SEMINAR on Drugs Used in Cardiac Diseases
Content
SEMINAR ON DRUGD USED IN CARDIAC DISEASE
CLASSIFICATION OF DRUGS USED IN CARDIAC DISEASES
Anti-arrhythmic agent
• Class 1 sodium channel blocker e.g. flecanide, quinidine • Class 2 beta adrenoreceptor blocker e.g. metoprolol, propanolol • Class 3 sodium channel blocker e.g. amiodarone • Class 4 calcium blocker e.g. diltiazem, verapamil, nifedipine • Other Anti-arrhythmic drug e.g. adenosine, digoxin
Anti-anginal drug
• Organic nitrates e.g. isosorbide dinitrate, nitroglycerin • Beta blocker e.g. propanolol • Calcium channel blocker e.g. diltiazem, verapamil, nifedipine
Drugs affecting blood
• Platelet inhibitor e.g. aspirin, ticlopidine • Anticoagulant e.g. enoxaparin, warfarin, heparin. • Thrombolytic agent e.g. urokinase, streptokinase • Treatment of bleeding e.g. aminocaproic acid, vitamin k, tranexamic acid • Treatment of anemia e.g. folic acid, cyanocobalamine, iron
Antihypertensive drug
• Diuretics e.g. hydrochlorothiazide, frusemide, spirolactone • Alpha blocker e.g. doxazosin, prazosin • Beta blocker e.g. metoprolol, propanolol • ACE inhibitor e.g. catopril, analapril, ramipril • Angiotensin II antagonist e.g losartan • Calcium channel blocker e.g. diltiazem, verapamil, nifedipine, amlodipine • Vasodilators e.g sodium nitropruside
Inotropic agents
• Positive inotropic agent e.g. dobutamine • Negative inotropic agent e.g. dopaamine
• Cardiac glycosides e.g. digoxin, digitoxin • Hypolipidemic agents e.g. statin
FLECANIDE
• Group of drug – antiarrhythmic agent, sodium channel blocker • Pharmacological name- flecanide • Trade name – Almarytm, Apocard, Ecrinal, Flécaine • Dose of drug – 1-2.5mg/kg/body wt
• Indication: Prevention of paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disablin
• Contraindication: hypersensitivity, cardiogenic shock, CHF, pre-existing sinus node dysfunction or 2nd or 3rd degree heart block (without a pacemaker), renal impairment, pregnancy, lactation or children.
• Adverse effect
– Nausea and vomiting, convulsions, hypotension, bradycardia, syncope, extreme widening of the QRS complex, widening of the QT interval, widening of the PR interval, ventricular tachycardia, AV nodal block, asystole, bundle branch block, cardiac failure, and cardiac arrest. – CNS – dizziness, anxiety, fatigue, headache, mental depressin. tremor, Blurred vision, – Chest pain, CHF
QUINIDINE
• Group of drug - antiarrhythmic agent (class 1 A), sodium channel blocker
• Pharmacological name–Quinidine
• Dose of drug–
– PO (Adults): 324–972mg q 8–12 hr. – IV (Adults): 200–400 mg given at a rate <10 mg/min until arrhythmia is suppresses
• Action – decrease myocardial excitability, Slow conduction velocity and suppresses arrhythmias • Indication –atrial fibrillation, atrial flutter, recurrent ventricular arrhythmias and treatment of malaria
Contraindication – hypersensitivity, conduction defects (without a pacemaker) CHF, severe liver dosease, Hypokalemia or hypomagnesemia(↑ risk of torsades de pointes); Bradycardia (↑risk of torsades de pointes), pregnancy, lactation or children.
Adverse effect
• CNS: dizziness, confusion, fatigue, headache,syncope, vertigo • EENT: blurred vision, diplopia,mydriasis, photophobia, tinnitus. • CV: hypotension,torsades de pointes, arrhythmias, palpitations, tachycardia • GI: anorexia, abdominalcramping, diarrhea, nausea, vomiting, druginduced hepatitis. • Derm: rash. Neuro: ataxia, tremor.Misc: fever. • Hemat: agranulocytosis, hemolytic anemia, thrombocytopenia.
METOPROLOL
• • • • Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker Pharmacological name - metoprolol Trade name - tartarate 25, 50, 100mg Dose of drug– PO (Adults):
– Antihypertensive/antianginal—25–100 mg/day as a single dose initially or 2 divided doses, 450 mg/day (for angina, give in divided doses) – MI—25–50 mg (starting 15 min after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily for a minimum of 3 month. – Heartfailure—12.5–25 mg once daily – Migraneprevention—50–100 mg 2–4 times daily
IV (Adults):
– MI—5 mg q 2 min for 3 doses, followed by oral dosing
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Action Blocks stimulation of beta1(myocardial)-adrenzinergic receptors. Does not usually affect beta2 (pulmonary, vascular, uterine) adrenergic receptor sites. decreases blood pressure and heart rate. De creased frequency of attacks of angina pectoris. Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure
Indication - Hypertension. Angina pectoris. Prevention of MI, heart failure due to ischemic, ventricular arrhythmias/tachycardia, Migraine, tremors, drug induced akathesia, anxiety Contraindication - Uncompensated CHF, Pulmonary edema, Cardiogenic shock, Bradycardia or heart block Adverse effect • CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia,memory loss, mental status changes, nervousness, nightmares. • EENT: blurred vision, stuffy nose. • Resp: bronchospasm, wheezing • CV: bradycardia, CHF, pulmonary edema, hypotension, peripheral vasoconstriction. • GI: constipation, diarrhea, drug induced hepatitis, drymouth, flatulence, gastricpain, heartburn. • GU: erectile dysfunction • MS: arthralgia, back pain, joint pain
PROPANOLOL
• Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker • Pharmacological name - Propanolol • Trade name - novopropranolol • Dose of drug– Oral
– Antianginal 80-320mg/day in 2-4 divided doses.(childrens 0.5-1mg/kg/day in 24 divided doses) – Antihypertensive 40mgtwice daily (usual range 120-240mg/day) – Antiarrhythmia 10-30mg/day
Intravenous
– Adults 1-3 mg repeated after 2 min and again in 4 hr if needed – Children 0.01-0.1 mg/kg repeated after 6-8 hr
• Action: Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic receptor sites. Decreases heart rate and blood pressure, suppresses arrhythmia and prevents MI
Indication Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma. Also used in the prevention and management of MI and prevention of vascular headaches
Contraindication Uncompensated CHF, Pulmonary edema; Cardiogenic shock; Bradycardia or heart block
Adverse effect
– CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares. – EENT: blurred vision, dry eyes, nasal stuffiness. Resp: bronchospasm, wheezing – CV: arrhythmias, bradycardia, CHF, pulmonary edema – GU: erectile dysfunction
AMIODARONE
• Group of drug - antiarrhythmic class III • Pharmacological name – Amiodarone • Trade name - cardarone, pacerone • Dose of drug: 1ml contains 50 mg amiodarne Oral
– Adults 800-1600mg/day in 1-2 doses for 1-3 wk, then 600-800mg/day in 1-2 doses for 1 month then 400mg maintenance dose – Children 10mg/kg/day for 10 days, then 5 mg/day for several weeks then 2.5 mg/kg/day maintenance dose.
Intravenous
– Adults: 150 mg over 10 min, followed by 360 mg over the next 6 hr – Continuous infusion at 0.5 mg/min until oral therapy is initiated – ACLSguidelines for pulseless ventricular fibrillation or ventricular tachycardia 5 mg/kg as bolus
• Action Prolongs action potential and refractory period. Inhibits adrenergic stimulation. Slows the sinusrate,increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation). Ths suppresses arrhythmia • Indication Life threatening ventricular arrhythmia, Supraventricular tachycardia, ACLS • Contraindication Cardiogenic shock, SA node dysfunction, 2nd and 3rd degree AV block, syncope, hypersensitivity. • Adverse effect
– CNS: confusional states, disorientation, hallucinations, fatigue, malaise, dizziness, headache, insomnia. – EENT: corneal micro-deposits – Resp: adult respiratory distress syndrome (ards), pulmonary fibrosis, pulmonary toxicity. – CV: CHF, worsening of arrhythmias, bradvcardia, hypotension.
