Pharm7e-Ch10-Presentation

[Audio] Welcome to the Pharmacology for Technicians Seventh Edition Watch and Learn Lessons!.

[Audio] Chapter 10, The Cardiovascular System and Drug Therapy.

[Audio] In this chapter you will learn about the anatomy and physiology of the cardiovascular system. In the hypertension and drug treatments section, you will learn about drug classes used to treat hypertension. In addition, you will discover the multiple therapeutic indications for these drugs. In the cardiac arrythmias and drug treatments section, you will get an overview of agents commonly used to treat cardiac arrhythmia. In the angina, myocardial infarction, and corresponding drug treatments section of this chapter, you will compare and contrast the drug classes used to treat angina and myocardial infarction. You will then get an overview of these agents and their descriptions..

[Audio] In the next section, the heart failure and drug treatments section, you will develop an awareness of the drugs used, how they are used, and their side effects. As you study the dyslipidemia, hypercholesterolemia, hyperlipidemia and drug treatments section, you will learn about drugs used to treat hyperlipidemia. In the clotting disorders, stroke, and drug treatments section of this chapter, you will be introduced to the drugs used to treat these conditions. You will also develop an awareness of specific antidotes for dabigatran, heparin, oral factor Xa inhibitors, and warfarin. In the last section of this chapter, complementary and alternative therapies, you'll get an overview of therapies used for disorders of the cardiovascular system..

[Audio] Chapter 10, Section 1, Anatomy and Physiology of the Cardiovascular System.

[Audio] The cardiovascular system circulates blood throughout the body and is also called the circulatory system. It brings oxygen and nutrients to tissues and carries away carbon dioxide and toxic by-products. This system is composed of the heart and various types of blood vessels. The heart pumps blood to the body through arteries and veins. An artery carries blood away from the heart to the body. A vein carries blood from tissues back to the heart. Blood takes deoxygenated blood to the lungs for gas exchange and then sends that reoxygenated blood to other tissues in the body..

[Audio] The heart is divided into four chambers: the right atrium, the left atrium, the right ventricle, and the left ventricle. The atria receive the blood that is brought to the heart from the veins and the ventricles pump the blood out through the arteries. The arteries direct blood either to the lungs or other body tissues. Systole refers to the period during which the heart is contracting. Diastole describes the period when the cardiac muscle relaxes..

[Audio] A normal heartbeat begins in the cells of the sinoatrial node. This is called the heart's natural pacemaker. Between beats, these cells are polarized. This means that the inside of each cell has a negative voltage compared to the outside. A heartbeat originates when channels in a cell membrane open to allow positively charged sodium and calcium ions to flow into the cell. The voltage then becomes positive instead of negative. This is called depolarization. Other channels in the cell membrane then open to allow positively charged potassium ions to flow out of the cell. The voltage then becomes negative again. This is called repolarization. An action potential or electrical signal results causing a muscle to contract. The signal spreads to the other cells of the myocardium continuing the cycle of depolarization and repolarization. The electrical signal from the SA node is carried through the atria and at the same time down to the atrioventricular or AV node. It then travels through the bundle of His and the bundle branches to the heart's apex. At this point, the electrical signal branches into the Purkinje fibers. A Purkinje fiber is one of the fibers that stretch from the apex up into the ventricles to contract the lower and largest part of the heart. The typical rate at which the SA node fires is 60 to 100 times per minute. This is the heart rate and is typically reported in beats per minute, abbreviated BPM. It is measured by taking a person's pulse..

[Audio] Blood pressure, abbreviated BP, describes the force of blood in the circulatory system and is maintained by various feedback mechanisms. Blood pressure is a function of capacitance, cardiac output, peripheral vascular resistance, and the renin-angiotensin system. Capacitance is the amount of blood held in the veins and venules. Cardiac output is the force and volume of blood coming from the heart. Peripheral vascular resistance is the degree to which the blood vessels are constricted or relaxed The renin-angiotensin system is the feedback mechanism that is regulated by the kidneys and balances fluid volume and vessel constriction..

[Audio] Blood pressure is expressed as the systolic blood pressure reading, which measures the pressure when the heart contracts and ejects blood, and the diastolic blood pressure reading, which measures the pressure when the heart relaxes and fills. Both readings are in millimeters of mercury. The reading is stated as systolic over diastolic pressure. Measurements of 120 millimeters of mercury systolic and 80 millimeters of mercury diastolic are written and read as 120 over 80. A blood pressure of 120/80 is often considered normal..

[Audio] Chapter 10, Section 2, Hypertension and Drug Treatment.

