Chapter 9: Cardiac Agents

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 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.
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 Cardiovascular Overview
 Chronotropic
 HR
 Inotropic
 Force of contraction
 Dromotropic
 Rate of conduction

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

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

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 Cardiac Conduction

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

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9.1c Adrenergic and Cholinergic Effects on the Heart

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

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9.1d Electrical Conduction Through the Heart

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9.1e Normal ECG Tracing

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

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

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

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

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 Antiarrhythmic Agents

 Restore normal sinus rhythm

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

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 Antiarrhythmic Mechanism of Action

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

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9.2c Antiarrhythmic Drug Classes with Representative Drugs

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 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
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 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

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

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9.3c Sites of Action of Drugs to Treat HF

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

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 Drugs To Treat Heart Failure
 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

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

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 Drugs To Treat Heart Failure
 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
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 Drugs To Treat Heart Failure
 β-antagonists (β-blockers)
 Slow HR
 More ventricular filling
 Reduction in myocardial oxygen demand
 Carvedilol, Toprol XL®, bisoprolol

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 Drugs To Treat Heart Failure
 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

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 Drugs To Treat Heart Failure
 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
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9.3i Subgroups of Drugs for HF

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

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 Drugs To Treat Heart Failure
 Intravenous Inotropes
 Β1 agonists
 Dobutamine
 Phosphodiesterase inhibitors
 Milrinone
 Remember the mechanism of action for phosphodiesterase
inhibitors.

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 Drugs To Treat Heart Failure
 Dopamine
 Stimulates dopaminergic
 Β1 receptors
 α receptors
 Low doses
 Improved renal flow
 High doses
 Inotropic effects

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 Drugs To Treat Heart Failure
 Nitrates
 Nitroprusside
 Decreases afterload
 Photosensitive medication
 Given intravenously
 Nitroglycerin
 Preload and afterload reduction
 Sublingual administration

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 Drugs To Treat Heart Failure
 Nesiritide
 Mimics BNP
 Causes vasodilation
 Not used frequently
 Associated with death

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

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

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9.5b Subgroups of Drugs for Angina

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9.5c Comparison of β-Blockers

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9.5d Comparison of Calcium-Channel Blockers

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9.5e Comparison of Antianginals

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 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

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 Acute Coronary Syndromes

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

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

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 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.

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9.6b The ABCs of Diabetes Care

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9.6c Pharmacologic Agents for Diabetes

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9.6c Types of Insulin

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9.6d Lipid-Lowering Agents

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 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.

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 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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