digoxin. In this case,
digoxin must be taken 2-4 hours after taking any of these drugs.
 St. John’s wort, psyllium: decreased therapeutic effect of digoxin
 Ginseng, hawthorn, licorice: increased risk of digoxin toxicity

Nursing ConsiderationsNursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug such as renal insufficiency,
acute MI, hypersensitivity, to prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy and evaluate potential adverse
effects.
 Obtain baseline status for weight while noting recent manifestations that increase or
decreases to determine patient’s fluid status.
 Assess closely patient’s heart rate and blood pressure to identify cardiovascular
changes that may warrant a change in digoxin drug dose.
 Auscultate heart sounds to note the presence of abnormal sounds and possible
conduction problems.
 Determine urinary pattern and output to assess gross indication of renal function.

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 Obtain baseline electrocardiogram (ECG) to identify heart rate and rhythm.
 Monitor serum electrolyte and renal function test results to determine whether
changes in drug dose is needed or not.

Nursing Diagnoses

 Risk for fluid volume deficit related to increased renal perfusion as effect of the drug
 Decreased cardiac output related to inefficient myocardial contractility
 Ineffective tissue perfusion related to decreased blood flow to different parts of the
body

Implementation with Rationale

Vital nursing interventions done in patients who are taking cardiac glycosides:

 Check drug dose and preparation carefully to avoid medication errors because drug
has narrow safety margin.
 Do not administer drug with food and antacids to prevent decreased in drug
absorption.
  IMPORTANT!  Count apical pulse for one full minute before administering drug to
monitor for adverse effects.
o Drug is withheld if pulse is less than 60 beats per minute in adults and 90
beats per minute in infants.
o Apical pulse is taken after one hour and if it remains low, nurse must
document it, withhold the dose, and inform doctor.
 Assess pulse rhythm to detect arrhythmias which are early signs of drug toxicity.
 Weigh the patient daily to monitor for fluid retention and HF. Assess dependent
areas for presence of edema and note its degree of pitting to assess severity of fluid
retention.
 Monitor serum digoxin level as ordered (normal: 0.5-2 ng/mL) to evaluate
therapeutic dosing and development of adverse effects.
 Provide comfort measures such as small frequent meals for GI upset, instituting
safety measures for drowsiness and weaknesses, and providing adequate room
lighting for patients with visual disturbances to help patient tolerate drug effects.
 Promote rest periods and relaxation techniques to balance supply and demand of
oxygen.

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 Ensure maintenance of emergency drugs and equipment at bedside (e.g. potassium
salts and lidocaine for arrhythmias, phenytoin for seizures, atropine in case of
clinically significant low heart rate, and cardiac monitor) to promote prompt
treatment in cases of severe toxicity.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

Phosphodiesterase Inhibitors

 Phosphodiesterase inhibitors aid in increasing force of myocardial contractility

through their enzyme-blocking effect. This in turn, increases the flow of calcium into
the myocardial cells.

Therapeutic Action

 By blocking the enzyme phosphodiesterase, cyclic adenosine monophosphate

(cAMP) increases. cAMP stimulates flow of calcium towards the myocardium and
thereby, increases force of cardiac contractility.
 Increases intracellular calcium and prolongs effect of sympathetic stimulation. This
leads to three major effects: vasodilation, increased oxygen consumption, and
arrhythmias.

Indications

 Only indicated for short-term treatment of patients not responding to cardiac

glycosides, vasodilators, and diuretics.
  Drug use is only limited to severe situations because it is associated with fatal
ventricular arrhythmias.

Children

 Drug is not recommended for this age group

Adults

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 This age group should be educated on manifestations that should be reported
signifying drug adverse effects.
 It is important for these patients to be taught how to take their own heart rate and
assess its regularity.
Pregnant women

 Safety of this drug for pregnant and lactating women is not established.
Older adults

 Are more susceptible to drug toxicity because of underlying conditions that would
interfere with metabolism and excretion of drug.
 Renal and hepatic function should always be monitored. Relatives should be
instructed on how to take heart rate and assess its regularity.
 Careful attention should be given to other drugs taken by older adult patients as well
as their alternative therapies.