[Audio] Hypertension is defined as elevated blood pressure. It includes an elevation of systolic blood pressure, diastolic blood pressure, or both. Patients typically can't feel the effects of hypertension and it is often called the silent killer. Hypertension puts patients at risk for heart disease, stroke, heart failure, and kidney disease. Definite risk factors for hypertension are family history, cigarette smoking, and diet and lifestyle choices..

[Audio] Other factors that may contribute to hypertension include kidney disease, obesity, adrenal tumor, decreased blood pressure or delayed pulse in the lower extremities, and use of drugs such as oral contraceptives, corticosteroids, NSAIDs, decongestants, and appetite suppressants. Lifestyle interventions to decrease blood pressure include weight loss for overweight or obese patients, a heart-healthy diet, physical activity, and alcohol consumption limits. Treatment of hypertension often requires more than one medication. Drug classes commonly used to treat hypertension include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics. Less commonly used are alpha-blockers, beta-blockers, and direct renin inhibitors..

[Audio] The generic names of several angiotensin-converting enzyme inhibitors are listed in the table. These drugs are commonly called ACE inhibitors. See Table 10.1 for the brand names, common dosages, and dispensing status of these and all other medications in this section. ACE inhibitors relax blood vessels by inhibiting the conversion of angiotensin 1 to angiotensin 2. In doing so, they lower peripheral vascular resistance and overall blood pressure. In addition to the treatment of hypertension, they are used in the treatment of angina, myocardial infarction, heart failure, and kidney disease. ACE inhibitors are available as tablets and capsules with the exception of enalaprilat which is only available as an injection. A persistent cough is one of the most common side effects of ACE inhibitors. The resulting drug and unproductive cough can be annoying and can affect patient adherence. Angioedema is the most dangerous side effect. It typically presents as swelling of the face and tongue. ACE inhibitors can also cause dizziness and elevated potassium levels. An important consideration in the use of ACE inhibitors is the potential for hypotension or low blood pressure. This can happen dramatically, sometimes on the first dose. Hyperkalemia is another serious side effect. It tends to occur in patients taking potassium-sparing diuretics. Although patients who have kidney problems can take ACE inhibitors, doses may need to be decreased..

[Audio] The generic names of several angiotensin receptor blockers are listed in this table. They relax blood vessels by blocking angiotensin 2 receptors. Angiotensin 2 is a vasoconstrictor. In addition to their indication for hypertension treatment, ARBs are used in the treatment of heart failure, diabetic nephropathy, cardiovascular risk reduction, and post-myocardial infarction. They are available in tablet form. Common side effects of ARBs include headache, dizziness, fatigue, and mild diarrhea. In contrast to ACE inhibitors, cough is not a typical side effect of ARBs. ARBS should not be used in pregnancy. Patients taking diuretics along with ARBs may experience hypotension. Patients should be careful not to get up too quickly from a sitting or lying position until they know how these drugs affect them. Patients with kidney or liver impairment may need special dosing and monitoring if they are to take these medications..

[Audio] In this table are the generic names of calcium channel blockers. They relax blood vessels by blocking the entrance of calcium into blood vessel cells and reduce heart contractility by preventing calcium from entering heart cells. Relaxation of blood vessels increases blood flow which increases oxygen delivery throughout the body. Calcium channel blockers are used in hypertension, heart failure, and arrhythmias. They are available as oral dosage forms such as tablets, capsules, and an oral suspension. Three calcium channel blockers, nicardipine, diltiazem, and verapamil, are available as an injection. Bradycardia or slowed heart rate is a side effect of the calcium channel blockers. Other side effects include hypotension, heart block, cardiac failure, nausea, constipation, headache, dizziness, and fatigue. Patients sometimes feel worse after taking them and this may lead to poor adherence. Some calcium channel blockers cause fluid retention and heart palpitations. To balance the positive and negative effects on the heart, healthcare practitioners closely monitor patients taking this class of drugs..

[Audio] Multiple beta-blockers are available. This class reduces heart rate and heart contractility by inhibiting the action of catecholamines on beta receptors. Catecholamines are neurotransmitters released in response to anxiety, physical activity, or emotional stress. They increase heart rate and the contractile force of the heart. Beta-blockers are used in several cardiac conditions including hypertension, angina, heart failure, tachycardia, myocardial infarction, and arrhythmias. Their use is not restricted to cardiac conditions. Beta blockers are used in migraine prevention, glaucoma, hyperthyroidism, and essential tremors. They are available in oral dosage forms such as tablets, capsules, and an oral solution. Two beta-blockers are available as an injection. These are labetalol and propranolol. The most common side effect of beta-blockers is fatigue. These medications also cause bradycardia. Beta-blockers mask symptoms of hyperthyroidism and hypoglycemia. For this reason, patients who have diabetes should avoid taking them. Certain beta-blockers should be used with caution in bronchospastic disease because they may inhibit the bronchodilating effects of endogenous catecholamines. Several beta-blockers have boxed warnings for increased risk of cardiac problems with abrupt discontinuation. Gradual dose reduction is recommended over several weeks. Sotalol has a boxed warning for increased risk of life-threatening arrhythmia. By blocking the beta receptors in the airways, some medications in this class constrict airways in the lungs. This can be harmful to patients with impaired respiratory function. The beta-blockers of choice for these patients are acebutolol, atenolol, betaxolol, bisoprolol, esmolol, metoprolol, and nebivolol..

