The document discusses various types of cardiovascular drugs used to treat different types of angina and arrhythmias. It describes the three main types of angina - stable angina, unstable angina, and Prinzmetal angina - and their treatments, which may include drugs like nitrates, beta-blockers, and calcium channel blockers. It also discusses various arrhythmias like atrial fibrillation, atrial flutter, ventricular tachycardia, and treatments with drugs like digoxin, verapamil, quinidine, lidocaine, and procainamide. Representative drugs like atenolol, glyceryl trinitrate, isosorbide dinitrate, and verapamil are
Anti anginal Agents /certified fixed orthodontic courses by Indian dental aca...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
drug therapy in ventricular tachyarrhithmias in emergenciesEmergency Live
Antiarrhythmic drug therapy in patients with supraventricular or ventricular tachyarrhythmias in emergencies
Dietrich Andresen, Hans-Joachim Trappe*
Klinik für Kardiologie, Allgemeine Innere Medizin und konservative Intensivmedizin, Vivantes Klinikum am Urban und im Friedrichshain, Berlin, Germany;
*Medizinische Klinik II (Kardiologie und Angiologie), Ruhr-Universität Bochum, Herne, Germany
presentation for drugs used to treat different types of angina pectoris : stable, unstable and vasospastic and the best for each type and side effects,
This document discusses various drugs used to treat angina pectoris. It begins by defining angina and describing its causes as inadequate blood flow through the coronary arteries. It then discusses the different types of angina - stable, unstable, and Prinzmetal's variant angina. The main drugs used to treat angina are described - nitrates, beta-blockers, calcium channel blockers, and newer drugs like ranolazine. Nitrates work by dilating blood vessels to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium entry to arteries and heart muscle. Ranolazine inhibits sodium channels to reduce oxygen demand. Combinations of these drugs
Recent advances in ischemic heart diseasessaachslides15
This document provides an overview of ischemic heart diseases and recent advances in treatment. It discusses the types of angina pectoris and myocardial infarction. Current treatment strategies include nitrates, beta blockers, calcium channel blockers, and potassium channel openers. Newer agents that are discussed include trimetazidine, ranolazine, and ivabradine which lower cardiac oxygen demand and improve symptoms of angina. Combination therapies are also used to maximize antianginal effects while minimizing side effects.
This document discusses different types of drugs used to treat angina pectoris, including nitrates, beta-blockers, calcium channel blockers, and ranolazine. Nitrates work by dilating blood vessels to reduce oxygen demand on the heart. Beta-blockers lower heart rate and contractility. Calcium channel blockers inhibit calcium influx to protect heart tissue. Ranolazine inhibits sodium channels to improve the balance of oxygen supply and demand in the heart. These drugs are commonly used alone or in combination to manage stable angina by reducing factors that can trigger chest pain.
An interesting ppt on antianginal drugs and drug therapy of myocardial infarction with illustrations for better understanding of concepts and grasping facts...
This document discusses antianginal drugs used to treat angina pectoris, or chest pain caused by reduced blood flow to the heart. There are three main classes of drugs used: organic nitrates, beta-blockers, and calcium channel blockers. Organic nitrates like nitroglycerin work by dilating blood vessels to increase blood flow to the heart and reduce its workload. Beta-blockers lower the heart rate and force of contraction to decrease oxygen demand. Calcium channel blockers inhibit calcium entry into heart and blood vessel cells to relax vessels and reduce workload. Each drug class is described in more detail regarding mechanisms, effects, pharmacokinetics, uses, and side effects.
Anti anginal Agents /certified fixed orthodontic courses by Indian dental aca...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
drug therapy in ventricular tachyarrhithmias in emergenciesEmergency Live
Antiarrhythmic drug therapy in patients with supraventricular or ventricular tachyarrhythmias in emergencies
Dietrich Andresen, Hans-Joachim Trappe*
Klinik für Kardiologie, Allgemeine Innere Medizin und konservative Intensivmedizin, Vivantes Klinikum am Urban und im Friedrichshain, Berlin, Germany;
*Medizinische Klinik II (Kardiologie und Angiologie), Ruhr-Universität Bochum, Herne, Germany
presentation for drugs used to treat different types of angina pectoris : stable, unstable and vasospastic and the best for each type and side effects,
This document discusses various drugs used to treat angina pectoris. It begins by defining angina and describing its causes as inadequate blood flow through the coronary arteries. It then discusses the different types of angina - stable, unstable, and Prinzmetal's variant angina. The main drugs used to treat angina are described - nitrates, beta-blockers, calcium channel blockers, and newer drugs like ranolazine. Nitrates work by dilating blood vessels to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium entry to arteries and heart muscle. Ranolazine inhibits sodium channels to reduce oxygen demand. Combinations of these drugs
Recent advances in ischemic heart diseasessaachslides15
This document provides an overview of ischemic heart diseases and recent advances in treatment. It discusses the types of angina pectoris and myocardial infarction. Current treatment strategies include nitrates, beta blockers, calcium channel blockers, and potassium channel openers. Newer agents that are discussed include trimetazidine, ranolazine, and ivabradine which lower cardiac oxygen demand and improve symptoms of angina. Combination therapies are also used to maximize antianginal effects while minimizing side effects.
This document discusses different types of drugs used to treat angina pectoris, including nitrates, beta-blockers, calcium channel blockers, and ranolazine. Nitrates work by dilating blood vessels to reduce oxygen demand on the heart. Beta-blockers lower heart rate and contractility. Calcium channel blockers inhibit calcium influx to protect heart tissue. Ranolazine inhibits sodium channels to improve the balance of oxygen supply and demand in the heart. These drugs are commonly used alone or in combination to manage stable angina by reducing factors that can trigger chest pain.
An interesting ppt on antianginal drugs and drug therapy of myocardial infarction with illustrations for better understanding of concepts and grasping facts...
This document discusses antianginal drugs used to treat angina pectoris, or chest pain caused by reduced blood flow to the heart. There are three main classes of drugs used: organic nitrates, beta-blockers, and calcium channel blockers. Organic nitrates like nitroglycerin work by dilating blood vessels to increase blood flow to the heart and reduce its workload. Beta-blockers lower the heart rate and force of contraction to decrease oxygen demand. Calcium channel blockers inhibit calcium entry into heart and blood vessel cells to relax vessels and reduce workload. Each drug class is described in more detail regarding mechanisms, effects, pharmacokinetics, uses, and side effects.
1) Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs due to issues with how the heart fills or empties.
2) Common causes include heart attacks, high blood pressure, and heart valve problems.
3) The renin-angiotensin system helps regulate blood pressure and fluid levels in the body and is activated in heart failure. Drugs that block this system such as ACE inhibitors are used to treat heart failure.
New pharmocological agents in the management of angina nicorandilJerin Kuruvilla
Nicorandil is a potassium channel activator used to treat angina. It works by dilating both epicardial coronary arteries through its nitrate-like properties as well as peripheral coronary arterioles through potassium channel activation. This dual mechanism of action decreases myocardial oxygen demand and increases supply. Nicorandil has been shown to be effective in treating stable and unstable angina, improving outcomes in acute myocardial infarction when administered before reperfusion, and preventing the no-reflow phenomenon during percutaneous coronary intervention. It provides cardioprotection through ischemic preconditioning with a good safety profile.
Antihypertensives and anesthetic implications - Dr. VaibhavVaibhav Tulsyan
This document discusses recommendations for treating hypertension from the JNC 8 guidelines. It outlines first-line antihypertensive drug classes including thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers, and beta blockers. For each class, it provides details on mechanisms of action, advantages, side effects, and implications for anesthesia. Thiazide diuretics are recommended as first-line but can cause hypokalemia, so potassium sparing diuretics are often added. ACE inhibitors and ARBs block the renin-angiotensin system. Calcium channel blockers relax blood vessels. Beta blockers reduce cardiac output and sympathetic outflow. Alpha blockers reduce peripheral resistance
This document discusses antianginal agents used to treat angina pectoris including nitrates, beta blockers, and calcium channel blockers. Nitrates work by causing vasodilation of coronary arteries to increase blood flow. Beta blockers decrease heart rate and contractility to lower oxygen demand. Calcium channel blockers cause peripheral vasodilation and reduce contractility. Nursing implications include monitoring for side effects like hypotension and ensuring proper administration of different drug formulations.
Modern principles of hypertension treatmentNishuVerma20
Introduction
Classification of BP
Total Cardiovascular Risk Stratification
Pre Hypertension stage
Four main classes of medication
Medication based on the comorbidity
Combination Therapy
Treatment of acute complications
Conclusion
Anti anginal drugs, uses, mechanism of action, adverse effectsKarun Kumar
A presentation outlining the causes of angina, mechanism of action of various anti-anginal drugs, their uses and side effects alongwith contraindications
Antihypertensive drugs and hypertension managementAnas Indabawa
This document discusses antihypertensive drugs and hypertension management. It begins with an introduction to hypertension and outlines types of hypertension like primary or essential hypertension. It then discusses risk factors, diagnosis, and management of hypertension including both non-pharmacological lifestyle changes and various classes of pharmacological treatments. Specific drug classes are explained like ACE inhibitors, calcium channel blockers, diuretics, and others. The document also covers hypertension during pregnancy and hypertensive emergencies. It concludes with precautions for using antihypertensive drugs.
Ranolazine is a new antianginal drug that represents a new class of drugs. It partially inhibits fatty acid oxidation and shifts energy production to a more efficient carbohydrate oxidation during ischemia. It also inhibits late inward sodium currents, reducing calcium overload and improving diastolic function and myocardial perfusion. Ranolazine has been shown to reduce angina frequency and improve exercise ability with no effects on blood pressure or heart rate. Its benefits and mechanisms of action were discussed along with its indications, studies, and potential role in other conditions such as diabetes and cardioplegia.
This document describes screening methods for evaluating potential antianginal drugs. It discusses in vivo and in vitro models. In vivo models include testing drugs in pithed rats to assess calcium antagonism, in rats to evaluate protection against isoproterenol-induced myocardial necrosis, and in dogs to study effects on ischemia from microsphere injection or coronary artery occlusion. In vitro models involve testing drugs in isolated rat hearts, using the Langendorff preparation to assess coronary vasodilation, and in isolated bovine or rat aorta to measure smooth muscle relaxation. The screening methods are aimed at identifying drugs that can improve blood flow to the heart and protect against ischemia.
- A study compared the effects of glibenclamide and gliclazide, two sulphonylureas, on ischemic preconditioning (IPC) and nicorandil-induced myocardial protection in rats.
- Glibenclamide abolished the protective effects of both IPC and nicorandil, but gliclazide did not affect IPC or nicorandil-induced protection.
- Nicorandil caused a partial depolarization of mitochondrial membrane potential, an effect blocked by glibenclamide but not gliclazide. These results suggest gliclazide may allow protective effects in diabetic patients at risk of acute coronary syndromes unlike
This document discusses the patterns of angina pectoris and their characteristics. It describes stable angina, which produces reproducible chest pain relieved by rest. Unstable angina occurs with less exertion or at rest and is less responsive to nitroglycerin. Prinzmetal angina is an uncommon variant occurring at rest, often in young individuals, triggered by substances like alcohol. The document also outlines various drug classes used to treat angina, including nitrates, calcium channel blockers, beta blockers, and other adjunctive therapies. It provides details on the mechanisms and side effects of these drug classes.
This document discusses ranolazine, a drug used to treat chronic angina. It begins by introducing chronic angina as a condition affecting many Americans. It then reviews the history of anti-anginal drugs and discusses why newer treatments are needed. The document focuses on the mechanism of action and clinical trial results of ranolazine. Ranolazine is a unique anti-anginal that acts by inhibiting fatty acid oxidation and blocking late sodium channels. Clinical trials such as MARISA, CARISA and ERICA demonstrated ranolazine's ability to reduce angina symptoms and improve exercise tolerance when added to standard anti-anginal therapies.
This document provides an overview of various classes of antihypertensive drugs including centrally acting alpha adrenergic antagonists, peripheral acting alpha adrenergic antagonists, alpha blockers, beta blockers, calcium channel blockers, diuretics, angiotensin receptor blockers, ACE inhibitors, renin inhibitors, aldosterone inhibitors, vasodilators. It discusses specific drugs from each class, their mechanisms of action, indications, contraindications, side effects, and important nursing considerations.
This document discusses antiarrhythmic drugs. It defines arrhythmias as irregularities of cardiac rhythm and explains that antiarrhythmic drugs are used to prevent or treat arrhythmias. The document then provides detailed information on the classification, mechanisms of action, uses, and side effects of various antiarrhythmic drugs including quinidine, procainamide, lidocaine, propafenone, propranolol, sotalol, esmolol, amiodarone, and dronedarone.
The document discusses various types of angina and treatments for restoring the balance between oxygen supply and demand in the heart. It describes 3 main types of angina - chronic stable angina, unstable angina, and vasospastic angina. The goal of antianginal drug therapy is to increase blood flow to the heart and decrease myocardial oxygen demand. The major antianginal drug classes discussed are nitrates, beta-blockers, calcium channel blockers, and potassium channel openers. Specific drugs within each class are also named and their mechanisms and uses summarized within 3 sentences.
