Drugs of the Heart Part II

  1. Antiarrhythmics (Category 4)
    1. Characteristics
      1. Decreases arrhythmias
      2. Inhibits Na and Ca into cells
      3. Prolongs refractory period
      4. Slows conduction velocity by inhibiting Na channels
      5. Adrenergic blockade
    2. Amiodarone (Cordarone)
      1. Helps in
        1. SVT
        2. Atrial flutter/fibrillations
      2. Treatment – frequent ventricular fibrillation and unstable ventricular tachycardia
      3. Side effects
        1. Pulmonary fibrosis and can make CHF even worse
        2. Hypotension (especially when loading)
        3. Bradycardia and AV block
        4. Effects CNS with depression, insomnia, and nightmares
        5. Causes blueness in skin
        6. Get baseline thyroid and liver functions
    3. Lidocaine (Xylocaine)
      1. Action
        1. Suppresses automatically of ectopic foci
        2. Does little with atrial tissue
        3. Increases fibrillation threshold
      2. Indications
        1. VT and VF
        2. Wide use in different types of tachycardia (also if etiology is unknown)
        3. Non-sustained VT
        4. Multiple types of PVCs and couplets
      3. Side effects
        1. Becomes toxic at >7ug/mL
        2. Pt will acted confused, slurred speech, dizziness, blurred vision, lethargic, and may have seizures
        3. Caution should be given if: elderly, has hepatic disease, and/or is in acute LV failure
    4. Procainamide (Pronestyl)
      1. Action
        1. Depresses cardiac automatically, excitability, and conductivity
        2. Vasodilation that may lead to hypotension
      2. Indications
        1. Continuous VF/VT or recurrent VF/VT
        2. Use in patients that have VF/VT and are unresponsive to amiodarone or lidocaine
      3. Side effects
        1. Hypotension
        2. Prolonged PR and QT intervals
        3. Bradycardia and heart block
        4. Level becomes toxic at >16 mcg/mL
      4. Special notes
        1. Time changes with amiodarone therefore:
        2. Monitor the heart rate
        3. Evaluate K,Mg, and Ca
        4. Monitor drug levels for toxicity
        5. After 6 hours of use the level to should be cut in half
  2. Tachydysrhythmias (Ca channel blockers)
    1. Characteristics
      1. Acts on: contractility/conductivity tissues in the heart and on vascular smooth muscle
      2. Decreases contractility, automatically, and conduction velocity
      3. Major point - prevents extracellular Ca from moving into the cell
      4. Dilates coronary and peripheral arteries
      5. HR, BP, SVR (Systemic Vascular Resistance), and MVO2 myocardial oxygen consumption) all decrease
      6. Vasodilates
    2. General indications
      1. Supraventricular tachycardia (SVT) not caused by Wolff-Parkinson-White syndrome (WPW)
      2. Atrial flutter and fibrillation
      3. Paroxysmal supraventricular tachycardia ( PSVT ) that doesn't respond to adenosine
      4. Contraindicated for the following: WPW, VT, VF, and severe cardiac failure
    3. Side effects
      1. Bradycardia
      2. Hypotension
      3. Don't use with beta blockers
      4. Ca is the antidote should the patient become toxic
    4. Name of these pharmaceuticals are:
      1. Diltiazem (Cardizem)
      2. Nicardipine (Cardene)
      3. Verapamil (Calan)
      4. For the complete list can be found at http://en.wikipedia.org/wiki/Calcium_channel_blocker
  3. Tachydysrhythmias (beta blockers)
    1. Characteristics and indications
      1. Stops binding of catechcholamines to receptors
      2. Decreases HR, BP, MVO2, and contractility
      3. Controls hypertension, tachycardia, and SVTs
      4. Limits MI size and decreases incidence of ventricular failure post MI
    2. Side effects
      1. My cause bronchospasm
      2. Exacerbates acute CHF
      3. Bradycardia, hypotension, nausea, and dizziness
      4. Do not administer to patients with pulmonary edema
    3. Name of the pharmaceuticals
      1. Propranolol (Inderal)
      2. Metoprolol (Lopressor)
      3. Atenolol (tenormin)
      4. Brevibloc (esmolol)
      5. Notice how many of the beta blockers have an ..ol ending
      6. For a complete list of beta blockers go to http://en.wikipedia.org/wiki/Beta_blockers
    4. Tachydysrhythmic - Adenosine (adenocard)
      1. Action
        1. Endogenous purine nucleoside that slows conduction through the AV node, interrupts pathways and resources normal sinus rhythm
        2. Should not be given with other cardiac medication and administered only through the an IV line
      2. Indication
        1. Drug of choice for narrow-complex tachycardia (SVT)
        2. Use with wide-complex tachycardia
        3. SVT with WPW
        4. Cardiac stress testing
      3. Side effects
        1. Causes bronchospam in asthmatics