[Audio] Two classes of medications already discussed involve the renin-angiotensin system. These are the ACE inhibitors and ARBs. A newer drug class, the direct renin inhibitors, also works on the renin-angiotensin system. The only such agent available in the US is aliskiren. It relaxes blood vessels by decreasing the activity of renin. It is available as a tablet. Side effects of this agent include diarrhea, skin rash, increased serum creatinine, and cough. Aliskiren should not be used in pregnancy. Another class of medications sometimes used in hypertension is the alpha-blockers. These drugs relax blood vessels by blocking alpha-1 receptors. By relaxing the blood vessels, blood pressure is decreased. Alpha-blockers are particularly beneficial in men with benign prostatic hypertrophy because of their effects on the alpha-1 receptors in the bladder. Finally, thiazide diuretics lower blood pressure by eliminating sodium and water from the body..

[Audio] Chapter 10, Section 3, Cardiac Arrythmias and Drug Treatment.

[Audio] Sinus rhythm is the normal heart rhythm. It is referred to as sinus because it originates in the sinoatrial node, or pacemaker. Any deviation from normal sinus rhythm is considered an arrhythmia. Abnormalities of heart rate, rhythm, or both occur when the heart rate is too slow or too fast or when the contractions of the ventricles and atria are not synchronized. An electrocardiogram is a graphical representation of the electrical activity of the heart. The spikes and dips on an ECG are referred to as waves. Different waves and segments correspond to electrical activity in various portions of the heart. ECG readings are used to observe heart function and diagnose arrhythmias..

[Audio] Tachycardia refers to an increased heart rate; whereas bradycardia refers to a decreased heart rate. Flutter occurs when select portions of the heart are slightly out of sync with the rest of the heart. Fibrillation occurs when large portions of the heart beat out of sequence. Atrial fibrillation is not necessarily life-threatening; whereas ventricular fibrillation is an emergency. The symptoms of abnormal heart rhythms or rates include palpitations, syncope, lightheadedness, visual disturbances, pallor, cyanosis, weakness, sweating, chest pain, and hypotension..

[Audio] Antiarrhythmics are organized into classes based on their mechanism of action. Membrane-stabilizing agents or sodium channel blockers are one such class. These are referred to as class 1 antiarrhythmics. Another class is the potassium channel blockers which are referred to as class 3 antiarrhythmics. Beta-blockers are classified as class 2 antiarrhythmics while calcium channel blockers are class 4 antiarrhythmics. These last two classes of antiarrhythmics were discussed earlier in the Hypertension and Drug Treatments section. In this table are listed the generic names of the membrane-stabilizing agents which are also called the sodium channel blockers. These drugs dampen potential abnormal rhythms and heart rates by slowing the movement of sodium into myocardial cells. They are used for either ventricular or atrial arrhythmias depending on the agent. They are available as tablets or capsules. Lidocaine, procainamide, and quinidine are available as injections. Both the common and life-threatening side effects vary by agent. This class of medications is to be reserved for life-threatening arrhythmias and they are to be used with caution in heart failure..

[Audio] As their name suggests, the potassium channel blockers decrease abnormal beats by slowing the movement of potassium across cell membranes. Amiodarone, dofetilide, and dronedarone are the generic names of medications in this class. Their indication varies depending on the agent. Medications in this class are available as tablets or capsules. Amiodarone is the only injection. Similar to the sodium channel blockers, both the common and life-threatening side effects vary by agent. There are several cautions and considerations for agents in this class. Amiodarone has the potential for fatal toxicities to the lungs, liver, and heart. Dofetilide must be started in a setting with clinical monitoring and caution is advised in renal impairment. Dronedarone is not to be used in patients with symptomatic heart failure. It may increase mortality in patients with permanent atrial fibrillation..

