Debbie's Cardiac Meds Presentation Final Nn

Cardiac Medications Michelle Mungcal, B.S. University of the Pacific Thomas J. Long School of Pharmacy Doctor of Pharmacy Candidate, Class of 2009 January 12, 2009

Overview
Inotropes
Chronotropes
Antianginal Agents
Antidysrhythmics
Sympathomimetics
Vasopressors
Diuretics
Anticoagulants
Fibrinolytic Enzymes
Beta Blockers
Ca Channel blockers

Inotropes

Inotropes
Agents that affect myocardial contraction
Positive Inotropes
Cardiac glycosides
Bypyridine derivatives (Milrinone)
PDE-I (Theophylline)
Catecholamines
Negative Inotropes
BB
CCB
Class IA & IC anti-arrhythmics

Class Participation Question #1
Which of the following is an example of a positive inotrope?
Docusate
Digoxin
HCTZ
Propranolol
Nitroglycerin

Cardiac Glycosides
Prototype: Digoxin (Lanoxin ® , Digitek ® , Lanoxicaps ® )

Digoxin MOA

Digoxin (cont’d)
Indications/dosage:
Afib & HF
LD : 10-15 mcg/kg IV or PO, given in 3 divided doses every 6-8 hrs, with the first dose equalling approximately 1/2 the total
MD : 125-350 mcg PO or IV per day, depending on CrCl, given in 1-2 divided doses
CrCL < 60 requires renal adjustment
Monitoring
ECG
serum Ca
Scr/BUN
serum Mg
serum K

Class Participation Question 2:
AJ is a 54 year old male weighing 50kg who has class III heart failure. AJ’s doctor will be starting him on Digoxin therapy. Calculate the Digoxin LOADING dose .

AJ is a 54 year old male weighing 50kg who has class III heart failure. AJ’s doctor will be starting him on Digoxin therapy. Calculate the Digoxin LOADING dose .
Recall
LD: 10-15 mcg/kg IV or PO, given in 3 divided doses every 6-8 hrs, with the first dose equalling approximately 1/2 the total

TOTAL dose
100 kg x 10 mcg = 1000 mcg total
kg
1 st dose is ½ the total dose
1000 mcg / 2 = 500 mg
2 nd & 3 rd dose
500 mg / 2 = 250 mg

Answer:
500 mcg IV or PO initially
followed by 250 mcg IV or PO every 6 hours x 2 doses

Latest News on Digoxin
On April 28, 2008, Actavis Totowa LLC notified healthcare professionals of a Class I nationwide recall of all strengths of Digitek ™.
The products are distributed by Mylan Pharmaceuticals Inc. under a Bertek label and by UDL Laboratories, Inc. under a UDL label.

Digitalis Toxicity
Visual changes (unusual)
Confusion
Loss of appetite
Nausea, vomiting, diarrhea
Palpitations
Irregular pulse
Additional symptoms that may be associated with digitalis toxicity include:
Decreased urine output
Excessive nighttime urination
Overall swelling
Decreased consciousness
Difficulty breathing when lying down

Chronotropes

Chronotropes
Agents that change heart rate
affects the nerves controlling the heart
changes the rhythm produced by the SA node

Chronotropes (cont’d)
Positive Chronotropes
Atropine
Quinidine
Dopamine
Dobutamine
Epinephrine
Isuprel
Negative Chronotropes
Beta-blockers
Acetylcholine
Digoxin
Diltiazem
Verapamil
Ivabradine
Metoprolol

Positive Chronotrope
Prototype: Atropine
belladonna alkaloid
d,l -hyoscyamine
Anticholinergic
Uses
Symptomatic bradycardia
Aspiration prophylaxis
Produces mydriasis
IBS
Parkinson’s?
Organophosphate toxicity
Adjunct nerve agent & insecticide poisoning

