The Cardiovascular Drugs Questions and Answers,100% CORRECT

The Cardiovascular Drugs Questions and Answers Antianginal Drugs Angina Pectoris (chest pain) When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart, the heart muscle “aches.” The heart requires a large supply of oxygen to meet the demands placed on it. Ischemia Ischemia Poor blood supply to an organ Ischemic heart disease Poor blood supply to the heart muscle Atherosclerosis Coronary artery disease Myocardial infarction Necrosis, or death, of cardiac tissue Disabling or fatal Type of angina Chronic stable angina (also called classic or effort angina) Unstable angina (also called preinfarction angina) Vasospastic angina (also called Prinzmetal or variant angina) Goal of medical management • Minimize the frequency, decrease the durations and intensity of angina attacks • Improve functional capacity with few adverse effects • Prevent or delay MI A person who is mowing the lawn on a hot Saturday afternoon begins to notice chest pain. What should this person’s first action be? A. Take a nitroglycerin tablet. B. Stop mowing and sit or lie down. C. Go inside the house to cool off and get a drink of water. D. Call 911. Correct answer: B Rationale: At the first sign of chest pain, the person should stop all activity and sit or lie down before taking the nitroglycerin tablet. Drugs for Angina Nitrates and nitrites ß-Blockers Calcium channel blockers Nitrates and Nitrites Available forms Sublingual* Chewable tablets Oral capsules/tablets Intravenous solutions* Transdermal patches* Ointments Translingual sprays* *Bypass the liver and the first-pass effect Mechanism of Action and Drug Effects Cause vasodilation because of relaxation of smooth muscles Potent dilating effect on coronary arteries Result: oxygen to ischemic myocardial tissue Used for prevention and treatment of angina Rapid-acting forms Used to treat acute anginal attacks Sublingual tablets or spray; IV infusion Long-acting forms Used to prevent anginal episodes nitroglycerin (both rapid and long acting) isosorbide dinitrate (both rapid and long acting) isosorbide mononitrate (primarily long acting) A patient with extremely high blood pressure (BP) is in the emergency department. The health care provider will order therapy with nitroglycerin to manage the patient’s blood pressure. Which form of nitroglycerin is most appropriate? A. Sublingual spray B. Transdermal patch C. Oral capsule D. Intravenous infusion Correct answer: D Rationale: The IV infusion of nitroglycerin will have the fastest effect, and the dose will be titrated to the patient’s response. Nitrates Nitroglycerin Prototypical nitrate Large first-pass effect with oral forms Used for symptomatic treatment of ischemic heart conditions (angina) Intravenous form used for control of blood pressure in perioperative hypertension, treatment of heart failure, ischemic pain, pulmonary edema associated with acute myocardial infarction, and hypertensive emergencies Adverse effects Headaches Usually diminish in intensity and frequency with continued use Reflex tachycardia Postural hypotension Tolerance may develop. A patient who was walking a dog developed chest pain and sat down. The patient continues to experience chest pain when sitting down. When should the patient call 911? A. Immediately B. If the pain becomes more severe C. If one sublingual tablet does not relieve the pain after 5 minutes D. If the pain is not relieved after three sublingual tablets, taken 5 minutes apart Correct answer: C Rationale: With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe. The patient should sit or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes after one dose, the patient (or family member) should call 911 immediately. The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later but no more than three tablets total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate an MI. Tolerance Occurs in patients taking nitrates around the clock or with long-acting forms Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish Transdermal forms: may be instructed to remove patch at bedtime for 8 hours, then apply a new patch in the morning Contraindications Known drug allergy Severe anemia Closed-angle glaucoma Hypotension Severe head injury Use of the erectile dysfunction drugs sildenafil citrate (Viagra®), tadalafil (Cialis®), and vardenafil hydrochloride (Levitra®) Isosorcide Dinitrate Organic nitrate Available in rapid-acting sublingual tablets and long-acting oral dosage forms Slower onset, not first choice for acute angina episodes Nitroclycerin Prototypical nitrate The most important drug used in the symptomatic treatment of ischemic heart conditions such as angina Routes: oral, sublingual, metered-dose aerosol that is sprayed under the tongue, intravenous, and topical Nursing Implications Nitroglycerin o Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain. o Instruct patients never to chew or swallow the sublingual form. o Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent. o Instruct patients to keep a fresh supply of sublingual medication on hand; potency is good for about 3 to 6 months. o To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler. o Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication. o To reduce tolerance, the patient may be instructed to remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period. o Instruct patients to take as-needed nitrates at the first hint of anginal pain. o Monitor vital signs frequently during acute exacerbations of angina and during intravenous administration. o If experiencing chest pain, the patient taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension. o If anginal pain occurs tell patient to o stop activity and sit or lie down and take a sublingual tablet. o Call 911 or emergency services immediately and take a second sublingual tablet if there is no relief in 5 minutes. o Take a third sublingual tablet If there is no relief in 5 minutes. o Do not try to drive to the hospital. o Intravenous forms of nitroglycerin must be given with special non– polyvinyl chloride tubing and bags. o Discard parenteral solutions that not clear and are discoloured. o Follow specific manufacturer’s instructions for intravenous administration. Beta Blockers Mainstay in the treatment of several cardiovascular diseases o Angina o Myocardial infarction o Hypertension o Dysrhythmias Antianginal Beta Blockers o atenolol o metoprolol o propranolol hydrochloride o nadolol Mechanism of Action o β1-receptors located in hearts conduction system and through myocardium o Normally stimulated by epinephrine and norepinephrine which are released in exercise, or stress – causes heart to contract more strongly and causes the heart to spend more time in systole o When beta receptors are blocked by beta blockers the rate which the pacemaker (SA node) fires decreases o =slow heart rate =reduce myocardial oxygen