Cardiac Glycosides, Antianginals, and Antidysrhythmics

What are the different Cardiovascular Drugs?

1. Cardiac Glycosides

2. Anti-anginals

3. Anti-dysrhythmics

4. Diuretics

5. Anti-hypertensives

6. Anti-coagulants

7. Anti-platelets

8. Thrombolytics

9. Antilipidemics

10. Peripheral Vasodilators 

What drug is effective in treating congestive heart failure?

Cardiac glycosides, or specifically Digitalis 

What is the best way to treat CHF (congestive heart failure)?

The best is always to treat the underlying cause.

Ang CHF ay laging mangyayari dahil may dahilan. Usually, it is just a complication of another heart problem. — (Example, pinanganak ang bata na may butas sa puso, hindi namanage agad at hindi natreat agad kaya nagka-CHF.)

Thus, the best is always treat the underlying cause.

CHF itself can be treated with digitalis or cardiac glycosides but if the underlying cause will not be addressed, CHF could just come back again. TF?

True

What are the different signs and symptoms of CHF?

What are the two late signs that can be observed in people with CHF?

1. Engorged, pulsating neck veins

2. Enlarged liver or spleen, with abdominal distention 

When digitalis is given to a person with CHF, it is expected for her heart to beat faster. TF?

False

It will start to slow down and beat normally

Pero kapag nag-improve na ang fiber contraction, syempre babagal na ang tibok ng pusok. Magiging effective na ang functioning niya at mawawala ang congestion.

What are the different Effects of Digitalis on the Heart Muscle?

1. Positive inotropic action

2. Negative chronotropic action

3. Negative chromotropic action

What are the different cautions when giving Digoxin?

1. Give 1 hour before or 2 hours after feeding (on an empty stomach for better absorption)

2. Take apical pulse for 1 minute 

3. Expect that colored vision and diarrhea is common.

4. Monitor K level, if less 3.5 mEq/L, hold dose

5. Monitor Digoxin levels at 0.8 to 2 micrograms per liter and check for toxicity such as nausea, anorexia, vomiting, lethargy, and bradycardia

6. Give Digoxin immune Fab (ovine, Digibind) to treat severe digitalis toxicity

When giving digoxin, what side effects are common?

1. Colored Vision

2. Diarrhea

   but will resolve eventually

When giving digoxin, you need to monitor what levels?

1. K level

2. Digoxin levels 

You hold dose and stop digoxin, if the K level is what?

Less than 3.5 mEq/L 

If less than 3.5 mEq/L, hold dose and stop digoxin.

Because digoxin is a drug which has a low therapeutic index.

Which means merong possible digoxin or digitalis toxicity even if you give this drug at the right dose, route, time, computation. Dahil sadyang meron siyang low therapeutic index or narrow margin of safety, meron pa ring risk of toxicity.

A decreased potassium level in the blood will increase digitalis toxicity, monitor K with digitalis.

What is the acceptable level of digoxin in the blood, wherein more than this level may already indicate toxicity?

0.8 to 2 micrograms per liter 

0.8 to 2 micrograms per liter lang ang acceptable normal range in the blood.

If it is more than that, it may already indicate toxicity.

If there’s already signs of toxicity, aside from stopping the drug you have to give Digoxin immune Fab (ovine, Digibind)

What is the antidote to treat severe digitalis toxicity?

Digoxin immune Fab (Ovine, Digibind) 

It is a precursor for myocardial infarction.

Angina Pectoris 

What is the difference between Myocardial infarction (MI) and Angina Pectoris?

Kung sa MI, zero oxygen supply na sa heart.

Ang angina pectoris, hindi pa siya 0, but there is less oxygen supply kaya reversible pa ang angina pectoris.

Angina Pectoris is an irreversible condition. TF?

False

It is a reversible condition 

What are the 3 General Classes of Anti-anginals?

1. Nitrates (for variant)

2. Beta Blockers (for classic)

3. Calcium Channel Blocker (for variant) 

Among the 3 general classes of anti-anginals, which is the only one that can be used for the classic kind of angina, whereas the other two are used for variant angina?

Beta Blockers (for Classic Angina)

Nitrations & Calcium channel blocker (for variant) 

This refers to any deviation from normal rate or pattern of heartbeat.

Cardiac Dysrhythymia or Arrythymia 

Ang normal heartbeat natin ay lub dub

What are the different Antidysrhythmic drugs?

1. Class 1 (Sodium Channel Blockers) - procainamide or lidocaine

2. Class 2 (Beta Blockers) - acebutolol

3. Class 3 (Drugs that prolong repolarization) - Adenosine

4. Class 4 (Calcium Channel Blockers) - Verapamil 

This is a drug for preventing seizure that can also be used as an anti-dysrhythmic. 

Phenytoin

What class IV calcium channel blocker can you use to improve myocardial contraction and treat irregularities of the heart?

Verapamil 

This is a drug that can be used to treat CHF but also have an effect on regularizing the rhythms of the heart.

Digoxin 

T/F: Cardiovascular drugs are drugs which affect both the heart and the blood vessels. 

TRUE

When there is congestive heart failure, there are two problems.

• The first is heart failure where there’s an inability of the heart to pump blood effectively.

• Second is congestion wherein because of its failure to pump blood effectively, the blood becomes congested in the heart since the heart cannot effectively pump or release it to the systemic circulation; thus, retaining blood into the four chambers. 

CHF can be classified as left or right-side heart failure.

When it's a left-side heart failure, the symptoms are focused on?

Regardless whether it's left or right, both show symptoms of tachycardia.

pulmonic symptoms

CHF can be classified as left or right-side heart failure.

When it's a right-side heart failure, the symptoms are focused on?

