CARDIAC DISEASE

IN PREGNANCY

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GROUP MEMBER:
1. Amy Chaw Jie Xiang
2. Fadhilah Binti Mohd Fazlan
3. Nor Arzura Binti Zainon
4. Nurfatihah Binti Mohd Yusof
5. Nur Mastura Binti Che Amdan
6. Tuan Mariani Binti Noh

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 LEARNING OUTCOME
• States the classification of cardiac disease in pregnancy based on NYHA

• Explain the pathophysiology of cardiac disease in pregnancy

• State the clinical manifestation of cardiac disease in pregnancy

• State the diagnosis of cardiac disease in pregnancy

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• Explain the management of mother with cardiac disease in pregnancy

 LEARNING OUTCOME
• State the complications of cardiac disease in pregnancy
• State the health education to mother of cardiac disease in pregnancy:
-Family planning
-Well balance diet
-Prevention of infection
-Follow-up care
-Pre-conception counselling

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 INTRODUCTION
Heart disease in pregnancy remains a significant cause of mortality and
morbidity in malaysia.
Early detection and appropriate management improves maternal and fetal
outcomes.
Confidential enquiry on maternal deaths (cemd) reports since 1997 have
shown that maternal deaths due to heart diseases are the main non
obstetric cause of maternal mortality in malaysia.

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EXAMPLE OF CARDIAC DISEASE IN
PREGNANCY

CHRONIC RHEUMATIC HEART DISEASE (CRHD)

 CONGENITAL HEART DISEASE
ISCHEMIC HEART DISEASE/ MYOCARDIAL
INFECTION
CARDIOMYOPATHY
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 CARDIAC DISEASE IN PREGNANCY
A) Congenital Heart Disease
i. Atrial Septal Defect
ii. Ventricular Septal Defect
iii. Patent Ductus Arteriosus
iv. Pulmonary Stenosis
v. Aortic Stenosis
vi. Tetralogy Of Fallot
vii. Mitral Valve Stenosis
* If the defect or lesion is not corrected surgically during childhood, the mother will
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experience conditions such as hypertension, cyanosis and severe ventricular failure and
is at high risk during pregnancy.
 CARDIAC DISEASE IN PREGNANCY
B) Acquired Heart Disease

i. Rheumatic heart disease- inflammation and scarring of the heart valve causes
stenosis of the valve which causes regurgitation and the mother will experience
apnea and fatigue
ii. Myocardiac infarction and ischaemic heart disease - hemodynamic changes and
thrombotic risk due to hypercoagulability due to hormonal changes causing less
blood supply to the coronary artery.
iii. Aortic dissection- severe hypertension which is systolic over 160mmhg results in
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injury to the innermost layer of the aorta.
 CARDIAC DISEASE IN PREGNANCY

IV. Endocarditis- infection of organisms such as staphylococcus aureus,

staphylococcus pneumonia and neisseria gonorrhoea on the heart valve.

V. Peripartum cardiomyopathy- inflammation and enlargement of the myocardium

caused by hypertension, pre-eclampsia, obesity and diabetes

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 CLASSIFICATION NYHA
•The new york heart association (NYHA) functional clasification provides
a simple way of classifying the extent of heart failure.
•It places patient in one of 4 categories based on how much they are
limited during physical activity.

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 PATHOPHYSIOLOGY
• Pregnancy stresses the CVS system.
• Often worsening if known heart disorders.
• Stresses include : - Decrease Hb
- Increased Blood Volume
- Increased Stroke Volume
- Increased Heart Rate
• Stresses do not return to pre-pregnancy levels until several weeks after delivery.
• Cardiac output increases 45-50% secondary to increase in blood volume and
heart rate. 14
 PATHOPHYSIOLOGY
• Blood pressure decreases by 10-15 mm hg owing to a decrease in systemic
vascular resistance caused by the creation of a low resistance circuit by the
placenta and vasodilatation.

• Decrease in venous return –supine hypotension of pregnancy.

• Stroke volume normally increases in the 1st and 2nd trimester and decreases in
the 3rd trimester- due to partial vena cava obstruction.
• In late pregnancy
-Supine position – fall in cardiac output-due to caval compression by the gravid
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uterus-supine hypotensive syndrome.

 PATHOPHYSIOLOGY
During labour and delivery
- Anxiety
- Pain Cardiac Ouput
- Uterine Contractions

• During delivery, cardiac output, heart rate, blood pressure, and

systemic vascular resistance increase with each uterine contraction.

• Delivery-related pain and anxiety aggravate the increase in heart rate

and blood pressure.
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HAEMODYNAMIC
CHANGES IN
PREGNANCY

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 CLINICAL MANIFESTATION
Resembling Heart Failure

• Mild Dyspnea

• Systolic Murmurs

• Jugular Vein Distensions

• Tachycardia

• Dependent Edema

• Mild Cardiomegaly-seen On The Chest X-ray

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 CLINICAL MANIFESTATION
Symptoms Signs
• Severe and progressive • Cyanosis
dypsnea • Spoon shape
• Progressive orthopnea • Persistent neck vein
• Paroxymal, nocturnal dyspnea distension

• Haemoptysis • Cardiac murmur

• Syncope with exertion • Cardiomegaly

• Chest pain related to effort or • Arrthymia 19

emotion
 DIAGNOSIS OF CARDIAC DISEASE IN
PREGNANCY
CLINICAL EXAMINATION
Peripheral oedema is common finding Ejection systolic murmurs and continuous
flow murmurs due to mammary souffle’ and
venous hum are common

Pulse rate may be increased Splitting of the first heart sound is common

Pulse may be bounding The intensity of the pulmonary second

sound (P2) may be accentuated

Occasional Ectopic are common and are Physiological third heart sound may be
often benign present

Apex beat may be shifted more laterally A fourth heart sound is seldom heard20
 DIAGNOSIS OF CARDIAC DISEASE IN
PREGNANCY
ECG
Heart rate may be increased Minor T wave changes
Occasional atrial or ventricular ectopics may There may be a shift of the QRS plane axis
be present to the left
CXR
Heart Size is normal The heart may shifted to more horizontal
position late in pregnancy
Pulmonary blood vessels may become more prominent due to the increased blood flow

Echocardiogram
There may be an increase in the left and right The left ventricular mass may be increased
ventricular end-diastolic dimensions 21
compared with a previous echo done in the
non-pregnant state
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MANAGEMENT
OF MOTHER
WITH CARDIAC
DISEASE IN
PREGNANCY
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1. Pre-conceptual counseling
2. Diagnosis and assessment at primary care
3. Antenatal care
4. Intrapartum care
5. Postnatal care

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 PRE CONCEPTUAL COUNSELLING
• Assessed to maternal and fetal risk in event of pregnancy.

• Encouraged to complete their family early and discouraged from having too many
pregnancies.

• High risk advised on permanent contraceptive measures.

• Prior cardiac imaging studies such as ECHO, CT and magnetic resonance

imaging scans

• Review med with potential harm to fetus and advice given accordingly (discontinue
Fetotoxic med and sub statue with safer alternative) 25
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 DIAGNOSIS AND ASSESSMENT AT
PRIMARY CARE
Role of primary care physician:
• Pre –conception counseling and health promotion
• Detection diagnosis and classification of heart disease.
• Referral
• Shared antenatal care
• Postnatal care
• Contraception
• Long term follow-up and medication
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 ANTENATAL CARE
Detection diagnosis and classification of heart disease :
• Review history – dyspnea, palpitation,cardiac surgery , orthopnoea, haemoptysis
• Examination - clubbing, cyanosis , murmur , blood pressure , heart sound.
• Echo finding, ECG recording-documented .
• Contraceptive advise and size of a family –discussed.
• Details of heart lesion, nyha class, medications.
 Advised hospital delivery
• All patient with cardiac disease should deliver in hospital under the combined care
of physician, obstetrician and anesthesiologist. All facilities for resuscitation 37should
be ready.
 ANTENATAL CARE
Historical taking
Identify cases during registration
Take a history of heart disease / medical history
• - Heart problems
• - Rheumatic fever
• - Have taken penicillin for a long time to prevent infection
• - Heart surgery
• - Take anti-angina medicine
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 ANTENATAL CARE
Ask the mother if there are signs such as:
• - Severe or progressive dyspnea
• - Shortness of breath while lying down (orthopnea)
• - Waking up at night due to shortness of breath
• - Coughing blood
• - Palpitations
• - Blackouts with or without activity
• - Chest pain related to activity or emotion
If there are signs above consult a doctor 39
 ANTENATAL CARE
Tagging high risk pregnancy
• - Code yellow: heart disease without symptoms
• - Code red: heart disease with signs and symptoms
• - Need to consult a specialist hospital and doctor, combined clinic
Refer to dental
• - Important to prevent the risk of subacute bacterial endocarditis

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 ANTENATAL CARE
Physical examination
I) check the mother for the following signs:
• Anemia - pale
• Cyanosis in the peripheral part
• Distension of the jugular vein - prominent
• Clubbing fingers
• Damage to the teeth
• Edema on the ankle
• Infection, URTI, UTI 41

• Signs of hypertension due to high BP will increase the load on the heart
 ANTENATAL CARE
• Consult a doctor for a heart and lung examination or admit to the hospital if there are complications/symptoms
such as difficulty breathing, haemoptysis,
• Abdominal palpation:

