1. Cardiac Medication Review
Idaho Society of Health-Systems Pharmacists
Cardiac Medication Review
Lindsay Crawford, PharmD & Lindsey Hunt, PharmD
PGY1 Pharmacy Residents
Boise VA Medical Center
March 6, 2016

2. Disclosures
The presenters have no disclosures or conflicts of interest
Medications discussed off label are identified throughout the presentation

3. Learning Objectives
List various classes of medications used for various cardiac conditions
Briefly explain basic pathophysiology of different cardiac conditions
Recognize errors associated with dispensing cardiac medications
Identify various formulations available and conversions made for cardiac medications

4. Cardiac Conditions Overview
CARDIO = HEART
Pressure abnormality  Hypertension
Conduction abnormality  Arrhythmias
Structural abnormality  Heart Failure
VASCULAR = VESSELS
Arterial
Cerebrovascular disease (stroke, TIAs)
Peripheral arterial disease
Coronary artery disease (angina, myocardial infarction)
Venous
Thromboembolism (DVTs, PEs)
OTHER
Infections, autoimmune disorders, congenital disease
Coronary artery disease is narrowing of coronary arteries which causes progressive thickening/plaque rupture of arterial wall leading to angina or myocardial infarction

5. Terminology Hypertension Arrhythmias Heart Failure Hypertension:
>140/90 from 2+ BP measurements per visit at 2+ visits
Hypertensive Crisis:
severe elevations in blood pressure with or without signs of end organ dysfunction
Caused by:
genetics (~30%), age, gender, ethnicity, stress, environment, dietary factors, drugs, diseases
Consequences:
Coronary artery disease, heart failure, chronic kidney disease, stroke, intracerebral hemorrhage, transient ischemic attack (TIA), peripheral arterial disease (PAD), atrial flutter, mild cognitive impairment (MCI)
Multifactorial
Dietary factors- high salt, obesity, alcohol
Drugs- cocaine, caffeine, adrenergics like pseudoephedrine, beta agonists, tobacco uses, NSAIDs
Diseases: hyperaldosteronism, renal artery stenosis, pheochromocytoma, diabetes, sleep apnea
Physiology: anxiety, pain, exercise

6. Pathophysiology Hypertension Arrhythmias Heart Failure
Sites of BP control: In most cases, elevated blood pressure is associated with an
overall increase in resistance to flow of blood through arterioles, whereas cardiac output is usually normal.
Physiologically, in both normal and hypertensive individuals, blood pressure is maintained by moment-to-moment regulation of cardiac output and peripheral vascular resistance, exerted at three anatomic sites:
arterioles,
postcapillary venules (capacitance vessels)
heart.
the kidney, contributes to maintenance of blood pressure by regulating the volume of intravascular fluid.
Baroreflexes, mediated by autonomic nerves, act in combination with humoral mechanisms, including the renin-angiotensin-aldosterone system, to coordinate function at these four control sites and to maintain normal blood pressure.
Finally, local release of vasoactive substances from vascular endothelium may also be involved in the regulation of vascular resistance. For example, endothelin-1 constricts and nitric oxide dilates blood vessels.

7. Antiadrenergic agents
Hypertension
Arrhythmias
Heart Failure
Antiadrenergic agents
Antiadrenergic agents
CNS centrally acting alpha-2 agonists
Clonidine Methyldopa Guanfacine
Alpha & Beta Blockers
Beta
Selective B1: Metoprolol Esmolol Nebivolol Atenolol
Bisoprolol
Non-Selective: Propranolol
Alpha 1
Doxazosin Terazosin Prazosin
Non Selective
Carvedilol Labetalol
Vasodilators
Angiotensin/
renin agents
Diuretics

8. Alpha-2 Agonists Hypertension Arrhythmias Heart Failure Mechanism:
Acts on CNS neurons to prevent the release of adrenergic molecules
Medications:
Clonidine
Methyldopa
Guanfacine
Guanabenz