demand=less angina Block β1-receptors on the heart o Decrease heart rate, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart o Decrease myocardial contractility, helping to conserve energy or decrease demand o After a myocardial infarction, a high level of circulating catecholamines irritates the heart, causing an imbalance in supply and demand ratio and even leading to life-threatening dysrhythmias. o β-blockers block the harmful effects of catecholamines, thus improving survival after a myocardial infarction. o Beta blockers also supress renin which is a potent vasoconstrictor released by the kidneys. Results in blood vessels to and in the kidney to dilate = reduced blood pressure. Beta Blockers Indications o Angina o Hypertension o Cardiac dysrhythmias o myocardial infarction o Some used for migraine headaches, essential tremors, and stage fright Contraindications o Systolic heart failure o Serious conduction disturbances o Caution: bronchial asthma, because any level of blockade of β2-receptors can promote bronchoconstriction o Diabetes mellitus: can mask hypoglycemia-induced tachycardia o Peripheral vascular disease: may further compromise cerebral or peripheral blood flow Beta blockers and Asthma o Beta 1 receptors are located in the heart and kidney o Beta 2 receptors are located in the lungs, skeletal muscle and peripheral blood vessels o Beta 2 receptors promote vasodilation in the lungs o Beta Blockers have potential risk of blocking Beta 2 receptors leading to potential bronchospasm o Beta blockers can also cause vasodilation of peripheral blood vessels leading to cold extremities o Increased risk with non-cardioselective options (propranolol) Beta Blockers: adverse effects Body system Cardiovascular - brachycardia, hypotension, atrioventricular block Metabolic – hyperglycemia, hypoglycemia, hyperlipidemia Central nervous system – dizziness, fatigue, depression, lethargy Other- Erectile dysfunction, wheezing, dyspnea Atenolol (Tenormin) o Cardioselective β1-adrenergic receptor blocker o Indication: prophylactic treatment of angina pectoris o Use of atenolol after myocardial infarction has been shown to decrease mortality o Oral dosage form Metoprolol Tartrate (lopresor, betaloc) o Cardioselective β1-adrenergic receptor blocker o Indication: prophylactic treatment of angina o Many of the same characteristics as atenolol o Reduces mortality rate in patients after myocardial infarction and in treating angina o Forms: oral (immediate release and long acting) and parenteral (injectable) forms o Intravenous metoprolol is commonly administered to hospitalized patients after a myocardial infarction and is used for treatment of hypertension in patients unable to take oral medicine. β-Blockers o Patients taking ß-blockers should monitor their pulse rates daily and report any rate lower than 60 beats/min or symptoms of relative bradycardia. o Instruct patients to report dizziness or fainting. o Inform patients that these medications should never be abruptly discontinued. o Inform patients that these medications are for long-term prevention of angina, not for immediate relief. A patient who has had a myocardial infarction is taking a ß-blocker. What is the main benefit of ß-blocker therapy for this patient? A. Vasodilation of the coronary arteries B. Increased force of cardiac contraction C. Slowing of the heart rate D. Maintaining adequate blood pressure Correct answer: C Rationale: Slowing the heart rate in patients with ischemic heart disease reduces myocardial oxygen demand and allows the coronary arteries time to fill with oxygen- and nutrient-rich blood. β blockers also block the irritating effects of circulating catecholamines on the heart. Calcium Channel Blockers for Chronic Stable Angina o amlodipine o diltiazem o nifedipine o verapamil hydrochloride MOA o Block the calcium channel o Cause coronary artery vasodilation o Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance o Reduce the workload of the heart o Result: decreased myocardial oxygen demand o Dysrhythmias: depression of the automaticity of and conduction through the sinoatrial and atrioventricular nodes (slow the pacemaker, SA node, and inhibit atrioventricular conduction) Indications o Angina o Hypertension o Supraventricular tachycardia o Coronary artery spasms (Prinzmetal angina) o Short-term management of atrial fibrillation and flutter o Migraine headaches o Raynaud’s disease o dihydropyridine nimodipine: cerebral artery spasms associated with aneurysm rupture Contraindications o Known drug allergy o Acute myocardial infarction o Second- or third-degree atrioventricular block (unless the patient has a pacemaker) o Hypotension Adverse Effects o Limited o Primarily relate to overexpression of their therapeutic effects o May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea, other adverse effects, lower leg edema Amlodipine Besylate (Norvasc) o Most popular calcium channel blocker of the dihydropyridine subclass o Indicated for both angina and hypertension o Available only for oral use o Side effect: lower leg edema Diltiasem Hydrochloride (Cardizem, tiazac) o Very effective for the treatment of angina pectoris resulting from coronary insufficiency and hypertension o Used in the treatment of atrial fibrillation and flutter along with paroxysmal supraventricular tachycardia Nursing Implication o Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fibre foods. o Before administering, perform a complete health history to determine the presence of conditions that may be contraindications for use or those that may call for cautious use. o Obtain baseline vital signs, including respiratory patterns and rate. o Assess for drug interactions. o Patients should not take any medications, including over-the-counter medications, without checking with their physicians. o Patients should be encouraged to limit caffeine intake. o Patients should report o Blurred vision o Persistent headache o Dry mouth o Edema o Fainting episodes o Weight gain of 1 kg in 24 hours or 2.3 kg in 1 week o Pulse rate less than 60 beats/min o Dyspnea o Alcohol consumption and spending time in hot baths or whirlpools, hot tubs, or saunas will result in vasodilation, hypotension, and the possibility of fainting. o Teach patients to change positions slowly to avoid postural changes in blood pressure. o Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of pills taken, and therapeutic effects. o Antianginal drugs o Monitor for adverse reactions: allergic reactions, headache, lightheadedness, hypotension, dizziness. o Monitor for therapeutic effects: relief of angina, decreased blood pressure, or both The nurse is preparing to educate a group of patients on the management of angina. 