DILTIAZEM
• Group of drug – antiarrhythmia class IV, antihypertensive, antianginals, calcium channel blocker.
• Pharmacological name - diltiazem • Trade name–cardiazem, taztia XT
• Dose of drug
– Oral: 30-120 mg 3-4 times daily or 60-120 mg twice daily or 180-240 mg once a day (max 360mg/day) – Intravenous: 0.25 mg/kg repeat in 15 min with 0.35mg/kg – Continuous infusion at 10 mg/hr for 24 hr (5-15mg/hr)
• Action Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation contraction coupling and subsequent contraction, results in decreased blood pressure, coronary vasodilatation and suppresses arrhythmias
• Indication Hypertension, Angina pectoris and vasospastic angina, Supraventricular tachycardia and rapid ventricular rates in atrial flutter or fibrillation.
• Contraindication Hypersensitvity, 2nd or 3rd degree AV block, recent MI, pulmonary congestion, blood pressure <90 mm Hg, CHF
• Adverse effect – CNS: abnormal dreams, anxiety, confusion. – EENT: blurred vision, disturbed eqilibrium, epistaxis tinnitus. – Resp: cough, dyspnoea. – CV: arrhythmias, CHF, peripheral edema, bradycardia, chest pain, hvpotension. palpitations, svncope, tachvcardia. – Misc: stevens-johnson syndrome, gingival hyperplasia.
VERAPAMIL
• Group of drug: antianginals, antiarrhythmiac agents class IV, antihypertensive, vascular headache suppressants, calcium channel blocker • Pharmacological name: verapamil • Trade name : apo-verap, isoptin, verelan • P0 (Adults): 80-1 20 mg 3 times daily Extended-release preparations 120-240 mg/day as a single dose • IV (Adults): 5-10mg (75-150 mcg/kg); may repeat with 10mg (150 mcg/kg) after 15-30 min.
Action
• Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitationcontraction coupling and subsequent contraction. Decreases SA node and AV node conduction and prolongs AV node refractory period in conduction tissue. • Systemic vasodilatation, resulting in decreased blood pressure. • Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina. • Suppression of ventricular tachycarrhythmias.
Indication
• Management of hypertension, angina pectoris, vasospastic angina (prinzmetal’s). • Management of Supraventricular arrhythmias, rapid ventricular arrhythmia, rapid ventricular rates in atrial flutter or fibrillation. • Prevention of migraine, management of cardiomyopathy.
Contraindication • Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, • BP <90 mmHg,CHF, • Severe ventricular dysarrhythmias, cardiogenic shock,
Adverse effect • CNS :- abnormal dreams, anxiety, confusion, dizziness, drowsiness, weakness, psychiatric disturbance • EENT:- blurred vision, disturbed equilibrium, dyspnoea, tinnitus • RESP:- dyspnoea, shortness of breath • CV:-arrhythmias, CHF, chest pain, hypotension, palpitation, peripheral edema, syncope
NIFEDIPINE
Group of drug:- antianginals, antihypertensive, calcium channel blocker. Pharmacological name:- Nifedipine Trade name:- Adalat XL, procardia Dose of drug PO (adults):- 10-30mg 3 times daily (not to exceed 180mg/day) or 30-90 mg once daily as sustained release form (CC, XL) (not to exceed 90-120 mg/day) Action • Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. • Systemic vasodilatation, resulting in decreased blood pressure. • Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina
Indication
• Management of hypertension(extended release only), angina pectoris, vasospastic angina. • Prevention of migraine headache • Management of CHF or cardiomyopathy.
Contraindication
• Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, BP <90 mmHg • Co-administration with grapefruit juice, history of porphyria
Adverse effect
• CNS :- headache, abnormal dreams, anxiety, dizziness, drowsiness, weakness. • EENT:- blurred vision, disturbed equilibrium, epistaxis, tinnitus • RESP:- dyspnoea, shortness of breath • CV:-arrhythmias, CHF, chest pain, hypotension, palpitation, peripheral edema, syncope
ADENOSINE
• Group of drug:- antiarrhythmic • Pharmacological name:- adenosine • Trade name:- adenocard, adenoscan • Dose of drug:IV (adult and children>50kg):– Antiarrhythmic- 6mg by rapid bolus; if no result repeat 1-2 min later as 12 mg rapid bolus (dose can be repeated not more than 12mg). – Diagnostic:- 140 mcg/kg/min for 6 min (0.84m/kg) – IV (children <50kg): Antiarrhythmic- 0.05-0.1 mg/kg as rapid bolus; if no result repeat by 0.05-0.1mg/kg until sinus rhythm is established or maximum dose of 0.3mg/kg is used.
Action Restores normal sinus rhythm by interrupting re-enterant pathway in AV node. Slows conduction time through the AV node, also produces coronary vasodilatation. Indication • Paraoxymal Supraventricular tachycardia(PSVT) when vagal maneuvers are unsuccessful. • To asses myocardial perfusion defect occurring as a result of coronary artery dIsease. • Contraindication • Hypersensitivity, 2nd or 3rd degree AV block or sick sinus syndrome • Patient of asthama (induces bronchospasm), unstable angina
Adverse effect • Resp:- shortnessofbreath, hyperventilation • CVS:- facial flushing, transient arrhythmias, chest pain, palpitation. • GI:- metallic taste, nausea • CNS:- dizziness, headache
DIGOXIN
• Group of drug:- antiarrhythmic, inotrope, digitalis glycoside • Pharmacological name:- digoxin • Trade name:- lanoxin • Action Increases the force of myocardial contraction. Prolongs refractory period of the AV node. Decreases conduction through the SA & AV nodes. Increases cardiac output (positive inotropic effect) and slowing of heart rate (negative inotrope).
Indication
• CHF, tachycardia, Atrial fibrillation and atrial flutter, paraoxysmal atrial tachycardia.
Contraindication
• Hypersensitivity, uncontrolled ventricular arrhythmias, AV block • Idiopathic hypertrophic subaortic stenosis, constrictive pericarditis, • Alcohol intolerance
Adverse effect
• • • • CNS:-fatigue, headache, weakness. CVS:- arrhythmia, bradycardia, ECG changes, AV block, SA block. GI:- anorexia, nausea, vomiting, diarrhea. Thrombocytopenia, digoxin toxicity with electrolyte imbalance.
Role and responsibility of nurse
• Monitor apical pulse for 1 full minute before administration. Withhold dose and notify physician if pulse rate is <60/min in adult, <70/min in children, <90/min in infant. • Monitor blood pressure periodically in patient receiving IV digoxin. • Monitor ECG throughout IV administration and 6 hours after each dose • Observe IV site for redness or infiltration, extravasation can lead to tissue irritation and sloughing. • Monitor intake and output, weigh daily. • Enquire history of previous digitalis therapy after administration. • Teach the patient about pulse monitoring and notify, if <60min and >100 min. • Instruct the patient for follow up. • Assess the patient’s clinical response to digoxin therapy by evaluatingrelief of symptoms such as dyspnea, orthopnea, crackles, hepatomegaly and peripheral edema. • Monitor serum potassium levels in patients receiving digoxin,especially those receiving both digoxin and diuretics. Anundetected, uncorrected potassium imbalance predisposes patients to digoxin toxicity and dysrhythmias.
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Assess for symptoms of electrolyte depletion: lassitude, apathy, mental confusion, anorexia, decreasing urinary output, azotemia. • Monitor the patient for factors that increase the risk of toxicity: – Oral antibiotics, quinidine, amiodarone, calcium channelblocker therapy. – Decreased potassium level (hypokalemia), which increases theaction of digoxin and which may be caused by malnutrition,diarrhea, vomiting, or prolonged muscle wasting – Impaired renal function, particularly in patients age 65 andolder with decreased renal clearance. • Monitor for gastrointestinal side effects: anorexia, nausea, vomiting,abdominal pain and distention. • Monitor for neurologic side effects: headache, malaise, nightmares,forgetfulness, social withdrawal, depression, agitation,confusion, paranoia, hallucinations, decreased visual acuity,Yellow or green halo around objects (especially lights), or“snowy” vision.
