PHARMACOLOGY

1. 2. PHARMACOLOGY RELATED TO CARDIAC TECHNOLOGY
Course and
toxicity, management of toxic effect, drug interaction, knowledge of chemical and
trade names,
importance of manufacture and expiry dates and instructions about handling each
drug.
1. Anti-anginal agents
Beta blockers-propranolol, atenolol, metoprolol, bisoprolol carvedilol, esmolol.
Nitrates-nitroglycerine, isosorbide dinitrate, isosorbide mononitrate, transdermal
nitrate patches
Calcium channel blockers-nifedipine, verapamil, dilteazem, amlodipine
Nicorandil, Trimetazidine, Ranolazine, Ivabradine,
Routes of Administration :
 Sublingual and buccal routes. ...
 Rectal route. ...
 Vaginal route. ...
 Otic route. ...
 Nasal route
 Transdermal route.
 Oral
 Intra venous
 Intra dermal
 Subcutaneous
 Intra cardiac

2. Advantage and disadvantages of routes :
Sublingual route :
Advantages of the Sublingual Route
 Rapid drug absorption.
 Quick onset of action.
 Avoids first-pass metabolism.
 The patient can self-administer.
 Convenient for the patient.
 Can be quickly terminated by spitting out the sublingual tablet if required.
 This route can be used by people who have difficulty in swallowing tablets.
Disadvantage
Disadvantages of the Sublingual Route
 Most drugs are not available as sublingual formulations.
 The taste of the sublingual dosage form may not be liked by the patient.
 Placing the sublingual dosage form under the tongue until it dissolves may be
considered inconvenient by some patients.
 Irritation to the oral mucosa.
Advantages of oral route of drug administration
 It is the simplest, most convenient, and safest means of drug administration.
 It is convenient for repeated and prolonged use.
 It can be self-administered and pain-free.
 It is economical since it does not involve the patient in extra cost. ...

3.  No sterile precautions needed.
Disadvantages of the Oral Route
 Drug absorption may vary. ...
 Subject to first-pass metabolism.
 Oral route not possible in unconscious patients.
 Unsuitable in patients who are vomiting.
 Slow onset of action.
 Rectal route
 The drug may be destroyed by digestive enzymes and/or stomach acid.
Rectal absorption results in more of the drug reaching the systemic circulation with
less alteration on route. As well as being a more effective route for delivering
medication, rectal administration also reduces side-effects of some drugs, such as
gastric irritation, nausea and vomiting
Disadvantages of Rectal Route
 Uncomfortable and messy to use.
 Inconvenient for the patient.
 Absorption can be slow and erratic.
 Not well accepted by the patient.
Advantage of vaginal route
Vaginal drug delivery offers many advantages; the avoidance of hepatic first-pass
metabolism, a reduction in the incidence and severity of gastrointestinal side effects, a
decrease in hepatic side effects and avoidance of pain, tissue damage, and infection
commonly observed for parenteral drug delivery
Disadvantages of Vaginal Route

4.  Uncomfortable and messy to use.
 Patient compliance.
 Local irritation.
 Inconvenient to the patient.
 Not well accepted by the patient.
Advantages intra muscular
 Rapid and uniform absorption of the drug, especially those of the aqueous solutions.
 Rapid onset of the action compared to that of the oral and the subcutaneous routes.
 IM injection bypasses the first-pass metabolism.
 It also avoids the gastric factors governing the drug absorption.
Disadvantages
 Expert and a trained person is required for administrating the drug by IM route.
 The absorption of the drug is determined by the bulk of the muscle and its vascularity.
 The onset and duration of the action of the drug is not adjustable.
An advantage of IV administration
is the ability to rapidly titrate the dosage to achieve the desired depth of sedation.
Depending on patient need, sedation can vary from light to profound and nearly all
patients can be adequately sedated with this method.
Disadvantage
Disadvantages of the Intravenous Route
 Possible anaphylaxis.
 Risk of infection.
 Inconvenient to the patient.
 Painful.

5.  Expensive compared to other routes.
 Risk of phlebitis or extravasation.
 Requires trained medical/nursing staff to administer.
 Once injected, the drug cannot be recalled.
Advantages Subcutaneous :
subcutaneous tissue has few blood vessels, the injected drug is diffused very slowly at
a sustained rate of absorption. Therefore, it is highly effective in administering
vaccines, growth hormones, and insulin, which require continuous delivery at a low
dose rate.
Disadvantages of the Subcutaneous Route
 Variable drug absorption dependent on blood flow.
 Only a small volume of the drug can be administered.
What is intracardiac route of administration?
Intracardiac injections are injections that are given directly into the heart muscles or
ventricles. They can be used in emergencies, although they are rarely used in modern
practice.
What is the purpose of intracardiac injection?
Intracardiac injection should be considered when vascular access is not readily
available in a patient in cardiac arrest. The goal of the procedure is to administer
epinephrine rapidly to improve the likelihood of achieving a return of spontaneous
circulation
Where do you give an intracardiac injection?
Intracardiac injection. The needle is inserted 1 cm to the left of the xiphoid process
and aimed toward the left shoulder. The needle may also be inserted parasternally in
the left fourth or fifth intercostal space

