Atherosclerosis

Hyperlipidemia

Rhabdomyolysis

Atorvastatin (Lipitor)

• TC: anti-hyperlipidemic
• PC: HMG – CoA reductase inhibitor, statin
• Primary indication is hypercholesterolemia. Act by inhibiting HMC-CoA reductase. 
• Heachache, cramping, diarrhea, and constipation. Possible liver damage
• Contraindicated in patients with serious liver disease. Grapefruit juice inhibits metabolism. Interacts with azole antifungals, HIV protease inhibitors, and telaprevir. 

Cholestyramine (Questran)

• TC: anti-hyperlipidemic
• PC: Bile acid sequestrant 
• Acts by binding with bile acids in an insoluble complex that is secreted in the feces. 
• Rarely produces side effects. Patients may experience constipation, bloating, gas, and nausea that sometimes limits its use. 
• Contraindicated in patients with total biliary obstruction and in those with prior hypersensitivity to the drug. Can bind to digoxin, penicillin, thyroid hormonr, and thiazide diuretics. 

Explain the primary function of the kidneys.

·         The kidneys are the primary organs for regulating fluid balance, electrolyte composition, and acid-base balance of body fluids. They also secrete the enzyme renin, which helps regulate blood pressure, and erythropoietin, a hormone that stimulates red blood cell production. In addition, the kidneys are responsible for the production of calcitriol, the active form of vitamin D, which helps maintain bone homeostasis. 

 Identify indications for diuretics.

•HTN

•Heart failure

•Kidney failure

•Liver failure or cirrhosis

•Pulmonary edema

Describe general adverse effects of diuretic pharmacotherapy.

·         Minor hypokalemia, postural hypotension, tinnitus, nausea, diarrhea, dizziness, fatigue, blood dyscrasias, dehydration, ototoxicity, electrolyte imbalances, circulatory collapse

Furosemide (Lasix)

• TC: Drug for heart failure and HTN
• PC: Diuretic (Loop type)
• Used in the treatment of acute HF because it has the ability to remove large amounts of excess fluid from the patient in a short period. Acts by preventing the reabsorption of sodium and chloride in the loop of Henle region of the nephron. 
• Pregnancy category C, potential electrolyte imbalances, hypokalemia, excess fluid loss, dehydration, and hypotension, orthostatic hypotension and syncope, ototoxicity.
• Contraindications include hypersensitivity to the drug, sulfonamides, anuria, hepatic coma, and severe fluid or electrolyte depletion. 

Hydrochlorothiazide (Macrozide) 

• TC: Drug for hypertension and edema
• PC: Thiazide diuretic
• Most widely prescribed diuretic for HTN. Acts on the kidney tubule to decrease the reabsorption of Na. Used for the treatment of ascites, edema, heart failure, HTN, and nephrotic syndrome.
• Very few side effects. Sometimes potential electrolyte imbalances can result. Can cause cardiac conduction abnormalities. 
• Contraindicated in patients with anuria and prior hypersensitivity to thiazides or sulfonamides. Overdose treated with infusions of fluids containing electrolytes.  

spironolactone (Aldactone)

• TC: Antihypertensive, drug
• PC: Potassium-sparing diuretic, aldosterone antagonist
• Used to treat mild HTN, often in combination with other anti-hypertensives. Acts by inhibiting aldosterone, the hormone secreted by the adrenal cortex responsible for increasing the renal reabsorption of Na in exchange for K, causing water retention. 
• Hyperkalemia, muscle weakness, fatigue, bradycardia, gynecomastia, impotence, diminished libido, menstrual irregularities, hirsutism, and breast tenderness
• Contraindicated in patients with anuria, significant impairment of renal function, or hyperkalemia. Contraindicated during pregnancy and lactation. 

Explain the importance of electrolyte imbalance in the body.

Electrolyte imbalances can be signs of underlying medical conditions. Renal impairment is the largest disorder associated with electrolyte imbalances. Certain drug therapies can cause electrolyte imbalances. If electrolyte imbalances are not treated they can lead to serious complications. 

Sodium Normal range

135 mEq/L – 145 mEq/L

Potassium Normal range:

3.5 mEq/L – 5 mEq/L 

Hyperkalemia

Occurs when the serum potassium level is greater than 5 mEq/L. Symptoms can include muscle twitching, fatigue, paresthesia’s, dyspnea, cramping, and diarrhea. 

