Volume bradycardia by liaoqinmei

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									                  Cardiovascular Drugs 2




             Cardiovascular Drugs
                      2




12/14/2011            1                    Rick Johnson
                                 Cardiovascular Drugs 2


Procainamide (Pronestyl):
   Class
       Antidysrhythmic (Class I-A)
   Description
       ester-type local anesthetic
       Suppresses phase 4 depolarization
         o normal ventricular muscle
         o Purkinje fibers
       reducing the automaticity of ectopic pacemakers
       suppresses reentry dysrhythmias
         o slowing intraventicular conduction.




          12/14/2011                   2                  Rick Johnson
                              Cardiovascular Drugs 2


Procainamide (Pronestyl)
   Onset & Duration
       Onset: 10-30 min
       Duration: 3-6 hours
   Indications
       Suppressing PVCs refractory to lidocaine
       Suppressing VT (with pulse) refractory to lidocaine
       Suppressing VF refractory to lidocaine
       PSVT with wide complex tachycardia of unknown origin




          12/14/2011              3                    Rick Johnson
                             Cardiovascular Drugs 2


Procainamide (Pronestyl)
   Contraindications
       2nd & 3rd degree AV block
       Digitalis toxicity
       Torsades de pointes
       Myasthenia gravis
   Adverse Reactions
       Hypotension, bradycardia, reflex tachycardia, AV block, widened
        QRS, Prolonged P-R or Q-T interval, PVCs, VT, VF, Asystole, CNS
        depression, confusion, seizure, respiratory depression,
        cardiovascular collapse, thrombocytopenia




          12/14/2011             4                    Rick Johnson
                                 Cardiovascular Drugs 2


Procainamide (Pronestyl)
   Drug Interactions
       Increased effects
         o   neuromuscular blockers
         o   anticholinergics
         o   antihypertensives
         o   antihistamines
         o   antidepressants
         o   atropine
       Increased procainamide effects
         o Cimetidine
         o quinidine
       Decreased procainamide effects with barbiturates
       Increased toxicity with other antidysrhythmics



          12/14/2011                  5                   Rick Johnson
                                   Cardiovascular Drugs 2


Procainamide (Pronestyl)
   How Supplied
       1 g in 10 ml vial
       1 g in 2 ml s for infusion
   Dosage & Administration
       Infusion of 20 mg/min until:
          o   arrhythmia is suppressed
          o   hypotension ensues
          o   the QRS complex is widened by 50% of original width
          o   a total of 17 mg/kg is infused.




          12/14/2011                    6                           Rick Johnson
                                 Cardiovascular Drugs 2


Procainamide (Pronestyl)
   Dosage & Administration
       Maintenance infusion
         o Mix 1 g in 250 ml of D5W (4 mg/ml)
         o Infuse at 1-4 mg/min

   Special Considerations
       Pregnancy Safety: Category C
       Procainamide has potent effects
         o Vasodilating
         o inotropic
       Rapid infection may cause procainamide-induced hypotension
       Carefully monitor vital signs and ECG
       Administer cautiously to patients with asthma, digitalis-induced
        dyrhythmias, AMI, or cardiac, hepatic or renal insufficiency


          12/14/2011                  7                   Rick Johnson
                                 Cardiovascular Drugs 2


Adenosine (Adenocard)
   Class
       Antiarrhythmic
       endogenous nucleoside
   Description
       naturally occurring nucleoside
       acts on the AV node to
         o negative dromotropy
         o inhibit reentry pathways
       acts directly on sinus pacemaker cells and vagal nerve terminal to
        decrease
         o chronotropy
         o dromotropy




          12/14/2011                  8                   Rick Johnson
                                Cardiovascular Drugs 2


Adenosine (Adenocard)
   Onset & Duration
       Onset Immediate
       Duration 10 seconds
   Indications
       Conversion of PSVT
         o including that associated with WPW syndrome

   Contraindications
        nd     rd
        2 or 3 degree heart block
       Sick sinus syndrome
       Hypersensitivity




          12/14/2011                9                    Rick Johnson
                            Cardiovascular Drugs 2


Adenosine (Adenocard)
   Adverse Reactions
       Lightheadedness, parasthesia, headache
       diaphoresis
       chest pain, palpitations
       hypotension
       SOB
       transient periods of sinus bradycardia
       asystole and ventricular ectopy
       nausea
       metallic taste
       facial flushing



          12/14/2011            10                   Rick Johnson
                             Cardiovascular Drugs 2


Adenosine (Adenocard)
   Drug interactions
       Smoking: increased tachycardia
       Methylzanthines antagonize action of adenosine
         o caffeine
         o theophylline
       Dipyridamole potentiates the effects of adenosine
         o reduce dose
       Carbamazepine may potentiate the AV nodal blocking effect of
        adenosine
       Possible VF with digoxin




          12/14/2011             11                      Rick Johnson
                                            Cardiovascular Drugs 2


Adenosine (Adenocard)
   How supplied
       3mg/ml in 2 ml vial
   Dosage & Administration
       Initial dose
          o 6 mg rapid bolus over 1-3 seconds
                 followed immediately by a 20 ml saline flush.
                 If using an IV line use port near injection site.

       If no response
          o Administer 12 mg bolus as before
          o may repeat one additional time if no response




          12/14/2011                               12                 Rick Johnson
                               Cardiovascular Drugs 2


Adenosine (Adenocard)
   Special Considerations
       Pregnancy safety category C
       A brief period of asystole up to 15 seconds followed by resumption
        of NSR, is common after rapid administration
       Patients taking theophylline may require larger doses of adenosine
       cardiac transplant recipients may require only a small dose
       May produce bronchoconstriction in patients with:
         o Asthma
         o bronchopulmonary disease




          12/14/2011                  13                Rick Johnson
                             Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Class
       Calcium Channel Blocker, Class IV
       antidysrhythmic
       Antihypertensive & Antianginal
   Description
       Calcium channel antagonist
       Inhibits calcium ion influx across cell membrane during cardiac
        depolarization
       Produces relaxation of coronary vascular smooth muscle
       Dilates coronary arteries
       Decreases SA/AV node conduction
       Dilates peripheral arteries

          12/14/2011             14                     Rick Johnson
                             Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Onset and Duration
       Onset 2-5 min
       Duration      30-60 min
   Indications
       PSVT refractory to adenosine
       Atrial flutter with RVR
       Atrial fibrillation with RVR




          12/14/2011              15                  Rick Johnson
                                Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Contraindications
       Hypersensitivity
       Sick sinus syndrome
        nd    rd
        2 or 3 degree heart block
       Hypotension
       Cardiogenic shock
       Severe CHF
       WPW with atrial fibrillation or flutter
       Patients receiving intravenous Beta blockers
         o CHF, Bradycardia and Asystole
       Wide complex tachycardias



          12/14/2011                16                   Rick Johnson
                          Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Adverse Reactions
       Dizziness
       Headache
       Nausea & vomiting
       Hypotension
       Bradycardia
       CHF
       Complete AV Block
       Peripheral edema
       Asystole
       Stevens-Johnson Syndrome



         12/14/2011           17                   Rick Johnson
                             Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Drug Interactions
       Verapamil increases serum concentration of digoxin
       Beta adrenergic blockers may have additive negative inotropic and
        chronotropic effects
       Antihypertensives may potentiate hypotensive effects




          12/14/2011             18                    Rick Johnson
                                  Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   How Supplied
       5mg/2ml in 2,4,5 ml vials or ampules
   Dosage
       2.5 mg IV bolus over 2-3 minutes
       If no response
         o 5-10 mg IV bolus over 2-3 minutes 15-30 minutes after initial dose;
         o or 5 mg q 15 min until a desired response is achieved
         o Maximum dose 30 mg




          12/14/2011                   19                          Rick Johnson
                              Cardiovascular Drugs 2