ISOSORBIDE DINITRATE
Group of drug:- antaniginal Pharmacological name:- isosorbide dinitrate Dose of drug • ISOSOBIDE DINITRATE SL (ADULTS): Acute attack of angina pectoris: - 2.5-5mg repeated after 5-10 min for 3 doses in 15-3 min PO (ADULTS): Prophylaxis of angina :- 520mg 2-3 times daily • ISOSORBIDE MONONITRATE PO (ADULT): 5-20mg twice daily with 2 doses given 7 hours apart
Action Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks. Indication • Acute treatment of angina attack • Prophylactic management of angina pectoris • Unlabeled CHF Contraindication • Hypersensitivity • Concurrent use of sildenafil, verdanefil Adverse effect • CNS: dizziness, headache • CV: hypotension, tachycardia, paradoxic bradycardia, syncope • GI: nausea and vomiting
NITROGLYCERIN
Group of drug:- antianginals Pharmacological name:- nitroglycerin Trade name:- nitrocard,nitrol, nitrostat
Dose of drug
• SL (adults):- 0.3-0.6mg, subligual spray1-2 sprays, 5-10 min before activities that may precipitate an caute attack. • BUCCAL (adults):- 1mg every 5 hourly • PO (adults) extended release capsules:- 2.5-9mg every 8-112 hr • IV (adult):- 5mcg/min to 20mcg/min, then increase by 1020mcg/min • TRANSDERMAL (adults):- ointment 1 inch = 15mg, 1-2 inches every 8hrly (transdermal patch 0.1-0.6 mg/hr upto 0.8mg/hr)
Action
Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks, increases cardiac output and reduces blood pressure.
Indication
• • • Prophylactic management of angina pectoris Acute MI Adjunct treatment of CHF
Contraindication
• • • • • • Hypersensitivity Severe anemia Pericardial tamponade Constrictive pericarditis Alcohol intolerance Cerebral hemorrhages
Adverse effect
Dizziness, headache, hypotension, tachycardia, syncope, abdominal pain, alcohol intoxication(in case of large IV dose)
TICLOPIDINE
Group of drug:- antiplatelet agent, platelet aggregation factor Pharmacological name:- ticlopidine
Dose of drug • PO (adult):- 250mg twice a day with food • Availability: - 250mg Action • Inhibitsplatelet aggregation by altering the function of platelet membranes. Prolongs bleeding time & decreases incidence of stroke in high risk patients
Indication • Prevention of stroke in patients who have completed thrombotic stroke or precursor of stroke and unable to tolerate aspirin • Prevention of early restenosis in intra-coronary stents
WARFARIN
Group of drug – anticoagulant Pharmacological name - warfarin Trade name – warfiline, coumadin Dose of drug – • PO or IV (adults) : 2.5-1.mg/day for 2-4 days and then adjust by result of prothrombin time or international normalized time (INR). • Availability tablets 1mg, 2.5mg, 4mg, 5mg. Action It interferes with the hepatic synthesis of vitamin K dependent clotting factors (2, 7, 9 and 10), and prevents the thrombus formation and thus decreases the density of blood. It decreases risk of subsequent MI Indication • Prophylaxis and treatment of venous thrombus, pulmonary thrombus, pulmonary embolism, atrial fibrillation with embolization. • Prevention of thrombus and embolization after prosthetic valve placement
Contraindication
• Uncontrolled bleeding, active ulcer disease, • Severe liver or kidney disease, • Uncontrolled hpertension
Adverse effect
• Uncontrolled bleeding(internal or external), cramps, nausea, dermal necrosis, fever.
Role and responsibility of nurse
• Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) • Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose • Liver function should be monitored before and after therapy. • Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving • Avoid IM injections • Instruct the patient to avoid alcohol, NSAIDs intake during the therapy
LOW MOLECULAR WEIGHT HEPARIN
Group of drug: anticoagulant, antithrombotic, low molecular
weight heparin
Pharmacological name: enoxaparin, dalteparin
Trade name: fragmin, lovenox
Dose of drug
• Fragmin - Unstable angina or non STEMI 120IU/kg (subcutenous) • Enoxaparin - Unstable angina or non STEMI 1mg/kg with aspirin. » STEMI 30mg + 1mg/kg IV
Action
• Potentiate the inhibitory effect of anti-thrombin on factor Xa & thrombin and thus prevents thrombus formation.
Indication
• • • • Prevention of ischemic unstable angina & non STEMI Treatment of acute STEMI with percutenous coronary intervention DVT Venous thromboembolism
Contraindication
• • • • Contraindications with specific agent or pork products Active major bleeding History of heparin induced thrombocytopenia Severe liver or kidney diseases
Adverse effect
• • • • • Anaemia, thrombocytopenia Headache, insomania Constipation, nausea Ecchymoses, pruritis, rash urticaria Bleeding from injured site, haematoma.
Role and responsibility of nurse
• Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) • Monitor for hypersensitivity reaction. • Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose • Liver function should be monitored before and after therapy. • Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving • Avoid IM injections • Instruct the patient to avoid alcohol, NSAIDs intake during the therapy • Observe subcutenous injection site for hematomas, ecchymosis or inflammation • During administering subcutenous injection use alternate sites (ant. Abdominal wall, upper thigh or buttocks)
UROKINASE STREPTOKINASE
Group of drug: thrombolytic agent, plasminogen activator Pharmacological name: urokinase, streptokinase Dose of drug • Streptokinase IV (adults): 1.5 million units is given as a continous infusion over 60 min. Intracoronary: 20,000 unit bolus followed by 2000-4000 units/ min infusion for 30-90 min • Urokinase IV (adults): 4400 nits/kg loading dose, followed by 4400 unit/kg/hr for 12 hr Action • Convert plasminogen to plasma, which is then able to degrade fibrin present in clots. Urokinase directly activates plasminogen, streptokinase combines plasminogento form activator or complexes, which then converts plasminogen into plasmin. Which results in lysis of thrombi with preservation or improvement of ventricular function (decreases the rish of CHF or death).
Indication
• Urokinase: acute massive pulmonary emboli. • Streptokinase: acute arterial thrombi(MI)
Contraindication
• Active internal bledding • History of cerebrovascular accident(can case intracranial bleeding), • Recent intracranial or intraspinal injury or trauma, intracranial neoplasm, AV malformation • Severe uncontrolled hypertension, hypersensitivity
Adverse effect
• • • • Intracranial haemorrhage Gastrointestinal, retroperitoneal, genitourinary bleeding Hypotension Phlebitis, epistaxis, bronchospasm
Role and responsibility of nurse
• • • • • • History collection of CVA, head trauma Monitor the vital signs before during and after the therapy. Check for hypesensitivity reaction. Do not administer bolus proper dilution should be should be done, intracranial bolus should be administered for over 15-90 seconds Flush IV line before infusion Asses the patient for bleeding for every 15 min during 1st hour of therapy, every 1-2 hourly after the drug administration, if bleeding occurs stop the drug immediately. Monitor ECG continuously If local bleeding occurs apply pressure to site and discontinue the infusion
• •
HYDROCHLOROTHIAZIDE
Group of drug: antihypertensive, thiazide diuretics Pharmacological name: hydrochlorothiazide
Dose of drug • PO(adults): 12.5-100mg/day in 1-2 divided doses, should not exceed 50mg/day for hypertension, (doses >25mg are associated to have electrolyte imbalance abnormality) • PO(children): 1-3mg/kg/day in 1-2 divided doses max 37.5mg/day Action • Increases excretion and sodium and water by inhibiting sodium reabsorption in distal tubule. Promotes excretion of chloride, potassium, magnesium and bicarbonate. It produces arteriolar dilation and thus reduces blood pressure in hypertensive patients and mobilizes oedema.
