This document provides an overview of various cardiovascular medications, including their uses, dosages, and key effects. It discusses medications that alter hemodynamics such as heart rate, preload, afterload, and contractility. Specific drugs covered include antiarrhythmics like amiodarone and diltiazem, preload enhancers and reducers, vasopressors like dopamine and epinephrine, afterload reducers like nitroprusside, inotropes like dobutamine, and anticoagulants like heparin. Important considerations for each drug class and specific medications are outlined, such as dosing protocols, hemodynamic impacts, and monitoring parameters.

1. Cardiovascular Medications
CV CORE CURRICULUM
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2. Hemodynamic alterations
• Heart Rhythm/Rate – Efficiency
• Preload enhancers
• Preload reducer
• Blood thinners
• Afterload enhancer
• Afterload reducer
• Contractility - Squeeze
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3. Antiarrhythmics
• Amiodarone: VT, SVT, Afib/flutter
– Delays repolarization and slows action potential
– IV dosing by 24 HR protocol: 150 mg rapid bolus 10
minutes
– 1.0 mg/min X 6 hours and 0.5 mg/min for 18 hours
– MD prerogative to order titration changes.
• Cardizem: Afib/flutter, SVT
– Slows AV node conduction – IV dosing bolus per MD
– Titrate generally for rate control.
• Magnesium: intractable ventricular arrhythmias,
torsades de pointes
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4. Preload Enhancers – Filling the tank
Fluid bolus:
• Normal saline/LR - Crystalloid
• Plasmalyte– Volume expander
• Albumin - Colloid
• Blood Products - Colloid
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5. Preload reducers
• Used to treat volume overload associated
with pulmonary congestion
• Hemodynamic evidence of elevated preload
elevated PAD associated with decreased
SvO2
• Actions of preload reducers:
– Vasodilation: MSO4, NTG, Nipride
– Decreased intravascular volume: Lasix
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6. Furosemide
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7. Nitroglycerin
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8. Preload reducers - Expectations
.
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9. Hemodynamic Impact
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10. Afterload enhancers
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• Vasopressors
• Increase perfusion pressure
• May be preceded by fluid administration
• May not improve tissue oxygenation despite
increased B/P.
• Indications:
– Decreased SVR
– Decreased B/P
– Decreased MAP

11. Dopamine
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12. Epinephrine – Big Bag of FEAR
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• Common Vasopressor
• Stronger Beta than Alpha Stimulant
• Titration commonly for BP & CI
• Dosing varies – Initiation 0.05 mcg/kg/min
• Titration – by 0.01 mcg/kg/min. Note:
System orders indicate titration by 0.05
mcg/kg/min. Do NOT titrate by this rate.
• Parameter usually MAP