Atropine (cont’d)
MOA
competitive inhibitor at autonomic postganglionic cholinergic receptors
Clinical effects
“ anti-SLUD”
↓ in salivary bronchial, & sweat gland secretions; mydriasis; cycloplegia; changes in heart rate; contraction of the bladder detrusor muscle and of the GI smooth muscle; ↓ gastric secretion; and ↓ GI motility

Atropine Dosing
Bradycardia
0.5-1 mg IV push; repeat if needed every 5 min up to 2 mg
Aspiration prophylaxis
po: 2 mg PO 30-60 min prior to anesthesia
parental: ≥ 20 kg: 0.2-1 mg (the usual dose is 0.4 mg) IV, IM or SC 30-60 min prior to anesthesia
IBS
po: 0.3-1.2 mg PO every 4-6 hours
Organophosphate insecticide toxicity
1-2 mg IM or IV initially; repeat if needed every 20-30 min as needed until symptoms dissipate. Adjunct nerve agent & insecticide poisoning
Mydriasis
Opthalmic: drop of 1% solution instilled in eye 1 hour prior to procedure or, 0.3-0.5 cm of 1% ointment placed in conjunctival sac up to tid
Note: Lab monitoring not necessary

Anti-anginal Drugs

Antianginal Drugs
Prototype: Nitrites & Nitrates
BB
Calcium Channel Blockers (CCBs)

Symptoms of Angina

Nitrites/Nitrates
Previously known as “coronary dilators”
Main effect: to produce general vasodilation of systemic vein & arteries
↓ preload & ↓afterload
↓ cardiac work & oxygen consumption
2 main uses
Angina attacks
Angina prophylaxis

Class Participation Question #3:
Which is the PREFERRED route for nitroglycerin during angina attacks?
Topical (ointment 2%)
IV infusion
Transdermal
SL
Extended release tablets/capsules

Which is the PREFFERED route for nitroglycerin during angina attacks?
Topical (ointment 2%)
IV infusion
Transdermal
SL
Extended release tablets/capsules

8 - 12 hr 30 min 1,2,3 mg XR tab ( Nitrogard ® ) 24 hr 30-60 min 2.5 - 15 mg/day Transdermal patch ( Transderm-Nitro ® ) 10 - 45 min 1-3 min 0.3 - 0.6 mg SL ( Nitrostat ® ) 4 - 8 hr 15 min 2% ointment ( Nitro-bid ® ) Nitroglycerin 2 - 4 hr 2-5 min 2.5 - 10 mg SL 5 - 30 mg po qid ISDN (Isordil ® ) 10 min 30-60 sec 0.3 ml inhalation Amyl nitrate (Vaporole ® ) Duration Onset Common Dosage Drug (Trade Name)

Nitroglycerin (NG)
Indications
Angina
Acute MI
HF
HTN
Hypertensive emergency
Hypotension induction
Peri/postoperative HTN
Pulmonary edema
Pulmonary HTN

NG (cont’d)
Dosing
1 tablet (0.3 mg, 0.4 mg, or 0.6 mg strength) SL, dissolved under the tongue or in buccal pouch immediately following indication of anginal attack
During drug administration, the patient should rest, preferably in the sitting position
Symptoms typically improve within 5 minutes. If needed for immediate relief of stable angina symptoms, SL nitroglycerin may be repeated every 5 minutes as needed, up to 3 doses

NG (cont’d)
Adverse Effects
dizziness or fainting
flushing of the face or neck
headache, this is common after a dose, but usually only lasts for a short time
irregular heartbeat, palpitations
nausea, vomiting
Contraindication:
sildenafil (Viagra®)
tadalafil (Cialis®)
vardenafil (Levitra ®)
Lab monitoring not necessary

Antidysrhythmics/Antiarrhythmics

What are Arrhythmias?
Cardiac disorder of
Rate
Rhythm
Impulse generation
Conduction of electrical impulses in the heart
Causes
May develop from a diseased heart
Consequence of chronic drug therapy
Symptoms
Mild palpitations  cardiac arrest
Treatment goal
Covert arrhythmia to a normal rhythm