Indication
• Management of mild to moderate hypertension • Oedema assocoiated with CHF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy.
Contraindication
• Hypersensitivity with thiazide or sulfonamides • Some products contain tartazine and should be avoided in patient with anuria, intolerance, lactation.
Adverse effect
• Electrolyte imbalance: Hypokalaemia, dehydration, hypercalcemia, hypomagnesia • Thrombocytopenia, hyperuricemia • Dizziness, weakness • Hypotension, cramping, hepatitis
FRUSEMIDE
Group of drug: Loop diuretic Trade name: lasix Dose of drug: • PO (adults): 20-40mg q6-8hr until desired response in hypertension
• In case of CCF max. 2.5mg/day • Hypercalcemia: 120mg/day in 2-3 doses
• PO (childrens): 2mg/kg/day max. 6mg/kg/day • IV (adults): 20-40mg/day and can be repeated, for continous infusion bolus- 0.1mg/kg followed by 0.10.4mg/kg/hr
Action: • Inhibits the absorption of sodium and chloride from loop of henle and distal renal tubule, increases renal excretion of water,sodium, chloride magnesium, potassium, and calcium. Inturn causes diuresis and lowers down the blood pressure Indication • Oedema due to heart failure, hepatic impairment or renal disease • Hypertension Contraindication • Hypersensitivity with thiazide or sulfonamides may cause hepatic coma or anuria • Some products contain alcohol and should be avoided in patient with alcohol intolerance Adverse effect • Dehydration and Electrolyte imbalance: Hypokalaemia, dehydration, hypercalcemia, hypomagnesia • Thrombocytopenia, hyperuricemia • Dizziness, weakness, headache • Hypotension, cramping, hepatitis, excessive urination.
SPIROLACTONE
Group of drug: spatassium sparing diuretic Pharmacological name: Spirolactone Trade name: novospartin, aldactone Dose of drug • PO (Adults): HTN—5–10mg/day (up to 20mg) • PO (Adults): Edema—25–200 mg/day in 1–2 divided doses • Diagnosis of primary hyperaldosteronism- 100–400 mg/day in 1–2 divided dose. • CHF: 12.5–25 mg/day (unlabeled use)
Action • Inhibition of sodium reabsorption in the kidney while saving potassium and hydrogen ions (spironolactone achieves this effect by antagonizing aldosterone receptors). Weak diuretic and antihypertensive response when compared with other diuretics but conserves potassium.
Indication • To counteract potassium loss caused due to other diuretics • Primary aldosteronism • Management of CCF Contraindication • Hypersensitivity • Hyperkalaemia • Anuria, acute renal insufficiency (sr. creat >2.5mg/dl) Adverse effect • Clumsiness, headache • Hperkalemia, hyponatremia • Erectile dysfunction • Increases hypotension with ingestion of alcohol
ACE INHIBITOR
Group of drug: ACE INHIBITOR
Pharmacological name: enalapril, ramipril, captopril Trade name: vasotec, monopril, altace • IV (adults): 0.625-1.25mg/kg/day if receiving diuretics • CHF—2.5 mg 1–2 times daily, • Asymptomatic left ventricular dysfunction—2.5mg twice daily, • PO (Adults): Hypertension—2.5–5 mg once daily
• Action: it blocks the conversion of anfiotensin I to the vasoconstrictor angiotensin II and also prevents the degradation of bradykinin and other vasodilatory prostaglandins. It increases the plasma rennin levels and reduces aldosterone
Indication
• • • • Primary Hypertension Development of CCF followed by MI Reduction in MI, Stoke Diabetic neuropathy
Contraindication
• Hypersensitivity • Previous angioedema caused by ACE inhibitors • Womans with child bearing
Adverse effect
• Cough, taste disturbances, GI disturbances • Hypotension • Angioedemaproteinuria, renal dysfunction
DOBUTAMINE
Group of drug: inotropic, adrenergic Trade name: dobutrex
Dose of drug • IV (Adults and Children): Start with low infusion rates (0.5–1 mcg/kg/min), titrated at intervals of a few minutes, guided by the patient’s response (range 2–20 mcg/kg/min, up to 40 mcg/kg/min)
Action Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance (decreased afterload). Dobutamine enhances the strength of cardiac contraction, improving stroke volume ejection and overall cardiac output without significant increased heart rate.
Indication: cardiac decompensation caused by heart disease or surgical procedures
Contraindication: • Hypersensitivity to dobutamine • Idiopathic hypertrophic subaortic stenosis
Adverse effect • Shortness of breath • Hpetension • Premature ventricular contracture • Angina • Palpitations
DOPAMINE
Group of drug: inotropic, vasopressor, adrenergic Pharmacological name: dopamine Dose of drug • Small doses (0.5–3 mcg/kg/min) stimulate dopaminergic receptors, producing renal vasodilation. • Larger doses (2–10 mcg/kg/min) stimulate dopaminergic and beta1-adrenergic receptors, producing cardiac stimulation and renal vasodilation. • Doses greater than 10 mcg/kg/min stimulate alphaadrenergic receptors and may cause renal vasoconstriction.
Indication Adjuvant measures to improve blood pressure, cardiac output, urine otput, shock unresponsive to fluid replacement. Contraindication • Tachycardia • Pheochromocytoma • Hypersensitivity
Adverse effect Arrhtmias, hypotension, angina, ECG changes, palpitations, vasoconstriction
• USE OF CARDIAC DRUGS RELATES TO DAMPENED BLOOD PRESSURE CHANGES AND REDUCED MORTALITY IN INCIDENT HEMODIALYSIS PATIENTS • Abstract INTRODUCTION AND AIMS: It has been shown that both absolute blood pressure levels and changes in blood pressure over time relate to mortality in hemodialysis (HD) patients (pts). We aimed to study the association between cardiac drug (CD) use, blood pressure changes over time and mortality in incident HD pts. METHODS: Renal Research Institute in-center incident HD pts between Jan 1, 2000 and Feb 28, 2010 were followed for 1 year each. Pre HD systolic blood pressures (SBPs) were averaged for each pt over the first 30 days on HD (“starting SBP”); the slope of SBP was computed by linear regression using all SBP values in the first year of HD. Pts were grouped by (a) starting SBP, and (b) first year SBP slope (increased: >1 mmHg/month, decreased: <1 mmHg/mo, stable: between -1 and + 1 mmHg/mo). Cox regression was used to analyze the hazard ratio (HR) of death adjusted for starting SBP, interdialytic weight gain, BMI, gender, age, race, ethnicity, serum albumin, use of CD, and 13 comorbid conditions. Presence of CD therapy was based on whether a patient was prescribed ACE inhibitors, ARBs, or beta blockers at any time before the end of year one on HD (incl. before initiating HD).
