DRUGS ACTING ON

CARDIOVASCULAR SYSTEM
DRUGS AFFECTING BLOOD PRESSURE
CARDIOTONIC DRUGS
ANTIARRHYTHMIC DRUGS
LIPID LOWERING DRUGS
DRUGS AFFECTING BLOOD COAGULATION
DRUGS USED TO TREAT ANEMIA

DRUGS ACTING ON CARDIOVASCULAR SYSTEM

Antihypertensive Agents
Antihypotensive Agents

DRUGS AFFECTING BLOOD PRESSURE

Increase in BP
Essential hypertension – 90%
Secondary hypertension – 10%

HYPERTENSION
 REGULATORS OF BLOOD PRESSURE

Kidneys
Blood vessels
Hormones
 REGULATORS OF BLOOD PRESSURE

KIDNEYS
control fluid volume
Renin-Angiotensin-Aldosterone system (RAAS)
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
BARORECEPTORS
CATECHOLAMINES
increase BP through VASOCONSTRICTION
activity
Norepinephrine - released from the
sympathetic nerve terminals
Epinephrine – released from the adrenal
medulla

HORMONES
ANTIDIURETIC HORMONE
produced by the hypothalamus and is stored
and released by the posterior pituitary gland
stimulates the kidneys to conserve and retain
water when there is fluid volume deficit

HORMONES
HORMONES
BRAIN NATRIURETIC PEPTIDE
is a hormone secreted by
cardiomyocytes in the heart ventricles
in response to stretching ventricular
volume

HORMONES
 ACCORDING TO JNC
2 out of 3 patients with hypertension have
uncontrolled BP or not optimally treated…
CVD risks doubles with each increase of
20/10 mm Hg starting at 115/75
2017 GUIDELINES FOR HYPERTENSION
STEP 1:
• Lifestyle modification
STEP 2:
• continue step 1; add one agent (diuretic, Ca Channel
Blockers, ACE inhibitors, Beta-blockers)
STEP 3:
• continue Step 1;add or change another agent
(Adrenergic Blocking Agents)
STEP 4:
• continue step 1; add or change another agent (Direct
vasodilator)

STEPPED-CARE APPROACH FOR HYPERTENSION

exercise
reduction of stress
cessation of smoking
loss of excess weight
restriction of sodium
decrease in alcohol consumption

NONPHARMACOLOGICAL
CONTROL OF HYPERTENSION
1.Diuretics
2.Sympatholytics (Sympathetic depressants)
3.Direct-acting arteriolar vasodilators
4.ACE inhibitors
5.Angiotensin II Receptor Blockers (ARBs)
6.Calcium Channel Blockers

ANTIHYPERTENSIVES
Effective first line drugs for treating mild
hypertension
Promote sodium depletion, which
decreases ECF volume

DIURETICS
DIURETICS
ACTIONS:
• increase sodium and water excretion
• decrease cardiac output
• decrease peripheral vascular resistance
(PVR): a resistance to the flow of blood
determined by the tone of systemic vascular
musculature and the diameter of the blood
vessels.
CLASSIFICATIONS:
thiazide
loop diuretics
Potassium-sparing
*Carbonic anhydrase inhibitors
(acetazolamide)

DIURETICS
Actions:
• inhibit sodium and chloride reabsorption in the
distal tubule and lower peripheral vascular
resistance.
Major S/E:
 orthostatic hypotension
 electrolyte imbalance – Hypokalemia
 anorexia, N/V – due to electrolytes loss
 glucose intolerance – High glucose levels
 dry mouth, thirst

THIAZIDE AND THIAZIDE-LIKE AGENTS

Interactions:
• Decreased excretion of lithium – could cause
toxicity
• Increased dysrhythmias with DIGITALIS in the
presence of hypokalemia
• Increased potassium loss with corticosteroids
and some penicillin
• Orthostatic hypotension if taken with alcohol
or other hypotensive agents
• Hyponatremia and hyperglycemia which may
be caused by oral hypoglycemic and insulin

THIAZIDE AND THIAZIDE-LIKE AGENTS

• Nursing Implications
• Check for allergies to sulfonamides
• Monitor for glucose and potassium levels
• Monitor closely in the presence of renal or liver
dysfunction
• Common Drugs
• Chlorothiazide (Diuril)
• Hyrdorchlorothiazide (Esidrix, HydroDiuril)