Uses
restore normal cardiac rhythm
Successful conversion of an arrhythmia depends on the type of arrhythmia present

4 major classes
Class I
Class IA
Class IB
Class IC
Class II
Class III
Class IV

Cardiac Action Potential
4: resting membrane potential; steady K+ flux
0: Na+ influx into cell
1: K+ efflux
2: K+ efflux & Ca+ influx
3: K+ efflux

True or False?
Although antiarrthymics are used for treating arrhythmias, they can also PRODUCE arrhythmias.

True or False?
Although antiarrthymics are used for treating arrhythmias, they can also PRODUCE arrhythmias.
Answer: TRUE

The Catch 22 with Antiarrhythmics
People with structural heart disease are at INCREASED risk for arrhythmias!
The problem…
Many antiarrhythmic drugs INCREASE sudden death in these patients compared to placebo

Antiarrthymics: Class I
Na channel blockers
Common features
Local anesthetic activity
Interferes with movement of Na ions
Slow conduction velocity
Prolong refractory period
Decreases automaticity of the heart

Class I A
Quinidine (Quinidine sulfate ® , Quinaglute ® , Quinidex ® , Cardioquin ® )
Disopyramide (Norpace ® )
Procainimide (Procainimide HCI ® , Procan ® , Procanabid ® , Pronestyl ® )

Class 1A – Quinidine
Derived from cinchona tree
Depresses both the myocardium & conduction system
Overall effect: slows heart rate
Pharmacokinetics
Well absorbed in GI tract after po administration
Metabolized to several active metabolites
Primarily excreted by urinary tract
Cardiac poison when large amounts are present in blood

Class 1A – Quinidine (cont’d)
Adverse Effects
N/V, diarrhea, weakness, fatigue, cinchonism
Drug Interactions
Hyperkalemia
Digitalis
propranolol
Monitoring
CBC
ECG
serum quinidine concentrations (target range 2-6 µg/ml or higher)
CI: AV block

Class I B
prototype: Lidocaine (Xylocaine®)
Tocainide (Tonocard®)
Mexiletene (Mexitel®)
Phenytoin (Dilantin®)

Lidocaine – Class IB
MOA: blocks influx of Na fast channels
What phase of the action potential does this affect?
Indication: ventricular arrhythmias

Dosage
Vfib, Vtach
IM 300 mg. May be repeated after 60 to 90 min
IV bolus 50 to 100 mg at rate of 25 to 50 mg/min; may repeat, but do not exceed 200 to 300 mg/h
Continuous infusion 1 to 4 mg/min
Lidocaine is prepared by mixing:
2 Grams Lidocaine in 500 mL D5W
1 Gram Lidocaine in 250 mL D5W

Lidocaine – Class IB (cont’d)
Common Adverse Effects
anxiety, nervousness
dizziness, drowsiness
feelings of coldness, heat, or numbness; or pain at the site of the injection
N/V
Monitoring
LFTs
Scr/BUN
serum lidocaine concentrations (target range 2-6 µg/ml): parenteral use

Lidocaine (cont’d)
CI
Hypersensitivity to amide local anesthetics
Stokes-Adams syndrome
Wolff-Parkinson-White syndrome
severe degrees of sinoatrial, AV or intraventricular block in absence of pacemaker
ophthalmic use

Class I C
prototype: Flecainide (Tambocor®)
Propafenone (Rhythmol®)

Flecainide – Class IC
MOA
Blocks fast Na channels depresses the upstroke of the action potential, which is manifested as a decrease in the maximal rate of phase 0 depolarization.
significantly slow His-Purkinje conduction and cause QRS widening
shorten the action potential of Purkinje fibers without affecting the surrounding myocardial tissue.
Indications
Afib
Atrial flutter
Paroxysmal supraventricular tachycardias
Ventricular tachycardia prophylaxis
Wolff-Parkinson-White Syndrome

