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Cardiac Medications
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Mildred Yarborough
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 Overview
 Drugs used to treat arrhythmias
 Antiarrhythmic & Cardiac glycosides

 Beta blockers & calcium channel blockers

 Drugs given intravenously to affect the
cardiovascular system
 Inotropes
 Adrenergic agonists
 Antiarrhythmics
Class I Sodium Channel Lidocaine
Blockers Propafenone

Class II Beta Blockers Sotalol

Class III K+ Blockers,pro- Amiodarone

long repolorization
Class IV Calcium Channel Diltiazem
Blocker
Other Adenosine
 Class I: Lidocaine
 Shortens repolarization, raises VF threshold
 Administered IV
 life-threatening arrhythmias: VT, VF
 short-term management
 Side effects: drowsiness, parasthesias, other CNS
effects
 Toxicity: seizures, respiratory depression, coma
 Contraindications: heart block
 Class II: Sotalol
 Beta blocker: decreases excitability of heart
due to sympathetic stimulation
 Uses: atrial and ventricular arrhythmias
 Oral administration
 Telemetry monitoring with initiating therapy
 Side effects: bradyarrhythmias, CHF, fatigue
 Class III: Amiodarone
 Prolongs action potential and refractory
period, inhibits adrenergic stimulation
 Uses: supraventricular and ventricular
arrhythmias not responsive to other drugs
 Very effective! Potentially very toxic!
 Administered IV in ICU, emergencies;
usually oral administration
 Very long half life (up to several months)
 Amiodarone
 Side effects: anorexia, other GI,
arrhythmias, others
 Toxicities: pulmonary fibrosis, corneal
micro-deposits, liver function abnormalities,
hypothyroidism, others
 Periodic monitoring for toxicities: pulmonary
function tests, eye exam, LFTs
 Class IV: Diltiazem
 Calcium channel blocker
 slows AV node conduction and AV node
refractory period
 Uses: rate control in atrial fibrillation or
flutter
 IV used acutely
 Oral administration or another drug class for
chronic management
 Diltiazem
 Monitoring: telemetry, blood pressure
 Side effects: hypotension, arrhythmias,
CHF, edema Contraindication: 2nd or 3rd
degree AV block, recent MI or pulmonary
congestion
 Others: Adenosine
 Used for acute management of rapid SVT
 Must be given rapid IV (1-2 sec) :
 half life 10-20 seconds

 IV push followed immediately by 20 CC NS

 Cardiac monitoring on Lifepac during
administration
Nursing Implications: Antiarrhythmics
 Cardiac monitoring with initiation and dosage
adjustment
 Obtain ECG strip prior to administration
 Analyze for rate, rhythm, intervals
 Be alert for changes over time
 Monitor for adverse & toxic effects
 Amiodarone requires special monitoring
 Drug blood levels as appropriate
 Timeliness of dosing essential
 Patient education
 Purpose & importance of drug
 Signs & symptoms of toxicity to notify MD
 Digoxin (Lanoxin)
 Cardiac glycoside
 Derived from foxglove
 Properties
 Increases contractility
 Positive inotrope

 Used for heart failure treatment

 Decreases heart rate
 Negative chronotrope
 Used to control heart rate in atrial fibrillation
 Digoxin (Lanoxin)
 Adverse effects usually related to toxicity
 Causes of toxicity
 Improper dosing
 Hypokalemia, hypomagnesemia
 Signs & symptoms
 Anorexia, nausea, diarrhea, weakness, fatigue
 Bradycardia, AV block, arrhythmias
 Visual changes: halos, double vision, color perception
changes
 Monitoring for toxicity
 Blood levels: 0.5-2 mcg/mL normal
 Check pulse before administration
 Digibind used to treat toxicity
 Digoxin
 Nursing implications
 Check pulse before administration
 Monitor electrolyte levels (K 4.0-5.2)
 Cardiac monitoring with digitalization
 Digoxin 0.25-0.5 mg po q8 hrs x 3
 Digoxin 0.125-0.25 mg IV q 4-8 hrs x 2-3
 Many drug interactions
 Narrow therapeutic margin
 Patient education
 Proper dosing & pulse check
 Blood level monitoring
 Drug interactions: check before starting new drugs
 Other inotropes
 Phosphodiesterase inhibitors
 Amrinone
 Milrinone
 Adrenergic agonist
 Dobutamine