Dextran 40

• TC: Plasma volume expander
• PC: Colloid
• Acts by raising the osmotic pressure of the blood, thereby causing fluid to move from the interstitial spaces of the tissues to the intravascular space (blood). Causes increased blood pressure, increased cardiac output, and improved venous return to the heart. Used for patients experiencing hypovolemic shock due to hemorrhage, surgery, or severe burns. 
• Side effects include fluid overload which can cause tachycardia, peripheral edema, distended neck veins, dyspnea, or cough. Small percentage of patients are allergic to Dextran 40, with uticaria being the most common sign. 
• Contraindicated in patients with renal failure or severe dehydration. Also in patients with severe congestive heart failure (CHF) and hypervolemic disorder. Pregnancy category C. 

Sodium chloride (NaCl)

• TC: Drug for hyponatremia
• PC: electrolyte, sodium supplement
• Acts by increasing serum sodium levels. Used to treat hyponatremia, corneal edema, and dry/inflamed nasal membranes.
• Use can cause hypernatremia which causes lethargy, confusion, muscle tremor, hypotension, and restlessness. Periodic laboratory assessments are needed. 
• Contraindicated in patients with hypernatremia, heart failure, or impaired renal function. 

Potassium

• TC: Drug for hypokalemia
• PC: Electrolyte, potassium supplement
• Acts by increasing serum potassium levels. Used to treat hypokalemia and mild forms of alkalosis. 
• Side effects can include nausea, vomiting, and peptic ulcers. Hyperkalemia is a possible side effect of prolonged use of potassium chloride.  
• Contraindicated in patients with hyperkalemia, chronic renal failure, systemic acidosis, severe dehydration, extensive tissue breakdown as in severe burns, adrenal insufficiency, or the administration of a potassium-sparing diuretic. Must be administered slowly when given IV.  

Sodium Bicarbonate 

• TC: Drug used to treat acidosis or bicarbonate deficiency
• PC: Electrolyte, sodium and bicarbonate supplement
• Acts by directly raising the pH of body fluids to reverse acidosis. Also used to alkalinize the urine and speed the excretion of acidic substances. Can be used in chronic renal failure to neutralize the metabolic acidosis that occurs when the kidneys cannot excrete hydrogen ions. 
• Side effects may include gastric distension. Too much sodium bicarbonate may cause confusion, irritability, slow respiration rate, and vomiting. Ruing infusions, serum electrolytes should be carefully monitored. Hypokalemia can also be a potential problem. 
• Contraindicated in patients who are vomiting or have continuous GI suctioning, hypertension, peptic ulcers, diarrhea, or vomiting. Should be used with caution in patients with cardiac disease and renal impairment. 

 Explain how hypertension is defined and classified.

Hypertension is defined as the consistent elevation of systemic arterial blood pressure. A patient is said to have chronic HTN if he or she presents with a sustained systolic blood pressure or greater than 140 mmHg or diastolic pressure of greater than 90-99 mmHg after multiple measurements are made over several clinic visits. 

Diastole

Cardiac output

Peripheral vascular resistance (PVR)

Antidiuretic hormone (ADH)

Aldosterone

Renin-angiotensin-aldosterone system

Reflex tachycardia

  Discuss therapeutic lifestyle changes in the management of hypertension.

enalapril (Vasotec)

• TC: Drug for hypertension and heart failure
• PC: ACE inhibitor 
• Acts by reducing angiotensin II and aldosterone levels to produce a significant reduction in blood pressure with few serious adverse effects. May be used for symptomatic HF. 
• May cause hyperkalemia and orthostatic hypotension. Rapid fall in blood pressure may result after first dose. Other effects may include headache and dizziness. ACE inhibitors can cause life threatening angioedema, neutropenia, or agranulocytosis. 
• Black box warning for fetal injury and death may occur when taken during pregnancy. Contraindicated in patients with prior hypersensitivity. 

Nifedipine (Procardia)

• TC: Drug for hypertension and angina
• PC: Calcium channel blocker
• Acts by selectively blocking calcium channels in myocardial and vascular smooth muscle, including those in the coronary arteries. This results in less oxygen utilization by the heart, an increase in cardiac output, and a fall in blood pressure. Used for HTN and variant or vaso-spastic angina
• Adverse effects are generally minor and can include headache, dizziness, peripheral edema, and flushing. Immediate acting forms can cause reflex tachycardia. In rare cases can cause an increase in anginal pain.
• Pregnancy category C. Contraindicated in patients with prior hypersensitivity. Overdose treated with vasopressors.  

doxazosin (Cardura)