Pharmacokinetics

Route Onset Peak Duration

Oral Immediate 10 min 8h

Metabolism: liver
Excretion: urine and feces

Contraindications and Cautions

 Allergy to phosphodiesterase inhibitors and bisulfites. Prevent severe

hypersensitivity reactions.
 Severe aortic or pulmonary valvular disease. Exacerbated by increased contraction.
 Acute MI. Exacerbated by increased contraction and oxygen demand.

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 Conditions with fluid volume deficit. Exacerbated by increased renal perfusion
which ultimately leads to increased urine output.

Adverse Effects

 CV: ventricular arrhythmias, ventricular fibrillation, hypotension, chest pain

 GI: nausea, vomiting, GI upset, abdominal pain
 Hema: thrombocytopenia
 Associated hypersensitivity reactions: vasculitis, pericarditis, pleuritis, and ascites
 Burning at intravenous injection site

Interactions

 In solution together with furosemide: precipitate formation

Nursing Considerations

Important nursing considerations when administering phosphodiesterase inhibitors:

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug such as fluid volume deficit,
acute MI, hypersensitivity, etc. to prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy, and evaluate potential adverse
effects.
 Obtain baseline status for weight while noting recent manifestations that increases
or decreases to determine patient’s fluid status.
 Assess closely patient’s heart rate and blood pressure to identify cardiovascular
changes that may warrant change in drug dose.
 Determine urinary pattern and output to assess gross indication of renal function.

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 Obtain baseline electrocardiogram (ECG) to identify heart rate and rhythm.
 Monitor serum electrolyte, complete blood count, and renal and hepatic function
test results to determine whether changes in drug dose is needed or not.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:

 Risk for fluid volume deficit related to increased renal perfusion as effect of the drug
 Decreased cardiac output related to inefficient myocardial contractility
and hypotension
 Risk for injury related to easy bruising 20 thrombocytopenia
 Ineffective tissue perfusion related to decreased blood flow to different parts of the
body

Implementation with Rationale

Vital nursing interventions done in patients who are taking phosphodiesterase inhibitors:

 Protect drug from light to prevent drug from degradation.

 Ensure patency of intravenous access to promote safe administration of drug.
 Weigh patient daily and fluid intake and output to evaluate resolution of HF.
 Assess skin condition, noting presence of petechiae and other manifestations of easy
bruising and bleeding to assess presence of thrombocytopenia.
 Monitor intravenous injection site to promote prompt interventions in cases of
burning sensation and/or irritation.
 Provide comfort measures (e.g. small frequent meals for GI upset, instituting safety
measures for drowsiness and weaknesses, and providing adequate room lighting for
patients with visual disturbances) to help patient tolerate drug effects.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

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Drugs Affecting Coagulation (Anticoagulants, Antiplatelets, Thrombolytics)

- These groups of drugs affect clot formation and resolution by hindering different

steps in clotting formation which include altering the formation of platelet plug
(antiplatelet drugs), interfering the clotting cascade and thrombin formation
(anticoagulant drugs), and stimulating the plasmin system to break down the
formed clot (thrombolytic agents).

Coagulation Drugs: Generic and Brand Names

Classification Generic Name Brand Name

aspirin Aspro Clear, Disprin

cilostazol Pletal
Antiplatelet agents
dipyridamole Persantine

tirofiban Aggrastat

warfarin Coumadin

Anticoagulants dabigatran Pradaxa

rivaroxaban Xarelto

alteplase Activase

reteplase Retavase
Thrombolytic Agents
tenecteplase TNKase

urokinase Abbokinase

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Others:

dalteparin Fragmin

Low-molecular weight heparins enoxaparin Lovenox

tinzaparin Innohep

lepirudin Refludan

Anticoagulant adjunctive therapy protamine sulfate

vitamin K

Hemorrheologic agent pentoxifylline Trental

Thromboembolic and Hemorrhagic Disorders

Disorders that directly affect coagulation process are divided into two main categories:
1) thromboembolic disorders, which involve overproduction of clots; and 2) hemorrhagic
disorders, which is characterized by ineffective clotting process leading to excessive bleeding.