Verapamil (Isoptin, Calan)
   Special Considerations
       Pregnancy Safety: Category C
       Closely monitor patient’s vital signs
       Give smaller amounts (2-4mg) over longer periods of time (3-4 min)
        when treating the elderly or when the blood pressure is in the lower
        range of normal
       Be prepared to resuscitate patient
       AV block or asystole may occur due to slowed AV conduction
       Many physicians recommend slow IV administration of 500 mg of
        calcium chloride prior to verapamil to minimize the untoward
        results in hypotension and bradycardia




          12/14/2011              20                    Rick Johnson
                                 Cardiovascular Drugs 2


Diltazem (Cardizem)
   Class
       Calcium channel blocker Class IV
       antidysrhythmic
       Antihypertensive & Antianginal
   Description
       Calcium-ion antagonist
       Slows conduction,
         o increases refraction in the AV node
         o causes coronary vasodilaation
       Inhibits calcium ion influx across cell membrane during cardiac
        depolarization
       Dilates peripheral arteries


          12/14/2011                  21                  Rick Johnson
                               Cardiovascular Drugs 2


Diltazem (Cardizem)
   Onset & Duration
       Onset 2-5 min
       Duration      1-3 hr
   Indications
       Atrial fibrillation
       Atrial flutter
       Multifocal atrial tachycardias
       PSVT




          12/14/2011               22                   Rick Johnson
                            Cardiovascular Drugs 2


Diltazem (Cardizem)
   Contraindications
       Severe hypotension
       Cardiogenic shock
       Sick sinus syndrome
        nd    rd
        2 or 3 degree block
       Hypersensitivity to diltazem
       Concomitant use of IV beta blockers
       Wide-complex tachycardia of unknown origin




          12/14/2011            23                   Rick Johnson
                            Cardiovascular Drugs 2


Diltazem (Cardizem)
   Adverse Reactions
       Atrial flutter
        st       nd
        1 and 2 degree AV block
       Bradycardia, Chest pain, CHF
       Syncope
       Ventricular dysrhythmias & Asystole
       Dizziness, Sweating, Nausea and Vomiting
       Dry mouth
       Dyspnea
       Headache
       Acute Renal Failure



          12/14/2011            24                   Rick Johnson
                                            Cardiovascular Drugs 2


Diltazem (Cardizem)
   Drug interactions
       Caution is warranted in patients receiving medications that affect
        cardiac contractility and/or SA or AV node conduction
       Incompatible with simultaneous furosemide injection
       Increased effects of diltazem with cimetidine
   How supplied
       25 mg (5 ml vial)
       50 mg (10 ml vial)
       Dosage
         o 0.25 mg/kg (20 mg for the average patient) IV bolus over 2 min
         o May repeate in 15 min (0.35 mg/kg; 25 mg for average patient) IV over 2-5 min
         o Maintenance infusion
                Dilute 125 mg (25 ml) in 100 ml of solution; infuse 5-15 mg/hr titrated to heart rate



          12/14/2011                              25                                      Rick Johnson
                                Cardiovascular Drugs 2


Diltazem (Cardizem)
   Special Considerations
       Pregnancy Safety: Category C
       Use with caution in patients with impaired renal or hepatic function
       Hypotension may occasionally result carefully monitor vital signs
       PVC’s may be present on conversion of PSVT to sinus rhythm
       Shelf-life at room temperature
         o one month unless using reconstituted form




          12/14/2011                 26                  Rick Johnson
                                 Cardiovascular Drugs 2


Amiodarone HCL (Cordarone)
   Class
       Antiarrhythmic Agent Class III
   Description
       Prolongs duration of
         o action potential and effective refractory period
         o noncompetitive alpha and beta adrenergic inhibition
       Increases PR and QT intervals, decreases sinus rate and peripheral
        vascular resistance
   Onset and Duration
       Onset Unknown
       Duration Variable



          12/14/2011                  27                         Rick Johnson
                                   Cardiovascular Drugs 2


Amiodarone HCL (Cordarone)
   Indication
       Severe
         o VT, SVT,A-Fib, VF
         o not controlled by first-line agents and cardiac arrest

   Contraindications
       Lactation
        nd      rd
        2 and 3 degree AV block
       Severe sinus node dysfunction
       Bradycardia
       Hypersensitivity
       Neonates and infants



          12/14/2011                   28                           Rick Johnson
                             Cardiovascular Drugs 2


Amiodarone HCL (Cordarone)
   Adverse Reactions
       Hypotension
       Bradycardia, Prolonged PR interval
       Pulmonary toxicity
       CHF, sinus arrest, dysrhythmias, SA node dysfunction
   Drug Interactions
       Bradycardia: Beta Blockers, Calcium channel blockers
       Increased levels of digoxin, quinidine, procainamide, disopyramide,
        theophylline phenytoin
       Increased anticoagulant effects of warfarin




          12/14/2011             29                     Rick Johnson
                                 Cardiovascular Drugs 2


Amiodarone HCL (Cordarone)
   How Supplied
       Ampule of 150 mg/3 ml
   Dosage
       Recurrent VF/VT
         o Maximum cumulative does is 2.2 g over 24 hours
         o Cardiac Arrest 300 mg IV push
       Ventricular arrhythmias
         o 150 mg mixed in 100 ml of D5W over 10 minutes IV.
         o Mix in glass or polyolefin bottles.
         o Incompatible with normal saline
       Maintenance dose
         o 1mg/min for 6 hours then 0.5 mg/min.




          12/14/2011                 30                        Rick Johnson
                             Cardiovascular Drugs 2


Amiodarone HCL (Cordarone)
   Special considerations
       Pregnancy Class D
       Be aware of high risk of adverse reactions
       Can cause fatal toxicities including heptic and pulmonary




          12/14/2011             31                     Rick Johnson
                                   Cardiovascular Drugs 2


Phenytoin (Dilantin)
   Class
       Class 1-B
       Anticonvulsant
       Antiarrhythmic
   Description
       Drug of choice in controlling
         o grand mal seizure activity
         o focal motor seizure activity
       Digitalis-induced atrial and ventricular dysrhythmias
         o stabilizing the sodium influx in Purkinje fibers of the heart
         o decreasing abnormal ventricular automaticity
         o decreasing the refractory period




          12/14/2011                      32                         Rick Johnson
                              Cardiovascular Drugs 2


Phenytoin (Dilantin)
   Onset and Durations
       Onset Immediate
       Duration Unknown
   Indications
       Major motor seizures
       Digitalis or tricyclic – Induced dysrhythmias
   Contraindications
       Hypersensitivity
       Bradycardia
        nd     rd
        2 and 3 degree heart block
       Stokes-Adams syndrome


          12/14/2011              33                    Rick Johnson
                             Cardiovascular Drugs 2


Phenytoin (Dilantin)
   Adverse Reactions
       Hypotension, VF, cardiovascular collapse, dysrhthmias
       Drowsiness, dizziness, headache,
       Nausea, vomiting
       Respiratory depression
       CNS depression




          12/14/2011             34                   Rick Johnson
                              Cardiovascular Drugs 2


Phenytoin (Dilantin)
   Drug interactions
       Anticoagulants, cimetidine, sulonamides and salicylates may
        increase serum phenytonin levels.
       Chronic alcohol speeds metabolism of the drug
       Xanthines may result in decreased phenytonin absorption
       Precipitation may occur when mixed with D5W
       Incompatible with many solutions and medications
   How supplied
       50 mg/ml in 2 and 5 ml ampules, 2 ml prefilled syringe
       May be diluted in NS(1-10mg/ml) use and inline filter
       IV line should be flushed with 0.9% NS before and after the drug is
        administered


          12/14/2011              35                     Rick Johnson
                              Cardiovascular Drugs 2


Phenytoin (Dilantin)
   Dosage and Administration
       50-100 mg (diluted) slow IV
       q 5-15 min prn
       maximum dose 1 g
   Special considerations
       Pregnancy safety Category D
       Phenytoin may normally have slight yellow color
       Carefully monitor vital signs
       Venous irritation can occur due to alkalinity of solution
       Use with caution in patients with pulmonary, cardiovascular, heptic,
        or renal insufficiency
       Use large, stable vein for injection