• RESULTS: We studied 10,245 pts (57% male, 38% black, 54% white, 54% diabetic, age±SD 62.1±15.6 years). • CONCLUSIONS: These results suggest that use of CD is linked to a 28% risk reduction for mortality in incident HD pts. Given that pts with a stable SBP slope in the first year on dialysis show lower mortality rates than those with increasing or decreasing SBP (Usvyat, WCN/ASN 2011), our finding of CD use being related to dampened SBP changes suggests a possible mechanism by which these drugs may mediate improved survival. Prospective randomized trials are warranted to help discern cause and effect. CD use was significantly associated with a dampened SBP slope in both SBP increasers and decliners, even after adjustment for relevant covariates. In SBP decliners, the decline was less steep by 1.02 mmHg per month in pts on CD, while in SBP increasers, the increase was smaller by 0.81 mmHg per month in those on CD
CLASSIFICATION OF DRUGS USED IN CARDIAC DISEASES
Anti-arrhythmic agent
• Class 1 sodium channel blocker e.g. flecanide, quinidine • Class 2 beta adrenoreceptor blocker e.g. metoprolol, propanolol • Class 3 sodium channel blocker e.g. amiodarone • Class 4 calcium blocker e.g. diltiazem, verapamil, nifedipine • Other Anti-arrhythmic drug e.g. adenosine, digoxin
Anti-anginal drug
• Organic nitrates e.g. isosorbide dinitrate, nitroglycerin • Beta blocker e.g. propanolol • Calcium channel blocker e.g. diltiazem, verapamil, nifedipine
Drugs affecting blood
• Platelet inhibitor e.g. aspirin, ticlopidine • Anticoagulant e.g. enoxaparin, warfarin, heparin. • Thrombolytic agent e.g. urokinase, streptokinase • Treatment of bleeding e.g. aminocaproic acid, vitamin k, tranexamic acid • Treatment of anemia e.g. folic acid, cyanocobalamine, iron
Antihypertensive drug
• Diuretics e.g. hydrochlorothiazide, frusemide, spirolactone • Alpha blocker e.g. doxazosin, prazosin • Beta blocker e.g. metoprolol, propanolol • ACE inhibitor e.g. catopril, analapril, ramipril • Angiotensin II antagonist e.g losartan • Calcium channel blocker e.g. diltiazem, verapamil, nifedipine, amlodipine • Vasodilators e.g sodium nitropruside
Inotropic agents
• Positive inotropic agent e.g. dobutamine • Negative inotropic agent e.g. dopaamine
• Cardiac glycosides e.g. digoxin, digitoxin • Hypolipidemic agents e.g. statin
FLECANIDE
• Group of drug – antiarrhythmic agent, sodium channel blocker • Pharmacological name- flecanide • Trade name – Almarytm, Apocard, Ecrinal, Flécaine • Dose of drug – 1-2.5mg/kg/body wt
• Indication: Prevention of paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disablin
• Contraindication: hypersensitivity, cardiogenic shock, CHF, pre-existing sinus node dysfunction or 2nd or 3rd degree heart block (without a pacemaker), renal impairment, pregnancy, lactation or children.
• Adverse effect
– Nausea and vomiting, convulsions, hypotension, bradycardia, syncope, extreme widening of the QRS complex, widening of the QT interval, widening of the PR interval, ventricular tachycardia, AV nodal block, asystole, bundle branch block, cardiac failure, and cardiac arrest. – CNS – dizziness, anxiety, fatigue, headache, mental depressin. tremor, Blurred vision, – Chest pain, CHF
QUINIDINE
• Group of drug - antiarrhythmic agent (class 1 A), sodium channel blocker
• Pharmacological name–Quinidine
• Dose of drug–
– PO (Adults): 324–972mg q 8–12 hr. – IV (Adults): 200–400 mg given at a rate <10 mg/min until arrhythmia is suppresses
• Action – decrease myocardial excitability, Slow conduction velocity and suppresses arrhythmias • Indication –atrial fibrillation, atrial flutter, recurrent ventricular arrhythmias and treatment of malaria
Contraindication – hypersensitivity, conduction defects (without a pacemaker) CHF, severe liver dosease, Hypokalemia or hypomagnesemia(↑ risk of torsades de pointes); Bradycardia (↑risk of torsades de pointes), pregnancy, lactation or children.
Adverse effect
• CNS: dizziness, confusion, fatigue, headache,syncope, vertigo • EENT: blurred vision, diplopia,mydriasis, photophobia, tinnitus. • CV: hypotension,torsades de pointes, arrhythmias, palpitations, tachycardia • GI: anorexia, abdominalcramping, diarrhea, nausea, vomiting, druginduced hepatitis. • Derm: rash. Neuro: ataxia, tremor.Misc: fever. • Hemat: agranulocytosis, hemolytic anemia, thrombocytopenia.
METOPROLOL
• • • • Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker Pharmacological name - metoprolol Trade name - tartarate 25, 50, 100mg Dose of drug– PO (Adults):
– Antihypertensive/antianginal—25–100 mg/day as a single dose initially or 2 divided doses, 450 mg/day (for angina, give in divided doses) – MI—25–50 mg (starting 15 min after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily for a minimum of 3 month. – Heartfailure—12.5–25 mg once daily – Migraneprevention—50–100 mg 2–4 times daily
IV (Adults):
– MI—5 mg q 2 min for 3 doses, followed by oral dosing
•
Action Blocks stimulation of beta1(myocardial)-adrenzinergic receptors. Does not usually affect beta2 (pulmonary, vascular, uterine) adrenergic receptor sites. decreases blood pressure and heart rate. De creased frequency of attacks of angina pectoris. Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure
Indication - Hypertension. Angina pectoris. Prevention of MI, heart failure due to ischemic, ventricular arrhythmias/tachycardia, Migraine, tremors, drug induced akathesia, anxiety Contraindication - Uncompensated CHF, Pulmonary edema, Cardiogenic shock, Bradycardia or heart block Adverse effect • CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia,memory loss, mental status changes, nervousness, nightmares. • EENT: blurred vision, stuffy nose. • Resp: bronchospasm, wheezing • CV: bradycardia, CHF, pulmonary edema, hypotension, peripheral vasoconstriction. • GI: constipation, diarrhea, drug induced hepatitis, drymouth, flatulence, gastricpain, heartburn. • GU: erectile dysfunction • MS: arthralgia, back pain, joint pain
PROPANOLOL
• Group of drug - antiarrhythmic agent, beta adrenoreceptor blocker • Pharmacological name - Propanolol • Trade name - novopropranolol • Dose of drug– Oral
– Antianginal 80-320mg/day in 2-4 divided doses.(childrens 0.5-1mg/kg/day in 24 divided doses) – Antihypertensive 40mgtwice daily (usual range 120-240mg/day) – Antiarrhythmia 10-30mg/day
Intravenous
– Adults 1-3 mg repeated after 2 min and again in 4 hr if needed – Children 0.01-0.1 mg/kg repeated after 6-8 hr
• Action: Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic receptor sites. Decreases heart rate and blood pressure, suppresses arrhythmia and prevents MI
Indication Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma. Also used in the prevention and management of MI and prevention of vascular headaches
Contraindication Uncompensated CHF, Pulmonary edema; Cardiogenic shock; Bradycardia or heart block
Adverse effect
– CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares. – EENT: blurred vision, dry eyes, nasal stuffiness. Resp: bronchospasm, wheezing – CV: arrhythmias, bradycardia, CHF, pulmonary edema – GU: erectile dysfunction
AMIODARONE
• Group of drug - antiarrhythmic class III • Pharmacological name – Amiodarone • Trade name - cardarone, pacerone • Dose of drug: 1ml contains 50 mg amiodarne Oral
– Adults 800-1600mg/day in 1-2 doses for 1-3 wk, then 600-800mg/day in 1-2 doses for 1 month then 400mg maintenance dose – Children 10mg/kg/day for 10 days, then 5 mg/day for several weeks then 2.5 mg/kg/day maintenance dose.
Intravenous
– Adults: 150 mg over 10 min, followed by 360 mg over the next 6 hr – Continuous infusion at 0.5 mg/min until oral therapy is initiated – ACLSguidelines for pulseless ventricular fibrillation or ventricular tachycardia 5 mg/kg as bolus
• Action Prolongs action potential and refractory period. Inhibits adrenergic stimulation. Slows the sinusrate,increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation). Ths suppresses arrhythmia • Indication Life threatening ventricular arrhythmia, Supraventricular tachycardia, ACLS • Contraindication Cardiogenic shock, SA node dysfunction, 2nd and 3rd degree AV block, syncope, hypersensitivity. • Adverse effect
– CNS: confusional states, disorientation, hallucinations, fatigue, malaise, dizziness, headache, insomnia. – EENT: corneal micro-deposits – Resp: adult respiratory distress syndrome (ards), pulmonary fibrosis, pulmonary toxicity. – CV: CHF, worsening of arrhythmias, bradvcardia, hypotension.
DILTIAZEM
• Group of drug – antiarrhythmia class IV, antihypertensive, antianginals, calcium channel blocker.
