Ati Cardiovascular System Meds (Meds Affecting Blood Pressure)

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angiotensin-converting enzyme (ACE) inhibitors

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proto: captopril (Capoten)

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enalanapril (Vasotec)

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ACE inhibitor

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enalaprilat (Vasotec Intravenous)

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Ace inhibitor

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fosinopril (Monopril)

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Ace inhibitor

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lisinopril (Prinivil)

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Ace inhibitor

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ramipril (Altace)

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Ace inhibitor

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moexipril (Univasc)

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Ace inhibitor

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ACE inhibitor MOA

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blocking conversion of angiotensin I to angiotensin II leading to:
vasodilation

excretion of sodium and water, and retention of potassium by actions in the kidneys

reduction in pathological changes in the blood cells and heart that result from the presence of angiotensin II and aldosterone

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Ace inhibitor use

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hypertension, heart failure, MI, (to decrease mortality and to decrease risk of heart failure and left ventricular dysfunction)
diabetic and nondiabetic neuropathy
for clients at high risk for a cardiovascular event, ramiipril can be used to prevent MI, stroke, or death

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ACE inhibitor adverse

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first-dose orthostatic hypotension- if client is taking diuretic meds should be stopped temporarily for 2-3 days prior to the start of an ACE inhibitor
taking another type of antihypertensive increases the hypotensive effects of an ACE inhibitor
start treatment with a low dose of med
change position slowly and lie down if feeling faint, dizzy, or lightheaded

cough related to inhibition of kinase- notify provider if dry cough- med should be discontinued

hyperkalemia- monitor potassium levels to maintain a level within the expected reference range of 3.5-5 mEq/L, advise clients to avoid use of salt substitutes containing potassium

rash and dyspnea (primarily with captopril)- symptoms will stop with discontinuation of meds

angioedema- treat severe effects with subcutaneous injection of epinepherine, meds should be discontinued

neutropenia- monitor WBC counts every 2 weeks for 3 months
condition is reversible when detected early
first indications of infection, med should be D/C

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Ace inhibitor contraindications

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pregnancy category D during 2nd and 3rd trimester, related to fetal injury
history of allergy/angioedema to ACE inhibitors, in bilateral renal stenosis, or in clients who have a single kidney
caution in those with renal impairment and collagen vascular disease because they are at great risk for developing neutropenia.

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Ace inhibitor interactions

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diuretics can contribute to first-dose hypotension- temporarily stop taking diuretics 2-3 days before the start of therapy with ACE inhibitor
antihypertensives may have an additive hypotensive effect
potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia
ACE inhibitors can increase levels of lithium carbonate (Eskalith)
use of NSAIDS may decrease antihypertensive effect of ACE inhibitors

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ACE inhibitor admin

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administer orally except for enalaprilate, which is the only ACE inhibitor for IV use
captopril and moexipril should be taken at least one hour before meals
cough, rash, dysgeusia, and or signs of infection occur

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angiotensin II receptor blockers (ARBs)

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losartan (Cozaar)

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malsartan (Diovan)

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ARBs

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irbesartan (Avapro)

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ARBs

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candesartan (Atacand)

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ARBs

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olmesartan (Benicar)

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ARBs

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ARBs MOA

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block action of angiotensin II in the body which results in:
vasodilation
excretion of sodium and water and retention of potassium (through kidneys)

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ARBs Uses

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hypertension
HF and prevention of mortality following MI
stroke preventions
delay progression of diabetic nephropathy

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ARBs adverse

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angioedema- treat severe effects with subq injection of epinepherine, med should be discontinued

fetal injury- risk during second and third trimester

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ARBs contraindications

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pregnancy risk D- causes fetal damage in second and third trimesters
renal stenosis when present bilaterally or in a single kidney
caution to those who experience angioedema with ACE inhibitor

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ARBs interactions

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antihypertensives may have an additive effect when used with ARBs- dosage of meds may need to adjust if ACe inhibitors are added to treatment regimen

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ARBs admin

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may be prescribed as a single formulation or in combination with hydrochlorothiazide
can be taken with or without food

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aldosterone antagonists

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proto: eplernone (Inspra)
spironolactone (Aldactone)

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aldosterone MOA

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reduce blood volume by blocking aldosterone receptors in the kidney, thus promoting excretion of sodium and water

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aldosterone uses

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hypertension
heart failure

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aldosterone adverse

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hyperkalemia, hyponatremia
flu-like manifestations
dizziness

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aldosterone contraindications

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high potassium levels, kidney impairment, and type 2 diabetes with albuminuria
caution in liver impairment

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aldosterone interactions

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verapamil, ACE inhibitors, ARBs, erythromycin, and ketoconazole can increase risk of hyperkalemia

lithium toxicity may occur if taken concurrently

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aldosterone admin

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administer with or without food
do not administer with potassium supplements

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aldosterone use

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relieves hypertension when used alone or with another antihypertensive medication

