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Adenosine (Adenocard)
Class: Antiarrhythmic
Use: Treat PSVT.
Action: Slows conduction time through the AV node, interrupting
the re-entry pathways through the AV node, restoring normal sinus
rhythm. Promotes K+ efflux = repolarization (hyperpolarization).
Cardiac Effect: Treat PSVT.
Administration Routes: IV
Onset Time: Effects occur rapidly
½ Life: < 10 seconds
Metabolism -- Excretion: In the blood and tissue to
inosine then to AMP and hypoxanthine --
Side Effects: CP. Hypotension. Dyspnea (12%).
Anesthesia Interactions: Methylxanthines antagonize effects.
Dipyrdamole (Persantine) potentiates effects. Carbamazepine (Tegretol)
may increase heart block.
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Amiloride (Midamor)
Class: K+ Sparing Diuretic
Use: Counteracts K+ loss induced by other diuretics. Usually used
in conjunction with more potent diuretics such as thiazides or loop
diuretics.
Action: Interferes with K+/Na+ exchange (active transport) in the
distal tubule. Decreases Na+ reabsorption in the distal tubule
Cardiac Effect:
Administration Routes: PO
Onset Time: 2 hours
½ Life: 6-9 hours
Metabolism -- Excretion: No active metabolites. -- Excreted
unchanged equally in the urine and feces
Side Effects: Hyperkalemia.
Anesthesia Interactions: ACE Inhibitor may increase chance of
hyperkalemia.
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Amiodarone (Cordarone)
Class: Antiarrhythmic – Class III (K+ channel blocker) (Also
blocks some Na+ & Ca2+ channels and is a sympatholytic agent)
Use: Treat ventricular arrhythmias or supraventricular
arrhythmias
Action: Inhibits adrenergic stimulation. Prolongs the action
potential and refractory period in myocardial tissue. Decreases AV
conduction and sinus node function. Doesn’t effect the resting
membrane potential. chance of DAD’s
& EAD’s.
Cardiac Effect: Treat ventricular arrhythmias or supraventricular
arrhythmias
Administration Routes: PO, IV
Onset Time: 2-3 days
½ Life: 40-55 days. Shortened in children.
Metabolism -- Excretion: In liver, major metabolite
active. -- Via biliary excretion. Possible enterohepatic
recirculation.
Side Effects: Pulmonary fibrosis. Interstitial pneumonitis
alveolitis. CHF. Arrhythmias. Myocardial depression. Hypotension.
Increases [Digitalis].
Anesthesia Interactions: Use with general anesthetics may result
in hypotension, atropine-resistant bradycardia, sinus arrest or AV
block. Combined use with b -blockers,
digitalis or Ca2+ blockers may result in bradycardia or sinus arrest.
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Amrinone (Inocor)
Class: Positive inotropic agent – Phosphodiesterase inhibitor
Use: Treatment of low cardiac output states (sepsis, CHF).
Action: Inhibits phosphodiesterase (PDE) III, the major PDE in
cardiac vascular tissues. Inhibition of PDE III increases cAMP
potentiating delivery of Ca2+ to myocardial contractile systems
resulting in a positive inotropic effect
Cardiac Effect: Increased inotropy
Administration Routes: IV
Onset Time: IV – 2-5 minutes
½ Life: Neonates: 22.2 hrs. Infants: 6.8 hrs. Adults (normal):
3.6 hrs. Adults (with CHF): 5.8 hrs
Metabolism -- Excretion: Hepatic. -- 60-90% excreted as
metabolites in urine within 24 hours
Side Effects: Supraventricular and ventricular arrhythmias,
hypotension, thrombocytopenia, chest pain, hepatotoxicity
Anesthesia Interactions:
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Atenolol (Tenormin)
Class: b -blocker
Use: Treatment of hypertension, alone or in combination with
other agents. Management of angina pectoris, post-myocardial infarction
patients
Action: Competitively blocks response to b
-adrenergic stimulation. Selectively blocks b
1 receptors with little or no effect on b 2
receptors except at high doses
Cardiac Effect:
Administration Routes: PO, IV
Onset Time: PO 1 hr. IV Rapid.