          12/14/2011              36                    Rick Johnson
                                  Cardiovascular Drugs 2


Edrophonium chloride (Tensilon)
   Class
       Antiarrhythmic
       cholinesterase inhibitor
   Description
       Inhibits destruction of acetylcholine
         o increases concentration at sites where acetylcholine is released
         o facilitates transmission of impulses across myoneural junction

   Onset & Duration
       Onset < 1 minute
       Duration 5-20 minutes
   Indication
       PSVT refractory to vagal maneuvers and adenosine

          12/14/2011                  37                           Rick Johnson
                             Cardiovascular Drugs 2


Edrophonium chloride (Tensilon)
   Contraindications
       Hypersensitivity
       Hypotension or bradycardiac
   Adverse Reactions
       Dizziness, weakness, sweating, increased salivation, constricted
        pupils, hypotension, bradycardia, abdominal cramps, nausea &
        vomiting
       Paralysis of respiratory muscles




          12/14/2011             38                     Rick Johnson
                              Cardiovascular Drugs 2


Edrophonium chloride (Tensilon)
   Drug Interactions
       Dextrose solutions because it tends to crystallize in the tubing
       Bradycardia with digitalis
       Prolonged action of depolarizing muscle relaxants
       Decreased action of procainamide, quinidine, atropine
   How Supplied
       10 mg in 1 ml of solvent
   Dosage and Administration
       5 mg initially IV
                                 nd
        After 10 if unsuccessful 2 dose of 10 mg




          12/14/2011               39                    Rick Johnson
                              Cardiovascular Drugs 2


Edrophonium chloride (Tensilon)
   Special considerations
       Pregnancy category C
       Monitor vital signs frequently
       Be prepared to administer atropine
       Closely monitor respiratory status of patient




          12/14/2011              40                    Rick Johnson
                             Cardiovascular Drugs 2


Magnesium Sulfate
   Class
       Antiarrhythmic
       Electrolyte
       Anticonvulsant
   Description
       Magnesium sulfate reduces striated muscle contractions and
        blocks peripheral neuromuscular transmission by reducing
        acetylcholine release at the myoneural junction
   Onset and Duration
       Onset IV Immediate
       Duration IV 30 minutes



          12/14/2011             41                   Rick Johnson
                               Cardiovascular Drugs 2


Magnesium Sulfate
   Indications
       Seizures of eclampsia
       Torsades de pointes
       Suspected hypomagnesemia
       Refractory ventricular fibrillation
   Contraindication
       Heart block
       Myocardial damage
       Shock
       Severe hypertension




          12/14/2011               42                   Rick Johnson
                              Cardiovascular Drugs 2


Magnesium Sulfate
   Adverse Reactions
       Diaphoresis
       Facial flushing, itching and rash
       Hypotension
       Depressed reflexes
       Hypothermia
       Reduced heart rate
       Circulatory collapse
       Respiratory depression
       Diarrhea




          12/14/2011              43                   Rick Johnson
                             Cardiovascular Drugs 2


Magnesium Sulfate
   Drug Interactions
       Serious changes in cardiac function may occur with cardiac
        glycosides
       CNS depressant effects may be enhanced if the patient is taking
        other CNS depressants
   How Supplied
       10%, 12.5%, 50% solution in 40 mg, 80 mg, 100 mg and 125 mg/ml
   Dosage and Administration
       1-2 g (2-4 ml of a 50% solution) in 10 ml of D5W over 1-2 min IV
       Use the same dose or higher for patients with Torsades de pointes




          12/14/2011             44                    Rick Johnson
                              Cardiovascular Drugs 2


Magnesium Sulfate
   Special Considerations
       Pregnancy safety: Category B
       Magnesium sulfate is administered for the treatment of toxemia of
        pregnancy.
       IV calcium gluconate or calcium chloride should be available as an
        antagonist to magnesium if needed
       Magnesium must be used with caution in patients with renal failure,
        since it is cleared by the kidney and can reach toxic levels easily in
        those patients




          12/14/2011              45                      Rick Johnson
                              Cardiovascular Drugs 2


Parasympatholics
   Parasympathetic innervation of the heart
       through the vagus nerve
   Parasympatholytics (anticholinergics)
       Drugs that inhibit the actions of the parasympathetic nervous
        system
   Vagus nerve stimulation
       Valsalva maneuver
       carotid sinus massage
       pain
       distention of the urinary bladder




          12/14/2011              46                    Rick Johnson
                              Cardiovascular Drugs 2


Atropine Sulfate
   Class
       Anticholinergic
   Description
       Inhibits actions of acetylcholine at postganglionic parasympathetic
        receptor sites
       Blocked vagal effects result in increased heart rate & enhanced AV
        conduction with limited or no inotropic effect
   Onset & Duration
       Onset Rapid
       Duration    2-6 hours




          12/14/2011              47                    Rick Johnson
                             Cardiovascular Drugs 2


Atropine Sulfate
   Indications
       Hemodynamically significant bradycardia
       Asystole, PEA
       Organophosphate or nerve gas poisoning
       Bronchospastic pulmonary disorders
   Contradictions
       None in emergency situations
       Tachycardia
       Hypersensitivity
       Obstructive disease of GI tract
       Unstable cardiovascular status in acute hemorrhage with
        myocardial ischemia

          12/14/2011             48                   Rick Johnson
                             Cardiovascular Drugs 2


Atropine Sulfate
   Adverse Reactions
       Tachycardia
       Paradoxical bradycardia when pushed too slowly or when used at
        doses less than 0.5 mg
       Palpitations
       Dysrhythmias
       Headache
       Anticholinergic effects (dry mouth/nose/skin, photophobia, blurred
        vision, urinary retention, constipation
       Nausea and vomiting
       Flushed, hot dry skin
       Allergic reactions


          12/14/2011             49                     Rick Johnson
                              Cardiovascular Drugs 2


Atropine Sulfate
   Drug interactions
       Use with other anticholinergic agents may increase vagal blockade
       Potential adverse when administered in conjunction with digitalis,
        cholinergics
       The effects of atropine may be enhanced by antihistamines,
        procainamide, quinidine, antipsychotics and antidepressants,
        thiazides
       Increased toxicity with amantadine
   How supplied
       Prefilled syringes containing 1 mg in 10 ml of solution




          12/14/2011              50                     Rick Johnson
                                 Cardiovascular Drugs 2


Atropine Sulfate
   Dosage and Administration
       Bradydysrhythmias
         o 0.5-1 mg IV
         o may be repeated every 3-5 minutes for desired response
         o Max 0.04 mg/kg
       Asystole and PEA with absolute or relative bradycardia
         o 1 mg IV every 3-5 min
         o max 0.04 mg/kg (2-2.5 the dose for ET)

   Special Considerations
       Pregnancy Safety: Category C
       Follow ET administration with several positive pressure ventilations
       Pupillary dilation, pupils nonreactive; pupils may not be useful in
        monitoring CNS status


          12/14/2011                  51                        Rick Johnson
                              Cardiovascular Drugs 2


Cardiac Glycosides
   Naturally occurring plant substances
       Have characteristic effects on the heart
       Positive inotropic effect
       Modest negative chronotropic effect
       Profound negative dromotropic effect




          12/14/2011              52                   Rick Johnson
                              Cardiovascular Drugs 2


Digoxin (Lanoxin)
   Class
       Cardiac Glycoside
       Miscellaneous antidysrhythmic
   Description
       Derived primarily from the foxglove plant
       Involves alteration of ion transport across cardiac cell membranes
       Increased intracellular calcium improves myocardial contractility
       Decreases sinus node rate, reduces sympathetic tone and
        increases AV node conduction velocity




          12/14/2011              53                    Rick Johnson
                              Cardiovascular Drugs 2