Thromboembolic disorders include medical conditions like CAD which involve overproduction

of clots which result into decreased blood flow and total vessel occlusion. Manifestations
include hypoxia, anoxia, and even necrosis. These disorders are treated by drugs that interfere
with normal coagulation process to prevent formation of clots.

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On the other hand, less common hemorrhagic disorders is characterized by excessive bleeding.

These are treated by drugs that promote the clotting process. Some of these conditions include:

 Hemophilia: characterized by genetic lack of clotting factors

 Liver disease: characterized by non-production of proteins and clotting factors
necessary for clot formation
 Bone marrow disorders: characterized by insufficient quantity of platelets rendering
them ineffective

Antiplatelet Agents

 This drug class exerts its action by decreasing the responsiveness of platelets to
stimuli that cause it to clump or aggregate. Through this, formation of platelet plug is
decreased.

Therapeutic Action

  By blocking receptor sites on the platelet membrane, platelet adhesion and
aggregation is inhibited.
 Also, platelet-platelet interaction as well as interaction of platelets to clotting
chemicals are prevented.

Indications

 Primarily indicated for cardiovascular diseases that have potential for development
of vessel occlusion.
 Other indications include maintenance of arterial and venous grafts, preventing
cerebrovascular occlusion, and including them as adjunct to thrombolytic therapy for
treatment of myocardial infarction.
 One drug, anagrelide, blocks the production of platelets in the bone marrow.
Children

 Only heparin and warfarin are indicated for children but these drugs alone require
careful dose calculation.

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Adults

 Caution is particularly important to prevent injury such as using electric razor and
soft-bristled toothbrush.
 It is also important that adults are educated on what to do should bleeding occurs
such as applying firm pressure as well as what signs of bleeding should be watched
out for.
 Other drugs taken should be documented because there are a lot of drug
interactions with these drug class. It should also be emphasized that periodic blood
tests is expected to monitor the effect of therapy.
Pregnant women

 In pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus. On the other hand, for lactating women, it is
generally inadvisable.
Older adults

 Are more susceptible to drug toxicity and drug-to-drug interactions.

 Careful monitoring of liver and kidney function is important for this age group.
 Therapy is always started at the lowest level possible and adjusted accordingly.

Pharmacokinetics

Route Onset Peak Duration

Oral 5-30 min 0.25-2 h 3-6 h

Metabolism: liver
Excretion: bile

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Contraindications and Cautions

 Allergy to antiplatelet agents. Prevent severe hypersensitivity reactions.

 Known bleeding disorder. Increased risk of excessive blood loss
 Recent surgery. Increased risk of bleeding in unhealed blood vessels
 Closed head injuries. Increased risk of bleeding in injured blood vessels of the brain
 History of thrombocytopenia. Anagrelide decreased bone marrow production of
platelets.
 Pregnancy, lactation. Generally inadvisable because of potential adverse effects to
fetus or neonate

Adverse Effects

 CNS: headache, dizziness, weakness

 GI: GI distress, nausea
 Skin: skin rash
 Hema: bleeding oftenly occurs while brushing the teeth

Interactions

 Increased risk of bleeding if combined with another drug that affects blood clotting.

Nursing Considerations

Important nursing considerations when administering antiplatelet agents.

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and

examination:

 Assess for the mentioned contraindications to this drug such as hypersensitivity,

acute liver disease, pregnancy to prevent potential adverse effects.

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 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy, and evaluate potential adverse
effects.
 Obtain baseline status for complete blood count and clotting studies to determine
any potential adverse effects.

Nursing Diagnoses

 Disturbed sensory perception related to CNS effects

 Acute pain related to CNS and GI effects
 Risk for injury related to CNS effects and bleeding tendencies

Implementation with Rationale

Vital nursing interventions done in patients who are taking antiplatelet agents:

 Administer drug with meals to relieve GI upset.

