Cardiac Medications Overview

Cardiac medications target multiple pathophysiological mechanisms — neurohormonal activation in heart failure, arterial stiffness in hypertension, ischemia in coronary artery disease, and abnormal electrical conduction in arrhythmias. Most patients with cardiac conditions take multiple drug classes, each targeting a different mechanism.

The nurse's role includes: verifying pre-administration vital signs, knowing hold parameters, recognizing adverse effects, monitoring laboratory values, and educating patients on adherence and safety.

ACE Inhibitors (-pril)

Angiotensin Receptor Blockers (ARBs) (-sartan)

ARNIs — Angiotensin Receptor-Neprilysin Inhibitors

Beta-Blockers (-olol)

Calcium Channel Blockers (CCBs)

Nitrates

Diuretics

• Blood pressure and HR: Check before every cardiac medication administration. Know drug-specific hold parameters.
• Electrolytes: Potassium is critical — diuretics deplete it; potassium-sparing agents and RAAS drugs increase it.
• Renal function: BUN and creatinine affected by ACE inhibitors, ARBs, and aggressive diuresis.
• Weight and fluid balance: Daily weights for heart failure patients — trend is more important than absolute number.
• Cardiac monitoring: Beta-blockers and non-dihydropyridine CCBs require monitoring for bradycardia and AV block.
• Signs of hypotension: Dizziness, syncope, lightheadedness — especially with first doses of ACE inhibitors and after diuresis.

• Hold beta-blockers if HR < 60 or SBP < 90 — document and notify provider per protocol
• Never abruptly stop beta-blockers — taper over days to weeks to prevent rebound tachycardia and angina
• ACE inhibitor dry cough is a class effect — patient may need to switch to ARB, not just a different ACE inhibitor
• Furosemide IV push: administer slowly (no faster than 20 mg/min) to reduce risk of ototoxicity
• Nitroglycerin sublingual for acute angina: up to 3 doses q5 minutes — if not relieved after 3 doses, call 911
• Assess for angioedema (ACE inhibitors/ARBs/ARNIs) at every assessment — can be life-threatening
• Loop diuretics cause potassium loss — supplement potassium as ordered and educate patient on dietary sources

• Never stop cardiac medications abruptly — especially beta-blockers and antiarrhythmics. Call provider first.
• ACE inhibitor cough: This is a side effect of the medication, not an allergy. Inform provider — a switch to an ARB may be appropriate.
• Furosemide timing: Take in the morning to avoid nighttime urination. Track daily weight — report gain > 2 lb/day to provider.
• Potassium: If on a potassium-wasting diuretic, eat potassium-rich foods (bananas, oranges, potatoes) unless on a potassium-sparing drug.
• Nitroglycerin (sublingual): Keep in original glass bottle, store at room temperature away from heat and light. Replace every 6 months.
• Orthostatic hypotension: Rise slowly from lying/sitting — especially with first-dose of antihypertensives and loop diuretics.

• ACE inhibitor → dry cough (bradykinin). ARB → no cough. Switch if cough is intolerable.
• Beta-blockers: hold for HR < 60. Never stop abruptly — rebound hypertension and angina.
• Furosemide (loop diuretic): causes hypokalemia — monitor K⁺, supplement as ordered
• Nitroglycerin + sildenafil (Viagra) = absolute contraindication. Fatal hypotension.
• Spironolactone: potassium-sparing → hyperkalemia risk. Avoid combining with ACE inhibitors without close monitoring.
• ARNI (Entresto): must wait 36 hours after last ACE inhibitor dose before starting — risk of angioedema
• Non-dihydropyridine CCBs (diltiazem, verapamil): slow the heart rate — useful for AF rate control; avoid in decompensated HF
• Priority assessment before cardiac medications: BP and HR