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Chapter 13
Cardiovascular Therapeutic
Management
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
Objectives

Identify the signs of perfusion in a patient
undergoing fibrinolytic therapy.
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
2
Objectives

Describe the functions of a temporary
pacemaker and an implantable cardioverterdefibrillator.
(continued)
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
3
Objectives (continued)


Outline the nursing management of a patient
undergoing cardiac surgery and cardiac
interventional procedures.
List the most important categories of
cardiovascular drugs, their intended actions,
and major significance.
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4
Temporary Pacemakers


Electronic devices used to initiate the heartbeat
when the heart’s intrinsic rhythm cannot
effectively generate a rate adequate to support
cardiac output
Uses

Temporarily
 Supportively
 Prophylactically
 Permanently

Duration – until the condition responsible for the
rate or conduction disturbance resolves.
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Indications



Bradydysrhythmias
Tachydysrhythmias
Causes




Drug toxicity
Acute MI
Acute Coronary Syndromes
Following cardiac surgery
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6
Pacemaker System





Simple electrical circuit consisting of
a pulse generator and a pacing lead
with one, two or three electrodes.
Pulse generator is designed to
generate an electrical current that
travels through the pacing lead and
exits through an electrode (exposed
portion of the wire) that is in direct
contact with the heart.
The electrical current initiates a
myocardial depolarization.
The current returns to the pulse
generator to complete the circuit.
Power source is a 9-volt alkaline
battery
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7
Pacing Lead Systems
FIGURE 13-1 The Components of a Temporary Bipolar Transvenous Catheter. A, Singlechamber
temporary (external) pulse generator. B, Bridging cable. C, Pacing lead. D, Enlarged view of the pacing
lead tip. (A, Courtesy Medtronic Inc., Minneapolis, Minn.)
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Pacemaker System

Routes for temporary pacing



Transcutaneous
Epicardial
Transvenous (endocardial)
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Pacing Routes

Transcutaneous use of two
large skin electrodes





One placed on the anterior
chest the other on the
posterior chest
These are connected to an
external pulse generator
Rapid, noninvasive procedure
First line intervention that
nurses can initiate in the
ACLS algorithm – for the
treatment of symptomatic
bradycardia
Used as an emergency shortterm therapy until the
situation resolves or another
route of pacing can be
established
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10
Epicardial Pacing




Insertion of temporary
epicardial pacing wires is a
routine procedure during
most cardiac surgical cases
Ventricular and in some case
atrial pacing wires are
loosely sewn to the
epicardium.
The terminal wires are pulled
through the skin before the
chest is closed.
These are removed several
days after surgery by gentle
traction at the skin surface
with minimal bleeding risk
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11
Transvenous Pacing
http://rnbob.tripod.com/transven.
htm


Temporary – transvenous
endocardial pacing is
accomplished by
advancing a pacing
electrode wire through the
subclavian or internal
jugular and into the right
atrium or right ventricle.
Insertion



Fluoroscopy
Through a pacing swan
Through a central line
cordis
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12
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13
Pacemaker Terminology

Three-letter pacemaker code




The first letter designates which chamber is paced
The second letter designates which chamber is
sensed
The third letter indicates the pacemaker’s
response to the sensed event
Five-letter pacemaker code

The fourth letter designates programmability
 The fifth letter designates dysrhythmia control
(continued)
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Pacemaker Terminology (continued)

Synchronous pacing modes



DDD pacing
VVI pacing
Asynchronous pacing modes

Ignores the patient’s intrinsic heartbeat
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Pacemaker Settings


Rate
Output: milliamps


Sensitivity control


Pacing threshold
Sensitivity threshold
AV interval control
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Pacing Artifacts


Pacing artifact is a spike seen on the
electrocardiogram (ECG) tracing as the
pacemaker delivers the pacing stimulus
Pacing artifacts