This document discusses various drugs used to treat angina. It outlines different classes of antianginal drugs including organic nitrates like nitroglycerin, beta-blockers, calcium channel blockers like verapamil, and ACE inhibitors. It provides details on the mechanisms and clinical uses of these drug classes and examples of medications within each class. Side effects are also summarized for several individual drugs.
This document discusses evaluation methods for anti-anginal drugs, including both in vitro and in vivo models. The isolated heart (Langendorff) preparation is described in detail as an in vitro method where the heart is removed and retrogradely perfused with oxygenated fluid, allowing evaluation of drug effects on parameters like heart rate, contractile force, coronary flow, and myocardial oxygen consumption. The preparation offers reproducibility and the ability to study multiple parameters, though it does not fully represent in vivo cardiac function.
This document discusses various drug treatments for angina. It covers nitrates like nitroglycerin and isosorbide dinitrate which work by dilating veins and arteries to reduce blood pressure and oxygen demands on the heart. It also discusses beta blockers like propranolol which lower heart rate and contractility to reduce oxygen needs, and calcium channel blockers like diltiazem which increase blood flow to boost oxygen supply. Finally, it mentions antiplatelet drugs like aspirin that are recommended indefinitely to reduce heart attack risk.
Angina pectoris, or chest pain, is caused by a lack of oxygen to the heart muscle. There are different types of angina including stable angina and Prinzmetal's angina. Treatment goals are to reduce symptoms and prolong life. Treatment options include medications like beta blockers, calcium channel blockers, and nitrates as well as lifestyle changes and procedures like angioplasty. Exercise testing can help evaluate ischemia and risk stratify patients.
This document discusses different types of angina and treatments. It describes 3 main types of angina: atherosclerotic angina which is caused by partially blocked arteries and accounts for 90% of cases; vasospastic angina which involves coronary artery spasms and can occur at rest; and unstable angina which is a medical emergency and precursor to heart attack. The major treatment strategies aim to increase oxygen delivery to the heart and reduce oxygen demand. Traditional pharmacological therapies discussed include nitrates, calcium channel blockers, and beta blockers which all work to relax blood vessels or reduce heart rate to improve oxygen supply. Newer drugs like ranolazine and ivabradine are also mentioned.
The document discusses the different languages used in SQL - Data Definition Language (DDL) to create and modify database objects, Data Manipulation Language (DML) to manipulate data, Data Query Language (DQL) to retrieve data, Transaction Control Language (TCL) to manage transactions, and Data Control Language (DCL) to control access privileges. It then provides examples of using DDL to create a table, DML to insert records using various methods, DQL to select data using where clauses with operators like =, <, >, between, and, or.
NSTDA focuses on three technology areas: biotechnology, microelectronics and nanotechnology. The agency conducts research in biotechnology and supports the development of microelectronics and nanotechnology industries in Thailand. NSTDA aims to advance science and technology in the country through these three technology programs.
1) Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs due to issues with how the heart fills or empties.
2) Common causes include heart attacks, high blood pressure, and heart valve problems.
3) The renin-angiotensin system helps regulate blood pressure and fluid levels in the body and is activated in heart failure. Drugs that block this system such as ACE inhibitors are used to treat heart failure.
New pharmocological agents in the management of angina nicorandilJerin Kuruvilla
Nicorandil is a potassium channel activator used to treat angina. It works by dilating both epicardial coronary arteries through its nitrate-like properties as well as peripheral coronary arterioles through potassium channel activation. This dual mechanism of action decreases myocardial oxygen demand and increases supply. Nicorandil has been shown to be effective in treating stable and unstable angina, improving outcomes in acute myocardial infarction when administered before reperfusion, and preventing the no-reflow phenomenon during percutaneous coronary intervention. It provides cardioprotection through ischemic preconditioning with a good safety profile.
Antihypertensives and anesthetic implications - Dr. VaibhavVaibhav Tulsyan
This document discusses recommendations for treating hypertension from the JNC 8 guidelines. It outlines first-line antihypertensive drug classes including thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers, and beta blockers. For each class, it provides details on mechanisms of action, advantages, side effects, and implications for anesthesia. Thiazide diuretics are recommended as first-line but can cause hypokalemia, so potassium sparing diuretics are often added. ACE inhibitors and ARBs block the renin-angiotensin system. Calcium channel blockers relax blood vessels. Beta blockers reduce cardiac output and sympathetic outflow. Alpha blockers reduce peripheral resistance
This document discusses antianginal agents used to treat angina pectoris including nitrates, beta blockers, and calcium channel blockers. Nitrates work by causing vasodilation of coronary arteries to increase blood flow. Beta blockers decrease heart rate and contractility to lower oxygen demand. Calcium channel blockers cause peripheral vasodilation and reduce contractility. Nursing implications include monitoring for side effects like hypotension and ensuring proper administration of different drug formulations.
Modern principles of hypertension treatmentNishuVerma20
Introduction
Classification of BP
Total Cardiovascular Risk Stratification
Pre Hypertension stage
Four main classes of medication
Medication based on the comorbidity
Combination Therapy
Treatment of acute complications
Conclusion
Anti anginal drugs, uses, mechanism of action, adverse effectsKarun Kumar
A presentation outlining the causes of angina, mechanism of action of various anti-anginal drugs, their uses and side effects alongwith contraindications
Antihypertensive drugs and hypertension managementAnas Indabawa
This document discusses antihypertensive drugs and hypertension management. It begins with an introduction to hypertension and outlines types of hypertension like primary or essential hypertension. It then discusses risk factors, diagnosis, and management of hypertension including both non-pharmacological lifestyle changes and various classes of pharmacological treatments. Specific drug classes are explained like ACE inhibitors, calcium channel blockers, diuretics, and others. The document also covers hypertension during pregnancy and hypertensive emergencies. It concludes with precautions for using antihypertensive drugs.
Ranolazine is a new antianginal drug that represents a new class of drugs. It partially inhibits fatty acid oxidation and shifts energy production to a more efficient carbohydrate oxidation during ischemia. It also inhibits late inward sodium currents, reducing calcium overload and improving diastolic function and myocardial perfusion. Ranolazine has been shown to reduce angina frequency and improve exercise ability with no effects on blood pressure or heart rate. Its benefits and mechanisms of action were discussed along with its indications, studies, and potential role in other conditions such as diabetes and cardioplegia.
This document describes screening methods for evaluating potential antianginal drugs. It discusses in vivo and in vitro models. In vivo models include testing drugs in pithed rats to assess calcium antagonism, in rats to evaluate protection against isoproterenol-induced myocardial necrosis, and in dogs to study effects on ischemia from microsphere injection or coronary artery occlusion. In vitro models involve testing drugs in isolated rat hearts, using the Langendorff preparation to assess coronary vasodilation, and in isolated bovine or rat aorta to measure smooth muscle relaxation. The screening methods are aimed at identifying drugs that can improve blood flow to the heart and protect against ischemia.
- A study compared the effects of glibenclamide and gliclazide, two sulphonylureas, on ischemic preconditioning (IPC) and nicorandil-induced myocardial protection in rats.
- Glibenclamide abolished the protective effects of both IPC and nicorandil, but gliclazide did not affect IPC or nicorandil-induced protection.
- Nicorandil caused a partial depolarization of mitochondrial membrane potential, an effect blocked by glibenclamide but not gliclazide. These results suggest gliclazide may allow protective effects in diabetic patients at risk of acute coronary syndromes unlike
This document discusses the patterns of angina pectoris and their characteristics. It describes stable angina, which produces reproducible chest pain relieved by rest. Unstable angina occurs with less exertion or at rest and is less responsive to nitroglycerin. Prinzmetal angina is an uncommon variant occurring at rest, often in young individuals, triggered by substances like alcohol. The document also outlines various drug classes used to treat angina, including nitrates, calcium channel blockers, beta blockers, and other adjunctive therapies. It provides details on the mechanisms and side effects of these drug classes.
This document discusses ranolazine, a drug used to treat chronic angina. It begins by introducing chronic angina as a condition affecting many Americans. It then reviews the history of anti-anginal drugs and discusses why newer treatments are needed. The document focuses on the mechanism of action and clinical trial results of ranolazine. Ranolazine is a unique anti-anginal that acts by inhibiting fatty acid oxidation and blocking late sodium channels. Clinical trials such as MARISA, CARISA and ERICA demonstrated ranolazine's ability to reduce angina symptoms and improve exercise tolerance when added to standard anti-anginal therapies.
This document provides an overview of various classes of antihypertensive drugs including centrally acting alpha adrenergic antagonists, peripheral acting alpha adrenergic antagonists, alpha blockers, beta blockers, calcium channel blockers, diuretics, angiotensin receptor blockers, ACE inhibitors, renin inhibitors, aldosterone inhibitors, vasodilators. It discusses specific drugs from each class, their mechanisms of action, indications, contraindications, side effects, and important nursing considerations.
This document discusses antiarrhythmic drugs. It defines arrhythmias as irregularities of cardiac rhythm and explains that antiarrhythmic drugs are used to prevent or treat arrhythmias. The document then provides detailed information on the classification, mechanisms of action, uses, and side effects of various antiarrhythmic drugs including quinidine, procainamide, lidocaine, propafenone, propranolol, sotalol, esmolol, amiodarone, and dronedarone.
The document discusses various types of angina and treatments for restoring the balance between oxygen supply and demand in the heart. It describes 3 main types of angina - chronic stable angina, unstable angina, and vasospastic angina. The goal of antianginal drug therapy is to increase blood flow to the heart and decrease myocardial oxygen demand. The major antianginal drug classes discussed are nitrates, beta-blockers, calcium channel blockers, and potassium channel openers. Specific drugs within each class are also named and their mechanisms and uses summarized within 3 sentences.
This document discusses various drugs used to treat angina. It outlines different classes of antianginal drugs including organic nitrates like nitroglycerin, beta-blockers, calcium channel blockers like verapamil, and ACE inhibitors. It provides details on the mechanisms and clinical uses of these drug classes and examples of medications within each class. Side effects are also summarized for several individual drugs.
This document discusses evaluation methods for anti-anginal drugs, including both in vitro and in vivo models. The isolated heart (Langendorff) preparation is described in detail as an in vitro method where the heart is removed and retrogradely perfused with oxygenated fluid, allowing evaluation of drug effects on parameters like heart rate, contractile force, coronary flow, and myocardial oxygen consumption. The preparation offers reproducibility and the ability to study multiple parameters, though it does not fully represent in vivo cardiac function.
This document discusses various drug treatments for angina. It covers nitrates like nitroglycerin and isosorbide dinitrate which work by dilating veins and arteries to reduce blood pressure and oxygen demands on the heart. It also discusses beta blockers like propranolol which lower heart rate and contractility to reduce oxygen needs, and calcium channel blockers like diltiazem which increase blood flow to boost oxygen supply. Finally, it mentions antiplatelet drugs like aspirin that are recommended indefinitely to reduce heart attack risk.
Angina pectoris, or chest pain, is caused by a lack of oxygen to the heart muscle. There are different types of angina including stable angina and Prinzmetal's angina. Treatment goals are to reduce symptoms and prolong life. Treatment options include medications like beta blockers, calcium channel blockers, and nitrates as well as lifestyle changes and procedures like angioplasty. Exercise testing can help evaluate ischemia and risk stratify patients.
This document discusses different types of angina and treatments. It describes 3 main types of angina: atherosclerotic angina which is caused by partially blocked arteries and accounts for 90% of cases; vasospastic angina which involves coronary artery spasms and can occur at rest; and unstable angina which is a medical emergency and precursor to heart attack. The major treatment strategies aim to increase oxygen delivery to the heart and reduce oxygen demand. Traditional pharmacological therapies discussed include nitrates, calcium channel blockers, and beta blockers which all work to relax blood vessels or reduce heart rate to improve oxygen supply. Newer drugs like ranolazine and ivabradine are also mentioned.
The document discusses the different languages used in SQL - Data Definition Language (DDL) to create and modify database objects, Data Manipulation Language (DML) to manipulate data, Data Query Language (DQL) to retrieve data, Transaction Control Language (TCL) to manage transactions, and Data Control Language (DCL) to control access privileges. It then provides examples of using DDL to create a table, DML to insert records using various methods, DQL to select data using where clauses with operators like =, <, >, between, and, or.
NSTDA focuses on three technology areas: biotechnology, microelectronics and nanotechnology. The agency conducts research in biotechnology and supports the development of microelectronics and nanotechnology industries in Thailand. NSTDA aims to advance science and technology in the country through these three technology programs.
NSTDA focuses on three technology areas: biotechnology, microelectronics and nanotechnology. The agency conducts research in biotechnology and microelectronics through its BIOTEC and MTEC divisions. It also explores applications of nanotechnology.