1. Which drug groups are most often used to treat patients with angina? Nitrates and nitrites, ß-blockers, and calcium channel blockers are the drugs most often used to treat patients with angina pectoris. What instructions will the nurse include when teaching patients about taking ß2- blocking drugs for the treatment of angina? A. “Call your health care provider if you heart rate is 64 beats/min.” B. “These drugs are safe to use in patients who have asthma.” C. “Call your health care provider if you experience a weight gain of 1 kg or more in 24 hours or 2.3 kg or more in 1 week.” D. “Avoid taking these medications with grapefruit juice.” Correct answer: C Rationale: Weight gain can indicate serious adverse effects of ß2-blocking drugs, so the health care provider should be called. A pulse of 64 beats/min is acceptable; these drugs should be avoided in patients with asthma, and there is no interaction with grapefruit juice. Calcium channel blockers should not be administered with grapefruit juice. A patient asks how to apply transdermal nitroglycerin. What should the nurse say to the patient in response? A. “Always apply the transdermal patch over the area of your chest where your heart is.” B. “Keep the previous patch on for 1 full day so you always have two patches on at a time.” C. “Apply the patch to hairless areas of the body.” D. “First apply Vaseline® to your body; then apply the transdermal patch.” Correct answer: C Rationale: The transdermal patch should be applied to a hairless, residual-free area of the body with the sites being rotated each time. The old transdermal patch should be completely removed and a new one applied. Heart Failure Medications Heart Failure o Not a specific disease o Complex clinical syndrome resulting from any functional or structural impairment to the heart, specifically ejection of blood or ventricular filling o The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs. o One of the most common causes for hospitalization in Canada o 5 000 annual deaths from heart failure o 5-year survival rate in those with heart failure is 50%. o Prevention is key. o Symptoms depend on the cardiac area affected. o “Left-sided” heart failure: pulmonary edema, coughing, shortness of breath, and dyspnea o “Right-sided” heart failure: systemic venous congestion, pedal edema, jugular venous distension, ascites, and hepatic congestion Heart Failure: Causes Myocardial deficiency o Inadequate contractility o Myocardial infarction o Coronary artery disease o Cardiomyopathy o Valvular insufficiency o Inadequate filling o Atrial fibrillation o Infection o Tamponade o Ischemia Increased workload o Pressure overload o Pulmonary hypertension o Systemic hypertension o Outflow obstruction o Volume overload o Hypervolemia o Congenital abnormalities o Anemia o Thyroid disease o Infection o Diabetes Classes of Heart Failure ▪ Class I ▪ No physical activity limitations ▪ Class II ▪ Ordinary physical activity results in fatigue, dyspnea, or other symptoms. ▪ Class III ▪ Marked limitation in physical activity ▪ Class IV ▪ Symptoms at rest or with no physical activity at all Drug Therapy for Heart Failure o Inotropic Drugs: Drugs that affect the force or energy of muscular contractions (i.e. Contraction of heart muscle) o Positive inotropic drugs: increase the force of myocardial contraction o Chronotropic Drugs: Drugs that influence the rate of the heart beat o Positive chronotropic drugs: increase heart rate o Dromotropic Drugs: Drugs that influence the conduction of electrical impulses within the tissue o Positive dromotropic drugs: accelerate cardiac conduction o Positive inotropic drugs o Phosphodiesterase inhibitors o Cardiac glycosides o B-type natriuretic peptides o Other drugs used in heart failure o Angiotensin-converting enzyme inhibitors o Angiotensin receptor blockers o ß-Blockers o Diuretics Drug of choice for early treatment of heart failure o Angiotensin-converting enzyme inhibitors (lisinopril, enalapril maleate, captopril, and others) o Angiotensin II receptor blockers (valsartan and others) o Certain ß-blockers (bisoprolol, extended-release metoprolol tartrate, and carvedilol) o Loop diuretics (furosemide) are used to reduce the symptoms of heart failure secondary to fluid overload. o Aldosterone inhibitors (spironolactone, eplerenone) are added as the heart failure progresses. o Only after these drugs are used is digoxin added. o dobutamine: positive inotropic drug o hydralazine/isosorbide dinitrate recommended specifically for use in Black patients Angiotensin-Converting Enzyme Inhibitors o Prevent sodium and water resorption by inhibiting b secretion o Diuresis results, which decreases preload, or the left ventricular end volume, and the work of the heart o Examples: lisinopril, enalapril maleate, fosinopril sodium, quinapril hydrochloride, captopril, ramipril, trandolapril, and perindopril erbumine. Ace Inhibitors Uses: hypertension, heart failure, and acute myocardial infarction Adverse effects Hyperkalemia Dry cough Decreased renal function Angiotensin II Receptor Blockers (ARBS) o Potent vasodilators; decrease systemic vascular resistance (afterload) o Used alone or in combination with other drugs such as diuretics in the treatment of hypertension or heart failure o Examples: valsartan (Diovan®), candesartan cilexetil, eprosartan mesylate, irbesartan, telmisartan, olmesartan medoximil, and losartan potassium o ARB’s share many of the same adverse effects as ACE o Angiotensin II receptor blockers are not as likely to cause the cough associated with the angiotensin-converting enzyme inhibitors. o Angiotensin II receptor blockers are not as likely to cause hyperkalemia. B- Blockers o Cardioprotective quality of ß-blockers: prevent catecholamine-mediated actions on the heart by reducing or blocking sympathetic nervous system stimulation to the heart and the heart’s conduction system o metoprolol o carvedilol Aldosterone Antagonists o spironolactone and eplerenone o Useful in severe stages of heart failure o Action: activation of the renin-angiotensin-aldosterone system causes increased levels of aldosterone, which causes retention of sodium and water, leading to edema that can worsen heart failure. o Work by blocking aldosterone at its receptors in the kidney, heart, blood vessels, and brain o spironolactone (Aldactone®): potassium-sparing diuretic and aldosterone antagonist shown to reduce the symptoms of heart failure o eplerenone (Inspra®): selective aldosterone blocker, blocking aldosterone at its receptors in the kidney, heart, blood vessels, and brain Miscellaneous Drugs to treat heart failure o hydralazine/isosorbide dinitrate o Drug approved specifically for individuals who are Black. o Combination drug only available in the US o dobutamine hydrochloride o β1-selective vasoactive adrenergic drug o Structurally similar to dopamine o Route - IV Phosphodiesterase Inhibitors (Milkrinone) o Work by inhibiting the enzyme phosphodiesterase o Causing: o Intracellular increase in cyclic adenosine monophosphate o Positive inotropic response (inotropic drugs affect the force or energy of muscular