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Microsoft powerpoint - cardiovascular pharmacology handout.ppt

Current Cardiovascular
Pharmacology
Arthur Jones, EdD, RRT
http://rc-edconsultant.com/
Learning Objectives:
Explain the actions, effects, indications,
adverse effects and precautions for
agents from the following drug
categories:

ƒcardiotonic agents
ƒantidysrhythmic agents
ƒnitrates
ƒmiscellaneous cardiovascular agents
Cardiotonic Agents
Epinephrine
Actions
alpha1- vasoconstriction
beta1
chronotropic- heart rate
inotropic- contractility
dromotropic- conductivity
beta2- smooth muscle relaxation
bronchodilation
vasodilation
Epinephrine
Effects:
increase systemic vascular resistance
(SVR) blood pressure (BP), peripheral
blood flow

increase coronary and cerebral blood
increase myocardial electrical activity
==> increased automaticity ==>
increased HR

increase myocardial contractility
increase myocardial 02 requirements
Epinephrine
Indications
ƒresuscitation
ƒshock, including anaphylaxis
ƒsevere asthma
Epinephrine
Routes
ƒIntravenous (IV)
ƒSubcutaneous (SC)
ƒEndotracheal tube (ETT)- double IV
Epinephrine
Adverse effects
ƒHypertension
ƒMyocardial infarction
ƒTachycardia
ƒPeripheral tissue blood flow
impairment (ischemia)
Norepinephrine (Levophed)
Actions- alpha, beta1 adrenergic
Effects
ƒincreased SVR ==> increased
ƒincreased HR
ƒpositive inotropic
Norepinephrine (Levophed)
Indication- neurogenic or septic
Adverse effects
ƒMyocardial hypoxia ==> infarction
ƒrenal failure
ƒHypertension
ƒNecrosis of exposed tissues
ƒPeripheral ischemia
Dopamine
Actions- alpha1, beta1 adrenergic,
dopaminergic
Effects (dose-dependent)
ƒLow dose- Cerebral, renal,
mesenteric vasodilation
ƒModerate doses- increase cardiac
ƒHigh dose- generalized
vasoconstriction
Dopamine
Indications:
ƒhypotension (shock)
ƒdecreased urinary output
Dopamine
Adverse effects
ƒTachycardia
ƒRenal necrosis
ƒPeripheral tissue necrosis
ƒdysrhythmias
Vasopressin (Pitressin)
Synthetic endogenous hormone-
antidiuretic hormone
Effects
ƒanti-diuresis
ƒvasocontriction
ƒstimulation of ACTH release
FYI - Click for more information on vasopressin
http://www.cvphysiology.com/Blood%20Pressure/BP016.htm

Vasopressin (Pitressin)
Indications
ƒcardiac arrest
ƒshock
septic
hypovolemic
ƒdiabetes insipidus- accompanies
head trauma
Neosynephrine (Phenylephrine)
Action- alpha adrenergic
Effect- potent vasoconstrictor
Indications:
ƒnon-hypovolemic shock
ƒmucosal edema- post-extubation??
ƒmucosal bleeding
ƒprolong action of local anesthetics
Adverse effects- tissue ischemia
Dobutamine
Actions- alpha, beta1, beta2 adrenergic
Effects:
ƒpositive inotropic ==> increased
cardiac output
ƒMild peripheral vasodilation ==>
decreased PVR, SVR, increased
coronary perfusion

ƒDoes NOT increase myocardial 02
ƒCombined with dopamine ==>
maintain BP, without increasing PAP
Dobutamine
Indications
ƒAcute congestive heart failure
ƒright ventricular failure
Milrinone (Primacor)
Action- phosphodiesterase inhibitor
Effects
ƒinotropic
ƒvasodilation
Milrinone (Primacor)
Indications
ƒcardiomyopathy
ƒcongestive heart failure
ƒpulmonary arterial hypertension
FYI - click for article on aerosolized milrinone for PAH
http://ejcts.ctsnetjournals.org/cgi/reprint/31/6/1081

Digitalis glycoside- digoxin
Action- increased Ca++ in
myocardium
Effects
ƒpositive inotropic
ƒnegative dromotropic ==>
depresses AV conduction
Digitalis glycoside- digoxin
Indication
ƒspecific dysrhythmias
ƒChronic CHF
Digitalis glycoside- digoxin
Adverse effects- digitoxicity more
likely with hypokalemia
ƒMultiple types of dysrhythmias
ƒAgitation
ƒNausea & vomiting
Antidysrhythmic Agents
Atropine
Action- parasympatholytic
Effects (cardiac)
ƒincreased SA node automaticity
==> increased HR
ƒincreased AV node conductivity
Atropine
Indications
ƒBradycardia
ƒHeart block
ƒAsystole- may be worth a try
Routes
ƒIV
ƒinstillation through ETT
Side effects- tachycardia
Lidocaine
Action- sodium channel blocker
Effects
ƒdecreased automaticity
ƒdecreased conductivity
ƒincreased threshold for
fibrillation

Indications- rapid ventricular
dysrhythmias
Lidocaine
Routes
ƒETT administration ==> double dose
ƒIV
Adverse effects
ƒPsychoses, seizures
ƒdecreased contractility
ƒHeart block- asystole
ƒincreased threshold for defibrillation
ƒLethal if given for heart block with
escape beats
Amiodarone (Cordarone)
Action- multiple ion channel
Effects
ƒdecreased AV conduction
ƒdecreased sinus node function
Indications- dysrhythmias
Adverse effects (circulatory:
ƒhypotension
ƒbradycardia
Amiodarone (Cordarone)
Adverse effects (pulmonary)-
occurs over days-years of treatment
ƒpulmonary oxygen toxicity
ƒinterstitial pneumonitis
ƒpulmonary infiltrates
ƒorganizing pneumonia ±
bronchiolitis obliteran (BOOP)
ƒpulmonary fibrosis
FYI - Link to download article on amiodarone toxicity
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC341704/pdf/thij00006-0073.pdf

Amiodarone (Cordarone)
Adverse effects (pulmonary):
ƒA-C membrane permeability
edema with or without ARDS
ƒalveolar hemorrhage
ƒbronchospasm
ƒlaryngeal edema
ƒanaphylactic shock
ƒpleural effusion
ƒpleural/pericardial thickening
Dronedarone (Multaq)
Indication - atrial fibrillation/flutter
Contraindications
ƒsevere heart failure
ƒliver disease
Less effective than amiodarone
Fewer adverse effects
Hepatotoxic
More expensive than amiodarone;
but, reduces hospitalization for AF
FYI - click to download article on dronedarone
http://www.nejm.org/doi/pdf/10.1056/NEJMoa0803778

Beta adrenergic blockers
Action- beta1 blockade
Effects
ƒdecreased HR
ƒdecreased vascular resistance
ƒdecreased contractility
ƒdecreased conductivity
ƒdecreased myocardial 02
consumption
Beta adrenergic blockers
Indications
ƒangina
ƒhypertension
ƒPost-MI
ƒInhibit ventricular response to
atrial flutter, fibrillation
Beta adrenergic blockers
Side effects
ƒHypotension
ƒCHF
ƒBronchospasm- non-selective
Beta adrenergic blockers
Agents
ƒpropanolol (non-selective)
ƒatenolol
ƒmetoprolol
ƒsotalol (Betapace)- non-selective
ƒesmolol- short duration of action
ƒnadolol (Corgard)- non-selective
ƒsotalol (Betapace)
Calcium Channel Blockers
action- block entry of Ca++ to
myocardium
indications
ƒangina
ƒdysrhythmias; e.g., PSVT
ƒhypertension
Calcium Channel Blockers
agents
ƒverapamil (Calan, Isoptan)
ƒdiltiazem (Cardizem)
ƒamlodipine (Norvasc)
Magnesium Sulfate
Action- replacement for depletion of
ƒmalnourishment
ƒalcoholism
Effects
ƒreverses torsades des pointes
ƒrelaxes bronchial smooth muscle
ƒrelaxes uterine muscle
Magnesium Sulfate
Indications:
ƒhypomagnesemia
ƒtorsades des points VT
ƒstatus asthmaticus
ƒpre-eclampsia/eclampsia
Adverse effects- minimal
Nitrates
Sodium nitroprusside (Nipride)
Effects- vasodilation, arterial and
Indications
ƒHypertensive emergency
ƒLV failure
Sodium nitroprusside (Nipride)
Adverse effects
ƒcyanide poisoning
ƒhypotension
Precaution- avoid exposure of agent to
Nitroglycerine
Effect- decreased SVR ==> decreased
afterload and preload
Side effects- hypotension, headache
Indication- angina pectoris, AMI
Preparations- sublingual tablets, IV,
Miscellaneous Agents
Nesiritide (Natrecor)
Synthetic recombinant brain natriuretic
peptide (BNP)
ƒpotent vasodilator
ƒrapid reduction in PCWP
FDA approval in 2001
Indication
ƒsevere decompensated CHF
ƒdyspnea at rest or minimal activity
FYI - click for article on nesiritide
http://ccn.aacnjournals.org/content/26/1/39.full.pdf

Nesiritide (Natrecor)
Contraindications
ƒlow filling pressures
ƒhypotension
Adverse effects
ƒkidney failure
ƒdeath
ƒlitigation
Angiotensin converting enzyme (ACE)
inhibitors

action- block conversion of
angiotensin I to angiotensin II
effect- vasodilation
indications
ƒhypertension
ƒheart failure
side effect- chronic, dry cough
Angiotensin converting enzyme (ACE)
inhibitors

side effects
ƒchronic, dry cough
ƒangioedema- airway obstruction
FYI - click for more information on ACE inhibitors
http://www.chfpatients.com/ace.htm

ACE inhibitors
agents
ƒlisinopril (Zestril), (Prinivil)
ƒramipril (Altace )
ƒenalapril (Vasotec )
ƒbenazepril (Lotensin)
ƒcaptopril (Capoten)
Summary & Review
Cardiotonic agents- simulatory
cardiovascular effects
ƒepinephrine
ƒnorepinephrine
ƒdopamine
ƒdobutamine
ƒmilrinone
ƒvasopressin
ƒdigitalis
Summary & Review
Antidysrythmic agents
ƒAtropine
ƒLidocaine
ƒAmiodarone
ƒBeta adrenergic blockers
ƒCalcium channel blockers
ƒMagnesium sulfate
Summary & Review
Nitrates- vasodilators
ƒsodium nitroprusside
ƒnitroglycerine
Miscellaneous agents
ƒnesiritide- vasodilator for severe CHF
ƒACE inhibitors- antihypertensive

Source: http://www.respiratorycare-online.com/lecture_series/cardio_pharm_mp3/cardio_pharm_handout.pdf

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