❤️ Module 10 · Cardiovascular Part 2
17 drugs · 5 concepts · tested on Exam 6
💡 The big idea
Three cardiac problems in one module: the heart beats WRONG (antiarrhythmics), the heart cannot pump or the coronary supply is short (inotropes, nitrates, antianginals), and the plumbing is furring up (lipid drugs). Rhythm drugs sort into the four Vaughan-Williams classes. Angina drugs all do the same thing from different angles: raise supply or lower demand. Lipid drugs sort by which part of the lipid panel they move.
🧠 How to think about this module
- Antiarrhythmics in four classes: I sodium (procainamide, lidocaine), II beta blockers, III potassium (amiodarone, sotalol), IV calcium (verapamil, diltiazem). Adenosine and digoxin sit outside the classes.
- Angina is a supply-and-demand problem. Nitrates and calcium channel blockers raise supply by dilating; beta blockers and ranolazine lower demand.
- Calcium channel blockers have two personalities. Dihydropyridines (the -dipines) go to the vessels. Non-dihydropyridines (verapamil, diltiazem) go to the heart. Getting that split right answers half the CCB questions.
- Heart failure drugs either UNLOAD the heart (ACE inhibitors, ARBs, diuretics, nitrates) or make it SQUEEZE harder (digoxin, milrinone, dobutamine). ACE/ARB plus a beta blocker is the pair that actually prolongs life.
- Lipid drugs: statins move LDL the most, fibrates and niacin move triglycerides, and sequestrants and ezetimibe work in the gut.
🏷️ The whole module in 11 classes
Learn these groups and the drug list stops being 17 separate names.
| Class | What it does | Examples | What gets tested |
|---|
| Class I — sodium channel blockers | Slow conduction through the myocardium. | procainamide, quinidine (IA); lidocaine (IB); flecainide (IC) | Procainamide causes a lupus-like syndrome and prolongs the QT toward torsades. Continuous ECG during IV loading. Lidocaine toxicity starts with circumoral numbness, metallic taste, and tinnitus, then seizures. |
| Class II — beta blockers | Slow the rate and control the ventricular response in atrial fibrillation. | metoprolol, atenolol, esmolol, propranolol | Apical pulse under 60 means hold and call. Bronchospasm with non-selective agents; never stop abruptly. |
| Class III — potassium channel blockers | Prolong repolarization; used for serious atrial and ventricular arrhythmias. | amiodarone, sotalol, dofetilide, ibutilide | Amiodarone damages nearly every organ over time — pulmonary fibrosis, thyroid dysfunction (hypo OR hyper), hepatotoxicity, corneal deposits, blue-gray skin, and photosensitivity. Baseline and periodic chest x-ray, TSH, and liver enzymes. |
| Class IV — non-dihydropyridine calcium channel blockers | Slow the AV node, so they lower both blood pressure and heart rate. | verapamil, diltiazem | Bradycardia, heart block, and hypotension. Verapamil causes marked constipation. Combining with a beta blocker can produce complete heart block — verify before giving. |
| Dihydropyridine calcium channel blockers | Pure arterial vasodilators with little effect on heart rate. | amlodipine, nifedipine, nicardipine, felodipine | Peripheral (ankle) edema, flushing, headache, and reflex tachycardia. Grapefruit juice raises the level. These do NOT control heart rate. |
| Other antiarrhythmics | Drugs that do not fit the four classes. | adenosine, digoxin | Adenosine goes as a rapid IV push over 1 to 2 seconds into the port closest to the heart, immediately followed by a fast saline flush; it causes a brief asystolic pause — warn the client and have the crash cart nearby. Digoxin: apical pulse for a full minute, hold if under 60, therapeutic level 0.5 to 2 ng/mL. |
| ACE inhibitors and ARBs (heart failure and post-MI) | Block the RAAS to unload the failing heart and slow remodeling after an MI. | captopril, lisinopril, enalapril (ACE); losartan, valsartan (ARB) | Dry hacking cough with an ACE inhibitor is the reason to switch to an ARB. Both cause hyperkalemia and angiedema and are contraindicated in pregnancy. Captopril is taken on an empty stomach, 1 hour before meals. |
| Nitrates and other antianginals | Dilate coronary and systemic vessels or reduce myocardial workload. | nitroglycerin (SL, patch, IV), isosorbide mononitrate/dinitrate, ranolazine | Sublingual nitroglycerin: take one tablet, and if the pain is not relieved after that FIRST dose, call 911; the dose may be repeated every 5 minutes up to 3 tablets total. Headache is expected. Remove a nitrate patch for 10 to 12 hours daily to prevent tolerance. |
| Inotropes | Increase the force of contraction in heart failure. | digoxin, milrinone, dobutamine | Digoxin toxicity risk rises sharply with hypokalemia, so check the potassium. Milrinone is an inodilator — it drops blood pressure, so continuous BP and rhythm monitoring are required. |