Digoxin (Lanoxin)
   Onset and Duration
       Onset IV 5-30 minutes
       Duration 3-5 days
   Indications
       Supraventricular tachycardias, especially atrial flutter and A-FIB
       CHF
       Cardiogenic shock




          12/14/2011              54                      Rick Johnson
                             Cardiovascular Drugs 2


Digoxin (Lanoxin)
   Contraindications
       V-Fib
       V-tach
       AV block
       Digitalis toxicity
       Hypersensitivity
        nd     rd
        2 or 3 degree heart block in the absence of artificial pacing




          12/14/2011             55                     Rick Johnson
                              Cardiovascular Drugs 2


Digoxin (Lanoxin)
   Adverse Reactions (Most related to Dig Toxicity)
       Headache
       Weakness
       Visual disturbances (blurred, yellow or green vision)
       Confusion
       Seizures
       Dysrhythmias
       Nausea and vomiting
       Skin Rash
   How supplied
       2 mL ampules containing 0.5 mg of the drug


          12/14/2011              56                     Rick Johnson
                              Cardiovascular Drugs 2


Digoxin (Lanoxin)
   Dosage and Administration
       0.25-0.5 mg slow IV
   Special Considerations
       Pregnancy Safety Category C
       Patient should be constantly monitored for signs of digitalis toxicity
       Patients with MI and/or renal failure are prone to developing
        digitalis toxicity
       Digitalis toxicity is potentiated inpatients with hypokalemia,
        hypomagnesemia, & hypercalcemia
       Avoid use in patients with WPW syndrome because of possible
        ventricular dysrhythmias



          12/14/2011              57                      Rick Johnson
                              Cardiovascular Drugs 2


Thrombolytics
   MI begins with formation of blood clot
       thrombus in a coronary artery.
   Thrombolytic drugs dissolve clots after their formation
       by promoting the digestion of fibrin




          12/14/2011              58                   Rick Johnson
                                 Cardiovascular Drugs 2


Aspirin
   Class
       Platelet aggregator inhibitor
         o anti-inflammatory agent
         o analgesic and antipyretic

   Description
       Aspirin blocks pain impulses in the CNS
       Dilates peripheral vessels
       Decreases platelet aggregation
   Onset and Duration
       Onset 15-30 minutes
       Duration     4-6 hours



          12/14/2011                   59                 Rick Johnson
                              Cardiovascular Drugs 2


Aspirin
   Indications
       Mild to moderate pain or fever
       Prevention of platelet aggregation in:
         o Ischemia
         o thromboembolism
       Unstable angina
       Prevention of MI or reinfarction




          12/14/2011              60                   Rick Johnson
                             Cardiovascular Drugs 2


Aspirin
   Contraindications
       Hypersensitivity
       GI bleeding
       Active ulcer disease
       Hemorrhagic stroke
       Bleeding disorders
       Children with flu-like symptoms




          12/14/2011             61                   Rick Johnson
                              Cardiovascular Drugs 2


Aspirin
   Adverse Reactions
       Stomach irritations
       Heartburn or indigestion
       Nausea or vomiting
       Allergic reaction
   Drug interactions
       Decreased effects with antacids and steroids
       Increased effects with anticoagulants, insulin, oral hypoglycemics,
        thrombolytic agents, NSAIDs




          12/14/2011               62                   Rick Johnson
                                  Cardiovascular Drugs 2


Aspirin
   How Supplied
       Tablets (chewable and standard)
         o 65, 81, 325, 500, 650, 975 mg
       Capsules (325 and 500 mg)
       Controlled-release tablets (800 mg)
       Suppositories (60 mg to 1.2 g)
   Dosage and Administration
       160-325 mg for MI
         o Baby aspirin (81) is often preferred

   Special Considerations
       Pregnancy Category D
       Should be given as soon as possible to the patient with AMI


          12/14/2011                   63                  Rick Johnson
                              Cardiovascular Drugs 2


Streptokinase (Streptase)
   Class
       Thrombolytic
   Description
       Streptokinase combines with plasminogen to produce an activator
        complex that converts free plasminogen to the proteolytic enzyme
        plasmin
       Plasmin acts as an enzyme to degrade fibrin threads as well as
        fibrinogen
   Onset & Duration
       Onset 10-20 min (fibrinolysis, 10-20 min; clot lysis 60-90 min)
       Durations 3-4 hours prolonged bleeding times up to 24 hours



          12/14/2011              64                    Rick Johnson
                            Cardiovascular Drugs 2


Streptokinase (Streptase)
   Indications
       Acute evolving MI
       Massive pulmonary emboli
       arterial thrombosis and embolism
       to clear arteriovenous cannulas
       DVT




          12/14/2011            65                   Rick Johnson
                             Cardiovascular Drugs 2


Streptokinase (Streptase)
   Contraindications
       Hypersensitivity
       Active bleeding
       Recent surgery within 2-3 weeks
       Recent CVA with 6 months
       Prolonged CPR
       Intracranial or intraspinal surgery
       Recent significant trauma (particularly head trauma
       Pregnancy
       Uncontrolled hypertension




          12/14/2011             66                     Rick Johnson
                             Cardiovascular Drugs 2


Streptokinase (Streptase)
   Relative Contraindications
       History of trauma or surge in past 2 months
       Initial BP > 180 systolic or 110 diastolic
       Active peptic ulcer or blood in stool
       History of stroke, tumor, brain surgery or head injury
       Known bleeding disorder or current use of warfarin
       Exposure to streptokinase or anistreplase during preceding 12
        months
       Significant liver or kidney dysfunction
       Known cancer or illness with possible thoracic, abdominal or
        intracranial abnormalities



          12/14/2011             67                    Rick Johnson
                            Cardiovascular Drugs 2


Streptokinase (Streptase)
   Adverse Reactions
       Bleeding
       Allergic reactions
       Hypotension
       Chest pain
       Reperfusion dysrhythmias
       Abdominal pain
       Nausea and vomiting




         12/14/2011             68                   Rick Johnson
                               Cardiovascular Drugs 2


Streptokinase (Streptase)
   Drug interactions
       Heparin and other anticoagulants may increase risk of bleeding as
        well as improved outcome
   How Supplied
       250,000; 750,000; 1.5 million IU vials
       Reconstitute by slowly adding 5 mL of sodium chloride or D5W,
        directing stream toward the side of the vial rather than into the
        powder.
       Gently roll-DO NOT SHAKE the vial for reconstitution.
       Slowly dilute the entire contents of the vial to a total volume of 45
        mL




          12/14/2011               69                      Rick Johnson
                              Cardiovascular Drugs 2


Streptokinase (Streptase)
   Dosage and Administration
       750,000 to 1.5 million U diluted to 45 mL IV over 1 hour
   Special Considerations
       Pregnancy Safety: Category C
       Do not administer IV injections to patients receiving thrombolytic
        drugs
       Obtain blood sample for coagulation studies prior to administration
       Carefully monitor vital signs
       Observe the patient for bleeding
       Use caution when moving patient to avoid bruising or bleeding
       Do not draw arterial blood specimens in thrombolytic therapy
        candidates


          12/14/2011              70                     Rick Johnson
                              Cardiovascular Drugs 2


Anistreplase (Eminase, Apsac)
   Class
       Thrombolytic
   Description
       Activated in vivo by non-enzymatic process
       Active drug converts plasminogen to plasmin.
       Plasmin digest fibrin and fibrinogen resulting in dissolution of clots
   Onset and Duration
       Onset Immediate
       Durations 6 hours to 2 days
   Indications
       Acute MI


          12/14/2011              71                      Rick Johnson
                             Cardiovascular Drugs 2


Anistreplase (Eminase, Apsac)
   Contraindications
       Hypersensitivity
       Active bleeding
       Recent surgery within 2-3 weeks
       Recent CVA with 6 months
       Prolonged CPR
       Intracranial or intraspinal surgery
       Recent significant trauma (particularly head trauma
       Pregnancy
       Uncontrolled hypertension