9. Alpha-2 Agonists: Clonidine
Hypertension
Arrhythmias
Heart Failure
Alpha-2 Agonists: Clonidine
Usual total daily dose range
mg (BID dosing)
Dose Conversions:
Clonidine ER ≠ IR on mg:mg conversion
Switching from oral to patch will require a 3 day taper of oral clonidine
Other indications:
pain management (Duraclon® - epidural solution), nicotine withdrawal symptoms [off label]
Drug Names
Generic
Routes
Dosage Forms
Catapres®
Yes
Tablet IR
0.1, 0.2, 0.3 mg [scored]
Kapvay®
Tablet ER
0.1 mg
Catapres-TTS®
Transdermal patch (7d)
0.1, 0.2, 0.3 mg/24 hr
clonidine
Oral solution
Compounded

10. Alpha-2 Agonists: Methyldopa
Hypertension
Arrhythmias
Heart Failure
Alpha-2 Agonists: Methyldopa
Usual total daily dose range
mg (BID dosing)
Special Administration:
Dose increases should occur in the evening
Notable adverse effects
Same as clonidine
Hepatic dysfunction (watch for fever/flu-like symptoms)
Autoimmune disorders
Drug Names
Generic
Routes
Dosage forms
methyldopa
Yes
Oral Tablet IR
250 mg, 500 mg
IV solution
250mg/5mL
Oral suspension
compounded

11. Alpha-1 Blockers Hypertension Arrhythmias Heart Failure Mechanism:
Blocks alpha 1 receptors to cause vasodilation of the arteries and veins
Medications:
Prazosin (Minipress®)
Doxazosin (Cardura®)
Terazosin (Hytrin®)
Phentolamine
Alpha 1 & Alpha 2

12. Alpha-1 Blockers - Doxazosin
Hypertension
Arrhythmias
Heart Failure
Alpha-1 Blockers - Doxazosin
Usual total daily dose range
Doxazosin IR 1-16mg (QDaily dosing)
Other indications:
BPH (ER form is FDA approved for BPH)
Doses should be initiated in the evening
Drug Names
Generic
Routes
Dosage forms
Cardura®
Yes
Oral Tablet IR [scored]
1, 2, 4, 8 mg
Cardura XL® No
Oral Tablet ER (24 hr)
4, 8 mg

13. Alpha-1 Blockers - Prazosin
Hypertension
Arrhythmias
Heart Failure
Alpha-1 Blockers - Prazosin
Usual total daily dose range
HTN: Prazosin 2-20mg (BID-TID dosing)
PTSD: 1-15mg (QHS dosing)
Other indications:
PTSD-related nightmares and sleep disruption [off label]
Drug Names
Generic
Routes
Dosage forms
Minipress®
Yes
Oral capsule IR
1, 2, 5 mg

14. Alpha Blocker - Phentolamine
Hypertension
Arrhythmias
Heart Failure
Alpha Blocker - Phentolamine
Usual total daily dose range
HTN Crisis [off label]: 5-15mg IV/IM
1-5mg bolus + continuous infusion of 1-40mg/hr
Special indications:
Cocaine overdose, pheochromocytoma
Other Uses
Extravasation of norepinephrine
Drug Names
Generic
Routes
Dosage forms
phentolamine
Yes
IM, IV
5mg/mL

15. Beta Blockers Hypertension Arrhythmias Heart Failure Mechanism:
Block cardiac contractility
Decrease HR (Beta 1)
Block secretion of renin
Medications:
Metoprolol (Lopressor®, Toprol®)
Beta 1 selective
Propranolol (Inderal®)
Beta 1 & Beta 2
Esmolol (Brevibloc®)
Many others