Flecainide – Class IC
Adverse Reactions
visual impairment, dizziness, asthenia, edema, abdominal pain, constipation, headache, fatigue, and tremor, N/V, arrhea, dyspepsia, anorexia, rash, diplopia, hypoesthesia, paresthesia, paresis, ataxia, flushing, increased sweating, vertigo, syncope, somnolence, tinnitus, anxiety, insomnia, and depression.
Avoid in
CHF
Acute MI
Hx of MI (LVEF < 30%)
Monitoring
ECG
serum creatinine/BUN: baseline

Class II – Beta Blockers
Propranolol (Inderal®)
Acebutolol (Sectral®)
Atenolol (Tenormin®)
Betaxolol (Kerlone®)
Bisoprolol (Zebeta®)
Carvedilol (Coreg®)
Esmolol ( Brevibloc®)
Metoprolol(Toprol®, Lopressor®)
Nadolol (Corgard®)
Timolol (Blocadron®)

Propranolol Warning
2 situations in which propranolol requires extreme caution
AV block
CHF
Asthma or emphysema

Class III
K+ channel blockers
Drugs:
Prototype: Amiodarone (Cordarone)
Bretylium (Bretylol)
Sotalol (Betapace)

Amiodarone – Class III
MOA
noncompetitively inhibits alpha- and beta-receptors,
possesses both vagolytic and calcium-channel blocking properties
relaxes both smooth and cardiac muscle
Indications
Vfib
Vtach

Vfib Amiodarone Dosage
po
Initially, 800-1600 mg/day PO in single or divided doses for a minimum of 1-3 weeks in a monitored setting until an initial therapeutic response is achieved
followed by 600-800 mg/day PO in one or divided doses for about one month.
Then reduce dosage again to the lowest effective maintenance dose, usually 400 mg/day PO in one or divided doses
iv
initial IV rapid infusion of 150 mg over the first 10 minutes. Then begin a slow IV infusion of 1 mg/min for the next 6 hours (total dose infused = 360 mg). Then, the infusion rate is lowered to 0.5 mg/min for the next 18 hours (total dose infused = 540 mg). After the first 24 hours, a maintenance IV infusion of 0.5 mg/minute (720 mg/day) is recommended.

Amiodarone – Adverse Reactions
Cardiovascular: exacerbation of the arrhythmias, CHF (3%) and bradycardia. Cardiac arrhythmias, CHF, sinoatrial node dysfunction (1% to 3%); cardiac conduction abnormalities, hypotension (less than 1%)
CNS: 20% to 40% of patients and including malaise and fatigue, peripheral neuropathy, poor coordination & gait, & tremor and involuntary movements; they are rarely a reason to stop therapy and may respond to dose reductions or discontinuation; Abnormal gait/ataxia, dizziness, lack of coordination, malaise and fatigue, paresthesias, tremor/abnormal involuntary movements (4% to 9%); decreased libido, headache, insomnia, sleep disturbances (1% to 3%).
Dermatologic: ~ 15% of patients, with photosensitivity being most common (approximately 10%). Sunscreen and protection from sun exposure may be helpful, and drug discontinuation is not usually necessary. Prolonged exposure to amiodarone occasionally results in a blue-gray pigmentation; Solar dermatitis/photosensitivity (4% to 9%); alopecia, blue skin discoloration, rash, spontaneous ecchymosis (less than 1%).
Endocrine: Hyperthyroidism, hypothyroidism (1% to 3%).
GI: GI complaints, most commonly anorexia, constipation, N/V (10% to 33%); anorexia, constipation (4% to 9%); abdominal pain (1% to 3%)
Hepatic: Abnormal liver function tests (4% to 9%); nonspecific hepatic disorders (1% to 3%)
Ophthalmic: optic neuropathy and/or optic neuritis, in some cases progressing to corneal degeneration, eye discomfort, lens opacities, macular degeneration, papilledema, permanent blindness, photosensitivity, and scotoma, have been reported . Asymptomatic corneal microdeposits are present in virtually all adult patients who have been on the drug for more than 6 months. Some patients develop eye symptoms of dry eyes, halos, and photophobia. Vision is rarely affected and drug discontinuation is rarely needed. Visual disturbances (4% to 9%)
Respiratory: Fibrosis, pulmonary inflammation (4% to 9%)
Miscellaneous: Abnormal salivation, abnormal taste and smell, coagulation abnormalities, edema, flushing (1% to 3%).

