CARDIAC GLYCOSIDES AND
INOTROPIC AGENTS
Rapid-Acting Digitalis
Digoxin (Lanoxin) A: PO: 0.5-1 mg initially in 2 divided doses
(digitalization); maint: 0.125- 0.5 mg/d IV: Same as PO dose but
given over 5 min Older adults: 0.125 mg/d C: 1 mo-2y: PO: 0.01-0.02
mg/kg in 3 divided doses; maint: 0.012 mg/kg/d in 2 divided doses C:
IV: Dosage varies C: 2-10y: PO: 0.012-0.04 mg/kg in divided doses
.Pediatric doses are usually ordered in mcg in elixir form. t 12 : 30-40
h Excretion: 70% in urine; 30% by liver metabolism; To treat HF,
atrial fibrillation
Phosphodiesterase Inhibitors (Positive Inotropic Bipyridines)
Milrinone lactate A: IV: Initially: 50 mcg/kg/over 10 min
Continuous infusion: 0.375-0.75 mcg/kg/min with 0.45%-0.9% saline
For short-term treatment of HF. May be given before heart
transplantation. Heart rate and blood pressure should be closely
monitored. Pregnancy category: C; PB: 70%; t 12 : 1.5-2.5 h
Atrial Natriuretic Peptide Hormones
Nesiritide (Natrecor) A: IV bolus: 2 mcg/kg, followed by 0.01
mcg/kg/min, by IV infusions; max: 0.03 mcg/kg/min continuous IV
infusion. To treat acute HF by increasing sodium loss. Useful in
managing dyspnea at rest. Causes vasodilation. Contraindicated for
patients with systolic BP <90 mm Hg. Pregnancy category:
C;PB:UK;
t 12:18 min
Antidote for Digitalis Toxicity
Digoxin immune Fab (Digibin)
A: IV: 760-800 mg IV diluted in 50 mL NSS. Infuse
over 30 min For serious digitalis toxicity. Agent binds with digoxin to
form complex molecules. (Serum digoxin level >2 ng indicative of
digitalis toxicity.) Onset of action: 30 min; duration of action:
3-4 d. Pregnancy category: C; PB: UK; t 12 : 23 h
ANTIANGINAL DRUGS
Stress tests, echocardiogram, cardiac profile laboratory
tests, and cardiac catheterization may be needed to
determine the degree of blockage in the coronary arteries
and then also to treat the condition.
Nitrates
Dilation of veins, which decreases preload and decreases O2
demand
Short Acting
Nitroglycerin (Nitrostat, Nitro-Bid, Transderm-
Nitro) to control angina pectoris (anginal pain)
Pregnancy Category: C
A: PO/SL: 0.3, 0.4, 0.6 mg; repeat q5min × 3 as needed;
SR: 2.5- 6.5 mg, 2-4 times/d
IV: Initially: 5 mcg/min; dose may be increased
Pregnancy Category: C
Ointment: 2% 1-2 inches to chest or thigh area
Patch: 2.5-15 mg/d to chest or thigh area
Long Acting
Isosorbide Dinitrate (Isordil,Sorbitrate)
A: PO: IR: Initially 5-20 mg b.i.d/t.i.d.; maint:
10-40 mg b.i.d./t.i.d.
A: SL: 2.5-10 mg q2-3h PRN
A: SR: 40-160 mg/d
To prevent anginal attacks. Can lower blood pressure. Tolerance
builds up over time. Headaches, dizziness, lightheadedness, and
flush may occur. Pregnancy category: C; PB: UK; t 12: 1-4 h
Isosorbide mononitrate (Imdur)
A: PO: IR: 5-20 mg b.i.d.; max: 40 mg/d
A: PO: SR: 30-60 mg in morning; max: 240 mg/d
To prevent anginal attacks. SR form provides controlled delivery
and a 6-hour drug-free period, which helps reduce drug tolerance
and increase effectiveness. Pregnancy category: C; PB: 5%; t 12:
5h
Beta Adrenergic Blockers
Block the beta1- and beta2-receptor sites. Beta blockers
decrease the effects of the sympathetic nervous system by
blocking the action of the catecholamines (epinephrine and
norepinephrine), thereby decreasing the heart rate and
blood pressure.
Atenolol (Tenormin) (beta1) A: PO: 25-100 mg/d; max:
200 mg/d To control angina pectoris. Also effective in managing
hypertension. Closely monitor blood pressure and heart rate.