| Statins | Block cholesterol synthesis in the liver; the biggest LDL reduction available. | atorvastatin, simvastatin, rosuvastatin, pravastatin | New muscle pain, tenderness, or weakness with dark cola-colored urine means rhabdomyolysis — stop the drug and check CK. Baseline liver enzymes. Avoid grapefruit with simvastatin and atorvastatin. |
| Non-statin lipid agents | Lower lipids through the gut, the liver, or triglyceride metabolism. | cholestyramine (bile acid sequestrant), ezetimibe (absorption inhibitor), gemfibrozil and fenofibrate (fibrates), niacin | Sequestrants bind other drugs — give everything else 1 hour before or 4 hours after. Fibrates plus a statin raise rhabdomyolysis risk. Niacin causes intense flushing — take aspirin about 30 minutes before and avoid hot drinks and alcohol around the dose. |
⚖️ Dihydropyridine vs non-dihydropyridine calcium channel blockers
| Dihydropyridines (-dipine) | Non-dihydropyridines |
|---|
| Amlodipine, nifedipine, nicardipine, felodipine | Verapamil, diltiazem |
| Act on the blood VESSELS — vasodilation | Act on the HEART — slow the AV node |
| Used for hypertension and vasospastic angina | Used for rate control in atrial fibrillation and SVT, and for angina |
| BP goes down; heart rate may reflexively go UP | BP goes down AND heart rate goes down |
| Watch: ankle edema, flushing, headache | Watch: bradycardia, heart block, constipation; dangerous stacked on a beta blocker |
🚨 Red flags DANGER
- Nitroglycerin plus a PDE-5 inhibitor (sildenafil, tadalafil, vardenafil) causes profound, unrecoverable hypotension. Ask every client with chest pain about these drugs before giving a nitrate.
- Digoxin toxicity: nausea and vomiting, yellow-green vision or halos, new bradycardia, confusion. Hold the dose, draw a digoxin level and a potassium, and call. Hypokalemia is the biggest risk factor.
- New dry cough or shortness of breath on amiodarone: pulmonary toxicity. Hold and call, and expect a chest x-ray.
- Muscle pain with dark urine on a statin: stop the drug and call. Rhabdomyolysis can destroy the kidneys.
- IV verapamil or diltiazem in a client already on a beta blocker can cause complete heart block or asystole. Verify with the provider.
🧵 Exam traps ⭐ HIGH YIELD
- Not every -olol behaves like a plain beta blocker. Sotalol is a class III antiarrhythmic that prolongs the QT, and carvedilol and labetalol also block alpha receptors.
- Amlodipine (vessels) and verapamil (heart) are both 'calcium channel blockers' but are not interchangeable. Only the non-dihydropyridines control heart rate.
- Digoxin is a positive inotrope with a negative chronotropic effect — it makes the heart squeeze HARDER and beat SLOWER. That is not a contradiction, it is the point.
- The nitroglycerin instruction has changed: call 911 after the FIRST unrelieved dose, then continue up to 3 tablets 5 minutes apart. Older teaching said to take all three first.
- Short-acting statins like simvastatin are dosed in the evening because cholesterol is synthesized overnight. Atorvastatin and rosuvastatin have long half-lives and can be taken any time.
- Niacin flushing is uncomfortable but is not an allergic reaction. Aspirin beforehand and avoiding hot beverages reduce it.
🧠 Ways to remember it
- Vaughan-Williams order: Some Block Potassium Channels — Sodium (I), Beta (II), Potassium (III), Calcium (IV).
- Amiodarone hits everything: lungs, liver, thyroid, eyes, skin.
- Digoxin toxicity = halos and hurling. Yellow-green vision plus vomiting.
- '-dipine dilates' the vessels. Verapamil and diltiazem 'veer to the heart.'
- Nitrates plus sildenafil = the deadly V. Always ask.
🧠 The concepts 5
What is the pharmacological treatment plan for acute coronary syndrome?🚨 DANGER
Immediate treatment of ACS is ASPIRIN (162 to 325 mg CHEWED), NITROGLYCERIN, oxygen if SpO2 is under 90%, and morphine for pain not relieved by nitrates - the classic MONA, given in the order Aspirin, Nitro, Oxygen if needed, Morphine last. Then add a P2Y12 inhibitor, an anticoagulant, a beta blocker, a high-intensity statin, and an ACE inhibitor, and arrange REPERFUSION.
- ASPIRIN FIRST AND FAST. Chewed, not swallowed whole, so it is absorbed in minutes. It is the single intervention with the largest mortality benefit. The textbook lists immediate treatment as supplemental oxygen, aspirin, and nitroglycerin.
- NITROGLYCERIN: sublingual every 5 minutes up to 3 doses, checking blood pressure before each. HOLD if systolic BP is under 90, if the heart rate is under 50 or over 100, in right ventricular/inferior MI, or if the patient has taken a PDE-5 INHIBITOR (sildenafil or vardenafil within 24 hours, tadalafil within 48) - that combination causes catastrophic hypotension.