16. Beta Blockers - Metoprolol
Hypertension
Arrhythmias
Heart Failure
Beta Blockers - Metoprolol
Usual total daily dose range
IR: mg (BID)
ER: mg (Qdaily)
IV: mg+ Q6-12h
Other uses:
Heart failure (ER), A. Fib, post-MI, angina
Dose conversions
ER = IR mg:mg
POIV = 2-2.5:1 total daily dose
Drug Names
Generic
Routes
Dosage forms
Metoprolol tartrate (Lopressor®)
Yes IV
Oral IR tablets
1mg/mL, 5mg/5ml
25, 50, 100mg [scored]
Metoprolol succinate (Toprol®)
Oral ER tablets
25, 50, 100, 200 mg [scored]

17. Beta Blockers - Propranolol
Hypertension
Arrhythmias
Heart Failure
Beta Blockers - Propranolol
Usual total daily dose range
IR: mg IR BID
ER: mg QD
Other Uses
Essential tremor, migraine prophylaxis, pheochromocytoma, post MI, stable angina, arrhythmias, akathisia [off-label], performance anxiety [off label], thyroid storm [off label], tremor [off label], variceal hemorrhage prophylaxis [off label]
Drug Names
Generic
Routes
Dosage forms
Propranolol
Yes IV
1mg/ml
Oral solution
20mg/5mL, 40mg/5mL
Oral IR tablets
10, 20, 40, 60, 80 mg
Propranolol (Inderal LA®)
Oral ER capsules (24 hr)
60, 80, 120, 160 mg

18. Beta Blockers - Esmolol
Hypertension
Arrhythmias
Heart Failure
Beta Blockers - Esmolol
Usual total daily dose range
HTN Crisis:
Min 1: IV mcg/kg
Min 2-5: IV mcg/kg/min
Other uses
Tachycardia, arrhythmias
Special indications
During surgery, aortic dissection
Dosing varies, but this is an example
If extravasation occurs stop infusion immediately and disconnect with needle in place; gently aspirate extravasated solution (DO NOT FLUSH THE LINE) remove needle elevate extremity
Drug Names
Generic
Routes
Dosage forms
Esmolol
Yes IV
10mg/mL
[PF] 10mg/mL, 100mg/10mL
Esmolol HCl in NaCl (Brevibloc®) No
2000mg (100mL); 2500mg (250mL)

19. Alpha & Beta Blockers Hypertension Arrhythmias Heart Failure
Mechanism:
Block cardiac contractility
Decrease HR (Beta 1)
Block secretion of renin
Vasodilation of veins
Medications:
Labetalol
Carvedilol (Coreg®)

20. Alpha & Beta Blockers - Labetalol
Hypertension
Arrhythmias
Heart Failure
Alpha & Beta Blockers - Labetalol
Usual total daily dose range
HTN crisis: IV- bolus & infusion
20-80mg at 10 min intervals (MAX 300mg)
0.5-2 mg/min IV infusion
Hypertension: PO mg BID
Drug Names
Generic
Routes
Dosage forms
Labetalol
Yes IV
5 mg/mL
Oral tabs
Oral suspension
100, 200, 300 mg
Compounded

21. Alpha & Beta Blockers- Carvedilol
Hypertension
Arrhythmias
Heart Failure
Alpha & Beta Blockers- Carvedilol
Usual dosing ranges
HTN doses: 6.25 mg BID
Heart failure target: 25-50mg IR BID
Other Uses
Heart failure, angina [off label], A fib [off label]
Drug Names
Generic
Routes
Usual total dose range
Carvedilol
Yes
Oral IR tab , 6.25, 12.5, 25mg
mg BID
Carvedilol (Coreg CR®) No
Oral ER tab- 10, 20, 40,80mg
10-80 mg Qdaily

22. Vasodilators Hypertension Arrhythmias Heart Failure
Antiadrenergic agents
Vasodilators
Arterial
Hydralazine Minoxidil
Arterial and Venous
Calcium Channel Blockers
Nitroprusside Nitroglycerin
Angiotensin/
renin agents
Diuretics

23. Vasodilators Hypertension Arrhythmias Heart Failure Mechanism:
Many; dilates arteries and/or veins
Medications:
Arterial
Hydralazine
Minoxidil
Arterial & Venous
Nitroprusside
Nitroglycerin
Calcium Channel blockers (CCBs)
DHP
Nicardipine
Non-DHP