          12/14/2011             72                     Rick Johnson
                             Cardiovascular Drugs 2


Anistreplase (Eminase, Apsac)
   Relative Contraindications
       History of trauma or surge in past 2 months
       Initial BP > 180 systolic or 110 diastolic
       Active peptic ulcer or blood in stool
       History of stroke, tumor, brain surgery or head injury
       Known bleeding disorder or current use of warfarin
       Exposure to streptokinase or anistreplase during preceding 12
        months
       Significant liver or kidney dysfunction
       Known cancer or illness with possible thoracic, abdominal or
        intracranial abnormalities



          12/14/2011             73                    Rick Johnson
                            Cardiovascular Drugs 2


Anistreplase (Eminase, Apsac)
   Adverse Reactions
       Bleeding
       Allergic reactions
       Hypotension
       Chest pain
       Reperfusion dysrhythmias
       Abdominal pain
       Nausea and vomiting




         12/14/2011             74                   Rick Johnson
                              Cardiovascular Drugs 2


Anistreplase (Eminase, Apsac)
   Drug interactions
       Heparin and other anticoagulants may increase risk of bleeding as
        well as improved outcome
   How Supplied
       30 unit vial
   Dosage and Administration
       30 units injected slowly over 4-5 minutes
       Follow manufacturer’s instructions for reconstitution
   Special Considerations
       Pregnancy Category C
       Do not shake


          12/14/2011              75                    Rick Johnson
                             Cardiovascular Drugs 2


Alteplase (Activase, TPA)
   Class
       Thrombolytic
   Description
       Binds to fibrin in a thrombus and converts the plasminogen into
        plasmin.
       Plasmin then digest fibrin and fibrinogen
   Onset and Duration
       Onset Unknown
       Duration Unknown




          12/14/2011             76                    Rick Johnson
                             Cardiovascular Drugs 2


Alteplase (Activase, TPA)
   Contraindications
       Hypersensitivity
       Active bleeding
       Recent surgery within 2-3 weeks
       Recent CVA with 6 months
       Prolonged CPR
       Intracranial or intraspinal surgery
       Recent significant trauma (particularly head trauma
       Pregnancy
       Uncontrolled hypertension




          12/14/2011             77                     Rick Johnson
                             Cardiovascular Drugs 2


Alteplase (Activase, TPA)
   Relative Contraindications
       History of trauma or surge in past 2 months
       Initial BP > 180 systolic or 110 diastolic
       Active peptic ulcer or blood in stool
       History of stroke, tumor, brain surgery or head injury
       Known bleeding disorder or current use of warfarin
       Exposure to streptokinase or anistreplase during preceding 12
        months
       Significant liver or kidney dysfunction
       Known cancer or illness with possible thoracic, abdominal or
        intracranial abnormalities



          12/14/2011             78                    Rick Johnson
                              Cardiovascular Drugs 2


Alteplase (Activase, TPA)
   Drug interactions
       Heparin and other anticoagulants may increase risk of bleeding as
        well as improved outcome
   How Supplied
       20, 50 and 100 mg vials
   Dosage
       IV a total of 100 mg; 6-10 mg given IV bolus over 1-2 min; 60 mg
                                                nd      rd
        given over first hour, 20 mg give over 2 and 3 hour
   Special Considerations
       Pregnancy risk Category C




          12/14/2011              79                    Rick Johnson
                             Cardiovascular Drugs 2


Reteplase (Retavase)
   Class
       Thrombolytic
   Description
       Generates plasmin from plasminogen that degrades the fibrin
        matrix of a thrombus
   Onset
       Onset Prompt effecting vessel patency within 90 minutes for most
        patients
       Duration       Variable
   Indications
       Management of AMI in adults



          12/14/2011             80                    Rick Johnson
                             Cardiovascular Drugs 2


Reteplase (Retavase)
   Contraindications
       Hypersensitivity
       Active bleeding
       Recent surgery within 2-3 weeks
       Recent CVA with 6 months
       Prolonged CPR
       Intracranial or intraspinal surgery
       Recent significant trauma (particularly head trauma
       Pregnancy
       Uncontrolled hypertension




          12/14/2011             81                     Rick Johnson
                             Cardiovascular Drugs 2


Reteplase (Retavase)
   Relative Contraindications
       History of trauma or surge in past 2 months
       Initial BP > 180 systolic or 110 diastolic
       Active peptic ulcer or blood in stool
       History of stroke, tumor, brain surgery or head injury
       Known bleeding disorder or current use of warfarin
       Exposure to streptokinase or anistreplase during preceding 12
        months
       Significant liver or kidney dysfunction
       Known cancer or illness with possible thoracic, abdominal or
        intracranial abnormalities



          12/14/2011             82                    Rick Johnson
                              Cardiovascular Drugs 2


Reteplase (Retavase)
   Drug interactions
       Heparin and other anticoagulants may increase risk of bleeding as
        well as improved outcome
       Incompatible with heparin do not use same IV line
   How Supplied
       10.4 units (18.1 mg) / vial
       Supplied in a kit with components for reconstitution for two single-
        use vials




          12/14/2011              83                     Rick Johnson
                                 Cardiovascular Drugs 2


Reteplase (Retavase)
   Dosage & Administration
       IV double bolus injections
         o 10 units over 2 min
         o 2nd bolus is given 30 minutes after 1st bolus
         o Heparin and aspirin should be administered concomitantly

   Special Considerations
       Pregnancy Category C
       Reteplase should be given in an IV line in which no other
        medication is simultaneously injected or infused
       Protect contents of package from light




          12/14/2011                 84                         Rick Johnson
                                  Cardiovascular Drugs 2


Heparin Solution
   Class
       Anticoagulant
   Description
       Inhibits the clotting cascade by activating specific plasma proteins
       Considered part of the “thrombolytic package” administered to
        patients with acute MI along with aspirin and thrombolytic agents
   Onset and Duration
       Onset
         o IV     Immediate
         o SQ     20-60 minutes
       Duration          4-6 hours



          12/14/2011                  85                   Rick Johnson
                              Cardiovascular Drugs 2


Heparin Solution
   Indications
       Acute MI
       Prophylaxis and treatment for thrombolytic disorders (DVT,
        pulmonary emboli)
   Contraindications
       Hypersensitivity
       Active bleeding
       Recent intracranial, intraspinal or eye surgery
       Severe hypertension
       Bleeding tendencies
       Severe thrombocytopenia



          12/14/2011              86                      Rick Johnson
                               Cardiovascular Drugs 2


Heparin Solution
   Adverse Reactions
       Allergic reaction (chills, fever, back pain)
       Thrombocytopenia
       Hemorrhage
       Bruising
   Drug Interactions
       Salicylates, ibuprofen, dipyridamole, hydroxychloriquine may
        increase risk of bleeding
   How Supplied
       10, 100, & 1000-4000 U/mL




          12/14/2011               87                   Rick Johnson
                              Cardiovascular Drugs 2


Heparin Solution
   Drug Administration
       If used with thrombolytic therapy, always obtain a blood sample for
        control of partial thromboplastin time (PTT) before heparin
        administration. Heparin along with aspirin is part of the
        “thrombolytic package.”
       Heparin doses range fro 100-5000 U (follow medical direction and
        local protocols)
   Special Considerations
       Pregnancy safety category C
       Heparin does not lyse existing clots




          12/14/2011              88                    Rick Johnson
                             Cardiovascular Drugs 2


Sodium Bicarbonate
   Class
       Buffer
       Alkalinizing agent
       electrolyte supplement
   Description
       Used to buffer metabolic acidosis
       Produces water and carbon dioxide
   Onset and Duration
       Onset 2-10 min
       Duration     30-60 min




          12/14/2011             89                   Rick Johnson
                              Cardiovascular Drugs 2