contractions, especially the contraction of the heart muscle) o Resulting in o Vasodilation (results in a reduction in force the heart needs to pump to eject blood) o Increase in calcium for myocardial muscle contraction. o Inodilators (inotropics and dilators) Indications: o One drug in this category available in Canada: milrinone. o Short-term management of heart failure for patients in the Critical Care Unit. o The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines advise against long-term infusions of milrinone. Milrinone o Only available phosphodiesterase inhibitor o Available only in injectable form o Adverse effects: cardiac dysrhythmias, hypotension, angina, hypokalemia, tremor, and thrombocytopenia o Interactions: diuretics (additive hypotensive effects) and digoxin (additive inotropic effects) o Furosemide must not be injected into intravenous lines with milrinone. Nursing Implications: Milrinone Use an infusion pump. Monitor input and output, heart rate and rhythm, blood pressure, daily weights, respirations, and so on Cardiac Glycosides o No longer used as first-line treatment o Not been shown to reduce mortality o Originally obtained from the Digitalis plant (foxglove) o Digoxin is the prototype. o Used in heart failure and to control ventricular response to atrial fibrillation o Indicated for patients with normal sinus rhythm, with moderate to severe symptoms, despite other treatments to relieve symptoms and reduce hospital visits. Mechanism of Action o Increase myocardial contractility o Change electrical conduction properties of the heart o Decrease rate of electrical conduction o Prolong the refractory period ▪ Area between sinoatrial node and atrioventricular node Cardiac Glycosides: Drug Effects o Positive inotropic effect o Increased force and velocity of myocardial contraction (without an increase in oxygen consumption) o Negative chronotropic effect o Reduced heart rate o Negative dromotropic effect o Decreased automaticity at sinoatrial node, decreased atrioventricular nodal conduction, and other effects o Increased stroke volume o Reduction in heart size during diastole o Decrease in venous blood pressure and vein engorgement o Increase in coronary circulation o Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis o Promotion of tissue perfusion and diuresis o Improved symptom control, quality of life, and exercise tolerance, with no apparent reduction in mortality A patient is in the emergency department with new-onset atrial fibrillation. Which order for digoxin would most likely have the fastest therapeutic effect? A. Digoxin 0.25 mg PO daily B. Digoxin 1 mg PO now, then 0.25 mg PO daily C. Digoxin 0.5 mg IV push daily D. Digoxin 0.75 mg IV push now, then 0.125 mg IV tid Correct answer: D Rationale: A digitalizing dose (0.5 – 0.75 mg IV) is often used to quickly bring serum levels of the drug up to a therapeutic level. IV doses would accomplish this more quickly. Adverse Effects o digoxin (Lanoxin®) o Very narrow therapeutic window o Drug levels must be monitored. ▪ 0.8 to 2 ng/mL o Low potassium levels increase its toxicity. o Electrolyte levels must be monitored. o Cardiovascular: dysrhythmias, including bradycardia or tachycardia o Central nervous system: headaches, fatigue, malaise, confusion, convulsions o Eyes: coloured vision (seeing green, yellow, purple), halo vision o Gastrointestinal: anorexia, nausea, vomiting, diarrhea Digoxin Toxicity o digoxin immune Fab therapy – inactivates free digoxin o Use is indicated in: o Hyperkalemia (serum potassium greater than 5 mmol/L) in a digitalis-toxic patient o Life-threatening cardiac dysrhythmias o Life-threatening digoxin overdose A patient is receiving digoxin 0.25 mg/day as part of treatment for heart failure. The nurse assesses the patient before administering medication. Which assessment finding would be of most concern? (Normal potassium level =3.6-5.2, normal digoxin level=0.5-2.0) A. Apical heart rate of 62 beats/min B. Ankle edema +1 bilaterally C. Serum potassium level of 2.9 mmol/L D. Serum digoxin level of 0.8 ng/mL Correct answer: C Rationale: The hypokalemia may precipitate digoxin toxicity; therefore, it is the biggest concern. The apical pulse is slightly over 60 beats/min, but bradycardia may occur with digoxin therapy, and the heart rate should be monitored. The ankle edema may be a manifestation of the patient’s heart failure and not a new concern. The digoxin level is within the normal range. Conditions that predispose to digoxin toxicity o Hypokalemia o Use of cardiac pacemaker o Atrioventricular block o Hypercalcemia o Dysrhythmias o Hypothyroid, respiratory, or renal disease o Advanced age o Ventricular fibrillation Sacubitril/valsartan (entresto) o neprilysin inhibitor / ARB o Neprilysin – increases natriuretic peptides o Indication- heart failure Class II or III o o Adverse Effects – Hypotension, hyperkalemia, renal impairment, cough, dizziness, renal failure Heart Failure Drugs: Nursing Implications o Assess history, drug allergies, and contraindications. o Assess clinical parameters, including o blood pressure o Both radial and apical pulse for 1 full minute o Heart sounds, breath sounds o Weight, input, and output measures o Electrocardiogram o Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies o Before giving any dose, count apical pulse for 1 full minute. o For an apical pulse less than 60 or greater than 100 beats/min o Hold dose. o Notify prescriber. o Hold dose and notify prescriber if the patient experiences signs or symptoms of toxicity. o Anorexia, nausea, vomiting, diarrhea o Visual disturbances (blurred vision, seeing green or yellow halos around objects) o Check dosage forms carefully and follow instructions for administering. o Avoid giving digoxin with high-fibre foods (fibre binds with digitalis). o Patients should immediately report a weight gain of 1 kg or more in 24 hours or 2 kg or more in 1 week. o Monitor for therapeutic effects. o Increased urinary output o Decreased edema, shortness of breath, dyspnea, crackles, fatigue o Resolution of paroxysmal nocturnal dyspnea o Improved peripheral pulses, skin colour, temperature o Monitor for adverse effects. A patient with a history of heart failure presents to the emergency department with difficulty breathing, cough, and edema of the lower extremities. The nurse anticipates the administration of which type of medication? A. Positive chronotrope B. Negative chronotrope C. Positive inotrope D. Negative inotrope Correct answer: C Rationale: Positive inotropes are used to increase the force of myocardial contraction in the treatment of patients with HF. Negative inotropes would cause the heart to have a decreased force of myocardial contraction and would not be effective. Positive chronotropes increase the rate at which the heart beats, and negative chronotropes decrease the rate at which the heart beats. The patient is prescribed an