24. Vasodilators - Hydralazine
Hypertension
Arrhythmias
Heart Failure
Vasodilators - Hydralazine
Usual total daily dose range
HTN Crisis: mg slow IVP
HTN: 10-50mg QID (Max 300)
Max rate 5mg/min IV push
Drug Names
Generic
Routes
Dosage forms
Hydralazine
Yes
Oral tab
Oral suspension
10, 25, 50, 100mg
compounded IV
20 mg/mL

25. Vasodilators - Nitroprusside
Hypertension
Arrhythmias
Heart Failure
Vasodilators - Nitroprusside
Usual total daily dose range
HTN Crisis: mcg/kg/min IV infusion
Other uses
Acute decompensated HF
Special Administration:
protect from light
Cyanide intoxication-
Drug Names
Generic
Routes
Dosage forms
Nitropress® No IV
25 mg/mL

26. Vasodilators - Nitroglycerin
Hypertension
Arrhythmias
Heart Failure
Vasodilators - Nitroglycerin
Usual total daily dose range
HTN Crisis: mcg/min IV infusion
Special indications
Myocardial infarction, ischemia
Other uses
Chest pain, anal fissure, variceal hemorrhage (off label)
Drug Names
Generic
Routes
Dosage forms
Nitronal®
Yes
IV solution
NitroStat® No
SL tab
0.3, 0.4, 0.6 mg
Other forms: Translingual spray, ER cap, rectal ointment, transdermal ointment, patch

27. CCBs – Dihydropyridines (DHP)
Hypertension
Arrhythmias
Heart Failure
CCBs – Dihydropyridines (DHP)
Amlodipine is a first line hypertension agent
Other uses
Migraine prophylaxis, angina, pulmonary hypertension (off label)
Avoid in
Acute heart failure
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Amlodipine (Norvasc®)
Yes
Oral tab- 2.5, 5, 10mg
2.5-10mg (Qdaily)
Nicardipine
IV, Oral cap- 20, 30mg
60-120mg (Qdaily)
Nifedipine (Procardia XL®)
Oral IR cap- 10,20mg
Oral ER cap- 30,60,90mg
30-60mg (Qdaily)

28. CCBs-Nicardipine Hypertension Arrhythmias Heart Failure
Usual total daily dose range
HTN Crisis: 5-15mg/hr IV
Special indications
BP lowering for ischemic stroke
Avoid in
Acute heart failure
Drug Names
Generic
Routes
Dosage forms
Nicardipine
Yes
IV- central line preferred
2.5mg/mL

29. CCBs- Non-DHPs Hypertension Arrhythmias Heart Failure Mechanism
Dose conversions
Affects contractility of heart
Diltiazem (IR=ER)
Other uses
Diltiazem (IV:PO)
A Fib – rate control, Angina, migraine prophylaxis (off label)
[(Rate) x 3 +3] x 10 = PO dose
3mg/hr = 120mg Qdaily
Notable adverse effects
Avoid in
drug interactions, heart block, edema, headache
Heart failure
Drug Names
Generic
Routes/Dosage Form
Diltiazem
Yes
IV – for arrhythmias  0.25mg/kg IVP over 2 minutes
Oral IR Cap – 30, 60, 90, 120mg (given Q6h)
Oral ER Cap
12h- 60, 90, 120mg
24h- 120, 180, 240, 300, 360, 420mg
Oral ER Tab 24h- 180, 240, 300, 360, 420mg
Verapamil
IV – for arrhythmias 2.5-5mg IVP over 2 minutes
Oral IR Tab – 40, 80, 120mg (given BID-TID)
Oral ER Cap-100, 120, 180, 200, 240, 300, 360mg
Oral ER Tab- 120, 180, 240 mg
less potent vasodilators
Avoid IR for long term use
Capsules may be sprinkled on applesauce do not chew