The document analyzes COSTI Immigrant Services using John Friedmann's 7 action-related questions. COSTI is a government-funded immigrant service organization that provides services to immigrants in Toronto, York Region, and Peel. The analysis examines the actors involved in COSTI, including the Board of Directors, Executive Director, staff, funders, and community partners. It also looks at how COSTI balances the interests of immigrants with government priorities and ensures it has sufficient power to enact change through strategic relationships and expertise. The analysis reveals tensions between COSTI's intimate knowledge of immigrant struggles and government policies that view immigrants primarily as economic drivers.
NSTDA focuses on three technology areas: biotechnology, microelectronics and nanotechnology. The agency conducts research in biotechnology and microelectronics through its BIOTEC and MTEC divisions. It also explores applications of nanotechnology.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise boosts blood flow, releases endorphins, and promotes changes in the brain which help regulate emotions and stress levels.
This document provides an overview of a barcode scanner and printer system developed by Supersoft Solutions. The system has 3 main modules: entering product data, printing barcodes, and scanning barcodes. Users can enter product name and size, generate a barcode, print it and stick it on the product. Then the barcode can be scanned to quickly retrieve the product details. The system requires both hardware like a barcode scanner and software to function. Supersoft Solutions developed this embedded system to be robust and secure.
İnsan Kaynakları Yöneticilerinin, bordroya ilişkin tüm mevzuat ve hesaplama yöntemleri hakkında geniş bilgi sahibi olabilmeleri ve yürürlükte olan güncel personel özlük bilgilerini farklı durumlar için yorumlayarak; ilgili yasalar hakkında bilgilerini tazelemeleri hedeflenmektedir
- The main difference between OBIEE 10g and 11g architectures is that 11g wraps components in the WebLogic Server (WLS) platform and uses Enterprise Manager (EM) for management.
- Key components like the BI server, presentation server, and BI publisher are unchanged, but some reworking in 11g includes unified logging and managing configuration files through EM.
- New features in the RPD include support for ragged/skipped hierarchies, parent-child hierarchies, lookup tables, and the action framework.
- New analytics features include hierarchical columns, KPIs, scorecards, chart viewer with sliders, and BI published reporting.
احدث واكبر دليل عملي مصور عن طرق التسويق الإلكتروني باللغة العربيه علي مستوى الشرق الأوسط
The latest and greatest practical pictorial guide for ways of e-marketing in the Middle East
في حالة شراء الموسوعه كامله؛ يرجي الاطلاع علي المحتويات:
http://www.internetmarketing-art.com/p/digital.html
00201001997405
00966567564518
e-marketing@windowslive.com
This document discusses angina pectoris, its causes, symptoms, diagnosis and management. It provides details on:
- Angina is caused by transient myocardial ischemia due to an imbalance of oxygen supply and demand in the heart. The most common cause is atherosclerosis.
- Risk factors, symptoms, and physical exam findings for angina are described. Management involves identifying and treating risk factors, introducing anti-anginal drugs, and considering revascularization if drugs do not control symptoms.
- Five main classes of anti-anginal drugs are discussed - nitrates, beta-blockers, calcium channel blockers, potassium channel activators, and ivabradine. Their mechanisms of action and usage guidelines are
The document discusses the use of organic nitrates and calcium antagonists to treat angina. It provides details on their mechanisms of action, pharmacological effects, and clinical uses. Specifically, it explains that organic nitrates act by relaxing smooth muscle and increasing cGMP, while calcium antagonists prevent the opening of voltage-gated calcium channels. Both drug classes are used to reduce cardiac oxygen demand and redistribute blood flow for the treatment of stable and unstable angina.
Hypertension is high blood pressure over 140/90. It is managed through lifestyle changes and medications including diuretics, ACE inhibitors, calcium channel blockers, and ARBs. Angina is chest pain from reduced blood flow to the heart. It is treated with nitrates, beta blockers, and calcium channel blockers to open blood vessels and reduce the heart's workload. These drugs help prevent or treat angina attacks but can cause side effects like low blood pressure and headaches.
Anti-Angina & Anti arryhthias Drugs .pptssuser504dda
This document discusses drugs used to manage angina and arrhythmias, and current guidelines for managing acute coronary syndrome (ACS). It describes the classification and pathophysiology of angina, then focuses on pharmacological management including nitrates like nitroglycerin, calcium channel blockers like nifedipine, beta blockers like atenolol, and alpha/beta blockers like carvedilol. It provides details on their mechanisms of action, indications, interactions, and side effects in treating conditions like angina, heart failure and ACS.
This document discusses angina pectoris, also known as stable angina. It defines angina as chest pain or discomfort that occurs due to decreased blood flow to the heart muscle. It then describes the different types of angina and their causes. The main causes are atherosclerosis, coronary artery spasm, traumatic injury, and embolic events which can all restrict blood flow to the heart. The document outlines the goals of treatment which are to prevent heart attacks and death while reducing angina symptoms. It then discusses the various pharmacological treatments used including nitrates, beta blockers, calcium channel blockers, antiplatelet agents, ACE inhibitors, and ranolazine. Non-pharmacological options like percutaneous coronary
This document discusses chronic stable angina, including its definition, causes, diagnosis, goals of treatment, and treatment options. It defines chronic stable angina as chest pain or discomfort caused by insufficient blood flow to the heart muscle during physical exertion or emotional stress. The major determinants of insufficient flow are described as heart rate, contractility, and intramyocardial wall tension. Diagnosis involves electrocardiograms and stress tests, while treatment goals are to reduce symptoms and prevent complications through lifestyle changes, medications, and procedures. Common medications discussed are antiplatelet drugs, beta-blockers, calcium channel blockers, nitrates, ACE inhibitors, statins, and newer options like ranolazine and ivabrad
This document discusses medications used to treat angina, including nitrates, beta blockers, and calcium channel blockers. It describes their mechanisms of action, therapeutic uses, side effects and nursing implications for administration and patient education. Nursing responsibilities include assessing for contraindications, monitoring for therapeutic effects and side effects, and instructing patients on proper use, storage, application, and reporting of symptoms.
Discuss and describe the medications used in patients.pptxSuhailRafik1
1. Medications used in acute coronary syndrome include antiplatelet drugs like aspirin and clopidogrel to prevent clotting, high-dose statins to lower cholesterol, and anticoagulants like heparin.
2. For treatment, anti-angina drugs like nitrates provide pain relief while beta-blockers and calcium channel blockers lower blood pressure and oxygen demand.
3. In STEMI patients presenting within 12 hours, fibrinolytic therapy can be used to dissolve clots when immediate PCI is not available. Congestive heart failure is treated with diuretics, inotropes, and vasodilators to reduce preload and afterload.
Angina pectoris is chest pain due to ischemia of the heart muscle. It is usually felt as a tightness or pressure in the middle of the chest that may spread to the neck, jaw, or arm. There are three main types - stable angina brought on by exertion, unstable angina that occurs at rest, and Prinzmetal or variant angina caused by coronary artery spasm. Treatment involves medications to relieve symptoms like nitrates, beta blockers, calcium channel blockers, and newer drugs that open potassium channels or have a cytoprotective effect. Combination therapy with two or more classes is often used for better management of angina.
This document summarizes drugs that affect the cardiovascular system. It describes the components of the cardiovascular system and classifies drugs as cardiotonics, anti-anginals, or antihypertensives. Cardiotonics like digoxin are used to increase heart contractility in heart failure. Anti-anginal drugs like nitrates and beta-blockers treat angina by improving blood flow or decreasing oxygen demand. Antihypertensive drug classes include diuretics, adrenergic inhibitors, calcium channel blockers, and angiotensin inhibitors which are used to lower blood pressure.
Drugs used in congestive heart failure-1Goutam Mallik
This document discusses drugs used to treat congestive heart failure. It begins by defining congestive heart failure and describing the two main types: systolic and diastolic dysfunction. It then discusses the pathophysiology of CHF and outlines two main treatment goals: relieving symptoms and improving cardiac function, and arresting disease progression. The main drug classes used are described in detail, including diuretics, renin-angiotensin system inhibitors, vasodilators, and beta-blockers. Diuretics are first-line treatment to reduce fluid retention, while ACE inhibitors, ARBs, and beta-blockers provide both symptomatic relief and prolong survival by modifying disease progression. Vasodilators are used
This document discusses angina pectoris, including its causes, risk factors, classifications, and treatments. Angina is chest pain due to an imbalance between myocardial oxygen demand and supply. It is classified into four types based on triggers and severity. Treatment includes short-acting nitrates for acute attacks and long-acting options like nitrates, calcium channel blockers, and beta-blockers for prophylaxis. Additional therapies discussed are potassium channel openers, fatty acid oxidase inhibitors, and antiplatelets/anticoagulants. Combination drug regimens and surgical options are also outlined for management of angina.
Anti anginal drugs ppt by anjali kotwalanjali kotwal
This document discusses various anti-anginal drugs used to treat angina pectoris. It describes three main classes of drugs: nitrates, beta-blockers, and calcium channel blockers. Nitrates work by dilating blood vessels to increase oxygen supply and decrease oxygen demand. Beta-blockers lower heart rate and contractility to reduce myocardial oxygen consumption. Calcium channel blockers inhibit calcium entry into cardiac and vascular muscle to produce vasodilation and reduce myocardial work. Combination therapy using drugs from different classes is often most effective for treating angina due to their additive effects on myocardial oxygen balance.
Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure). Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction.
The document discusses different types of angina pectoris and treatments for angina. It defines typical angina, variant angina, and unstable angina. It then explains drugs that can be used to treat angina by decreasing oxygen demand and/or increasing oxygen supply, including nitrates, calcium channel blockers, and beta blockers. Nitrates are described as being effective for treating acute angina by dilating blood vessels and reducing workload on the heart. Calcium channel blockers and beta blockers are also outlined as treatments that decrease oxygen demand. Combination therapies are noted to provide additive effects in managing angina.
The document discusses different types of angina pectoris and treatments for angina. It defines typical angina, variant angina, and unstable angina. It then explains drugs that can be used to treat angina by decreasing oxygen demand and/or increasing oxygen supply, including nitrates, calcium channel blockers, and beta blockers. Nitrates are described as being effective for treating acute angina by dilating blood vessels and reducing workload on the heart. Calcium channel blockers and beta blockers are also outlined as treatments that decrease oxygen demand. Combination therapies are noted to provide additive effects in managing angina.
The document discusses different types of angina pectoris and treatments for angina. It defines typical angina, variant angina, and unstable angina. It then explains drugs that can be used to treat angina by decreasing oxygen demand and/or increasing oxygen supply, including nitrates, calcium channel blockers, and beta blockers. Nitrates are described as being effective for treating acute angina by dilating blood vessels and reducing workload. Calcium channel blockers and beta blockers are also outlined as treatments that reduce oxygen demand. Combination therapies are noted to provide additive effects.
The document discusses different types of angina pectoris and treatments for angina. It defines typical angina, variant angina, and unstable angina. It then explains drugs that can be used to treat angina by decreasing oxygen demand and/or increasing oxygen supply, including nitrates, calcium channel blockers, and beta blockers. Nitrates are described as being effective for treating acute angina by dilating blood vessels and reducing workload. Calcium channel blockers and beta blockers are also outlined as treatments that reduce oxygen demand. Combination therapies are noted to provide additive effects.
This document discusses antianginal agents used to treat angina pectoris including nitrates, beta blockers, and calcium channel blockers. Nitrates work by causing vasodilation of blood vessels including coronary arteries to increase blood flow and oxygen to the heart. Beta blockers decrease heart rate and contractility to lower oxygen demand. Calcium channel blockers cause peripheral vasodilation and reduce contractility to decrease oxygen demand. The document provides details on common medications in each class and nursing considerations for administration and patient education.
Angina pectoris is caused by transient episodes of myocardial ischemia due to an imbalance in the myocardial oxygen supply-demand relationship. There are three main types of angina: stable angina, which is triggered by exertion and relieved by rest; unstable angina, which occurs at rest and is a medical emergency; and Prinzmetal angina, which occurs due to coronary artery spasm. Treatment strategies for angina include nitrates like nitroglycerin which relieve symptoms rapidly, calcium channel blockers which prevent calcium entry and relax blood vessels, beta blockers which reduce the heart's oxygen demand, and ranolazine which inhibits sodium channels to reduce the heart's work.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
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Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Debunking Nutrition Myths: Separating Fact from Fiction"AlexandraDiaz101
In a world overflowing with diet trends and conflicting nutrition advice, it’s easy to get lost in misinformation. This article cuts through the noise to debunk common nutrition myths that may be sabotaging your health goals. From the truth about carbohydrates and fats to the real effects of sugar and artificial sweeteners, we break down what science actually says. Equip yourself with knowledge to make informed decisions about your diet, and learn how to navigate the complexities of modern nutrition with confidence. Say goodbye to food confusion and hello to a healthier you!
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
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Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
2. Antianginal drugs
The three main types of angina are:
• stable angina (angina of effort), where atherosclerosis restricts blood flow in
the coronary vessels; attacks are usually caused by exertion and relieved by
rest
• unstable angina (acute coronary insufficiency), which is considered to be an
intermediate stage between stable angina and myocardial infarction
• Prinzmetal angina (variant angina), caused by coronary vasospasm, in which
attacks occur at rest.