• TC: Drug for hypertension and BPH
• PC: Alpha1 – adrenergic blocker
• Acts by dilating arteries and veins and is capable of causing a rapid, profound fall in BP. Also relaxes smooth muscle around the prostate gland. 
• Side effects can include dizziness, dyspnea, asthenia, headache, hypotension, postural hypotension, and somnolence. When starting therapy some patients may experience serious orthostatic hypotension. 
• Pregnancy category B. Contraindicated in patients with prior hypersensitivity to alpha blockers. Overdose treated with vasopressor and/or IV infusion of fluids. 

hydralazine (Apresoline)

• TC: Drug for hypertension and heart failure
• PC: Direct-acting vasodilator
• Acts through a direct vasodilation of arterial smooth muscle; it has no effect on veins. Therapy begun with low doses, which are gradually increased until the desired therapeutic response is obtained. 
• Side effects may include headache, reflex tachycardia, palpitations, flushing, nausea, and diarrhea are common. May possibly cause a Lupus like state. 
• Pregnancy category C. Contraindicated in patients with angina, rheumatic heart disease, MI, or tachycardia. Patients with Lupus should not receive hydralazine, because the drug can worsen symptoms

Relate how the symptoms associated with heart failure may be caused by weakened heart muscle and diminished cardiac output.  Include symptoms of both right and left heart failure. 

·         If it occurs on the left side of the heart, excess blood accumulates in the left ventricle. The wall of the left ventricle thickens and enlarges (hypertrophy) in an attempt to compensate for the increased workload. When blood “backs up” into the lungs, resulting in the classic symptoms of cough and shortness of breath. Left HF is sometimes called congestive heart failure.

·         In right HF, the blood backs up into veins, resulting in peripheral engorgement of organs such as the liver. 

Inotropic effect

Cardiac remodeling

peripheral edema 

lisinopril (Zestril)

• TC: drug for heart failure and HTN
• PC: ACE inhibitor
• Acts by inhibiting angiotensin-converting enzyme and decreasing aldosterone secretion. Blood pressure is decreased and cardiac output is increased. 2-3 weeks of therapy may be required to reach maximum effectiveness, and several months of therapy may be needed for cardiac function to return to normal. 
• Side effects may include cough, headache, dizziness, orthostatic hypotension, and rash. Hyperkalemia may occur. Other effects include taste disturbances, chest pain, nausea, vomiting, and diarrhea. 
• Pregnancy category C (first trimester) or D (second and third trimester). Contraindicated in patients with hyperkalemia and in those who have experienced angioedema caused by ACE inhibitor therapy. Overdose may be treated with the administration of normal saline or a vasopressor.  

Digoxin (Lanoxin)

• TC: Drug for heat failure
• PC: Cardiac glycoside
• Acts by inhibiting Na-K ATPase, the critical enzyme responsible for pumping sodium ions out of the myocardial cell in exchange for potassium ions. As sodium accumulates, calcium ions produces a more forceful contraction of the myocardial fibers. 
• Side effects may include dysrhythmias, particularly in patients who have hypokalemia or impaired renal function. Concurrent use of digoxin and diuretics must be carefully monitored. Other adverse effects may include nausea, vomiting, fatigue, anorexia, and visual disturbances. Pregnancy category A. 
• Contraindicated in patients with AV block or ventricular dysrhythmias unrelated to HF. Administer with caution to older adults because these patients experience a higher incidence of adverse effects. Patients with renal impairment should receive a lower dose. Should be used in caution in patients with MI, cor pulmonale, and hypothyroidism. 

metoprolol (Lopresor)

• TC: Drug for heart failure and HTN
• PC: Beta-adrenergic blocker
• Acts by reducing sympathetic stimulation of the heart, thus decreasing cardiac workload. Has been found to slow the progression of HF and to significantly reduce the long-term consequences of the disease. Usually combined with other HF drugs such as ACE inhibitors. 
• Side effects may include slowing of the heart rate and hypotension, abnormal sexual function, drowsiness, fatigue, and insomnia. 
• Pregnancy category C. 
• Contraindicated in patients with asthma, cardiogenic shock, sinus bradycardia, heart block greater than first degree, and overt cardiac failure. 

Coronary artery disease (CAD)

Myocardial ischemia

Atherosclerosis

Plaque

Angina

Stable angina pectoris

Unstable angina

 Describe the signs and symptoms of angina pectoris.

Presents itself as a steady, intense pain in the anterior chest, sometimes accompanied by a crushing or constricting sensation. Discomfort may radiate to the left shoulder and proceed down the left arm and it may extend posterior to the thoracic spine or move upward to the jaw. In women gastric distress, nausea, and vomiting, a burning sensation in the chest or chest wall, overwhelming fatigue, and sweating. 