[Audio] Beta-blockers are classified as class 2 antiarrhythmics and are commonly used in the treatment of cardiac arrhythmias. Information on beta-blockers can be found in the Hypertension and Drug Treatments section of this chapter. The calcium channel blockers diltiazem and verapamil are classified as class 4 antiarrhythmics. Information on calcium channel blockers can be found in the Hypertension and Drug Treatments section of this chapter. Atropine is an anticholinergic that increases heart rate and cardiac output. It is used to treat bradycardia. Low doses may worsen bradycardia; whereas high doses may increase heart rate too much. This can lead to increased oxygen demand, which can result in ischemia and lead to arrythmias. Digoxin is used in atrial flutter or fibrillation. It is also used to treat symptoms of heart failure. It should be used with caution due to the risk of digitalis toxicity. The three primary signs of digitalis toxicity are nausea, vomiting, and arrhythmias. The antidote for digitalis toxicity is digoxin immune Fab available as the brand name DigiFab. Isoproterenol is used for ventricular arrhythmias, bradyarrhythmias, and third-degree AV block..

[Audio] Chapter 10, Section 4, Angina, Myocardial Infarction, and Corresponding Drug Treatments.

[Audio] Ischemia is a term used to describe inadequate blood supply to an organ. In the cardiovascular system, it usually occurs as a result of blockage in the coronary arteries. Angina pectoris or angina is chest pain caused by myocardial ischemia. The characteristic symptom of angina is severe chest discomfort. Other symptoms may include sweating, dizziness, or dyspnea or shortness of breath. Risk factors for angina include advanced age, coronary artery disease, hypertension, increased serum glucose levels, increased lipoprotein levels, obesity, smoking, and stress..

[Audio] A myocardial infarction is also known as a heart attack. It occurs when cardiac muscle is deprived of oxygen long enough that cells die or infarct. Symptoms of an MI include tightness, heaviness, or a squeezing sensation in the chest; neck, chest, or jaw pain; chest pain that radiates down the left arm; indigestion or nausea; a sense of impending doom; weakness or fatigue; and sweating..

[Audio] Factors that increase the risk of an MI include a history of angina, alcohol consumption, reduced pulmonary vital capacity, cigarette smoking, and atherosclerosis. Lifestyle modifications to reduce the risk of an MI include eliminating smoking, controlling blood pressure, getting regular physical activity, choosing healthy foods and beverages, keeping a healthy weight, using preventive medications when appropriate, and managing diabetes..

[Audio] Acute MI is considered a medical emergency. The immediate goals of treatment are opening blocked arteries, controlling blood pressure, and regulating heart rhythm. Oxygen, nitroglycerin, and aspirin may be used in acute MI. Chronic treatment of MI includes the use of anticoagulants, beta-blockers, ACE inhibitors, and antihyperlipidemics. Calcium channel blockers and nitrates may be used in patients with ischemia..

[Audio] The three nitrate products that are available are isosorbide dinitrate, isosorbide mononitrate, and nitroglycerin. Nitrates are considered to be vasodilators. They relieve chest pain and ischemia by dilating coronary vessels. Short-acting nitrates are used in angina attacks and acute MI. Long-acting nitrates are used to prevent angina attacks. These medications are available as tablets or capsules. Nitroglycerin can cause severe headaches when a patient first takes it. Aspirin or acetaminophen may provide relief. Nitroglycerin can also cause orthostatic hypotension when first used, so patients should be advised to move slowly, especially when changing from a sitting or lying position. The drug can also cause flushing. Special cautions and considerations with short-acting nitroglycerin products is that these should not be swallowed. They are designed for immediate absorption under the tongue or through the check. If a patient takes nitroglycerin and does not get relief of pain 5 minutes, they should call 911 and repeat the dose. Patients should be instructed to keep sublingual nitroglycerin in the original container and protect the contents from light, heat, and moisture. The tablets are good for 6 months in the container. Patients should be instructed to write the date the bottle was opened on the container. A special consideration for the nitroglycerin patch is to provide a drug-free interval of at least 8 hours a day. This is to prevent tolerance which develops after constant exposure to the drug and results in reduced effectiveness..

[Audio] Ranolazine is used for chronic angina in combination with other drugs. It is a metabolic modifier that helps the heart generate energy more efficiently. Its side effects include hypotension, bradycardia, palpitations, QT prolongation, edema, dizziness, headache, confusion, and syncope. Ranolazine should be used cautiously in patients with kidney dysfunction and in older adults due to the increased risk for adverse events. ACE Inhibitors, beta-blockers, and calcium channel blockers may be used in the treatment of patients with a history of MI or angina. They are addressed in the Hypertension and Drug Treatments section of this chapter. Anticoagulants may be used in the treatment of patients with a history of MI or angina. They are addressed in the clotting disorders section of this chapter..

[Audio] Chapter 10, Section 5, Heart Failure and Drug Treatments.