Management depends on the type of angina and may include drug treatment, coronary
artery bypass surgery, or percutaneous transluminal coronary angioplasty.
Stable angina
Drugs are used both for the relief of acute pain and for prophylaxis to reduce further
attacks; they include organic nitrates, beta-adrenoceptor antagonists (beta-blockers),
and calcium-channel blockers.
NITRATES
Organic nitrates have a vasodilating effect; they are sometimes used alone,
especially in elderly patients with infrequent symptoms. Tolerance leading to reduced
antianginal effect is often seen in patients taking prolonged-action nitrate
formulations. Evidence suggests that patients should have a ‘nitrate-free’ interval to
prevent the development of tolerance. Adverse effects such as flushing, headache, and
postural hypotension may limit nitrate therapy but tolerance to these effects also soon
develops. The short-acting sublingual formulation of glyceryl trinitrate is used both
for prevention of angina before exercise or other stress and for rapid treatment of
chest pain. A sublingual tablet of isosorbide dinitrate is more stable in storage than
glyceryl trinitrate and is useful in patients who require nitrates infrequently; it has a
slower onset of action, but effects persist for several hours.
BETA-BLOCKERS
Beta-adrenoceptor antagonists (beta-blockers), such as atenolol , block beta-
adrenergic receptors in the heart, and thereby decrease heart rate and myocardial
contractility and oxygen consumption, particularly during exercise. Beta-blockers are
first-line therapy for patients with effort-induced chronic stable angina; they improve
exercise tolerance, relieve symptoms, reduce the severity and frequency of angina
attacks, and increase the anginal threshold.
Beta-blockers should be withdrawn gradually to avoid precipitating an anginal attack;
they should not be used in patients with underlying coronary vasospasm (Prinzmetal
angina).
3. Beta-blockers may precipitate asthma and should not be used in patients with asthma
or a history of obstructive airways disease. Some, including atenolol, have less effect
on beta2 (bronchial) receptors and are therefore relatively cardioselective. Although
they have less effect on airways resistance they are not free of this effect and should
be avoided.
Beta-blockers slow the heart and may induce myocardial depression, rarely
precipitating heart failure. They should not be given to patients who have incipient
ventricular failure, second- or third-degree atrioventricular block, or peripheral
vascular disease.
Beta-blockers should be used with caution in diabetes since they may mask the
symptoms of hypoglycaemia, such as rapid heart rate. Beta-blockers enhance the
hypoglycaemic effect of insulin and may precipitate hypoglycaemia.
CALCIUM-CHANNEL BLOCKERS
A calcium-channel blocker, such as verapamil, is used as an alternative to a beta-
blocker to treat stable angina. Calcium-channel blockers interfere with the inward
movement of calcium ions through the slow channels in heart and vascular smooth
muscle cell membranes, leading to relaxation of vascular smooth muscle. Myocardial
contractility may be reduced, the formation and propagation of electrical impulses
within the heart may be depressed and coronary or systemic vascular tone may be
diminished. Calcium-channel blockers are used to improve exercise tolerance in
patients with chronic stable angina due to coronary atherosclerosis or with abnormally
small coronary arteries and limited vasodilator reserve.
Calcium-channel blockers can also be used in patients with unstable angina with a
vasospastic origin, such as Prinzmetal angina, and in patients in whom alterations in
cardiac tone may influence the angina threshold.
Unstable angina
Unstable angina requires prompt aggressive treatment to prevent progression to
myocardial infarction.
Initial treatment is with acetylsalicylic acid to inhibit platelet aggregation, followed by
heparin. Nitrates and beta-blockers are given to relieve ischaemia; if beta-blockers are
contraindicated, verapamil is an alternative, provided left ventricular function is
adequate.
Prinzmetal angina
Treatment is similar to that for unstable angina, except that a calcium-channel
blocker is used instead of a beta-blocker.
Atenolol
Atenolol is a representative beta-adrenoceptor antagonist. Various drugs can serve as
alternatives
4. Tablets , atenolol 50 mg, 100 mg
Injection (Solution for injection), atenolol 500 micrograms/ml, 10-ml ampoule [not
included on WHO Model List]
Uses:
angina and myocardial infarction; arrhythmias (section 12.2); hypertension (section
12.3); migraine prophylaxis (section 7.2)
Contraindications:
asthma or history of obstructive airways disease (unless no alternative, then with
extreme caution and under specialist supervision); uncontrolled heart failure,
Prinzmetal angina, marked bradycardia, hypotension, sick sinus syndrome, second-
and third-degree atrioventricular block, cardiogenic shock; metabolic acidosis; severe
peripheral arterial disease; phaeochromocytoma (unless used with alpha-blocker)
Precautions:
avoid abrupt withdrawal in angina; may precipitate or worsen heart failure; pregnancy
(Appendix 2); breastfeeding (Appendix 3); first-degree atrioventricular block; liver
function deteriorates in portal hypertension; reduce dose in renal impairment
(Appendix 4); diabetes mellitus (small decrease in glucose tolerance, masking of
symptoms of hypoglycaemia); history of hypersensitivity (increased reaction to
allergens, also reduced response to epinephrine (adrenaline)); myasthenia gravis;
interactions: Appendix 1
Dosage:
Angina, by mouth, ADULT 50 mg once daily, increased if necessary to 50 mg twice
daily or 100 mg once daily
Myocardial infarction (early intervention within 12 hours), by intravenous injection
over 5 minutes, ADULT 5 mg, then by mouth 50 mg after 15 minutes, followed by
50 mg after 12 hours, then 100 mg daily
Adverse effects:
gastrointestinal disturbances (nausea, vomiting, diarrhoea, constipation, abdominal
cramp); fatigue; cold hands and feet; exacerbation of intermittent claudication and
Raynaud phenomenon; bronchospasm; bradycardia, heart failure, conduction
disorders, hypotension; sleep disturbances, including nightmares; depression,
confusion; hypoglycaemia or hyperglycaemia; exacerbation of psoriasis; rare reports
of rashes and dry eyes (oculomucocutaneous syndrome—reversible on withdrawal)
Glyceryl trinitrate
Sublingual tablets , glyceryl trinitrate 500 micrograms
5. Note. Glyceryl trinitrate tablets are unstable. They should therefore be dispensed in glass or stainless
steel containers, and closed with a foil-lined cap which contains no wadding. No more than 100
tablets should be dispensed at one time, and any unused tablets should be discarded 8 weeks after
opening the container
Uses:
prophylaxis and treatment of angina
Contraindications:
hypersensitivity to nitrates; hypotension; hypovolaemia; hypertrophic obstructive
cardiomyopathy, aortic stenosis, cardiac tamponade, constrictive pericarditis, mitral
stenosis; marked anaemia; head trauma; cerebral haemorrhage; angle-closure
glaucoma
Precautions:
severe hepatic or renal impairment; hypothyroidism; malnutrition; hypothermia;
recent history of myocardial infarction; interactions: Appendix 1
Dosage:
Angina, sublingually, ADULT 0.5–1 mg, repeated as required
Adverse effects:
throbbing headache; flushing; dizziness, postural hypotension; tachycardia
(paradoxical bradycardia also reported)
Isosorbide dinitrate
Isosorbide dinitrate is a representative nitrate vasodilator. Various drugs can serve as
alternatives
Sublingual tablets , isosorbide dinitrate 5 mg
Sustained-release (prolonged-release) tablets or capsules , isosorbide dinitrate 20 mg,
40 mg [not included on WHO Model List]
Uses:
prophylaxis and treatment of angina; heart failure (section 12.4)
Contraindications:
hypersensitivity to nitrates; hypotension; hypovolaemia; hypertrophic obstructive
cardiomyopathy, aortic stenosis, cardiac tamponade, constrictive pericarditis, mitral
stenosis; marked anaemia; head trauma; cerebral haemorrhage; angle-closure
glaucoma
6. Precautions:
severe hepatic or renal impairment; hypothyroidism; malnutrition; hypothermia;
recent history of myocardial infarction; interactions: Appendix 1
Tolerance. Patients taking isosorbide dinitrate for the long-term management of angina may often
develop tolerance to the antianginal effect; this can be avoided by giving the second of 2
daily doses of longer-acting oral presentations after an 8-hour rather than a 12-hour interval,
thus ensuring a nitrate-free interval each day
Dosage:
Angina (acute attack), sublingually, ADULT 5–10 mg, repeated as required
Angina prophylaxis, by mouth, ADULT 30–120 mg daily in divided doses (see
advice on Tolerance above)
Adverse effects:
throbbing headache; flushing; dizziness, postural hypotension; tachycardia
(paradoxical bradycardia also reported)
Verapamil hydrochloride
Tablets, verapamil hydrochloride 40 mg, 80 mg
Note. Sustained-release (prolonged-release) tablets are available. A proposal to include such a product
in a national list of essential drugs should be supported by adequate documentation
Uses:
angina, including stable, unstable, and Prinzmetal; arrhythmias (section 12.2)
Contraindications:
hypotension, bradycardia, second- and third-degree atrioventricular block, sinoatrial
block, sick sinus syndrome; cardiogenic shock; history of heart failure or significantly
impaired left ventricular function (even if controlled by therapy); atrial flutter or
fibrillation complicating Wolff-Parkinson-White syndrome; porphyria
Precautions:
first-degree atrioventricular block; acute phase of myocardial infarction (avoid if
bradycardia, hypotension, left ventricular failure); hepatic impairment (Appendix 5);
children (specialist advice only); pregnancy (Appendix 2); breastfeeding (Appendix
3); avoid grapefruit juice; interactions: Appendix 1
Dosage:
7. Angina, by mouth, ADULT 80–120 mg 3 times daily (120 mg 3 times daily usually
required in Prinzmetal angina)
Adverse effects:
constipation; less commonly nausea, vomiting, flushing, headache, dizziness, fatigue,
ankle oedema; rarely allergic reactions (erythema, pruritus, urticaria, angioedema,
Stevens-Johnson syndrome); myalgia, arthralgia, paraesthesia, erythromelalgia;
increased prolactin concentration; gynaecomastia and gingival hyperplasia on long-
term treatment; with high doses, hypotension, heart failure, bradycardia, heart block,
and asystole (due to negative inotropic effect)
Antiarrhythmic drugs
Treatment of arrhythmias requires precise diagnosis of the type of arrhythmia, and
electrocardiography is essential; underlying causes such as heart failure require
appropriate treatment.
Antiarrhythmic drugs must be used cautiously since most drugs that are effective in
treating arrhythmias can provoke them in some circumstances; this arrhythmogenic
effect is often enhanced by hypokalaemia. When antiarrhythmic drugs are used in
combination, their cumulative negative inotropic effects may be significant,
particularly if myocardial function is impaired.
Atrial fibrillation
The increased ventricular rate in atrial fibrillation can be controlled with a beta-
adrenoceptor antagonist (beta-blocker) or verapamil . Digoxin is often effective
for controlling the rate at rest; it is also appropriate if atrial fibrillation is accompanied
by congestive heart failure. Intravenous digoxin is occasionally required if the
ventricular rate needs rapid control. If adequate control at rest or during exercise
cannot be achieved readily verapamil may be introduced with digoxin, but it should
be used with caution if ventricular function is impaired. Anticoagulants are indicated
especially in valvular or myocardial disease, and in the elderly. Warfarin is preferred
to acetylsalicylic acid in preventing emboli. If atrial fibrillation began within the
previous 48 hours and there does not appear to be a danger of thromboembolism,
antiarrhythmic drugs, such as procainamide or quinidine , may be used to terminate
the fibrillation or to maintain sinus rhythm after cardioversion.
Atrial flutter
Digoxin will sometimes slow the ventricular rate at rest. Reversion to sinus rhythm is
best achieved by direct current electrical shock. If the arrhythmia is long-standing,
treatment with an anticoagulant should be considered before cardioversion to prevent
emboli. Intravenous verapamil reduces ventricular fibrillation during paroxysmal
(sudden onset and intermittent) attacks of atrial flutter. An initial intravenous dose
may be followed by oral treatment; hypotension may occur with high doses. It should
not be used for tachyarrhythmias where the QRS complex is wide unless a
8. supraventricular origin has been established beyond doubt. If the flutter cannot be
restored to sinus rhythm, antiarrhythmics such as quinidine can be used.
Paroxysmal supraventricular tachycardia
In most patients this remits spontaneously or can revert to sinus rhythm by reflex
vagal stimulation. Failing this, intravenous injection of a beta-adrenoceptor antagonist
(beta-blocker) or verapamil may be effective. Verapamil and a beta-blocker should
never be administered concomitantly because of the risk of hypotension and asystole.
Ventricular tachycardia
Very rapid ventricular fibrillation causes profound circulatory collapse and must be
treated immediately with direct current shock. In more stable patients intravenous
lidocaine or procainamide may be used. After sinus rhythm is restored, drug therapy
to prevent recurrence of ventricular tachycardia should be considered; a beta-
adrenoceptor antagonist (beta-blocker) or verapamil may be effective.