½ Life: 6-7 hrs. Longest in patients with reduced renal function
Metabolism -- Excretion: None -- 40% excreted as
unchanged drug in urine. 50% in feces
Side Effects: Bradycardia, hypotension, chest pain, heart
failure, 2nd or 3rd degree AV block, dyspnea
Anesthesia Interactions: By decreasing the clearance of
continuous infusions it may increase the effect of perioperative agents
such as fentanyl, propofol, sufentanil, ketamine and etomidate. May
increase the effect/toxicity of haloperidol (hypotensive effects),
hydralazine.
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Bretylium (Bretylol)
Class: Antiarrhythmic – Class III (K+ channel blocker)
Use: Treatment of ventricular tachycardia and fibrillation. Used
in the treatment of other serious ventricular arrhythmias resistant to
lidocaine
Action: Causes an initial release of Norepinephrine (NE) at the
peripheral adrenergic nerve terminals. After the initial release of NE,
it inhibits further release by depressing postganglionic nerve endings
in response to sympathetic nerve stimulation.
Cardiac Effect:
Administration Routes: IM, IV
Onset Time: IM 2 hrs. IV 6-20 minutes
½ Life: 7-11 hrs. ESRD: 16-32 hrs.
Metabolism -- Excretion: Not metabolized -- 70-80%
excreted over the first 24 hrs. Excreted unchanged in the urine.
Side Effects: Hypotension, bradycardia, hyperthermia, respiratory
depression.
Anesthesia Interactions: Increases toxicity of other
antiarrhythmic agents. Additive toxicity or effect by bretylium, pressor
catecholamines, digitalis
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Bumetanide (Bumex)
Class: Loop Diuretic
Use: Management of edema secondary to CHF or hepatic or renal
disease. Can be used in furosemide-allergic patients (1 mg = 40 mg
furosemide)
Action: Inhibits reabsorption of Na+ and Cl- in the ascending
loop of Henle and proximal renal tubule, interfering with the Cl-
binding cotransport system, thus causing increased excretion of H2O,
Na+, Cl-, Mg2+, PO4 and Ca2+. It does not appear to act on the distal
tubule
Cardiac Effect:
Administration Routes: PO, IM, IV
Onset Time: PO/IM 30-60 mins. IV within a few mins.
½ Life: Infants: 2.5 hrs. Children & Adults: 1-3 hrs.
Metabolism -- Excretion: Partial, occurs in the liver -- Majority
of unchanged drug and metabolites excreted in urine.
Side Effects: Hypokalemia, hypochloremia, hypotension
Anesthesia Interactions: Nondepolarizing agents will have a
prolonged duration. Digoxin predisposed to digoxin toxicity secondary to
potential hypokalemia.
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Captopril (Capoten, Capozide)
Class: Angiotensin Converting Enzyme (ACE) Inhibitor -
Vasodilator
Use: Management of hypertension and treatment of CHF.
Action: Competitive inhibitor of ACE. Prevents conversion of
angiotensin I to angiotensin II, a potent vasoconstrictor. Results in
lower levels of angiotensin II which causes an increase in plasma renin
activity and a reduction in aldosterone secretion.
Cardiac Effect:
Administration Routes: PO
Onset Time: 15 mins
½ Life: Normal: 1.9 hrs. CHF: 2.06 hrs. Anuria: 20-40 hrs.
Metabolism -- Excretion: 50% Metabolized. -- 95%
excreted in urine in 24 hrs.
Side Effects: Tachycardia, chest pain, Cough
Anesthesia Interactions: Increased hypotension when used with
anesthetic agents
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Clonidine (Catapres, Duraclon)
Class: a 2 agonist (Centrally acting)
Use: Tx. of mild to moderate HTN. Used for narcotic withdrawal
and smoking cessation. Decreases the stress response to surgery, the
hemodynamic response to intubation, the dose of anesthetic drugs needed
to produce anesthesia. Intrathecal and epidural clonidine used to
enhance postop analgesia.
Action: Stimulates a 2 receptors in
the brain inhibiting NE release from SN terminals. Reduces SNS activity
producing sedation and a decrease in vasomotor tone and HR. Also
enhances parasympathetic tone. Epidural use produces segmental analgesia
via pre and postsynaptic a 2 activation,
which prevents pain signal transmission.
Cardiac Effect:
Administration Routes: PO, Transdermal, epidural
Onset Time: PO 0.5-1 hr. IV 10 mins. Epidural 20 mins.
½ Life: Normal: 6-20 hrs. Renal impairment: 18-41 hrs. Epidural
CSF: 1-2 hrs.
Metabolism -- Excretion: Hepatic (50%). Metabolized to
inactive metabolites -- 65% excreted in urine. 32% unchanged. 22%
feces.
Side Effects: Somnolence, orthostatic hypotension, agitation,
tachycardia, bradycardia, CHF
Anesthesia Interactions: b -blockers
may bradycardia and may
the rebound HTN of withdrawal
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Digitoxin ()
Class: Positive inotropic agent – Cardiac Glycoside
Use: Treatment of CHF and to slow the ventricular rate in tachy
arrhythmias such as atrial fibrillation, atrial flutter, and SVT.
Cardiogenic shock
Action: CHF—Inhibition of the Na+/K+ ATPase pump, which acts to
the intracellular Na+-Ca2+ exchange to
intracellular Ca2+ leading to,
contractility. Supraventricular Arrhythmias—Direct suppression of the
AV node conduction to effective refractory
period and ¯ conduction velocity – +
inotropic effect, enhanced vagal tone, and ¯
ventricular rate to fast atrial arrhythmias.
Cardiac Effect:
Administration Routes: PO, IM, IV
Onset Time:
½ Life: 168 hrs
Metabolism -- Excretion: Liver -- In gut, by bile
Side Effects: Sinus brady, AV & SA block, atrial or nodal
ectopic beats, Ventricular arrhythmias
Anesthesia Interactions: Amiodarone & Verapamil
[Dig]
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Digoxin (Lanoxin)
Class: Positive inotropic agent – Cardiac Glycoside –
Antiarrhythmic
Use: Treatment of CHF and to slow the ventricular rate in tachy
arrhythmias such as atrial fibrillation, atrial flutter, and SVT.
Cardiogenic shock
Action: CHF—Inhibition of the Na+/K+ ATPase pump, which acts to
the intracellular Na+-Ca2+ exchange to
intracellular Ca2+ leading to,
contractility. Supraventricular Arrhythmias—Direct suppression of the
AV node conduction to effective refractory
period and ¯ conduction velocity – +
inotropic effect, enhanced vagal tone, and ¯
ventricular rate to fast atrial arrhythmias.
Cardiac Effect:
Administration Routes: PO, IM, IV
Onset Time: PO 1-2 hrs. IV 5-30 mins
½ Life: Neonates: 35-170 hrs. Infants: 18-25 hrs. Children: 35
hrs. Adults: 38-48 hrs. Adults (anephric): 4-6 days.
Metabolism -- Excretion: Some metabolism in stomach or
gut. Metabolites are still active. -- 50-70% excreted unchanged in
urine
Side Effects: Sinus brady, AV & SA block, atrial or nodal
ectopic beats, Ventricular arrhythmias
Anesthesia Interactions: Amiodarone & Verapamil
[Dig]
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Diltiazem (Cardizem, Dilacor)
Class: Antiarrhythmic – Class IV (Ca2+ channel blocker). --
Antihypertensive agent
Use: Hypertension. Chronic stable angina or angina from coronary
artery spasm. Atrial fibrillation or atrial flutter. PSVT.
Action: Inhibits Ca2+ from entering the "slow channels or
select voltage-sensitive areas of VSM and myocardium during
depolarization, producing a relaxation of coronary VSM and coronary
vasodilation. Increases myocardial O2 delivery in patients with
vasospastic angina. Compared to nifedipine it has more inhibitory
effects on cardiac conduction system and less vasodilation properties.
