1.

Nitroglycerin

Brand name> Nitrostat

Classification> nitrates

Action> Nitroglycerin forms free radical nitric oxide (NO) which activates guanylate
cyclase, resulting in an increase of guanosine 3'5' monophosphate (cyclic GMP) in
smooth muscle and other tissues. These events lead to dephosphorylation of myosin light
chains, which regulate the contractile state in smooth muscle, and result in vasodilation.

Route of Dosage> Depending on clinical and hemodynamic indicators the dose steals up
individually for each patient. At use in the conditions of a hospital treatment it is
necessary to begin with a dose of 0 mg/ch, if necessary a dose gradually enlarge. The
maximum dose makes 8-10 mg/ch.

Indication> - A stenocardia (including an astable stenocardia, an angiospastic

stenocardia);
- An acute myocardial infarction;
- An acute left ventricular failure;
- A hypertensive crisis with a decompensation of warm activity;
- A controllable hypotension at operative measures.

Contraindication> - Acute vascular insufficiency (a shock, a vascular collapse);

- A cardiogenic shock (if correction of final diastolic pressure of a left ventricle by means
of an intraaortal counterpulsation or preparations with positive inotropic action is
impossible);
- A toxic fluid lungs;
- The expressed arterial hypotension (a systolic BP below 90 mm hg);
- The diseases accompanied by rising of intracranial pressure;
With care it is necessary to prescribe a preparation at a hypertrophic subaortic stenosis, a
chronic cardial compression, a cardiac tamponade, a stenosis of a mouth of an aorta and-
or a mitral stenosis, at pressure decrease of filling of a left ventricle (for example, at an
acute myocardial infarction, insufficiency of a left ventricle; it is necessary to avoid
depression of a systolic BP below 90 mm hg), predilections to orthostatic reactions, at
renal insufficiency, hepatic insufficiency (since the risk of development of a
methemoglobinemia increases).

Adverse Reactions> A persistent, throbbing headache commonly occurs with

nitroglycerin therapy. Aspirin, acetaminophen, or ibuprofen may be used to relieve the
pain. Flushing of the head and neck can occur with nitroglycerin therapy as can an
increase in heart rate or palpitations. This can be associated with a drop in blood pressure
which can be accompanied by dizziness or weakness. To reduce the risk of low blood
pressure, patients often are told to sit or lie down during and immediately after taking
nitroglycerin
Nursing Responsibility> Inform the patient such as..
Do not use nitroglycerin if you are taking sildenafil (Viagra). Serious, life-threatening
side effects can occur if you take nitroglycerin while you are using sildenafil. You should
not use this medication if you are allergic to nitroglycerin, isosorbide mononitrate
(Imdur), or isosorbide dinitrate (BiDil, Isordil), or if you have:

• early signs of a heart attack (chest pain or heavy feeling, pain spreading to the arm
or shoulder, nausea, sweating, general ill feeling);
• severe anemia (a lack of red blood cells); or
• a brain injury, hemorrhage, or tumor.

Before taking nitroglycerin, tell your doctor if you are allergic to any drugs, or if you
have:

• congestive heart failure;

• a history of heart attack, stroke, or head injury;
• low blood pressure;
• glaucoma;
• migraine headaches;
• liver disease.

• 2. Nifedipine

Brand name> Adalat, Procardia, Afeditab, Nifediac

Classification> Calcium Channel Blockers

Action> nifedipine works by blocking the flow of calcium into the muscle cells
surrounding the arteries that supply blood to the heart (coronary arteries) as well as other
arteries of the body. Since the inflow of calcium is what causes the muscle cells to
contract, blocking the entry of calcium relaxes the muscles and dilates (widens) the
arteries. By dilating coronary arteries, nifedipine increases the flow of blood to the heart.

Route of Dosage> The usual dose for nifedipine capsules is 10 to 20 mg three times
daily. It is important to swallow capsules whole. For extended release tablets, the usual
dose is 30 or 60 mg once daily. The tablets should be swallowed whole and not bitten or
cut in half. Nifedipine can be taken with or without food

Indication> Administration of the drug for the treatment of hypertension is well documented for
patients of different age groups.

Contraindication> hypersensitivity
Adverse Reactions> Side effects of nifedipine are generally mild, and reversible. Most
side effects are expected consequences of the dilation of the arteries. The most common
side effects include headache, dizziness, flushing, and edema (swelling) of the lower
extremities. Less common side effects include dizziness, nausea and constipation.