Cardioselective drug; blocks beta1. Can be used by patients with
asthma. Pregnancy category: D; PB: 5%-15%; t 12 : 6-7 h
Metoprolol tartrate (Lopressor, Toprol XL) (beta1) PO:
50-100 mg in 2 divided doses; may increase to 100-400 mg/d PO: ER:
100 mg/d; may increase to 400 mg/d IV: 5 mg q2min; followed in 1-2
h by PO: 25-50 mg q6h; Similar to atenolol in blocking beta1. High
doses of metoprolol can affect beta2 and could cause
bronchoconstriction. Can reduce cardiac oxygen demand, which
decreases heart rate and contractility. Pregnancy category: C; PB:
12%; t 12 : 3-7 h
Nadolol (Corgard) (beta1 and beta2) A: PO: 40 mg/d; may
increase dose; max:240-320 mg/d in divided doses; For angina
pectoris and hypertension. Pregnancy category: C; PB: 30%; t 12 : 10-
24 h
Propranolol HCl (Inderal) (beta1 and beta2)
A: PO: Initially: 40 mg b.i.d.; maint: 160-480 mg/d in 2-3 divided
doses; max: 640 mg/d SR: 80-160 mg/d; may increase to 120-160
mg/d; max: 640 mg/d; First beta blocker; blocks beta1 and beta2.
No longer drug of choice to prevent angina because drug poses
risk for bronchospasm. Monitor heart rate, blood pressure, and
respiratory status. Pregnancy category: C; PB: 90%; t 12 : 2-6 h
Calcium Channel Blockers
Amlodipine (Norvasc) A: PO: Initially: 5 mg/d; maint: 5-10
mg/d; max: 10 mg/d Older adults: Initially: 2.5 mg/d; maint: 2.5-10
mg/d; For angina pectoris and hypertension. May be given with
another antianginal or antihypertensive drug. Pregnancy category:
C; PB: 93%; t 12 : 30-50 h
Diltiazem HCl (Cardizem) A: PO: 30-60 mg q.i.d.; may
increase to 360 mg/d in 4 divided doses; max: 480 mg/dSR: 60 mg
q12h; max: 360 mg/d CR: 120-180 mg/d; max: 360 mg/d; For
angina pectoris. Hypotensive effect not as severe as with
nifedipine. Monitor kidney function. Pregnancy category: C; PB:
70%-80%; t 12 : 3.5-9 h
Felodipine (Felendil XL) A: PO: Initially: 5 mg/d single
dose; maint: 2.5-10 mg/d; max: 10 mg/dOlder adults: Initially:
2.5 mg/d; max: 10 mg/d; To treat chronic angina pectoris and
manage hypertension. Reduces O2 demand by the heart. Potent
peripheral vasodilator; increases heart rate and myocardial
contractility. Pregnancy category: C; PB: >99%; t 12 : 10-16 h
Isradipine (DynaCirc) A: PO: 2.5-7.5 mg b.i.d.; max: 10
mg/d Primary use is to treat hypertension. Also given for angina
pectoris. Pregnancy category: C; PB: 95%; t 12 : 8 h
Nicardipine HCl (Cardene SR, Cardene IV) PO: 20 mg
t.i.d.; maint: 20-40 mg t.i.d. PO: SR: 30 mg b.i.d.; maint: 30-60
mg b.i.d. IV: Initially 5 mg/h infusion; max: 15 mg/h; For angina
pectoris. May be used alone or in combination with other
antianginals. Also used for hypertension. Peripheral edema,
headache, dizziness, and lightheadedness may occur. Pregnancy
category: C; PB: 95%; t 12 : 2-4 h
Nifedipine (Procardia, Adalat) A: PO: Initially 10 mg
t.i.d.; 30 mg q6-8h; max:180 mg/d. PO:ER: 30-60 mg/d; max: 90
mg/d; For angina pectoris. Closely monitor blood pressure,
especially if patient taking nitrates or beta blockers. A potent
calcium channel blocker. Pregnancy category: C; PB: 92%-98%;
t 12 : 2-5 h
Nisoldipine (Sular) A: PO: ER: Initially 17 mg/d; maint: 17-
34 mg/d. Older adults: PO: Initially 8.5 mg/d; maint: 8.5-34 mg/d
For angina pectoris and hypertension. Suppresses contraction of
cardiac and vascular smooth muscle. Increases heart rate and
cardiac output. Decreases blood pressure. Caution: Patients with
heart disease are prone to MI and HF. Pregnancy category: C;
PB: 99%; t 12 : 7-12 h
Verapamil HCl (Calan, Isoptin) A: PO: 40-120 mg t.i.d.;
max: 480 mg/d. IV: 5-10 mg over 2 min; may repeat in 30 min if
needed. For angina pectoris, cardiac dysrhythmias, and
hypertension. Peripheral edema, constipation, dizziness,
headache, and hypotension may occur. Pregnancy category: C;
PB: 90%; t 12 : 3-8 h