  agonist
 Dopamine
 &  agonist
 Phosphodiesterase inhibitors
Amrinone (Inocor), Milrinone (Primacor)
Inhibits phosphodiesterase type III

 intracellular levels of C-AMP

 intracellular calcium levels

 contractility
 Phosphodiesterase inhibitors
 Use
 Management of decompensated CHF
 Administration: IV
 ICU/CCU: inpatient
 CHF clinics: outpatient
 Adverse effects
 Arrhythmias
 Thrombocytopenia
 Hypersensitivity
 Hypotension
 Hypokalemia
 Phosphodiesterase inhibitors
 Use
 Management of decompensated CHF
 Administration: IV
 ICU/CCU: inpatient
 CHF clinics: outpatient
 Adverse effects
 Arrhythmias
 Thrombocytopenia
 Hypersensitivity
 Hypotension
 Hypokalemia
Phosphodiesterase inhibitors
 Nursing implications
 Correct potassium prior to administration to reduce incidence of
arrhythmias
 Cardiac & vital sign monitoring with administration
 Monitor for therapeutic effect
  fatigue,  stamina
 Monitor labs: K, electrolytes, platelets Nursing implications
 Correct potassium prior to administration to reduce incidence of
arrhythmias
 Cardiac & vital sign monitoring with administration
 Monitor for therapeutic effect
  fatigue,  stamina
 Monitor labs: K, electrolytes, platelets
 Adrenergic agonists

 Dobutamine (Dobutrex)
 Beta-1 adrenergic agonist
 Stimulates sympathetic nervous system
 Increases contractility Used to treat
decompensated CHF

 Dobutamine Dobutamine
• Adverse effects
 Nervousness, nausea, headache, SOB
• Heart rate & BP increase
 Toxic effects
 Arrhythmias (PVC’s)
 Tachycardia
 Hypertension
• Angina
 Nursing implications
 Same as phosphodiesterase inhibitors
 Dopamine
 Effects differ depending on dose dose
 Low dose: 1-2 mcg/kg/min
 Renal dopaminergic receptors stimulated
  renal perfusion
 Used to promote diuresis in CHF, renal insufficiency
 Moderate dose: 2-10 mcg/kg/min
 Beta-1 receptor stimulation
  contractility & HR   cardiac output
 High dose: 10-20 or more
 Alpha receptor stimulation
  systemic vascular resistance   BP
 Used to support BP in cardiogenic shock, codes
 Dopamine
 Adverse effects
 Reduced renal & mesenteric perfusion with > 20
mcg/kg/min
 May compromise peripheral circulation at high
doses
 Headache, arrhythmias, hypotension,
extravasation
 Nursing implications
 Vital signs
 Cardiac monitoring
 I & O, daily weights
 Monitor renal function
 Assess peripheral perfusion at higher doses
 Epinephrine
 Pure Beta-agonist
 Stimulates sympathetic nervous system
 Uses: increase heart rate, in emergency
situations
 VT, VF, asystole given every 5 minutes
 Atropine
 Anticholinergic
 increasesheart rate by blocking parasympathetic
nervous system
 symptomatic bradycardia & high grade AV blocks
 asystole
 Case Discussion
 Mr. M is a 73 year old male admitted through the
ER, being driven in by his wife. His symptoms on
presentation were: 9/10 substernal chest
discomfort for 2 hours, radiating to the left arm.
He is also reporting nausea, difficulty breathing,
and appears diaphoretic.
 What do you suspect may be the cause of his
symptoms?
 What would your next actions be?
 Case Discussion
 Mr. M’s vital signs are:
 BP 90/50
 Pulse 96
 Respirations 30

 O2 sat 88% on room air

 He is placed on O2 3L NP which brings his sat
up to 93%
 With the administration of O2 he also notes that
the chest discomfort is now 7/10
 Case discussion
A 12 lead ECG is obtained within 5 minutes of
arrival which shows ST elevation in the anterior
leads
 What does this mean?