30. Medications Overview Hypertension Arrhythmias Heart Failure
Antiadrenergic agents
Vasodilators
Angiotensin/
renin agents
ACE Inhibitors
Lisinopril Enalapril Captopril
Angiotensin Receptor Antagonists
Losartan Valsartan Irbesartan
Diuretics

31. Angiotensin/Renin Agents
Mechanism:
Vasodilation by blocking angiotensin II effects
Reduces aldosterone to inhibit volume increase
Medications:
ACE Inhibitors “-prils”
Lisinopril
Enaloprilat
Many
ARBs “-sartans”
Losartan

32. ACE Inhibitors Hypertension Arrhythmias Heart Failure
First line hypertension agent
Uses
Heart failure, after MI, renal protection for diabetics
Contraindicated
pregnancy
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Benazepril (Lotensin®)
Yes
Oral tab-5,10,20,40mg
10-40mg (QD-BID)
Captopril (Capoten®)
Oral tab-12.5,25,50,100mg
25-100mg (BID-TID)
Fosinopril (Monopril®)
Oral tab- 10,20,40mg
Lisinopril (Zestril®)
Oral tab- 2.5,5,10,20,30,40mg
10-40mg (Qdaily)
Ramipril (Altace®)
Oral cap- 1.25,2.5,5,10mg
mg (Qdaily)
Interactions- lithium (HCTZ decreases lithium clearance, also lithium blocks thiazides effects)

33. ACE Inhibitors - Enalaprilat
Hypertension
Arrhythmias
Heart Failure
ACE Inhibitors - Enalaprilat
Usual total daily dose range
HTN Crisis: mg IV Q6h
Contraindicated
teratogenic
Avoid in
Myocardial infarction
Acute heart failure
Interactions- lithium (HCTZ decreases lithium clearance, also lithium blocks thiazides effects)
S/S of angioedema
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Enalapril (Vasotec®, Epaned®)
Tab-Yes
Sol-No
Oral tab- 2.5,5,10,20mg
Oral solution- 1mg/ml
(QD-BID)
Enalaprilat
Yes
IVP or infusion
1.25-5mg IV Q6h

34. ARBs Hypertension Arrhythmias Heart Failure
First line hypertension agent
Other uses
Heart failure, post MI
Administration:
No benefit to use with ACE-Inhibitors
Contraindicated
Pregnancy
Interactions- lithium (HCTZ decreases lithium clearance, also lithium blocks thiazides effects)
S/S of hyperkalemia -
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Candesartan (Atacand®)
Yes
Oral tab- 4,8,16,32mg
8-32 mg (Qdaily)
Irbesartan (Avapro®)
Oral tab- 75,150,300mg
mg (Qdaily)
Losartan (Cozaar®)
Oral tab- 25,50,100mg
25-100mg (QD-BID)
Olmesartan (Benicar®) No
Oral tab- 5, 20, 40mg
20mg (Qdaily)
Valsartan (Diovan®)
Oral tab- 40,80,160,360mg
80-320mg (Qdaily)

35. Diuretics Hypertension Arrhythmias Heart Failure Antiadrenergic agents
Vasodilators
Angiotensin/
renin agents
Diuretics
Thiazides
HCTZ Chlorthalidone Metolazone
Loops
Furosemide Bumetanide Torsemide
K+ Sparing
Spironolactone Triamterene

36. Hypertension
Arrhythmias
Heart Failure
Diuretics

37. Thiazides & Thiazide Like
Hypertension
Arrhythmias
Heart Failure
Thiazides & Thiazide Like
First line hypertension agent
Other Uses
Edema (heart failure/renal disease)
Dose conversions
Chlorthalidone is 1.5-2x more potent than HCTZ
Special Administration:
Dose should occur in AM
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Chlorothiazide (Diuril®)
IV-No
PO-Yes
IV- susp, solution
Oral tab- 250, 500mg
mg (Qdaily)
Hydrochlorothiazide
Yes
Oral tab-12.5,25,50mg
Oral cap-12.5mg
mg (Qdaily)
Chlorthalidone
Oral tab-25, 50, 100mg
mg (Qdaily)
Metolazone
Oral tab- 2.5, 5, 10 mg
2.5-10mg (Qdaily)
Interactions- lithium (HCTZ decreases lithium clearance, also lithium blocks thiazides effects)