• Pharmacological name - diltiazem • Trade name–cardiazem, taztia XT
• Dose of drug
– Oral: 30-120 mg 3-4 times daily or 60-120 mg twice daily or 180-240 mg once a day (max 360mg/day) – Intravenous: 0.25 mg/kg repeat in 15 min with 0.35mg/kg – Continuous infusion at 10 mg/hr for 24 hr (5-15mg/hr)
• Action Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation contraction coupling and subsequent contraction, results in decreased blood pressure, coronary vasodilatation and suppresses arrhythmias
• Indication Hypertension, Angina pectoris and vasospastic angina, Supraventricular tachycardia and rapid ventricular rates in atrial flutter or fibrillation.
• Contraindication Hypersensitvity, 2nd or 3rd degree AV block, recent MI, pulmonary congestion, blood pressure <90 mm Hg, CHF
• Adverse effect – CNS: abnormal dreams, anxiety, confusion. – EENT: blurred vision, disturbed eqilibrium, epistaxis tinnitus. – Resp: cough, dyspnoea. – CV: arrhythmias, CHF, peripheral edema, bradycardia, chest pain, hvpotension. palpitations, svncope, tachvcardia. – Misc: stevens-johnson syndrome, gingival hyperplasia.
VERAPAMIL
• Group of drug: antianginals, antiarrhythmiac agents class IV, antihypertensive, vascular headache suppressants, calcium channel blocker • Pharmacological name: verapamil • Trade name : apo-verap, isoptin, verelan • P0 (Adults): 80-1 20 mg 3 times daily Extended-release preparations 120-240 mg/day as a single dose • IV (Adults): 5-10mg (75-150 mcg/kg); may repeat with 10mg (150 mcg/kg) after 15-30 min.
Action
• Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitationcontraction coupling and subsequent contraction. Decreases SA node and AV node conduction and prolongs AV node refractory period in conduction tissue. • Systemic vasodilatation, resulting in decreased blood pressure. • Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina. • Suppression of ventricular tachycarrhythmias.
Indication
• Management of hypertension, angina pectoris, vasospastic angina (prinzmetal’s). • Management of Supraventricular arrhythmias, rapid ventricular arrhythmia, rapid ventricular rates in atrial flutter or fibrillation. • Prevention of migraine, management of cardiomyopathy.
Contraindication • Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, • BP <90 mmHg,CHF, • Severe ventricular dysarrhythmias, cardiogenic shock,
Adverse effect • CNS :- abnormal dreams, anxiety, confusion, dizziness, drowsiness, weakness, psychiatric disturbance • EENT:- blurred vision, disturbed equilibrium, dyspnoea, tinnitus • RESP:- dyspnoea, shortness of breath • CV:-arrhythmias, CHF, chest pain, hypotension, palpitation, peripheral edema, syncope
NIFEDIPINE
Group of drug:- antianginals, antihypertensive, calcium channel blocker. Pharmacological name:- Nifedipine Trade name:- Adalat XL, procardia Dose of drug PO (adults):- 10-30mg 3 times daily (not to exceed 180mg/day) or 30-90 mg once daily as sustained release form (CC, XL) (not to exceed 90-120 mg/day) Action • Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. • Systemic vasodilatation, resulting in decreased blood pressure. • Coronary vasodilatation resulting in decreased frequency and severity of attacks of angina
Indication
• Management of hypertension(extended release only), angina pectoris, vasospastic angina. • Prevention of migraine headache • Management of CHF or cardiomyopathy.
Contraindication
• Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, BP <90 mmHg • Co-administration with grapefruit juice, history of porphyria
Adverse effect
• CNS :- headache, abnormal dreams, anxiety, dizziness, drowsiness, weakness. • EENT:- blurred vision, disturbed equilibrium, epistaxis, tinnitus • RESP:- dyspnoea, shortness of breath • CV:-arrhythmias, CHF, chest pain, hypotension, palpitation, peripheral edema, syncope
ADENOSINE
• Group of drug:- antiarrhythmic • Pharmacological name:- adenosine • Trade name:- adenocard, adenoscan • Dose of drug:IV (adult and children>50kg):– Antiarrhythmic- 6mg by rapid bolus; if no result repeat 1-2 min later as 12 mg rapid bolus (dose can be repeated not more than 12mg). – Diagnostic:- 140 mcg/kg/min for 6 min (0.84m/kg) – IV (children <50kg): Antiarrhythmic- 0.05-0.1 mg/kg as rapid bolus; if no result repeat by 0.05-0.1mg/kg until sinus rhythm is established or maximum dose of 0.3mg/kg is used.
Action Restores normal sinus rhythm by interrupting re-enterant pathway in AV node. Slows conduction time through the AV node, also produces coronary vasodilatation. Indication • Paraoxymal Supraventricular tachycardia(PSVT) when vagal maneuvers are unsuccessful. • To asses myocardial perfusion defect occurring as a result of coronary artery dIsease. • Contraindication • Hypersensitivity, 2nd or 3rd degree AV block or sick sinus syndrome • Patient of asthama (induces bronchospasm), unstable angina
Adverse effect • Resp:- shortnessofbreath, hyperventilation • CVS:- facial flushing, transient arrhythmias, chest pain, palpitation. • GI:- metallic taste, nausea • CNS:- dizziness, headache
DIGOXIN
• Group of drug:- antiarrhythmic, inotrope, digitalis glycoside • Pharmacological name:- digoxin • Trade name:- lanoxin • Action Increases the force of myocardial contraction. Prolongs refractory period of the AV node. Decreases conduction through the SA & AV nodes. Increases cardiac output (positive inotropic effect) and slowing of heart rate (negative inotrope).
Indication
• CHF, tachycardia, Atrial fibrillation and atrial flutter, paraoxysmal atrial tachycardia.
Contraindication
• Hypersensitivity, uncontrolled ventricular arrhythmias, AV block • Idiopathic hypertrophic subaortic stenosis, constrictive pericarditis, • Alcohol intolerance
Adverse effect
• • • • CNS:-fatigue, headache, weakness. CVS:- arrhythmia, bradycardia, ECG changes, AV block, SA block. GI:- anorexia, nausea, vomiting, diarrhea. Thrombocytopenia, digoxin toxicity with electrolyte imbalance.
Role and responsibility of nurse
• Monitor apical pulse for 1 full minute before administration. Withhold dose and notify physician if pulse rate is <60/min in adult, <70/min in children, <90/min in infant. • Monitor blood pressure periodically in patient receiving IV digoxin. • Monitor ECG throughout IV administration and 6 hours after each dose • Observe IV site for redness or infiltration, extravasation can lead to tissue irritation and sloughing. • Monitor intake and output, weigh daily. • Enquire history of previous digitalis therapy after administration. • Teach the patient about pulse monitoring and notify, if <60min and >100 min. • Instruct the patient for follow up. • Assess the patient’s clinical response to digoxin therapy by evaluatingrelief of symptoms such as dyspnea, orthopnea, crackles, hepatomegaly and peripheral edema. • Monitor serum potassium levels in patients receiving digoxin,especially those receiving both digoxin and diuretics. Anundetected, uncorrected potassium imbalance predisposes patients to digoxin toxicity and dysrhythmias.
•
Assess for symptoms of electrolyte depletion: lassitude, apathy, mental confusion, anorexia, decreasing urinary output, azotemia. • Monitor the patient for factors that increase the risk of toxicity: – Oral antibiotics, quinidine, amiodarone, calcium channelblocker therapy. – Decreased potassium level (hypokalemia), which increases theaction of digoxin and which may be caused by malnutrition,diarrhea, vomiting, or prolonged muscle wasting – Impaired renal function, particularly in patients age 65 andolder with decreased renal clearance. • Monitor for gastrointestinal side effects: anorexia, nausea, vomiting,abdominal pain and distention. • Monitor for neurologic side effects: headache, malaise, nightmares,forgetfulness, social withdrawal, depression, agitation,confusion, paranoia, hallucinations, decreased visual acuity,Yellow or green halo around objects (especially lights), or“snowy” vision.