angiotensin-converting enzyme inhibitor. The nurse understands the primary mechanism by which angiotensin-converting enzyme inhibitors exert their therapeutic effect in a patient in heart failure is A. to inhibit catecholamine release. B. to inhibit acetylcholine release. C. to inhibit aldosterone secretion. D. to prevent vagal stimulation. Correct answer: C Rationale: The ACE inhibitors are beneficial in the treatment of HF because they prevent sodium and water resorption by inhibiting aldosterone secretion. This causes diuresis, which decreases blood volume and blood return to the heart. This in turn decreases preload, or the left ventricular end-diastolic volume, and the work required of the heart. The patient is discharged home and returns to the emergency department 4 days later. The patient is admitted to the Critical Care Unit with acute decompensated heart failure with dyspnea at rest. The nurse anticipates the administration of which medication? A. atropine B. carvedilol C. lisinopril D. milrinone Correct answer: D Rationale: Milrinone is primarily used in the Critical Care Unit setting for the short- term management of acute heart failure. Lisinopril is an angiotensin-converting enzyme inhibitor that is used in the management of heart failure. Carvedilol has been shown to slow the progression of heart failure and to decrease the frequency of hospitalization in patients with mild to moderate (Class II or III) heart failure. Atropine is used to increase the heart rate. Antidysrhythmics o Dysrhythmia o Any deviation from the normal rhythm of the heart o Antidysrhythmics o Used for the treatment and prevention of disturbances in cardiac rhythm Resting membrane potential o An energy-requiring pump is needed to maintain this uneven distribution of ions. o Sodium-potassium adenosine triphosphatase (ATPase) pump Cardiac Cell o Inside the resting cardiac cell, there is a net negative charge relative to the outside of the cell. o This difference in electronegative charge results from an uneven distribution of ions (sodium, potassium, calcium) across the cell membrane. o Resting membrane potential Action Potential o A change in the distribution of ions causes cardiac cells to become excited. o The movement of ions across the cardiac cell’s membrane results in an electrical impulse spreading across the cardiac cells. o This electrical impulse leads to contraction of the myocardial muscle. o Four phases o The sinoatrial node and the Purkinje cells each have separate action potentials. Action potential duration o Absolute or effective refractory period o Relative refractory period o Threshold potential o Automaticity or pacemaker activity Electrocardiography o Electrocardiogram (ECG or EKG) o P wave o PR interval o QRS complex o ST segment o T wave Common Dysrhythmias o Supraventricular dysrhythmias o Ventricular dysrhythmias o Ectopic foci o Conduction blocks Vaughan William Classification o System commonly used to classify antidysrhythmic drugs o Based on the electrophysiological effect of particular drugs on the action potential o Describes where and how the drug classifications affect the cardiac cells Class I Class Ia Class Ib Class Ic Class II Class III Class IV o Class I (Sodium Blockers) o Membrane-stabilizing drugs o Fast sodium channel blockers o Divided into Ia, Ib, and Ic drugs, according to effects o Class Ia: procainamide, quinidine, and disopyramide o Block sodium (fast) channels o Delay repolarization o Increase action potential duration (APD) o Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, ventricular tachycardia, Wolff-Parkinson-White syndrome Procainamide Hydrochloride Uses: atrial and ventricular tachydysrhythmias Significant adverse effects include ventricular dysrhythmias and blood disorders. Other adverse effects include hypotension, rash, diarrhea, nausea, vomiting, agranulocytosis, systemic lupus erythematosus (SLE)–like syndrome, and torsades de pointes resulting from prolongation of the QT interval. Contraindications: known hypersensitivity, heart block, and SLE o Class Ib: lidocaine hydrochloride (Xylocaine®) o Block sodium channels o Accelerate repolarization o Increase or decrease APD o Lidocaine is used for ventricular dysrhythmias only. o Phenytoin is used for atrial and ventricular tachydysrhythmias caused by digitalis toxicity or long QT syndrome. Lidocaine Action: raises the ventricular fibrillation threshold Significant adverse effects on the central nervous system (CNS): twitching, convulsions, confusion, respiratory depression or arrest, hypotension, bradycardia, and dysrhythmias Contraindications: hypersensitive, severe sinoatrial or atrioventricular intraventricular block, or Stokes-Adams or Wolff-Parkinson-White syndrome o Class Ic: flecainide, propafenone o Block sodium channels (more pronounced effect) o Little effect on APD or repolarization o Used for severe ventricular dysrhythmias o May be used in atrial fibrillation or flutter, Wolff-Parkinson-White syndrome, supraventricular tachycardia dysrhythmias Flecainide First-line drug in the treatment of atrial fibrillation Has a negative inotropic effect and depresses left ventricular function Adverse effects: dizziness, visual disturbances, and dyspnea Contraindications: hypersensitivity, cardiogenic shock, second- or third- degree atrioventricular block, and non–life-threatening dysrhythmias o Class II: ß-blockers o Reduce or block sympathetic nervous system stimulation, thus reducing transmission of impulses in the heart’s conduction system o Depress phase 4 depolarization o General myocardial depressants for both supraventricular and ventricular dysrhythmias o Also used as antianginal and antihypertensive drugs Atenolol Cardioselective ß-blocker; preferentially blocks the ß1-adrenergic receptors that are located primarily in the heart. Noncardioselective ß-blockers block not only the ß1-adrenergic receptors in the heart but also the ß2-adrenergic receptors in the lungs and therefore can exacerbate pre-existing asthma or chronic obstructive pulmonary disease. Uses: antidysrhythmic, hypertension, and angina Contraindications: severe bradycardia, second- or third-degree heart block, heart failure, cardiogenic shock, or a known hypersensitivity o Class III (potassium blockers): amiodarone, dronedarone, sotalol, ibutilide o Increase APD o Prolong repolarization in phase 3 o Used for dysrhythmias that are difficult to treat ▪ Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter that is resistant to other drugs Amiodarone Hydrochloride Markedly prolongs the action potential duration and the effective refractory period in all cardiac tissues Blocks both the α- and ß-adrenergic receptors of the sympathetic nervous system Uses: one of the most effective antidysrhythmic drugs for controlling supraventricular and ventricular dysrhythmias Drug of choice for ventricular dysrhythmias according to the Advanced Cardiac Life Support guidelines