[Audio] Heart failure is a chronic, progressive condition in which the heart is no longer able to pump enough oxygen-rich blood to meet the body's needs. Symptoms of heart failure include shortness of breath, fatigue, edema, and exercise intolerance. The goals of therapy for heart failure treatment are to prolong survival, relieve symptoms, improve quality of life, and prevent progression of disease. Most patients are managed with a combination of drugs..

[Audio] Most patients with heart failure are managed with a combination of drugs. Therapy typically includes a medication that inhibits the renin-angiotensin system and a beta-blocker. ACE inhibitors and angiotensin receptor blockers inhibit the renin-angiotensin system and were discussed in the Hypertension and Drug Treatments section of this chapter. Beta-blockers were also discussed in this section. Diuretics are used as needed to help with fluid overload. A loop diuretic is used most commonly. They produce fast and profound diuresis by inhibiting reabsorption of sodium, chloride, and water in the kidneys. They are addressed in Chapter 15. In certain cases, the combination of hydralazine and a nitrate may be used. Hydralazine is discussed in Chapter 14 and nitrates are discussed in the Angina, Myocardial Infarction, and Corresponding Drug Treatments section of this chapter. Some patients with heart failure use an aldosterone antagonist. These increase urine production by inhibiting the hormone aldosterone. Digoxin is used for heart failure and as an antiarrhythmic drug. Digoxin is addressed in the Cardiac Arrhythmias and Drug Treatments section of this chapter..

[Audio] The combination of an angiotensin receptor and a neprilysin inhibitors are a newer class of drugs used to treat heart failure. Sacubitril is currently the only ARNI available in the United States and is sold as a combination product with the ARB valsartan. The active metabolite of sacubitril increases diuresis and dilates blood vessels. It is available in tablet form and its only indication is heart failure. The main side effects are hypotension and orthostatic hypotension. Other side effects include increased potassium levels, increased serum creatinine, dizziness, falling, decreased hematocrit and hemoglobin, angioedema, renal failure, and cough..

[Audio] Chapter 10, Section 6, Dyslipidemia, Hypercholesterolemia, Hyperlipidemia and Drug Treatments.

[Audio] Cholesterol is odorless, white, waxlike, powdery substance present in all foods of animal origin but not in foods of plant origin. Some cholesterol is necessary for good health. However, as cholesterol increases it enhances other risk factors for coronary artery disease. Atherosclerosis is the narrowing of arteries due to deposits of cholesterol and fat on their inner surfaces..

[Audio] Over time, cholesterol is deposited on artery walls, eventually clogging them. Compare the normal artery on the left with the clogged artery on the right.

[Audio] Hypercholesterolemia is defined as an excessive amount of cholesterol in the blood. The term hyperlipidemia is more specific in that it is an elevation of one or more lipoproteins. A lipoprotein is a spherical package consisting of lipids bound to proteins. Most blood lipoproteins can be classified as high-density or low-density lipoproteins. High-density lipoprotein is the good cholesterol. Low-density lipoprotein is the bad cholesterol. Triglycerides are a neutral fat made from carbohydrates and stored in fat cells..

[Audio] Lifestyle modifications are key to preventing and treating dyslipidemia. Dietary interventions can be effective in reducing cholesterol by 10% to 15%. The major dietary recommendations are to reduce the amount of saturated fats in the diet and increase dietary fiber intake. Physical activity is a lifestyle modification that can also be beneficial. Cholesterol-lowering drugs are always used as an adjunct to lifestyle modifications. Some medications work better for decreasing LDLs, some for decreasing triglycerides, and others for increasing HDLs..

[Audio] In this table are listed the generic names of the HMG-Co reductase inhibitors, most often referred to as the statins. They decrease cholesterol by inhibiting the enzyme that catalyzes the rate-limiting step in cholesterol formation. The statins are typically first-line therapy for hyperlipidemia. They are also used for prevention of cardiovascular disease in patients with a history of heart disease and in those at risk for heart disease. Statins are only available in oral dosage forms such as tablets, capsules, and an oral suspension. Side effects of statins include GI upset and headache, which dissipate over time. Patients with muscle pain or weakness should report this to their healthcare practitioners immediately. The most serious side effect is rhabdomyolysis, the destruction of muscle. Special concerns with the statins include the risk of rhabdomyolysis with acute kidney failure. Another related concern is myopathy which is a muscle disease marked by muscle pain, tenderness, or weakness. Liver function abnormalities and increases in blood glucose may also occur in patients taking these medications. Dose adjustment may be necessary in patients with kidney dysfunction..