Torsades de pointes is a special form of ventricular tachycardia associated with
prolongation of the QT interval. Initial treatment with intravenous infusion of
magnesium sulfate (usual dose 2 g over 10–15 minutes, repeated once if necessary)
together with temporary pacing is usually effective; alternatively, isoprenaline
infusion may be given with extreme caution until pacing can be instituted.
Isoprenaline is an inotropic sympathomimetic; it increases the heart rate and
therefore shortens the QT interval, but given alone it may induce arrhythmias.
Bradyarrhythmias
Sinus bradycardia (less than 50 beats/minute) associated with acute myocardial
infarction may be treated with atropine. Temporary pacing may be required in
unresponsive patients. Drugs are of limited value for increasing the sinus rate long
term in the presence of intrinsic sinus node disease and permanent pacing is usually
required.
Cardiac arrest
In cardiac arrest, epinephrine (adrenaline) is given by intravenous injection in a dose
of 1 mg (10 ml of 1 in 10 000 solution) as part of the procedure for cardiopulmonary
resuscitation.
Atenolol
Atenolol is a representative beta-adrenoceptor antagonist. Various drugs can serve as
alternatives
Tablets , atenolol 50 mg, 100 mg
Uses:
9. arrhythmias; angina (section 12.1); hypertension (section 12.3); migraine prophylaxis
(section 7.2)
Contraindications:
asthma or history of obstructive airways disease (unless no alternative, then with
extreme caution and under specialist supervision); uncontrolled heart failure,
Prinzmetal angina, marked bradycardia, hypotension, sick sinus syndrome, second-
and third-degree atrioventricular block, cardiogenic shock; metabolic acidosis; severe
peripheral arterial disease; phaeochromocytoma (unless used with alpha-blocker)
Precautions:
avoid abrupt withdrawal especially in angina; may precipitate or worsen heart failure;
pregnancy (Appendix 2); breastfeeding (Appendix 3); first-degree atrioventricular
block; liver function deteriorates in portal hypertension; reduce dose in renal
impairment (Appendix 4); diabetes mellitus (small decrease in glucose tolerance,
masking of symptoms of hypoglycaemia); history of hypersensitivity (increased
reaction to allergens, also reduced response to epinephrine (adrenaline)); myasthenia
gravis; interactions: Appendix 1
Dosage:
Arrhythmias, by mouth, ADULT 50 mg once daily, increased if necessary to 50 mg
twice daily or 100 mg once daily
Adverse effects:
gastrointestinal disturbances (nausea, vomiting, diarrhoea, constipation, abdominal
cramp); fatigue; cold hands and feet; exacerbation of intermittent claudication and
Raynaud phenomenon; bronchospasm; bradycardia, heart failure, conduction
disorders, hypotension; sleep disturbances, including nightmares; depression,
confusion; hypoglycaemia or hyperglycaemia; exacerbation of psoriasis; rare reports
of rashes and dry eyes (oculomucocutaneous syndrome—reversible on withdrawal)
Digoxin
Tablets , digoxin 62.5 micrograms, 250 micrograms
Oral solution , digoxin 50 micrograms/ml
Injection (Solution for injection), digoxin 250 micrograms/ml, 2-ml ampoule
Uses:
supraventricular arrhythmias, particularly atrial fibrillation; heart failure (section
12.4)
Contraindications:
10. hypertrophic obstructive cardiomyopathy (unless also atrial fibrillation and heart
failure); Wolff-Parkinson-White syndrome or other accessory pathway, particularly if
accompanied by atrial fibrillation; intermittent complete heart block; second-degree
atrioventricular block
Precautions:
recent myocardial infarction; sick sinus syndrome; severe pulmonary disease; thyroid
disease; elderly (reduce dose); renal impairment (Appendix 4); avoid hypokalaemia;
avoid rapid intravenous administration (nausea and risk of arrhythmias); pregnancy
(Appendix 2); breastfeeding (Appendix 3); interactions: Appendix 1
Dosage:
Atrial fibrillation, by mouth , ADULT 1–1.5 mg in divided doses over 24 hours for
rapid digitalization or 250 micrograms 1–2 times daily if digitalization less urgent;
maintenance 62.5–500 micrograms daily (higher dose may be divided), according to
renal function and heart rate response; usual range 125–250 micrograms daily (lower
dose more appropriate in elderly)
Emergency control of atrial fibrillation, by intravenous infusion over at least 2 hours,
ADULT 0.75–1 mg
Note. Infusion dose may need to be reduced if digoxin or other cardiac glycoside given in previous 2
weeks
Adverse effects:
usually associated with excessive dosage and include anorexia, nausea, vomiting,
diarrhoea, abdominal pain; visual disturbances, headache, fatigue, drowsiness,
confusion, delirium, hallucinations, depression; arrhythmias, heart block; rarely rash,
intestinal ischaemia; gynaecomastia on long-term use; thrombocytopenia reported
Epinephrine (adrenaline)
Injection (Solution for injection), epinephrine hydrochloride 100 micrograms/ml (1 in
10 000), 10-ml ampoule
Uses:
cardiac arrest; anaphylaxis (section 3.1)
Precautions:
heart disease, hypertension, arrhythmias, cerebrovascular disease; hyperthyroidism,
diabetes mellitus; angle-closure glaucoma; second stage of labour; interactions:
Appendix 1
Dosage:
11. Caution: different dilutions of epinephrine injection are used for different routes of
administration
Cardiac arrest, by intravenous injection through a central line using epinephrine
injection 1 in 10 000 (100 micrograms/ml), ADULT 1 mg (10 ml), repeated at 3-
minute intervals if necessary
Note. If central line not in place, same dose is given via peripheral vein, then flushed through with at
least 20 ml sodium chloride 0.9% injection (to expedite entry into circulation)
Adverse effects:
anxiety, tremor, tachycardia, headache, cold extremities; nausea, vomiting, sweating,
weakness, dizziness, hyperglycaemia also reported; in overdosage arrhythmias,
cerebral haemorrhage, pulmonary oedema
Isoprenaline
Isoprenaline is a complementary antiarrhythmic for use in rare disorders or in
exceptional circumstances
Injection (Solution for injection), isoprenaline hydrochloride 20 micrograms/ml, 10-
ml ampoule
Uses:
severe bradycardia, unresponsive to atropine; short-term emergency treatment of heart
block; ventricular arrhythmias secondary to atrioventricular nodal block
Precautions:
ischaemic heart disease, diabetes mellitus or hyperthyroidism; interactions:
Appendix 1
Dosage:
Cardiac disorders, by slow intravenous injection, ADULT 20–60 micrograms (1–3
ml of solution containing 20 micrograms/ml); subsequent doses adjusted according to
ventricular rate
Bradycardia, by intravenous infusion, ADULT 1–4 micrograms/minute
Heart block (acute Stokes-Adams attack), by intravenous infusion, ADULT 4–8
micrograms/minute
Dilution and administration. According to manufacturer’s directions
Adverse effects:
12. arrhythmias, hypotension, sweating, tremor, headache, palpitations, tachycardia,
nervousness, excitability, insomnia
Lidocaine hydrochloride
Injection (Solution for injection), lidocaine hydrochloride 20 mg/ml, 5-ml ampoule
Uses:
ventricular arrhythmias (especially after myocardial infarction); local anaesthesia
(section 1.2)
Contraindications:
sino-atrial disorder, any grade of atrioventricular block or any other type of
conduction disturbances, severe myocardial depression, acute porphyria or
hypovolaemia
Precautions:
lower dosage in congestive heart failure, bradycardia, hepatic impairment (Appendix
5), marked hypoxia, severe respiratory depression, following cardiac surgery and in
elderly; pregnancy (Appendix 2), breastfeeding (Appendix 3); interactions:
Appendix 1
Dosage:
Ventricular arrhythmias, by intravenous injection, ADULT , loading dose of 50–100
mg (or 1–1.5 mg/kg) at a rate of 25–50 mg/minute, followed immediately by
intravenous infusion of 1–4 mg/minute, with ECG monitoring of all patients (reduce
infusion dose if required for longer than 24 hours)
IMPORTANT. Following intravenous injection lidocaine has a short duration of action (of 15–20
minutes). If it cannot be given by intravenous infusion immediately, the initial
intravenous injection of 50–100 mg can be repeated if necessary once or twice at
intervals of not less than 10 minutes
Adverse effects:
dizziness, paraesthesia, drowsiness, confusion, apnoea, respiratory depression, coma,
seizures, and convulsions, hypotension, arrhythmias, heart block, cardiovascular
collapse and bradycardia (may lead to cardiac arrest); nystagmus often an early sign
of lidocaine overdosage
Procainamide hydrochloride
Procainamide hydrochloride is a representative antiarrhythmic drug. Various drugs
can serve as alternatives
13. Procainamide hydrochloride is also a complementary drug for use when drugs in the
core list are known to be ineffective or inappropriate for a given patient
Tablets , procainamide hydrochloride 250 mg, 500 mg [not included on WHO Model
List]
Injection (Solution for injection), procainamide hydrochloride 100 mg/ml, 10-ml
ampoule
Uses:
severe ventricular arrhythmias, especially those resistant to lidocaine or those
appearing after myocardial infarction; atrial tachycardia, atrial fibrillation;
maintenance of sinus rhythm after cardioversion of atrial fibrillation
Contraindications:
asymptomatic ventricular premature contractions, torsades de pointes, systemic lupus
erythematosus, heart block, heart failure, hypotension
Precautions:
elderly, renal and hepatic impairment (Appendices 4 and 5), asthma, myasthenia
gravis, pregnancy; breastfeeding (Appendix 3); use only under specialist supervision;
interactions: Appendix 1
Dosage:
Ventricular arrhythmias, by mouth , adult up to 50 mg/kg daily in divided doses
every 3–6 hours, preferably controlled by monitoring plasma-procainamide
concentration (therapeutic concentration usually within range 3–10 micrograms/ml)
Atrial arrhythmias, higher doses may be required
Ventricular arrhythmias, by slow intravenous injection, ADULT 100 mg at rate not
exceeding 50 mg/minute, with ECG monitoring; may be repeated at 5-minute
intervals until arrhythmia controlled; maximum 1 g
Ventricular arrhythmias, by intravenous infusion, ADULT 500–600 mg over 25–30
minutes with ECG monitoring, reduced to maintenance dose of 2–6 mg/minute; if
further treatment by mouth required, allow interval of 3–4 hours after infusion
Adverse effects:
nausea, vomiting, diarrhoea, anorexia, rashes, pruritus, urticaria, flushing, fever,
myocardial depression, heart failure, angioedema, depression, dizziness, psychosis;
blood disorders include leukopenia, haemolytic anaemia and agranulocytosis after
prolonged treatment; lupus erythematosus-like syndrome; high plasma procainamide
concentration may impair cardiac conduction
14. Quinidine sulfate
Quinidine is a representative antiarrhythmic drug. Various drugs can serve as
alternatives
Quinidine sulfate is also a complementary antiarrhythmic drug for use when drugs in
the core list cannot be made available
Tablets, quinidine sulfate 200 mg
Note. Quinidine sulfate 200 mg = quinidine bisulfate 250 mg
Uses:
suppression of supraventricular arrhythmias and ventricular arrhythmias; maintenance
of sinus rhythm after cardioversion of atrial fibrillation
Contraindications:
complete heart block
Precautions:
partial heart block; extreme care in uncompensated heart failure, myocarditis, severe
myocardial damage; myasthenia gravis; acute infections or fever (symptoms may
mask hypersensitivity reaction to quinidine); breastfeeding (Appendix 3);
interactions: Appendix 1
Dosage:
Initial test dose of 200 mg to detect hypersensitivity to quinidine
Arrhythmias, by mouth, ADULT 200–400 mg 3–4 times daily; increased if necessary
in supraventricular tachycardia to 600 mg every 2–4 hours (maximum 3–4 g daily);
frequent ECG monitoring required
Adverse effects:
hypersensitivity reactions, nausea, vomiting, diarrhoea, rashes, anaphylaxis, purpura,
pruritus, urticaria, fever, thrombocytopenia, agranulocytosis after prolonged
treatment, psychosis, angioedema, hepatotoxicity, respiratory difficulties; cardiac
effects include myocardial depression, heart failure, ventricular arrhythmias and
hypotension; cinchonism including tinnitus, impaired hearing, vertigo, headache,
visual disturbances, abdominal pain, and confusion; lupus erythematosus-like
syndrome
Verapamil hydrochloride
Tablets, verapamil hydrochloride 40 mg, 80 mg
15. Note. Sustained-release (prolonged-release) tablets are available. A proposal to include such a product
in a national list of essential drugs should be supported by adequate documentation
Injection (Solution for injection), verapamil hydrochloride 2.5 mg/ml, 2-ml ampoule
Uses:
supraventricular arrhythmias; angina (section 12.1)
Contraindications:
hypotension, bradycardia, second- and third-degree atrioventricular block, sinoatrial
block, sick sinus syndrome; cardiogenic shock; history of heart failure or significantly
impaired left ventricular function (even if controlled by therapy); atrial flutter or
fibrillation complicating Wolff-Parkinson-White syndrome; porphyria
Precautions:
first-degree atrioventricular block; acute phase of myocardial infarction (avoid if
bradycardia, hypotension, left ventricular failure); hepatic impairment (Appendix 5);
children (specialist advice only); pregnancy (Appendix 2); breastfeeding (Appendix
3); avoid grapefruit juice (may affect metabolism); interactions: Appendix 1
Verapamil and Both verapamil and beta-blockers have cardiodepressant activity, and their use together
beta-blockers. may lead to bradycardia, heart block and left ventricular failure, particularly in patients
with myocardial insufficiency. Treatment with beta-blockers should be discontinued at
least 24 hours before intravenous administration of verapamil
Dosage:
Supraventricular arrhythmias, by mouth, ADULT 40–120 mg 3 times daily
Supraventricular arrhythmias, by intravenous injection, ADULT 5–10 mg over 2
minutes (preferably with ECG monitoring); ELDERLY 5–10 mg over 3 minutes; in
paroxysmal tachyarrhythmias, further 5 mg may be given after 5–10 minutes if
required
Adverse effects:
constipation; less commonly nausea, vomiting, flushing, headache, dizziness, fatigue,
ankle oedema; rarely allergic reactions (erythema, pruritus, urticaria, angioedema,
Stevens-Johnson syndrome); myalgia, arthralgia, paraesthesia, erythromelalgia;
increased prolactin concentration; gynaecomastia and gingival hyperplasia on long-
term treatment; with high doses, hypotension, heart failure, bradycardia, heart block,
and asystole (due to negative inotropic effect)
Antihypertensive drugs
Management of hypertension
16. Treatment of hypertension should be integrated into an overall programme to
manage factors that increase the risk of cardiovascular events (such as stroke and
myocardial infarction). Treatment is oftten life-long. Hypertension was formerly
classified as mild, moderate or severe, but a grading system is now preferred. Grade 1
hypertension is defined as 140–159 mmHg systolic blood pressure and 90–99 mmHg
diastolic blood pressure, Grade 2 hypertension 160–179 mmHg systolic and 100–109
mmHg diastolic and Grade 3 hypertension more than 180 mmHg systolic and more
than 110 mmHg diastolic. The goal of treatment is to obtain the maximum tolerated
reduction in blood pressure.