ISOSORBIDE DINITRATE
Group of drug:- antaniginal Pharmacological name:- isosorbide dinitrate Dose of drug • ISOSOBIDE DINITRATE SL (ADULTS): Acute attack of angina pectoris: - 2.5-5mg repeated after 5-10 min for 3 doses in 15-3 min PO (ADULTS): Prophylaxis of angina :- 520mg 2-3 times daily • ISOSORBIDE MONONITRATE PO (ADULT): 5-20mg twice daily with 2 doses given 7 hours apart
Action Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks. Indication • Acute treatment of angina attack • Prophylactic management of angina pectoris • Unlabeled CHF Contraindication • Hypersensitivity • Concurrent use of sildenafil, verdanefil Adverse effect • CNS: dizziness, headache • CV: hypotension, tachycardia, paradoxic bradycardia, syncope • GI: nausea and vomiting
NITROGLYCERIN
Group of drug:- antianginals Pharmacological name:- nitroglycerin Trade name:- nitrocard,nitrol, nitrostat
Dose of drug
• SL (adults):- 0.3-0.6mg, subligual spray1-2 sprays, 5-10 min before activities that may precipitate an caute attack. • BUCCAL (adults):- 1mg every 5 hourly • PO (adults) extended release capsules:- 2.5-9mg every 8-112 hr • IV (adult):- 5mcg/min to 20mcg/min, then increase by 1020mcg/min • TRANSDERMAL (adults):- ointment 1 inch = 15mg, 1-2 inches every 8hrly (transdermal patch 0.1-0.6 mg/hr upto 0.8mg/hr)
Action
Produces vasodilation (venous greater than arterial), decreases left ventricular end diastolic pressure and left ventricular end diastolic volume (preload). Net effect is reduced myocardial oxygen consumption, increases coronary blood flow by dilating coronary aarteries and improving collateral flow to ischemic region and thus relieves and prevents angina attacks, increases cardiac output and reduces blood pressure.
Indication
• • • Prophylactic management of angina pectoris Acute MI Adjunct treatment of CHF
Contraindication
• • • • • • Hypersensitivity Severe anemia Pericardial tamponade Constrictive pericarditis Alcohol intolerance Cerebral hemorrhages
Adverse effect
Dizziness, headache, hypotension, tachycardia, syncope, abdominal pain, alcohol intoxication(in case of large IV dose)
TICLOPIDINE
Group of drug:- antiplatelet agent, platelet aggregation factor Pharmacological name:- ticlopidine
Dose of drug • PO (adult):- 250mg twice a day with food • Availability: - 250mg Action • Inhibitsplatelet aggregation by altering the function of platelet membranes. Prolongs bleeding time & decreases incidence of stroke in high risk patients
Indication • Prevention of stroke in patients who have completed thrombotic stroke or precursor of stroke and unable to tolerate aspirin • Prevention of early restenosis in intra-coronary stents
WARFARIN
Group of drug – anticoagulant Pharmacological name - warfarin Trade name – warfiline, coumadin Dose of drug – • PO or IV (adults) : 2.5-1.mg/day for 2-4 days and then adjust by result of prothrombin time or international normalized time (INR). • Availability tablets 1mg, 2.5mg, 4mg, 5mg. Action It interferes with the hepatic synthesis of vitamin K dependent clotting factors (2, 7, 9 and 10), and prevents the thrombus formation and thus decreases the density of blood. It decreases risk of subsequent MI Indication • Prophylaxis and treatment of venous thrombus, pulmonary thrombus, pulmonary embolism, atrial fibrillation with embolization. • Prevention of thrombus and embolization after prosthetic valve placement
Contraindication
• Uncontrolled bleeding, active ulcer disease, • Severe liver or kidney disease, • Uncontrolled hpertension
Adverse effect
• Uncontrolled bleeding(internal or external), cramps, nausea, dermal necrosis, fever.
Role and responsibility of nurse
• Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) • Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose • Liver function should be monitored before and after therapy. • Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving • Avoid IM injections • Instruct the patient to avoid alcohol, NSAIDs intake during the therapy
LOW MOLECULAR WEIGHT HEPARIN
Group of drug: anticoagulant, antithrombotic, low molecular
weight heparin
Pharmacological name: enoxaparin, dalteparin
Trade name: fragmin, lovenox
Dose of drug
• Fragmin - Unstable angina or non STEMI 120IU/kg (subcutenous) • Enoxaparin - Unstable angina or non STEMI 1mg/kg with aspirin. » STEMI 30mg + 1mg/kg IV
Action
• Potentiate the inhibitory effect of anti-thrombin on factor Xa & thrombin and thus prevents thrombus formation.
Indication
• • • • Prevention of ischemic unstable angina & non STEMI Treatment of acute STEMI with percutenous coronary intervention DVT Venous thromboembolism
Contraindication
• • • • Contraindications with specific agent or pork products Active major bleeding History of heparin induced thrombocytopenia Severe liver or kidney diseases
Adverse effect
• • • • • Anaemia, thrombocytopenia Headache, insomania Constipation, nausea Ecchymoses, pruritis, rash urticaria Bleeding from injured site, haematoma.
Role and responsibility of nurse
• Asses the patient for signs of bleeding and hemorrhage (gums, nose, tarry black stool, hematuria, hypotension) • Monitor for hypersensitivity reaction. • Monitor Prothrombin time or INR before the drug therapy and 3-5 days after therapy to evaluate the required dose • Liver function should be monitored before and after therapy. • Instruct the patient to avoid use of sharp metals or articles, protect him from injury to avoid hemorrhage, use of soft bristle tooth brush, use electric razor for shaving • Avoid IM injections • Instruct the patient to avoid alcohol, NSAIDs intake during the therapy • Observe subcutenous injection site for hematomas, ecchymosis or inflammation • During administering subcutenous injection use alternate sites (ant. Abdominal wall, upper thigh or buttocks)
UROKINASE STREPTOKINASE
Group of drug: thrombolytic agent, plasminogen activator Pharmacological name: urokinase, streptokinase Dose of drug • Streptokinase IV (adults): 1.5 million units is given as a continous infusion over 60 min. Intracoronary: 20,000 unit bolus followed by 2000-4000 units/ min infusion for 30-90 min • Urokinase IV (adults): 4400 nits/kg loading dose, followed by 4400 unit/kg/hr for 12 hr Action • Convert plasminogen to plasma, which is then able to degrade fibrin present in clots. Urokinase directly activates plasminogen, streptokinase combines plasminogento form activator or complexes, which then converts plasminogen into plasmin. Which results in lysis of thrombi with preservation or improvement of ventricular function (decreases the rish of CHF or death).
Indication
• Urokinase: acute massive pulmonary emboli. • Streptokinase: acute arterial thrombi(MI)
Contraindication
• Active internal bledding • History of cerebrovascular accident(can case intracranial bleeding), • Recent intracranial or intraspinal injury or trauma, intracranial neoplasm, AV malformation • Severe uncontrolled hypertension, hypersensitivity
Adverse effect
• • • • Intracranial haemorrhage Gastrointestinal, retroperitoneal, genitourinary bleeding Hypotension Phlebitis, epistaxis, bronchospasm
Role and responsibility of nurse
• • • • • • History collection of CVA, head trauma Monitor the vital signs before during and after the therapy. Check for hypesensitivity reaction. Do not administer bolus proper dilution should be should be done, intracranial bolus should be administered for over 15-90 seconds Flush IV line before infusion Asses the patient for bleeding for every 15 min during 1st hour of therapy, every 1-2 hourly after the drug administration, if bleeding occurs stop the drug immediately. Monitor ECG continuously If local bleeding occurs apply pressure to site and discontinue the infusion
• •
HYDROCHLOROTHIAZIDE
Group of drug: antihypertensive, thiazide diuretics Pharmacological name: hydrochlorothiazide
Dose of drug • PO(adults): 12.5-100mg/day in 1-2 divided doses, should not exceed 50mg/day for hypertension, (doses >25mg are associated to have electrolyte imbalance abnormality) • PO(children): 1-3mg/kg/day in 1-2 divided doses max 37.5mg/day Action • Increases excretion and sodium and water by inhibiting sodium reabsorption in distal tubule. Promotes excretion of chloride, potassium, magnesium and bicarbonate. It produces arteriolar dilation and thus reduces blood pressure in hypertensive patients and mobilizes oedema.