 Provide comfort measures for headache because pain due to headache may
decrease patient compliance to treatment regimen.
 Educate patient on ways to promote safety like using electric razor, soft-bristled
toothbrush, and cautious movement because any injury at this point can precipitate
bleeding.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

Anticoagulants

 By interfering with clotting cascade and thrombin formation, anticoagulants are able

to interfere with the normal clotting process.

Therapeutic Action

  Warfarin, an oral agent in this class, reduces Vitamin K-dependent clotting factors.
As a result, clotting process is prolonged.

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 Two new oral agents, dabigatran and rivaroxaban, directly inhibits thrombin (last
step in clotting process) and factor Xa, respectively.
 Heparin and antithrombin block formation of thrombin from prothrombin.

Indications

 Among the many indications for this drug class include: stroke and systemic emboli
risk reduction, nonvalvular atrial fibrillation, and deep vein thrombosis.
 Heparin is used for prevention of blood clots in blood samples, dialysis, and venous
tubing. It also does not enter breastmilk so it is the anticoagulant of choice for
lactating women.
 Antithrombin is a naturally-occurring anticoagulant and is a natural safety feature in
the clotting system.
Children

 Only heparin and warfarin are indicated for children but these drugs alone require
careful dose calculation.
Adults

 Caution is particularly important to prevent injury such as using electric razor and
soft-bristled toothbrush.
 It is also important that adults are educated on what to do should bleeding occurs
such as applying firm pressure as well as what signs of bleeding should be watched
out for.
 Other drugs taken should be documented because there are a lot of drug
interactions with these drug class. It should also be emphasized that periodic blood
tests is expected to monitor the effect of therapy.
Pregnant women

 For pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus. On the other hand, for lactating women, it is
generally inadvisable.
Older adults

 Are more susceptible to drug toxicity and drug-to-drug interactions.

 Careful monitoring of liver and kidney function is important for this age group.

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 Therapy is always started at the lowest level possible and adjusted accordingly.

Pharmacokinetics

Route Onset Peak Duration

IV Immediate Minutes 2-6 h

Subcutaneous 20-60 min 2-4 h 8-12 h

Metabolism: cells
Excretion: urine

Contraindications and Cautions

 Allergy to anticoagulants. Prevent severe hypersensitivity reactions.

 Known bleeding disorder, recent trauma/surgery, presence of indwelling catheters,
threatened abortion, GI ulcers. These conditions can be compromised by increased
bleeding tendencies.
 Pregnancy, lactation. Warfarin is a contraindication.

Adverse Effects

 Warfarin is associated with alopecia, dermatitis, bone marrow depression, and less

frequently with prolonged and painful erections.
 Direct drug toxicity is characterized by nausea, GI upset, diarrhea, and hepatic
dysfunction.

Interactions

 Anticoagulants, salicylates, penicillin, cephalosporin: increased bleeding if combined

with heparin
 Nitroglycerin: decreased anticoagulation if combined with heparin

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 Cimetidine, clofibrate, glucagon, erythromycin: increased bleeding if combined with
warfarin
 Vitamin K, phenytoin, rifampin, barbiturates: decreased anticoagulation if combined
with warfarin
 Antifungals, erythromycin, phenytoin, rifampin: alteration in metabolism of
dabigatran and rivaroxaban

Nursing Considerations

Nursing Assessment

Important things the nurse should include in conducting assessment, history taking, and
examination:

 Assess for the mentioned contraindications to this drug such as hypersensitivity,

acute liver disease, pregnancy to prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy, and evaluate potential adverse
effects.
 Obtain baseline status for complete blood count and clotting studies to determine
any potential adverse effects.

Nursing Diagnoses

 Ineffective tissue perfusion related to blood loss

 Disturbed body image related to direct drug toxicity characterized by rash and
alopecia
 Risk for injury related to bleeding tendencies and bone marrow depression

Implementation with Rationale

Vital nursing interventions done in patients who are taking anticoagulants:

 Assess for signs signifying blood loss such as petechiae, bruises, dark-colored stools,
to determine therapy effectiveness and promote prompt intervention for bleeding
episodes.