Lifestyle changes should be introduced for all patients; they include weight reduction,
reduction in alcohol intake, reduction of dietary sodium, stopping tobacco smoking,
and reduction in saturated fat intake. The patient should eat a healthy nutritious diet
including adequate fruit and vegetables and should exercise regularly. These measures
alone may be sufficient in mild hypertension, but patients with moderate to severe
hypertension will also require specific antihypertensive therapy.
Drug treatment of hypertension
Three classes of drug are used for first-line treatment of hypertension: thiazide
diuretics, beta-adrenoceptor antagonists (beta-blockers), and angiotensin-converting
enzyme (ACE) inhibitors. Calcium-channel blockers are considered first-line in
specific populations only e.g. Africans or the elderly. Other classes of drugs may be
used in certain situations.
Thiazide diuretics, such as hydrochlorothiazide (see also section 16.1), have been
used as first-line antihypertensive therapy, and are particularly indicated in the
elderly. They have few adverse effects in low doses, but in large doses they may cause
a variety of unwanted metabolic effects (principally potassium depletion), reduced
glucose tolerance, ventricular ectopic beats and impotence; they should be avoided in
gout. These effects can be reduced by keeping the dose as low as possible; higher
doses do not produce an increased reduction in blood pressure. Thiazides are
inexpensive and, when used in combination, can enhance the effectiveness of many
other classes of antihypertensive drug.
Beta-adrenoceptor antagonists (beta-blockers) such as atenolol are effective in all
grades of hypertension, and are particularly useful in angina and following myocardial
infarction; they should be avoided in asthma, chronic obstructive pulmonary disease,
and heart block.
Angiotensin-converting enzyme inhibitors (ACE inhibitors) such as enalapril are
effective and well tolerated by most patients. They can be used in heart failure, left
ventricular dysfunction and diabetic nephropathy, but should be avoided in
renovascular disease and in pregnancy. The most common adverse affect is a dry
persistent cough.
Dihydropyridine calcium-channel blockers such as nifedipine are useful for isolated
systolic hypertension, in populations unresponsive to other antihypertensives (e.g.
Africans) and in the elderly when thiazides cannot be used. Short-acting formulations
17. of nifedipine should be avoided as they may evoke reflex tachycardia and cause large
variations in blood pressure.
Drugs acting on the central nervous system are also effective antihypertensive drugs.
In particular, methyldopa is effective in the treatment of hypertension in pregnancy.
A single antihypertensive drug is often not adequate and other antihypertensive drugs
are usually added in a stepwise manner until blood pressure is controlled.
Hypertensive emergencies
In situations where immediate reduction of blood pressure is essential and treatment
by mouth is not possible, intravenous infusion of sodium nitroprusside is effective.
Over-rapid reduction in blood pressure is hazardous and can lead to reduced organ
perfusion and cerebral infarction.
Hypertension in pregnancy
This is defined as a sustained diastolic blood pressure of 90 mmHg or more. Drug
therapy for chronic hypertension during pregnancy remains controversial. If diastolic
blood pressure is greater than 95 mmHg, methyldopa is the safest drug. Beta-
blockers should be used with caution in early pregnancy, since they may retard fetal
growth; they are effective and safe in the third trimester. ACE inhibitors are
contraindicated in pregnancy since they may damage fetal and neonatal blood
pressure control and renal function. Women who are taking these drugs and become
pregnant should have their antihypertensive therapy changed immediately.
Pre-eclampsia and eclampsia . If pre-eclampsia or severe hypertension occurs
beyond the 36th week of pregnancy, delivery is the treatment of choice. For acute
severe hypertension in pre-eclampsia or eclampsia, intravenous hydralazine can be
used. Magnesium sulfate (section 22.1) is the treatment of choice to prevent
eclamptic convulsions in eclampsia and severe pre-eclampsia.
Atenolol
Atenolol is a representative beta-adrenoceptor antagonist. Various drugs can serve as
alternatives
Tablets, atenolol 50 mg, 100 mg
Uses:
hypertension; angina (section 12.1); arrhythmias (section 12.2); migraine prophylaxis
(section 7.2)
Contraindications:
asthma or history of obstructive airways disease (unless no alternative, then with
extreme caution and under specialist supervision); uncontrolled heart failure,
Prinzmetal angina, marked bradycardia, hypotension, sick sinus syndrome, second- or
18. third-degree atrioventricular block, cardiogenic shock; metabolic acidosis; severe
peripheral arterial disease; phaeochromocytoma (unless used with alpha-blocker)
Precautions:
avoid abrupt withdrawal especially in angina; may precipitate or worsen heart failure;
pregnancy (Appendix 2); breastfeeding (Appendix 3); first-degree atrioventricular
block; liver function deteriorates in portal hypertension; reduce dose in renal
impairment (Appendix 4); diabetes mellitus (small decrease in glucose tolerance,
masking of symptoms of hypoglycaemia); history of hypersensitivity (increased
reaction to allergens, also reduced response to epinephrine (adrenaline)); myasthenia
gravis; interactions: Appendix 1
Dosage:
Hypertension, by mouth, ADULT 50 mg once daily (higher doses rarely necessary)
Adverse effects:
gastrointestinal disturbances (nausea, vomiting, diarrhoea, constipation, abdominal
cramp); fatigue; cold hands and feet; exacerbation of intermittent claudication and
Raynaud phenomenon; bronchospasm; bradycardia, heart failure, conduction
disorders, hypotension; sleep disturbances, including nightmares; depression,
confusion; hypoglycaemia or hyperglycaemia; exacerbation of psoriasis; rare reports
of rashes and dry eyes (oculomucocutaneous syndrome—reversible on withdrawal)
Enalapril
Enalapril is a representative angiotensin-converting enzyme inhibitor. Various drugs
can serve as alternatives
Tablets, enalapril 2.5 mg
Uses:
hypertension; heart failure (section 12.4)
Contraindications:
hypersensitivity to ACE inhibitors (including angioedema); renovascular disease;
pregnancy (Appendix 2)
Precautions:
use with diuretics; hypotension with first doses, especially in patients on diuretics, on
a low-sodium diet, on dialysis, if dehydrated, or with heart failure; peripheral vascular
disease or generalized atherosclerosis (risk of clinically silent renovascular disease);
use with great care in severe or symptomatic aortic stenosis; monitor renal function
before and during treatment; renal impairment (reduce dose, see also Appendix 4);
liver impairment (Appendix 5); possibly increased risk of agranulocytosis in collagen
19. vascular disease; history of idiopathic or hereditary angioedema (use with care or
avoid); breastfeeding (Appendix 3); interactions: Appendix 1
Use with Risk of very rapid falls in blood pressure in volume-depleted patients; treatment should
diuretics. therefore be initiated with very low doses. High-dose diuretic therapy (furosemide dose
greater than 80 mg) should be discontinued, or dose significantly reduced, at least 24 hours
before starting enalapril (may not be possible in heart failure—risk of pulmonary oedema).