Cardiac Effect:
Administration Routes: PO, IV
Onset Time: PO: 30-60 mins.
½ Life: 4-10 hrs. May increase with renal impairment
Metabolism -- Excretion: Extensive first-pass metabolism
in liver. -- In urine and bile mostly as metabolites.
Side Effects: Bradycardia, AV block (first & second degree),
pharyngitis
Anesthesia Interactions:
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Dobutamine (Dobutrex)
Class: Positive inotropic agent - b
-agonist
Use: Increase cardiac output in the short-term treatment of
patients with cardiac decompensation caused by depressed contractility
from organic heart disease, cardiac surgical procedures, or acute MI
Action: Stimulates b 1 receptors,
causing increased contractility and heart rate, with little effect on b
2 or a receptors. Mimics Norepinephrine.
Cardiac Effect:
Administration Routes: IV
Onset Time: IV: 1-2 mins
½ Life: 2 mins
Metabolism -- Excretion: In tissues and the liver to
inactive metabolites. -- Metabolites are excreted in urine.
Side Effects: Ectopic beats, increased HR, CP, HTN, Ventricular
tachycardia (with high doses). PVC’s, dyspnea, paresthesia
Anesthesia Interactions: Increased TPR. General anesthetics and
dobutamine have resulted in ventricular arrhythmias in animals.
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Enalapril (Vasotec)
Class: Angiotensin Converting Enzyme (ACE) Inhibitor -
Vasodilator
Use: Management of hypertension and treatment of CHF.
Action: Competitive inhibitor of ACE. Prevents conversion of
angiotensin I to angiotensin II, a potent vasoconstrictor. Results in
lower levels of angiotensin II which causes an increase in plasma renin
activity and a reduction in aldosterone secretion.
Cardiac Effect:
Administration Routes: PO, IV
Onset Time: About 1 hr.
½ Life: Infants: 6-10 hrs. Adults: 35-38 hrs.
Metabolism -- Excretion: Is a pro-drug and undergoes
biotransformation in the liver to enalaprilat the active compound. -- 60-80%
in urine with some fecal excretion.
Side Effects: Tachycardia, syncope, paresthesia, dyspnea,
hypotension, bronchospasm
Anesthesia Interactions: Increased hypotensive effects when
anesthetic agents are added.
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Flecainide (Tambocor)
Class: Antiarrhythmic – Class I C (Na+ channel blocker)
Use: Prevention and suppression of documented life-threatening
ventricular arrhythmias (sustained VT). Controlling symptomatic,
disabling SVT in patients without structural heart disease in whom other
agents fail.
Action: Slows conduction in cardiac tissue by altering transport
of ions across cell membranes. Causes slight prolongation of refractory
periods. Decreases the rate of rise of the action potential without
affecting its duration. Increases electrical stimulation threshold of
ventricle, HIS-Purkinje system. Possesses local anesthetic and moderate
negative inotropic effects.
Cardiac Effect:
Administration Routes: PO
Onset Time:
½ Life: Infants: 11-12 hrs. Children: 8 hrs. Adults: 7-22 hrs.
ESRD: 19-26 hrs.
Metabolism -- Excretion: In the liver. -- 80-90%
excreted in urine as unchanged drug and metabolites (10-50%)
Side Effects: Dyspnea. CP, edema, tachycardia, bradycardia, heart
blocks, increased PR & QRS, CHF, hypoesthesia, paresthesia
Anesthesia Interactions:
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Furosemide (Lasix)
Class: Loop Diuretic
Use: Management of edema associated with CHF and hepatic or renal
disease.
Action: Inhibits reabsorption of Na+ and CL- in the ascending
loop of Henle and distal tubule. Increased excretion of H2O, Na+, Cl-,
K+, Mg2+, Ca2+, HCO3. Decreases CSF production by interfering with Na+
transport in cerebral glial tissue.
