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Cardiac Medications
C. CUMMINGS RN, EDD
Cardiac Meds
Cardiac Output
Stroke Volume
Afterload
PVR
Preload
Venous
Return
Viscosity
Aortic
Impedance
Ventricular
Compliance
X
Contractility
=
Heart Rate
Meds
Sympathetic
Stimulation
Preload
 Function of the volume of blood to the LV and the
compliance (ability of the ventricle to stretch) of the
ventricles at the end of diastole (LVEDP)
 Factors affecting are: venous return, total blood
volume and atrial kick
 Hypovolemic patient has too little preload
 Heart failure patient has too much preload
Afterload
 Ventricular wall tension or stress during systolic
ejection
 Increase in afterload relates to an increase in the
work of the heart
 Increased afterload R/T:



Aortic stenosis
Vasoconstriction and SVR
Blood volume and viscosity
 To decrease, use vasodilators, decrease myocardial
oxygen demand
Contractility
 Inotrophy or enhancing strength, can be positive or
negative
 Sympathetic medications increase contractility
 Ca++ is a medication that will increase contractility
by increasing actin and myosin contractions
 Digoxin also works to increase Ca++ channels by
slowing the Na/Ca pump
Control of Heart Rate
 SNS- sympathetic nervous system


Fight or flight
Increase HR, BP, respirations, dilate pupils
 PNS- parasympathetic system


Decreases contractility, rate
Vagus nerves to the SA and AV nodes
 Baroreceptors- pressure sensors in carotids and aortic arches
 Chemoreceptors- pH levels in aortic arch
 ANF- atrial natriuretic factor- hormone secreted by the atria in
response to atrial pressure

Causes Na and water to be excreted and also vasodilates
Control of Stroke Volume
 Preload
 Increase use:


 Afterload
 Decrease use:
Vasodilators
 Diuretics
 Decrease sympathetic
stimulation

Fluid resusitation
Decrease use:

Diuretics and vasodilators
 Afterload
 Increase use:
Vasopressors
 Volume expanders
 Contractility
 Increase use:



Sympathetic stimulants
Decrease use:
CCB’s
 Decrease sympathetics

Vasopressors
 Sympathomimetic-inotrophic
 Medications that mimic the sympathetic system,




work on alpha, beta and dopamineric receptors
Require continuous monitoring of BP and heart rate
Alpha: vasoconstricts peripheral arterioles
Beta 1: Increased HR, contractility
Beta 2: Bronchodilation
Vasopressor
 Dopamine
 Stimulates alpha and beta
receptors
 In small doses (2-5
mcg/kg/min) produces
renal vasodilation
 Larger doses (max 20
mcg/kg/min) alpha and
beta stimulation
 Increases HR and BP
 Precautions:
 Give IV only, can
sloughing of tissue with
extravasation, if it does
infiltrate, give
phentolamine IV to the
site
 Tachyarrhythmias,
palpations, hypotension if
not hydrated, headache,
dyspnea
Vasopressor
 Epinephrine
 Alpha-Adrenergic, beta 1
and beta 2 stimulant
 Produces bronchodilation
and vasoconstriction
 Increases HR, BP and
bronchodilates
 Given IV, SQ and
inhalation
 Max is 20 mcg/min
 Precautions:
 Tachyarrhythmias
 Angina
 Nervousness, tremors
 Hypertension
 Works almost
immediately IV
 Watch for chest pain and
HR >120, can cause
cardiac arrest with too last
a rate
Vasopressor
 Norepinephrine
 Stimulates alpha, beta
receptors
 Need to hydrate patient
 Lacks beta 2 effects
 Marked alpha
vasoconstriction
 Used in shock states
 Max is 16 mcg/min
 Precautions:
 Closely monitor HR and
BP, can elevate quickly
 Monitor for peripheral
vasoconstriction, in high
doses, can constrict all
extremities
 Can decrease the C.O. if
rate is too high
Vasopressor
 Dobutamine
 Synthetic cathecholamine
with mainly beta effects
 Mild stimulation of beta 2
 Increases myocardial
contractility
 Useful with heart failure
patients
 Max is 20 mcg/kg/min
 Precautions:
 Monitor for increased HR
and BP
 PVC’s and angina
 Watch for shortness of
breath
 May be given over a long
infusion for heart failure
patients
VasopressorsPhosphodiesterase Inhibitors
 Cause increased levels of
AMP and Ca++
 Medications:


Amrinone (Inocor)
Milrinone (Primacor)
 Cause an increase in
cardiac output and some
decreased afterload
 Effective in heart failure
patients to increase C.O.
 Precautions:




Given as a continuous IV
infusion
Can cause PVC’s and V tach
because of increased
contraction
Monitor for drops in BP R/T
decreased afterload
Watch for thrombocytopenia
and abnormal liver function
Other Vasopressors
 Phenylephrine (neo-
synephrine)




Stimulates alpha receptors
only
Used by anesthesia
Can increase myocardial
demand
Works very quickly
 Vasopressin
(antidiuretic hormone)



Nonadrenergic peripheral
vasoconstrictor
Used in VF and pulseless
VT, 40Units
Used as an IV infusion in
sepsis with peripheral
vasodilation
Vasodilators- Direct Smooth Muscle
Relaxants
 Decrease PVR
 Arterial and venous
dilation
 Improves cardiac output
 Medications:



Nitroprusside (Nipride)
Nitroglyceride
Hydralazine (Apresoline)
 Precautions:




Closely monitor BP, can drop
dramatically, especially
nipride
Long term nitroprusside
therapy can lead to
thiocyanate toxicity
NTG is used with unstable
angina (given 5-300
mcg/min
Apresoline is not a
continuous infusion, major
side effect is tachycardia
Vasodilators- Ca++ Channel Blockers
 Arterial vasodilation
 Reduce the influx of
calcium and decrease
resistance
 Used mostly for
hypertension
 Also to slow rapid
rhythms, such as SVT,
and Atrial fib
 Medications:
 Nicardipine (Cardene)
 Nifedipine (Procardia)
 Diltiazem (Cardizem)
 Verapamil (Calan)
 Side effects:
 Hypotension, bradycardia,
nausea, heart failure and
peripheral edema
Vasodilators-ACE inhibitors
 Vasodilate by blocking
the conversion of
angiotensin I to
angiotensin II,
decreases PVR
 May drop BP
dramatically if volume
depleted
 Stops Na and water
retention
 Medications:
 Captopril (Capoten)
 Enalapril (Vasotec)
 Precautions:
 Hypotension, chronic
cough, neutropenia and
elevated liver enzymes
Vasodilators- Alpha adrenergic blockers
 Block peripheral alpha
receptors in arteries
and veins
 Orthostatic changes
may result
 May lead to fluid
retention
 Medications:
 Labetalol (normadyne)
Alpha & beta blocker
 Decreased BP without
increased HR
 Used in aortic dissections


Phentolamine (Regitine)
Peripheral alpha blocker,
decreases afterload
 Used with
pheochromocytomas

Vasodilators- DA-1 receptor agonists &
Synthetic BNP
 Dopamine DA-1
receptor agonists,
vasodilates peripheral
and renal arteries
 Medication:

Fenoldopam (Corlapam)
Hypertensive emergencies
 Watch for hypotension
and tachycardia

 Natrecor:
 Brain naturietic peptide
 Used for decompensated
HR with dyspnea
 Vasodilates pulmonary
bed, reduces SVR and PVR
 Lowers BNP levels
 Infusion runs for 6-48
hours
Vaughn Williams Classification- Used for
Antiarrhythmics
 Class I agents interfere with the sodium (Na+)




channel.
Class II agents are anti-sympathetic nervous system
agents. Most agents in this class are beta blockers.
Class III agents affect potassium (K+) efflux.
Class IV agents affect calcium channels and the AV
node.
Class V agents work by other or unknown
mechanisms.
Class Ia
 Medications:
 Quinidine
 Procainamide
 Disopyramide
 Type:
 Na+ channel block
intermediate
 Use:
 Ventricular
arrhythmias
 Prevents recurrent
atrial fib, triggered by
overactive vagal
stimulation (WolffParkinson-White
syndrome)
Class Ib
 Medication:
 Lidocaine
 Phenytoin
 Mexiletine
 Type:
 Na+ channel block fast
 Use:
 Ventricular tachycardia
 Atrial fib
 Prevention during and
immediately after an MI,
but it is now discouraged
R/T increased risk of
asystole
Class Ic
 Medications:
 Flecainide
 Propafenone
 Moricizine
 Type:
 Na+ channel block slow
 Use:
 Prevents paroxysmal atrial
fib
 Treats recurrent
tachyarrhythmias of
abnormal conduction
system
Class II
 Medications:
 Propranolol
 Esmolol
 Timolol
 Metoprolol
 Atenolol
 Type:
 Beta Blocker
 Use:
 Decrease myocardial
infarction mortality, used
post MI
 Prevent recurrence of
tachyarrhythmias
 Decrease Beta 1 and 2
stimulation, decrease HR
and BP
 Side effects of
bradycardia, fatigue, wt.
gain, impotence,
depression
Class III
 Medications:




Amiodarone
Sotalol (also a Beta)
Ibutilide
Dofetilide
 Type:

K+ channel blocker
 Use:
 Ventricular
tachyarrhythmias
 Atrial flutter and atrial fib
 Wolff-Parkinson-White
syndrome
 Side effects:
 SOB, bronchospasm, renal or
hepatic insufficiency
 Photosensitive, use
sunscreen and sunglasses,
may cause bluing of
periphery
Class IV
 Medications:


Verapamil
Diltiazem
 Type:

 Use:



Ca++ channel blocker


Prevent recurrence of
paroxysmal SVT
Reduce ventricular rate in
patients with atrial fib
Decrease the contraction of
muscle tissue, prevents slide
of actin and myosin
Avoid grapefruit juice it can
increase serum levels, as do
high fat meals
Monitor thyroid function
Class V
 Medications:
 Adenosine
 Digoxin
 Type:
 Work by other methods,
direct nodal inhibition
 Na/Ca pump
 Use:
 Supraventricular
arrhythmias
 Contraindicated in
ventricular arrhythmias
 Side effects:
 Digoxin- bradycardia,
anorexia, nausea & vomiting,
yellow/green halos, heart
blocks, arrhythmias, causes
hypocalcemia and
hypokalemia
Aspirin
 Acts to reduce inflammation by inhibiting the
production of prostaglandins
 Decreases platelet aggregation, decreases the
incidence of TIA’s and MI
 Dosage of 81 mg maintenance, not enteric coated
in MI
 Monitor for GI bleeding, exfoliative dermatitis,
Stevens-Johnson syndrome, tinnitus
Other Emergency Medications
 Atropine:



Parasympathicolytic, enhances
the SA node and AV node
conduction
Used for bradycardia and
asystole
Side effects:
 Tachycardia, urinary
retention, blurred vision,
bowel obstruction, not for
Complete heart block
 Calcium Cl:


Enhances myocardial
contractility for pts with
elevated K, Mg and low Ca
and CCB toxicity
Side effects:

Coronary and cerebral
vasospasm, ventricular
irritability, cautious if on
Digoxin
Other Emergency Medications
 Magnesium



Reduces post infarction
arrhythmias and pump failure
Hypomagnesemia can cause
refractory V fib and sudden
cardiac death
Side effects:
 Flushing, sweating,
hypotension, sensation of
heat, flaccid paralysis,
circulatory collapse
 Diprivan (Propofol)


Short acting sedative, used
for sedation with patients
who have airway and
ventilatory support
Side effects:

Hypotension, rebound
tachycardia and increased
ICP when wean off,
hepatotoxicity
Other Emergency Medications
 Lorazepam (Ativan)






Benzodiazepine sedative
Effects last 6-8 hours
If given intraarterial can cause
gangrene and limb loss
CNS depression is prominent if
over 50
Contraindicated if glaucoma
Watch for airway depression
 Midazolam (Versed)





Benzodiazepine sedative
Effects last 1.5-2 hours
Depresses respiratory rate,
apnea, can cause hypotension
Hiccups, headache, nausea,
amnesia, confusion
Can be reserved with romazicon
(flumazenil)
Other Emergency Medications
 Succinylcholine



Neuromuscular blocking agent
Rapid acting agent for
intubation
Side effects:
 Hypotention, tachycardia,
hyperkalemia, severe in
neurologic patients
myoglobinuria, malignant
hyperthemia
 Rocuronium or
vecuronium



Neuromuscular blocking agent
Lasts 20-60 minutes
Can cause tachycardia,
hypotension and bronchospasm
in some patients, prolonged
weakness if renal involvement