THIAZIDE AND THIAZIDE-LIKE

AGENTS
LOOP DIURETICS
ACTIONS:
• Block the reabsorption of Na in the loop of
henle (the descending loop where the
greatest Na reabsorption normally occurs)

LOOP DIURETICS
MAJOR SIDE EFFECTS;
• Increased electrolyte depletion because of its
potency – hypokalemia
• Excessive diuresis which could lead to circulatory
collapse
• High doses: transient hearing loss, abdominal pain
• Leukopenia: abnormal decrease in WBC
(<5,000/mm3)
• Thrombocytopenia: reduction in platelets to
<150,000/mm3)
• Postural hypotension
 LOOP DIURETICS
INTERACTIONS:
• Hypotension with alcohol
• Toxicity with lithium
• GI bleeding with anticoagulants
• Toxicity with digitalis (cardiac glycoside)
• Hyponatremia with oral hypoglycemic
• Hypertension with NSAIDs
• NURSING IMPLICATIONS:
• Schedule the last dose early enough to prevent nocturia
• Assess allergies to sulfonamides – they are chemically
related
• Teach the client to do the following:
• Consume K+ rich foods
• Report muscle cramps, which are usually in calves of
the legs especially at night
• Assess for dehydration, especially in older adults
• Caution client about switching brands without
physician consent – this may change bioavailability
and the clinical effects.

LOOP DIURETICS
 LOOP DIURETICS

•Common Drugs:
• Furosemide (Lasix)
• Ethacrynate Na (Edecrin)
• Bumetanide (Bumex)
ACTIONS:
• Inhibit the pump system that normally exchanges
potassium for sodium in the distal convoluted
tubule.
• Spironolactone (Aldactone) – antagonizes
aldosterone, which mediates Na and K exchange.
This mechanism reduces Na reabsorption while
retaining K.
• Other drugs within this class produce the same
effects as spironolactone (aldactone) but do not
depend on aldosterone.

POTASSIUM-SPARING AGENTS
• MAJOR SIDE EFFECTS:
• Hyperkalemia if used with high-potassium diet
or supplements
• Hypotension
• GI upset: N/V, diarrhea, abdominal cramps
• Weakness, fatigue
• Paresthesia (numbness or tingling) of the
hands and feet
• Megaloblastic anemia

POTASSIUM SPARING AGENTS

 POTASSIUM SPARING AGENTS

• INTERACTIONS:
• Hyperkalemia with K supplements
• Toxicity with lithium
• Nephrotoxicity with Indocin
• NURSING IMPLICATIONS:
• Teach that high-potassium diet is contraindicated
• Monitor other medications for potassium sources
• Frequently monitor CBC (Complete Blood Count) –
anemia
• Teach the client the symptoms of hyperkalemia and to
report these as soon as noticed
• Keep tablets stored in a dark container
• Asses K levels closely if patient is receiving blood. Blood
can contain > 30mEq of K/Liter when stored.
• COMMON DRUGS:
• Spironolactone (Aldactone)
• Amiloride Hydrochloride (Midamor)
SYMPATHOLYTICS (SYMPATHETIC
DEPRESSANTS)
 ANTIHYPERTENSIVE

Beta adrenergic blockers / beta blockers

ACTIONS:
• Inhibit sympathetic stimulation, which lowers
heart rate and decreases cardiac output
and lower BP
• Often used in combination with a diuretic

BETA ADRENERGIC BLOCKERS (BETA BLOCKERS)

MAJOR SIDE EFFECTS:
CV: hypotension, bradycardia
Bronchospasm
Fatigue
Edema – gain weight
Beta blocker blues: decreased libido

BETA BLOCKERS
NURSING IMPLICATIONS:
• Monitor BP and pulse before, during,
and after therapy. If the apical pulse is
below 60 for a full minute, refer to the
physician.
• Assess other medications the client is
taking. Avoid administering at the same
time as antacids (wait 1 to 2 hours),
calcium blockers or cardiac glycosides
• Use cautiously in clients with Chronic
Airway Limitations
BETA ADRENERGIC BLOCKERS (BETA BLOCKERS)
Client teaching:
Do not abruptly withdraw the medication without
consulting the physician first – abrupt withdrawal
may result in angina
Take the medication at the same time each day
If a dose is forgotten, do not double dose
Report any side effects to the physician
Do not take hot baths, sit in hot tubs, or be
exposed to the hot sun for long periods
Monitor the pulse / CR at the same time daily –
count for 1 full minute
BETA BLOCKERS
• INTERACTIONS:
• Increased potential for bradycardia with concurrent use
of cardiac glycoside and calcium channel blockers and
an increased hypotensive effect with diuretics.
• COMMON DRUGS (these drugs end in “lol”)
• Propranolol hydrochloride (Inderal)
• Nadolol (Corgard)
• Metoprolol Tartrate (Lopressor)
• Atenolol (Tenormin)
• Pindolol (Viskin)
• Timolol Maleate (Blocarden)

BETA ADRENERGIC BLOCKERS (BETA

BLOCKERS)
• ACTIONS:
• Inhibit release of intracellular calcium, which
decreases the force of contraction and prevents
entry of calcium ions into smooth muscles – this
lowers arteriole constriction, thereby lowering PVR
and decreasing BP.
• USES: mild to moderate hypertension – alone or
in combination with diuretics

CALCIUM CHANNEL BLOCKERS

 CALCIUM CHANNEL BLOCKERS

• MAJOR SIDE EFFECTS:

• Hypotension
• Bradycardia
• Worsening CHF
• Dyspnea
• Wheezing
INTERACTIONS:
• Increased effects if taken with a beta blocker

NURSING IMPLICATIONS:
• Monitor BP, PR before during and after
administration.
• Watch out for bradycardia
• Administer these medications with meals
• Monitor renal status: urine output
CALCIUM CHANNEL BLOCKERS
 CALCIUM CHANNEL BLOCKERS

• COMMON DRUGS:
• Diltiazem hydrochloride (Cardizem)
• Felodipine (Plendil)
• Nicardipine HCl (Cardene)
• Nifedipine (Procardia)
• Verapamil HCl (Calan, Isoptin)
ACTIONS:
• Intrerrupt the renin-angiotensin-aldosterone
system
 Inhibit conversion of angiotensin I to angiotensin II
 Decrease aldosterone secretion
 Compete with angiotensin II to block its effect
(Angiotensin II Receptor Blockers)

• USES: mild to moderate hypertension

ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN

CONVERTING ENZYME INHIBITORS OR ACE INHIBITORS)
RENIN-ANGIOTENSIN-
ALDOSTERON SYSTEM
(RAAS)
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)
MAJOR SIDE EFFECTS:
• Chest pain
• Palpitations
• Hypotension
• Tachycardia
• Proteinuria: large quantities of protein in the urine
• Rash
• Neutropenia: abnormal decrease in the number of
neutrophils in the blood
• Agranulocytosis: reduction in the number of granulocytes
• Hyperkalemia: potassium > 5.0 mEq/L
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)

NURSING IMPLICATIONS:
• Monitor CBC and K levels
• Assess for signs of infection
• Check BP daily and keep a monthly log as needed
• Instruct client to:
 Inform any new physician about the medication taken
 Avoid excess intake of foods rich in potassium and
potassium supplements
 Do not abruptly stop taking the medication
 Avoid OTC drugs without the approval of the physician
 Take medication on an empty stomach
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)

COMMON DRUGS (drugs usually ending in “ril”)

• Captopril (Capoten)
• Enalapril maleate (Vasotec)
• Ramipril (Altace)
• Benazepril hydrochloride (Lotensin)
• Losartan
• Candesartan
• Eprosartan
• Losartan
• Olmesartan
• Telmisartan
• Valsartan
Angiotensin II Blockers (angiotensin II
receptor blockers)
• GROUPS OF DRUGS WITHIN THIS CLASS
• CENTRALLY ACTING ADRENERGIC AGENTS
• GANGLIONIC BLOCKERS
• ALPHA ADRENERGIC BLOCKING AGENTS
• PERIPHERALLY ACTING ANTIADRENERGIC AGENTS

• ACTIONS: INHIBIT stimulation of the SYMPATHETIC NERVOUS

SYSTEM, which causes a DROP IN BP from peripheral
VASODILATION or DECREASED CARDIAC OUTPUT.

