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