Amiodarone – Class III (cont’d)
Monitoring
CBC
chest x-ray
ECG
LFTs
ophthalmologic exam
PFTs: baseline
thyroid function tests (TFTs)

Class IV
Ca channel blockers
Drugs
Adenosine (Adenocard ® )
Diltiazim (Cardizem®, Tiazac®)
Verapamil (Dovera®, Isoptin®, Calan®)
Clinical Effects
widen the blood vessels
may decrease the heart’s pumping strength

Sympathomimetics

Sympathomimetics
2 classes:
α - agonist
Phenylephrine
Clonidine
Oxymetazoline
Tetrahydralazine
Xylometazoline
β -agonist
Prototype: Epinephrine
Norepinephrine
Dopamine
Dobutamine
Isoproterenol
SE:
hypertension,
excessive cardiac stimulation
cardiac arrhythmias
Long-term use increases mortality in heart failure patients.
CI
CAD

Epinephrine
“ fight or flight “hormone
Aka “adrenaline”
increases heart rate and stroke volume
dilates the pupils
constricts arterioles in the skin and gastrointestinal tract while dilating arterioles in skeletal muscles

Epinephrine MOA

Epinephrine (cont’d)
Indications
Vfib
Ventricular asystole
Cardiac arrest
Pulseless electrical activity
IV Dosage
IV: 1 mg (10 ml of a 1:10,000 solution) IV; may repeat every 3-5 minutes
Each dose may be given by peripheral injection followed by a 20 ml flush of IV fluid.

Epinephrine
Common Adverse Effects
anxiety or nervousness
dry mouth
drowsiness or dizziness
headache
increased sweating
nausea
weakness or tiredness
Monitoring
ECG: in patients receiving IV therapy
PFTs

Vasopressors

Vasopressors
Vasoconstrictors vs. Vasodilators
2 Vasoconstrictor Classes
Sympathomimetics
Vasopressin Analogs
Vasodilators
Alpha-adrenoceptor antagonists (alpha-blockers)
Angiotensin converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Beta2-adrenoceptor agonists (b2-agonists)
Calcium-channel blockers (CCBs)
Centrally acting sympatholytics
Direct acting vasodilators
Endothelin receptor antagonists
Ganglionic blockers
Nitrodilators
Phosphodiesterase inhibitors
Potassium-channel openers
Renin inhibitors

Vasoconstrictor
any agent that produces vasoconstriction and a rise in blood pressure (usually understood as increased arterial pressure)
Drugs
Prototype: Vasopressin
Epinephrine
Dobutamine
Dopamine
Norepinephrine

Vasopressin
aka : “AVP” or “ADH”
MOA
↑ the resorption of water at the renal collecting ducts
Vasoconstrictive property: stimulates the contraction of vascular smooth muscle in coronary, splanchnic, GI, pancreatic, skin, and muscular vascular beds

Vasopressin (cont’d)
FDA indication: Diabetes Insipidus
Non-FDA indications
Cardiac arrest
Cardiogenic shock
Cardiopulmonary resuscitation
Hypotension
Septic shock
And many more….