Atrial artifact
 Ventricular artifact
 Dual-chamber (both atrial and ventricular) pacing
artifact
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Pacing Artifacts
FIGURE 13-2 Pacing Examples. A, Atrial pacing. B, Ventricular pacing. C, Dual-chamber
pacing. Each asterisk represents a pacemaker impulse.
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Pacemaker Malfunctions

Pacemaker malfunctions



Failure to pace
Failure to capture
Sensing abnormalities
• Undersensing
• Oversensing
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Failure to Pace
FIGURE 13-3 Pacemaker Malfunction: Failure to Pace. A, Patient with a transvenous pacemaker is turned onto the
left side. Immediately, there is a failure to pace (i.e., loss of pacer artifacts on the electrocardiogram). The patient’s
heart rate is extremely low without pacemaker support. B, The nurse turns the patient onto the right side, the
transvenous electrode floats into contact with the right ventricular wall, and pacing is resumed. (From Kesten KS,
Norton CK: Pacemakers: patient care, troubleshooting, rhythm analysis, Baltimore, 1985, Resource Applications.)
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Question
The RN is caring for a patient with a temporary
pacemaker. While observing the patient’s ECG
rhythm, the RN notes unexplained pauses in
the patient’s rhythm. The RN suspects the
patient is experiencing:
failure to capture.
B. generator failure.
C. undersensing.
D. oversensing.
A.
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21
Answer
D.
Oversensing.
Oversensing occurs as a result of inappropriate
sensing of extraneous electrical signals that leads to
unnecessary triggering or inhibition of stimulus
output, depending on the pacer mode. Oversensing
results in unexplained pauses in the ECG tracing as
the extraneous signals are sensed and inhibit pacing.
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Failure to Capture
FIGURE 13-4 Pacemaker Malfunction: Failure to Capture. Atrial pacing and capture occur after pacer artifacts
(spikes) 1, 3, 5, and 7. The remaining pacer artifacts fail to capture the tissue, resulting in loss of the P wave,
no conduction to the ventricles, and no arterial waveform. Each asterisk represents a pacemaker impulse.
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Undersensing
FIGURE 13-5 Pacemaker Malfunction: Undersensing. After the first two paced beats, a series of intrinsic
beats occur; the pacemaker unit fails to sense these intrinsic QRS complexes. These pacer artifacts do not
capture the ventricle because they occur during the refractory period of the cardiac cycle. Each asterisk
represents a pacemaker impulse.
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Medical Management

Medical management



Determine pacing route based on situation
Place transvenous or epicardial lead(s)
Determine pacing rate and mode and evaluate
patient’s response to pacing
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Nursing Management

Nursing priorities for the patient connected to
a temporary pacemaker focus on:




Preventing pacemaker malfunction
Protecting from microshock
Monitoring for complications
Providing patient education
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26
Nursing Care of the patient with an
emergent pacemaker







Continuous ECG monitoring – patent IV access (two sites at
least)
Set monitor on pacing to sense pacer energy or spikes
Assess vitals regularly depending on patient status
Assess perfusion – check a radial pulse while watching the
monitor. Does the pacer spike generate a pulse
Reassure the patient
Provide pain medication/sedation for a patient with
transcutaneous pacing
Prepare for transfer or for transvenous pacing/permanent
pacer insertion depending on the setting.
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27
Question
Which of the following interventions
should be implemented to minimize the
incidence of microshock in the patient
with a temporary pacemaker?
A.
B.
C.
D.
Unplug all electric equipment around the patient
Ensure all the pacing connections are tight
Wear gloves when handling pacing wires
Suspend the pulse generator away from the patient
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Answer
C.
Wear gloves when handling pacing wires
The possibility of microshock can be minimized by
wearing rubber gloves when handling the pacing
wires and by proper insulation of terminal pins of
pacing wires when they are not in use.
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Myocardial Perforation

Very rare but can
occur

Symptoms
• Rhythmic
hiccoughs
• Cardiac
Tamponade
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Patient education temporary
pacemakers