If high-dose diuretic cannot be stopped, medical supervision advised for at least 2 hours
after administration or until blood pressure stable
Anaphylactoid Avoid enalapril during dialysis with high-flux polyacrilonitrile membranes and
reactions. during low-density lipoprotein apheresis with dextran sulfate; also withhold before
desensitization with wasp or bee venom
Dosage:
Hypertension by mouth , initially 5 mg once daily; if used in addition to diuretic, in
elderly patients, or in renal impairment, initially 2.5 mg daily; usual maintenance dose
10–20 mg once daily; in severe hypertension may be increased to maximum 40 mg
once daily
Adverse effects:
dizziness, headache; less commonly, nausea, diarrhoea, hypotension (severe in rare
cases), dry cough, fatigue, asthenia, muscle cramps, rash and renal impairment; rarely,
vomiting, dyspepsia, abdominal pain, constipation, glossitis, stomatitis, ileus,
anorexia, pancreatitis, liver damage, chest pain, palpitations, arrhythmias,
angioedema, bronchospasm, rhinorrhoea, sore throat, pulmonary infiltrates,
paraesthesia, vertigo, nervousness, depression, confusion, drowsiness or insomnia,
pruritus, urticaria, alopecia, sweating, flushing, impotence, Stevens-Johnson
syndrome, toxic epidermal necrolysis, exfoliative dermatitis, pemphigus, taste
disturbance, tinnitus, blurred vision; electrolyte disturbances and hypersensitivity-like
reactions (including fever, myalgia, arthralgia, eosinophilia, and photosensitivity)
reported
Hydralazine hydrochloride
Tablets, hydralazine hydrochloride 25 mg, 50 mg
Injection, (Powder for solution for injection), hydralazine hydrochloride, 20-mg
ampoule
Uses:
in combination therapy in moderate to severe hypertension, hypertensive crises;
hypertension associated with pregnancy (including pre-eclampsia or eclampsia); heart
failure (section 12.4)
Contraindications:
20. idiopathic systemic lupus erythematosus, severe tachycardia, high output heart failure,
myocardial insufficiency due to mechanical obstruction, cor pulmonale, dissecting
aortic aneurysm, porphyria
Precautions:
hepatic impairment (Appendix 5); renal impairment (reduce dose, Appendix 4);
coronary artery disease (may provoke angina, avoid after myocardial infarction until
stabilized); cerebrovascular disease; check acetylator status before increasing dose
above 100 mg daily; test for antinuclear factor and for proteinuria every 6 months;
pregnancy (Appendix 2); breastfeeding (Appendix 3); occasionally over-rapid blood
pressure reduction even with low parenteral doses; interactions: Appendix 1
Dosage:
Hypertension, by mouth , ADULT 25 mg twice daily, increased if necessary to
maximum 50 mg twice daily
Hypertensive crises (including during pregnancy), by slow intravenous injection,
ADULT 5–10 mg diluted with 10 ml sodium chloride 0.9%; if necessary may be
repeated after 20–30 minutes
Hypertensive crises (including during pregnancy), by intravenous infusion, ADULT
initially 200–300 micrograms/minute; maintenance usually 50–150
micrograms/minute
Reconstitution and administration. According to manufacturer’s directions
Adverse effects:
tachycardia, palpitations, postural hypotension; fluid retention; gastrointestinal
disturbances including anorexia, nausea, vomiting, diarrhoea, rarely constipation;
dizziness, flushing, headache; abnormal liver function, jaundice; systemic lupus
erythematosus-like syndrome, particularly in women and slow acetylators; nasal
congestion, agitation, anxiety, polyneuritis, peripheral neuritis, rash, fever,
paraesthesia, arthralgia, myalgia, increased lacrimation, dyspnoea; raised plasma
creatinine, proteinuria, haematuria; blood disorders including haemolytic anaemia,
leukopenia, thrombocytopenia
Hydrochlorothiazide
Hydrochlorothiazide is a representative thiazide diuretic. Various drugs can serve as
alternatives
Tablets, hydrochlorothiazide 25 mg
Uses:
alone in mild hypertension, and in combination with other drugs in moderate to severe
hypertension; heart failure (section 12.4); oedema (section 16.1)
21. Contraindications:
severe renal or severe hepatic impairment; hyponatraemia, hypercalcaemia, refractory
hypokalaemia, symptomatic hyperuricaemia; Addison disease
Precautions:
renal and hepatic impairment (Appendices 4 and 5); pregnancy and breastfeeding
(Appendices 2 and 3); elderly (reduce dose); may cause hypokalaemia; may aggravate
diabetes mellitus and gout; may exacerbate systemic lupus erythematosus; porphyria;
interactions: Appendix 1
Dosage:
Hypertension, by mouth , ADULT 12.5–25 mg daily; ELDERLY initially 12.5 mg
daily
Adverse effects:
fluid and electrolyte imbalance leading to dry mouth, thirst, gastrointestinal
disturbances (including nausea, vomiting), weakness, lethargy, drowsiness, seizures,
headache, muscle pains or cramps, hypotension (including postural hypotension),
oliguria, arrhythmias; hypokalaemia, hypomagnesaemia, hyponatraemia,
hypochloraemic alkalosis, hypercalcaemia; hyperglycaemia, hyperuricaemia, gout;
rash, photosensitivity; altered plasma lipid concentration; rarely impotence
(reversible); blood disorders (including neutropenia, thrombocytopenia); pancreatitis,
intrahepatic cholestasis; acute renal failure; hypersensitivity reactions (pneumonitis,
pulmonary oedema, severe skin reactions)
Methyldopa
Tablets , methyldopa 250 mg
Uses:
hypertension in pregnancy
Contraindications:
depression; active liver disease; phaeochromocytoma, porphyria
Precautions:
history of hepatic impairment (Appendix 5); renal impairment (Appendix 4); blood
counts and liver-function tests advised; history of depression; positive direct Coomb
test in up to 20% of patients (affects blood cross-matching); interference with
laboratory tests; pregnancy and breastfeeding (Appendices 2 and 3); interactions:
Appendix 1
Skilled tasks. May impair ability to perform skilled tasks, for example operating machinery, driving
22. Dosage:
Hypertension in pregnancy, by mouth, ADULT initially 250 mg 2–3 times daily; if
necessary, gradually increased at intervals of 2 or more days, maximum 3 g daily
Adverse effects:
tend to be transient and reversible, including sedation, dizziness, lightheadedness,
postural hypotension, weakness, fatigue, headache, fluid retention and oedema, sexual
dysfunction; impaired concentration and memory, depression, mild psychosis,
disturbed sleep and nightmares; drug fever, influenza-like syndrome; nausea,
vomiting, constipation, diarrhoea, dry mouth, stomatitis, sialadenitis; liver function
impairment, hepatitis, jaundice, rarely fatal hepatic necrosis; bone-marrow depression,
haemolytic anaemia, leukopenia, thrombocytopenia, eosinophilia; parkinsonism; rash
(including toxic epidermal necrolysis); nasal congestion; black or sore tongue;
bradycardia, exacerbation of angina; myalgia, arthralgia, paraesthesia, Bell palsy;
pancreatitis; hypersensitivity reactions including lupus erythematosus-like syndrome,
myocarditis, pericarditis; gynaecomastia, hyperprolactinaemia, amenorrhoea; urine
darkens on standing
Nifedipine
Nifedipine is a representative dihydropyridine calcium-channel blocker. Various
drugs can serve as alternatives
Sustained-release tablets (Modified-release tablets), nifedipine 10 mg
Note. Sustained-release (prolonged-release) tablets are available for once daily administration. A
proposal to include such a product in a national list of essential drugs should be supported by
adequate documentation
Uses:
hypertension
Contraindications:
cardiogenic shock; advanced aortic stenosis; within 1 month of myocardial infarction;
unstable or acute attacks of angina; porphyria
Precautions:
stop if ischaemic pain occurs or existing pain worsens shortly after starting treatment;
poor cardiac reserve; heart failure or significantly impaired left ventricular function;
reduce dose in hepatic impairment (Appendix 5); diabetes mellitus; may inhibit
labour; pregnancy (Appendix 2); breastfeeding (Appendix 3); avoid grapefruit juice
(may affect metabolism); interactions: Appendix 1
Dosage:
23. Hypertension, by mouth (as sustained-release tablets), ADULT usual range 20–100
mg daily in 1–2 divided doses, according to manufacturer’s directions
Note. Prescribers should be aware that different formulations of sustained-release tablets may not have
the same clinical effect; if possible, the patient should be maintained on the same brand
Short-acting formulations of nifedipine should be avoided in hypertension, particularly in
patients who also have angina, since their use may be associated with large variations in blood
pressure and reflex tachycardia, possibly leading to myocardial or cerebrovascular ischaemia
Adverse effects:
headache, flushing, dizziness, lethargy; tachycardia, palpitations; gravitational
oedema (only partly responsive to diuretics); rash (erythema multiforme reported),
pruritus, urticaria; nausea, constipation or diarrhoea; increased frequency of
micturition; eye pain, visual disturbances; gum hyperplasia; paraesthesia, myalgia,
tremor; impotence, gynaecomastia; depression; telangiectasis; cholestasis, jaundice
Sodium nitroprusside
Sodium nitroprusside is a complementary drug for the treatment of hypertensive
crisis
Infusion (Powder for solution for infusion), sodium nitroprusside, 50-mg ampoule
Uses:
hypertensive crisis (when treatment by mouth not possible)
Contraindications:
severe hepatic impairment; compensatory hypertension; severe vitamin B12
deficiency; Leber optic atrophy
Precautions:
impaired pulmonary function; hypothyroidism; renal impairment (Appendix 4);
ischaemic heart disease, impaired cerebral circulation; hyponatraemia; raised
intracranial pressure; elderly; hypothermia; monitor blood pressure and blood-cyanide
concentration, also blood-thiocyanate concentration if given for more than 3 days;
avoid sudden withdrawal (reduce infusion over 15–30 minutes to avoid rebound
effects); pregnancy; breastfeeding; interactions: Appendix 1
Dosage:
Hypertensive crisis, by intravenous infusion , ADULT initially 0.3
micrograms/kg/minute; usual maintenance dose 0.5–6 micrograms/kg/minute;
maximum dose 8 micrograms/kg/minute; stop infusion if response unsatisfactory after
10 minutes at maximum dose; lower doses in patients already being treated with
antihypertensives
24. Reconstitution and administration. According to manufacturer’s directions
Adverse effects:
severe hypotension; effects associated with over-rapid reduction in blood pressure
include headache, dizziness; retching, abdominal pain; perspiration; palpitations,
apprehension, retrosternal discomfort; rarely reduced platelet count, acute transient
phlebitis
Adverse effects associated with excessive concentration of cyanide metabolite include
tachycardia, sweating, hyperventilation, arrhythmias, marked metabolic acidosis
(discontinue infusion and give antidote, section 4.2.7)
Drugs used in heart failure
Treatment of heart failure aims to relieve symptoms, improve exercise tolerance,
reduce incidence of acute exacerbations, and reduce mortality. Drugs used to treat
heart failure due to left ventricular systolic dysfunction include ACE inhibitors,
diuretics, cardiac glycosides and vasodilators. In addition, measures such as weight
reduction, moderate salt restriction, and appropriate exercise should be introduced.
The primary treatment of heart failure is with angiotensin-converting enzyme
inhibitors (ACE inhibitors) such as enalapril which can be used in all stages of
chronic heart failure to prevent further deterioration and progression of heart disease.
A thiazide diuretic such as hydrochlorothiazide is used in the management of mild
to moderate heart failure when the patient has mild fluid retention and severe
pulmonary oedema is not present; however thiazides are ineffective if renal function
is poor. In these patients, and in more severe fluid retention, a loop diuretic such as
furosemide (section 16.2) is required. In severe fluid retention, intravenous
furosemide produces relief of breathlessness and reduces preload sooner than would
be expected from the time of onset of diuresis. Hypokalaemia may develop, but is less
likely with the shorter-acting loop diuretics than with the thiazides; care is needed to
avoid hypotension.
A combination of a thiazide and a loop diuretic may be required to treat refractory
oedema. The combination often produces a synergistic effect on solute and water
excretion, which relieves symptoms in the diuretic-resistant heart failure patient.
However, the combination may produce excessive intravascular volume depletion and
electrolyte disturbances including potentially life-threatening hypokalaemia.
The aldosterone antagonist spironolactone (section 16.3) may be considered for
patients with severe heart failure who are already receiving an ACE inhibitor and a
diuretic; a low dose of spironolactone (usually 25 mg daily) reduces symptoms and
mortality rate in these patients. Close monitoring of serum creatinine and potassium is
necessary with any change in treatment or in the patient's clinical condition.
Digoxin , a cardiac glycoside, increases the strength of cardiac muscle contractions
and increases cardiac output. In mild heart failure, digoxin inhibits the sympathetic
nervous system and produces arterial vasodilation. It produces symptomatic
25. improvement, increases exercise tolerance, and reduces hospitalization, but it does not
reduce mortality. It is considered for patients with atrial fibrillation and those who
remain symptomatic despite treatment with an ACE inhibitor, a diuretic, and a
suitable beta-blocker.
Vasodilators are used in heart failure to reduce systemic vascular resistance.
Isosorbide dinitrate (section 12.1) produces mainly venous dilatation, which reduces
left ventricular preload, leading to a reduction in pulmonary congestion and dyspnoea.
Hydralazine (section 12.3) produces mainly arterial vasodilation, which reduces left
ventricular afterload, and increases stroke volume and cardiac output. Isosorbide
dinitrate and hydralazine can be used in combination when an ACE inhibitor cannot
be used.
Dopamine , an inotropic sympathomimetic, may be given for short periods in the
treatment of severe heart failure. Dosage is critical; at low doses it stimulates
myocardial contractility and increases cardiac output, however, higher doses (more
than 5 micrograms/kg per minute) cause vasoconstriction, with a worsening of heart
failure.