[Audio] Fenofibrate, fenofibric acid, and gemfibrozil are in the class called fibric acid derivatives. It is not fully understood how they work. This class is used for hypertriglyceridemia, primary hypercholesterolemia, mixed dyslipidemia, and prevention of heart disease although the indications are agent-specific. They are only available as oral dosage forms such as tablets and capsules. Upset stomach, diarrhea, indigestion, and abdominal cramps are common side effects of the fibric acid derivatives. Side effects specific to fenofibrate include fatigue and muscle cramps. Fibric acids should not be used in patients with gallbladder problems. They should be used cautiously in combination with statins due to the potential for rhabdomyolysis..

[Audio] Cholestyramine, colesevelam, and colestipol are in a class called the bile acid sequestrants. These drugs increase the excretion of bile acids which results in the increased conversion of cholesterol to bile acids. This effectively lowers serum cholesterol levels. Bile acid sequestrants are indicated in hypercholesterolemia. Cholestyramine has the additional indication of pruritis associated with partial biliary obstruction. This class of drugs is available as tablets, packets, and powder. Gastrointestinal side effects are common with bile acid sequestrants. Constipation or diarrhea may occur with use. Weakness and flu-like symptoms may also occur. This class of drugs should be used cautiously if a patient's triglyceride level is more than 300 milligrams per deciliter. They may decrease the absorption of fat-soluble vitamins and should be used with caution in patients with deficiencies of these. Bile acid sequestrants may either produce or exacerbate constipation which may lead to fecal impaction..

[Audio] Bempedoic acid, Nexletol, is the only ATP citrate lyase inhibitor currently available in the US. Bempedoic acid inhibits cholesterol synthesis in the liver. It is used as an adjunct to diet and maximally tolerated statin therapy in adults with heterozygous familial hypercholesterolemia or established cardiovascular disease. The only dosage form available is a tablet. Side effects of the ACL inhibitor include upper respiratory tract infection, muscle spasms, hyperuricemia, back pain, abdominal pain or discomfort, bronchitis, pain in extremity, anemia, and elevated liver enzymes. Important considerations to keep in mind with bempedoic acid are that it may increase uric acid and that tendon rupture has occurred with this medication. It should be stopped at the first sign of tendon rupture and avoided in patients with a history of this..

[Audio] Ezetimibe lowers cholesterol by inhibiting absorption of cholesterol in the small intestine. This leads to decreased delivery of cholesterol to the liver. Its side effects include upper respiratory tract infections, sinusitis, diarrhea, and pain in joints and extremities. It should be used cautiously in liver or kidney disease. The omega-3 fatty acids are used for hypertriglyceridemia. While they are widely available as OTC dietary supplements, some prescription forms are available. The omega-3 fatty acids are thought to decrease liver production of very low-density lipoproteins. Their side effects include diarrhea, burping, bad breath, and gastrointestinal upset. They should be used cautiously in patients with fish or shellfish allergies. Bleeding has been reported with their use..

[Audio] Chapter 10, Section 7, Clotting Disorders, Stroke, and Drug Treatments.

[Audio] A thrombus is a blood clot that stays where it originated. In contrast, an embolus is a blood clot that circulates in the blood. Clots that form in the veins usually form in areas with slow blood flow, in areas of surgical or other vein injury, or in large pockets formed by the valves in deep veins. A piece of a clot that breaks off and travels to the lung or blocks the pulmonary artery is called a pulmonary embolism. A deep vein thrombosis is the formation of a blood clot in one or more deep veins. These are typically located in the legs. Symptoms of a DVT include swelling, discoloration, and pain..

[Audio] Symptoms of a DVT include swelling, discoloration, and pain. Two classes of drugs, anticoagulants and antiplatelets, are used to reduce the risk of blood clots. An anticoagulant prevents clot formation by inhibiting clotting factors. An antiplatelet reduces the risk of clot formation by inhibiting platelets from sticking or clumping together. Drugs in a third class, thrombolytics, dissolve clots that have already formed..

[Audio] The brain is an oxygen-rich organ and requires a constant supply of oxygenated blood to keep brain tissue alive and functional. A cerebrovascular accident, commonly known as a stroke, is the result of an event that interrupts the oxygen supply to a localized area of the brain. It is considered a medical emergency. If the block in blood flow is brief, an individual may experience a transient ischemic attack. A TIA may be an important warning sign of imminent stroke. One of the symptoms of a stroke is numbness or weakness on one side of the body. This can affect the face, arm, or leg. Other symptoms include confusion and difficulty speaking or understanding speech, trouble seeing in one or both eyes, dizziness and loss of balance or coordination, and severe headache with no known cause..

[Audio] There are two major types of strokes: ischemic and hemorrhagic. An ischemic stroke occurs when a blood clot obstructs a blood vessel supplying the brain. A hemorrhagic stroke occurs when a blood vessel ruptures. This results in cerebral hemorrhage or bleeding in or around the brain. Ischemic stroke is the most common type of stroke..