Most serious effect: pulmonary toxicity Other adverse effects: corneal microdeposits, which may cause visual halos, photophobia, and dry eyes; photosensitivity; and pulmonary toxicity Drug interactions: digoxin and warfarin sodium Contraindications: hypersensitivity, severe sinus bradycardia or second- or third-degree heart block Monitoring: BP, heart rate, edema to hands and feet, lethargy, weight loss, pulmonary toxicity (need baseline pft and yearly chest X-ray), electrolytes (magnesium an potassium), thyroid, ophthalmic exam Class IV: o Calcium channel blockers o Inhibit slow channel (calcium-dependent) pathways o Depress phase 4 depolarization o Reduce atrioventricular node conduction o Used for paroxysmal supraventricular tachycardia (PSVT); rate control for atrial fibrillation and flutter Diltiazem Temporary control of a rapid ventricular response in patients with atrial fibrillation or flutter and PSVT Contraindications: hypersensitivity, acute myocardial infarction, pulmonary congestion, Wolff-Parkinson-White syndrome, severe hypotension, cardiogenic shock, sick sinus syndrome, or second- or third-degree AV block Contraindications to the use of Antidysrhythmic drugs o Known drug allergy o Second- or third-degree atrioventricular block, bundle branch block, cardiogenic shock, sick sinus syndrome, and any other ECG changes, depending on the clinical judgment of a cardiologist. o Other antidysrhythmic drugs Adverse Effects o All antidysrhythmics can cause dysrhythmias! o Hypersensitivity reactions o Nausea, vomiting, and diarrhea o Dizziness o Headache, and blurred vision o Prolongation of the QT interval Drug Interactions o Warfarin sodium (Coumadin®): monitor international normalized ratio (INR) o Grapefruit juice: amiodarone, disopyramide, and quinidine Unclassified antidysrhythmic drug adenosine (Adenocard®) Slows conduction through the atrioventricular node Used to convert PSVT to sinus rhythm Very short half-life—less than 10 seconds Only administered as fast intravenous (IV) push May cause asystole for a few seconds Other adverse effects are minimal. A patient has received an IV dose of adenosine, and almost immediately the heart monitor shows asystole. What should the nurse do next? A. Check the patient’s pulse. B. Prepare to administer cardiopulmonary resuscitation. C. Set up for defibrillation. D. Continue to monitor the patient. Correct answer: D Rationale: The half-life of adenosine is very fast—only 10 seconds—and the asystole only lasts for a few seconds. The nurse should continue to monitor the patient for therapeutic and adverse effects of the medication. Nursing Implications o Obtain a thorough drug and medical history. o Measure baseline blood pressure, pulse, input and output, and cardiac rhythm. o Measure serum potassium levels before initiating therapy. o Assess for conditions that may be contraindications to the use of specific drugs. o Assess for potential drug interactions. o Instruct patients to report dosing schedules and adverse effects to physician. o During therapy, monitor cardiac rhythm, heart rate, blood pressure, general well- being, skin colour, temperature, and heart and lung sounds. o Assess plasma drug levels as indicated. o Monitor for toxic effects. o Instruct patients to take medications as scheduled and not to skip doses or double up for missed doses. o Instruct patients to contact their physicians for instructions if a dose is missed. o Instruct patients not to crush or chew oral sustained-release preparations. o Monitor ECG for prolonged QT interval with use of antidysrhythmics, including amiodarone, procainamide, quinidine, sotalol, and flecainide. o Administer IV infusions with an IV pump. o Solutions of lidocaine that contain epinephrine should not be given intravenously; they are to be used only as local anaesthetics. o Ensure that the patient knows to notify the health care provider of any worsening of dysrhythmia or toxic effects. o Shortness of breath o Edema o Dizziness o Syncope o Chest pain o Gastrointestinal distress o Blurred vision o Edema o Teach patients taking ß-blockers, digoxin, and other drugs how to take their own radial pulse for 1 full minute and to notify their physician before taking the next dose if the pulse is less than 60 beats/min. o Monitor for therapeutic response. o Decreased blood pressure in hypertensive patients o Decreased edema o Decreased fatigue o Regular pulse rate o Pulse rate without major irregularities o Improved regularity of rhythm o Improved cardiac output A patient is in the emergency department with an unspecified supraventricular dysrhythmia. The physician has ordered a dose of diltiazem IV push. While the nurse administers the medication through the IV lock, the patient says that something wet is spilling on one arm. The heart rate is unchanged. What will the nurse do next? A. Assess the patient for diaphoresis. B. Check the IV lock to see if it is functioning properly. C. Repeat the dose of diltiazem. D. Restart the IV in another location. Correct answer: B Rationale: Because the heart rate was unchanged and the patient felt fluid on an arm, the IV lock is probably not working properly. Before anything else is done, the IV lock should be checked for proper functioning. Another dose would be wasted if the IV lock is not working. A patient is receiving oral quinidine. Which assessment finding is of most concern? A. Nausea B. Prolonged QT interval C. Diarrhea D. Occasional palpitations Correct answer: B Rationale: Patients taking quinidine need to be monitored for prolonged QRS and QT intervals, which may be precursors to more-serious dysrhythmia problems. QT interval A measure of ventricular repolarization Normal value men <0.44sec Women <0.46 sec Antilipemic Medications Triglycerides and Cholesterol o Two primary forms of lipids in the blood o Water-insoluble fats that must be bound to apolipoproteins, specialized lipid- carrying proteins o Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein. o Lipoproteins transport lipids in the blood Lipoproteins (we want LDL to be LOW!! And HDL to be HIGH) o Very-low-density lipoprotein (VLDL) o Produced by the liver o Transports endogenous lipids to peripheral cells o Intermediate-density lipoprotein (IDL) o Low-density lipoprotein (LDL) o “Bad cholesterol” o High-density lipoprotein (HDL) o Responsible for “recycling” of cholesterol o Also known as “good cholesterol” The risk of coronary heart disease in patients with cholesterol levels of 5.2 mmol/L is three to four times greater than that in patients with levels less than 4 mmol/L. Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult o Farmingham Risk Score o Heart Age Calculator o Medications to treat dyslipidemia All reasonable nondrug means of controlling blood cholesterol levels (e.g., diet, exercise) Drug therapy based upon the specific lipid profile of the patient Antilipemics o Five established classes of drugs o Hydroxymethylglutaryl–coenzyme A (HMG–CoA) reductase inhibitors (statins) o Bile acid sequestrants o B vitamin niacin (vitamin B3, nicotinic acid) o Fibric acid derivatives (fibrates) o Cholesterol absorption inhibitor (Ezetrol®) o New Class o Antilipemic Agent – PCSK9 Inhibitor 1.) Statins o First-line therapy for hypercholesterolemia o Reduces plasma concentrations of LDL (low-density lipoprotein) cholesterol by 30 to 40% o Decrease in plasma triglycerides by 10 to 30% o Increase in HDL (high-density lipoprotein) cholesterol by 2 to 15% o Dose dependent Most potent LDL reducers pravastatin sodium simvastatin (Zocor®) atorvastatin (Lipitor®) fluvastatin sodium (Lescol®) rosuvastatin calcium (Crestor®) lovastatin Mechanism of Action o Inhibit HMG-CoA reductase, which is used by the liver to produce cholesterol o Lower the rate of cholesterol production Adverse effects o Mild, transient gastrointestinal disturbances o Rash o Headache o Myopathy (muscle pain), possibly leading to rhabdomyolysis, a serious condition o Do not use for patients with elevated liver enzymes or liver disease Rhabdomyolysis o Breakdown of muscle protein o Myoglobinuria: urinary elimination of the muscle protein myoglobin o Can lead to acute kidney injury and even death o When recognized reasonably early, rhabdomyolysis is usually reversible with discontinuation of the statin drug. o Instruct patients to immediately report any signs of toxicity, including muscle soreness or changes in urine colour (tea-coloured). Interactions o Oral anticoagulants o Drugs metabolized by CYP3A4 o erythromycin o azole antifungals o quinidine sulphate o verapamil hydrochloride o diltiazem hydrochloride o Human immunodeficiency virus (HIV) and hepatitis C protease inhibitors o Drugs metabolized by CYP3A4 (cont.) o amiodarone hydrochloride o Grapefruit juice o cyclosporine o clarithromycin o amlodipine Atorvastatin Calcium and simvastatin o Two of the most commonly used drugs in this class of cholesterol-lowering drugs o Lowers total and LDL cholesterol levels as well as triglyceride levels and raises “good” cholesterol, the HDL component o Dosed once daily, usually with the evening meal or at bedtime to correlate with diurnal rhythm A patient with a new prescription for an HMG-CoA (statin) drug is instructed to take the medication with the evening meal or at bedtime. The patient asks why it must be taken at that time of day. The reason is that A. the medication is better absorbed at that time. B. that time frame correlates better with the natural diurnal rhythm of cholesterol production. C. there will be fewer adverse effects if the drug is taken at night instead of with the morning meal. D. this timing reduces the incidence of myopathy. Correct answer: B Rationale: All statins are generally dosed once daily, usually with the evening meal or at bedtime, to best coincide with the body’s natural diurnal rhythm of cholesterol production. 2.) Bile and Sequestrants o cholestyramine resin (Olestyr®) o colestipol hydrochloride o colesevelam o Also called bile acid–binding resins and ion-exchange resins Mechanism of action o Prevent resorption of bile acids from small intestine o Bile acids are necessary for absorption of cholesterol. Indications o Type II hyperlipoproteinemia o Relief of pruritus associated with partial biliary obstruction (cholestyramine) o May be used along with statins Adverse effects o Constipation o Heartburn, nausea, belching, bloating o These adverse effects tend to disappear over time. o Increasing dietary fibre intake or taking a fibre supplement such as psyllium (Metamucil® and others), as well as increasing fluid intake, may relieve constipation and bloating. o May also cause mild increases in triglyceride levels Considerations o Overdose can cause obstruction because the bile acid sequestrants are not absorbed. o Treatment of overdose includes restoring gut motility. o Drug interactions o All drugs must be taken at least 1 hour before or 4 to 6 hours after the administration of bile acid sequestrants. o High doses of a bile acid sequestrant decrease the absorption of fat- soluble vitamins (A, D, E, and K). Cholestyramine Resin o Contraindications: known hypersensitivity, phenylketonuria or complete biliary obstruction o Pregnancy and lactation considerations o Treatment of loose bowel movements o Caution when administering dry powder A patient has been ordered the powdered form of the bile acid sequestrant colestipol hydrochloride. Which information does the nurse identify as true? A. The nurse should have the patient swallow the dose of the colestipol powder one teaspoonful at a time. B. The powder should be dissolved and immediately administered. C. The colestipol should be administered 1 hour before or 4 to 6 hours after any other oral medication. D. The colestipol should be administered with meals. Correct answer: C Rationale: It is important that colestipol and any bile acid sequestrant be taken 1 hour before or 4 to 6 hours after any other oral medication or meals because of the high risk of drug–drug and drug–food interactions. The powder should be dissolved for 1 full minute before administration and should not be taken in dry form. 3.) Niacin o Vitamin B3 o Lipid-lowering properties require much higher doses than when used as a vitamin. o Effective, inexpensive, often used in combination with other lipid-lowering drugs Mechanism of action o Thought to inhibit lipolysis in adipose tissue, decrease esterification of triglycerides in the liver, and increase the activity of lipoprotein lipase o Reduces the metabolism or catabolism of cholesterol and triglycerides Indications • Effective in lowering triglyceride, total serum cholesterol, apolipoprotein B and LDL cholesterol levels • Increases HDL levels Contraindications: • Allergy, liver disease, hypertension, peptic ulcer, active hemorrhage • Use with catioun in patients with gout as it may increase serum uric acid Adverse Effects o Flushing (caused by histamine release) o Pruritus o Gastrointestinal distress A patient will be taking niacin as part of antilipemic therapy. The best way to avoid problems with flushing or pruritus would be for the patient to A. take the medication at bedtime. B. take the medication with a small dose of a steroid. C. take the medication with a full glass of water on an empty stomach. D. start with a low initial dose and then increase it gradually. Correct answer: D Rationale: Cutaneous flushing may be minimized if the niacin is started at a smaller dose and gradually increased. Premedication with a small dose of aspirin or a nonsteroidal antiinflammatory drug 30 minutes before taking the niacin, as well as taking the niacin with meals, may help to minimize these undesirable effects. Fibric Acid Derivatives o Also known as fibrates o bezafibrate o gemfibrozil o fenofibrate o Believed to work by activating lipoprotein lipase, which breaks down cholesterol o Also