38. Loop Diuretics Hypertension Arrhythmias Heart Failure
Special Administration:
Doses should occur earlier in the day
Other uses
Edema (d/t heart failure), hepatic cirrhosis
Dose conversions
Furosemide POIV = 2:1
Furosemide IV  Bumetanide IV = 20:1
Furosemide PO  Bumetanide PO  Torsemide PO = 40:1:20
Furosemide Oral tab may be used sublingual (under tongue x 5min)
Furosemide – 20-40mg/min
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Bumetanide (Bumex®)
IV, IM, oral-tab
0.5-2mg+ (QD-BID)
Furosemide (Lasix®)
Yes
IV [PF], oral-tab, solution
20-80mg+ (QD-BID)
Torsemide (Demadex®)
oral-tab [scored]
2.5-10mg (Qdaily)

39. Dose Conversions H.S. is a 58 y/o male admitted to hospital and
unable to take oral medications
On furosemide 40mg po QAM for edema at
home
You are asked to deliver furosemide 40mg IV
to the floor
Is this an equivalent dose?
Team decides to convert H.S. to IV torsemide (Demadex®) from furosemide 20mg IV
What is the equivalent dose?
H.S. is discharged from hospital and would like to pick up his bumetanide (Bumex®) 3mg po QAM for edema.
Is this an equivalent dose to what he was taking at home?

40. K+ Sparing Diuretics Hypertension Arrhythmias Heart Failure Other uses
Spironolactone
Edema, hypokalemia, hyperaldosteronism, hirsutism in women [off label], acne in women [off label], ascites from cirrhosis [off label]
Eplerenone
Heart Failure
Contraindicated
Pregnancy
Drug Names
Generic
Routes/Dosage Form
Usual dosage range
Spironolactone
Yes
Oral tab- 25, 50, 100mg
25-50mg+ (QD-BID)
Eplerenone (Inspra®)
Oral tab- 25, 50mg
50-100mg (QD-BIDD)
Triamterene (Direnium®) PO
2.5-10mg (Qdaily)

41. Arrhythmias Hypertension Arrhythmias Heart Failure
Definition: cardiac condition caused by abnormalities in the formation and/or conduction of electrical impulses controlling the rate of the heart
Causes
Myocardial ischemia/infarction
Conditions damaging heart tissue
Heart valve disorders, hypertension, heart failure
Electrolyte imbalances
Elevated sympathetic states
Hyperthyroidism, infection
Drugs
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

42. Pathophysiology Hypertension Arrhythmias Heart Failure
Cardiac Conduction Pathway

43. Pathophysiology Hypertension Arrhythmias Heart Failure
Cardiac Muscle Cell Action Potential

44. Types of Arrhythmias Hypertension Arrhythmias Heart Failure
Supraventricular (above AV node)
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Ventricular (below AV node)
Premature ventricular contractions
Ventricular tachycardia
Ventricular fibrillation
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

45. Atrial Fibrillation Hypertension Arrhythmias Heart Failure
Definition: the result of the heart’s two upper chambers (atria) beating chaotically and out of coordination with the two lower chambers (ventricles), leading to an irregular and usually rapid heart rate
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

46. Medication Overview Hypertension Arrhythmias Heart Failure
Sodium channel blockers
Class IA
Procainamide
Class IB
Lidocaine
Class IC
Flecainide Propafenone
Beta-blockers (Class II)
Potassium channel blockers (Class III)
Amiodarone Sotalol Dofetilide Dronedarone
Calcium channel blockers (Class IV)
Verapamil Diltiazem
Digoxin