Dosage for cardiac arrest including ventricular asystole and pulseless electrical activity (PEA) during cardiopulmonary resuscitation (CPR)
IV or intraosseous dosage:
Adults: A single dose of 40 units IV (or intraosseous) may be given one time to replace the first or second dose of epinephrine during cardiac arrest
Do not interrupt cardiopulmonary resuscitation to administer drug therapy.

Adverse Effects
Cardiovascular: Cardiac arrest; circumoral pallor; arrhythmias; decreased cardiac output; angina; myocardial ischemia; peripheral vasoconstriction; and gangrene
CNS: Tremor; vertigo; “pounding” in head
Dermatologic: Sweating; urticaria; cutaneous gangrene
GI: Abdominal cramps; nausea; vomiting; passage of gas
Hypersensitivity: Anaphylaxis (cardiac arrest and/or shock) has been observed shortly after injection
Respiratory: Bronchial constriction.
Monitoring
serum osmolality
serum Na

Diuretics

Diuretics
“water pill”
Promotes formation of urine by the kidney  forced diuresis
Uses
HTN
Edema
Glaucoma
Anuria

Diuretic Properties Diuretic agent Site of Action & Misc. Chlorothiazide PO/IV Distal Tubule Calcium Reabsorption Increased May transiently increase Lipids, BG and UA Hypomagnesemia (may complicate K+ correction) Severe Potassium Depletion – Creation of Combos ??? Pregnancy categories: B and C Hydrochlorothiazide Indapamide Metolazone (Mykrox) Furosemide Ascending Limb of Henle Ototoxocity (reversible and irreversible) Hypokalemia (supplement with K+) Pregnancy categories: B Torsemide Bumetanide Ethacrynic acid Amiloride Distal and Proximal tubule Impact Hyperkalemia and serum creatinine elevations Avoidance: BUN > 30 mg/dl or SCr > 1.5 mg/dl Triamterene Eplerenone Distal and Aldosterone receptor Impact Same as amiloride and triamterene – avoid K spare combos Spironolactone

Diuretics
Prototype: Furosemide (Lasix ® )
MOA
inhibits the reabsorption of sodium and chloride in the ascending limb of the loop of Henle
Indications
Edema
HF
HTN
Nephrotic syndrome
Pulmonary edema
Renal impairment

Furosemide – Edema Dosage
po : Initially, 20-80 mg as a single dose; may repeat dose in 6-8 hr. Titrate upward in 20-40 mg increments. The usual dosage is 40-120 mg/day. Max dosage is 600 mg/day.
IV or IM : Initially, 20-40 mg, increasing by 20 mg every 2 hours prn to attain clinical response. Administer IV doses slowly. A max infusion rate of 4 mg/min has been recommended when administering doses >120 mg or for patients with cardiac or renal failure

Furosemide
Common Adverse Reactions
Cardiovascular: Orthostatic hypotension may occur and be aggravated by alcohol, barbiturates or narcotics.
CNS: Tinnitus and hearing loss, paresthesias, vertigo, dizziness, headache, blurred vision, xanthopsia. Dermatologic: Exfoliative dermatitis, erythema multiforme, purpura, photosensitivity, urticaria, rash, pruritus. GI: Pancreatitis, jaundice (intrahepatic cholestatic jaundice), anorexia, oral and gastric irritation, cramping, diarrhea, constipation, nausea, vomiting. Hematologic: Aplastic anemia (rare), thrombocytopenia, agranulocytosis (rare), hemolytic anemia, leukopenia, anemia. Hypersensitivity: Systemic vasculitis, interstitial nephritis, necrotizing angiitis. Miscellaneous: Hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, urinary bladder spasm, thrombophlebitis, fever.

