Cardiac Drug Therapy in the Critical Care Unit D5 Major Categories Pain Relief Pain caused by myocardial tissue

ischemia Medication Goals in ischemic chest pain: Direct Analgesia Relieve ischemiastop source of chest pain Nitrates Potent vasodilator Direct dilation of coronary arteries Powerful dilation of venous system Reduces preload Decreased myocardial O2 demand Requires adequate fluid volume (Profound hypotension in hypovolemic patients Requires adequate BP Forms IV Titrated by nurse until pain free Oral Isosorbide Dinitrate (ISDN, Isordil) Isosorbide mononitrate (SR, q24h, Dont Crush Sublingual Should sting (wont if stale Dermal Absorption Nitropaste Absorbed through skin Applied in inches (1 inch q6 Nitrate Side Effects: Hypotension Goals: Treat Cardiogenic Shock Treat Heart Failure Correct Rhythm Disturbances Prevent Blood Clots

Improve CO Reduce afterload

Adrenergic Agonists Stimulate the adrenergic receptor system Alpha receptors - regulate arterial & venous tone B1 receptors - regulate heart rate & myocardial contractility B2 receptors regulate vasodilation & relaxation of bronchial, uterine & gastric smooth muscle Dopamine Dose dependent adrenergic stimulant Low dose o (1-3 mcg/kg/min) o Dilates renal vasculature o Increases Urine O/P o Useful in CHF Moderate Dose o (3-10 mcg/k/min) o Increases myocardial contractility o Increases CO o For mod/severe hypotension High Dose o (10-20 mcg/kg/min) o Stims alpha receptors o Powerful arterial

Dobutamine Mostly B1 agonist increases myocardial contractility Decreases afterload via arterial dilation Used for chronic CHF S/E: Sinus tach, PVCs, VT, variable FX on BP (higher or lower) Milrinone Phosphodiesterase inhibitor Increase in contractility Reduction in afterload SE: Usually well tolerated but may lower BP or produce arrythmias ,

Amniodorone Originally developed for life threatening vtach, vfib, now used for afib as well Complex dosing regimen Often not given due to side effects: Irritating to veins & skin (can get maybe 24h from a vein- central or PICC preferred) Hypotension Blue skin coloration Pulmonary fibrosis Lidocaine Ventricular anti-arrythmic Used to prevent PVCs, Vtach, VFib Bolus or infusion SE: Lightheadedness, confusion, slurred speech, Circumoral numbness, resp. depression (late) Diltiazem (cardizem) Ca Channel blocker Vasodilator

Heparin Anticoagulant prevents new clot formation Used in unstable angina & acute MI Dosage: 5000-10,000 units Followed by drip titrated to therapeutic aPTT level Short Acting SE: Bleeding, thrombocytopenia (destroys platelets in some people HIT) IIb/IIIa Platelet Inhibitors Inhibit IIb/IIIa receptor sites on platelets from clumping together 3 brands: Abcixmab(ReoPro), Tirofibran (Agrostat) Eptifibitide (Integrelin) Oral: Clopidogrel (Plavix) (Cannot skip a day) Usage: Acute MI, unstable angina, PTCA stent IV infusion SE: bleeding

Headache Reflex tachycardia Attenuation/tolerance

o S/E o o o o

vasoconstriction Increases BP/increases myocardial demand

Opiates Direct reduction of pain via neurologic pain receptors Venodilationpreload reductionmyocardial workload reduction Relieves Anxiety Decreases cathelcholamines coronary artery dilation Common opiates (narcotics) for chest pain Morphine Sulfate small incremental IV push doses Hydromorphone (Dilaudid) Same effects as morphine (10X as powerful) Side Effects: Hypotension Need adequate fluid vol Hypoventilation Always have Narcan May wear off before Sedation/Somnolence Sensitivities N/V - common

Tachycardia PVCs/VT Skin damage (infiltrations) Peripheral ischemia (high dose) Norepinephrine (Levophed) Major alpha fx, minor B1 fx For cardiogenic & septic shock Major effect: increases BP o S/E: HTN Phenylephrine (Neosynephrine) Pure alpha agonist (stimulator) Sole effect: vasoconstriction Treats hypotension assoc/w vasodilation S/E: Reflex bradycardia Skin slough d/t infiltration use Regitine Epinephrine (Adrenalin) Non-selective stimulates everything (alpha, B1, B2) Bronchodilator, used for shock codes Antianaphylactic drug (bee stings, etc.) S/E: HTN & Tachycardia Vasodilators Used to reduce afterloadincrease CO & reduce cardiac workload so heart doesnt have to push as hard Nitroprusside (Nipride) potent arterial vasodilator short acting (few minutes) S/E: hypotension Thiocyanate toxicity

TX: Afib, SVT (also HTN, chest pain) Bolus or infusion SE: Decreases myocardial contractility May exacerbate CHF in left heart failure HTN, heart block