47. Class I Antiarrhythmics
Hypertension
Arrhythmias
Heart Failure
Class I Antiarrhythmics
Sodium channel blockers
Sub-classified based on duration of time they bind to sodium channel
1A: intermediate; also block potassium channels
1B: fast
1C: long-acting
Black Box Warning: increased risk of mortality
Class IA
Class IB
Class IC
disopyramide PO
mexiletine
moricizine
quinidine
IV, PO
lidocaine
IV, IM (off-label)
flecainide
procainamide IV
tocainide
propafenone
phenytoin
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

48. Class I Antiarrhythmic Acronym
Double (disopyramide)
Quarter (quinidine)
Pounder (procainamide)
1B:
Mayo (mexiletine)
Lettuce (lidocaine)
Tomato (tocainide)
Pickles (phenytoin)
IC:
More (moricizine)
Fries (flecainide)
Please (propafenone)

49. Class II Antiarrhythmics
Hypertension
Arrhythmias
Heart Failure
Class II Antiarrhythmics
Beta-blockers
Esmolol
Propranolol
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

50. Class III Antiarrhythmics
Hypertension
Arrhythmias
Heart Failure
Class III Antiarrhythmics
Potassium Channel Blockers
Amiodarone dosing dependent on arrhythmia type
Special Administration:
Amiodarone infusions longer than 2 hours must be administered in non-PVC container
Inline 0.22 micron filter should be used
Dofetilide requires REMS program
Drug Names
Generic
Routes/Dosage Form
Amiodarone (Pacerone®)
Yes
IV, PO (tablet)
Sotalol (Betapace®)
IV, PO (tablet & solution)
Dofetilide (Tikosyn®) No
PO (capsule)
Dronedarone (Multaq®)
PO (tablet)
To minimize risk of induced arrhythmia, pts initiated or re-initiated on tikosyn are placed for a minimum of 3 days in facility that can provide CrCl, continuous ECG and cardiac resuscitation
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

51. Class IV Antiarrhythmics
Hypertension
Arrhythmias
Heart Failure
Class IV Antiarrhythmics
Non-dihydropyridine calcium channel blockers
Verapamil
Diltiazem
Talk about difference– non dihydro vs. dihydro Ca channel blockers
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

52. Digoxin Hypertension Arrhythmias Heart Failure
Dose adjusted to fall between a therapeutic range (0.5-2ng/mL)
Not given alone– usually in combination with a calcium channel blocker or beta-blocker
Increased risk of toxicity
Toxicity: greater than 2
Antiarrhythmics. In: Shapiro K, Brown SA, eds. 2015

53. Heart Failure Hypertension Arrhythmias Heart Failure
Definition: clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood
Causes:
Coronary artery disease/heart attack
High blood pressure
Heart defects
Damage to heart muscle
Arrhythmias
Heart Failure. In: Shapiro K, Brown SA, eds. 2015

54. Pathophysiology Hypertension Arrhythmias Heart Failure
Source: Pharmacotherapy © 2003 Pharmacotherapy Publications

55. Presentation Hypertension Arrhythmias Heart Failure
Chronic vs. Acute (“decompensated”)
Image from:

56. Types of Heart Failure Hypertension Arrhythmias Heart Failure
“Reduced Ejection Fraction”
“Preserved Ejection Fraction”
Wiggins BS. In: ACCP Updates in Therapeutics

57. Most often used for decompensated heart failure
Hypertension
Arrhythmias
Heart Failure
Medication Overview
Vasodilators
ACE inhibitors
ARBs
Beta-blockers
Diuretics
Potassium-sparing
Loop
Positive Inotropes
Digoxin
Sympathomimetics
Dobutamine Dopamine
Most often used for decompensated heart failure

58. ACE-inhibitors Hypertension Arrhythmias Heart Failure
Shown to significantly decrease cardiovascular mortality, heart attacks and hospitalizations for heart failure patients with reduced ejection fraction
Image from: Do AN, et al. Front. Pharmacol