Regardless whether it's left or right, both show symptoms of tachycardia.

systemic symptoms

This is a group of drugs that inhibit the Na-K pump, resulting in an increase in Intracellular Na and Influx of Ca causing cardiac muscle fibers to contract effectively.

Digitalis

When the heart is struggling, it always compensates by?

This is why CHF is characterized initially by tachycardia.

beating faster

T/F:

When digitalis is given to a person with CHF.

• It has a positive inotropic action wherein it increases myocardial contraction, thus increasing stroke volume.

• It also produces a negative chronotropic action wherein it decreases the heart rate.

• Apart from that is its negative chromotropic action wherein it decreases conduction of heart cells, thus improving myocardial contractility.

TRUE

This refers to the amount of oxygenated blood that is released from the aorta every heartbeat.

Its average amount is 80-120 ml. 

Stroke volume

This is the amount of oxygenated blood that exits the aorta for every 1 minute.

It is about 5-6 liters of blood which is enough to supply oxygenated blood to the cells. 

Cardiac output

This is a rapid-acting digitalis and is a secondary drug for heart failure that may be given PO or IV.

Digoxin (Lanoxin)

Bakit secondary? Kasi nga aside from heart failure, mayroon pang congestion sa CHF.

And first drug will also address the congestion which will be discussed later on.

What is important to remember when giving digoxin?

a decreased potassium level in the blood will increase digitalis toxicity

Less than 3.5 mEq/L 

If less than 3.5 mEq/L, hold dose and stop digoxin. Because digoxin is a drug which has a low therapeutic index. Which means merong possible digoxin or digitalis toxicity even if you give this drug at the right dose, route, time, computation. Dahil sadyang meron siyang low therapeutic index or narrow margin of safety, meron pa ring risk of toxicity.

A decreased potassium level in the blood will increase digitalis toxicity, monitor K with digitalis.

Angina Pectoris is an acute cardiac pain lasting for a few minutes caused by inadequate blood flow to the myocardium due to?

plaque occlusions or spasms of coronary arteries

There are 3 Kinds of Angina Pectoris.

The first one occurs with stress or exertion.

classic (stable)

There are 3 Kinds of Angina Pectoris.

The second occurs frequently over the course of a day with progressive severity.

unstable (preinfarction)

There are 3 Kinds of Angina Pectoris.

The third is the most critical since it occurs even at rest. 

Variant (prinzmetal, vasospactic)

T/F: To treat Angina Pectoris, we need to give drugs that will improve blood flow (do what?) to the heart so that there would be more oxygen supply to the heart. 

TRUE

Mag increase yung blood flow, mag increase yung oxygen supply, therefore, mag decrease yung oxygen demand ng myocardium

These drugs increase blood flow either by increasing oxygen supply or decreasing oxygen demand by the myocardium

Antianginal

There are 3 General Classes of Anti-anginals. 

Which reduces venous tones, decreases the workload of the heart, and promotes vasodilation?

NITRATES

There are 3 General Classes of Anti-anginals. 

Which decreases the effects of SNS which decreases the workload of the heart and decreases oxygen demand?

BETA BLOCKERS

There are 3 General Classes of Anti-anginals. 

Which inhibits calcium action within the myocardium, which decreases the workload of the heart and decreases oxygen demand?

CALCIUM CHANNEL BLOCKER

This is a nitrate that can be used to treat angina and can be given only for 3 doses.

It must be given every 5 to 15 minutes apart

Nitroglycerin SL

Pag sublingual (SL) tinutunaw sa ilalim ng dila. Nitroglycerin SL can be given only for 3 doses.

Possible every 5 to 15 minutes apart.

T/F: Beta Blockers used to treat Angina like Atenolol (beta blocker drug) are very specific for Beta 1 which are the receptors found in the heart.

TRUE

This is an example of a calcium channel blocker used to treat angina.

When taking this, it is important to take the pulse rate for 1 full minute.

• Dizziness is the most common complaint. 

Amlodipine

The heart has 4 chambers.

Which are the upper chambers?

Atria

• The right atrium collect unoxygenated blood, while

• The left atrium collects oxygenated blood.  

The heart has 4 chambers.

Which are the lower chambers? .

Ventricles

• The right ventricle pumps unoxygenated blood going to the pulmonic circulation, while

• The left ventricle pumps oxygenated blood going to the systemic circulation. 

In an ECG there is what we call the P wave, the QRS Complex, and the T Wave.

Which represents the atrial contraction whenever the right and left atria collects blood?

P wave

In an ECG there is what we call the P wave, the QRS Complex, and the T Wave.

Which represents the ventricles pumping blood (both R and L)?

QRS Complex

In an ECG there is what we call the P wave, the QRS Complex, and the T Wave.

Which represents the recovery time or relaxation time?  

T Wave

When there is an irregularity in the rhythm of the heart (there is no regular pace), what do we give to regularize the rhythm?

anti-dysrhythmics

This is a class 1 sodium channel blocker and is an emergency drug for anti-dysrhythmia because it produces anaesthetic effects on the heart, especially when there is an irregularity in the rhythm. 

Lidocaine

This can improve blood flow to the myocardium of the heart which is why they can also regularize the rhythm of the heart.

An example would be acebutolol.

Class 2 Beta Blockers

An example would be acebutolol.

T/F: Prolonging relaxation can also improve the rhythm of the heart.

TRUE

T/F: Prolonging relaxation can also improve the rhythm of the heart.

This is why you give drugs that prolong repolarization since it means the heart relaxes while depolarization is the heart contracting.

TRUE

In this case, you can give adenosine which is a drug that can prolong repolarization.

What does repolarization means?

the heart relaxes

What does depolarization means?

the heart contracting