1.2 Cardiovascular and Anticoagulant Medications
Key Takeaways
Cardiovascular medications include antihypertensives, antiarrhythmics, antianginals, and lipid-lowering agents.
Warfarin requires INR monitoring; common target is 2.0-3.0 for most conditions.
DOACs (Direct Oral Anticoagulants) like rivaroxaban and apixaban have fewer drug interactions than warfarin.
Sublingual nitroglycerin stays in its original glass container, tightly capped after each use, to prevent loss of potency; tablets work within 1-3 minutes.
Many cardiovascular drugs require dose adjustments for renal impairment.
Cardiovascular disease is the leading cause of death in the United States, making cardiovascular medications among the most frequently dispensed. Pharmacy technicians must understand these medications thoroughly.
Antihypertensive Medications
These drugs lower blood pressure and reduce the risk of heart attack, stroke, and kidney disease.
ACE Inhibitors (-pril)
| Generic Name | Brand Name | Common Strengths | Key Points |
|---|---|---|---|
| lisinopril | Zestril, Prinivil | 2.5, 5, 10, 20, 40 mg | Most prescribed ACE inhibitor |
| enalapril | Vasotec | 2.5, 5, 10, 20 mg | Available IV as enalaprilat |
| benazepril | Lotensin | 5, 10, 20, 40 mg | Often combined with amlodipine |
| ramipril | Altace | 1.25, 2.5, 5, 10 mg | Indicated post-MI |
Side Effects: Dry cough (up to 20% of patients), hyperkalemia, angioedema (rare but serious)
Contraindications: Pregnancy (can cause fetal harm), history of angioedema
ARBs (Angiotensin Receptor Blockers) (-sartan)
| Generic Name | Brand Name | Common Strengths | Key Points |
|---|---|---|---|
| losartan | Cozaar | 25, 50, 100 mg | First ARB approved |
| valsartan | Diovan | 40, 80, 160, 320 mg | Also for heart failure |
| olmesartan | Benicar | 5, 20, 40 mg | High potency |
| irbesartan | Avapro | 75, 150, 300 mg | Diabetic nephropathy |
Advantage: Less likely to cause cough than ACE inhibitors; used when ACE inhibitors aren't tolerated
Beta Blockers (-olol)
| Generic Name | Brand Name | Common Strengths | Selectivity |
|---|---|---|---|
| metoprolol tartrate | Lopressor | 25, 50, 100 mg | Cardioselective (beta-1) |
| metoprolol succinate | Toprol-XL | 25, 50, 100, 200 mg | Extended release |
| atenolol | Tenormin | 25, 50, 100 mg | Cardioselective |
| carvedilol | Coreg | 3.125, 6.25, 12.5, 25 mg | Non-selective + alpha blocker |
| propranolol | Inderal | 10, 20, 40, 60, 80 mg | Non-selective |
Side Effects: Bradycardia, fatigue, cold extremities, may mask hypoglycemia symptoms
Warning: Should not be stopped abruptly - may cause rebound hypertension
Calcium Channel Blockers
| Generic Name | Brand Name | Type | Key Points |
|---|---|---|---|
| amlodipine | Norvasc | Dihydropyridine | Most prescribed CCB |
| nifedipine ER | Procardia XL | Dihydropyridine | Must not be crushed |
| diltiazem | Cardizem, Dilacor | Non-dihydropyridine | Also for arrhythmias |
| verapamil | Calan, Verelan | Non-dihydropyridine | Strongest negative inotrope |
Side Effects (Dihydropyridines): Peripheral edema, headache, flushing, reflex tachycardia
Lipid-Lowering Agents
Statins (HMG-CoA Reductase Inhibitors)
| Generic Name | Brand Name | Relative Potency | Metabolism |
|---|---|---|---|
| atorvastatin | Lipitor | High | CYP3A4 |
| rosuvastatin | Crestor | Highest | Minimal CYP |
| simvastatin | Zocor | Moderate | CYP3A4 |
| pravastatin | Pravachol | Lower | Not CYP dependent |
| lovastatin | Mevacor | Moderate | CYP3A4, take with food |
Side Effects: Myalgia (muscle pain), elevated liver enzymes, rare but serious rhabdomyolysis
Drug Interactions: Grapefruit juice increases levels of some statins (atorvastatin, simvastatin, lovastatin)
Anticoagulants
Anticoagulants prevent blood clots and are critical in preventing stroke and treating DVT/PE.
Warfarin (Coumadin)
| Parameter | Details |
|---|---|
| Mechanism | Vitamin K antagonist |
| Monitoring | INR (International Normalized Ratio) |
| Target INR | 2.0-3.0 for most conditions; 2.5-3.5 for mechanical heart valves |
| Antidote | Vitamin K (phytonadione), FFP, or PCC |
Key Drug Interactions:
- Increased bleeding risk: NSAIDs, aspirin, antibiotics, antifungals
- Decreased effectiveness: Vitamin K (green leafy vegetables), rifampin
Counseling Points: Maintain consistent vitamin K intake; avoid significant dietary changes
Direct Oral Anticoagulants (DOACs)
| Generic Name | Brand Name | Mechanism | Key Points |
|---|---|---|---|
| rivaroxaban | Xarelto | Factor Xa inhibitor | Take with food (15 mg, 20 mg doses) |
| apixaban | Eliquis | Factor Xa inhibitor | Twice daily dosing |
| dabigatran | Pradaxa | Direct thrombin inhibitor | Keep in original container |
| edoxaban | Savaysa | Factor Xa inhibitor | Once daily |
Advantages over Warfarin:
- No routine monitoring required
- Fewer drug and food interactions
- Predictable pharmacokinetics
- Rapid onset and offset
Antiplatelet Agents
| Generic Name | Brand Name | Mechanism | Common Use |
|---|---|---|---|
| aspirin | Bayer, Ecotrin | COX inhibitor | MI prevention, stroke prevention |
| clopidogrel | Plavix | P2Y12 inhibitor | Post-stent, ACS |
| prasugrel | Effient | P2Y12 inhibitor | ACS with PCI |
| ticagrelor | Brilinta | P2Y12 inhibitor | ACS, reversible binding |
Important: Clopidogrel is a prodrug requiring CYP2C19 activation; avoid PPIs like omeprazole (interaction)
Antianginal Medications
Nitroglycerin
| Formulation | Onset | Duration | Storage Requirements |
|---|---|---|---|
| Sublingual tablet | 1-3 min | 30-60 min | Original glass container, tightly capped after each use; 20-25°C |
| Translingual spray | 2-5 min | 30-60 min | 3-year shelf life |
| Transdermal patch | 30-60 min | 12-14 hours | Nitrate-free interval needed |
Counseling Points:
- SL tablets: Place under tongue, do not swallow; may take up to 3 doses (5 minutes apart)
- Call 911 if chest pain not relieved after first dose
- Headache is a common side effect (indicates drug is working)
Contraindication: Do NOT use with PDE-5 inhibitors (sildenafil, tadalafil) - severe hypotension risk
A patient on warfarin has a target INR of 2.0-3.0. Which of the following vitamins can decrease warfarin's effectiveness?
Vitamin D
Vitamin B12
Vitamin K
Vitamin C
Which statement about nitroglycerin sublingual tablets is correct?
They should be swallowed whole with water
They keep full potency indefinitely once opened
They stay in their original glass bottle, tightly capped
They can be safely used with sildenafil (Viagra)
A patient reports a dry, persistent cough after starting a new blood pressure medication. Which drug class is most likely responsible?
Beta blockers
Calcium channel blockers
ACE inhibitors
ARBs
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