• -Measure fundal height to detect IUGR

• -Check FHR
• Help the doctor take blood and urine samples
• All mothers who suffer from this disease need to be labeled high risk, more frequent visits for example:
• - <28 weeks = once every 2-3 weeks
• - 28-32 weeks = 1-2 weeks
• - 32-36 weeks = once a week
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• The mother needs to be admitted to the ward at 36 weeks of pregnancy
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 INTRAPARTUM CARE
• Most cardiac patient may be allowed to labor via vaginal delivery. However, obstetric factor
make the outcome of more speculative than normal, plan for caesarean section, may be the
safest choice.
1) All mothers with heart problems should give birth in a hospital
2) The mother can give birth by SVD (no IOL) if there are no contraindications.
3) LSCS and induction usually if there are problems such as pe, dm and postdate
4) Trial of labor is not allowed if there is a problem such as breech or the mother has undergone
LSCS surgery for a previous birth
5) In the case of severe rheumatic heart disease, the mother needs LSCS
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6) Avoid doing artificial rupture membrane (ARM) to avoid the risk of infection
 INTRAPARTUM CARE- 1 ST
STAGE
1. Emotional and psychological support
• - Give a clear explanation of the labor process experienced, which is the pain due to the opening
of the os for the birth of the fetus
• - Tell the mother the 'findings' from the VE procedure so that the mother's anxiety can be
reduced and the mother is prepared
2. Position
• - Position the mother in prop up/ semi fowler's position
• - Mothers are more sensitive to aorta caval compression by the gravid uterus in the recumbent
position and cause hypotension
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 INTRAPARTUM CARE- 1 ST
STAGE
3. Rest the mother in bed and plan treatment so that the mother gets enough rest to reduce cardiac
workload
4. Attach 2 large bore branula for preparation for drug administration, intravenous infusion and
LSCS emergency preparation in case of any complications
5. Give intravenous infusion to maintain hydration to reduce maternal and fetal acidosis or
distress.
6. Strict IO chart to monitor fluid flow in and out to prevent pulmonary oedema

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 INTRAPARTUM CARE- 1 ST
STAGE
7. Reduce pain to avoid excessive cardiac workload
I) non pharmacological: -sacral massage, deep breathing exercise
-Comfortable position
Ii) pharmacology:- IM pethidine 50-100mg @ phenargen 25mg as per doctor's instructions
- Entonox inhalation to reduce pain
- Epidural analgesic is ideal for some cases (discussion with anesthetic if
necessary)
8. Giving oxygen through nasal prong if SPO2 is less than 95% to maintain oxygen saturation
9. GXM blood collection for surgical preparation 51
 INTRAPARTUM CARE- 1 ST
STAGE
10.Observation
Maternal
• - The mother's general condition such as restlessness, dyspnoea and pallor indicate increased
cardiac workload or maternal distress
• - Closed vital sign monitoring every 15 minutes to detect blood pressure abnormalities such as
hypertension, pulse rate to detect tachycardia, respiratory rate to detect tachypnoea and
temperature every 4 hours to detect hyperthermia
• - Cardiac monitor and pulse oximeter are connected continuously to monitor heart activity and
oxygen saturation
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 INTRAPARTUM CARE- 1 ST
STAGE
10. Observation
Fetus
• - Perform continuous CTG monitoring to detect changes in fetal heart rate such as baseline
tachycardia or present deceleration
• - Evaluate the characteristics of liquor such as light meconium or stained liquor to detect fetal
distress
11. Catheterization to empty the bladder every 2 hours to encourage the descent of the fetal head
so that the labor process progresses

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 INTRAPARTUM CARE- 1 ST
STAGE
12. Giving antibiotics as prophylaxis such as:
• - IV ampicillin 2mg stat followed by 500mg 6 hourly x 3 doses according to doctor's
instructions
• - IV augmentin 1.2gm with gentamycin I/M 60-80GM 8hourly x 3 doses according to doctor's
instructions
13. Monitor the progress of labor, ie birth in time 6 hours
• - Do contraction timing to detect advanced uterine contractions because weak contractions can
cause prolonged labor and lead to emergency caesarean section.
• - Perform vaginal examination to evaluate the progress of the opening of the os, detect the
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descent of the head, identify malpositions that can cause prolonged labor and detect abnormal
signs of the fetus such as light meconium or stained liquor
 INTRAPARTUM CARE- 1 ST
STAGE
14. Give comfort by cleaning the mother and changing clean cloths
15. Documentation and records
• - All observations, vital signs, intake output, VE finding and FHR are recorded in the partograph
and intake output chart.
16. Immediately report to the doctor if there are signs such as abnormal CTG, abnormal maternal
vital sign for emergency cesarean preparations.

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 INTRAPARTUM CARE- 2 ND
STAGE
1.Cardiac monitoring & CTG monitoring
2.Presence of doctors - obstetrician, paediatrician, anaest
3. Position - low fowlers and dorsal, Recumbent lithotomy is contraindicated because it can cause
overloading heart
4. Monitor labor progress to prevent prolonged labor
5. Episiotomy is performed to reduce the pressure on the mother during labor
6.Perform assisted delivery to shorten the 2nd stage of labor. If necessary vacuum / forceps

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 INTRAPARTUM CARE- 3 RD
STAGE
1.Active management to avoid PPH
2. Sew the episiotomy immediately to avoid bleeding
3. Giving IM oxytocin 10units /1mls after birth. Avoid using syntometrine because it has an effect
on smooth muscles and a direct effect on the heart and causes atonic uterine contraction.
4. Empty the bladder to encourage contraction and retract the uterus to speed up separation of the
placenta.

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 INTRAPARTUM CARE- 3 RD
STAGE
5. Observations
• I) general conditions such as restlessness, pain, fatigue, dyspnoea and pallor that indicate
increased cardiac workload.
• Ii) vital sign monitoring continues every 15 minutes such as bp to detect hypertension, pulse
rate to detect tachycardia, respiration rate to detect tachypnea and temperature every 4 hours to
detect hyperthermia
• Iii) cardiac monitor and pulse oximeter continue to monitor heart activity and oxygen saturation
6. Deliver the placenta by control cord traction (CCT) after there are signs of separation of the
placenta
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7. If bleeding occurs, syntocinon can be given through infusion accompanied by iv frusemide to
prevent pulmonary oedema
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 POSTNATAL CARE
1. Close observation in the first 24 hours :-
• Admitted to HDU/ICU for 24 hours
• Monitor signs of pulmonary edema
• Monitor fluid and electrolyte balance
• Monitor hourly vital signs
2. Position
• Position the mother on the bed in a prop up position

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 POSTNATAL CARE
3. Rest
• CRIB 24-48 hours
• After 48 hours - ambulation to avoid DVT, hypostatic pneumonia and pulmonary edema
• Do passive movements of the lower limbs
• Breathing exercise (deep breathing)
• Rest in bed for 5 days and allow normal activities if the mother tolerates
• Can be discharged after 5-6 days
4. Avoid constipation by eating foods that contain fiber such as vegetables and fruits
5. Anticoagulant/ prophylactic antibiotics must be continued according to the doctor's prescription
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6. Hygiene care - personal hygiene, swabbing
 POSTNATAL CARE
7. Breastfeeding
• Mothers with heart problems without complications are encouraged to breastfeed their babies
with breast milk
8. Contraceptives
• An effective method with no contraindications for heart problems is recommended
9. Follow-up visit (TCA)
• An appointment to see a cardiologist was given before the mother was discharged from the
hospital
• Home visit
10. Take care of the perineum by changing the pad every 2 hours to avoid infection 63
 POSTNATAL CARE
11. Monitor the chart pad to identify the amount and type of lochia to detect signs of post partum
haemorrhage.
12. Advise the mother to keep the wound clean by cleaning the wound with flavin supplied by the
hospital only and monitor signs of infection such as pain, redness and edema.
13. Palpate the uterus to ensure that the uterus retracts and contracts properly, i.E. The uterus will
feel hard and mobile.
14. Encourage the mother to wear ted socks to prevent DVT from happening.
15. Advise the mother if she feels palpitation or dyspnea immediately tell the nurse so that further
treatment can be given

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 ANTIBIOTICS IN PREGNANCY
STANDARD REGIME
• Ampicillin Gentamicin
IV Or IM Ampicilin 2.0gm + IV Or IM Gentamycin 1.5 Mg/Kg (Not To Exceed 80 Mg)
30 Minutes Before Procedure,
Followed By : Amoxicillin 1.5 Gm Orally 6 Hours After Initial Dose Or Repeat Parenteral
Regime 8 Hours After Initial Dose.
• Penicillin Allergic Patients
Vancomycin Gentamycin IV Vancomycin 1.0 Gm Over 1 Hour + IV Or IM Gentamycin
1.5 Mg/Kg (Not To Exceed 80 Mg)
1 Hour Before Procedure And Repeat 8 Hours Later.

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 ANTIBIOTICS IN PREGNANCY
DRUGS EFFECTS OF FETAL CONSIDERATIONS LACTATION
PREGNANCY
Penicillins/ Increased renal Cross placenta, considered Small amount in
cephalosporins excretion, lower safe breastmilk, safe
plasma level

Tetracyclines - Increased risk NTD, cleft Found in breastmilk.

palate and cardiovascular Concern about effect on
effects (not doxycline). Tooth teeth
discoloration