- REPERFUSION IS THE PRIORITY IN STEMI: primary PCI within 90 minutes of first medical contact, or a fibrinolytic (alteplase, tenecteplase) within 30 minutes of arrival if PCI is not available within 120 minutes. The textbook lists thrombolytics such as tPA with heparin, angioplasty with stents, or bypass surgery.
- DUAL ANTIPLATELET THERAPY: aspirin plus a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel), continued for about 12 months after stenting. Plus an anticoagulant (heparin, enoxaparin, or bivalirudin) during the acute phase.
- Within 24 hours if no contraindication: a BETA BLOCKER (reduces oxygen demand and mortality; hold if in acute heart failure, bradycardic, or hypotensive), a HIGH-INTENSITY STATIN (atorvastatin 80 mg regardless of the lipid panel), and an ACE INHIBITOR (especially with reduced ejection fraction, anterior MI, or diabetes).
- Oxygen ONLY if SpO2 is under 90% or the patient is dyspneic. Routine oxygen in a normoxic patient may cause harm. Morphine is now last-line, for pain refractory to nitrates, because it blunts P2Y12 absorption. Nursing: continuous ECG monitoring, serial troponins and 12-lead ECGs, two large-bore IVs, bed rest, and continuous assessment for arrhythmia, heart failure, and bleeding after fibrinolytics.
| Drug | Why | Nursing catch |
|---|
| Aspirin 162-325 mg CHEWED | Antiplatelet; biggest mortality benefit | Chew it. Give it first. Ask about true aspirin allergy |
| Nitroglycerin SL q5min x3 | Vasodilation, reduces preload and chest pain | Check BP before EACH dose. NEVER with a PDE-5 inhibitor. Hold if SBP under 90 or right ventricular MI |
| Oxygen | Only if SpO2 under 90% or dyspneic | Routine oxygen in a normoxic patient can be harmful |
| Morphine | Pain and anxiety refractory to nitrates | Now last-line: monitor BP and respirations |
| P2Y12 inhibitor: ticagrelor, prasugrel, clopidogrel | Dual antiplatelet therapy | Bleeding risk; hold before CABG per protocol |
| Heparin or enoxaparin | Prevents clot extension | Monitor aPTT and platelets (HIT) |
| Beta blocker within 24 h | Lowers oxygen demand and mortality | Hold in acute decompensated HF, bradycardia, hypotension |
| High-intensity statin, ACE inhibitor | Plaque stabilization; remodeling prevention | Start regardless of the lipid panel |
| PCI within 90 min OR fibrinolytic within 30 min | REPERFUSION - the definitive treatment | Time is muscle. Screen fibrinolytics for bleeding contraindications |
MONA greets everyone, but ASPIRIN goes first and REPERFUSION is what actually saves the muscle.
Which medications cause a reduction in heart rate?⭐ HIGH YIELD
BETA BLOCKERS (metoprolol, atenolol, propranolol, carvedilol), NON-DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS (diltiazem, verapamil), DIGOXIN, AMIODARONE, ADENOSINE, and IVABRADINE. Also alpha-2 agonists (clonidine, dexmedetomidine), cholinesterase inhibitors (donepezil), and opioids.
- The first four are the ones tested: beta blockers, diltiazem and verapamil, digoxin, and amiodarone. All are negative chronotropes.
- COMBINING a beta blocker WITH diltiazem or verapamil is the classic dangerous pairing: additive bradycardia, heart block, and reduced contractility. Watch for it on a medication list.
- ADENOSINE causes a dramatic, transient asystole (a few seconds of flatline) as it converts SVT. Give it as a RAPID IV PUSH (6 mg, then 12 mg) as close to the heart as possible, immediately followed by a rapid saline flush, with the patient on a monitor and a code cart nearby. Warn the patient they will feel a moment of chest pressure and impending doom.
- DIGOXIN: take an APICAL pulse for a FULL MINUTE and HOLD for a rate under 60 in adults (under 70 in children, under 90 to 110 in infants). Toxicity signs are nausea, vomiting, anorexia, visual changes (yellow-green halos), confusion, and arrhythmias. HYPOKALEMIA potentiates toxicity. Antidote is digoxin immune Fab (DigiFab).
- Before giving ANY of these: check the apical heart rate and blood pressure and hold per parameters. The standard hold is HR under 60.
- IVABRADINE slows the SA node only, without affecting contractility or blood pressure. It is used in heart failure when the heart rate stays above 70 on a maximally tolerated beta blocker. Non-drug causes of bradycardia to consider in the differential: increased intracranial pressure, hypothyroidism, hypothermia, hyperkalemia, athletic conditioning, and vagal stimulation (suctioning, straining, vomiting).
Beta blockers, dilTIAZem and verapamil, digoxin, amiodarone, adenosine. Apical pulse, full minute, hold under 60.
