Cardiovascular System Treatments

Class IA antiarrhythmic agents

Indications: Supraventricular and ventricular tachycardia

Class IA antiarrhythmic mechanism of action

Binds and blocks fast sodium channels that cause rapid depolarization of fast-response cardiac action potentials (phase 0)

Class IA antiarrhythmic adverse reactions

Ventricular fibrillation, QT prolongation, seizures, dizziness, and drowsiness

Class IA antiarrhythmic drug interactions

TCAs and fluoroquinolones

Class IA antiarrhythmic contraindications/cautions

Electrolyte abnormalities, renal impairment, and elderly patients

Class IA antiarrhythmic notes

Must be taken at prescribed levels; do not skip doses unless directed by the physician.

Alcohol and nicotine should not be taken with antiarrhythmics.

Swallow whole; do not crush or chew ER dosage forms.

Examples of class IA antiarrhythmics

1. disopyramide

2. procainamide

3. quinidine

Generic: disopyramide

Brand names: Norpace, Norpace CR

Dosage form: capsule

Dosage: 150 mg PO q6h

Generic: procainamide

Brand: N/A

Dosage form: solution

Dosage: 1-6 mg/min IV

Note: procainamide should be taken on an empty stomach

Generic: quinidine

Brand: N/A

Dosage forms: tablet, ER tablet

Dosage: varies by condition

Note: quinidine should not be taken with grapefruit juice

Class IB antiarrhythmic agents

Indications: Supraventricular and ventricular tachycardia

Class IB antiarrhythmic mechanism of action

Inhibits the fast sodium channel while shortening the action potential duration in non-diseased tissue (Class 1 effect)

Class IB antiarrhythmic adverse reactions

Dizziness, tremors, and impaired coordination

Class IB antiarrhythmic drug interactions

Clozapine and duloxetine

Class IB antiarrhythmic contraindications/cautions

First-degree atrial ventricular block, seizure disorder, and cardiogenic shock

Class IB antiarrhythmic notes

Must be taken at prescribed levels and doses; must not be skipped unless directed by the physician.

Alcohol and nicotine should not be taken with antiarrhythmics.

Examples of Class 1B antiarrhythmics

1. lidocaine

2. mexiletine

Generic: lidocaine

Brand: Xylocaine

Dosage form: solution
Dosage: 1-4 mg/min IV infusion

Generic: mexiletine

Brand: NA

Dosage form: capsule

Dosage: 200 mg PO q8h

Notes

1. Store mexiletine at room temp away from moisture and heat.

2. Mexiletine should be taken with a full glass of water.

3. Take mexiletine with food or an antacid to lessen stomach upset.

Angiotensin converting enzyme (ACE) inhibitors

Indications: elevated blood pressure, congestive heart failure, and post-myocardial infarction

ACE inhibitor mechanism of action

Inhibits the conversion of angiotensin I to angiotensin II.

Lower quantities of angiotensin II increase plasma renin activity and reduce aldosterone secretion.

ACE inhibitor adverse reactions

Dry, unproductive cough, angioedema, and possible postural hypotension.

Dizziness occurs during the first few days of therapy.

ACE inhibitor drug interactions

NSAIDs, certain diuretics, potassium supplements, and lithium

ACE inhibitor contraindications/cautions

Renal impairment, pregnancy, and elderly patients

ACE inhibitor notes

Take with a full glass of water.

May be taken with or without food.

ACE inhibitors have a potassium-sparing effect; be aware of possible hyperkalemia.

If patient is pregnant, discontinue ACE inhibitors immediately; fetal or neonatal morbidity or mortality may occur.

ACE inhibitors should be avoided in patients taking lithium.

Examples of ACE inhibitors

1. benazepril

2. captopril

3. enalapril

4. lisinopril

5. quinapril

6. ramipril

Generic: benazepril

Brand: Lotensin

Dosage form: tablet

Dosage: 5–20 mg PO qd

Generic: captopril

Brand: Capoten

Dosage form: tablet

Dosage: 12.5–50 mg PO tid

Generic: enalapril

Brand: Vasotec

Dosage form: tablet

Dosage: 2.5–20 mg PO bid

Generic: lisinopril

Brand names: Prinivil, Zestril

Dosage form: tablet

Dosage: 5–20 mg PO qd

Generic: quinapril

Brand: Accupril

Dosage form: tablet

Dosage: 5–20 mg PO bid

Generic: ramipril

Brand: Altace

Dosage form: capsule

Dosage: 2.5–20 mg PO div qd–bid

Angiotensin II receptor blockers (ARBs)

Indications: Hypertension, congestive heart failure, and preventing kidney failure in people with diabetes or high blood pressure.

ARB mechanism of action

Binds to angiotensin II receptors and blocks vasoconstrictive effects of the arteries

ARB adverse reactions

Angioedema, cough, dyspepsia, and fatigue

ARB drug interactions

Lithium, ketoconazole, and phenobarbital

ARB contraindications/cautions

Pregnancy, renal artery stenosis, and renal or hepatic impairment

ARB notes

May be taken with or without food.

Blood pressure will need to be monitored.

If patient is pregnant, discontinue ARBs immediately or fetal or neonatal morbidity or mortality may occur.

Examples of ARBs

1. azilsartan

2. candesartan

3. irbesartan

4. losartan

5. telmisartan

6. valsartan

Generic: azilsartan

Brand: Edarbi

Dosage form: tablet

Dosage: 80 mg PO qd

Generic: candesartan

Brand: Atacand

Dosage form: tablet

Dosage: 32 mg PO qd

Generic: irbesartan

Brand: Avapro

Dosage form: tablet

Dosage: 75-300 mg PO qd

Generic: losartan

Brand: Cozaar

Dosage form: tablet

Dosage: 25–100 mg PO div qd–bid

Generic: telmisartan

Brand: Micardis

Dosage form: tablet

Dosage: 20–80 mg PO qd

Generic: valsartan

Brand: Diovan

Dosage form: tablet

Dosage: 40-160 mg PO bid

Beta blockers

Indications: Hypertension, angina, and myocardial infarction

Beta blocker mechanism of action

Blocks response to beta stimulation

Results in a reduction in heart rate, myocardial contractility, blood pressure, and myocardial demand.

Beta blocker adverse reactions

Heart depression, bronchoconstriction, impotence, fatigue, depression, and bradycardia

Beta blocker drug interactions

Diuretics, hypoglycemic agents, NSAIDs, and calcium channel blockers

Beta blocker contraindications/cautions

Sinus bradycardia, second- or third-degree AV block, and congestive heart failure

Beta blocker notes

May be taken with or after a meal.

Blood pressure should be monitored.

May mask symptoms of hypoglycemia and hyperthyroidism.

Medication should be tapered off when therapy is discontinued.

Examples of beta blockers

1. carvedilol

2. nadolol

3. propanolol

Cardio-selective

1. acebutolol

2. atenolol

3. metoprolol succinate

4. metoprolol tartrate

Generic: carvedilol

Brands: Coreg, Coreg CR

Dosage forms: tablet, capsule

Dosage: 25 mg PO bid

Generic: nadolol

Brand: Corgard

Dosage form: tablet

Dosage: 40–80 mg PO qd

Generic: propanolol

Brand: NA

Dosage form: tablet, capsule

Dosage: 180–240 mg/day PO div tid–qid

Generic: acebutolol

Brand: Sectral

Dosage form: capsule

Dosage: 400–800 mg PO qd

Generic: atenolol

Brand: Tenormin

Dosage form: tablet

Dosage: 50-100 mg PO qd

Generic: metoprolol succinate

Brand: Toprol XL

Dosage form: tablet

Dosage: 25-400 mg PO qd

Generic: metoprolol tartrate

Brand: Lopressor

Dosage forms: tablet, IV solution

Dosage: 50-200 mg PO BID

Nitrates

Indications: angina, hypertension, and congestive heart failure

Nitrate mechanism of action

Relaxes vascular smooth muscle, resulting in lower venous return and cardiac filling.

Decreases tension in cardiac walls and coronary vessels that are dilated.

Nitrate adverse reactions

Postural hypotension, bradycardia, and flushing

Nitrate drug interactions

Beta blockers, verapamil, diltiazem, sildenafil, tadalafil, or vardenafil

Nitrate contraindications/cautions

Cardiomyopathy, constrictive pericarditis, and anemia

Nitrate note

Medication should be tapered, not stopped abruptly.

Examples of nitrates

1. isosorbide dinitrate

2. isosorbide mononitrate

3. nitroglycerin

Generic: isosorbide dinitrate

Brand: Dilatrate-SR

Dosage form: capsule

Dosage: 40-80 mg PO qd-bid

Generic: isosorbide mononitrate

Brand: NA

Dosage form: tablet

Dosage: 30-60 mg PO q AM

Generic: nitroglycerin

Brands: Nitrostat, Nitro-Bid, Nitro-Dur

Dosage forms: tablet, ER transdermal patch, ointment

Dosages

• Tablet: 0.3-0.6 mg SL q 5 min

• Patch: 0.2-0.4 mg/h patch qd

• Ointment: 0.5-2 inch topical q4–6h

Notes

• Nitroglycerin should be refilled before the prescription runs out.

• Nitroglycerin tablets should be stored in the original glass container at room temp, away from moisture and heat.

• SL nitroglycerin tablets should be placed under the tongue and allowed to dissolve; they should not be chewed or swallowed. Additional tablets every 5 minutes, but not more than three tablets in 15 minutes.

Calcium channel blockers (CCBs)

Indications: Hypertension, angina, and arrhythmias

CCB mechanism of action

Inhibits calcium ions from entering “slow channels” of the vascular smooth muscle and the myocardium.

Results in relaxation of the coronary smooth muscle and coronary vasodilation and a decrease in oxygen demand.

CCB adverse reactions

Peripheral edema, palpitations, drowsiness, and headache

CCB drug interactions

Beta blockers, digitalis, and potassium-depleting medications

CCB contraindications/cautions

Severe coronary artery disease, severe aortic stenosis, and congestive heart failure

CCB notes

Should be taken with food.

Use with alcohol may result in hypotensive crisis.

Nicotine reduces the effect of CCBs.

CCBs should be tapered before being discontinued.

Examples of CCBs

Dihydropyridine CCBs

• amlodipine

• felodipine

• nicardipine

• nifedipine

Non-dihydropyridine CCBs

• diltiazem

• verapamil

Generic: amlodipine

Brand: Norvasc

Dosage form: tablet

Dosage: 5-10 mg PO qd

Generic: felodipine

Brand: Plendil

Dosage form: tablet

Dosage: 2.5-10 mg PO qd

Generic: nicardipine

Brand: NA

Dosage form: capsule

Dosage: 20-40 mg PO tid

Generic: nifedipine

Brands: Procardia, Procardia XL

Dosage forms: tablet, ER tablet

Dosage: 10-20 mg PO tid

Generic: diltiazem

Brand: Dilacor XR

Dosage form: ER capsule

Dosage: 120-240 mg PO qd

Generic: verapamil

Brands: Calan, Calan SR, Verelan, Verelan PM

Dosage forms: ER tablet, ER capsule

Dosage: 80-120 mg PO tid