Indication
• Management of mild to moderate hypertension • Oedema assocoiated with CHF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy.
Contraindication
• Hypersensitivity with thiazide or sulfonamides • Some products contain tartazine and should be avoided in patient with anuria, intolerance, lactation.
Adverse effect
• Electrolyte imbalance: Hypokalaemia, dehydration, hypercalcemia, hypomagnesia • Thrombocytopenia, hyperuricemia • Dizziness, weakness • Hypotension, cramping, hepatitis
FRUSEMIDE
Group of drug: Loop diuretic Trade name: lasix Dose of drug: • PO (adults): 20-40mg q6-8hr until desired response in hypertension
• In case of CCF max. 2.5mg/day • Hypercalcemia: 120mg/day in 2-3 doses
• PO (childrens): 2mg/kg/day max. 6mg/kg/day • IV (adults): 20-40mg/day and can be repeated, for continous infusion bolus- 0.1mg/kg followed by 0.10.4mg/kg/hr
Action: • Inhibits the absorption of sodium and chloride from loop of henle and distal renal tubule, increases renal excretion of water,sodium, chloride magnesium, potassium, and calcium. Inturn causes diuresis and lowers down the blood pressure Indication • Oedema due to heart failure, hepatic impairment or renal disease • Hypertension Contraindication • Hypersensitivity with thiazide or sulfonamides may cause hepatic coma or anuria • Some products contain alcohol and should be avoided in patient with alcohol intolerance Adverse effect • Dehydration and Electrolyte imbalance: Hypokalaemia, dehydration, hypercalcemia, hypomagnesia • Thrombocytopenia, hyperuricemia • Dizziness, weakness, headache • Hypotension, cramping, hepatitis, excessive urination.
SPIROLACTONE
Group of drug: spatassium sparing diuretic Pharmacological name: Spirolactone Trade name: novospartin, aldactone Dose of drug • PO (Adults): HTN—5–10mg/day (up to 20mg) • PO (Adults): Edema—25–200 mg/day in 1–2 divided doses • Diagnosis of primary hyperaldosteronism- 100–400 mg/day in 1–2 divided dose. • CHF: 12.5–25 mg/day (unlabeled use)
Action • Inhibition of sodium reabsorption in the kidney while saving potassium and hydrogen ions (spironolactone achieves this effect by antagonizing aldosterone receptors). Weak diuretic and antihypertensive response when compared with other diuretics but conserves potassium.
Indication • To counteract potassium loss caused due to other diuretics • Primary aldosteronism • Management of CCF Contraindication • Hypersensitivity • Hyperkalaemia • Anuria, acute renal insufficiency (sr. creat >2.5mg/dl) Adverse effect • Clumsiness, headache • Hperkalemia, hyponatremia • Erectile dysfunction • Increases hypotension with ingestion of alcohol
ACE INHIBITOR
Group of drug: ACE INHIBITOR
Pharmacological name: enalapril, ramipril, captopril Trade name: vasotec, monopril, altace • IV (adults): 0.625-1.25mg/kg/day if receiving diuretics • CHF—2.5 mg 1–2 times daily, • Asymptomatic left ventricular dysfunction—2.5mg twice daily, • PO (Adults): Hypertension—2.5–5 mg once daily
• Action: it blocks the conversion of anfiotensin I to the vasoconstrictor angiotensin II and also prevents the degradation of bradykinin and other vasodilatory prostaglandins. It increases the plasma rennin levels and reduces aldosterone
Indication
• • • • Primary Hypertension Development of CCF followed by MI Reduction in MI, Stoke Diabetic neuropathy
Contraindication
• Hypersensitivity • Previous angioedema caused by ACE inhibitors • Womans with child bearing
Adverse effect
• Cough, taste disturbances, GI disturbances • Hypotension • Angioedemaproteinuria, renal dysfunction
DOBUTAMINE
Group of drug: inotropic, adrenergic Trade name: dobutrex
Dose of drug • IV (Adults and Children): Start with low infusion rates (0.5–1 mcg/kg/min), titrated at intervals of a few minutes, guided by the patient’s response (range 2–20 mcg/kg/min, up to 40 mcg/kg/min)
Action Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance (decreased afterload). Dobutamine enhances the strength of cardiac contraction, improving stroke volume ejection and overall cardiac output without significant increased heart rate.
Indication: cardiac decompensation caused by heart disease or surgical procedures
Contraindication: • Hypersensitivity to dobutamine • Idiopathic hypertrophic subaortic stenosis
Adverse effect • Shortness of breath • Hpetension • Premature ventricular contracture • Angina • Palpitations
DOPAMINE
Group of drug: inotropic, vasopressor, adrenergic Pharmacological name: dopamine Dose of drug • Small doses (0.5–3 mcg/kg/min) stimulate dopaminergic receptors, producing renal vasodilation. • Larger doses (2–10 mcg/kg/min) stimulate dopaminergic and beta1-adrenergic receptors, producing cardiac stimulation and renal vasodilation. • Doses greater than 10 mcg/kg/min stimulate alphaadrenergic receptors and may cause renal vasoconstriction.
Indication Adjuvant measures to improve blood pressure, cardiac output, urine otput, shock unresponsive to fluid replacement. Contraindication • Tachycardia • Pheochromocytoma • Hypersensitivity
Adverse effect Arrhtmias, hypotension, angina, ECG changes, palpitations, vasoconstriction
• USE OF CARDIAC DRUGS RELATES TO DAMPENED BLOOD PRESSURE CHANGES AND REDUCED MORTALITY IN INCIDENT HEMODIALYSIS PATIENTS • Abstract INTRODUCTION AND AIMS: It has been shown that both absolute blood pressure levels and changes in blood pressure over time relate to mortality in hemodialysis (HD) patients (pts). We aimed to study the association between cardiac drug (CD) use, blood pressure changes over time and mortality in incident HD pts. METHODS: Renal Research Institute in-center incident HD pts between Jan 1, 2000 and Feb 28, 2010 were followed for 1 year each. Pre HD systolic blood pressures (SBPs) were averaged for each pt over the first 30 days on HD (“starting SBP”); the slope of SBP was computed by linear regression using all SBP values in the first year of HD. Pts were grouped by (a) starting SBP, and (b) first year SBP slope (increased: >1 mmHg/month, decreased: <1 mmHg/mo, stable: between -1 and + 1 mmHg/mo). Cox regression was used to analyze the hazard ratio (HR) of death adjusted for starting SBP, interdialytic weight gain, BMI, gender, age, race, ethnicity, serum albumin, use of CD, and 13 comorbid conditions. Presence of CD therapy was based on whether a patient was prescribed ACE inhibitors, ARBs, or beta blockers at any time before the end of year one on HD (incl. before initiating HD).
• RESULTS: We studied 10,245 pts (57% male, 38% black, 54% white, 54% diabetic, age±SD 62.1±15.6 years). • CONCLUSIONS: These results suggest that use of CD is linked to a 28% risk reduction for mortality in incident HD pts. Given that pts with a stable SBP slope in the first year on dialysis show lower mortality rates than those with increasing or decreasing SBP (Usvyat, WCN/ASN 2011), our finding of CD use being related to dampened SBP changes suggests a possible mechanism by which these drugs may mediate improved survival. Prospective randomized trials are warranted to help discern cause and effect. CD use was significantly associated with a dampened SBP slope in both SBP increasers and decliners, even after adjustment for relevant covariates. In SBP decliners, the decline was less steep by 1.02 mmHg per month in pts on CD, while in SBP increasers, the increase was smaller by 0.81 mmHg per month in those on CD