Ciprofloxacin - Only small amount cross Concentrated in

placenta, but has been breastmilk. Neonatal
associated with bone/cartilage Clostridium difficile has
problems. been reported
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O&G Kedah
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CPG Heart
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CPG Heart
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 CARDIOVASCULAR SYSTEM DRUGS
IN PREGNANCY
DRUGS PRECONCEPTION EFFECTS OF FETAL LACTATION
PREGNANCY CONSIDERATIONS
Ace Should be changed Avoid-only use if Teratogenic in first Considered compatible
inhibitors, to alternative if no alternative with trimester. Renal and
ARBs possible fetal monitoring of cardiac problem in late
growth and liquor gestation
volume. Stop if
oligohydramnios
Anti- Optimize blood Nifedipine may Beta-blocker Present in breast milk
hypertensives pressure control demonstrate associated with fetal (except nifedipine,
increased growth restriction (less which is >90% protein
clearance in 3rd so with labetolol). bound). Infant reported
trimester Intravenous doses normotensive, so
should be given with considered safe
fetal monitoring
Statins - - Usually stop as may Considered compatible
adversely affect
placental development. O&G Kedah
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(Epomedicine, 2021)
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 ADENONOSINE
Intravenous - Myocardial
imaging
Adult: 140 mcg/kg/min for 6
minutes as a continuous
infusion via infusion pump
(total dose: 0.84 mg/kg). The
radionuclide is injected at
midpoint (after 3 minutes) of
infusion.
Intravenous- Paroxysmal
supraventricular tachycardia
Adult: Initially, 3 mg via rapid
inj into a central or large
peripheral vein over 2 seconds;
6 mg may be given after 1-2
minutes if necessary, then 12
mg after a further 1-2 minutes.
Alternatively, an initial dose of
6 mg, followed by 2 further
doses of 12 mg, if necessary, at
1-2 minute intervals. Follow
each dose with normal saline
flush.
Intravenous- Differential
diagnosis of supraventricular
tachycardias
Adult: Initially, 3 mg via rapid
inj into a central or large
peripheral vein over 2 seconds;
6 mg may be given after 1-2
minutes if necessary, then 12
mg after a further 1-2 minutes.
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AHA
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AHA
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AHA
 ADENONOSINE
SIDE Nausea, light-headedness, flushing, headache, angina-like chest
EFFECT pain, apprehension, dyspnoea, bronchospasm; bradycardia, heart
block; tachy- and bradyarrhythmia, AF, MI; abdominal, throat, neck,
and jaw discomfort. Rarely, hypotension, reflex tachycardia, severe
bradycardia.
Potentially Fatal: Cardiac and resp arrest, asystole. Rarely,
ventricular fibrillation
HEALTH • Monitor ECG, BP, and heart rate. Continuously monitor cardiac
TEACHING and haemodynamic states during infusion.
• Overdosage Symptoms: Severe hypotension, bradycardia,
asystole. Management: IV aminophylline/theophylline or caffeine
may be used.
• Reduced effect w/ food and drinks containing x anthines - caffeine
(e.g. tea, coffee, chocolate, cola).

Intravenous -Supraventricular
arrhythmias, Ventricular
arrhythmias
Adult: Initially, 5 mg/kg via
infusion over a period of 20-
120 minutes, may repeat
infusion up to 1,200 mg
(approx 15 mg/kg) per 24
hours, with a rate of infusion
adjusted based on clinical
response. For emergency cases:
150-300 mg via slow inj over
≥3 minutes, may be repeated at
least 15 minutes after the first
dose.
Amiodarone
Intravenous - Pulseless
ventricular tachycardia,
Ventricular fibrillation
Adult: For cardiopulmonary
resuscitation in cases that are
resistant to defibrillation:
Initially, 300 mg (or 5 mg/kg)
via rapid inj. Additional 150
mg (or 2.5 mg/kg) may be
given if ventricular fibrillation
or pulseless ventricular
tachycardia persists.
Oral - Supraventricular
arrhythmias, Ventricular
arrhythmias
Adult: Initially, 200 mg tid for
1 week then reduced to 200 mg
bid for another week.
Maintenance: ≤200 mg daily
based on patient response..
 Amiodarone
SIDE Significant: Bradycardia, QT prolongation, hypotension, peripheral neuropathy,
EFFECT photosensitivity, optic neuropathy and/or optic neuritis.
Eye disorders: Corneal microdeposits.
Gastrointestinal disorders: Nausea, vomiting, dysgeusia, constipation.
General disorders and administration site conditions: Inj site reactions (e.g. pain,
erythema, oedema, extravasation, infiltration, inflammation, induration, necrosis,
infection, thrombophlebitis, phlebitis, cellulitis).
Investigations: Increased serum transaminases, elevated bilirubin levels.
Nervous system disorders: Extrapyramidal tremor.
Psychiatric disorders: Nightmares, sleep disorders.
Skin and subcutaneous tissue disorders: Blue-grey skin discolouration (prolonged
use), eczema.
Potentially Fatal: Onset or worsening of arrhythmia, hepatotoxicity (e.g. cirrhosis,
hepatitis, jaundice, hepatic failure), pulmonary toxicity (e.g. hypersensitivity
pneumonitis, alveolar/interstitial pneumonitis, fibrosis, pleural effusion), Stevens-
Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), hyperthyroidism.
 Amiodarone
HEALTH • Monitor blood pressure, heart rate and rhythm (ECG), LFT, serum
TEACHING electrolytes (particularly K and Mg); pacing or defibrillation
thresholds prior to and during treatment (in patients with
implantable cardiac devices). Evaluate thyroid function tests prior to
therapy and periodically (every 3-6 months) thereafter. Perform
regular ophthalmologic examination, chest X-ray, and pulmonary
function tests.
• This drug may cause eye disorders, if affected
• Avoid excessive exposure to sunlight and use proper protective
measures during treatment.
• Increased plasma concentrations with grapefruit juice.
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AHA
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AHA
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AHA
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CPG Heart
CPG Heart
90

Intravenous- Cardiac
arrhythmias
Adult: Initially, 2.5 mg via
slow inj at a rate of 1 mg/min,
may be repeated at 5-minute
intervals until a response is
achieved up to a Max of 10
mg. Alternatively, 0.15 mg/kg
via infusion over 20 minutes.
May repeat the inj or infusion
12 hourly if required. Once
control is achieved, maintain
the patient with oral atenolol.
Atenolol
Intravenous -Acute Oral - Hypertension
myocardial infarction Adult: Monotherapy or in
Adult: For the early combination with other
management of cases antihypertensive agents: 25-
presenting within 12 hours of 100 mg once daily. Adjust dose
the onset of chest pain: 5-10 according to individual
mg via slow inj at a rate of 1 requirements.
mg/min; if tolerated, may give
oral atenolol dose of 50 mg
after approx 15 minutes,
followed by another 50 mg oral
dose 12 hours after the IV inj
then maintain with the
recommended oral dose after
12 hours

Oral - Angina pectoris
Adult: Initially, 50 mg once
daily, may increase at weekly
intervals according to
frequency and severity of
symptoms and patient
tolerability. Usual dose range:
50-100 mg once daily.
Atenolol
Oral - Cardiac arrhythmias
Adult: Maintenance: 50-100
mg once daily after having
controlled with IV atenolol.
Oral - Acute myocardial
infarction
Adult: Maintenance: 100 mg
once daily. Initiate oral
maintenance dose 12 hours
after management with IV
atenolol.

CONTRAINDICATION Sinus bradycardia cardiogenic shock, hypotension, metabolic acidosis,