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aldosterone adverse

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allergic reaction: angioedema
hyperkalemia
diarrhea- dose related, often seen in women and older adults

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aldosterone contraindications

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pregnancy risk C- first trimester, category D- second/third trimesters
previous allergy to aliskiren or in clients who have hyperkalemia
asthma or other respiratory disorders, history of angioedema, clietns who have DM and older adults

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aldosterone interactions

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decreases serum levels of furosemide (Lasix)- furosemide dosage may need to be increased

increases effect of other antihypertensive meds- monitor BP for hypotension

atorvastatin (Lipitor) and ketoconazole (Nizoral) increase levels of aliskiren

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aldosterone admin

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high fat meals interfere with absorption- take at same time daily away from foods high in fat
available alone or in combination tablets with a variety of other antihypertensives

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calcium channel blockers

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Prototypes:
nifedipine (Adalat)
verapamil (Calan)
diltiazem (Cardizem)

others:
amlodipine (Norvasc)
felodipine (Plendil)
nicardipine (Cardene, cleviprex)

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nifedipine MOA (calcium channel blockers)

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blocks calcium channels in blood vessels, leads to vasodilation of peripheral arterioles and arteries/arterioles of the heart
acts primarily on arterioles, veins are not significantly effected

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nifedipine adverse (calcium channel blockers)

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reflex tachycardia- monitor clients with increased heart rate, a beta blocker can be administered to counteract tachycardia
peripheral edema- observe for swelling in lower extremities, a diuretic may be used to control edema
acute toxicity- monitor vitals and ECG, gastric lavage and carthatic may be indicated
(norepinepherine, calcium, isoptroternol, lidocaine, and IV fluids)
have equipment for cardioversion and cardiac pacer available

Front 40

veramipril, diltiazem adverse (calcium channel blockers)

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orthostatic hypotension and peripheral edema
constipation (primarily veramipril)
supression of cardiac function (bradycardia, heart failure)
dysrhythmias (QRS is widened and QT interval is prolonged)
acute toxicity resulting in hypotension, bradycardia, AV block, and ventricular tachydysrthymias

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calcium channel blockers interactions (nifedipine)

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beta blockers, such as metaprolol (lopressor) are used to decrease reflex tachycardia
consuming grapefruit juice and nifedipine can lead to toxicity

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calcium channel blockers verapamil, dilitiazem

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verapamil can increase digoxin levels which increases digoxin toxicity. digoxin can cause an additive effect and intensify AV conduction suppression
concurrent use of beta-blockers can lead to heart failure, AV block, and bradycardia
consuming grapefruit juice and verapamil or diltiazem can lead to toxicity

Front 43

nursing administration calcium channel blockers

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IV admin of verapamil, administer injections slowly over a period of 2-3 minutes
advise clients who have angina to record pain frequency, intensity, duration, and location.
monitor BP and heart rate, as well as keep blood pressure record

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alpha adrenergic blockers (sympatholytics)

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prototype: prazosin (Minipress)
others: doxazosin mesylate (Cardura), terazosin

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alpha adrenergic blockers MOA

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selective alpha 1 blockade results in:
venous and arterial dilation
smooth muscle relaxation of the prostatic capsule and bladder neck

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alpha adrenergic blockers Use

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primary hypertension
doxazosin and terazosin also can be used to decrease manifestation of benign prostatic hyperplasia (BPH) which include urgency, frequency, and dysuria

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alpha adrergic blocker adverse

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first dose orthostatic hypotension- start with low dose,
first dose is often given at night
monitor BP 2 hours after treatment

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alpha adrenergic blocker contrainidications

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pregnancy risk C
hypotension
angina pectoris or renal insufficiency
older adults

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alpha adrenergic blocker interactions

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antihypertensive meds can have an additive hypotensive effect

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alpha adrenergic admin

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meds can be taken with food
initial dose at bedtime to decrease first-dose hypotensive effect

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centrally-acting alpha2 agonists

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clonidine (Catapres)
others: guanfacine HCL (Tenex), methyldopa (Aldomet)

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centrally-acting alpha 2 agonists MOA

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act within the CNS to decrease sympathetic outflow resulting in decreased stimulation of the adrenergic receptors (both alpha and beta receptors) of the heart and peripheral vascular system

decrease in sympathetic outflow myocardium results in bradycardia and decreased cardiac output

decrease in sympathetic outflow to the peripheral vasculature results in vasodilation, which leads to decreased blood pressure

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centrally-acting alpha 2 agonists use

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primary hypertension (administered alone, with a diuretic, or with another antihypertensive agent)

severe cancer pain

investigational use: migraine headaches, flushing from menopause, ADHD and Tourette's, management from opioid, tobacco and alcohol withdrawals

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centrally-acting alpha 2 agonists adverse

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drowsiness and sedation
dry mouth
rebound hypertension if abruptly discontinued

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centrally-acting alpha 2 agonists contraindications

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clonidine pregnancy category risk c
methyldopa and guanfacine are pregnancy category risk b
lactation
avoid use of skin patch on affected skin in scleroderma, and systemic lupus erythematous
stroke, MI, DM, major depressive disorder, or chronic renal failure

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centrally-acting alpha 2 agonist interactions

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antihypertensives may have an addiitive hypotensive effect
concurrent use of prazosin (Minipress), MAOIs and TCAs can counteract the antihypertensive effects of clonodine
additive CNS depression can occur with concurrent use of other CNS depressants such as alcohol

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centrally-acting alpha 2 admin

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administerd twice a day in divided doses. Take larger dose at bedtime to decrease the occurence of daytime sleepiness
transdermal patches are applied every 7 days. Advise clients to apply patch on hairless, intact skin on torso or upper arm

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beta-adrenergic blocker (sympatholytics)

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prototypes:
cardioselective: beta 1 (affects only the heart)
metoprolol (lopressor)
atenolol (Tenormin)
metoprolol succinate (Torprol XL)
Esmolol HCL (Brevibloc)

Non selective beta1 and beta 2 (affecting both heart and lungs)
propranolol (Inderal)
nadolol (Corgard)

Alpha and beta blockers
carvedilol (Coreg)
labetalol (Trandate)

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beta-adrenergic blocker MOA

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primary effects are a result of beta-adrergic blockade in the myocardium and in the electrical conduction system of the heart
decreased heart rate
decreased myocardial contractility
decreased rate of conduction through the AV node
alpha blockade adds vasodilation to meds such as carvedilol and labetolol

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beta-adrenergic blocker use

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primary hypertension
angina, tachydysrhythmias, heart failure, MI
others: hyperthyroidism, migraine, stage fright, pheochromocytoma, and glaucoma

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beta 1 blocker adverse (metoprolol, propranolol)

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bradycardia
decreased cardiac output
AV block
orthostatic hypotension
rebound myocardium excitation

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beta 2 blocker adverse (propranolol)

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bronchoconstriction- avoid in clients who have asthma
glycongenolysis is inhibited

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beta blocker contraindications

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AV block and sinus bradycardia
nonselective beta adrenergic blockers are contraindicated in clients who have asthma, bronchospasm, and heart failure
use cardioselective beta adrergic blockers cautiously in clients who have asthma
use cautiously in patients who have myasenthia gravis, DM, depression, and in older adults, history of allergies

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beta 1 blocker interactions (metaprolol, propranolol)

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calcium channel blockers, verapamil, and diltiazem (Cardizem) intensify the effects of beta-blockers
decreased heart rate
decreased myocardial contractility
decreased rate of conduction through AV node
concurrent use of antihypertensive meds with beta blockers can intensify the hypotensive effect of both meds

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beta 2 blockade interactions (propranolol)

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mask hypoglycemic effects of insulin and prevent the breakdown of fat in response to hypoglycemia

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beta-adrenergic blocker admin

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admin usually once or twice a day
IV route: atenolol, metoprolol, labetalol, propranolol

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beta-adrenergic blocker effetiveness

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absence of chest pain
absence of cardiac dysrhythmias
normotensive BP readings
control of HF signs and symptoms

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Meds for hypertensive crisis

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proto: nitroprusside (Nitropress), a centrally-acting vasodilator
nitroglycerin (Nitrostat IV), a vasodilator
nicardipine (Cardene) a calcium channel blocker
clevidipine (Cleviprex) a calcium channel blocker
enlalprilate (Vasotec IV) an ACE inhibitor
Esmolol HCL (Brevibloc) Ace inhibitor

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Meds for hypertensive crisis MOA

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direct vasodilation of arteries and veins resulting in rapid reduction of blood pressure (decreased preload and afterload)

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Meds for hypertensive crisis use

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hypertensive crisis

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meds for hypertensive crisis adverse

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excessive hypotension
cyanide poisoning- clients who have liver dysfunction are at increased risk
risk of cyanide poisoning may be reduced by administering meds at a rate of 5 mcg/kg/min or less and giving thiosulfate concurrently. Med should be discontinued if cyanide toxicity occurs
thocynate toxicity accumulates when nitroprusside is given over several days- levels should be maintained at less than 10 mg/dl

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meds for hypertensive crisis contraindications

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pregnancy risk C
liver, kidney, or fluid and electrolyte imbalances, especially in older adults

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meds for hypertensive crisis interactions

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nitroprusside should not be administered in the same infusion as any other meds

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meds for hypertensive crisis admin

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prepare med by adding to diluent for IV infusion
solution may be light brown in color- discard solution of any other color
protect IV container and tubing from light
discard med after 24 hour
monitor vitals and ECG continously

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hypertensive crisis meds effectiveness

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decrease in BP and maintenance of normotensive BP
improvement of HF such as ability to perform ADL, improved breath sounds, and absence of edema
improvement in renal function and delay of further progression of renal disease