        2. Patient may complain of: flushing, chest pressure, H/A, light headedness, and dyspnea
        3. Only has a 10 second half-life
        4. May cause transient AV block or asystole
        5. Theophylline blocks drug effect - completes for the same receptor sites
  4. Bradydysrhythmics
    1. Atropine
      1. Action
        1. Increases conduction through the AV node resulting in increased HR
        2. Blocks the vagus nerve
        3. Indicated for bradycardia and asystole
      2. Side effects
        1. Tachycardia
        2. Hot skin/flushing
        3. Delirium
        4. Coma
  5. Electrolytes (Category 5)
    1. Sodium Bicarbonate
      1. Characteristics
        1. Acts as a alkaline agent and given if patient has acidosis
        2. Buffer maintains acid-base balance
        3. Not recommended for cardiac arrest
      2. Indications
        1. Acidosis
        2. Acute hyperkalemia
        3. ASA overdose
        4. Tricyclic overdose
      3. Side effects
        1. Alkalosis
        2. Hypokalemia
        3. Hypernatremia (electrolyte disturbance indicating increase sodium levels)
        4. Hyperosmolarity
        5. Seizures
    2. Magnesium sulfate
      1. Characteristics
        1. Electrolyte with many multiple functions
        2. Depresses CNS and smooth muscle
        3. Decreases seizers
      2. Indications
        1. Torsades de point (ventricular tachycardia with irregular "twisted" QRS complex)
        2. Hypomagnesemia
        3. Dysrhythmias
        4. Might be used for acute MI
        5. Vasodilator
      3. Side effects
        1. Bradycardia
        2. hypotension
        3. Flushing and sweating
        4. May cause respirator depression and heart block (reverse with Ca - 5 to 10 meq)
        5. May compromise renal function
    3. Calcium chloride
      1. Characteristics
        1. Myocardial contractility
        2. Clotting factor
      2. Indications
        1. Cardiac arrest
        2. Protects form hyperkalemia
        3. Causes hypokalemia
        4. Antidote to magnesium toxicity
        5. Calcium channel blocker toxicity
      3. Side effects
        1. Irritates veins and destroys them over a period of time
        2. Bradycardia
        3. \Constipation
        4. Fatigue
        5. Depression
  6. Anti-thrombotic Agents
    1. Antiplatelet agents IIb/IIIa inhibitors
      1. Pharmaceutical types
        1. Eptifibatide (Integrilin)
        2. Abciximab (ReoPo)
        3. Tirofiban (Aggrastat)
      2. Contraindications
        1. If patient has been actively bleeding in the last 30 days
        2. Surgery or trauma
        3. History of stroke
        4. Severe HTN (>180 systolic)
    2. Anticoagulants
      1. Usages
        1. Prophylaxis or treatment for DVTs
        2. Used following surgery
        3. Ischemic complications and unstable angina/MI
      2. Pharmaceuticals
        1. Heparin (Unfractionated)
        2. Enoxaparin (Lovenox)
        3. Dalteparin (Fragmin)
    3. Fibrinolytic agents - tissue plasminogen activators
        1. Characteristics and indications
          1. Binds to fibrin in a thrombus and breaks down the clot
          2. Use in ischemic stroke and PE
        2. Pharmaceutics
          1. Alteplase (Activase)
          2. Retaplase (Retavase)
          3. Tenectaplase (TNKase)
        3. Contraindications
          1. Active bleeding
          2. Uncontrolled HTN
  7. Pain management
    1. Morphine Sulfate
      1. Drug of choice of for cardiac chest pain
      2. Decreases pain, anxiety, and preloading
    2. Meperidine (Demerol)
      1. Alternative to MS especially if the patient is allergic to it
      2. Normeperidine metabolite builds up toxicity over time
      3. Issues with elderly patients and renal insufficiency
      4. MI injection has variability in absorption
      5. Naloxone (Narcan) - is an opioid antidote
  8. Sedatives and Paralytics
    1. Lorazepam (Ativan)
    2. Midazolam (Versed)
    3. Flumazenil (Romazicon) - reverses conscious sedation
    4. Propofol (Diprivan)
      1. For induction and maintenance of a sedated state
      2. Patient must be on a ventilator
      3. Side effects: hypotension, apnea, nausea, and tachy/bradycardia
      4. Which famous "Rock" Star died from this drug (an overdose)?
    5. Succinylcholine (Anectine) - relieves all pain
    6. Vecuronium (Norcuron) - muscle blocker
  9. Sepsis
    1. Drotrecogin (Xigris)
      1. Characteristics
        1. Recombinant human activated protein C (rhAPC)
        2. Must follow specific guideline for administration of this drug
        3. Very expensive
      2. Contraindications
        1. Active bleeding.
        2. No stroke for the last 3-months
        3. No cranial or spinal surgery 2-months
        4. No trauma
        5. No neoplasm or lesion within the brain

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