2nd- or 3rd-degree heart block, severe peripheral arterial disease, sick
sinus syndrome, uncontrolled cardiac failure, untreated
phaeochromocytoma.
 Atenolol
SIDE Significant: Bradycardia; may exacerbate angina and precipitate MI and ventricular
EFFECT arrhythmias after abrupt discontinuation (in patients with angina); may precipitate or
aggravate peripheral arterial insufficiency.
Ear and labyrinth disorders: Vertigo.
Gastrointestinal disorders: Nausea, diarrhoea, dry mouth.
General disorders and administration site conditions: Fatigue, lethargy.
Immune system disorders: Hypersensitivity reaction (including urticaria and
angioedema).
Investigations: Elevated transaminase levels.
Musculoskeletal and connective tissue disorders: Lupus-like syndrome.
Nervous system disorders: Dizziness, drowsiness.
Psychiatric disorders: Sleep disturbances, depression.
Skin and subcutaneous tissue disorders: Rarely, exacerbation of psoriasis,
psoriasiform skin reactions.
Vascular disorders: Cold extremities, hypotension, orthostatic hypotension
 Atenolol
HEALTH • May be taken with or without food.
TEACHING • Monitor blood pressure and heart rate (before and after initiation of therapy and
following any dose changes); serum glucose (in diabetic patients); renal
function. Obtain ECG when used for acute cardiac treatment.
• Overdosage Symptoms: Lethargy, wheezing, bronchospasm, sinus pause, acute
cardiac insufficiency, bradycardia, hypotension, hypoglycaemia.
• Management: Symptomatic and supportive treatment. Closely monitor the
patient. Perform gastric lavage, induce emesis, or administer activated charcoal
and laxative. Treat hypotension and shock with plasma or plasma substitutes.
May consider haemodialysis or haemoperfusion. In case of excessive
bradycardia, administer atropine 1-2 mg IV and/or use a pacemaker.
Hypotension and acute cardiac insufficiency may also be treated by
dobutamine. Administer bronchodilators to reverse bronchospasm. Administer
IV dextrose to treat hypoglycaemia.
 ACE-inhibitors (Perindopril)
Oral - Hypertension
Adult: As perindopril erbumine:
Initially, 4 mg once daily, may be
titrated according to clinical response.
Max: 8 mg daily. As perindopril
arginine: Initially, 5 mg once daily,
may be titrated according to clinical
response. Max: 10 mg daily. Patient
with renovascular hypertension,
volume depletion, severe
hypertension or patient on diuretics:
As perindopril erbumine: Initially, 2
mg once daily; As perindopril
arginine: 2.5 mg once daily.
Oral - Heart failure
Adult: As perindopril
erbumine: Initially, 2 mg once
daily, preferably in the
morning, may adjust according
to clinical response. Usual
maintenance dose: 4 mg once
daily. As perindopril arginine:
Initially, 2.5 mg once daily,
preferably in the morning, may
adjust dose according to
clinical response. Usual
maintenance dose: 5 mg once
daily.
Oral - Stable coronary
artery disease
Adult: As perindopril
erbumine: Initially, 4 mg
once daily for 2 weeks,
may be titrated according
to clinical response. Max
dose: 8 mg daily. As
perindopril arginine:
Initially, 5 mg once daily
for 2 weeks, may be
titrated according to
clinical response. Max
dose: 10 mg daily.
 ACE-inhibitors (Perindopril)
CONTRA- History of angioedema related to previous ACE inhibitor treatment, hereditary or
INDICATION idiopathic angioedema, bilateral or unilateral renal stenosis, patients with
extracorporeal treatments leading to contract of blooding with negatively charged
surfaces. In patient with diabetes mellitus or renal impairment (GFR <60
mL/min/1.73 m2). Concomitant use with sacubitril/valsartan. Pregnancy and
lactation
HEALTH • Monitor BP, BUN, serum K and creatinine levels, renal function, CBC with
TEACHING differential. Monitor for signs of angioedema and assess pregnancy status
• Overdose Symptoms: Hypotension, bradycardia, circulatory shock, renal
failure, hyperventilation, electrolyte disturbances, tachycardia, palpitations,
dizziness, anxiety, and cough.
• Management: Administer IV infusion of NaCl 0.9%. If hypotension occurs,
place the patient in shock position. May also consider administration of
angiotensin II infusion and/or IV catecholamines. Haemodialysis may be
beneficial.
• May reduce hepatic biotransformation with food
 ACE-inhibitors
SIDE Significant: Cholestatic jaundice, hypotension, syncope, hyperkalaemia, cough, neutropenia,
EFFECT agranulocytosis, anaemia, thrombocytopenia.
Cardiac disorders: Palpitations, tachycardia.
Ear and labyrinth disorders: Tinnitus.
Eye disorders: Visual disturbance.
Gastrointestinal disorders: Nausea, constipation, diarrhoea, dyspepsia, vomiting, abdominal pain.
General disorders and admin site conditions: Asthenia, peripheral oedema.
Immune system disorders: Urticaria.
Investigations: Elevated BUN, increased serum creatinine, increased serum bilirubin.
Musculoskeletal and connective tissue disorders: Muscle cramps.
Nervous system disorders: Headache, paresthesia, vertigo, dysgeusia, dizziness.
Psychiatric disorders: Mood disturbances, sleep disorders.
Renal and urinary disorders: Renal insufficiency, proteinuria.
Reproductive system and breast disorders: Erectile dysfunction.
Respiratory, thoracic and mediastinal disorders: Dyspnoea, bronchospasm.
Skin and subcutaneous tissue disorders: Pruritus, rash.
Vascular disorders: Vasculitis, flushing, impaired peripheral circulation, epistaxis, Raynaud’s
phenomenon.
Potentially Fatal: Angioedema, arrhythmia. Rarely, fulminant hepatic necrosis.
 Angiotensin Receptors Blockers
Oral - Hypertension
Adult: 50 mg once daily, may
increase to 100 mg once daily
according to clinical response.
Patient with intravascular
volume depletion: Initially, 25
mg once daily.
Oral - Chronic heart failure
Adult: In patients with reduced
LVEF where treatment with
ACE-inhibitors is unsuitable or
contraindicated: Initially, 12.5
mg once daily, may titrate dose
at weekly intervals up to Max
of 150 mg once daily according
to clinical response and
tolerability.
Oral - Hypertension with left
ventricular hypertrophy
Adult: To reduce the risk of
stroke: Initially, 50 mg once
daily. Hydrochlorothiazide
should be added and/or
losartan should be increased to
100 mg once daily according to
clinical response.
 Angiotensin Receptors Blockers
CONTRAINDICATION Severe hepatic impairment. Pregnancy. Concomitant use with
Aliskiren-containing products (TX of HPT) in patients with diabetes
mellitus or renal impairment (GFR <60 mL/min/1.73 m2).
HEALTH TEACHING • Monitor blood pressure (at baseline and periodically), renal
function, and electrolytes (e.g. serum K). Assess for signs of
angioedema.
• Overdosage Symptoms: Hypotension, tachycardia, bradycardia
(may occur from parasympathetic [vagal] stimulation).
• Management: Supportive and symptomatic treatment. Prioritise
stabilisation of the CV system. Administer activated charcoal as
indicated. Perform close monitoring of vital parameters. Correct
vital parameters as necessary.
 Angiotensin Receptors Blockers
SIDE Significant: Renal failure (e.g. acute kidney injury), symptomatic hypotension (in volume-
EFFECT and/or Na-depleted patients), electrolyte imbalance (e.g. hyperkalaemia), angioedema.
Blood and lymphatic system disorders: Anaemia.
Cardiac disorders: Angina pectoris, palpitations.
Ear and labyrinth disorders: Tinnitus, vertigo.
Gastrointestinal disorders: Abdominal pain, nausea, vomiting, diarrhoea.
General disorders and administration site conditions: Oedema, asthenia, fatigue.
Hepatobiliary disorders: Rarely, hepatitis.
Investigations: Increase in serum creatinine or blood urea.
Metabolism and nutrition disorders: Hypoglycaemia.
Musculoskeletal and connective tissue disorders: Back pain, arthralgia, myalgia; rarely,
rhabdomyolysis.
Nervous system disorders: Dizziness, headache, migraine, paraesthesia.
Psychiatric disorders: Sleep disorders, depression.
Respiratory, thoracic and mediastinal disorders: Dyspnoea.
Skin and subcutaneous tissue disorders: Urticaria, pruritus, rash.
Vascular disorders: Orthostatic hypotension, syncope.
 Beta Blocker (Bisoprolol)
Oral - Chronic heart failure Oral - Angina pectoris,
Adult: In stable chronic heart failure with reduced systolic left Hypertension
ventricular function as an adjunct to ACE inhibitors, diuretics, and Adult: Initially, 5 mg
optionally cardiac glycosides: Initially, 1.25 mg once daily for 1 once daily. Usual
week. If tolerated, increase gradually as follows: 2.5 mg once daily maintenance dose: 10 mg
for a further week, 3.75 mg once daily for a further week, 5 mg once once daily. Max: 20 mg
daily for the 4 following weeks, 7.5 mg once daily for the 4 following daily. Adjust dose
weeks, then 10 mg once daily for maintenance. Max: 10 mg once according to individual
daily. Gradual dose reduction may be considered if the Max requirements.
recommended dose is not well tolerated.