Sodium Bicarbonate
   Indications
       Known pre-existing bicarbonate responsive acidosis
       Intubated patient with continued long arrest interval, PEA
       Upon return of spontaneous circulation after long arrest interval
       Tricyclic antidepressant overdose
       Alkalinization for treatment of specific intoxications
       Management of Metabolic acidosis
       DKA




          12/14/2011              90                     Rick Johnson
                              Cardiovascular Drugs 2


Sodium Bicarbonate
   Contraindications
       In patients with chloride loss from vomiting and GI suction
       Metabolic and respiratory alkalosis
       Severe pulmonary edema
       Hypocalcaemia
       Hypokalemia
       Hypernatremia
       When administration of NA could be detrimental




          12/14/2011              91                    Rick Johnson
                               Cardiovascular Drugs 2


Sodium Bicarbonate
   Adverse Reactions
       Metabolic alkalosis
       Hypoxia
       Rise in intracellular PCO2 and increased tissue acidosis
       Electrolyte imbalance (hypernatremia)
       Seizures
       Tissue sloughing at injection site
   Drug interactions
       May precipitate in calcium solutions
       Alkalinization of urine may shorten elimination half-lives of certain
        drugs
       Vasopressors may be deactivated

          12/14/2011               92                     Rick Johnson
                             Cardiovascular Drugs 2


Sodium Bicarbonate
   How supplied
       50 mEq in 50 mL
   Dosage and Administration
       1 mEq/kg IV, repeat with 0.5 mEq/kg q 10 minutes
   Special Considerations
       Pregnancy safety category C
       Blood gas analysis should guide bicarbonate administration
       Produces carbon dioxide which crosses cell membranes more
        rapidly than bicarbonate
       May increase edematous or sodium retaining states
       May worsen CHF, Maintain Adequate ventilation



          12/14/2011             93                    Rick Johnson
                             Cardiovascular Drugs 2


Morphine Sulfate (Astromorph PF and others)
   Class
       Opiate Analgesic
       Schedule II controlled substance
   Description
       Depresses pain impulse transmission at the spinal cord level by
        interacting with opioid receptors.
       Provides both analgesia and sedation
       Increases peripheral venous capacitance and decreases venous
        return
   Onset and Duration
       Onset 1-2 min
       Duration      2-7 hours

          12/14/2011              94                   Rick Johnson
                             Cardiovascular Drugs 2


Morphine Sulfate (Astromorph PF and others)
   Indications
       Chest pain associated with MI
       Pulmonary edema with or without associated pain
       Moderate to severe acute and chronic pain
   Contraindications
       Hypersensitivity
       Hypovolemia, Hypotension
       Head injury or undiagnosed abdominal pain
       Increased ICP
       Severe respiratory depression
       Patients who have taken MAO inhibitors within 14 days


          12/14/2011             95                   Rick Johnson
                            Cardiovascular Drugs 2


Morphine Sulfate (Astromorph PF and others)
   Adverse Reactions
       Hypotension
       Tachycardia, Bradycardia
       Palpitations
       Syncope
       Facial flushing
       Respiratory depression
       Euphoria
       Bronchospasm
       Dry Mouth
       Allergic reaction



          12/14/2011               96                Rick Johnson
                             Cardiovascular Drugs 2


Morphine Sulfate (Astromorph PF and others)
   Drug interactions
       CNS depressants may potentiate effects of morphine
       Phenothiazine may potentiate analgesia
       MAO inhibitors may cause paradoxical excitation
   How supplied
       Many different forms and concentrations
       Most common pre-hospital parenteral is 10 mg/ml in ampule or
        Tubex syringe




          12/14/2011             97                   Rick Johnson
                              Cardiovascular Drugs 2


Morphine Sulfate (Astromorph PF and others)
   Dosage and Administration
       2-10 mg IV
       Additional doses in 2 mg increments
   Special Considerations
       Pregnancy safety category B
       Use with caution in the elderly those with asthma and in those
        susceptible to CNS depression
       May worsen bradycardia or heart block
       Naloxone should be readily available




          12/14/2011              98                    Rick Johnson
                            Cardiovascular Drugs 2


Nitrous Oxide (Nitronox & Entonox)
   Class
       Analgesic
       Anesthetic gas
   Description
       Blend of 50% Nitrous oxide & 50% O2
       When inhaled depresses the CNS causing anesthesia
       Must be self administered
   Onset and Duration
       Onset 2-5 minutes
       Durations    2-5 minutes




          12/14/2011            99                   Rick Johnson
                              Cardiovascular Drugs 2


Nitrous Oxide (Nitronox & Entonox)
   Indications
       Moderate to severe pain
       Anxiety
       Apprehension
   Contraindications
       Impaired LOC
       Head injury
       Chest trauma (pneumothorax)
       Inability to comply with instructions
       Decompression sickness




          12/14/2011              100                  Rick Johnson
                            Cardiovascular Drugs 2


Nitrous Oxide (Nitronox & Entonox)
   Contraindications Continued
       Undiagnosed abdominal pain or marked distention
       Bowel obstruction
       Hypotension
       Shock
       COPD




          12/14/2011            101                  Rick Johnson
                              Cardiovascular Drugs 2


Nitrous Oxide (Nitronox & Entonox)
   Adverse Reactions
       Dizziness, light headedness
       Apnea
       Cyanosis
       Nausea & vomiting
       Malignant hyperthermia
   Drug interactions
       Potentiate the effects of other CNS depressants
   How Supplied
       D and E cylinders (blue and green in color)




          12/14/2011              102                     Rick Johnson
                                  Cardiovascular Drugs 2


Nitrous Oxide (Nitronox & Entonox)
   Dosage and Administration
       Instruct the patient to inhale deeply through a patient held demand
        valve and mask or mouthpiece
   Special Considerations
       Pregnancy safety: Nitrous oxide has been shown to increase the
        incidence of spontaneous abortion
       Nitrous oxide is a nonexplosive gas
         o However, it IS a powerful oxidizer
       Patient must hold mask and self-administer
       Nitrous oxide is 34 times more soluble than nitrogen and will
        diffuse into pockets of trapped gas in the patient




          12/14/2011                   103                 Rick Johnson
                              Cardiovascular Drugs 2


Diuretics
   CHF one of the most common cardiovascular emergencies
   Treatment of CHF
       increase cardiac output
       reduce pulmonary and peripheral edema
   Most effective therapy in acute heart failure
       reduce venous filling pressure
       administration of potent diuretics




          12/14/2011              104                  Rick Johnson
                              Cardiovascular Drugs 2


Furosemide (Lasix)
   Class
       Loop diuretic
   Description
       Potent diuretic that inhibits the reabsorption of sodium and
        chloride in the proximal tubule and loop of Henle.
   Onset and Duration
       Onset IV diuretic effect 15-20 minutes
       Duration      2 hours
   Indications
       Pulmonary edema associated with CHF, hepatic or renal disease




          12/14/2011              105                    Rick Johnson
                             Cardiovascular Drugs 2


Furosemide (Lasix)
   Contraindications
       Anuria
       Hypersensitivity
       Hypovolemia/dehydration
       Know hypersensitivity to sulfonamides
       Severe electrolyte depletion (hypokalemia)




          12/14/2011             106                  Rick Johnson
                              Cardiovascular Drugs 2


Furosemide (Lasix)
   Adverse Reactions
       Hypotension
       ECG changes associated with electrolyte disturbances
       Dry mouth
       Hypochloremia
       Hypokalemia
       Hyponatremia
       Hypercalcemia
       Hyperglycemia
       Hearing loss after too rapid infusion with renal impairment




          12/14/2011              107                    Rick Johnson
                              Cardiovascular Drugs 2


Furosemide (Lasix)
   Drug interactions
       Digitalis toxicity
       Increase ototoxic potential of aminoglycoside antibiotics
       Lithium toxicity
       May potentiate therapeutic effect of other antihypertensive drugs
       Should not be administered in the same line as Inocor
   How Supplied
       Parenteral      10mg / mL in 2,4,8 & 10 ml ampule or vial
   Dosage and Administration
       20-40 mg slow IV over 1-2 minutes




          12/14/2011              108                   Rick Johnson
                             Cardiovascular Drugs 2


Furosemide (Lasix)
   Special Considerations
       Pregnancy safety category C
       Lasix has been know to cause fetal abnormalities
       Should protect from light and stored at room temp.