What are the treatment options for atrial fibrillation?⭐ HIGH YIELD
Three goals: RATE control (beta blocker, diltiazem or verapamil, digoxin), RHYTHM control (amiodarone, flecainide, propafenone, sotalol, dofetilide, or electrical cardioversion/ablation), and ANTICOAGULATION to prevent stroke (a DOAC such as apixaban or rivaroxaban, or warfarin), based on the CHA2DS2-VASc score.
- ANTICOAGULATION IS THE PART THAT SAVES LIVES. Blood pools in the fibrillating atria, forms clot, and embolizes to the brain. Rate control makes the patient feel better; anticoagulation prevents the stroke.
- CHA2DS2-VASc scores stroke risk: Congestive heart failure, Hypertension, Age 75+ (2 points), Diabetes, prior Stroke/TIA (2 points), Vascular disease, Age 65-74, Sex category female. A score of 2 or more in men, or 3 or more in women, means anticoagulate.
- DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin for most patients: no routine monitoring, fewer food and drug interactions, less intracranial bleeding. WARFARIN is still required for mechanical heart valves and moderate-to-severe mitral stenosis.
- THE CARDIOVERSION RULE: if the atrial fibrillation has lasted MORE THAN 48 HOURS or the duration is unknown, the patient needs 3 weeks of therapeutic anticoagulation before cardioversion, or a transesophageal echocardiogram to rule out atrial thrombus. Then anticoagulate for at least 4 weeks after. Cardioverting a clot-filled atrium throws a stroke.
- Rate control targets a resting ventricular rate under about 100 to 110. Digoxin is a weak rate-control agent that works at rest but not with activity; it is used in heart failure or when the blood pressure will not tolerate a beta blocker or CCB. AMIODARONE is the most effective rhythm-control drug but the most toxic: pulmonary fibrosis, hepatotoxicity, thyroid dysfunction (both hyper and hypo), corneal deposits and vision loss, blue-gray skin discoloration, photosensitivity, and heart block. It requires baseline and periodic chest imaging, LFTs, TSH, and eye exams, and it raises digoxin and warfarin levels.
- UNSTABLE atrial fibrillation (hypotension, altered mental status, chest pain, acute heart failure) means IMMEDIATE SYNCHRONIZED CARDIOVERSION, not drugs. Long-term definitive options are catheter ablation and left atrial appendage occlusion.
| Goal | Options |
|---|
| Rate control | Beta blockers (metoprolol, esmolol); diltiazem or verapamil; digoxin (in HF or hypotension) |
| Rhythm control | Amiodarone, flecainide, propafenone, sotalol, dofetilide; synchronized cardioversion; catheter ablation |
| Anticoagulation (stroke prevention) | DOACs: apixaban, rivaroxaban, dabigatran, edoxaban. Warfarin (INR 2-3) for mechanical valves or mitral stenosis |
| UNSTABLE patient | IMMEDIATE synchronized cardioversion |
Rate, Rhythm, Ribbon-thin blood. The anticoagulant is what prevents the stroke.
Review the definitions of inotropy and chronotropy. Identify examples of positive chronotropes, negative chronotropes, positive inotropes, and negative inotropes.⭐ HIGH YIELD
INOTROPY is the FORCE of contraction; CHRONOTROPY is the RATE. POSITIVE INOTROPES: digoxin, dobutamine, dopamine, epinephrine, milrinone. NEGATIVE INOTROPES: beta blockers, diltiazem, verapamil. POSITIVE CHRONOTROPES: atropine, epinephrine, dopamine, isoproterenol. NEGATIVE CHRONOTROPES: beta blockers, diltiazem, verapamil, digoxin, amiodarone, adenosine.
- DIGOXIN IS THE ONE TO REMEMBER because it splits: POSITIVE inotrope (harder squeeze) but NEGATIVE chronotrope (slower rate). That combination is exactly what heart failure with atrial fibrillation needs.
- Beta blockers and non-dihydropyridine CCBs are negative on BOTH counts, which is why they are held for bradycardia and hypotension, avoided together, and avoided in acute decompensated heart failure.
- Cardiac output = heart rate x stroke volume. Positive inotropes raise the stroke volume side. Positive chronotropes raise the rate side. Push either one too far and myocardial oxygen demand outruns supply.
- DOBUTAMINE is the pure inotrope of cardiogenic shock: it increases contractility and cardiac output but can LOWER blood pressure through beta-2 vasodilation, so it is often paired with a vasopressor.
- ATROPINE is the first-line positive chronotrope for symptomatic bradycardia (1 mg IV, repeat every 3 to 5 minutes to a maximum of 3 mg), followed by transcutaneous pacing, dopamine, or epinephrine.