6. ANTI ANGINAL AGENTS
Angina pectoris is the medical term for chest pain or discomfort due to coronary heart
disease. It occurs when the heart muscle doesn't get as much blood as it needs. This
usually happens because one or more of the heart's arteries is narrowed or blocked,
also called ischemia.
What are Antianginal agents?
 Nitrates (eg, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin). ...
 Calcium antagonists (eg, diltiazem, nifedipine, nimodipine, verapamil). ...
 Beta blockers (eg, atenolol, pindolol, propranolol, metoprolol). ...
 Ranolazine.
Nitrates :
Nitrates (eg, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin). These relax
smooth muscle within the blood vessels, widening them and making it easier for
blood and oxygen to reach the heart. Calcium antagonists (eg, diltiazem, nifedipine,
nimodipine, verapamil).
Nitrates are a vasodilator. Vasodilators widen (dilate) the blood vessels, improving
blood flow and allowing more oxygen-rich blood to reach the heart muscle. Nitrates
also relax the veins to ease the workload on the heart when blood is returning to the
heart from the arms and legs.
Nitroglycerine
The body breaks nitroglycerin down into nitric oxide. Nitric oxide causes the smooth
muscle within the blood vessels to relax. This allows the arteries and veins to open up,

7. allowing more blood to flow through. Healthcare professionals call this action
vasodilation.
During an angina attack, a person will experience intense chest pain. Nitroglycerin will
start working within 1–3 minutesTrusted Source, but its maximal effect occurs after 5
minutes.
Different forms of the medication start working at different time periods, depending
on their formulation. For example:
 sublingual tablet: 1–3 minutes
 translingual spray: 1–3 minutes
 extended-release tablet: 60 minutes
 topical ointment: 15–30 minutes
 transdermal patch: 30 minutes
 intravenous: immediately
The medication’s maximal effect also depends on its formation. For example:
 sublingual tablet: 7 minutes
 translingual spray: 4–15 minutes
 extended-release tablet: 2.5 to 4 hours
 topical ointment: 60 minutes
 transdermal patch: 120 minutes
 intravenous: immediately
When people use nitroglycerin for anal fissures, the ointment will relax the anal
sphincter, which is the muscle tissue around the anus, and lower pressure in the anus.
This promotes blood flow to the area and helps the fissure heal.
Uses

8. Doctors usually use nitroglycerin to treat the pain associated with angina.
The narrowing of the arteries that supply the heart with blood is what causes unstable
angina. Doctors call this condition coronary artery disease (CAD).
CAD is the most common type of heart disease. Almost 366,000 peopleTrusted
Source in the United States die every year because of CAD.
Nitroglycerin allows the blood vessels to open up, letting oxygen and nutrient-rich
blood feed the heart muscle. This action offers immediate relief from chest pain.
People can also use nitroglycerin to treat anal fissures. Anal fissures are tears in the
skin of the anus. People can develop anal fissures from passing hard stools.
Similar to its effects on angina, nitroglycerin as a rectal ointment helps the healing
process by stimulating blood flow to the affected area.
How to take it
The following table lists the different formulations of nitroglycerin.
Form of nitroglycerin How to use
aerosol solution
packet
pumpspray
tablet
dissolve under the tongue
ointment
24-hour patch
apply to the skin
rectal ointment rectal use only
Angina

9. When someone is experiencing intense chest pain, it is vital to resolve this symptom as
quickly as possible. People can also take fast-acting nitroglycerin formulations 5–10
minutes before doing an activity that may cause an angina attack.
The aerosol spray, pumpspray, packet, and tablet are all fast-acting forms of
nitroglycerin. The following sections look at these forms in more detail.
Aerosol spray and pumpspray
People can use these devices by giving one or two sprays on or under the tongue once
they feel angina pain. They should not inhale the spray.
Packet
A sublingual packet of nitroglycerin contains 400 micrograms of nitroglycerin powder.
A person places the contents of the packet under their tongue when angina pains
begin.
Tablet
At the first sign of angina pain, a person should place the tablet under their tongue or
between the gums and the cheek. The tablet will dissolve and absorb through the
tissues of the mouth.
People who use the aerosol spray, pumpspray, packet, or tablet should not swallow
the drug. Nitroglycerin will absorb through the mouth tissues on its own. This provides
faster relief than swallowing the medication. People should also avoid rinsing or
spitting for 5 minutes after administering the dose.
A person can take each of these forms of fast-acting nitroglycerin at 5-minute intervals.
If they do not feel relief from the intense chest pain, they can take two more doses 5
minutes apart.
If someone has taken three doses of a fast-acting formulation and does not experience
any pain relief, they need medical attention immediately.