Enalapril
Enalapril is a representative angiotensin-converting enzyme inhibitor. Various drugs
can serve as alternatives
Tablets, enalapril 2.5 mg
Uses:
heart failure (with a diuretic); prevention of symptomatic heart failure and prevention
of coronary ischaemic events in patients with left ventricular dysfunction;
hypertension (section 12.3)
Contraindications:
hypersensitivity to ACE inhibitors (including angioedema); renovascular disease;
pregnancy (Appendix 2)
Precautions:
use with diuretics; hypotension with first doses, especially in patients on diuretics, on
a low-sodium diet, on dialysis, if dehydrated, or with heart failure; peripheral vascular
disease or generalized atherosclerosis (risk of clinically silent renovascular disease);
use with great care in severe or symptomatic aortic stenosis; monitor renal function
before and during treatment; renal impairment (reduce dose, see also Appendix 4);
liver impairment (Appendix 5); possibly increased risk of agranulocytosis in collagen
vascular disease; history of idiopathic or hereditary angioedema (use with care or
avoid); breastfeeding (Appendix 3); interactions: Appendix 1
Use with Risk of very rapid falls in blood pressure in volume-depleted patients; treatment should
diuretics. therefore be initiated with very low doses. High-dose diuretic therapy (furosemide dose
26. greater than 80 mg daily) should be discontinued, or dose significantly reduced, at least 24
hours before starting enalapril (may not be possible in heart failure—risk of pulmonary
oedema). If high-dose diuretic cannot be stopped, medical supervision advised for at least 2
hours after administration or until blood pressure stable
Anaphylactoid Avoid enalapril during dialysis with high-flux polyacrilonitrile membranes and
reactions. during low-density lipoprotein apheresis with dextran sulfate; also withhold before
desensitization with wasp or bee venom
Dosage:
Heart failure, asymptomatic left ventricular dysfunction, by mouth , adult , initially
2.5 mg daily under close medical supervision; usual maintenance dose 20 mg daily in
1–2 divided doses
Adverse effects:
dizziness, headache; less commonly, nausea, diarrhoea, hypotension (severe in rare
cases), dry cough, fatigue, asthenia, muscle cramps, rash and renal impairment; rarely,
vomiting, dyspepsia, abdominal pain, constipation, glossitis, stomatitis, ileus,
anorexia, pancreatitis, liver damage, chest pain, palpitations, arrhythmias,
angioedema, bronchospasm, rhinorrhoea, sore throat, pulmonary infiltrates,
paraesthesia, vertigo, nervousness, depression, confusion, drowsiness or insomnia,
pruritus, urticaria, alopecia, sweating, flushing, impotence, Stevens-Johnson
syndrome, toxic epidermal necrolysis, exfoliative dermatitis, pemphigus, taste
disturbance, tinnitus, blurred vision; electrolyte disturbances and hypersensitivity-like
reactions (including fever, myalgia, arthralgia, eosinophilia, and photosensitivity)
reported
Digoxin
Tablets , digoxin 62.5 micrograms, 250 micrograms
Oral solution , digoxin 50 micrograms/ml
Injection (Solution for injection), digoxin 250 micrograms/ml, 2-ml ampoule
Uses:
heart failure; arrhythmias (section 12.2)
Contraindications:
hypertrophic obstructive cardiomyopathy (unless also severe heart failure); Wolff-
Parkinson-White syndrome or other accessory pathway, particularly if accompanied
by atrial fibrillation; intermittent complete heart block; second-degree atrioventricular
block
Precautions:
27. recent myocardial infarction; sick sinus syndrome; severe pulmonary disease; thyroid
disease; elderly (reduce dose); renal impairment (Appendix 4); avoid hypokalaemia;
avoid rapid intravenous administration (nausea and risk of arrhythmias); pregnancy
(Appendix 2); breastfeeding (Appendix 3); interactions: Appendix 1
Dosage:
Heart failure, by mouth , ADULT 1–1.5 mg in divided doses over 24 hours for rapid
digitalization or 250 micrograms 1–2 times daily if digitalization less urgent;
maintenance 62.5–500 micrograms daily (higher dose may be divided), according to
renal function and heart rate response; usual range 125–250 micrograms daily (lower
dose more appropriate in elderly)
Emergency loading dose, by intravenous infusion over at least 2 hours, ADULT
0.75–1 mg
Note. Infusion dose may need to be reduced if digoxin or other cardiac glycoside given in previous 2
weeks
Adverse effects:
usually associated with excessive dosage and include anorexia, nausea, vomiting,
diarrhoea, abdominal pain; visual disturbances, headache, fatigue, drowsiness,
confusion, delirium, hallucinations, depression; arrhythmias, heart block; rarely rash,
intestinal ischaemia; gynaecomastia on long-term use; thrombocytopenia reported
Dopamine hydrochloride
Dopamine hydrochloride is a complementary drug for inotropic support
Concentrate for infusion (Concentrate for solution for infusion), dopamine
hydrochloride 40 mg/ml, 5-ml ampoule
Uses:
cardiogenic shock in myocardial infarction or cardiac surgery
Contraindications:
tachyarrhythmia, ventricular fibrillation; ischaemic heart disease;
phaeochromocytoma; hyperthyroidism
Precautions:
correct hypovolaemia before, and maintain blood volume during treatment; correct
hypoxia, hypercapnia, and metabolic acidosis before or at same time as starting
treatment; low dose in shock due to myocardial infarction; history of peripheral
vascular disease (increased risk of ischaemia of extremities); elderly; interactions:
Appendix 1
28. Dosage:
Cardiogenic shock, by intravenous infusion into large vein, ADULT initially 2–5
micrograms/kg/minute; gradually increased by 5–10 micrograms/kg/minute according
to blood pressure, cardiac output and urine output; seriously ill patients up to 20–50
micrograms/kg/minute
Dilution and administration. According to manufacturer’s directions
Adverse effects:
nausea and vomiting; peripheral vasoconstriction; hypotension with dizziness,
fainting, flushing; tachycardia, ectopic beats, palpitations, anginal pain; headache,
dyspnoea; hypertension particularly in overdosage
Hydrochlorothiazide
Hydrochlorothiazide is a representative thiazide diuretic. Various drugs can serve as
alternatives
Tablets, hydrochlorothiazide 25 mg
Uses:
heart failure; hypertension (section 12.3); oedema (section 16.1)
Contraindications:
severe renal or severe hepatic impairment; hyponatraemia, hypercalcaemia, refractory
hypokalaemia, symptomatic hyperuricaemia; Addison disease
Precautions:
renal and hepatic impairment (Appendices 4 and 5); pregnancy and breastfeeding
(Appendices 2 and 3); elderly (reduce dose); may cause hypokalaemia; may aggravate
diabetes mellitus and gout; may exacerbate systemic lupus erythematosus; porphyria;
interactions: Appendix 1
Dosage:
Heart failure, by mouth , ADULT initially 25 mg daily on rising, increasing to 50 mg
daily if necessary; ELDERLY initially 12.5 mg daily
Adverse effects:
fluid and electrolyte imbalance leading to dry mouth, thirst, gastrointestinal
disturbances (including nausea, vomiting), weakness, lethargy, drowsiness, seizures,
headache, muscle pains or cramps, hypotension (including postural hypotension),
oliguria, arrhythmias; hypokalaemia, hypomagnesaemia, hyponatraemia,
29. hypochloraemic alkalosis, hypercalcaemia; hyperglycaemia, hyperuricaemia, gout;
rashes, photosensitivity; altered plasma lipid concentration; rarely impotence
(reversible); blood disorders (including neutropenia, thrombocytopenia); pancreatitis,
intrahepatic cholestasis; acute renal failure; hypersensitivity reactions (pneumonitis,
pulmonary oedema, severe skin reactions)
Antithrombotic drugs and myocardial infarction
Anticoagulants prevent thrombus formation or the extension of an existing thrombus.
For further details see section 10.2 (drugs affecting coagulation).
Antiplatelet drugs also help to inhibit thrombus formation by decreasing platelet
aggregation.
Thrombolytics (fibrinolytics) such as streptokinase are used to break up thrombi;
they are used to treat acute myocardial infarction, extensive deep vein thrombosis,
major pulmonary embolism and acute arterial occlusion.
Myocardial infarction
Management of myocardial infarction includes two phases:
• initial management of the acute attack
• long-term management, including prevention of further attacks
Initial management
Oxygen (section 1.1.3) should be given to all patients, except those with severe
chronic obstructive pulmonary disease.
Pain and anxiety are relieved by slow intravenous injection of an opioid analgesic
such as morphine (section 2.2). Metoclopramide (section 17.2) may also be given by
intramuscular injection to prevent and treat nausea and vomiting caused by morphine.
Acetylsalicylic acid 150–300 mg by mouth (preferably chewed or dispersed in water)
is given immediately for its antiplatelet effect.
Thrombolytic drugs such as streptokinase help to restore perfusion and thus relieve
myocardial ischaemia; they should ideally be given within 1 hour of infarction (use
after 12 hours requires specialist advice).
Nitrates (section 12.1) may also be given to relieve ischaemic pain.
Early administration of beta-blockers such as atenolol (section 12.1) have been
shown to reduce both early mortality and the recurrence rate of myocardial infarction;
initial intravenous administration is followed by long-term oral treatment (unless the
patient has contraindications).
30. ACE inhibitors (section 12.4) have also been shown to be beneficial in initial
management (unless patient has contraindications) when given within 24 hours, and if
possible continued for 5–6 weeks.
If arrhythmias occur, they should be treated aggressively, but the likelihood decreases
rapidly over the first 24 hours after infarction. Ventricular fibrillation should be
treated immediately with a defibrillator; if this is ineffective alone, the antiarrhythmic
drug lidocaine (section 12.2) should be given.
All patients should be closely monitored for hyperglycaemia; those with diabetes
mellitus or raised blood-glucose concentration should receive insulin .
Long-term management
Acetylsalicylic acid should be given to all patients in a dose of 75–150 mg daily by
mouth, unless it is contraindicated. The prolonged antiplatelet effect has been shown
to reduce the rate of reinfarction.
Treatment with beta-blockers should be continued for at least 1 year, and possibly for
up to 3 years.
ACE inhibitors such as enalapril (section 12.4) should also be used since they reduce
mortality, particularly in patients with left ventricular dysfunction.
Nitrates (section 12.1) may be required for patients with angina.
The use of statins (section 12.6) may also be considered in patients with high risk of
recurrence.
Stroke
Stroke (cerebrovascular accident) may be ischaemic or haemorrhagic; precise
diagnosis is essential, as management for the two types of stroke is quite different.
Primary prevention of both types of stroke includes reduction of high blood pressure,
stopping smoking, weight reduction, and cholesterol reduction. Atrial fibrillation,
acute myocardial infarction, and valvular disease may produce embolism and
ischaemic stroke. Prophylaxis in patients at risk of ischaemic stroke includes oral
anticoagulants such as warfarin (section 10.2) and antiplatelet drugs such as
acetylsalicylic acid. Treatment of acute ischaemic stroke includes use of
acetylsalicylic acid , anticoagulants such as heparin, and of thrombolytics, such as
streptokinase. Streptokinase must be used with extreme caution due to risk of
bleeding. Long-term therapy with acetylsalicylic acid reduces the risk of having
another stroke.
Antiplatelet and thrombolytic drugs are not used in the management of haemorrhagic
stroke, as they may exacerbate bleeding. The main treatment is to normalize blood
pressure.
31. Acetylsalicylic acid is normally given for at least one year after coronary artery
bypass surgery. It is also given to patients with prosthetic heart valves who have had
cerebral embolism despite warfarin treatment.
Acetylsalicylic acid
Tablets , acetylsalicylic acid 100 mg
Dispersible tablets (Soluble tablets), acetylsalicylic acid 75 mg [not included on
WHO Model List]
Uses:
prophylaxis of cerebrovascular disease or myocardial infarction; pyrexia, pain,
inflammation (section 2.1.1); migraine (section 7.1)
Contraindications:
hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to acetylsalicylic
acid or any other NSAID; children and adolescents under 16 years (Reye syndrome,
see section 2.1.1); active peptic ulceration; haemophilia and other bleeding disorders
Precautions:
asthma; uncontrolled hypertension; pregnancy (Appendix 2); breastfeeding (Appendix
3); see also section 2.1.1; interactions: Appendix 1
Dosage:
Prophylaxis of cerebrovascular disease or myocardial infarction, by mouth , ADULT
75–100 mg daily
Adverse effects:
bronchospasm; gastrointestinal haemorrhage (rarely major), also other haemorrhage
(for example subconjunctival); see also section 2.1.1
Streptokinase
Streptokinase is a complementary drug; it is used in the management of myocardial
infarction and thromboembolism
Injection (Powder for solution for injection), streptokinase 1.5 million-unit vial
Uses:
life-threatening deep-vein thrombosis, pulmonary embolism, acute arterial
thromboembolism; thrombosed arteriovenous shunts; acute myocardial infarction
Contraindications:
32. recent haemorrhage, surgery (including dental), parturition, trauma; heavy vaginal
bleeding; haemorrhagic stroke, history of cerebrovascular disease (especially recent or
if residual disability); coma; severe hypertension; coagulation defects; bleeding
diatheses, aortic dissection; risk of gastrointestinal bleeding such as recent history of
peptic ulcer, oesophageal varices, ulcerative colitis; acute pancreatitis; sever liver
disease; acute pulmonary disease with cavitation; previous allergic reactions
Precautions:
risk of bleeding from any invasive procedure, including injection; external chest
compression; pregnancy (Appendix 2); abdominal aneurysm or where thrombolysis
may give rise to embolic complications such as enlarged left atrium with atrial
fibrillation (risk of dissolution of clot and subsequent embolization); diabetic
retinopathy (small risk of retinal haemorrhage); recent or concurrent anticoagulant
treatment
Dosage:
Thrombosis, by intravenous infusion, ADULT 250 000 units over 30 minutes,
followed by 100 000 units every hour for 12–72 hours according to condition with
monitoring of clotting parameters
Myocardial infarction, by intravenous infusion, ADULT 1 500 000 units over 60
minutes
Thrombosed arteriovenous shunts, consult manufacturer’s literature
Adverse effects:
nausea and vomiting; bleeding, usually limited to site of injection but internal
bleeding including intracranial haemorrhage may occur (if serious bleeding occurs,
discontinue infusion—coagulation factors may be required); hypotension, arrhythmias
(particularly in myocardial infarction); allergic reactions including rash, flushing,
uveitis, anaphylaxis; fever, chills, back or abdominal pain; Guillain-Barré syndrome
reported rarely
Lipid-regulating drugs
The primary aim of therapy is to reduce progression of atherosclerosis and to
improve survival in patients with established cardiovascular disease, to reduce
premature cardiac morbidity and mortality in people at high risk of cardiovascular
events and to prevent pancreatitis due to hypertriglyceridaemia. Before starting drug
therapy dietary measures, reduction of blood pressure and cessation of smoking
should be tried. The WHO Expert Committee on the Selection and Use of Essential
Medicines recognizes the value of lipid-lowering drugs in treating patients with
hyperlipidaemia. Beta-hydroxy-beta-methylglutaryl-coenzyme A (HMG Co A)
reductase inhibitors, often referred to as ‘statins’, are potent and effective lipid-
lowering drugs with a good tolerability profile. Several of these drugs have been
shown to reduce the incidence of fatal and non-fatal myocardial infarction, stroke and
mortality (all causes), as well as the need for coronary bypass surgery. All remain
33. very costly, but may be cost-effective for secondary prevention of cardiovascular
disease as well as for primary prevention in some very high-risk patients. Since no
single drug has been shown to be significantly more effective or less expensive than
others in the group, none is included in the WHO Model List; the choice of drug for
use in patients at highest risk should be decided at national level.