ADRENERGIC BLOCKING AGENTS

USES: moderate to severe essential hypertension
COMMON DRUGS:
• Centrally acting adrenergic agents
Methyldopa (aldomet)
Quanfacine (Tenex)
Guanabenz acetate (Wytensin)
Clonidine hydrochloride (catapres)
• Ganglionic blockers
Mecamylamine hydrochloride (Invesine)
Trimethaphan camsylate (Arfonad)

ADRENERGIC BLOCKING AGENTS

Ganglionic blockers - inhibits transmission
between preganglionic and postganglionic neurons in the Autonomic Nervous
System
• Prevents response to sympathetic stimulation to the blood vessels – vasodilation
ALPHA ADRENERGIC BLOCKERS
•PRAZOSIN hydrochloride (minipress)
•Phentolamine (regitine)
PERIPHERALLY ACTING ANTIADRENERGIC
AGENTS
•Reserpine (Serpalan)
•TERAZOSIN (Hytrin)
ADRENERGIC BLOCKING AGENTS
PRAZOSIN AND TERAZOSIN – BPH
MAJOR SIDE EFFECTS:
•Postural hypotension
•Bradycardia
NURSING IMPLICATIONS
•Monitor BP and HR
•Instruct client to change position slowly

ADRENERGIC BLOCKING AGENTS

• ACTIONS:
• RELAX ARTERIOLAR SMOOTH MUSCLE, DILATE
ARTERIES and DECREASE PERIPHERAL
VASCULAR RESISTANCE
• USES: moderate to severe hypertension and
hypertensive crisis

DIRECT VASODILATING AGENTS

MAJOR SIDE EFFECTS:
• Headache, N/V
• Sodium retention
• Rebound hypertension
• Increased workload of the heart:
tachycardia, palpitations.

DIRECT VASODILATING AGENTS

• NURSING IMPLICATIONS:
• Monitor VS q 5 to 15 minutes – do not leave
patient unmonitored
• Monitor I and O
• Do not mix with other drugs
• Since sodium nitroprusside (Nipride) must be
protected from light, wrap IV bag and
tubings with foil
• Use microdrip tubing
DIRECT VASODILATING AGENTS
• COMMON DRUGS:
• Sodium nitroprusside (Nipride)
• Hydralazine Hcl (Apresoline)
• Diazoxide (Hyperstat)
• Guanethidine Sulfate (Ismelin)

DIRECT VASODILATING AGENTS

• Monitor baseline BP and pulse before, during and
after therapy
• Monitor I and O, renal function
• Encourage lifestyle change
• Teach client to report edema, cough and weight
gain (> 2 lbs/week)
• Stress need to comply with taking the BP and
medication
• Stress the need to avoid all OTC products unless
physician has been consulted
GENERAL IMPLICATIONS FOR ANTIHYPERTENSIVES
Sympathetic Adrenergic Agonists – first choice in
treating SHOCK
• Drugs react with sympathetic adrenergic
receptors to cause the effects of a
sympathetic stress response: increased BP,
increased blood volume and increase
strength of muscle contraction
• Used to treat severe hypotension and shock

ANTIHYPOTENSIVE AGENTS
Common drugs
• Dobutamine
• Dopamine
• Epinephrine

ANTIHYPOTENSIVE AGENTS
• A drug used to treat orthostatic hypotension
• Activates ALPHA RECEPTORS in arteries and
veins to produce an INCREASE in
VASCULAR TONE and an INCREASE in
BLOOD PRESSURE.

MIDODRINE
 Contraindications:
• Pheochromocytoma • Urinary retention –
– could precipitate can be
hypertensive crisis exacerbated
• Acute renal disease because of
– interfere with sympathetic
excretion stimulation
• Thyrotoxicosis

MIDODRINE
 MIDODRINE

CAUTION
• Pregnancy and lactation
• Visual problems
• Renal and hepatic impairment
ADVERSE EFFECTS
• Piloerection
• Chills and rash
• Hypertension
• BRADYCARDIA
• Dizziness
• Vision changes
• Headache
• Problems in urination

MIDODRINE
 INTERACTIONS:

• Increased risk of toxicity of cardiac

glycosides, beta-blockers, alpha-
adrenergic agents, and corticosteroid if
taken with midodrine
NURSING IMPLICATIONS:
• Monitor BP, HR carefully
• Monitor patients with known visual problems
carefully
• Encourage patient to VOID before taking a
dose of the drug to decrease the risk of
urinary retention problems
MIDODRINE