Nursing Responsibility> Monitor BP carefully during titration period.

Patient may become severely hypotensive, especially if also taking other drugs
known to lower BP. Withhold drug and notify physician if systolic BP <90.

• Monitor blood sugar in diabetic patients. Nifedipine has diabetogenic

properties.
• Monitor for gingival hyperplasia and report promptly. This is a rare but
serious adverse effect (similar to phenytoin-induced hyperplasia).

Patient & Family Education

• Keep a record of nitroglycerin use and promptly report any changes in

previous pattern. Occasionally, people develop increased frequency, duration,
and severity of angina when they start treatment with this drug or when dosage
is increased.
• Be aware that withdrawal symptoms may occur with abrupt
discontinuation of the drug (chest pain, increase in anginal episodes, MI,
dysrhythmias).
• Inspect gums visually every day. Changes in gingivae may be gradual,
and bleeding may be exhibited only with probing.
• Seek prompt treatment for symptoms of gingival hyperplasia (easy
bleeding of gingivae and gradual enlarging of gingival mass, especially on
buccal side of lower anterior teeth). Drug will be discontinued if gingival
hyperplasia occurs.
• Research shows that smoking decreases the efficacy of nifedipine and
has direct and adverse effects on the heart in the patient on nifedipine treatment.
• Do not breast feed while taking this drug without consulting physician.

3.Lidocaine
Brand name> Xylocaine

Classification> Local anesthetic, antiarrhythmic

Action> Injectable lidocaine is used to numb an area before surgery or before another
medical procedure.

Route of Dosage> TOPICAL APPLICATION: For laryngoscopy, bronchoscopy and

endotracheal intubation, the pharynx may be sprayed with 1−5 mL (40−200 mg of
Lidocaine HCl), i.e., 0.6−3 mg/kg or 0.3-1.5 mg/lb body weight.

Normal Healthy Adults: The maximum recommended dose of 4% Lidocaine

Hydrochloride Injection, USP should be such that the dose of Lidocaine HCl is kept
below 300 mg and in any case should not exceed 4.5 mg/kg (2 mg/lb) body weight.

Indication> 4% Lidocaine Hydrochloride Injection, USP is indicated for the production

of topical anesthesia of the mucous membranes of the respiratory tract or the genito-
urinary tract. It may be injected trans-tracheally to anesthetize the larynx and trachea, and
it may be administered by retrobulbar injection to provide anesthesia for ophthalmic
surgery.

Contraindication> Lidocaine is contraindicated in patients with a known history of

hypersensitivity to local anesthetics of the amide type.

Adverse Reactions> Adverse experiences following the administration of Lidocaine are

similar in nature to those observed with other amide local anesthetic agents. These
adverse experiences are, in general, dose-related and may result from high plasma levels
caused by excessive dosage, rapid absorption or inadvertent intravascular injection, or
may result from a hypersensitivity, idiosyncrasy or diminished tolerance on the part of
the patient.

Nursing Responsibility> Inform the patient such as..

When topical anesthetics are used in the mouth, the patient should be aware that the
production of topical anesthesia may impair swallowing and thus enhance the danger of
aspiration. For this reason, food should not be ingested for 60 minutes following use of
local anesthetic preparations in the mouth or throat area. This is particularly important in
children because of their frequency of eating.

4. Tocainide HCL

Brand name> Tonocard

Classification> Therapeutic—

Antiarrhythmic, Group IB

Action> Tocainide, like lidocaine, produces dose dependent decreases in sodium and
potassium conductance, thereby decreasing the excitability of myocardial cells. In
experimental animal models, the dose-related depression of sodium current is more
pronounced in ischemic tissue than in normal tissue.

Route of Dosage> The recommended initial dosage is 400 mg every 8 hours. The usual
adult dosage is between 1200 and 1800 mg/day in a three dose daily divided regimen.
Doses beyond 2400 mg per day have been administered infrequently. Patients who
tolerate the t.i.d. regimen may be tried on a twice daily regimen with careful monitoring.

