Cardiovascular Diseases

Chapter 12

Heart’s Functional Anatomy

cardiac muscle conducting system

blood supply

Normal Heartbeat

• Begins in cell membranes of sinoatrial (SA) node

• Ion channels in cell membrane open– Na+ and Ca + + ions flow into cell– Voltage becomes positive (depolarization)

• Other channels open– K+ ions flow out of cell– Voltage becomes negative (repolarization)

Blockers Close Gate, Stimulant Opens Gate

Predetermined Factors for Cardiovascular Disease

• Heredity– Children of parents with CV disease higher risk– African Americans 2 to 3x more likely than

other ethnic groups to have hypertension

• Gender– Men greater risk than women until age55

• Increasing AgeAlmost 55% of heart attack victims age 65+

Factors Influenced by Lifestyle Modification

• Cigarette Smoking– Smokers twice the risk of heart attack

than nonsmokers• High Blood Pressure– Increases stroke and heart attack risk– Lower blood pressure by diet, exercise,

weight loss, reduce salt, drugs

Factors Influenced by Lifestyle Modification

• High Blood Cholesterol Levels– Reduces blood flow to heart– Diet low in cholesterol and fats, drugs

• Obesity– Increases blood pressure, cholesterol levels,

lead diabetes, strains heart• Diabetes

– Leads to vascular problems– Diet, drugs

Beta Blockers (lol, olol)

• heart rate, myocardial contractility, BP

• frequency and severity of attacks• Also used to treat arrhythmias and

HTN, and most commonly used after a MI

Side Effects of Beta Blockers

• Tiredness is most common • Bradycardia primary side effect• May mask symptoms of hypoglycemia and

hyperthyroidism– Diabetics should avoid

Beta Blockers in the top 100

• Atenolol/tenormin• Metoprolol/Lopressor• Carvedilol/Coreg

Nitrates

• Most commonly used drugs for angina• Dilate coronary vessels, leading to

redistribution of blood to ischemic tissues

• Reduce preload on the heart, which reduces cardiac workload and decreases afterload

• Helps with pulmonary edema in CHF

Nitrates

• Isosorbide Mononitrate (imdur, ismo)• Technicians—watch for patients who

get prescriptions for nitrates and ED drugs

• Severe headache when patients first start using

• Orthostatic hypotension• Flushing

Calcium Channel Blockers (dipine)

• Inhibit calcium ions moving into cardiac muscle cells– Calcium triggers muscle contraction– Reduces contractility of cell

• Relaxes vascular smooth muscle• Used for most supraventricular

tachyarrhythmias

Calcium Channel Blocker Info.

• Constipation most common side effect

• Some should be taken with food• Caffeine should be limited• Also first-line therapy for

hypertension

Calcium channel Blockers in the top 100

• Amlodipine/Norvasc

Arrhythmias

• Digoxin/Lanoxin• Used with caution, possibility of

systemic accumulation of drug• Patients may experience digitalis

toxicity, or digtoxicity, especially elderly

• Primary signs of digtoxity: nausea, vomiting, arrhythmias

Congestive Heart Failure (CHF)

• Form of heart failure• Heart pumps less blood than it

receives– Excess blood pools in the chambers and

stretches the walls of the heart

Fluid Accumulation in CHF

• Kidneys retain water and fluid accumulates in body tissues

• In lungs when left side of heart fails• In abdomen and lower extremities

when right side of heart fails

ACE Inhibitors (pril)

• Angiotensin-converting enzyme inhibitor

• Inhibits conversion of angiotensin I to angiotensin II

• Lowers blood pressure and stress on the heart

• Used for HTN, HF, post-MI• Considered to preserve potassium– Warning if patient taking ACE inhibitor and

K

ACE Inhibitors (pril)

• Prinivil/Lisinopril• Vasotec/Enapril• Altace/Ramipril

Dispensing Issues of ACE Inhibitors

• Warning!• Stand slowly to prevent orthostatic

hypotension• Avoid salt substitutes• Given with caution to patients taking

lithium

Side Effects of ACE Inhibitors

• Dry, nonproductive cough• Dizziness during first few days

Angiotensin Receptor Blockers (ARBs) (artan)

• Reduce blood pressure by blocking angiotensin II at its receptors

• Bound angiotension II cannot exert its effects

• ARBs: less coughing and angioedema than ACEIs

ARB’s

• Diovan/Valsartan• Cozaar/Losartan

Dispensing Issues of ARBs and ACEs

• Pharmacy technician—if patient has prescriptions for both drug classes from two different prescribers, make pharmacist or prescribers aware

Blood Clots

• thrombi (singular: thrombus)• Develop from abnormalities in– Blood coagulation – Blood flow– Platelet adhesiveness– Vessel walls

Clotting Cascade

• Damage to tissue cells activates a pathway of coagulation, or clotting cascade

• If any factor in the cascade is missing, blood will not clot (hemophilia)

Classes of Drugs to Reduce Risk of Blood Clots

• Anticoagulant: prevents clot formation by inhibiting clotting factors

• Antiplatelet: reduces the risk of clot formation by inhibiting platelet aggregation

• Third class of drugs, fibrinolytics, dissolve clots already formed

Antiplatelet Agent

• Plavix/Clopidogrel

Cholesterol

• High blood cholesterol is major risk factor for heart attacks and strokes

• Hypercholesterolemia: excessive amount of cholesterol in blood

• Hyperlipidemia: levels of one or more of the lipoproteins are elevated

HDL and LDL

• HDL: Good cholesterol – Carry 20 to 30% of the total serum

cholesterol• LDL: Bad cholesterol– Carry 60 to 70% of the total serum

cholesterol

HMG-CoA Reductase Inhibitors (Statins)

• Inhibit enzyme responsible for cholesterol biosynthesis

• Side effects: GI upset and headache• Take at night (most cholesterol

formed at night)

Statins

• Some combinations of these drugs are synergistic and some may be dangerous

• Report any symptom of muscle pain to physician immediately

• Thiazide diuretics, loop diurectics, and glucocorticoids increase lipid profile unfavorably

Statins

• Zocor/Simvastatin• Lipitor/Atrovastatin• Pravachol/Pravastatin• Crestor/Rosuvastatin• Mevacor/Lovastatin• Vytorin/Exetimibe+Simvastatin

atorvastatin (Lipitor)

• Potent lipid-lowering drug• Lowers LDLs significantly• Lowers triglycerides

simvastatin (Zocor)

• Take at bedtime• Report muscle pain accompanied by

fever• Store in well-sealed containers

Fibric Acid Derivatives

• Exact mechanism of action is unknown

• Increase excretion of cholesterol in bile, thereby increasing the risk of gallstones

• Report muscle pain

fenofibrate (TriCor)

• Increases breakdown of very low-density lipoproteins (VLDLs)

• Should be used with dietary modification

• Primary side effects are GI disturbances

ezetimibe (Zetia) (Cholesterol-Lowering Agent)

• Lowers total cholesterol by inhibiting absorption in the small intestine

• Also increases HDL levels

Terms to Define

Terms• Angina• Arrhythmias• CHF• BP• Hypertension• Thrombus• hypercholesterolemia

Mechanisms of action• Beta Blocker• Calcium Channel Blocker• Nitrate • ACE inhibitor