- MILRINONE is a phosphodiesterase-3 inhibitor: an 'inodilator' that increases contractility AND vasodilates, used in acute decompensated heart failure. It causes hypotension and arrhythmias. In heart failure, chronic beta blockade is beneficial despite being a negative inotrope, because it protects the heart from chronic sympathetic overdrive. Start LOW and titrate SLOWLY, and never start a beta blocker during acute decompensation.
| POSITIVE (increases) | NEGATIVE (decreases) |
|---|
| INOTROPY (force) | digoxin, dobutamine, dopamine, epinephrine, norepinephrine, milrinone, calcium | beta blockers, diltiazem, verapamil, flecainide, high-dose propofol |
| CHRONOTROPY (rate) | atropine, epinephrine, dopamine, isoproterenol, dobutamine, theophylline | beta blockers, diltiazem, verapamil, DIGOXIN, amiodarone, adenosine, ivabradine, clonidine |
Digoxin: squeezes HARDER, beats SLOWER. Everything that slows the rate also weakens the squeeze, except digoxin.
Compare dihydropyridine and non-dihydropyridine calcium channel blockers. Identify examples of medications in each class.⭐ HIGH YIELD
DIHYDROPYRIDINES (the -DIPINES: amlodipine, nifedipine, felodipine, nicardipine, clevidipine) are VASCULAR-selective: they dilate arteries to lower blood pressure and have little effect on the heart. NON-DIHYDROPYRIDINES (verapamil and diltiazem) are CARDIAC-selective: they slow the heart rate, slow AV conduction, and reduce contractility.
- That difference drives every clinical decision. If you want to lower blood pressure, reach for a -dipine. If you want to slow the ventricular rate in atrial fibrillation or SVT, reach for diltiazem or verapamil.
- The textbook's version: calcium channel blockers treat hypertension because they relax smooth muscle and cause vasodilation, and they treat arrhythmias because they increase the refractory period of the AV node, decreasing the ventricular response and the heart rate. Diltiazem is indicated for angina, hypertension, and supraventricular tachycardias.
- DIHYDROPYRIDINE side effects come from vasodilation: PERIPHERAL EDEMA (especially ankles, and it does NOT respond to diuretics), headache, flushing, dizziness, and REFLEX TACHYCARDIA. Short-acting immediate-release nifedipine is avoided in hypertension because the reflex tachycardia can precipitate an MI.
- NON-DIHYDROPYRIDINE side effects come from cardiac suppression: bradycardia, AV block, hypotension, and worsening heart failure (the textbook notes diltiazem can worsen heart failure because of its negative inotropic effect). VERAPAMIL causes severe CONSTIPATION.
- DO NOT COMBINE a non-dihydropyridine with a beta blocker: additive bradycardia, heart block, and reduced contractility. AVOID both in heart failure with reduced ejection fraction. Amlodipine is the CCB that IS considered safe in heart failure.
- BOTH classes: avoid GRAPEFRUIT JUICE (CYP3A4 inhibition raises levels and causes hypotension), do not crush extended-release forms, check BP and apical pulse before dosing, and rise slowly. Verapamil raises digoxin levels. Nicardipine and clevidipine are IV dihydropyridines used as titratable drips for hypertensive emergency.
| Dihydropyridine (-dipine) | Non-dihydropyridine |
|---|
| amlodipine, nifedipine, felodipine, nicardipine, clevidipine, nimodipine | verapamil, diltiazem |
| Acts on VESSELS (vascular smooth muscle) | Acts on the HEART (SA and AV node, myocardium) |
| Lowers BP by vasodilation; little effect on rate | Slows heart rate, slows AV conduction, reduces contractility |
| Uses: hypertension, angina, Raynaud's; nimodipine for subarachnoid hemorrhage vasospasm | Uses: atrial fibrillation and SVT rate control, angina, hypertension |
| Adverse: ANKLE EDEMA, headache, flushing, REFLEX TACHYCARDIA | Adverse: bradycardia, AV block, worsening heart failure; verapamil causes CONSTIPATION |
| Amlodipine is safe in heart failure | AVOID in heart failure with reduced EF and with beta blockers |
-DIPINE dilates the PIPEs. Verapamil and diltiazem talk to the HEART.