suppress the release of free fatty acid from adipose tissue, inhibit the synthesis of triglycerides in the liver, and increase the secretion of cholesterol in the bile Indications o The fibric acid derivatives bezafibrate, gemfibrozil, and fenofibrate decrease the triglyceride level and increase the HDL cholesterol level by as much as 25%. Contraindications o Known drug allergy o Severe liver or kidney disease o Cirrhosis o Gallbladder disease Adverse Effects o Abdominal discomfort, diarrhea, nausea o Blurred vision, headache o Increased risk of gallstones o Prolonged prothrombin time o Increased enzyme levels perhaps shown by liver studies Interactions o Gemfibrozil enhances the action of oral anticoagulants. o When given with a statin, increases risk of myositis, myalgia, and rhabdomyolysis. o Laboratory test reactions: o Decreased hemoglobin level, hematocrit value, and white blood cell count o Increased aspartate aminotransferase, activated clotting time, lactate dehydrogenase level, and bilirubin level Cholesterol absorption inhibitor o ezetimibe (Ezetrol) ▪ Inhibits absorption of cholesterol and related sterols from the small intestine ▪ Results in reduced total cholesterol, LDL cholesterol, apolipoprotein B, and triglyceride levels ▪ Also increases HDL cholesterol levels ▪ Often combined with a statin drug ▪ Can be used as monotherapy Antilipemic agent- PCSK9 Inhibitor o Evolocumab (Repatha) o Indications: Hyperlipidemia o Mechanism of action: PCSK9 binds to LDLR (low density lipoprotein receptors) to promote degradation of LDLR in the liver. As LDLR is the primary receptor that clears LDL (bad cholesterol) then this results in increased LDL. Repatha Inhibits the binding of PCSK9 to LDLR which allows more LDLR in the blood to clear LDL (bad cholesterol) o Dosing – sub Q, Autoinjector, every 2 weeks or monthly o Adverse Effects: hypertension, dizziness, fatigue, GI upset, skin rash, urinary tract infection, influenza, myalgia, increase risk of respiratory infections o Contraindications – allergy o Drug interactions – Belumumab Herbal Product: Garlic o Used as an antispasmodic, antiseptic, antibacterial, antiviral, antihypertensive, antiplatelet, and lipid reducer o Adverse effects: dermatitis, vomiting, diarrhea, anorexia, flatulence, antiplatelet activity o Possible interactions with warfarin, diazepam, and protease inhibitors o May enhance bleeding when taken with nonsteroidal anti-inflammatory drugs (NSAIDs) A patient wants to take garlic tablets to improve cholesterol levels. Which condition would be a contraindication? A. Hypertension B. Bowel obstruction C. Sinus infection D. Scheduled surgery Correct answer: D Rationale: Garlic has antiplatelet activity and is contraindicated for patients who will undergo surgery within 2 weeks and in patients with human immunodeficiency virus infection or diabetes. Herbal Product: Flax o Both the seed and oil of the plant are used. o Uses: atherosclerosis, hypercholesterolemia, hypertriglyceridemia, gastrointestinal distress, menopausal symptoms, bladder inflammation, others o May cause diarrhea and allergic reactions o Possible interactions: antihyperglycemic drugs, anticoagulant drugs Herbal Product: Omega 3 fatty acids o Fish oil products o Used to reduce cholesterol o May cause rash, belching, allergic reactions o Potential interactions with anticoagulant drugs Nursing Implications o Before beginning therapy, obtain a thorough health and medication history. o Assess dietary patterns, exercise level, weight, height, vital signs, tobacco and alcohol use, and family history. o Assess for contraindications, conditions that require cautious use, and drug interactions. Which patient would benefit from the administration of simvastatin (Zocor) 80 mg? A. A patient newly diagnosed with hyperlipidemia B. A patient with muscle aches who was taking another antilipidemic drug C. A patient who is taking verapamil hydrochloride D. A patient who has already been taking simvastatin for 12 months with no evidence of myopathy Correct answer: D Rationale: The use of the 80-mg dose of simvastatin is discouraged during the first 12 months of treatment due to increased risk of myopathy and rhabdomyolysis. In addition, simvastatin is not to be used with potent CYP3A4 inhibitors, including itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, HIV protease inhibitors, boceprevir, telaprevir, gemfibrozil, cyclosporine, and danazol. In patients taking verapamil hydrochloride and diltiazem hydrochloride, the dose of simvastatin is not to exceed 10 mg. Nursing Implications o Contraindications include biliary obstruction, liver dysfunction, and active liver dysfunction. o Obtain results of baseline liver function studies. o Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K). o Refer to guidelines regarding administration times and meals. o Counsel patient concerning diet and nutrition on an ongoing basis. o Instruct patient on proper procedure for taking the medications. o Powder forms must be taken with a liquid, mixed thoroughly but not stirred, and never taken dry. o Other medications should be taken 1 hour before or 4 to 6 hours after meals to avoid interference with absorption. o To minimize adverse effects of niacin, start on a low initial dose and gradually increase it, and have the patient take the medication with meals. o Small doses of aspirin or NSAIDs may be taken 30 minutes before niacin to minimize cutaneous flushing. o Provide teaching regarding the use of NSAIDs and aspirin. o Inform patients that these medications may take several weeks to show effectiveness. o Instruct patients to report persistent gastrointestinal upset, constipation, abnormal or unusual bleeding, and yellow discoloration of the skin. o Monitor for adverse effects, including increased liver enzyme studies. o Monitor for therapeutic effects. o Reduced cholesterol and triglyceride levels Before administering niacin, which is most important for the nurse to assess? A. Allergy to erythromycin B. Gout C. Coronary artery disease D. Hypothyroidism Correct answer: B Rationale: With niacin, patient assessment includes noting contraindications such as liver disease, peptic ulcer disease, gout, hypertension, and any active bleeding. Although a thorough assessment of all patient conditions is helpful, the other conditions do not preclude use of niacin. Drug Profiles 1. Nitrates 2. B Blockers 3. Calcium Channel Blockers 4. ACE inhibitors 5. ARB 6. Phosphodiesterase Inhibitors 7. Cardiac Glycosides 8. Aldosterone Inhibitors 9. Class 1 – Sodium Blockers 10. Class III – Potassium Blockers 11. Statins 12. Bile Acid Sequestrants 13. Niacin 14. Fibric Acid Derivatives 15. Cholesterol Absorption Inhibitor 16. PCSKA Inhibitor Class: Most Common Medications: Routes: Indications: Brief Mechanism of Action: Adverse Effects: Major Contraindications: Drug Interactions: Interesting Facts (e.g. special education points, monitoring…)