Cardiac Agents

Chapter 9: Cardiac Agents
Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Bruce J. Colbert & Luis S. Gonzalez III ©2019 Better textbooks, better prices.
Learning Objectives
 Define key terms related to  Understand the role of
cardiac agents. pharmacologic therapy in
 Relate cardiovascular physiology arrhythmias, heart failure, acute
to pharmacologic treatments. coronary syndrome, myocardial
infarction, hyperlipidemia,
 Describe indications and
diabetes, and angina.
pharmacologic effects of
antiarrhythmics, ACE inhibitors,  Discuss the relationship
angiotensin-receptor blockers, between diabetes and
inotropic agents, antidiabetic cardiovascular disease.
agents, antilipidemics, and  Describe the pharmacologic
vasodilators. treatment for diabetes.
Cardiovascular Overview
 Chronotropic
 HR
 Inotropic
 Force of contraction
 Dromotropic
 Rate of conduction
All of the above can either be positive (increased) or negative (decreased).

Cardiac Circulation
 Four chamber heart
 Two atria
 Two ventricles
 Left side systemic circuit
 Right side pulmonary circuit

Cardiac Conduction
 SA node
 AV node
 Bundle of HIS
 Bundle branches
 Purkinje fibers

9.1c Adrenergic and Cholinergic Effects on the Heart

Ion Influence
 Action potential
 Depolarization
 Repolarization
 Ion channels
 Na
 K+
 Ca++
 Refractory period

9.1d Electrical Conduction Through the Heart

9.1e Normal ECG Tracing

Arrhythmias
 Arrhythmia
 Without rhythm
 Possibly better to call them dysrhythmias
 Any deviation from normal

Arrhythmias
 Automaticity
 Ability to generate pace-making activity
 Ischemia
 Infarction
 Oxygen deficit
 Proarrhythmia
 Induced by medication

Arrhythmias
 Supraventricular
 Above the ventricles
 A-fib
 A-flutter
 PSVT

Arrhythmias
 Ventricular
 Within in the ventricles
 V-fib
 V-tach
 Torsades de pointes
 PVCs

Antiarrhythmic Agents
 Restore normal sinus rhythm

 Suppress ectopic foci
 Control ventricular rate
 Optimize cardiac output

Antiarrhythmic Mechanism of Action
 Pharmacologic
 Electrophysiologic
 Alter conduction
 Atria
 Ventricles
 Threshold level of excitable cells
 Depolarization

9.2c Antiarrhythmic Drug Classes with Representative Drugs

Unclassified Antiarrhythmic Drugs
 Digoxin
 Inhibits the sodium/potassium exchange pump in the
heart
 Increases force of contraction
 Half-life of 36 hours
 Slows ventricular rate
 Adenosine
 Converts SVT
 Slows SA to AV conduction
 Can be scary to administer
Heart Failure
 Right or left sided heart failure
 Whole heart or one side of heart unable to pump
effectively
 Right
 Back up into systemic circulation
 Left
 Back up into pulmonary circulation
 Systolic dysfunction
 Diastolic dysfunction

Heart Failure
 Preload
 Blood in ventricles prior to contraction
 Afterload
 Resistance
 Medications are used to affect either preload or
afterload.
 Vasoconstriction
 Vasodilation

9.3c Sites of Action of Drugs to Treat HF

Drugs To Treat Heart Failure
 Digoxin
 Positive inotropic medication
 Negative dromotropic medication
 Increased CO
 Increased renal perfusion

 ACE Inhibitors
 Inhibit enzyme that converts angiotensin I to
angiotensin II
 Angiotensin II is a potent vasoconstrictor.
 Decrease
 Vascular resistance
 Aldosterone secretion
 Salt and water retention
 Captopril, benazepril, and enalapril

 ARBs
 Given in conjunction in ACE inhibitors
 Block the angiotensin receptor blocker
 Decreases vasoconstriction
 Can cause:
 Hypotension
 Hyperkalemia
 Renal insufficiency

 Angiotensin receptor neprilysin inhibitor
 Given in conjunction in ACE inhibitors
 Sacubitrill, valsartan (Entresto®)
 Increases sodium and vasodilation
 Can cause:
 Hypotension
 Cough
 Hyperkalemia
 Dizziness
 Kidney injury
 β-antagonists (β-blockers)
 Slow HR
 More ventricular filling
 Reduction in myocardial oxygen demand
 Carvedilol, Toprol XL®, bisoprolol