 His cardiac monitor is showing the following

rhythm:
What is this rhythm?

What actions would the nurse take based on

this rhythm?
 Case Discussion
 The patient is prepared to be transported for
an emergent primary angioplasty. As the
nurse is accompanying him to the elevator,
she notices this on the monitor:
What rhythm is this?
What would your next actions be?
 Case discussion
The patient is unresponsive, not breathing and
pulseless. The nurse calls for help and
prepares to defibrillate. After 3 successive
shocks the monitor shows:
The code team has arrived. The patient is
receiving CPR and is being bagged. The
doctor running the code orders Epinephrine
1 mg IV

What will this medication do for this

patient?
 Case discussion
 The patient is shocked again
unsuccessfully, and the doctor orders
Lidocaine 75 mg IV

What will this medication do for this

patient?
 Case discussion
After shocking the patient again at 360 J,
the monitor shows the following rhythm:
What will you anticipate the doctor to order
for this patient?
 Case discussion
The patient is brought to the cardiac cath lab
and the LAD is found to be totally occluded
The LAD is opened with angioplasty, and the
patient is then taken to ICU. The patient is
stable over the next 24 hours, then he
develops the following rhythm:
Case discussion
 Case discussion
What is the heart rate and rhythm?
What would the next appropriate nursing
interventions be?
 Case discussion
 The nurse finds that he is feeling
lightheaded, with a BP of 86/40.
 What does this mean?
 What would be the next appropriate
nursing action?
 Case discussion
The ICU standing orders include an
order for atropine 1 mg prn
bradycardia.
 Why is atropine effective in treating this
problem?
 After administration of atropine, the heart
rate is up to 70, the BP is 104/70 and the
patient is feeling better.
 Case discussion
 2 days after his MI, Mr. M has an ECHO done to
evaluate his heart function. His EF is 25%.
 What medications do you expect would be
ordered for him post-MI?
 Case discussion
 On the third day, Mr. M has taken a turn for the
worse. His creatinine has risen from an
admission value of 1.1 to 3.0 today.
 What does this mean?
 What might the doctor order to treat this
problem?
 Case discussion
 His other medications include:
 ASA EC 325 mg QD
 Enalapril 5 mg bid
 Atenolol 25 mg po qd

Amiodarone 200 mg qd
 Why do you think he is on the
amiodarone?
 What do you need to watch out for with
this drug?
 Case discussion
 Despite these efforts, he is still feeling very fatigued,
and his renal function has only improved mildly to
2.5. The doctor orders a Dobutamine drip at 2
mcg/kg/min.
 What effect would you expect the dobutamine to
have?
 Case discussion
 After4 days on the dobutamine and
dopamine drips, they are tapered off,
and digoxin is started.
 What effect should the digoxin have on
Mr M’s cardiac status?
 Case Discussion
After 10 days in the hospital, Mr M is
finally preparing for discharge. He is
ambulating slowly in the hall, and his
cardiovascular status is stable. His
discharge meds include:
 Case discussion
 Enalapril 10 mg BID
 ASA EC 325 qd
 Digoxin 0.25 mg po qd
 Amiodarone 200 mg po qd
 Atenolol 25 mg po qd
 Lasix 40 mg po qd
 Potassium Chloride 20 meq po qd
 Nitroglycerin prn
 What teaching points would you need to include with these
medications?
 What interventions might facilitate compliance with this
complex medication regimen?
 Summary
In caring for the critically ill client, the nurse must
anticipate the care needs and apply her
knowledge and skill based on the established
protocols of the agency in which he/she is
employed.
 Case discussion
 Despite these efforts, he is still feeling very fatigued,
and his renal function has only improved mildly to
2.5. The doctor orders a Dobutamine drip at 2
mcg/kg/min.
 What effect would you expect the dobutamine to
have?