Cardiac Effect:
Administration Routes: PO, IV, IM
Onset Time: PO: 30-60 min. IV: 5 min. IM: 30 min
½ Life: 0.5 - 1.1 hrs. Pt. With ESRD: 9 hrs
Metabolism -- Excretion: -- 50% of oral and 80% of IV
dose excreted in the urine within 24 hrs. The rest by non-renal
pathways.
Side Effects: Electrolyte imbalance, hypotension,
Anesthesia Interactions: Increased antihypertensive agents
effects. Interferes with hypoglycemic effect of antidiabetic agents.
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Hydralazine (Apresoline)
Class: Vasodilator
Use: Management of moderate to severe HTN, CHF, HTN secondary to
pre-eclampsia / eclampsia. Also use in treatment of primary pulmonary
HTN.
Action: Direct vasodilation of arterioles (with little effect on
veins) producing decreased systemic vascular resistance. It binds to
arterioles and activates guanylate cyclase producing accumulation of
6MP. It is associated with reflex tachycardia, increased cardiac output
and plasma volume.
Cardiac Effect:
Administration Routes: PO, IM, IV
Onset Time: PO: 20-60 mins. IV: 5-20 mins.
½ Life: 2-8 hrs. ESRD: 7-16 hrs.
Metabolism -- Excretion: Large hepatic first pass. -- 14%
excreted unchanged in urine
Side Effects: Tachycardia, hypotension
Anesthesia Interactions:
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Hydrochlorothiazide (HCTZ, Ezide)
Class: Thiazide Diuretic
Use: Management of mild to moderate HTN. Treatment of edema in
CHF and nephrotic syndrome
Action: Inhibits Na+ reabsorption in the distal tubules causing
increased excretion of Na+ and H2O as well as K+ and H+. Allows Ca2+
reabsorption. Not as potent as loop diuretics.
Cardiac Effect:
Administration Routes: PO
Onset Time: PO: within 2 hrs
½ Life: Lasts 6-12 hrs
Metabolism -- Excretion: -- Excreted unchanged in the
urine
Side Effects: Hypotension
Anesthesia Interactions:
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Isosorbide Dinitrate (Isordil, Iso-Bid,
Sorbitrate)
Class: Nitrate – Vasodilator
Use: Prevention and treatment of angina pectoris. For CHF. To
relieve pain, dysphagia, and spasm in esophageal spasm with GE reflux
Action: Stimulation of intracellular cGMP results in VSM
relaxation of both arterial and venous vasculature. Increased venous
pooling decreases left ventricular pressure (preload) and art4rial
dilation decreases arterial resistance (afterload). Therefore, this
reduces cardiac oxygen demand. Coronary artery dilation improves
collateral flow to ischemic regions. Converted in liver to its active
form, mononitrate. Longer lasting than other nitrates.
Cardiac Effect:
Administration Routes: PO, Sublingual
Onset Time: SL: 2-10 mins. PO: 45-60 mins.
½ Life: 1-4 hrs. Metabolite: 4 hrs.
Metabolism -- Excretion: Extensive liver metabolism. -- In
urine and feces
Side Effects: Tolerance buildup, hypotension
Anesthesia Interactions: ASA may increase serum nitrate
concentration
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Isradipine (DynaCirc)
Class: Ca2+ Channel blocker (Dihydropyridines) (DHP)
Use: Treatment of HTN, CHF, migraine prophylaxis
Action: Inhibits Ca2+ from entering the "slow channels"
or select voltage-sensitive areas of VSM and myocardium during
depolarization, producing peripheral and coronary vasodilation.
Increases myocardial O2 delivery in patients with vasospastic angina.
Decrease in TPR may enhance cardiac function. Closed channel blocker.
Cardiac Effect:
Administration Routes: PO
Onset Time:
½ Life: 8 hrs
Metabolism -- Excretion: 100% hepatic -- Renal
excretion by metabolites.
Side Effects: Edema, tachycardia, Heart failure
Anesthesia Interactions:
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