          12/14/2011             109                   Rick Johnson
                             Cardiovascular Drugs 2


Bumetanide (Bumex)
   Class
       Loop diuretic
   Description
       Act on ascending loop of Henle
       inhibiting reabsorption of chloride and sodium
   Onset and Duration
       Onset 5 min
       Duration        2-3 hours
   Indications
       CHF and pulmonary edema



          12/14/2011                110                  Rick Johnson
                             Cardiovascular Drugs 2


Bumetanide (Bumex)
   Contraindications
       Hypersensitivity to sulfonamides
       Anuria
       Hepatic coma
   Drug Interactions
       Decreased effects of antidiabetics
       Hypokalemia: potassium wasting drugs and corticosteroids
       Increased toxicity of digitalis and lithium
       Ototoxicity: aminoglycosides




          12/14/2011             111                  Rick Johnson
                              Cardiovascular Drugs 2


Bumetanide (Bumex)
   Adverse Reactions
       Renal failure
       Loss of hearing
       Dehydration and electrolyte depletions
   How supplied
       0.25 mg/mL in 2,4, & 10 mL vials
   Dosage
       0.5-1.0 mg over 1-2 minutes
        nd     rd
        2 or 3 dose can be administered at 2-3 hour interval
       Maximum dose 10 mg per day




          12/14/2011              112                  Rick Johnson
                            Cardiovascular Drugs 2


Bumetanide (Bumex)
   Special Considerations
       Pregnancy safety category C




          12/14/2011            113                  Rick Johnson
                             Cardiovascular Drugs 2


Antiangial Agents
   Angina pectoris
       symptom of myocardial ischemia
       caused by an imbalance between myocardial oxygen supply and
        demand
   Medication given
       to dilate coronary arteries
       relive coronary artery vasopasm to increase oxygen supply




          12/14/2011             114                  Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   Class
       Nitrate vasodilator
   Description
       Potent smooth muscle relaxant
       Dilates arterioles and veins it the periphery
       Results in reduction in preload, and to a lesser extent after-load,
        decrease the workload of the heart and lowers myocardial oxygen
        demand.
   Onset and Duration
       Onset 1-2 minutes
       Duration     30-60 minutes



          12/14/2011              115                    Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   Indications
       Ischemic chest pain
       Pulmonary hypertension
       CHF
       Hypertensive emergencies
   Contraindications
       Hypersensitivity
       Hypotension
       Head injury
       Cerebral hemorrhage




         12/14/2011               116                  Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   Adverse Reactions
       Transient headache
       Reflex tachycardia
       Hypotension
       Nausea and vomiting
       Postural syncope
       Diaphoresis
   Drug interactions
       Other vasodilators may have additive hypotensive effects
       Can cause severe hypotension when administered to patients who
        have recently ingested alcohol



          12/14/2011              117                  Rick Johnson
                                  Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   How Supplied
       Tablets
         o   0.15 mg (1/400 gr)
         o   0.3 mg (1/200 gr)
         o   0.4 mg (1/150 gr)
         o   0.6 mg (1/100 gr)
         o   extended release capsules
         o   transdermal preparations
       Metered Spray
         o 0.4 mg per spray 200 doses per container
       Parenteral
         o 5 mg/mL, 10, 20, 40 mg/100 mL




          12/14/2011                     118               Rick Johnson
                                          Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   Dosage and Administration
       Tablet
         o 0.15-0.6 mg SL
                may be repeated in 5 min two times
                as long as patient is hemodynamically stable

       Metered spray
         o Spray onto oral mucosa using a lingual aerosol canister that delivers 0.4
           mg/spray may be repeated in 5 min two times
       Infusion
         o 200-400 mcg/mL at a rate of 10-20 mcg/min; increase by 5-10 mcg/min q 5-10
           minutes until desired effect is achieved




          12/14/2011                            119                Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin (Nitrostat)
   Special Considerations
       Pregnancy safety category C
       Increased susceptibility to hypotension in the elderly
       Nitroglycerin decomposes when exposed to light or heat Must be
        kept in airtight containers
       Active ingredient of nitroglycerin will “sting” when administered SL
       Always wear gloves when handling nitroglycerin




          12/14/2011              120                   Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin Paste (Nitro-bid Ointment)
   Class
       Nitrate Vasodilator
   Description
       Nitropaste contains a 2% solution of nitroglycerin in an absorbent
        paste
       When placed on the skin absorbed into systemic circulation and
        has same effects as SL nitroglycerin
   Onset and Duration
       Onset 15-60 min
       Duration     2-12 hrs




          12/14/2011              121                   Rick Johnson
                              Cardiovascular Drugs 2


Nitroglycerin Paste (Nitro-bid Ointment)
   Indications
       Angina pectoris
       Chest pain associated with AMI
   Contraindications
       Hypersensitivity
       Hypotension
       Head injury
       Cerebral hemorrhage
   Drug interactions
       Other vasodilators may have additive hypotensive effects




          12/14/2011              122                  Rick Johnson
                               Cardiovascular Drugs 2


Nitroglycerin Paste (Nitro-bid Ointment)
   How Supplied
       20, 60 g tubes of 2% nitroglycerin paste
   Dosage and Administration
       Apply 1-2 inches over 2-4 inch area of skin that is free of hair; cover
        with transparent wrap and secure with tape
   Special Considerations
       Pregnancy safety category C
       Wear gloves when apply paste
       Do not massage or rub paste
       Store paste in a cool place with the tube tightly capped
       Although adverse effects for nitropaste are the same as for SL
        nitroglycerin, their frequency and severity are usually less

          12/14/2011               123                    Rick Johnson
                              Cardiovascular Drugs 2


Antihypertensives
   High blood pressure
       affects as many as 50 million adults and children in the US
   Directly related to:
       Stroke
       cerebral hemorrhage
       heart and renal failure
       coronary heart disease
   Two categories of hypertensive emergencies
       Hypertensive emergency diastolic BP > 130 mm Hg must be
        lowered within 1 hour
       Hypertensive Urgency BP should be lowered within 24 hours



          12/14/2011              124                   Rick Johnson
                             Cardiovascular Drugs 2


Antihypertensives
   Ideal antihypertensive drug
       Maintain blood pressure within normal limits for various body
        positions
       Maintain or improve blood flow without compromising tissue
        perfusion or blood supply to the brain
       Reduce the workload of the heart
       Have no undesirable side effects
       Permit long-term administration without intolerance




          12/14/2011             125                    Rick Johnson
                             Cardiovascular Drugs 2


Nifedipine (Procardia, Adalat)
   Class
       Calcium channel blocker
   Description
       Inhibits calcium ion influx across cell membrane during cardiac
        depolarization; relaxes coronary vascular smooth muscle; dilates
        coronary arteries; increases myocardial oxygen delivery in patients
        with vasospastic angina; dilates peripheral arteries
   Onset and Duration
       PO Onset 20 minutes
       PO Duration 4-6 hours
   Indications
       Hypertension, Angina Pectoris

          12/14/2011              126                   Rick Johnson
                            Cardiovascular Drugs 2


Nifedipine (Procardia, Adalat)
   Contraindications
       Hypersensitivity
   Adverse Reactions
       Nausea & vomiting
       Dizziness
       Headache
       Dysrhythmias, bradycardia & asystole
       Heart block
       Hypotension
       MI, CHF, pulmonary edema




          12/14/2011            127                  Rick Johnson
                              Cardiovascular Drugs 2