CONTRA- Acute heart failure or during episodes of heart failure decompensation requiring
INDICATION IV inotropic therapy; symptomatic bradycardia; cardiogenic shock, 2nd- and
3rd-degree atrioventricular block (without pacemaker), sinoatrial block, severe
bronchial asthma or COPD; sick sinus syndrome, symptomatic hypotension;
severe peripheral arterial occlusive disease, severe Raynaud's syndrome;
metabolic acidosis, untreated phaeochromocytoma.
 Beta Blocker (Bisoprolol)
SIDE Cardiac disorders: Bradycardia, worsening of pre-existing heart failure (in patients with chronic
EFFECT heart failure).
Gastrointestinal disorders: Nausea, vomiting, constipation, diarrhoea.
General disorders and administration site conditions: Fatigue, asthenia.
Nervous system disorders: Headache, dizziness.
Vascular disorders: Feeling of coldness or numbness in the extremities, hypotension.
HEALTH • Monitor blood pressure, heart rate, ECG; serum glucose (in diabetic patients); symptoms of
TEACHING bronchospasm (in patients with pre-existing bronchospastic disease) and worsening heart failure
during the titration phase.
• Overdosage Symptoms: Bradycardia, bronchospasm, hypotension, acute cardiac insufficiency,
hypoglycaemia.
• Management: Supportive and symptomatic treatment. The following may be administered to treat
symptoms: IV atropine for bradycardia (isoprenaline or another agent with positive chronotropic
properties may be given if the response is insufficient; transvenous pacemaker insertion may be
considered if necessary); IV fluids and vasopressors for hypotension (IV glucagon may also be
useful); isoprenaline for 2nd- or 3rd-degree atrioventricular block (may consider transvenous
cardiac pacemaker insertion); IV diuretics, inotropic agents or vasodilating agents for acute
worsening of heart failure; bronchodilator therapy (e.g. isoprenaline, β2-sympathomimetic drugs
and/or aminophylline) for bronchospasm; IV glucose for hypoglycaemia.
 Digoxin
Intravenous - Atrial fibrillation, Atrial flutter, Heart
failure
Adult: In patients who have not received cardiac glycosides
in the previous 2 weeks: Dosage is individualised according
to age, lean body weight and renal status. Loading dose: 500-
1,000 mcg (0.5-1 mg) in divided doses via IV infusion over
10-20 minutes with approx half of the dose given as 1st dose
and further fractions of the total dose given every 4-8 hours.
Assess clinical response before giving each additional dose.
Maintenance: Calculated based on the percentage of the peak
body stores lost each day through elimination (refer to
individual product guidelines). Most patients with heart
failure are maintained on 125-250 mcg (0.125-0.25 mg)
daily; a lower dose of ≤62.5 mcg (0.0625 mg) daily may be
given to those who show increased sensitivity to the adverse
effects while some patients may require a higher dose. Adjust
dose based on toxicity, efficacy, and blood levels.
Oral - Atrial fibrillation, Atrial flutter,
Heart failure
Adult: Dosage is individualised according
to age, lean body weight and renal status.
Rapid digitalisation: Loading dose of 750-
1,500 mcg (0.75-1.5 mg) as a single dose;
or in divided doses 6 hours apart (with
approx half the total dose given as the 1st
dose) for cases of less urgency or greater
risk of toxicity. Assess clinical response
before giving each additional dose. Mild
heart failure: 250-750 mcg (0.25-0.75 mg)
daily for 1 week. Maintenance: Calculated
based on the percentage of the peak body
stores lost each day through elimination
Adjust dose based on toxicity, efficacy, and
blood levels.
 Digoxin
CONTRAINDICATION Ventricular tachycardia or fibrillation, arrhythmias caused by cardiac
glycoside intoxication, supraventricular arrhythmias associated with
an accessory atrioventricular pathway (e.g. Wolff-Parkinson-White
syndrome); hypertrophic obstructive cardiomyopathy (unless there is
concomitant atrial fibrillation and heart failure), intermittent complete
heart block or 2nd-degree atrioventricular block (especially if there is
a history of Stokes-Adams attacks), constrictive pericarditis (unless it
is used to control the ventricular rate in atrial fibrillation or to improve
systolic dysfunction).
 Digoxin
SIDE Significant: Arrhythmias, PR interval prolongation, depression of the ST segment on
EFFECT ECG.
Blood and lymphatic system disorders: Thrombocytopenia.
Cardiac disorders: Conduction disorder, bigeminy, trigeminy, sinus bradycardia.
Eye disorders: Visual impairment (e.g. blurred vision, xanthopsia).
Gastrointestinal disorders: Diarrhoea, nausea, vomiting, abdominal pain, intestinal
ischaemia, gastrointestinal necrosis.
General disorders and administration site conditions: Weakness.
Nervous system disorders: Dizziness, headache.
Psychiatric disorders: Apathy, confusion, mental disturbances (e.g. anxiety,
depression, delirium, hallucinations).
Reproductive system and breast disorders: Gynaecomastia.
Skin and subcutaneous tissue disorders: Rash.
Potentially Fatal: Digoxin toxicity.
 Digoxin
HEALTH • Assess serum electrolytes and renal function (serum creatinine concentration) at baseline and
TEACHING periodically. Obtain serum digoxin concentrations just before the next scheduled dose or ≥6
hours after the last dose. Monitor heart rate and rhythm along with periodic ECGs. Observe for
signs and symptoms of digoxin toxicity, including noncardiac signs such as confusion and
depression.
• Overdosage Symptoms: Almost every type of cardiac arrhythmia and multiple rhythm
disturbances; hyperkalaemia, nausea, vomiting, anorexia, dizziness, various CNS disturbances,
fatigue, malaise, aberration in colour vision (predominance of yellow-green), and weakness.
Management: Acute overdose: Administer activated charcoal orally or by nasogastric tube. Life-
threatening arrhythmias or hyperkalaemia require administration of digoxin; initial treatment
with glucose and insulin may be needed if the hyperkalemia is life-threatening. Bradycardia and
heart block respond to atropine. A temporary cardiac pacemaker may also be used. Ventricular
arrhythmias may respond to lidocaine or phenytoin. Chronic overdose: Place the patient on a
cardiac monitor. Correct factors such as electrolyte abnormalities, thyroid dysfunction, and
concomitant medications. Correct hypokalaemia by administering K so that serum K is
maintained between 4.0 and 5.5 mmol/L; avoid K salts in patients with bradycardia or heart
block. Symptomatic arrhythmias may be treated with digoxin.
 Diltiazem
Intravenous - Atrial fibrillation, Intravenous - Oral - Angina pectoris Oral - Hypertension
Atrial flutter Paroxysmal Adult: Dosage is adjusted Adult: Dosage is adjusted
Adult: For temporary control of supraventricular carefully according to carefully according to
rapid ventricular rate: Initially, tachycardia individual tolerance, individual tolerance,
0.25 mg/kg (average dose: 20 mg) Adult: For rapid response, and requirements. response, and requirements.
via bolus inj over 2 minutes, may conversion to sinus As conventional tab: As modified-release tab or
give a further dose of 0.35 mg/kg rhythm: Initially, Initially, 30 mg 4 times cap: Initially, 90-120 mg
(average dose: 25 mg) after 15 0.25 mg/kg (average daily, may be increased bid, may be increased as
minutes if response is inadequate. dose: 20 mg) via gradually at 1- to 2-day required to a Max of 360
Subsequent doses must be bolus inj over 2 intervals until optimum mg daily
individualised for each patient. minutes, may give a response is achieved. Usual
For continued heart rate further dose of 0.35 dose range: 180-360 mg
reduction: Following 1-2 bolus mg/kg (average dose: daily. As modified-release
inj, initiate infusion at a rate of 5- 25 mg) after 15 tab: Initially, 60 mg tid,
10 mg/hour, may be increased in minutes if needed. may be increased to 360
increments of 5 mg/hour up to a Subsequent doses mg daily if necessary. Max:
Max of 15 mg/hour, as needed. must be 480 mg daily.
May continue infusion for up to individualised for
24 hours. each patient.
 Diltiazem
CONTRAINDICATION Sick sinus syndrome, 2nd- or 3rd-degree AV block (without a
functioning pacemaker), severe bradycardia (<50 beats/min),
hypotension (systolic <90 mmHg), decompensated cardiac failure,
acute MI and pulmonary congestion. Lactation. Concomitant use with
ivabradine. IV: Cardiogenic shock, atrial flutter or fibrillation
associated with accessory bypass tract (e.g. Wolff-Parkinson-White
syndrome or short PR syndrome), ventricular tachycardia (with wide-
complex tachycardia [QRS ≥0.12 seconds]); concomitant use with or
within a few hours of IV β-blockers.
 Diltiazem
SIDE Significant: AV block, sinus bradycardia, mood changes (e.g. depression),
EFFECT bronchospasm. Rarely, symptomatic hypotension with or without syncope, increased
hepatic enzymes (e.g. AST, ALT, lactate dehydrogenase, alkaline phosphatase),
hepatic injury, severe cutaneous adverse reactions (e.g. Stevens-Johnson syndrome,
toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms,
acute generalised exanthematous pustulosis).
Cardiac disorders: Palpitations.
Gastrointestinal disorders: Nausea, dyspepsia, constipation, gastric pain, vomiting,
diarrhoea.
General disorders and administration site conditions: Peripheral oedema,
malaise; inj site reactions (e.g. itching, burning).
Nervous system disorders: Dizziness, headache.
Psychiatric disorders: Nervousness, insomnia.
Vascular disorders: Flushing.
 Diltiazem
HEALTH • Monitor blood pressure, ECG, heart rate, LFTs, and kidney function. For IV use,
TEACHING frequently measure blood pressure and continuously monitor ECG.
• Overdosage Symptoms: Hypotension leading to collapse and acute kidney
injury; sinus bradycardia (with or without isorhythmic dissociation), sinus arrest,
disturbances in atrioventricular (AV) conduction, cardiac arrest.
• Management: Supportive and symptomatic treatment. Perform gastric lavage
and/or osmotic diuresis; administer activated charcoal. Temporary cardiac
pacing may be used to manage conduction disturbances. Consider administration
of atropine to treat bradycardia and AV block; if no response to vagal blockade,
give isoproterenol cautiously. Fluids and vasopressors (e.g. dopamine,
norepinephrine) may be used to maintain blood pressure. May administer
inotropic agents (e.g. isoproterenol, dopamine, dobutamine) and diuretics in case
of cardiac failure.
 Diuretics (Frusemide)
Intramuscular, Intravenous -
Oedema
Adult: Initially, 20-50 mg.
Doses are individualised
and may be increased in
increments of 20 mg 2
hourly. Max: 1,500 mg
daily. Doses are given via
slow IV inj or via IM inj if
IV administration is not
feasible. Doses >50 mg
must be given via slow IV
infusion. Max IV infusion
or inj rate: 4 mg/min.
Oral - Oral - Oliguria in acute Oral - Oedema
Hypertension or chronic renal failure Adult: For the
Adult: As Adult: For the treatment treatment of cases
monotherapy or in of cases where GFR is associated with
combination with <20 mL/min: Initially, heart failure,
other 250 mg. If a satisfactory cirrhosis of the
antihypertensives: effect is not achieved, liver, and renal
40-80 mg daily. doses may be increased disease including
Dosage is in increments of 250 mg nephrotic syndrome:
individualised and every 4-6 hours up to a Initially, 20-40 mg.
adjusted according Max dose of 1,500 mg in Doses are
to patient response. 24 hours; in severe cases individualised and
up to 2,000 mg in 24 adjusted until
hours may be given. desired effect is
achieved.
 Diuretics (Frusemide)
CONTRAINDICATION Hypersensitivity to furosemide, sulfonamides or sulfonamide
derivatives, and amiloride. Electrolyte deficiency (e.g. severe
hypokalaemia or hyponatraemia), Addison's disease, porphyria,
dehydration, hypotension, hypovolaemia, comatose or pre-comatose
states associated with hepatic cirrhosis or encephalopathy, anuria or
renal failure with anuria not responding to furosemide, renal failure
due to poisoning with nephrotoxic or hepatotoxic agents, renal failure
due to hepatic coma. Jaundice in infants, or diseases which may cause
hyperbilirubinaemia or kernicterus. Renal impairment CrCl <30
mL/min/1.73 m2. Digitalis intoxication; concomitant use with K
supplements or K-sparing diuretics. Lactation.
 Diuretics (Frusemide)
SIDE Significant: Hyperuricaemia, transient increase in thyroid hormones followed by decrease in total
EFFECT thyroid hormone level (doses >80 mg), SLE activation or exacerbation, urinary retention; hypotension,
hypovolaemia, dehydration; impaired glucose tolerance, hyperglycaemia. Rarely, may cause gout.
Blood and lymphatic system disorders: Thrombocytopenia.
Cardiac disorders: Cardiac arrhythmias.
Ear and labyrinth disorders: Deafness, hearing disorders, tinnitus.
Eye disorders: Visual disturbance, blurred vision, yellow vision.
Gastrointestinal disorders: Nausea, vomiting, dry mouth, thirst, bowel motility disturbances,
diarrhoea, constipation.
General disorders and administration site conditions: Fatigue.
Investigations: Increased cholesterol, triglycerides level, blood creatinine, and blood urea levels.
Metabolism and nutrition disorders: Hyponatraemia, hypochloraemic metabolic alkalosis,
hypocalcaemia, hypomagnesaemia.
Musculoskeletal and connective tissue disorders: Muscle cramps, muscle weakness.
Skin and subcutaneous tissue disorders: Photosensitivity.
Potentially Fatal: Profound diuresis with water and electrolyte depletion (excessive dose). Increased
risk of ventricular arrhythmias due to furosemide-induced hypokalaemia.
 Diuretics (Frusemide)
HEALTH • Monitor blood pressure, serum electrolytes (e.g. serum Na, K), renal function,
TEACHING and blood glucose levels periodically; fluid intake and output. Monitor for signs
and symptoms of blood dyscrasias, liver damage, and idiosyncratic reactions.
• Overdosage Symptoms: Hypovolaemia, dehydration, blood volume reduction,
electrolyte imbalance, hyponatraemia, hypochloraemic alkalosis; hypokalaemia
leading to serious cardiac arrhythmias; severe hypotension progressing to
shock, acute renal failure, thrombosis, delirium, flaccid paralysis, apathy,
confusion, transient deafness, precipitation of gout.
• Management: Symptomatic and supportive treatment. Replacement of
excessive fluid and electrolyte losses, maintenance of blood pressure. May
consider giving activated charcoal within 1 hour of ingesting toxic doses.
Ensure adequate drainage in patients with urinary bladder outlet obstruction
(e.g. prostatic hypertrophy). Treat dehydration and hypotension with
appropriate IV fluids.
• Enhanced hypotensive effect with alcohol
 Labetolol
Intravenous - Intravenous - Emergency treatment of hypertension Intravenous -
Hypertension after Adult: Dosage must be individualised based on severity Hypertension in
myocardial and patient response. As inj: 50 mg via bolus inj over at pregnancy
infarction least 1 minute; if necessary, may be repeated at 5-minute Adult: Initiate
Adult: Initiate intervals until a satisfactory response occurs. Max total infusion at a rate of 20
infusion at a rate of 15 dose: 200 mg. Alternatively, an initial dose of up to 20 mg mg/hour; dose may be
mg/hour, then via slow inj over 2 minutes; subsequent doses of 40 mg or doubled every 30
gradually increased up 80 mg may be given at 10-minute intervals until a desired minutes until a
to a Max of 120 supine blood pressure is achieved or a total of 300 mg has satisfactory reduction
mg/hour depending on been injected. As an infusion: Initiate infusion at a rate of in blood pressure has
blood pressure 2 mg/minute until a satisfactory response occurs, then stop been obtained or a
control. the infusion. Usual effective dose: 50-200 mg, but larger dose of 160 mg/hour
doses may be given as necessary. Adjust dosage and rate is reached. Higher
of infusion according to the blood pressure response. doses may be
Patient should remain supine during and for up to 3 hours necessary in some
after administration. cases.