 Vasodilators
 Decrease BP
 Reduces afterload
 Dilating arterial vessels (hydralazine)
 Dilating venous vessels and decreasing preload (isosorbide
dinitrate, nitrates)
 Affecting both arterial and venous vessels (ACE inhibitors)
 Hydralazine, nitrates, ACE inhibitors, ARBs

 Diuretics
 Rid excess fluid
 Use caution not to eliminate needed electrolytes.
 Potassium
 Different types of diuretics
 Loop diuretics most often used for ridding excess fluid
 Side effects of diuretics
 Azotemia, dehydration, hypokalemia, hyponatremia,
hypochloremic alkalosis, hypomagnesemia, hyperglycemia,
and hyperuricemia
 Weigh daily
9.3i Subgroups of Drugs for HF

 Aldosterone antagonists
 Potassium loss contributes to arrhythmia.
 Potassium sparing diuretics
 Beneficial for HF patients
 Aldactone® and Inspra®

 Intravenous Inotropes
 Β1 agonists
 Dobutamine
 Phosphodiesterase inhibitors
 Milrinone
 Remember the mechanism of action for phosphodiesterase
inhibitors.

 Dopamine
 Stimulates dopaminergic
 Β1 receptors
 α receptors
 Low doses
 Improved renal flow
 High doses
 Inotropic effects

 Nitrates
 Nitroprusside
 Decreases afterload
 Photosensitive medication
 Given intravenously
 Nitroglycerin
 Preload and afterload reduction
 Sublingual administration

 Nesiritide
 Mimics BNP
 Causes vasodilation
 Not used frequently
 Associated with death

Management of Shock
 Sudden drop in BP
 Different causes
 Give vasopressors
 Vasoconstriction
 Increase in BP
 May need to give fluid bolus

Angina
 Chest pain
 Myocardial ischemia
 Lack of oxygen
 Treatment goal is to decrease oxygen consumption
 Give nitrates
 β blockers
 Ca++ channel blockers

9.5b Subgroups of Drugs for Angina

9.5c Comparison of β-Blockers

9.5d Comparison of Calcium-Channel Blockers

9.5e Comparison of Antianginals

Acute Coronary Syndromes
 Rupture of an atherosclerotic plaque
 ST-segment-elevation ACS
 Reperfusion therapy
 Percutaneous coronary intervention (PCI)
 Fibrinolytic therapy
 Also give oxygen, aspirin, sublingual nitroglycerin,
intravenous nitroglycerin, intravenous β-blockers, and
unfractionated heparin are used

Acute Coronary Syndromes
 Non-ST-segment elevation
 Clopidogrel (Plavix®) or prasugrel (Effient®)
 Glycoprotein IIb/IIIa-receptor blocker

Myocardial Infarction
 MI = myocardial death
 Treatment goal is to preserve myocardial.
 Specifically left ventricular function
 Reperfusion therapy
 Antithrombosis
 Anti-ischemic therapy

Diabetes Mellitus
 Type I
 Failure to produce insulin
 Type II
 Failure of cells to use insulin
 Both types encompass microvascular and
macrovascular disease complications
 Diabetic patients are at greater risk for developing
coronary heart disease.

9.6b The ABCs of Diabetes Care

9.6c Pharmacologic Agents for Diabetes

9.6c Types of Insulin

9.6d Lipid-Lowering Agents

Chapter Summary
 Understand normal anatomy and physiology
as it pertains to the heart.
 Understand the normal electrophysiology of
FIN
AL
the heart.
TH
OU
 Understand renal physiology.
GHT
S
 Understand the relationship between the
cardiopulmonary and renal system.

Chapter Summary
 Various agents are available to treat
 Cardiac arrhythmias
 Heart failure
FIN
AL
 Acute coronary syndromes
TH
OU
 Myocardial infarction
GHT  Diabetes
S
 Hyperlipidemia
 Angina


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Chapter 9: Cardiac Agents

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

All of the above can either be positive (increased) or negative (decreased).

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

 Restore normal sinus rhythm

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

Integrated Cardiopulmonary Pharmacology, 5th Edition BVT Publishing

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