[Audio] Risk factors for both types of stroke include advanced age, male sex, hypertension, smoking, alcohol abuse, diabetes, and high cholesterol levels..

[Audio] Bivalirudin and dabigatran (on the next slide) are direct thrombin inhibitors which work by binding directly to thrombin. This includes both circulating thrombin and thrombin bound to fibrin. Bivalirudin is used in the treatment of unstable angina in patients undergoing percutaneous coronary intervention. This is a nonsurgical procedure in which a catheter is used to place a stent to open blood vessels. Bivalirudin is only available as an injection. Its side effects include hypotension, pain, headache, nausea, bleeding, and back pain..

[Audio] Dabigatran, on the other hand, is given orally for the prevention of DVT and PE. It is also used for the prevention of stroke in nonvalvular atrial fibrillation. Nausea, headache, back pain, and bleeding due to excessive anticoagulation are side effects common to both agents. Dabigatran carries boxed warnings for an increased risk of thrombotic events if discontinued prematurely and an increased risk of spinal or epidural hematoma. Older adults and patients who have kidney impairment should use dabigatran with extreme caution. An antidote, idarucizumab, is available for dabigatran. It comes as an injection with the brand name Praxbind..

[Audio] Heparin works by inhibiting clotting factors in the clotting cascade and inactivating thrombin and factor 10A. It does not dissolve a clot that stays in place but helps stabilize it and prevents clots from breaking off and circulating in the blood. Heparin is only available as an injection. It is used in the treatment and prevention DVT or PE, the treatment of thrombotic complications of atrial fibrillation, the prevention of clotting in certain surgeries, and as an anticoagulant for dialysis. Bruising, bleeding due to excessive anticoagulation, and thrombocytopenia are the side effects to be aware of with heparin use. Heparin-induced thrombocytopenia is a serious side effect that can be life-threatening. It can only be fully detected by laboratory tests but often is preceded by a skin rash. Protamine sulfate is an antidote used to reverse the effects of heparin. It is used when a patient is hemorrhaging or has a high risk of hemorrhage. The dose is based on the amount of heparin reversal needed..

[Audio] Dalteparin and enoxaparin are both low-molecular-weight heparins. They work by inhibiting factors in the clotting cascade. Compared to heparin, they affect factor 10a more than they affect thrombin. The benefits of LMWHs compared to heparin is that they may present a lower likelihood of bleeding, can be injected subcutaneously, and have longer half-lives. Dalteparin is used to prevent thromboembolism. Enoxaparin is used to prevent thrombosis after surgery and in the treatment of DVT with or without pulmonary embolism. Side effects of the LMWHs include bruising, bleeding due to excessive anticoagulation, fever, pain at the injection site, and thrombocytopenia. As with heparin, the development of heparin-induced thrombocytopenia is a serious side effect that can be life-threatening. It can only be fully detected by laboratory tests but often is preceded by a skin rash. Patients who have a history of HIT should not use LMWHs..

[Audio] Apixaban, edoxaban, fondaparinux, and rivaroxaban belong to the class of anticoagulants called factor 10a inhibitors. As their name suggests, these agents block the activity of factor 10a. In doing so, they prevent blood clots from developing or getting worse. The indication for each drug in this class varies. As a class they are used for DVT and PE prophylaxis, DVT and PE treatment, to reduce risk of recurrence of DVT and PE, and for stroke prevention in nonvalvular atrial fibrillation. They are available as tablets except fondaparinux which is only available as an injection. Bleeding is the main side effect of the factor 10a inhibitors. They carry boxed warnings for an increased risk of spinal or epidural hematoma and an increased risk of thromboembolic events with premature discontinuation. Dose adjustment is usually required in patients with kidney impairment. An antidote, andexanet, is available for the factor 10a inhibitors. It comes as an injection with the brand name Andexxa..

[Audio] Warfarin is the only vitamin K antagonist available in the US. It works by preventing the production of the vitamin K-dependent clotting factors 2, 7, 9, and 10. By disrupting these factors, it decreases the body's ability to form clots. The objective of warfarin therapy is to prevent future clots from forming. It has no effect on existing clots, but it can prevent clot formation, the extension of formed clots, and secondary complications of thrombosis. Warfarin is available in tablet form. The most common side effect of warfarin is bleeding. Other side effects include hair loss, skin lesions, and purple/blue toe syndrome. It is important for patients to understand the signs of bleeding. Signs to watch for include blood in the urine or stool; black, tarry stools; bleeding in the mouth or gums; unusual or unexplained bruising; vomiting blood; and nose bleeds. These should be reported to the prescriber. Patients should be instructed to take warfarin at the same time each day. They should be told to avoid varying the amount of vitamin K consumed. Wide swings in the amount of vitamin K consumed will affect the activity of oral anticoagulants. Patients taking warfarin should avoid excessive alcohol intake to decrease the risk of bleeding..