Intravenous- Hypotensive
anaesthesia
Adult: Initially, 10-20 mg
depending on the patient’s age and
condition. If satisfactory
hypotension is not achieved after
5 minutes, increments of 5-10 mg
must be given until the desired
level of blood pressure is attained.
In patients for whom halothane is
contraindicated, a higher initial
dose (25-30 mg) may be required.
Labetolol
Oral -Hypertension in
pregnancy
Adult: Initially, 100 mg bid; if
necessary, may be increased in
increments of 100 mg bid at
weekly intervals. Further dose
titration to a 3 times daily regimen
may be required based on the
severity of hypertension. Max:
2,400 mg daily.
Oral -Hypertension
Adult: Initially, 100 mg bid; if
necessary, may be gradually
increased in increments of 100 mg
bid at intervals of 14 days
according to response.
Maintenance: 200-400 mg bid.
For severe, refractory
hypertension: Doses of up to
2,400 mg daily in 3-4 divided
doses may be given.
 Labetolol
CONTRA- Cardiogenic shock, sick sinus syndrome (including sino-atrial block), 2nd- or
INDICATION 3rd-degree heart block, Prinzmetal's angina, severe bradycardia (<45-50 bpm),
uncompensated heart failure, overt heart failure; uncontrolled, incipient or
digitalis-refractory heart failure; current or history of bronchospasm and
bronchial asthma, history of obstructive airway disease, untreated
phaeochromocytoma, metabolic acidosis, severe peripheral circulatory
disturbances, hypotension, other conditions associated with severe and
prolonged hypotension. Labetalol IV infusion should not be used to control
hypertensive episodes after myocardial infarction when peripheral
vasoconstriction suggests low cardiac output.
SIDE EFFECT Significant: Bradycardia, CHF, symptomatic hypotension , postural
hypotension, bronchospasm; exacerbation of angina, ventricular arrhythmia and
MI may precipitate or aggravate symptoms of arterial insufficiency (in patients
with peripheral circulatory disorders or Raynaud's disease); induction or
exacerbation of psoriasis, dry eyes, anaphylactic reactions.
Cardiac disorders: Rarely, heart block.
 Labetolol
SIDE Ear and labyrinth disorders: Vertigo.
EFFECT Eye disorders: Impaired vision.
Gastrointestinal disorders: Nausea, vomiting, diarrhoea, epigastric pain, dyspepsia,
dysgeusia.
General disorders and administration site conditions: Fatigue, asthenia, drug fever, lethargy.
Hepatobiliary disorders: Jaundice, hepatitis.
Investigations: Increased serum creatinine, BUN, and LFTs; positive antinuclear antibodies
unassociated with disease.
Musculoskeletal and connective tissue disorders: Cramps, toxic myopathy.
Nervous system disorders: Headache, dizziness, drowsiness, tremor, paraesthesia.
Psychiatric disorders: Confusion, sleep disturbance, nightmares, depressed mood.
Renal and urinary disorders: Urinary retention, difficulty in micturition.
Reproductive system and breast disorders: Ejaculatory failure, impotence, nipple pain.
Respiratory, thoracic and mediastinal disorders: Nasal congestion, dyspnoea.
Skin and subcutaneous tissue disorders: Hyperhidrosis, rash, tingling sensation in the scalp,
reversible lichenoid rash, SLE, reversible alopecia.
Vascular disorders: Peripheral coldness.
Potentially Fatal: Rarely, severe hepatocellular injury (reversible).
 Labetolol
HEALTH • Monitor blood pressure and heart rate before and after the 1st dose and during dose
TEACHING changes; hepatic function periodically; glucose levels in patients with diabetes mellitus.
Perform close pulse, cardiac, and blood pressure monitoring during and after
completion of IV inj or infusion.
• Overdosage Symptoms: Bradycardia, hypotension, bronchospasm and acute cardiac
insufficiency.
• Management: Performing gastric lavage or administration of activated charcoal and a
laxative may be considered to prevent further absorption shortly after ingestion.
Artificial respiration may be required. Administer atropine or methylatropine in case of
bradycardia or extensive vagal reactions. Hypotension and shock may be treated with
plasma or plasma substitutes and catecholamines, if necessary. May counteract the β-
blocking effect by slow IV administration of approx 5 mcg/min (starting dose)
isoprenaline hydrochloride or approx 2.5 mcg/min (starting dose) dobutamine until the
required effect has been obtained; IV administration of 8-10 mg glucagon may be
considered if the desired effect is not achieved. May consider giving Ca ions or using a
cardiac pacemaker if necessary.
 Lignocaine
Intramuscular- Intravenous- Pulseless ventricular fibrillation or ventricular
Emergency treatment of tachycardia
ventricular arrhythmias Adult: 1-1.5 mg/kg repeated as necessary. Max: 3 mg/kg. For
Adult: 300 mg injected ventricular arrhythmias in more stable patients: Usual loading dose:
into the deltoid muscle, 50-100 mg as an IV inj at 25-50 mg/min, may repeat once or twice up
repeat after 60-90 min if to a max of 200-300 mg in 1 hr, followed by 1-4 mg/min via
necessary. continuous IV infusion. May need to reduce dose if the infusion is
longer than 24 hr.

CONTRAINDICATION Hypovolaemia, complete heart block, Adam-Stokes syndrome, Wolff-

Parkinson-White syndrome. Must not be applied to inflamed or
injured skin.
 Lignocaine
SIDE Arrhythmia, bradycardia, arterial spasms, CV collapse, oedema, flushing, heart
EFFECT block, hypotension,, agitation, anxiety, coma, confusion, drowsiness,
hallucinations, headache, hyperaesthesia, hypoaesthesia, lightheadedness,
lethargy, nervousness, psychosis, seizure, slurred speech, unconsciousness,
somnolence, nausea, vomiting, metallic taste, tinnitus, disorientation, dizziness,
paraesthesia, resp depression and convulsions. Patch: Bruising, depigmentation,
petechiae, irritation. Ophth: Conjunctival hyperaemia, corneal epithelial changes,
diplopia,visual changes.
Pregnancy Category (US FDA)

HEALTH • May cause temporary loss of sensation and motor activity.

TEACHING • Monitor CV and resp vital signs, LFTs and careful ECG observation.
• Overdosage Symptoms: Severe hypotension, asystole, bradycardia, apnoea,
seizures, coma, cardiac arrest, resp arrest and death.
• Management: Maintain oxygenation, stop convulsion and support the
circulation.
122

AHA
 Methyldopa
Oral - Hypertension
Adult: Monotherapy: Initially, 250 mg bid or tid for 2 days. May increase or decrease at intervals of at
least 2 days according to response. Maintenance: 500-2,000 mg daily in 2-4 divided doses. Max: 3,000 mg
daily. Combination therapy with other antihypertensive agents: Initially, 500 mg daily in divided doses;
increased as necessary at intervals of at least 2 days. Administer new dosage increases in the evening to
minimise sedation.

CONTRA- Active liver disease (e.g. acute hepatitis, active cirrhosis), liver disorders associated with
INDICATION previous use of methyldopa, catecholamine-secreting tumour (e.g. phaeochromocytoma,
paraganglioma), porphyria, depression. Concurrent administration of MAOIs (e.g.
phenelzine).