59. Angiotensin II Receptor Blockers
Hypertension
Arrhythmias
Heart Failure
Angiotensin II Receptor Blockers
Shown to significantly decrease cardiovascular mortality, heart attacks and hospitalizations for heart failure patients with reduced ejection fraction
Angiotensin II Receptor Blockers
Image from: Do AN, et al. Front. Pharmacol

60. Beta-blockers Hypertension Arrhythmias Heart Failure
Shown to improve survival and reduce hospitalization in heart failure patients with reduced ejection fraction
Heart failure beta-blockers:
Carvedilol
Metoprolol
Bisoprolol

61. Diuretics Hypertension Arrhythmias Heart Failure
Reduces symptoms of heart failure
Image from: Do AN, et al. Front. Pharmacol

62. Potassium Sparing Diuretics
Hypertension
Arrhythmias
Heart Failure
Potassium Sparing Diuretics
Shown to improve survival and reduce morbidity and mortality in heart failure patients with reduced ejection fraction
NYHA class II-IV, CrCl >30, K <5.0
“Aldosterone antagonists”
Spironolactone
Eplerenone

63. Positive Inotropes Hypertension Arrhythmias Heart Failure
Increase cardiac contractility during heart failure exacerbations
Used as emergency medications (dobutamine, dopamine)
Warning: arrhythmias!
Digoxin
Dobutamine
Dopamine
Heart Failure. In: Shapiro K, Brown SA, eds. 2015

64. Drug Update: Entresto™ (sacubitril/valsartan)
Hypertension
Arrhythmias
Heart Failure
Drug Update: Entresto™ (sacubitril/valsartan)
Inactive fragments
Damaged Heart with CHF
Natriuretic Peptide System
Renin-Angiotensin-Aldosterone System
Natriuretic Peptides
Angiotensin-II
Beneficial Physiological Response
Pathophysiological Response
AT1 receptor
↑ BP
↑ Sympathetic tone
↑ Fibrosis
↑ Aldosterone
↑ Hypertrophy
Vasoconstriction
Vasodilation
↓ BP
Natriuresis/Diuresis
↓ Sympathetic tone
↓ Fibrosis
↓ Aldosterone
↓ Hypertrophy
NEPRILYSIN
Sacubitril
Valsartan
Tablets; $450/month
Adapted from : Langenickel TH, Dole WP. Drug Discovery Today: Therapeutic Strategies. 2013; 9 (4):

65. Assessment Question #1
Which of the following classes of medications is NOT indicated for the treatment of cardiac conditions?
Anti-arrhythmics
Beta-agonists
Angiotensin II receptor blockers
Thiazide diuretics
Correct Answer: B

66. Assessment Question #2
“The result of the heart’s two upper chambers (the atria) beating chaotically and out of coordination with the two lower chambers (the ventricles), leading to an irregular and usually rapid heart rate” is the clinical definition of what cardiac disease state?
Heart failure
Transient Ischemic Attack
Angina
Atrial fibrillation
Correct Answer: D

67. Assessment Question #3
Which of the following prescription order(s) may be wrong and should be brought to the attention of the pharmacist?
Metoprolol succinate 100mg po BID for heart failure #60
Hydralazine 25mg po Qdaily for hypertension #30
Diltiazem SA 240mg po BID for atrial fibrillation #60
All of the above
Correct Answer: D

68. Assessment Question #4
Patient is currently receiving furosemide 40 mg po Qdaily for heart failure. Provider wants to switch to bumetanide. What is the equivalent dose of bumetanide?
Bumetanide 40mg
Bumetanide 20mg
Bumetanide 10mg
Bumetanide 1mg
Correct Answer: D

69. References
Chyka PA, Boucher BA, Franks AS, eds. The APhA Complete Review for Pharmacy. 11th ed. Amer Pharmacists Assn.
Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at: Accessed January 17, 2016.
Katzung B, Trevor A. Basic & Clinical Pharmacology. 13th ed. McGraw-Hill Education
Shapiro K, Brown SA, eds. RxPrep CourseBook ed. Manhattan Beach, CA; RxPrep, Inc.

70. Questions