Nifedipine (Procardia, Adalat)
   Drug Interactions
       Increased risk of toxicity: propranolol, cimetidine, quindine, digoxin
       Increased risk of CHF, bradycardia and asystole with Beta blockers
   How Supplied
       10 and 20 mg capsules
   Dosage and Administration
       10 mg SL, several small holes placed in capsule place liquid under
        tongue and have patient swallow capsule
   Special Considerations
       Pregnancy safety category C




          12/14/2011              128                     Rick Johnson
                              Cardiovascular Drugs 2


Sodium Nitroprusside (Nitropress, Nipride)
   Class
       Antihypertensive and vasodilator
   Description
       Directly relaxes arteriolar venous smooth muscle, resulting in
        reduction in cardiac preload and after-load
   Indications
       Hypertensive crisis in which a prompt reduction in BP is essential
   Contraindications
       Hypersensitivity
       Hypertension




          12/14/2011              129                   Rick Johnson
                              Cardiovascular Drugs 2


Sodium Nitroprusside (Nitropress, Nipride)
   Adverse Reactions
       Dizziness, headache, hypotension, chest pain, dyspnea,
        palpitations, nausea and vomiting
       LOC
   Drug Interactions
       Severe hypotension: ganglionic blocker, volatile liquid anesthetics,
        circulatory depressants
   How Supplied
       50 mg/5 mL vials




          12/14/2011              130                    Rick Johnson
                             Cardiovascular Drugs 2


Sodium Nitroprusside (Nitropress, Nipride)
   Dosage and Administration
       50 mg diluted in 500 mL of D5W (100 mcg/mL)
       0.5 mcg/kg/min initially titrate to effect
       Normal dose 0.5-8.0 mcg/kg/min
   Special Considerations
       Pregnancy safety category C
       Always give diluted in D5W or NSS never as an IV bolus
       Always use infusion pump
       Protect from light




          12/14/2011             131                   Rick Johnson
                              Cardiovascular Drugs 2


Hydralazine (Apresoline)
   Class
       Antihypertensive and Vasodilator
   Description
       Arteriolar vasodilating agent that is used in the management of
        hypertensive crisis
       Decrease in arterial pressure, decrease in peripheral resistance and
        an increase in cardiac output (reflex tachycardia)
       Vasodilates arteriolar smooth muscle by direct relaxation;
        reduction in BP with reflex increase in cardiac function




          12/14/2011              132                   Rick Johnson
                               Cardiovascular Drugs 2


Hydralazine (Apresoline)
   Onset and Duration
       Onset
         o IV     5-30 min
         o IM     10-40 min
       Duration          2-6 hours
   Indications
       Hypertensive crisis
       Hypertension associated with renal failure, preeclampsia, and
        eclampsia
       Primary pulmonary HTN




          12/14/2011                  133               Rick Johnson
                              Cardiovascular Drugs 2


Hydralazine (Apresoline)
   Contraindications
       Compensatory hypertension
       Coronary artery disease
       Dissecting aneurysm
       Hypersensitivity
       Mitral valve/rheumatic heart disease




          12/14/2011              134                  Rick Johnson
                            Cardiovascular Drugs 2


Hydralazine (Apresoline)
   Adverse Reactions
       Reflex tachycardia
       Palpitations
       Hypotension
       Facial flushing
       Headache
       Diaphoresis
       Anxiety
       Nausea and vomiting, Diarrhea
       Altered mental status
       arrhythmias



          12/14/2011            135                  Rick Johnson
                                 Cardiovascular Drugs 2


   Drug Interactions
       Increased tachycardia, angina: sympathomimetics (epi and
        norepinephrine)
       Increased effects of Beta blockers
       Severe hypotension: MAOIs
   How Supplied
       20 mg in 1 mL
   Dosage and Administration
       10-40 mg IM or IV may be repeated in 10 min prn
       Infusion
         o 20 mg in 250 mL NS or LR at 5-20 mg/hr




          12/14/2011                 136                  Rick Johnson
                            Cardiovascular Drugs 2


Hydralazine (Apresoline)
   Special Considerations
       Pregnancy safety category C
       BP & ECG should be continuously monitored
       Color changes may occur when given with glucose solutions




          12/14/2011            137                  Rick Johnson
                              Cardiovascular Drugs 2


Diazoxide (Hyperstat)
   Class
       Antihypertensive & vasodilator
   Description
       Vasodilates arteriolar smooth muscle by direct relaxation
       reduction in BP by dilation of peripheral arterials
       concomitant increases in heart rate, cardiac output
       reduces release of insulin from pancreas
   Onset and Duration
       Onset 1 min
       Duration 2-12 hours




          12/14/2011              138                   Rick Johnson
                               Cardiovascular Drugs 2


Diazoxide (Hyperstat)
   Indications
       Hypertensive crisis when urgent decrease of diastolic pressure is
        required
   Contraindications
       Hypersensitivity to drug or to the thiazide class of diuretics
       Dissecting aortic aneurysm
   Adverse Reactions
       Hypotension
       Headache, dizziness, altered mental status
       Tachycardia, arrhythmias, chest pain, CHF, edema, hyperglycemia,
        nausea and vomiting
       Seizures, cerebral ischemia, paralysis

          12/14/2011               139                    Rick Johnson
                              Cardiovascular Drugs 2


Diazoxide (Hyperstat)
   Drug Interactions
       Severe hypotension: antihypertensives
       Decreased anticonvulsant effect with phenytoin
   How Supplied
       300 mg in 20 mL
   Dosage & Administration
       1-3 mg/kg rapidly IV up to max of 150 mg in a single injection; dose
        may be repeated at 5-15 min intervals until desired response is
        achieved; give IV in 30 sec or less
   Special Considerations
       Pregnancy safety category C



          12/14/2011              140                    Rick Johnson
                                 Cardiovascular Drugs 2


Calcium Chloride
   Class
       Calcium supplement
       Electrolyte
   Description
       Calcium is an essential component
         o functional integrity of the nervous and muscular systems
         o for normal cardiac contractility
         o the coagulation of blood
       Calcium chloride contains 27.2% elemental calcium
       Calcium chloride is a hypertonic solution
       should only be administered slowly intravenously.




          12/14/2011                  141                        Rick Johnson
                             Cardiovascular Drugs 2


Calcium Chloride
   Onset and Duration
       Onset 5-15 min
       Duration     Dose dependent may persist for up to 4 hours
   Indications
       Hyperkalema (except with digitalis toxicity)
       Hypocalcemia
       Calcium channel blocker toxicity
       Hypermagnesemia
       To prevent hypotensive effects of calcium channel blocking agents




          12/14/2011             142                   Rick Johnson
                                Cardiovascular Drugs 2


Calcium Chloride
   Contraindications
       VF during cardiac resuscitation
       In patients with digitalis toxicity
       Hypercalcemia
       Renal or cardiac disease




          12/14/2011                143                  Rick Johnson
                             Cardiovascular Drugs 2


Calcium Chloride
   Adverse Reactions
       Bradycardia, arrhythmias, syncope, nausea & vomiting, and cardiac
        arrest
       Hypotension
       Severe local necrosis and sloughing following IV use or IV
        infiltration
   Drug Interactions
       Calcium may worsen dysrhythmias secondary to digitalis
       May antagonize the peripheral vasodilatory effects of calcium
        channel blockers
       Interact with sodium bicarbonate and form a precipitate.



          12/14/2011             144                    Rick Johnson
                             Cardiovascular Drugs 2


Calcium Chloride
   How supplied
       10% solution in 10 mL (100 mg/mL0 ampules, vials and prefilled
        syringes
   Dosage and Administration
       2-4 mg/kg of 10% solution slow IV, may repeat every 10 minutes if
        necessary
   Special Considerations
       Pregnancy safety category C
       Calcium may produce vasospasm in coronary and cerebral arteries
       Hypertension and bradycardia may occur with rapid administration




          12/14/2011             145                    Rick Johnson

								
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