💉 The drugs 17
💉 AdenosineHIGH ALERT
Antidysrhythmic, Endogenous nucleoside
What it is for
PSVT, as a diagnostic aid to assess myocardial perfusion defects in CAD, Wolff-Parkinson-White syndrome Unlabeled: Wide-complex tachycardia diagnosis
How it works
Slows conduction through AV node, can interrupt reentry pathways through AV node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT)
Watch for
- CNS Light headedness, dizziness, arm tingling, numbness, headache; seizures
- CV Chest pain, pressure, atrial tachydysrhythmias, sweating, palpitations, hypotension, facial flushing, AV block, cardiac arrest, ventricular dysrhythmias, atrial fibrillation
- GI Nausea, metallic taste
- RESP Dyspnea …
Teaching
- To report facial flushing, dizziness, sweating, palpitations, chest pain; usually transient; chest pressure may occur immediately after administration
- To report IV discomfort
- Pregnancy/breastfeeding: to advise prescriber if pregnancy is planned or suspected or if breastfeeding; do not breastfeed
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 AmiodaroneHIGH ALERTBLACK BOX
Antidysrhythmic (class III), Iodinated benzofuran derivative
What it is for
Hemodynamically unstable ventricular tachycardia, supraventricular tachycardia, ventricular fibrillation not controlled by first-line agents
How it works
Prolongs duration of action potential and effective refractory period, noncompetitive α- and β-adrenergic inhibition; increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular resistance
Watch for
- CNS Headache, dizziness, involuntary movement, tremors, peripheral neuropathy, malaise, fatigue, ataxia, paresthesias, insomnia, confusion, hallucinations
- CV Hypotension, bradycardia, HF, dysrhythmias
- EENT Corneal microdeposits, dry eyes
- ENDO Hypo/hyperthyroidism
- GI Nausea, vomiting, diarrhea …
Teaching
- To take this product as directed; to avoid missed doses; not to use with grapefruit juice; not to discontinue abruptly, not to use other drugs, herbs without prescriber a …
- To use sunscreen or stay out of sun to prevent burns; that dark glasses may be needed for photophobia
- To report side effects immediately; more common at high dose and longer duration
- That skin discoloration is usually reversible
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Atenolol/metoprololHIGH ALERTBLACK BOX
Antihypertensive, antianginal, β-Blocker, β1-, β2-blocker (high doses)
What it is for
Hypertension, angina pectoris; suspected or known MI (IV use); MI prophylaxis
How it works
Competitively blocks stimulation of β-adrenergic receptor within vascular smooth muscle; produces negative chronotropic activity (decreases rate of SA node discharge, increases recovery time), slows conduction of AV node …
Watch for
- CNS Insomnia, fatigue, dizziness, mental changes, memory loss, depression, lethargy, drowsiness, strange dreams
- CV Profound hypotension, bradycardia, HF
- ENDO Hypo- and hyperglycemia
- GI Nausea, diarrhea, vomiting, constipation
- GU Impotence, decreased libido, urinary frequency
- MS Back …
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 CaptoprilBLACK BOX
Antihypertensive, Angiotensin-converting enzyme (ACE) inhibitor
What it is for
Hypertension, HF, left ventricular dysfunction after MI, diabetic nephropathy, proteinuria, acute MI, hypertensive emergency/urgency,
How it works
Selectively suppresses reninangiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II
Watch for
- CNS Fever, chills, dizziness, drowsiness, fatigue, headache, insomnia, weakness
- CV Hypotension, postural hypotension, tachycardia, angina
- GI Loss of taste, increased LFTs
- GU Impotence, dysuria, nocturia, proteinuria, nephrotic syndrome, acute reversible renal failure, polyuria, oliguria …
Teaching
- To take 1 hr prior to or 2 hr after meals; not to discontinue product abruptly; if dose is missed, take as soon as remembered but not if almost time for next dose; not to …
- Not to use OTC products (cough, cold, or allergy) unless directed by prescriber; to avoid salt substitutes, high-potassium or high-sodium foods
- To adhere to dosage schedule, even if feeling better
- To use cautiously in hot weather, make sure fluids are adequate
🔗 Full card in the drug guide
💉 Digoxin (What are the signs/symptoms and risk factors for toxicity?)HIGH ALERT
Cardiac glycoside, inotropic, antidysrhythmic, Digoxin preparation
What it is for
Heart failure, atrial fibrillation/flutter, paroxysmal supraventricular tachycardia (PSVT) treatment/prophylaxis
How it works
Inhibits the sodium-potassium ATPase pump, which makes more calcium available for contractile proteins, thereby resulting in increased cardiac output (positive inotropic effect); increases force of contractions …
Watch for
- CNS Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations
- CV Dysrhythmias, hypotension, bradycardia, AV block
- EENT Blurred vision, yellow-green halos, photophobia, diplopia
- GI Nausea, vomiting, anorexia, abdominal pain, diarrhea
Teaching
- Not to stop product abruptly; about all aspects of product; to take exactly as ordered; how to monitor heart rate
- To avoid OTC medications, herbal remedies because many adverse product interactions may occur; not to take antacid within 2 hr of this product
- To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity
- About the toxic symptoms of this product; when to notify prescriber
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 LosartanBLACK BOX