10. There are also two other formulations of nitroglycerin that can prevent angina attacks.
These are not fast-acting, so people should not use them to stop an attack when it is
happening.
Ointment
People can apply nitroglycerin ointment to their skin using a dose-measuring
applicator that comes with the tube. A person measures the desired dose onto the
measuring applicator and then places the applicator ointment side down on the skin.
They then spread the ointment across the skin. The person should not rub the
medication in but allow the ointment to absorb across the skin. Finally, they tape the
applicator to the skin.
People apply two doses of ointment each day. Doctors usually tell people to use the
ointment first thing in the morning and reapply it 6 hours later.
Side effects
People may experience many side effects when using nitroglycerin, including:
 headaches
 dizziness
 weakness
 an irregular heartbeat
 nausea
 vomiting
 excessive sweating

11.  fainting
When people use nitroglycerin for relieving angina, they should be in a relaxed, seated
position.
A person’s blood pressure can drop significantly after using nitroglycerin. If they stand
up too quickly after administering the dose, their blood pressure may drop even lower
and put them at risk of fainting.
The most common side effect of long-acting nitroglycerin is a headache, but this side
effect decreases with medication use.
Although people only apply rectal ointment to the anus, they may still experience
headaches and dizziness.
Precautions and risks
Some people may have allergies to nitroglycerin, so doctors do not recommend that
people use it if they have a history of allergic reactions to this medication.
Doctors do not prescribe nitroglycerin to anyone with a history of severe anemia, heart
attack occurring on the right side of the heart, or increased pressure in the brain.
Contraindications
Nitroglycerin contraindications include allergic reactions, though these reactions are
rare. Other contraindicationsTrusted Source include:
 increased intracranial pressure
 severe anemia
 heart attack
 hypersensitivity to nitroglycerin

12. Calcium channel blockers
Calcium channel blockers are medications used to lower blood pressure.
They work by preventing calcium from entering the cells of the heart and
arteries. Calcium causes the heart and arteries to squeeze (contract) more
strongly. By blocking calcium, calcium channel blockers allow blood vessels to
relax and open.
Why do I need to take a calcium channel blocker?
Calcium channel blockers are used to control high blood pressure (hypertension), chest
pain (angina), and irregular heartbeats (arrhythmia).
How do calcium channel blockers work?
Calcium channel blockers slow the rate at which calcium passes into the heart muscle
and into the vessel walls. This relaxes the vessels. The relaxed vessels let blood flow
more easily through them, thereby lowering blood pressure.
How much do I take?
There are many different kinds of calcium channel blockers. The amount of medicine
you need to take may vary. Talk to your doctor or pharmacist for more information
about how and when to take this medicine.
If you are taking an “extended-release” calcium channel blocker (any that end in XL,
XR, XT), do not chew or crush the pills.
What if I am taking other medicines?
Other medicines that you may be taking can increase or decrease the effect of calcium
channel blockers. These effects are called an interaction. Be sure to tell your doctor
about every medicine and vitamin or herbal supplement that you are taking, so he or she
can make you aware of any interactions.
The following are categories of medicines that can increase or decrease the effects of
calcium channel blockers. Because there are so many kinds of medicines within each

13. category, not every type of medicine is listed by name. Tell your doctor about every
medicine that you are taking, even if it is not listed below.
 Other medicines used to treat high blood pressure, especially beta-
blockers and ACE inhibitors.
 Medicines to treat an irregular heartbeat (antiarrhythmics).
 Diuretics.
 Digitalis.
 Certain medicines for your eyes.
 Corticosteroids or any cortisone-like medicines.
 Large doses of calcium or Vitamin D supplements.
While on calcium channel blockers, you should also avoid smoking. Smoking while you
are on calcium channel blockers may cause a rapid heartbeat (tachycardia). Also, some
studies have shown that grapefruit juice interferes with your body’s absorption of this
medicine. If you are going to drink grapefruit juice, you should wait at least 4 hours
after having taken your medicine.
What are the side effects?
Sometimes a medicine causes unwanted effects. These are called side effects. Not all of
the side effects for calcium channel blockers are listed here. If you feel these or any
other effects, you should check with your doctor.
Common side effects:
 Feeling tired
 Flushing
 Swelling of the abdomen, ankles, or feet
 Heartburn
Less common side effects:
 Very fast or very slow heartbeat
 Wheezing, coughing, or shortness of breath
 Trouble swallowing

14.  Dizziness
 Numbness or tingling in the hands or feet
 Upset stomach
 Constipation