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 Establish safety precautions like raising side rails, ensuring adequate room lighting,
padding sides of bed, to protect patient from injury.
 Maintain antidotes on bedside - protamine sulfate for heparin, Vitamin K for
warfarin) to promptly treat drug overdose.
 Evaluate effectiveness by monitoring the following blood tests: prothrombin time
(PT) and international normalized ratio (INR) for warfarin; and whole blood clotting
time (WBCT) and activated partial thromboplastin time (APTT) for heparin.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

Thrombolytic Agents

 Thrombolytic agents promote clot resolution, the process of activating the plasmin

system to break down the thrombus or clot that has been formed.

Therapeutic Action

  The conversion of plasminogen to plasmin is the body’s natural anticlotting system.

Thrombolytic agents’ action to activate this promotes breakdown of fibrin threads
and dissolution of formed clots.
 It is necessary to prevent vessel occlusion and therefore, to deliver adequate blood
flow to body systems.

Indications

 For treatment of acute MI, pulmonary embolism, and acute ischemic stroke.

 Also for clearing of occluded intravenous catheters and central venous access
devices.
Children

 Not indicated for this age group.

Adults

 Caution is particularly important to prevent injury such as using electric razor and
soft-bristled toothbrush

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 It is also important that adults are educated on what to do should bleeding occurs
such as applying firm pressure as well as what signs of bleeding should be watched
out for.
 Other drugs taken should be documented because there are a lot of drug
interactions with these drug class.
 It should also be emphasized that periodic blood tests is expected to monitor the
effect of therapy.
Pregnant women

 For pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus.
 On the other hand, for lactating women, it is generally inadvisable.
Older adults

 Are more susceptible to drug toxicity and drug-to-drug interactions.

 Careful monitoring of liver and kidney function is important for this age group.
 Therapy is always started at the lowest level possible and adjusted accordingly.

Pharmacokinetics

Route Onset Peak Duration

IV Immediate End of injection N/A

Metabolism: plasma
Excretion: unknown

Contraindications and Cautions

 Allergy to thrombolytics. Prevent severe hypersensitivity reactions.

 Known bleeding disorder, recent trauma/surgery, acute liver
disease, cerebrovascular accident within 2 months, GI ulcers. These conditions can
affect normal clotting factors and normal plasminogen production.

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 Pregnancy, lactation. Potential adverse effects to fetus or neonate.

Adverse Effects

 CV: cardiac arrhythmias, hypotension

 Hema: bleeding (most common)
 Hypersensitivity reaction (uncommon) is characterized by rash, flushing, and
bronchospasm.

Interactions

 Anticoagulant, antiplatelet: increased risk of bleeding

Nursing Considerations

Important nursing considerations when administering thrombolytics:

Nursing Assessment

 Assess for the mentioned contraindications to this drug such as hypersensitivity,

acute liver disease, CVA within 2 months, to prevent potential adverse effects.
 Conduct thorough physical assessment before beginning drug therapy to establish
baseline status, determine effectivity of therapy, and evaluate potential adverse
effects.
 Obtain baseline status for complete blood count, fecal occult blood test (FOBT), and
clotting studies to determine any potential adverse effects.

Nursing Diagnoses

 Decreased cardiac output related to cardiac arrhythmias and potential for bleeding

 Risk for injury related to clot-dissolving effects

Implementation with Rationale

Vital nursing interventions done in patients who are taking thrombolytics:

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 Assess for signs signifying blood loss such as petechiae, bruises, dark-colored stools,
etc.) to determine therapy effectiveness and promote prompt intervention for
bleeding episodes.
 Establish safety precautions such as raising side rails, ensuring adequate room
lighting, padding sides of bed, to protect patient from injury.
 Evaluate effectiveness by monitoring coagulation studies to adjust drug dose
appropriately.
 Educate patient on drug therapy including drug name, its indication, and adverse
effects to watch out for to enhance patient understanding on drug therapy and
thereby promote adherence to drug regimen.

SPCIAL REMINDER:
FAILURE TO RE- WRITE THIS NOTES ON YOUR
PHARMACOLOGY NOTEBOOK, IS NOT
ENTITLED TO SIGN HIS/HER CLEARANCE.

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