Antihypertensive, Angiotensin II receptor (type AT1) antagonist
What it is for
Hypertension, alone or in combination; nephropathy in type 2 diabetes; proteinuria; stroke prophylaxis for hypertensive patients with left ventricular hypertrophy
How it works
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II; selectively blocks the binding of angiotensin II to the AT1 receptor found in tissues
Watch for
- CNS Dizziness, insomnia, anxiety, confusion, abnormal dreams, migraine, tremor, vertigo, headache, malaise, depression, fatigue
- CV Angina pectoris, 2nd-degree AV block, cerebrovascular accident, hypotension, MI, dysrhythmias
- EENT Blurred vision, burning eyes, conjunctivitis
- GI Diarrhea …
Teaching
- To avoid sunlight or to wear sunscreen if in sunlight; that photosensitivity may occur
- To comply with dosage schedule, even if feeling better; not to discontinue abruptly; not to share with others
- To notify prescriber of mouth sores, fever, swelling of hands or feet, irregular heartbeat, chest pain
- That excessive perspiration, dehydration, vomiting, diarrhea may lead to fall in B/P; to consult prescriber if these occur
🔗 Full card in the drug guide
💉 MilrinoneHIGH ALERT
Inotropic/vasodilator agent, Bipyridine phosphodiesterase inhibitor
What it is for
Short-term management of advanced heart failure that has not responded to other medication
How it works
Positive inotropic agent; increases contractility of cardiac muscle with vasodilator properties; reduces preload and afterload by direct relaxation on vascular smooth muscle
Watch for
- CNS Headache
- CV Ventricular dysrhythmias, hypotension, chest pain, PVCs, palpitations, angina, ventricular tachycardia
- HEMA Thrombocytopenia
- MISC Inj site reactions
Teaching
- To report angina, palpitations immediately during infusion
- To report headache, which can be treated with analgesics
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Nifedipine/amlodipine
Calcium channel blocker, antianginal, antihypertensive, Dihydropyridine
What it is for
Chronic stable angina pectoris, variant angina, hypertension
How it works
Inhibits calcium ion influx across cell membrane during cardiac depolarization; relaxes coronary vascular smooth muscle; dilates coronary arteries; increases myocardial oxygen delivery in patients with vasospastic angina …
Watch for
- CNS Headache, fatigue, drowsiness, dizziness, anxiety, depression, weakness, insomnia, light-headedness, paresthesia, tinnitus, blurred vision, nervousness, tremor, flushing
- CV Dysrhythmias, edema, hypotension, palpitations, tachycardia
- GI Nausea, vomiting, diarrhea, gastric upset, constipation …
Teaching
- To avoid hazardous activities until stabilized on product, dizziness is no longer a problem
- To limit caffeine consumption; to avoid alcohol products
- To avoid OTC products unless directed by prescriber; give without regard to meals, not to use with grapefruit juice
- That empty tab shells may appear in stools and are not significant
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Nitroglycerin
Antianginal, Nitrate, vasodilator
What it is for
Acute angina and prevention of angina; acute coronary syndrome and MI; heart failure with pulmonary congestion; hypertension during surgery.
How it works
Turns into nitric oxide in the vessel wall, which relaxes smooth muscle. Veins dilate first, so less blood comes back to the heart — preload drops and the heart has less work to do. At higher levels arteries dilate too, and it opens the coronary arteries directly.
Watch for
- CNS Headache (very common, expected, and a sign it is working), dizziness, fainting.
- CV Hypotension, reflex tachycardia, flushing.
- GI Nausea, vomiting.
- INTEG Contact dermatitis under a patch.
- MISC Tolerance with continuous use.
Teaching
- Sit or lie down before taking it — it drops blood pressure and people faint standing up.
- Sublingual tablet: one dose, then call 911 if the pain is not gone in five minutes, then up to two more doses five minutes apart while help is coming. Newer teaching calls EMS after the first dose.
- A tingling or burning under the tongue and a headache mean the tablet is still potent. No headache at all can mean the supply has gone stale.
- Store sublingual tablets in the original glass bottle, tightly capped, away from heat and light, and honor the expiration date. Older nursing teaching says replace six months after opening.
🔗 Full card in the drug guide
💉 ProcainamideHIGH ALERTBLACK BOX
Antidysrhythmic (class IA), Procaine HCl amide analog
What it is for
Life-threatening ventricular dysrhythmias
How it works
Depresses excitability of cardiac muscle to electrical stimulation and slows conduction velocity in atrium, bundle of His, and ventricle; increases refractory period
Watch for
- CNS Headache, dizziness, confusion, psychosis, restlessness, irritability, weakness, depression
- CV Hypotension, heart block, cardiovascular collapse, arrest, torsades de pointes
- GI Nausea, vomiting, anorexia, diarrhea, hepatomegaly, pain, bitter taste
- HEMA SLE syndrome, agranulocytosis …
Teaching
- That wax matrix may appear in stools
- Not to discontinue without provider’s approval
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Ranolazine
Antianginal, Piperazine derivative
What it is for
Chronic angina pectoris
How it works
Antianginal, antiischemic; unknown, may work by inhibiting portal fatty-acid oxidation
Watch for
- CNS Headache, dizziness, hallucinations
- CV Palpitations, QT prolongation, orthostatic hypotension
