Drug Study (Left-sided heart failure) Nitrates: Isosorbide dinitrate, isosorbide mononitrate, nitroglycerin nitropruside Brand names: Isordil,

, Imdur, Isoket, Deponit Class: Anti-Anginal Mechanism of action: Glyceryl trinitrate, isosorbide dinitrate, and isosorbide-5mononitrate are organic nitrate esters commonly used in the treatment of angina pectoris, myocardial infarction, and congestive heart failure. Organic nitrate esters have a direct relaxant effect on vascular smooth muscles, and the dilation of coronary vessels improves oxygen supply to the myocardium. The dilation of peripheral veins, and in higher doses peripheral arteries, reduces preload and afterload, and thereby lowers myocardial oxygen consumption. Dosage and indication: Angina pectoris (oral tab 5-30mg qid. SL tab 5-10mg 23 hrly), Acute CHF (oral tab 10-40mg qid. SL tab 5-10mg 2 hrly) Chronic HF (initially 5-10mg 2 hrly SL. Maintenance: 20-40 mg qid oral). Adverse Effects: Cutaneous vasodilation with flushing, vascular HA. Occasionally, transient episodes of dizziness and weakness, cerebral ischemia associated with postural hypotension, nausea, vomiting, restlessness, pallor, perspiration and collapse; drug rash and/or exfoliative dermatitis Nursing interventions: Should be taken on an empty stomach (take 30mins before meal). Watch out for signs of adverse effects.

Calcium Channel Blocker Brand names: Amlodipine besylate (Norvasc , Amlodine), Nicardipine HCl (Cardipine), nifidipine (Adalat) Class: Anti Anginal Mechanism of Action: Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Therapeutic Effects: Systemic vasodilation resulting in decreased blood pressure. Coronary vasodilation resulting in decreased frequency and severity of attacks of angina. =Canadian drug name. *CAPITALS indicates life-threatening; underlines indicate most Dosage and Indication: CHF (1 cap 5-10mg TID), Coronary spasm (20,g 4-6 times daily, SL 10-20mg) Adverse Effects: hypotension, chest discomfort, temporary hyperglycemia, GI upset Nursing Intervention: maybe taken with or without food (do not crush or chew), watch for signs of adverse reactions, monitor VS

ACE : imidapril Brand Names: Norten, Vascor Class: antihypertensive Mechanism of action: Imidapril HCl is an ester prodrug which is hydrolyzed after absorption to imidaprilat, the active metabolite. Imidapril has potent angiotensin-converting enzyme (ACE) inhibitory effects, 1.2 x and 2.6 x that of enalaprilat and captopril, respectively. The hypotensive effect of Imidapril HCl is mainly due to ACE inhibition and the consequent reduction in angiotensin II, resulting in dilation of peripheral vessels and reduction in vascular resistance. The hypotensive effect of Imidapril HCl is comparable to enalapril and 5-10 x more potent than that of captopril. Imidapril HCl decreases total peripheral vascular resistance without increase in heart rate or cardiac contractility. Imidparil HCl increases renal blood flow and reduces renal vascular resistance mainly due to dilatation of the efferent arteriole. Imidapril HCl showed no specific effect on the CNS, digestive, respiratory, smooth muscle, reproductive, urologic, hematologic and metabolic systems. Dosage and indication: The initial dose of 5 to 10 mg once daily in hypertensive patients with normal renal function. Doses can be increased up to 20 mg according to patient response. The dosage of Imidapril HCl should be reduced in patients with renal insufficiency, renal hypertension or severe hypertension. Or as prescribed by the physician. Adverse Effects: Adverse reactions are usually mild and transient. The most frequent reactions include dry cough (2.8%), discomfort in the throat (0.5%), palpitation (0.2%), headache (0.2%) and rash (0.2%). The following side effects occurred rarely (0/1% each) and include fatigue, dizziness, hot flush, diarrhea, nausea and vomiting. Abnormal laboratory test values were observed in 5.6% (47/382) of patients but none is considered related to Imidapril HCl treatment. Nursing interventions: Hypertension should be managed according to appropriate guidelines. Treatment with an ACE inhibitor can be started in the community in the majority of people with heart failure. In patients taking diuretics, close supervision is needed when commencing treatment. The initial dose of ACE has a risk of first-dose hypotension, therefore patients should be advised to sit or lie down for 2-4 hours after this. Evaluate therapeutic response.

 Advise patients to avoid driving and other hazardous work until they are confident that they have no dizziness or fainting from possible hypotensive side-effects. Avoid excess intake of alcohol since this can enhance hypotensive effect. This medication should not be stopped without medical consultation. Advise patients to rise slowly in order to avoid postural hypotension. ARBS: losartan and telmesartan Brand names: Losargard, Lifezar amd Pritor Class: Angiotensin receptor blockers Mechanism of action: Losartan competitively inhibits the binding of angiotensin II to AT1 in many tissues including vascular smooth muscle and the adrenal glands. Losartan is metabolized to its active metabolite, E-3174, which is 10 to 40 times more potent than losartan and acts as a non-competitive AT1 antagonist. Inhibition of angiotensin II binding to AT1 inhibits its AT1-mediated vasoconstrictive and aldosterone-secreting effects and results in decreased vascular resistance and blood pressure. Losartan is 1,000 times more selective for AT1 than AT2. Inhibition of aldosterone secretion may increase sodium and water excretion while decreasing potassium excretion. Losartan is effective for reducing blood pressure and may be used to treat essential hypertension, left ventricular hypertrophy and diabetic nephropathy. Dosage and indication: The starting dose of losartan for adults is 25-50 mg daily. The maximum dose is 100 mg daily. The total daily dose may be divided and administered two doses daily. Losartan may be given with or without food. The starting dose of losartan for pediatric patients 6 years of age or older is 0.7 mg/kg up to 50 mg once daily. Doses more than 1.4 mg/kg or 100 mg daily have not been evaluated in pediatric patients. Losartan is used for treating hypertension, reducing the risk of stroke in patients with hypertension, and left ventricular hypertrophy (over developed heart muscle), and treating people with type 2 diabetes, and hypertensive patients with diabetic nephropathy (kidney disease). Losartan may be used alone or in combination with other drugs. Adverse Effects: cold or flu symptoms such as stuffy nose, sneezing, sore throat, fever; dry cough; muscle cramps; pain in your legs or back;

stomach pain, diarrhea; headache, dizziness; tired feeling; or sleep problems (insomnia).

Nursing interventions: Administer without regard to meals. Ensure that patient is not pregnant before beginning therapy, suggest the use of barrier birth control while using losartan; fetal injury and deaths have been reported. Find an alternative method of feeding the baby if given to a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous. Alert surgeon and mark patient's chart with notice that losartan is being taken. The blockage of the renin-angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to a decrease in blood pressure secondary to reduction in fluid volume--excessive perspiration, dehydration, vomiting, diarrhea--excessive hypotension can occur. BETA BLOCKERS: metoprolol Brand Names: Neoblock Class: Antihypertensive Mechanism of action: Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone. Dosage and indication: Tablets\u201450, 100 mg; ER tablets\u201425, 50, 100, 200 mg; injection\u20141 mg/mL Adverse Effects:

dizziness, tired feeling; confusion, memory problems; nightmares, trouble sleeping; diarrhea; or

mild itching or rash.

Nursing interventions: Assessment History: Sinus bradycardia (HR < 45 beats/min), second- or third-degree heart block (PR interval > 0.24 sec), cardiogenic shock, CHF, systolic BP < 100 mm Hg; diabetes or thyrotoxicosis; asthma or COPD; lactation Physical: Weight, skin condition, neurologic status, P, BP, ECG, respiratory status, kidney and thyroid function, blood and urine glucose Interventions Do not discontinue drug abruptly after long-term therapy (hypersensitivity to catecholamines may have developed, causing exacerbation of angina, MI, and ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring. Ensure that patient swallows the ER tablets whole; do not cut, crush, or chew them. Consult physician about withdrawing drug if patient is to undergo surgery (controversial). Give oral drug with food to facilitate absorption. Provide continual cardiac monitoring for patients receiving IV metoprolol. Teaching points Do not stop taking this drug unless instructed to do so by a health care provider. Swallow the ER tablets whole; do not cut, crush, or chew them. Report difficulty breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash, fever, sore throat.