Furosemide (cont’d)
Monitoring
audiometry
blood glucose
serum creatinine/BUN
serum electrolytes
serum uric acid
CI/Precautions
Sulfa allergy
Kidney failure
Anuria

Anticoagulants

Antiplatelets/Anticoagulants
Prevents/interferes with coagulation
Uses
deep vein thrombosis (DVTs), pulmonary embolism, myocardial infarctions & strokes in those who are predisposed

Types of Antiplatelets/Anticoagulants
Antiplatelets
Aspirin
Dipyridamole
Thienopyridines
Clopidogrel (Plavix)
Ticlopidine (Ticlid)
Glycoprotein IIb/IIIa antagonists
Abciximab (ReoPro)
Eptifibatide (Integrelin)
Tirofiban (Aggrastat )

Antiplatelets/Anticoagulants
Anticoagulants
Heparin
LMWH
Enoxaparin (Lovenox ® )
Dalteparin (Fragmin ® )
Tinzaarin (Innohep ® )
Factor Xa inhibitors
Fondaparinux (Arixtra ® )
Direct Thrombin Inhibitors
Argatroban
Lepirudin (Refludan ® )
Oral Anticoagulants
Prototype: Warfarin

Heparin Recall in 2008
In February 2008 , the FDA issued a MedWatch in response to an increase in the number of serious adverse events including allergic or hypersensitivity-type reactions with the administration of higher bolus doses of heparin. The reports have mainly involved the use of Baxter multiple-dose vials ; however, there have been reports of these reactions occurring when the combination of multiple- and single-dose vials have been used to administer a bolus dose. In February 2008, Baxter International announced expanding their voluntary recall to include all lots and doses of its Heparin Sodium UPS multi-dose, single-dose vials, and HEP-LOCK heparin flush products . The company initially recalled nine lots of heparin sodium injection multi-dose vials as a precautionary measure due to a higher than usual number of reports of adverse patient reactions involving the product. In March 2008, the FDA announced that the contaminant found in samples of Baxter's heparin was oversulfated chondroitin sulfate, a substance derived from animal cartilage. The FDA also stated that it does not know whether this contaminant caused the adverse events, only that a contaminant has been identified . Investigations continue as to whether this contaminant was added to heparin by accident or intentionally. Customers with questions regarding the Baxter recall may contact the Center for One Baxter at 1-800-422-9837.

Coagulation Cascade

Warfarin – Oral Anticoagulant
MOA: Warfarin inhibits the synthesis of vitamin K-dependent coagulation factors II, VII, IX, and X and anticoagulant proteins C and S

Warfarin (cont’d)
Indications
Stroke
DVT
Post MI
Afib
Cardiomyopathy….and many more!
Dosage
Initially, 2-5 mg PO or IV once daily, with dosage adjustments made according to INR result

Warfarin Warnings
Bleeding Risk!
Warfarin can cause major or fatal bleeding . Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher international normalized ratio [INR]). Risk factors for bleeding include high intensity of anticoagulation (INR of more than 4), 65 years of age and older, highly variable INRs, history of GI bleeding, hypertension, cerebrovascular disease, serious heart disease, anemia, malignancy, trauma, renal function impairment, concomitant drugs, and long duration of warfarin therapy. Regular monitoring of INR should be performed on all treated patients . Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to health care provider signs and symptoms of bleeding
Pregnancy Category X

Warfarin (cont’d)
SE
Hemorrhage: Signs of severe bleeding resulting in the loss of large amounts of blood depend upon the location and extent of bleeding. Symptoms include: chest, abdomen, joint, muscle, or other pain; difficult breathing or swallowing; dizziness; headache; low blood pressure; numbness and tingling; paralysis; shortness of breath; unexplained shock; unexplained swelling; weakness
Monitoring
INR
prothrombin time (PT)
stool guaiac
bleeding
DDIs
NSAIDs
3 G’s
Garlic
Ginger
Ginsing
Vitamin K intake

Which foods are high in vitamin K?