[Audio] Warfarin reversal can be achieved through the use of phytonadione, also known as vitamin K. It may be given orally, intramuscularly, intravenously, or subcutaneously. Subcutaneous administration is not preferred. IM or IV administration should be used only when oral dosing is not possible. Side effects of vitamin K include flushing, changes in taste, dizziness, sweating, rapid pulse, and difficulty breathing..

[Audio] An antiplatelet agent is a medication that interferes with the chemical reactions that cause platelets to be sticky and aggregate. Their individual mechanisms of action vary in accomplishing this. Aspirin is a commonly used antiplatelet drug and is covered in depth in Chapter 6. Clopidogrel prevents fibrinogen binding by blocking adenosine diphosphate receptors. It reduces platelet adhesion and aggregation. It is used to prevent recurrence of atherosclerotic events such as MI and stroke. Clopidogrel is available in tablet form and its most common side effect is bleeding. It should be discontinued at least five days prior to surgery due to bleeding risk..

[Audio] Prasugrel is an antiplatelet agent that maintains stents by keeping platelets from sticking together. As a result, it prevents blood clots from forming inside stents and the arteries of the heart. It is used with aspirin to reduce cardiovascular death, MI, and stroke in patients who have undergone percutaneous coronary intervention. This is a nonsurgical procedure in which a catheter is used to place a stent to open blood vessels in the heart. Prasugrel is available in tablet form. Potential side effects of prasugrel include bleeding, hypertension or hypotension, edema, and hyperlipidemia. This drug carries a boxed warning for risk of significant or fatal bleeding. Another warning states that prasugrel is not recommended in patients more than 75 years old or those likely to undergo coronary artery bypass surgery. Ticagrelor is an antiplatelet used to decrease cardiovascular events in patients who have coronary syndromes or a history of MI. It also indicated to reduce stent thrombosis. Like the other antiplatelet agents, ticagrelor is available as a tablet. Its major side effects are bleeding and shortness of breath. It has a boxed warning for increased risk of bleeding. Another warning states that maintenance doses of aspirin should be less than 100 mg per day. Ticagrelor should be avoided in patients requiring urgent coronary artery bypass grafts..

[Audio] Glycoprotein antagonists are a type of antiplatelet agent that binds to a receptor on platelets, preventing platelet aggregation as well as the binding of fibrinogen. Eptifibatide and tirofiban are indicated in acute coronary syndrome and are given during invasive procedures to prevent artery closure. The medications in this class are only available as injections. Bleeding and thrombocytopenia are the main side effects of eptifibatide. Bleeding and hypersensitivity are the main side effects of tirofiban. Eptifibatide should be used with caution in kidney impairment. Tirofiban may cause thrombocytopenia, and the dose of tirofiban should be reduced in kidney impairment. All the glycoprotein antagonists are considered high-alert medications by the Institute for Safe Medication Practices..

[Audio] Alteplase and tenecteplase are thrombolytic agents. These medications dissolve clots by binding to fibrin and converting plasminogen to plasmin, an enzyme. Plasmin degrades the fibrin matrix of the clot, which results in the clot dissolving. They are used in the treatment of acute ischemic stroke, pulmonary embolism, and acute MI. They are available as injections. Bleeding, arrhythmias, allergy, nausea, vomiting, hypotension, and fever are the side effects of the thrombolytic agents. The thrombolytics greatly increase the risk of bleeding and hemorrhage. They should be used cautiously in patients with conditions that increase the risk of bleeding. These agents should be used with caution in older adults..

[Audio] Chapter 10, Section 8, Complementary and Alternative Therapies.

[Audio] Plant sterol esters have been found to significantly lower LDL cholesterol. They can be used in addition to diet and drug therapy for hyperlipidemia. Red yeast rice is used in recipes and medications to lower cholesterol and improve cardiovascular health. It contains varying amounts of monacolins, agents with HMG-CoA reductase inhibitor activity. Alpha-tocopherol or vitamin E is an antioxidant used for cardiovascular disease, cancer, and diabetic neuropathy. Its effectiveness for these conditions has not been proven, and there is evidence to suggest that vitamin E may increase the risk of heart failure. However, many individuals take this antioxidant for better health. Garlic has been found to be possibly effective in treating atherosclerosis, hypertension, skin fungal infections, and some cancers. If a garlic supplement is used, it must contain allicin, the odorous active ingredient produced by crushing garlic cloves..