SIDE EFFECT Significant: Oedema, weight gain, reversible granulocytopenia and thrombocytopenia,
sedation, fever, jaundice, depression.
Blood and lymphatic system disorders: Bone marrow depression, leucopenia,
eosinophilia.
Cardiac disorders: Bradycardia, angina pectoris, myocarditis, pericarditis,
atrioventricular block.
 Methyldopa
SIDE Endocrine disorders: Hyperprolactinaemia.
EFFECT Gastrointestinal disorders: Nausea, vomiting, abdominal distension, constipation, flatulence,
diarrhoea, colitis, xerostomia, glossodynia, melanoglossia, sialoadenitis, pancreatitis.
General disorders and administration site conditions: Asthenia.
Hepatobiliary disorders: Hepatitis.
Immune system disorders: Lupus-like syndrome.
Investigations: Positive Coombs test, positive tests for antinuclear antibody, LE cells, and rheumatoid
factor, abnormal LFT, increased BUN.
Musculoskeletal and connective tissue disorders: Mild arthralgia, myalgia.
Nervous system disorders: Bell’s palsy, headache, paraesthesia, parkinsonism, choreoathetosis, carotid
sinus syndrome, dizziness, symptoms of cerebrovascular insufficiency.
Psychiatric disorders: Nightmares, impaired mental acuity, reversible mild psychosis.
Reproductive system and breast disorders: Breast hypertrophy, gynaecomastia, amenorrhoea,
lactation, decreased libido, erectile dysfunction, ejaculation failure.
Respiratory, thoracic and mediastinal disorders: Nasal congestion.
Skin and subcutaneous tissue disorders: Rash (i.e. eczema, lichenoid eruption), urticaria, toxic
epidermal necrolysis.
Vascular disorders: Orthostatic hypotension.
Potentially Fatal: Hepatic necrosis, haemolytic anaemia.
 Methyldopa
HEALTH • Monitor blood pressure (standing and sitting/lying down), CBC, liver
TEACHING enzymes (periodically during the 1st 6-12 weeks or when unexplained fever
occurs). Direct Coombs test before initiation of therapy and at 6 and 12
months is recommended.
• Overdosage Symptoms: Acute hypotension, excessive sedation, weakness,
bradycardia, dizziness, lightheadedness, constipation, abdominal distention,
flatus, diarrhoea, nausea, vomiting.
• Management: Symptomatic and supportive treatment. If ingestion is recent,
may perform gastric lavage or induce emesis. Administration of
sympathomimetic agents may be considered.

Oral - Prinzmetal's
angina
Adult: As extended-release
tab/cap: 10-40 mg bid or
30-90 mg once daily,
depending on the
preparation (refer to
detailed product guideline).
CONTRAINDICATION
Nifedipine
Oral - Hypertension Oral - Angina pectoris
Adult: As extended-release Adult: Prophylaxis of chronic
tab/cap: 10-40 mg bid or 20- stable cases: Monotherapy or in
90 mg once daily, depending combination with β-blockers: As
on the preparation (refer to extended-release tab/cap: 10-40 mg
detailed product guideline). bid or 30-90 mg once daily,
depending on the preparation (refer
to detailed product guideline).
Cardiogenic shock, clinically significant aortic stenosis, unstable
angina, during or within 1 month of MI, acute attacks of angina;
secondary prevention of MI. Concomitant use with rifampicin.
 Nifedipine
SIDE Significant: Peripheral oedema, reflex tachycardia, increased angina or MI, cardiac
EFFECT ischaemic pain, symptomatic hypotension with or without syncope; impaired glucose
tolerance. Rarely, bezoar formation (use of extended-release formulation in patients
with gastrointestinal strictures).
Gastrointestinal disorders: Constipation, abdominal pain, dyspepsia, flatulence, dry
mouth, nausea.
General disorders and administration site conditions: Feeling unwell, oedema,
fatigue.
Musculoskeletal and connective tissue disorders: Muscle cramps.
Nervous system disorders: Headache, dizziness, tremors.
Psychiatric disorders: Nervousness, mood changes.
Respiratory, thoracic and mediastinal disorders: Nasal congestion, cough,
wheezing, sore throat, dyspnoea.
Vascular disorders: Vasodilatation, flushing.
 Nifedipine
HEALTH • This drug may cause dizziness, lethargy, and transient blindness due to severe hypotension; if
TEACHING affected, do not drive or operate machinery.
• Monitor blood pressure, heart rate, LFTs; signs and symptoms of heart failure and peripheral
oedema.
• Avoid concomitant use with grapefruit or grapefruit juice as it increases plasma levels of
nifedipine. May reduce serum levels with St. John’s wort. May elevate serum concentrations
with alcohol. Food may decrease the rate but not the extent of absorption.
• Should be taken on an empty stomach. Swallow whole, do not crush/split/chew.
• Overdosage Symptoms: Hypotension, tachycardia, bradycardia, hyperglycaemia, metabolic
acidosis, hypoxia, cardiogenic shock with pulmonary oedema, and disturbances of
consciousness leading to coma.
• Management: Symptomatic and supportive treatment. Activated charcoal may be given if the
ingestion of a potentially toxic amount is within 1 hour. Alternatively, gastric lavage may be
considered in adults if potentially life-threatening overdose occurs within 1 hour. Treat
hypotension as a result of cardiogenic shock and arterial vasodilatation with Ca (10-20 mL of a
10% Ca gluconate solution administered IV over 5-10 minutes). May continue treatment with
ECG monitoring if the effects are inadequate. May administer vasoconstricting
sympathomimetics (e.g. dopamine, norepinephrine) if an insufficient increase in blood pressure
is achieved with Ca. Symptomatic bradycardia may be treated with atropine.
 Nitrates (Amlodipine)
Oral - Hypertension Oral - Chronic stable angina, Prinzmetal's angina
Adult: Initially, 5 mg once daily, may be increased Adult: Initially, 5 mg once daily, may be increased
to 10 mg once daily according to clinical response. to 10 mg once daily according to clinical response.

CONTRA- Severe hypotension, shock (including cardiogenic shock), left ventricular outflow tract
INDICATION obstruction (e.g. high-grade aortic stenosis), haemodynamically unstable heart failure
after acute MI.
HEALTH • Monitor blood pressure and heart rate.
TEACHING • Overdosage Symptoms: Excessive peripheral vasodilation, reflex tachycardia,
hypotension, shock.
• Management: Initiate active cardiac and respiratory monitoring if massive overdose
occurs. Frequent blood pressure measurements are essential. For clinically significant
hypotension, provide CV support including elevation of the extremities and judicious
administration of fluids. If hypotension remains unresponsive, consider administration
of vasopressors (e.g. phenylephrine) with attention to circulating volume and urine
output. IV Ca gluconate may help reverse the effects of Ca channel blockade
 Nitrates (Amlodipine)
SIDE Significant: Symptomatic hypotension, peripheral oedema.
EFFECT Cardiac disorders: Palpitations.
Eye disorders: Visual disturbance.
Gastrointestinal disorders: Abdominal pain, nausea, dyspepsia, diarrhoea,
constipation.
General disorders and administration site conditions: Oedema, fatigue, asthenia.
Musculoskeletal and connective tissue disorders: Ankle swelling, muscle cramps.
Nervous system disorders: Somnolence, dizziness, headache.
Respiratory, thoracic and mediastinal disorders: Dyspnoea.
Vascular disorders: Flushing.
 Propafenone
Oral - Supraventricular arrhythmias, Ventricular Oral - Atrial fibrillation
arrhythmias Adult: For preventing the
Adult: For prophylaxis and treatment of ventricular recurrence in patients with
arrhythmias, paroxysmal supraventricular tachyarrhythmias episodic (paroxysmal or
including paroxysmal atrial flutter or fibrillation and persistent) cases who do not have
paroxysmal re-entrant tachycardias involving AV node or structural heart disease: As
accessory pathway, where standard treatment is ineffective or extended-release/sustained-release
contraindicated: As immediate-release tab: Initially, 150 mg cap: Initially, 225 mg 12 hourly,
tid, may be increased to 300 mg bid at intervals of at least 3-4 may be increased up to 325-425
days if necessary. Max: 300 mg tid. For patients <70 kg: mg 12 hourly at intervals of at
Reduction of total daily dose is recommended. Individualise least 5 days according to
dosing according to ECG monitoring and blood pressure individual response and tolerance.
control. If the QRS interval is prolonged by >20%, consider a
dose reduction or discontinuation until the ECG returns to
normal limits.
.
 Propafenone
CONTRA- Significant structural heart disease, MI within the last 3 months, uncontrolled CHF with LVEF
INDICATION below 35%, cardiogenic shock (unless arrhythmia-induced), severe symptomatic bradycardia,
severe hypotension, known Brugada syndrome, marked electrolyte imbalance (e.g. K metabolism
disorders, hypomagnesaemia)

HEALTH • This drug may cause dizziness, blurred vision, fatigue, or postural hypotension
TEACHING • Closely monitor ECG, blood pressure, and pulse at treatment initiation. Monitor vital signs,
pacemaker function
• Overdosage Symptoms: Myocardial effects: PQ prolongation, QRS widening, suppression of
sinus node automaticity, AV block, ventricular tachycardia, flutter or fibrillation, and
hypotension which can lead to CV shock. Non-cardiac effects: Headache, dizziness, blurred
vision, tremor, dry mouth, nausea, constipation. In severe cases, clonic-tonic convulsions,
paraesthesia, somnolence, coma, respiratory arrest may occur.
• Management: Symptomatic and supportive treatment. Defibrillation, as well as administration
of dopamine or isoproterenol infusion to control rhythm and blood pressure. Administer IV
diazepam to alleviate convulsions. May consider mechanical respiratory assistance and
external cardiac massage.
 Propafenone
SIDE Significant: Cardiac conduction disorder (e.g. slows AV conduction), CNS effects
EFFECT (e.g. dizziness, blurred vision, fatigue), agranulocytosis, elevated antinuclear
antibody (ANA) titre, hepatic abnormalities, fulminant hepatitis.
Blood and lymphatic system disorders: Thrombocytopenia, leucopenia,
granulocytopenia.
Cardiac disorders: Palpitations, bradycardia, tachycardia.
Gastrointestinal disorders: Nausea, vomiting, dry mouth, dysgeusia, constipation,
diarrhoea, abdominal pain, flatulence.
General disorders and administration site conditions: Asthenia, chest pain,
pyrexia.

