Angiotensin-Converting Enzyme Inhibitors
-aka ACE Inhibitors
-Large group of safe and effective drugs
-First line agents for HF
-Secondary agents for HTN
-Can be combined with a thiazide diuretic or Ca++ channel blocker
-Drug suffix "-pril"
Why are ACE inhibitors safer/better?
Can be combined with other drugs (diuretics, Ca++ channel blockers) and still be as effective
ACE Inhibitors are the first-line agents for what?
For pts with Heart Failure
ACE Inhibitors are the secondary agents for what?
ACE Inhibitors are used primarily for HF now instead of which drug?
What is the action of ACE inhibitors?
-Decrease the demands on the heart
-Interferes with the RAAS
-Prevents breakdown of the vasodilating substance Bradykinin
How do ACE inhibitors interfere with the RAAS?
-prevents conversion of Angiotensin I to II which
-prevents Na+ and water resorption in the kidneys
What is the effect of bradykinin breakdown?
-decreased systemic vascular resistance (afterload)
-decreased vasodilation, and ultimately
What are ACE inhibitors used for?
-CHF: used either alone or in combo with other agents
-Slows progression of LV hypertrophy after an MI
-Renal protective effects in pts w/ diabetes
How are ACE inhibitors used after an MI?
decreases demands on the heart which ultimately slows down the hypertrophy- heart is not working as hard
What is a characteristic SE of a pt on ACE inhibitors?
Dry, non-productive cough; will stop when therapy is stopped
What are some SE of ACE inhibitor use?
What is the concern with ACE inhibitors regarding angioedema?
-Occurs in face, mucous membranes (can occur in gut- visceral angioedema)
-If not treated, will keep swelling until airway is obstructed & will need a trach
-Once you've had it, increased risk of having it again
-Higher risk in blacks than whites
What is the concern with ACE inhibitors regarding hypotension?
-First dose may cause hypotension
-Take their BP 30-45 min after first dose
What do you teach a pt about ACE inhibitors and BP?
-When you first take med, sit down for a while then get up slowly
-If you feel light headed/dizzy, call your doctor
Drug interactions with ACE inhibitors
Examples of ACE inhibitors
How is Ramipril (Altace) related to DM?
-Study looked at pts destined to get DM
-Put them on Altace
-Delayed onset of DM
Which ACE inhibitor is a prodrug?
Enalapril (Vasotec); so it works after it has been metabolized
Nursing Implications for pts on ACE inhibitors
-Get baseline VS
-Monitor for hypotension
-Check for angioedema
Why do we monitor labs for pts on ACE inhibitors?
-Monitor renal fx, liver fx, and potassium levels
-Must do this every month for the first 3 months
-Reduce cardiac remodeling
-Block catecholamine/SNS actions
Why are elderly not likely to be placed on beta blockers?
Given as an adjunct to other treatments for HF
Examples of vasodilators
What is significant of BiDils?
-Vasodilator that is proven to work for black pts
-Other don't seem to work as well
What is significant of Nesiritide (Natrecor)?
-Synthetic natriuretic peptide
-Causes decreased preload and afterload
-Inhibit the sodium potassium ATPase pump
-Allows more calcium to be available for contraction
What is a prime example of a cardiac glycoside?
What are the "tropic" characteristics of Digoxin?
What does it mean to be a positive/negative inotrope?
-Increases/decreases strength of cardiac contraction
What does it mean to be a positive/negative chronotrope?
-Increases/decreases heart RATE
What does it mean to be a positive/negative dromotrope?
-Decreases/increases refractory period
How is digoxin a negative chronotrope?
-Stimulates the PNS which decreases the HR
What are Cardiac Glycosides used for?
How do cardiac glycosides help with dysrhythmias/atrial fib/flutter?
-Slows down the heart rate so it can get into a somewhat normal rhythm
What are some SE of cardiac glycoside use?
-Confusion, convulsions, depression
What pt population is most likely to get depression SE?
What are the GI complications associated with Dig Toxicity?
What are the cardiac complications associated with Dig Toxicity?
What are the neurologic complications associated with Dig Toxicity?
-Blue-yellow color blindness/shading
How do you treat a pt experiencing Dig Toxicity?
-Give digoxin immune Fab, K+
-Will bind with free dig molecules, inactivate it
-Dig will then get excreted
Nursing Implications for Cardiac Glycosides
-Monitor pulse: if below 60, don't give med
-Serum dig levels (normal=0.5-2.0 ng/ml)
-Do NOT give IM
-IV: slow push
-Teach pt about high K+ foods
Examples of Other Inotropics
-Phosphodiesterase III inhibitors