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Cardiovascular Medication
Dr. Eric F. Schmidt, Pharm.D.
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Objectives Explain mechanism of action of various cardiac medications and hemodynamic effects. Describe side effects and monitoring parameters. List appropriate dosages and explain special considerations needed for administration.
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Abciximab (Reopro) Description Indication Dose Adverse Effects
Glycoprotein 2b3a inhibitor (platelet inhibitor) Indication Adjunct to PCI for Unstable Angina (with heparin) Dose Bolus 0.25 mg/kg Continuous infusion micrograms/kg/min Maximum 10 micrograms/min Give through a filter Adverse Effects Bleeding, bruising, thrombocytopenia, hypotension
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Eptifibatide Description Indications Dosage Adverse Effects
Glycoprotein 2b3a inhibitor Antiplatelet agent Indications Used in ACS and adjunct to PCI (with heparin) Dosage Bolus 180 mcg/kg (22.6 max) Infusion of 2 mcg/kg/min (15 mg/hr max) Must have estimated creatinine clearance to dose correctly Adverse Effects Bleeding, thrombocytopenia
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Class Ia Antiarrhythmics
Procainamide Disopyramide Quinidine Indications Ventricular tachycardia, PVC, PSVT, Atrial fib. Dose Bolus 20 mg/minute until 17 mg/kg administered Infusion 1-4 mg/minute Adverse Effects Torsades, QT prolongation, Lupus Like Reaction, hypotension
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Lidocaine Description Indications Dosage Adverse Effects
Antiarrhythmic Suppress ventricular ectopy by decreasing ventricular irritability Indications PVC, VT, VF Dosage 1.5 mg/kg every 3-5 min up to 3 mg/kg Infusion of 1-4 mg/min Adverse Effects Twitching, slurred speech, seizures (CNS-related)
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Class II Antiarrhythmics
Beta Blockers Metoprolol, Atenolol, Propranolol, Labetalol Description Decrease calcium flux in AV node Decrease excitability of cardiac tissue Selective vs. Nonselective Indications Hypertensive emergencies, atrial fibrillation, flutter, prevention of MI Dose Varies by actual medication IV Push route over 1-5 minutes depending on drug Adverse Effects Hypotension, bradycardia, arrhythmias,
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Ibutilide Description Indications Dosage Adverse Effects
Class 3 antiarrhythmic Indications Pharmacologic conversion of recent onset atrial fibrillation or flutter Dosage 1 mg over 10 minutes May be diluted in mL A second infusion may be necessary Continuous monitoring during infusion and 4 hours after is recommended Adverse Effects Headache, irregular heartbeat, QT prolongation
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Amiodarone Description Indications Dose Adverse Effects
Antiarrhythmic (Class III) Inhibits adrenergic stimulation and prolongs the action potential and refractory period Indications VT/VF, Stable VT, Atrial Arrhythmias, PSVT Dose 300 mg IV push (in an emergency / ACLS) 150 mg IV over 10 minutes Infusion: 1 mg/min x 6 hours; then 0.5 mg/min x 18 hours Adverse Effects Hypotension, bradycardia, hepatic dysfunction and others
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Diltiazem Description Indications Dosage Adverse Effects
Class IV antiarrhythmic Calcium channel blocker prolonging phase 2 of action potential Indications Conversion of rapid atrial fibrillation or flutter May be used for SVT Dosage 0.25 mg/kg over 2 minutes 10 mg/hr up to 15 mg/hr >24 hours not recommended Adverse Effects Hypotension, heart failure, heart block
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Adenosine Description Dosage Indications Adverse Effects
Depress SA and AV node activity Interrupts the re-entry pathway Dosage 6 mg IVP over 1-3 seconds with a 10 – 20 mL flush 12 mg if no response in 1-2 minutes May repeat 12 mg x 1 Indications SVT Adverse Effects Flushing, headache, dizziness, chest-discomfort Limited to about 5 seconds.
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Digoxin Description Indication Dose Adverse Effects Cardiac Glycoside
Slows ventricular rate by direct AV node suppression Inhibition of Na+/K+ ATPase pump increasing Ca2+ Indication CHF and supraventricular arrhythmias Dose ½ TDD, ¼ TDD, ¼ TDD (9 – 12 hours intervals) Push over > 5 minutes Adverse Effects Heart block, Nausea, confusion, visual disturbances, dizziness
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Atropine Description Indications Dosage Adverse effects
Parasympatholytic (vagolytic) action Increases sinus node activity and conduction Indications Bradycardia Asystole Dosage 0.5 – 1 mg IVP every 3-5 minutes as needed (3 mg max) Slow injection may cause paradoxical bradycardia Adverse effects Worsened ischemia, flushing, hypotension, weakness
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Magnesium Description Indications Dosage Adverse Effects
Antiarrhythmic Indications Hypomagnesemia, refractory VT/VF, TORSADES de Pointes Dosage 2 grams per hour MAX infusion VT/VF 1-2 grams / 100 ml D5W over 1-2 minutes (emergency use) IV Push no faster than 150 mg/min Adverse Effects Hypotension, Flushing and Burning
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ACE-Inhibitor (enalaprilat)
Description Angiotensin converting enzyme inhibitor Decreases production of Angiotensin II Indications Mild to severe hypertension, hypertensive crisis Dosage 1.25 mg IVP over 5 minutes every 6 hours Adverse Effects Hypotension, headache, syncope, weakness
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Dopamine Description Indications Dosage (0.5 – 20 mcg/kg/min)
Norepinephrine precursor Stimulates Alpha, Beta and Dopamine receptors Indications Hypotension, CHF, Shock, renal failure Dosage (0.5 – 20 mcg/kg/min) Low vs. Medium vs. High Adverse Effects Tachycardia, arrhythmias, extravasation
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Dobutamine Description Indications Dosage Adverse effects
Synthetic catecholamine Stimulates beta receptors increasing stroke volume Indications Decreased cardiac output, CHF Dosage 2.5 – 20 mcg/kg/min Adverse effects Tachyarrhythmias, ventricular ectopy, angina/MI
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Nitroglycerin Description Indication Dose Adverse Effects
Precursor to Nitric Oxide Indication Decreases preload Increases supply and decreases workload Dose 5 – 20 mcg/min (200 mcg/min max) Decrease dose slowly to avoid withdrawal Adverse Effects Headache, flushing, tachycardia, hypotension, withdrawal may cause vasospasm
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Milrinone Description Indications Dosage Adverse Effects
Phosphodiesterase inhibitor resulting in vasodilation Increases Ca2+ and contractile force in myocardium Indications Short-term IV therapy of congestive heart failure Dosage 50 mcg/kg slow IV over 10 minutes 0.5 mcg/kg/min infusion and titrate Adverse Effects Hypotension, arrhythmia, headache
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Nesiritide Description Indications Dosage Adverse Effects
Beta natriuretic peptide Increases intracellular GMP resulting in smooth muscle relaxation Indications Treatment of acutely decompensated heart failure with dyspnea at rest or minimal activity Dosage Bolus from reconstituted bag 2 mcg/kg 0.01 mcg/kg/min for 48 hours Adverse Effects Hypotension, bradycardia, nausea, headache
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Potassium Description Indications Dosage (monitored patient)
Electrolyte Indications Hypokalemia Dosage (monitored patient) Maximum 20 meq/hr peripheral line and 40 meq/hr central line Concentration max is 40 meq/100 ml central line and 40 meq/250 mL peripheral line Large volume infusions should contain no more than 80 meq / 1000 mL Adverse Effects
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QUESTIONS???
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