“clotbusters”
MOA: stimulate the synthesis of fibrinolysin which breaks the clot into soluble products
Drugs
Urokinase (Abbokinase ® )
Anistreplase (Eminase ® )
Alteplase (Activase ® )
Reteplase (Retevase ® )
Prototype: Streptokinase (Strepase ® )

Streptokinase (cont’d)
Indications
Acute MI
Acute ischemic stroke
Pulmonary embolism
Lysis of DVT
Dose Administration
Parental infusion (usually IV)
Deep vein or arterial thrombosis
IV: 250,000 IU over 30 min followed by 100,000 IU per hour up to 72 hours

Adverse Effects
Hemorrhage
Concomitant use of heparin, oral anticoagulants, NSAIDs is NOT recommended because of the increased risk of bleeding
Allergic reactions

Beta Blockers

Beta Blockers
MOA : bind to beta-adrenergic receptors & block the effects of EPI & NE
Indications
Angina
HTN
Arrhythmias
Glaucoma
Migraine prophylaxis
Post MI

Beta Blockers (cont’d)
Non-Selective BB
carvedilol (Coreg ® )
labetalol (Normodyne ® )
nadolol (Corgard ® )
pindolol (Visken ® )
propranolol (Inderal ® )
timolol (Blocadren ® )
Selective B-1 Blockers
acebutolol (Sectral ® )
altenolol (Tenormin ® )
bisoprolol (Zebeta ® )
esmolol (Brevibloc ® )
metoprolol tartrate (Lopressor ® )
metoprolol succinate (Toprol XL)

Propranolol
HTN Dosage
po: initially, 40 mg PO twice daily, then increase at 3-7 day intervals up to 160-480 mg/day, given in 2-3 divided doses. Maximum dosage is 640 mg/day
Main Effects
↓ in rate, force of contraction, & conduction velocity of the heart
Blocks carbohydrate & lipid metabolism

Propranolol (cont’d)
Adverse Reactions
changes in blood sugar
cold hands or feet
difficulty breathing, wheezing
difficulty sleeping, nightmares
dizziness or fainting spells
hallucinations (seeing and hearing things that are not really there)
muscle cramps or weakness
skin rash, itching, dry peeling skin
slow heart rate (less than 50 beats per minute)
swelling of the legs and ankles
vomiting
dark coloration of skin
diarrhea
dry sore eyes
hair loss
nausea
sexual difficulties (impotence or decreased sexual urges)
weakness or tiredness

Propranolol (cont’d)
Lab monitoring NOT necessary
Check vital signs frequently with parenteral drug administration
Observe patient for signs of cardiac depression & hypotension

Calcium Channel Blockers

Calcium Channel Blockers (CCBs)
MOA
prevent calcium from entering cells of the heart and blood vessel walls
relax and widen blood vessels by affecting the muscle cells in the arterial walls
Indications:
HTN
Angina
Migraine prophylaxis
Brain aneurysm complications
Arrhythmia
Reynaud's disease
Pulmonary HTN

CCBs (cont’d)
Drugs:
Amlodipine (Norvasc ® )
Diltiazem (Cardizem LA ® , Dilacor XR ® , Tiazac ® )
Felodipine (Plendil ® )
Isradipine (DynaCirc CR ® )
Nicardipine (Cardene ® , Cardene SR ® )
Nifedipine (Procardia ® , Procardia XL ® , Adalat CC ® )
Nisoldipine (Sular ® )
Verapamil (Calan ®, Verelan ® , Covera-HS ® )

Amlodipine
Indications
hypertension, chronic stable angina pectoris, and Prinzmetal's variant angina
Dosage
Initially, 5 mg PO qd
Maximum dosage is 10 mg qd

Amlodipine http://online.factsandcomparisons.com/MonoDisp.aspx?monoID=fandc-hcp10122&inProdGen=true&quick=Amlodipine&search=Amlodipine

Amlodipine
Monitoring
No lab monitoring needed
CI
Known sensitivity to amlodipine

Questions?

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Debbie's Cardiac Meds Presentation Final Nn

by guestf41297 on Jan 12, 2009

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Debbie’s Cardiac Meds Presentation Final Nn — Presentation Transcript