Nitroglycerine (Nitro-Bid, Nitro-Dur)

• TC: Anti-anginal drug
• PC: Organic nitrate, vasodilator
• Taken while an acute angina episode is in progress or just prior to physical activity. 
• Side effects include headache and reflex tachycardia.
• Pregnancy category risk C. 
• Contraindicated in patients with pre-existing hypotension or with high intracranial pressure or head trauma, pericardial tamponade and constrictive pericarditis, and dehydration and hypovolemia.  

Atenolol (Tenormin)

• TC: Anti-anginal drug
• PC: Beta-adrenergic blocker
• Acts by selectively blocking beta-adrenergic receptors in the heart. Its effectiveness in treating angina is attributed to its ability to slow heart rate and reduce contractility, both of which lower myocardial oxygen demand. 
• Black box warning that it should be avoided in patients with ischemic heart disease. 
• Side effects can include fatigue, weakness, bradycardia, and hypotension. 
• Pregnancy category D. 
• Begin with low doses, then gradually increase until therapeutic effect is reached. Contraindicated in patients with severe bradycardia, atrioventricular (AV) heart block, cardiogenic shock, or decompensated HF, and severe hypotension 

Sublingual Nitroglycerine

• TC: Anti-anginal drug
• PC: Organic nitrate, vasodilator
• When angina occurs:
• Stop activity 
• Sit down
• Place 1 NTG tablet under the tongue
• If the chest pain continues, repeat in 5 minutes
• If chest pain continues, repeat again in 5 minutes
• If chest pain continues call 911
• Do not drive yourself to the hospital

• TC: Anti-anginal drug
• PC: Calcium channel blocker
• Acts by inhibiting the transport of calcium into myocardial cells. It has the ability to relax both coronary and peripheral blood vessels, bringing more oxygen to the myocardium and reducing cardiac workload. 
• Side effects include headache, dizziness, and edema. Abrupt with-drawl may precipitate an acute anginal episode. 
• Pregnancy category C. 
• Contraindicated in patients with AV heart block, sick sinus syndrome, severe hypotension, or bleeding aneurysm, or those undergoing intracranial surgery. 

reteplase (Retavase)

• TC: drug for dissolving blood clots
• PC: Thrombolytic 
• Acts by cleaving plasminogen to form plasmin. Plasmin then degrades the fibrin matrix of thrombi. Like other drugs in this class, reteplase should be given as soon as possible after the onset of MI symptoms.Side effects may include abnormal bleeding and dysrhythmias. Pregnancy category C. 
• Contraindicated in patients with active bleeding or history of CVA or who have had recent surgical procedures. No specific treatment for overdose. 

Anaphylactic shock

• Acute allergic reaction
• Severe reaction to an allergen such as penicillin, nuts, shellfish, or animal proteins. 

Cardiogenic shock

• Failure of the heart to pump sufficient blood to tissues
• Left heart failure, myocardial ischemia, myocardial infarction (MI), dysrhythmias, pulmonary embolism, or myocardial or pericardial infection

Hypovolemic shock

• Loss of blood volume
• Hemorrhage, burns, excessive diuresis, or severe vomiting or diarrhea. 

Neurogenic shock

• Vasodilation due to overstimulation of the parasympathetic nervous system or under stimulation of the sympathetic nervous system.
• Trauma to the spinal cord or medulla, severe emotional stress or pain, or drugs that depress the central nervous system.

Septic shock

• Multiple organ dysfunction as a result of pathogenic organisms in the blood; often a precursor to acute respiratory distress syndrome and disseminated intravascular coagulation. 
• Widespread inflammatory response to bacterial, fungal or parasitic infection. 

  Explain the initial treatment priorities for a patient who is in shock. 

