Cardiac Medication Map
The major cardiac drug classes — what each is for, what it can do to a patient, and the monitoring that matters.
Learning Objectives
- 1.Name the major cardiac medication classes and their purpose.
- 2.Identify the key cautions and monitoring for each class.
- 3.Understand guideline-directed medical therapy (GDMT) for HFrEF at a high level.
Overview
You don’t need every dose memorized today — you need to know what each class does, what it can do to a patient, and what to monitor. That map makes titration and safety second nature.
Antithrombotics
- •Antiplatelets (aspirin, P2Y12 like clopidogrel/ticagrelor): prevent arterial clot; critical after stents (DAPT). Watch bleeding.
- •Anticoagulants (warfarin, DOACs): prevent stroke/clot in AFib/VTE. Watch bleeding; renal dosing for DOACs; INR for warfarin.
Neurohormonal / heart-failure agents
- •Beta-blockers: rate control, ischemia, HFrEF mortality benefit. Watch bradycardia/hypotension; don’t stop abruptly.
- •ACE-i / ARB / ARNI: BP and HFrEF benefit. Watch potassium, creatinine, hypotension; ARNI not with ACE-i (angioedema risk).
- •MRA (spironolactone/eplerenone): HFrEF benefit. Watch hyperkalemia/renal function.
- •SGLT2 inhibitors: HF benefit (HFrEF and HFpEF). Watch volume/genital infections; counsel sick-day rules.
Other workhorses
- •Diuretics (loop/thiazide): congestion/BP. Watch electrolytes, renal function, volume.
- •Calcium channel blockers: BP, rate (non-dihydropyridines), angina. Caution combining rate-lowering agents.
- •Nitrates: angina/symptom relief. Avoid with PDE5 inhibitors (severe hypotension).
- •Statins / lipid agents (ezetimibe, PCSK9): ASCVD risk reduction. Statins — muscle symptoms.
- •Antiarrhythmics (e.g., amiodarone): rhythm control; many have narrow safety margins, QT and organ effects.
- •Digoxin: rate/symptom control; narrow window, watch level and potassium.
GDMT for HFrEF (high level)
- •The four pillars: ARNI (or ACE-i/ARB), beta-blocker, MRA, and SGLT2 inhibitor.
- •Goal is to start all four and titrate as tolerated, watching BP, HR, potassium, and renal function.
- •This combination improves survival in HFrEF — getting patients on all four is a core APP task.
High-risk interactions / cautions
- •RAAS agent + MRA + potassium → hyperkalemia (monitor K/Cr).
- •Multiple rate-lowering drugs → bradycardia/heart block.
- •Nitrates + PDE5 inhibitors → dangerous hypotension.
- •Stopping antiplatelets after a stent → stent thrombosis; stopping beta-blockers abruptly → rebound.
Escalate / flag
Symptomatic bradycardia/hypotension on titration, hyperkalemia, or a patient who stopped a critical antithrombotic are flagged and addressed promptly.
Common beginner mistakes
- •Titrating without checking the relevant labs/vitals.
- •Forgetting GDMT pillars in an HFrEF patient.
- •Missing dangerous combinations (e.g., two rate-lowering agents).
- •Not counseling on what each medication is for (hurts adherence).
Nurse / MA workflow connection
- •Nurses review adherence and route labs; MAs reconcile the med list and flag stopped critical meds.
- •You set the monitoring plan the team helps execute.
Mini cases
A new HFrEF patient (EF 30%) is on a low-dose ACE inhibitor only.
What’s the gap?
Show answer
They’re missing GDMT pillars — a beta-blocker, an MRA, and an SGLT2 inhibitor (and ARNI may be preferred over the ACE-i). Plan to initiate/titrate the four pillars as tolerated with appropriate monitoring (BP, HR, K, Cr).
A patient on a beta-blocker is started on diltiazem for rate control and becomes bradycardic and hypotensive.
What happened?
Show answer
Two rate-lowering agents (beta-blocker + non-dihydropyridine CCB) caused excessive bradycardia/hypotension — a known dangerous combination. Hold/adjust per provider guidance and escalate; avoid stacking AV-nodal blockers without care.