Instruct the patient to not handle the exposed
portion of the lead wire.
Notify the nurse if the dressing over the
insertions site becomes soiled, wet, or
dislodged.
Done use any electrical devices brought in
from home that could interfere with
pacemaker function.
Restrict movement of the affected extremity
to avoid displacement.
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http://missinglink.ucsf.edu/lm/pac
emaker_module/index.htm
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Permanent Devices





Permanent pacemakers
Cardiac resynchronization therapy
Atrial dysrhythmia suppression
Medical management
Nursing management


Monitoring for complications
Patient education
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Implantable Cardioverter
Defibrillator (ICD)

Implantable device capable of:



Identification and termination of life-threatening
ventricular dysrhythmias
Primary prevention of sudden cardiac death
(SCD)
Treatment of refractory rhythms
(continued)
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34
Implantable Cardioverter
Defibrillator (ICD) (continued)

ICD system contains:



Sensing electrodes to recognize the
dysrhythmias
Defibrillation electrodes or coils to deliver a
“shock” and pacing impulses
Generator to provide the electrical energy for
shocks and for backup pacing, cardioversion, or
defibrillation
(continued)
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35
ICD System
FIGURE 13-6 A, Placement of an implantable cardioverter defibrillator (ICD) with a transvenous lead system in the
pectoral region of the upper chest. Pacing, cardioversion, and defibrillation functions are all contained in a lead (or
leads) inserted into the right atrium and ventricle. B, An example of a dual-chamber ICD (Medtronic Gem II DR)
with tiered therapy and pacing capabilities. C, Tiered therapy is designed to use increasing levels of intensity to
terminate ventricular dysrhythmias. (Courtesy Medtronic Inc., Minneapolis, Minn.)
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36
Implantable Cardioverter
Defibrillator (ICD) (continued)

ICD insertion


Leads may be placed epicardial or endocardial
Generators are smaller and can now be implanted
without major surgery
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Medical Management




Evaluation of patient’s dysrhythmias and
cardiac function
Cardiac diagnostic procedures
Decisions about placement, route, and type
of therapy needed
ICD programming


Insertion programming, testing, and threshold
measurements
Follow-up monitoring to determine function
performance and battery life
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38
Nursing Management

Nursing priorities for the patient with an ICD
focus on:


Monitoring for ICD-associated complications
Providing patient education
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Fibrinolytic Therapy

Goal:



Lysis of the acute thrombus
Opening the obstructed coronary artery
Restoring blood flow to the affected tissue
(continued)
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Fibrinolysis
FIGURE 13-7 Thrombus Formation and Site of Action of Medications Used in the Treatment of Acute
Myocardial Infarction. A, Site of action of antiplatelet agents such as aspirin and glycoprotein IIb/IIIa
inhibitors. B, Heparin bonds with antithrombin III and thrombin to create an inactive complex. C, Fibrinolytic
agents convert plasminogen to plasmin, an enzyme responsible for degradation of fibrin clots.
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41
Fibrinolytic Therapy (continued)

Inclusion criteria




12 hours or less after onset of chest pain
Persistent ST-elevation on ECG
Bundle branch block with a history suggestive of
AMI
Exclusion criteria

Patients who have stable clots from recent
surgery, trauma, or stroke
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Fibrinolytic Therapy Selection
Criteria




No more than 12 hours from onset of chest
pain (less if possible)
ST-segment elevation on electrocardiogram
or new-onset left bundle branch block
Ischemic chest pain unresponsive to
sublingual nitroglycerin
No conditions that might cause a
predisposition to hemorrhage
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Fibrinolytic Agents

Clot specific




Non–clot specific


t-PA (alteplase)
r-PA (reteplase)
TNKase (tenecteplase)
SK (streptokinase)
Outcomes
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Evidence of Reperfusion

Invasive evidence


Can be directly observed under fluoroscopy in the
cardiac catheterization laboratory
Noninvasive evidence




Cessation of chest pain
Reperfusion dysrhythmias, primarily ventricular
rhythms
Elevated ST segments return to baseline
Early and marked peaking of creatine kinase
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45
Nursing Management