- EENT Tinnitus
- GI Nausea, vomiting, constipation, dry mouth
- MISC Peripheral edema
- RESP Dyspnea
Teaching
- To avoid hazardous activities until stabilized on product, dizziness no longer a problem
- To avoid OTC drugs, grapefruit juice, products prolonging QTc (quiNIDine, dofetilide, sotalol, erythromycin, thioridazine, ziprasidone or protease inhibitors, diltiaZEM, …
- To comply with all areas of medical regimen
- To take as directed; not to skip dose, not to double dose
🔗 Full card in the drug guide
💉 Verapamil/diltiazemHIGH ALERT
Calcium channel blocker; antihypertensive; antianginal, antidysrhythmic (class IV), Diphen
What it is for
Chronic stable, vasospastic, unstable angina; dysrhythmias, hypertension, supraventricular tachycardia, atrial flutter or fibrillation Unlabeled uses: Prevention of migraines
How it works
Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle; dilates coronary arteries; decreases SA/AV node conduction; dilates peripheral arteries
Watch for
- CNS Headache, drowsiness, dizziness, anxiety, depression, weakness, insomnia, confusion, light-headedness, asthenia, fatigue
- CV Edema, HF, bradycardia, hypotension, palpitations, AV block, dysrhythmias
- GI Nausea, diarrhea, gastric upset, constipation, increased LFTs
- GU Impotence, gynecomastia …
Teaching
- To increase fluids, fiber to counteract constipation
- How to take pulse, B/P before taking product; to keep record or graph
- To avoid hazardous activities until stabilized on product, dizziness no longer a problem
- To limit caffeine consumption; to avoid alcohol products
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Atorvastatin
Antilipidemic, HMG-CoA reductase inhibitor (statin)
What it is for
As adjunct for primary hypercholesterolemia (types Ia, Ib), elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol, heterozygous familial hypercholesterolemia in pediatric patients …
How it works
Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis; high doses lead to plaque regression
Watch for
- CNS Headache, asthenia, insomnia
- EENT Lens opacities
- GI Abdominal cramps, constipation, diarrhea, flatus, heartburn, dyspepsia, liver dysfunction, pancreatitis, nausea, increased serum transaminase
- GU Impotence, UTI
- INTEG Rash
- MISC Hypersensitivity …
Teaching
- That compliance is needed for positive results to occur, not to skip or double doses
- That blood work and eye exam will be necessary during treatment
- To report blurred vision, severe GI symptoms, headache, muscle pain, and weakness; to avoid alcohol
- That previously prescribed regimen will continue: low-cholesterol diet, exercise program, smoking cessation
🔗 Full card in the drug guide
💉 Cholestyramine
Antilipemic, Bile acid sequestrant
What it is for
Primary hypercholesterolemia (esp. type IIa/IIb hyperlipoproteinemia), pruritus associated with biliary obstruction
🔗 Full card in the drug guide
💉 Ezetimibe
Antilipemic; cholesterol absorption inhibitor
What it is for
Hypercholesterolemia, homozygous familial hypercholesterolemia (HoFH), homozygous sitosterolemia
How it works
Inhibits absorption of cholesterol by the small intestine, causes reduced hepatic cholesterol stores
Watch for
- CNS Fatigue, dizziness, headache
- GI Diarrhea, abdominal pain
- MISC Chest pain
- MS Myalgias, arthralgias, back pain, myopathy, rhabdomyolysis
- RESP Pharyngitis, sinusitis, cough, URI
- EENT Sinusitis, nasopharyngitis
- SYST Angiedema
Teaching
- That compliance is needed
- That risk factors should be decreased: high-fat diet, smoking, alcohol consumption, absence of exercise
- To notify prescriber if pregnancy suspected, planned, or if breastfeeding
- To notify prescriber if unexplained weakness, muscle pain present
🔗 Full card in the drug guide
💉 Gemfibrozil
Antilipemic, Fibric acid derivative
What it is for
For use as an adjunct to diet for the treatment of hyperlipoproteinemia and for hypertriglyceridemia including type IV (elevated triglycerides, VLDL) and type V (elevated triglycerides, chylomicrons …
How it works
Inhibits biosynthesis of VLDL, decreases triglycerides, production in the liver increases HDL
Watch for
- CNS Fatigue, vertigo, headache, paresthesia, dizziness
- GI Dyspepsia, diarrhea, abdominal pain, nausea, vomiting
- HEMA Leukopenia, anemia, eosinophilia, thrombocytopenia
- INTEG Rash, urticaria, pruritus
- MS Myopathy, rhabdomyolysis
Teaching
- That compliance is needed for positive results; not to double or skip dose, to take missed dose as soon as remembered unless almost time for next dose
- To minimize risk factors: high-fat diet, smoking, alcohol consumption, absence of exercise
- To notify prescriber of diarrhea, nausea, vomiting, chills, fever, sore throat, muscle cramps, abdominal cramps, severe flatulence, tendon pain
- To avoid driving, hazardous activities if dizziness, blurred vision occur
🔗 Full card in the drug guide
💉 Niacin (vitamin B3/nicotinic acid)
Vit B3, antihyperlipidemic, Water-soluble vitamin
What it is for
Pellagra, hyperlipidemias (types 4, 5), peripheral vascular disease that presents a risk for pancreatitis
🔗 Full card in the drug guide
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Where this came from. The drug cards come from your own drug guide, fact-checked against FDA labeling. The explanations were written from your course textbook,
Pharmacology (WTCS, 2e). If anything here contradicts your instructor, believe your instructor — they write the exam.