First goal is to provide basic life support. ABC’s of life support need to be used. Immediately connect patient to a cardiac monitor and pulse oximeter. Administer 15L/min of oxygen via non-rebreather mask. Keep patient warm and quiet. 

normal serum albumin

• TC: Fluid replacement agent
• PC: Blood product, colloid
• Acts by increasing the oncotic pressure of the blood and causes fluid to move from the tissues to the general circulation. It is used to restore plasma volume in hypovolemic shock Allergic reaction possible. 
• Fever, chills, rash, dyspnea, and possibly hypotension. Protein overload may occur if excessive Albumin is infused\
• Contraindicated in patients with severe anemia or cardiac failure and an allergy to albumin

norepinephrine (Levophed)

• TC: drug for shock
• PC: nonselective adrenergic agonist: vasopressor
• Acts directly on alpha-adrenergic receptors in vascular smooth muscle to immediately raise BP. Stimulates beta-receptors in the heart, thus producing a positive inotropic responseContinuous monitoring of BP required. 
• Some side effects include reflex bradycardia, serious skin and soft tissue damage. Blurred vision and photophobia. 
• Contraindicated in patients who are experiencing hypotension due to blood volume deficits, may cause additional severe peripheral and visceral vasoconstriction with decreased urine output. 

dopamine (Intropin)

• TC: drug for shock
• PC: nonselective adrenergic agonist; inotropic drug
• At low doses stimulates dopaminergic receptors leading to vasodilation and an increased blood flow through kidneys. At high doses dopamine stimulates beta-adrenergic receptors causing the heart to beat more forcefully and increasing cardiac output, also causes vasoconstriction and raising blood pressure. 
• Constantly monitor for signs of dysrhythmias and hypertension. 
• Side effects may include severe skin and soft tissue damage. 
• Contraindicated in patients with pheochromocytoma or ventricular fibrillation. 

epinephrine (Adrenalin)

• TC: drug for anaphylaxis and shock
• PC: nonselective adrenergic agonist; vasopressor
• Acts by stimulating both alpha and beta adrenergic receptors. Activation of beta2 receptors in bronchi opens the airways, stimulation of alpha1 receptors raises BP, stimulation of beta1 receptors increases cardiac output
• Side effects include nervousness, tremors, palpitations, tachycardia, dizziness, headache, and stinging/burning at the site of application. When administered parenterally, hypertension and dysrhythmias may occur
• Use with caution in patients with dysrhythmias, cerebrovascular insufficiency, hyperthyroidism, narrow angle glaucoma, hypertension, or coronary ischemia. 

 Explain how rhythm abnormalities can affect cardiac function.

Rhythm abnormalities affect how the heart beats and how effectively blood is pumped into and out of the heart. Rhythm abnormalities cause disorganized heart rhythms which can cause the heart to have to work harder to pump blood through the body, causing damage to the heart over time. Causes of rhythm abnormalities can include hypertension, cardiac valve disease, coronary artery disease, medications such as digoxin, low potassium levels, myocardial infarction, stroke, diabetes mellitus, and heart failure. 

Supraventricular

Sinoatrial (SA) node

Bundle of His

Bundle branches

Purkinje network of fibers

Depolarization

Repolarization

 Describe the phases of the myocardial action potential.

• P wave: atrial polarization   
• QRS complex: ventricular depolarization
• T wave: ventricular repolarization

procainamide (Procanbid)

• TC: class I anti-dysrhythmic 
• PC: sodium channel blocker
• Acts by blocking sodium ion channels in myocardial cells, thus reducing automaticity and slowing conduction of the action potential across the myocardium
• Side effects may include nausea, vomiting, abdominal pain, hypotension, and headache. High doses may cause confusion and psychosis
• Contraindicated in patients with complete AV block, severe HF, blood dyscrasias, and myasthenia gravis. Overdose treated with vasopressors

propranolol (Inderal)

• TC: Class II anti-dysthymic
• PC: beta-adrenergic antagonist 
• Acts by reducing heart rate, slowing myocardial conduction velocity, and lowering BP. Most effective in treating tachycardia that is caused by excessive sympathetic stimulation. Used for HTN, angina, and migraine headaches, and for the prevention of MI. 
• Side effects may include fatigue, hypotension, and bradycardia. May cause diminished libido in men. Should be used cautiously in patients with diabetes. Should be used with caution in patients with reduced urine output. 
• Contraindicated in patients with cardiogenic shock, sinus bradycardia, greater than first degree heart block and HF, COPD, or asthma. Overdosed treated using vasopressors.  

amiodarone (Cordarone)

• TC: Class III anti-dysrhythmic
• PC: potassium channel blocker 
• Acts by blocking potassium ion channels and sodium ion channels in the heart. Used to treat ventricular tachycardia and atrial dysrhythmias. 
• Side effects may include pulmonary toxicity, blurred vision, rashes, photosensitivity, nausea, vomiting, anorexia, fatigue, dizziness, and hypotension. 
• Contraindicated in patients with severe bradycardia, cardiogenic shock, sick sinus syndrome, severe sinus node dysfunction, or third degree AV block.

verapamil (Calan)