Nursing priorities for the patient receiving
fibrinolytic therapy focus on:




Identifying candidates for thrombolytic therapy
Observing for clinical signs of reperfusion
Monitoring for signs of bleeding
Providing patient education
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46
Percutaneous Coronary
Interventions (PCI)

Indications


Trials demonstrate an advantage for catheter
interventions over drug therapy
Surgical backup less often required

Availability of cardiac surgical services on site still
recommended
(continued)
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47
Percutaneous Coronary
Interventions (PCI) (continued)

Percutaneous transluminal coronary
angioplasty (PTCA)


Use of balloon-tipped catheter to dilate the
stenotic area
Balloon pressure stretches the vessel wall,
fractures the plaque, and enlarges the vessel
(continued)
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48
PTCA
FIGURE 13-8 Percutaneous Transluminal Coronary Angioplasty (PTCA) is used to open a stenotic vessel
occluded by atherosclerosis.
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Percutaneous Coronary
Interventions (PCI) (continued)

Atherectomy




Directional atherectomy
Rotablator
Transluminal extraction catheter
Coronary stents


Stent thrombosis
Drug-eluting stents
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50
Atherectomy Devices
FIGURE 13-9 Atherectomy Devices. A, Directional coronary atherectomy catheter. B, Rotational
atherectomy catheter.
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51
PCI Complications

Acute complications

Coronary spasm
 Coronary thrombosis
 Coronary dissections
 Bleeding
 Hematoma
 Retroperitoneal bleed

Late complications
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52
Nursing Management

Nursing priorities for patients after PCI are
directed to:






Monitoring for recurrent angina
Protecting kidney function
Monitoring the femoral access site
• Assessing for bleeding
• Hemostatic devices
Monitoring peripheral pulses
Promoting ambulation
Providing patient education
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53
Percutaneous Valve Repair

Percutaneous balloon valvuloplasty


Aortic
Mitral
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54
Cardiac Surgery

Coronary artery bypass surgery (CABG)


Improved quality of life and relief of symptoms
Type of graft




Saphenous vein graft
Internal mammary artery graft
Right gastroepiploic artery graft
Radial artery graft
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55
CABG
FIGURE 13-11 Saphenous Vein Graft.
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56
CABG
FIGURE 13-12 Internal Mammary Artery Graft.
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Valvular Surgery

Mechanical valves




Caged-ball valve
Tilting-disk valve
Bi-leaflet valve
Biological (tissue) valves


Porcine (aortic valve) heterograft
Homograft
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Artificial Valves
FIGURE 13-13 Prosthetic Valves. A, The St Jude Medical mechanical heart valve is a mechanical central-flow
disk. B, In the Hancock II porcine aortic valve, the flexible Delrin stent and sewing ring are covered in Dacron
cloth. (A, Courtesy St Jude Medical, Inc., copyright 1993, St Paul, Minn; B, from Eagle K, et al, editors: The
practice of cardiology, ed 2, Boston, 1989, Little, Brown.)
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Cardiac Surgery


Minimally invasive cardiac surgery
Heart transplantation
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Heart Transplant
FIGURE 13-14 Heart Transplant Surgical Procedure. (Modified from Hurst JW, et al: Hurst’s The
Heart, ed 7, New York, 1990, McGraw-Hill.)
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Physiological Effects of
Cardiopulmonary Bypass





Intravascular fluid
deficit
Third spacing
Myocardial depression
Coagulopathy
Pulmonary dysfunction






Hemolysis
Hyperglycemia
Hypokalemia
Hypomagnesemia
Neurological
dysfunction
Hypertension
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62
Nursing Management

Nursing priorities for the patient after cardiac
surgery are directed toward:




Optimizing cardiac output
• Heart rate
• Preload
• Afterload
• Contractility
Temperature regulation
Controlling bleeding
Maintaining chest tube patency
(continued)
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63
Nursing Management (continued)

Nursing priorities for the patient after cardiac
surgery are directed toward:

Recognizing cardiac tamponade
 Promoting early extubation
 Assessing for neurological complications
 Preventing infection
 Preserving kidney function
 Providing patient education
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Question
The RN is caring for a postoperative cardiac
surgery patient who develops muffled heart
sounds, pulsus paradoxus, decreased BP and
cessation of chest tube output. The RN
suspects the patient has developed:
cardiac tamponade.
B. graft occlusion.
C. acute respiratory failure.
D. heart failure.
A.
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65
Answer
A.
Cardiac tamponade.
Cardiac tamponade may occur after surgery if blood
accumulates in the mediastinal space, impairing the
heart’s ability to pump. Signs of tamponade include
elevated and equalized filling pressures (e.g., CVP,
PADP, PAOP), decreased cardiac output, decreased
blood pressure, jugular venous distention, pulsus
paradoxus, muffled heart sounds, sudden cessation
of chest tube drainage, and a widened cardiac
silhouette on chest x-ray films.
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Minimally Invasive Cardiac
Surgery



Many of these procedures can be
accomplished without a median sternotomy,
by means of a series of holes, or ports, in the
chest and small thoracotomy incisions
May be performed without cardiopulmonary
bypass
OPCAB and MIDCABG
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67
Intraaortic Balloon Pump

Indications for use of intraaortic balloon pump
(IABP)

Left ventricular failure after cardiac surgery
 Unstable angina refractory to medications
 Recurrent angina after myocardial infarction
 Complications of acute myocardial infarction
• Cardiogenic shock
• Papillary muscle dysfunction/rupture
• Ventricular septal rupture
 Refractory ventricular dysrhythmias
(continued)
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68
Intraaortic Balloon Pump (continued)

Balloon inflates in diastole concurrent with
aortic valve closure



Augments diastolic coronary arterial blood flow
Increases myocardial oxygen supply
Balloon deflates just prior to the opening of
the aortic valve

Decreases resistance of left ventricular ejection
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69
Intraaortic Balloon Pump Function
FIGURE 13-15 Mechanisms of Action of the Intraaortic Balloon Pump. A, Diastolic balloon inflation augments
coronary blood flow. B, Systolic balloon deflation decreases afterload.
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70
Nursing Management

Nursing priorities for the patient being treated
with an IABP include:

Preventing dysrhythmias
 Preventing peripheral ischemia
 Monitoring for balloon complications
 Monitoring balloon-catheter position
 Preventing complications
 Providing psychological support
 Weaning patient from IABP
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71
Effects of Cardiovascular Drugs

Antidysrhythmic drugs

Class 1A, 1B, 1C: affect sodium channels
 Class II: blocks beta-receptors
 Class III: slows repolarization and prolongs
duration of the action potential
 Class IV: blocks calcium channels
 Unclassified antidysrhythmics
 Side effects
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Treatment of Atrial Fibrillation



Conversion/mainten
ance of sinus
rhythm
Control of
ventricular rate
Prevention of
thromboembolism
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Effects of Adrenergic Receptors

Alpha receptors


Beta 1 receptors


Vasoconstriction of arterioles in vessels of skin,
muscles, kidneys, and intestines
Cardiac: increased heart rate, contractility, and
conduction
Beta 2 receptors


Vasodilation of arterioles in bronchi
Bronchodilation
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Inotropic Drugs







Cardiac gylcosides
Sympathomimetics
Dopamine
Dobutamine
Epinephrine
Norepinephrine
Phosphodiesterase inhibitors
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Vasodilator Drugs








Direct smooth muscle relaxants
Sodium nitroprusside
Nitroglycerine
Calcium channel blockers
ACE inhibitors
B-type natriuretic peptide
Alpha-adrenergic blockers
Dopamine receptor agonists
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
76
Vasopressors

Vasopressin
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
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Pharmacological Management
Heart of Failure





ACE inhibitors
Angiotensin receptor blockers
Beta blocker
Aldosterone antagonist
Inotropes
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78