Oral - Supraventricular
arrhythmias, Ventricular
arrhythmias
Adult: Initially, 80 mg/day as single
or in 2 divided doses, increased
gradually every 2-3 days. Usual dose:
160-320 mg/day in 2 divided doses.
CONTRA- INDICATION
Sotalol
Oral- Life-threatening ventricular arrhythmias
Adult: Initially, 80 mg bid, increased gradually every 3
days to 240-320 mg/day in divided doses if needed.
Maintenance: 160-320 mg/day in divided doses. Max:
480-640 mg in divided doses.
Bronchial asthma or history of COPD, sick sinus syndrome,
symptomatic sinus bradycardia, cardiogenic shock. 2nd and
3rd degree AV block, untreated phaeochromocytoma, torsades
de pointes, congenital or acquired long QT syndromes,
uncontrolled cardiac failure, cardiogenic shock, metabolic
acidosis, hypotension, severe peripheral arterial disease,
Raynaud's disease, anaesth that causes myocardial depression.
Renal impairment (CrCl <10 mL/min). Concomitant use w/ Ca
channel blockers (e.g. verapamil and diltiazem).
 Sotalol
SIDE Bradycardia, hypotension, chest pain, heart failure, dyspnoea, palpitations,
EFFECT oedema, ECG abnormalities, proarrhythmia, syncope, presyncope, rash,
nausea/vomiting, dyspepsia, flatulence, diarrhoea, abdominal pain, cramps, fever,
headache, fatigue, lightheadedness, dizziness, asthenia, sleep disturbances, mood
changes, depression, paraesthesia, anxiety, sexual dysfunction, visual
disturbances, taste abnormalities, hearing disturbances.
Potentially Fatal: Polymorphic ventricular tachycardia (very rare).
HEALTH • Monitor BP, heart rate, serum creatinine; Mg and K levels.
TEACHING • Overdosage Symptoms: Bradycardia, CHF, hypotension, bronchospasm and
hypoglycaemia.
• Management: Symptomatic and supportive treatment. Admin IV atropine,
another anticholinergic drug, a β-adrenergic agonist or use transvenous cardiac
pacing for bradycardia; transvenous cardiac pacemaker for heart block;
epinephrine for hypotension; aminophylline or aerosol β2-receptor stimulant
for bronchospasm; and DC cardioverison, transvenous cardiac pacing,
epinephrine, Mg sulfate for torsade de pointes. Removed via haemodialysis.
 Spironolactone
Oral- Oedema Oral- Congestive Oral -Hypertension Oral -Heart failure
Adult: Initially, heart failure with Adult: Adjunct in Adult: In conjunction with standard
100 mg daily, oedema patients who are not therapy for the treatment of New York
may be adjusted Adult: For the adequately controlled Heart Association (NYHA) Class III-IV
up to 400 mg management of on other agents: As tab: cases: Patients with serum K ≤5 mEq/L
daily according oedema: Initially, Initially, 25-100 mg and eGFR >50 mL/min/1.73 m2: As tab:
to response. 100 mg daily or daily as a single dose or Initially, 25 mg once daily, if tolerated,
25-200 mg daily as in divided doses. As may be increased to 50 mg once daily as
a single dose or in susp: Initially, 20-75 clinically indicated. As susp: Initially, 20
divided doses. mg daily a single dose mg once daily, if tolerated, may be
Maintenance dose or in divided doses. increased to 37.5 mg once daily as
must be adjusted Dosage may be titrated clinically indicated. Patients who develop
according to at 2-week intervals, if hyperkalaemia on initial dose: As tab:
individual needed, according to May reduce dose to 25 mg every other
response. response and day. As susp: May reduce dose to 20 mg
tolerability. every other day.
 Spironolactone
CONTRA- Hyperkalaemia, Addison’s disease, anuria, acute renal insufficiency, diabetic nephropathy.
INDICATION Severe renal impairment. Children with moderate to severe renal impairment. Lactation.
Concomitant use with eplerenone or other K-sparing diuretics, and K supplements (except in
cases of initial K depletion).

HEALTH • This drug may cause dizziness, drowsiness or somnolence, if affected, do not drive or
TEACHING operate machinery. Do not switch between dosage forms unless instructed by your doctor.
• Monitor blood pressure, uric acid, blood glucose, renal function, volume status, serum
electrolytes, including K (within 1 week of treatment initiation or dose titration, and
regularly thereafter). Closely monitor serum K and renal function 3 days after initiating
therapy, at 1 week after initiation, at least monthly for the 1st 3 months of treatment, and
every 3 months thereafter for patient with heart failure.
• Overdosage Symptoms: Drowsiness, dizziness, mental confusion, nausea, vomiting,
diarrhoea, maculopapular or erythematous rash. Rarely, hyponatraemia, hyperkalaemia
manifested as paraesthesia, flaccid paralysis, muscle weakness or spasm; hepatic coma.
• Management: Supportive treatment. Perform gastric lavage or induce vomiting. Maintain
hydration, electrolyte balance and vital functions. For hyperkalaemia, may decrease K
intake, administer K-excreting diuretics, IV glucose with regular insulin or oral ion-
exchange resins.
 Spironolactone
SIDE Significant: Fluid-electrolyte imbalance (e.g. hypomagnesaemia, hyponatraemia, hypocalcaemia,
hyperglycaemia), hyperchloraemic metabolic acidosis (reversible), asymptomatic hyperuricaemia, gout,
EFFECT gynaecomastia (reversible), symptomatic dehydration, hypotension, and worsened renal function; increased
BUN (reversible).
Blood and lymphatic system disorders: Rarely, agranulocytosis, leucopenia, thrombocytopenia.
Gastrointestinal disorders: Nausea, vomiting, diarrhoea, gastritis, gastrointestinal ulcer or haemorrhage.
General disorders and administration site conditions: Malaise, ataxia, fever.
Hepatobiliary disorders: Hepatotoxicity.
Immune system disorders: Rarely, hypersensitivity.
Metabolism and nutrition disorders: Hypovolaemia.
Musculoskeletal and connective tissue disorders: Muscle spasms.
Nervous system disorders: Dizziness, headache, drowsiness.
Psychiatric disorders: Confusional state.
Renal and urinary disorders: Acute kidney injury.
Reproductive system and breast disorders: Breast pain, benign breast neoplasm (male), decreased libido,
irregular menses, erectile dysfunction, postmenopausal bleeding.
Skin and subcutaneous tissue disorders: Pruritus, rash, urticaria, toxic epidermal necrolysis (TEN),
Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS), alopecia,
hypertrichosis.
Potentially Fatal: Hyperkalaemia.
 Statins (Lovastatin)
DOSE 20-80mg OD
ROUTE Oral
INDICATION Hyperlipidaemias, Primary prophylaxis of coronary artery disease

CONTRAINDICATION Pregnant woman, Breastfeeding mother, active liver disease,

Alcoholism

SIDE EFFECT Drowsiness, Nausea, Difficulty sleeping (insomnia), Dizziness,

Headache, Arthralgia, Blurred vision, Rash, Myopathy
 Statins (Pravastatin)
DOSE 20-40mg OD
ROUTE Oral
INDICATION Hyperlipidemia, Primary Prevention of Coronary Events, Secondary
Prevention of Cardiovascular Events
CONTRAINDICATION Pregnant woman, Lactation mother, Hypersensitivity, Active liver
disease elevated LFTs, decompensated cirrhosis
SIDE EFFECT Nausea/vomiting ,Diarrhea , Headache, Chest pain , Fatigue, Rash ,
Cough , Heartburn, Flulike symptom, Myalgia
 Statins (Simvastatin)
DOSE 5 to 40mg OD
ROUTE Oral
INDICATION Cholesterol, Myocardial infarction

CONTRAINDICATION Pregnant woman, Breastfeeding mother, Alcoholis, Diabetes,

Hypothyroidism (an underactive thyroid) not well-controlled, Liver
disease. Electrolyte disorders, Endocrine disorders, Epilepsy
(seizures), Hypotension , Hypovolemia
Kidney disease, Metabolic disorders, Sepsis ,Surgery, major or
Trauma(risk for muscle or kidney problems),Hypercholesterolemia
SIDE EFFECT Nausea/vomiting ,Diarrhea , Headache, Chest pain , Fatigue, Rash ,
Cough , Heartburn, Flulike symptom, Myalgia
 Ticlopidine
DOSE 250 mg twice daily
ROUTE Oral
INDICATION Thrombotic stroke, Eutropenia, Agranulocytosis, aplastic anemia, Prophylaxis of
subacute stent occlusion after intracoronary stenting, people who cannot take aspirin to
prevent strokes.
CONTRA- Hypersensitivity to the drug, Presence of hematopoietic disorders such as neutropenia
INDICATION and thrombocytopenia or a past history of either TTP or aplastic anemia, Presence of a
hemostatic disorder or active pathological bleeding (such as bleeding peptic ulcer or
intracranial bleeding), Patients with severe liver impairment

SIDE EFFECT Diarrhea, Stomach upset or pain,nausea, Vomiting,dizzines, Ringing in your ears, or
itching. Hives,difficulty breathing, Swelling of your face, lips, tongue, or throat, Any
bleeding that will not stop, Pink or brown urine,fever,chills, Flu-like symptoms,
Swollen gums, Skin sores, Rapid heart rate,pale skin, Loss of appetite, Yellowing of the
skin or eyes (jaundice)
 Verapamil
DOSE 5-10mg /mL 40mg-360mg
ROUTE IV/PO
INDICATION Acute Coronary Syndromes w/out Persistent ST-Segment, Elevation, Chronic Coronary
Syndromes, Headache, Heart Failure – