6024 mod 10 non-adrenergic cardiotonics.pdf

Non-adrenergic Cardiotonics Milrinone ● MOA ○ Increase inhibition of PDE3 to decrease breakdown of cAMP & Ca in order to increase contractility and cause vasodilation ● SE ○ Hypotension, tachy ● Indications ○ Refractory HF; RV failure; post heart transplant w/ LV dysfunction; pulmonary HTN ● Contrai...

Non-adrenergic Cardiotonics Milrinone ● MOA ○ Increase inhibition of PDE3 to decrease breakdown of cAMP & Ca in order to increase contractility and cause vasodilation ● SE ○ Hypotension, tachy ● Indications ○ Refractory HF; RV failure; post heart transplant w/ LV dysfunction; pulmonary HTN ● Contraindications ○ Adjust dose if CrCl < 50 ○ Severe pulmonary or aortic valve disease ○ HOCM ● Monitoring ○ Renal ○ BP ● Facts/Population Considerations ○ Home infusion available Sildenafil ● MOA ○ Inhibit PDE5 to decrease the breakdown of cGMP to increase it in the pulmonary circulation to cause pulmonary arterial dilation ● SE ○ hypotension ● Indications ○ Pulmonary HTN; RV failure ● Contraindications ○ Use with nitrates, alpha blockers ○ Chronic angina; pulmonary veno occlusive disease ○ Malformation of the penis ○ Sickle cell, leukemia, multiple myeloma (increased risk of priapism) ● Monitoring ○ Renal, liver, right sided pressures (CVP) ● Facts/Population Considerations Vasopressin ● MOA ○ Exogenous vasopressin stimulates endogenous V1 (vasoconstriction), V2 (volume control), V3 (ACTH release) and oxytocin-type receptors ● SE ○ hypoNa ○ Nausea, cramps, excess gas ○ Fatigue, dizziness ○ Oliguria ● Indications ○ 2nd line tx for septic shock ○ Diabetes insipidus ○ Esophageal varices ○ Mesenteric bleeding ● Monitoring ○ Hemodynamics Dysrhythmia/Anti-arrhythmic (also Cardiotonics!) ● When would a provider consider utilizing/ordering an antiarrhythmic medication? ○ Only if there’s a clear benefit bc a lot of them can worsen the dysrhythmia or cause a new one ● What are the subtypes of tachyarrhythmias? ○ SVT, atrial tachycardia, afib, aflutter ● What are the subtypes of brady-arrhythmias? ○ Bradycardia, AV blocks ● What are the subtypes of ventricular dysrhythmias? ○ VT, Vfib, torsades, PVCs, dig induced ● What are the classes of Vaughan Williams antiarrhythmic (remember, they are based on MOA!) ○ See below ● What are the reversal agents for BB, CCB and lidocaine overdose? ○ CCB→ IV Ca chloride/gluconate ○ BB→ IV glucagon ○ Digoxin→ anti dig fab Atropine ● MOA ○ Competitively blocks muscarinic receptors (eyes, bladder, heart, sweat glands) ● SE ○ Anticholinergic effects ● Indications ○ Bradycardia ● If it fails, try pacing, dopamine, or epi Adenosine ● MOA ○ Inhibits cAMP by binding to adenosine receptors→ activates K+ channels→ inhibits Ca influx→ decreases conduction & HR ● SE ○ Sinus brady or arrest ○ Dyspnea ○ Hypotension ○ Chest pain ● Indications ○ Narrow QRS tachy ● Facts ○ Dosing: 6, 12 Digoxin ● MOA ○ Decreases conduction through AV node→ prolongs PR interval→ increases vagal tone ● SE ○ Toxicity → yellow halos ○ Avoid if hypoK ○ Avoid with NSAIDs & quinidine→ prolong dig levels ○ Caution with older adults due to their kidneys ● Indications ○ Primarily for HF ○ afib/flutter Vaughan Williams Class 1 (A, B, C)--sodium channel blockers (Quinidine, Procainamide, Lidocaine, phenytoin, mexiletine, flecainide) ● MOA ○ Slows impulse in atria, ventricles, and purkinje fibers ● SE ○ QT prolong ○ Negative inotrope ○ Lidocaine toxicity→ paresthesia, dizziness, blurred vision, sedation, hypotension, CNS depress, brady, seizures ● Indications ○ Ventricular arrhythmias ● Contraindications ○ Avoid lido with CCBs, BBs, vasopressin, or local anesthetics Class II–beta blockers [1st gen–propranolol, sotalol] [2nd gen–acebutolol (pvcs) esmolol (SVT)] ● SE ○ Sotalol→ torsades due to QT prolong ○ Sexual dysfunction ○ Hypoglycemia Class III*---potassium channel blockers (Bretylium, Amiodarone) ● MOA ○ Delay repolarization (phase 3) of cardiac cycle ● SE ○ Amio→ BBW→ lung toxic, liver injury, optic neuropathy/blindness ○ Photosensitivity (blue man syndrome), CNS reactions, GI reactions ○ Hypotension, brady ○ Thyroid toxic ○ Pulmonary fibrosis ● Indications ○ afib/flutter ○ VT/SVT ● Contraindication ○ Pregnancy Class IV—CCBs–verapamil & diltiazem ● MOA ○ Slows SA automaticity/delays AV node conduction/slow HR ● SE ○ Worsening HF, hypotension, leg edema, AV blocks, palpitations, HA ● Indications ○ afib ● Contraindications ○ Grapefruit juice