13. Vasopressin
• Antidiuretic hormone
• Causes constriction of smooth muscle
and all parts of the vascular bed
especially the capillaries, small arterioles
and venules –concerning for bowel
perfusion.
• Dosage – keep low and titrate slowly
• Last resort medication – As a rule add
Vasopressin last and titrate first
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14. Phenylephrine (NEO)
• Strong Alpha stimulant
• Titration usually based on MAP/SBP
• Dosing starts at 10 mcg/min – max dose 200
mcg/min. Usually call MD at 100 mcg/min
• More common with Vascular cases.
• Not used often in Open-Heart cases.
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15. Levophed - Norepinephrine
• Primarily alpha stimulant
• Titrating for MAP
• “My patient is septic…what do I use???”
• “Leave um dead Levophed”
• Starting dose 5 mcg/min – titrate to maximum
dose of 50 mcg/min – Call MD at 30 mcg/min
• Contraindicated for hypotension d/t blood
loss.
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16. Vasopressor Infusion Guidelines
• Always infuse vasopressors through a central
line.
• Start at low dose and titrate to effect
• Adjust small and WAIT 5-10 minutes
between adjustments.
• Do not forget basics – fluid boluses –
assessment – confirm a need before starting
vasoactive drugs.
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17. Vasopressors – Key Concepts
• Vasopressors work by stimulating alpha
receptors – sympathetic nervous system
• Normal response is a rapid rise in BP
• Failure to raise BP is an indication of acuity of
patient condition.
• Remember! No medication is benign!
Increased stress on the heart/body occurs
with these drugs. Be mindful of costs vs.
benefits.
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18. Afterload reduction
• Used to lower the resistance to ventricular
ejection to improve CO/CI
• Indicated for decreased CO/CI and SvO2
associated with elevated SVR and hypertension
• Categories:
– Direct arterial dilation: Nipride or high dose of
NTG
– Angiotensin converting enzyme inhibitors
– Calcium channel blockers
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19. Nipride
• Powerful direct arterial dilator and mild
venodilator. Effects much more profound
than NTG.
• Dosing –0.5 mcg/kg/min initiation and titrate
by 0.5 mcg/kg/min Q5 minutes to keep MAP
below 80mmHG. Call MD at 5 mcg/kg/min –
Max dose 8 mcg/kg/min.
• Consider Renal and Liver issues – cyanide
toxicity.
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20. Cardene - Nicardipine
• Calcium channel blocker – inhibits
contraction of smooth muscle. Think
Cardizem/Norvasc
• Benefits: reduces cardiac work through
vasodilation.
• Negatives: Can cause bradycardia, heart
block, decreased contractility.
• Dosing: Start at 5 mg/hr – titrate by 2.5 mg/hr
Q 10 minutes. Max rate 15 mg/hr
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21. Contractility Enhancers
• Positive inotropes – stimulate beta receptors
to increase inotropic state of the heart.
“Improve Squeeze”
• Indicated for decreased CO/CI with adequate
preload and normal/low afterload. “Is your
tank full?”
• “What’s the malfunction of your dysfunction?”
Know WHY a drug is hanging and WHAT to
look for by way of effect.
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22. Dobutamine
• Beta receptor stimulant – used to improve
CO/CI and SvO2. May lower SVR and BP
• Dosing: 1-20 mcg/kg/min – as a rule, not the
first drug class you titrate. Often a set rate.
• Titration parameters usually CO/CI
• Side effects: Tachycardia, increased
myocardial O2 consumption and potential for
hypotension.
• Think: Who needs Dobutamine?
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23. Dopamine
• Remember: Stimulates alpha & beta
receptors
• Dosing determines function!!!
• Low Dose – 1-5 mcg/kg/min = improves renal
and mesenteric blood flow.
• Mid Dose – 5-10 mcg/kg/min = positive
inotrope – improved contractility
• High Dose - > 10 mcg/kg/min = increased
SVR, HR and BP.
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24. Phosphodiesterase Inhibitors
• Milrinone (Primacor)
• Dosing: Loading dose 0.05 mg/kg over 10
minutes. Continuous infusion 0.375-0.75
mcg/kg/min. Max rate 0.75
• Milrinone is a bipyridine inotropic/vasodilator.
Increases intracellular ionized calcium and
contractile force of the heart muscles
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25. Contractility Reducers
• Beta Blockers/Negative inotropes/Calcium
Channel Blockers
• Common side effects – Lower HR and B/P
• Brevibloc Infusion – BB with rapid onset
and short half-life. Indications: HTN,
Tachycardia, SVT. Contraindications:
Cardiogenic shock, Overt cardiac failure, 2nd
and 3rd degree HB
• Dosing: Loading doses (see drug guide) – 50
mcg/kg/min – max rate of 200 mcg/kg/min
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26. AntiCoagulants
• Heparin - Glycosaminoglycan – inhibits
formation of thrombin through inactivation of
Factor X of the clotting cascade. Protamine
Sulfate.
• Argatroban - Direct thrombin inhibitor –
inhibits thrombin catalyzed or induced
reactions, inhibits fibrin formation and factors
V,VIII, XIII.
• Alteplase – Recombinant t-PA is clot specific
and activates fibrin bound plasminogen.
Lyses clots – Everywhere.
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27. Anticoagulant Concerns
• Heparin – Platelet Count and PTT
• Argatroban – PTT and Scheduled labs
• Warfarin – PT/INR
• ALL – Bleeding – GI – Surgical Site etc.
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28. Questions
Questions?
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