Indication> Initiation of treatment with tocainide HCl, as with other antiarrhythmic

agents used to treat life-threatening arrhythmias, should be carried out in the hospital. It is
essential that each patient given tocainide HCl be evaluated electrocardiographically and
clinically prior to, and during, therapy with tocainide HCl to determine whether the
response to tocainide HCl supports continued treatment.

Contraindication> Patients who are hypersensitive to this product or to local anesthetics

of the amide type.Patients with second or third degree atrioventricular block in the
absence of an artificial ventricular pacemaker.

Adverse Reactions> Tocainide HCl commonly produces minor, transient, nervous

system and gastrointestinal adverse reactions, but is otherwise generally well tolerated.
Tocainide HCl has been evaluated in both short-term (n = 1,358) and long-term (n = 262)
controlled studies as well as a compassionate use program. Dosages were lower in most
of the controlled studies (1200 mg/day) and higher in the compassionate use program
(1800 mg and more). In long-term (2-6 months) controlled studies, the most frequent
adverse reactions were dizziness/vertigo (15.3 percent), nausea (14.5 percent),
paresthesia (9.2 percent), and tremor (8.4 percent). These reactions were generally mild,
transient, dose-related and reversible with a reduction in dosage, by taking the drug with
food, or by therapy discontinuation. Tremor, when present, may be useful as a clinical
indicator that the maximum dose is being approached. Adverse reactions leading to
therapy discontinuation occurred in 21 percent of patients in long-term controlled trials
and were usually related to the nervous system or digestive system.

Nursing Responsibility> Inform the patient such as..

Take exactly as directed with food. If dose is missed, take as soon as possible, do not
double next dose. Do not discontinue without consulting prescriber. You will need
regular cardiac checkups while taking this medication. You may experience dizziness,
nervousness, or visual changes (use caution when driving or engaging in tasks requiring
alertness until response to drug is known); nausea, vomiting, or loss of appetite (small,
frequent meals, frequent mouth care, chewing gum, or sucking lozenges may help); or
mild muscle discomfort (analgesics may be recommended). Report chest pain,
palpitations, or erratic heartbeat; respiratory difficulty or unusual cough; mental
confusion or depression; muscle tremor, weakness, or pain; or vision changes.
Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to
become pregnant. Do not breast-feed.

5. Flecainide

Brand name> Tambocor

Classification> Antiarrhythmic Agent

Action> Class Ic antiarrhythmic; 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

Route of Dosage>

Oral:

Children:

Initial: 3 mg/kg/day or 50-100 mg/m2/day in 3 divided doses

Usual: 3-6 mg/kg/day or 100-150 mg/m2/day in 3 divided doses; up to 11 mg/kg/day or

200 mg/m2/day for uncontrolled patients with subtherapeutic levels

Adults:

Life-threatening ventricular arrhythmias:

Initial: 100 mg every 12 hours

Increase by 50-100 mg/day (given in 2 doses/day) every 4 days; maximum: 400 mg/day.

Indication> Prevention and suppression of documented life-threatening ventricular

arrhythmias (eg, sustained ventricular tachycardia); controlling symptomatic, disabling
supraventricular tachycardias in patients without structural heart disease in whom other
agents fail
Contraindication> Hypersensitivity to flecainide or any component of the formulation;
pre-existing second- or third-degree AV block or with right bundle branch block when
associated with a left hemiblock (bifascicular block) (except in patients with a
functioning artificial pacemaker); cardiogenic shock; coronary artery disease (based on
CAST study results); concurrent use of ritonavir or amprenavir

Adverse Reactions> In post-myocardial infarction patients with asymptomatic PVCs and

nonsustained ventricular tachycardia, Flecainide therapy was found to be associated with
a 5.1% rate of death and non-fatal cardiac arrest, compared with a 2.3% rate in a matched
placebo group.

Nursing responsibilities> Inform the patient such as..

Take exactly as directed, around-the-clock. Do not discontinue without consulting

prescriber. You will require frequent monitoring while taking this medication. You may
experience lightheadedness, nervousness, dizziness, visual disturbances (use caution
when driving or engaging in tasks requiring alertness until response to drug is known); or
nausea, vomiting, or loss of appetite (small frequent meals may help). Report
palpitations, chest pain, excessively slow or rapid heartbeat; acute nervousness, headache,
or fatigue; unusual weight gain; unusual cough; respiratory difficulty; swelling of hands
or ankles; or muscle tremor, numbness, or weakness. Pregnancy precaution: Inform
prescriber if you are or intend to become pregnant.

6.Esmolol

Brand name> Brevibloc

Classification> Antiarrhythmic Agent, Class II,Beta Blocker, Beta1 Selective

Action> Class II antiarrhythmic: Competitively blocks response to beta1-adrenergic

stimulation with little or no effect of beta2-receptors except at high doses, no intrinsic
sympathomimetic activity, no membrane stabilizing activity

Route of Dosage> I.V. infusion requires an infusion pump (must be adjusted to

individual response and tolerance):

Children:
SVT (unlabeled use): A limited amount of information regarding esmolol use in pediatric
patients is currently available. Some centers have utilized doses of 100-500 mcg/kg given
over 1 minute for control of supraventricular tachycardias.

Postoperative hypertension (unlabeled use): Loading doses of 500 mcg/kg/minute over 1

minute with maximal doses of 50-250 mcg/kg/minute (mean = 173) have been used in
addition to nitroprusside to treat postoperative hypertension after coarctation of aorta
repair.

Indication> Esmolol is given by slow intravenous injection. It is commonly used in

patients during surgery to prevent or treat tachycardia, and is also used in treatment of
acute supraventricular tachycardia. Esmolol is also the drug of choice when aortic
dissection is suspected.

Contraindication> Esmolol hydrochloride is contraindicated in patients with sinus

bradycardia, heart block greater than first degree, cardiogenic shock or overt heart failure

Adverse Reactions> The following adverse reaction rates are based on use of Esmolol
hydrochloride in clinical trials involving 369 patients with supraventricular tachycardia
and over 600 intraoperative and postoperative patients enroIled in clinical trials. Most
adverse effects observed in controlled clinical trial settings have been mild and transient.

Nursing Responsibility> Inform the patient such as..

Esmolol is administered in emergencies, patient education should be appropriate to
the situation. Pregnancy/breast-feeding precautions: Inform prescriber if you are
pregnant. Consult prescriber if breast-feeding.

7. Diltiazem

Brand Name: Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, Diltia XT, Tiazac

Classification: calcium channel blockers

Action: By blocking the entry of calcium, diltiazem decreases the force of contraction of
the heart and its rate of contraction. It also relaxes the muscles surrounding the arteries,
allowing the arteries to widen (dilate). In order to pump blood, the heart needs oxygen.

Route Of Dosage: Adult oral doses range between 120 and 480 mg daily. Immediate
release tablets are administered up to 4 times a day. Extended release formulations are
administered once daily at approximately the same time each day and should not be
crushed or chewed
Indication: Angina:

• Stable angina (exercise-induced) . Diltiazem increases coronary blood flow and

decreases myocardial oxygen consumption, secondary to decreased peripheral
resistance, heart rate, and contractility.[3][4]

• Variant angina. Diltiazem is effective due to its direct effects on coronary dilation.

• Unstable angina (preinfarction, crescendo). Diltiazem may be particularly

effective if the underlying mechanism is vasospasm.

Contraindication: CHF. Patients with reduced ventricular function may not be able to
counteract the inotropic and chronotropic effects of diltiazem, the result being an even
higher compromise of function.

Adverse Reactions: Diltiazem may cause side effects. Tell your doctor if any of these
symptoms are severe or do not go away:

• dizziness or lightheadedness
• flushing (feeling of warmth)
• headache
• weakness
• slow heartbeat
• vomiting
• diarrhea
• constipation
• nasal congestion
• cough

Nursing Responsibility: Inform the patient such as..

Do not use this medication if you have certain heart conditions such as "sick sinus
syndrome" or "AV block" (unless you have a pacemaker), low blood pressure, or if you
have recently had a heart attack.

Before taking diltiazem, tell your doctor if you are allergic to any drugs, or if you have
kidney disease, liver disease, or congestive heart failure.

Diltiazem can cause side effects that may impair your thinking or reactions. Be careful if
you drive or do anything that requires you to be awake and alert.
Do not stop taking this medication without first talking to your doctor. If you stop taking
diltiazem suddenly, your condition may become worse.

Diltiazem may be only part of a complete program of treatment that also includes diet,
exercise, and other medications. Follow your diet, medication, and exercise routines very
closely.

If you are being treated for high blood pressure, keep using this medication even if you
feel fine. High blood pressure often has no symptoms.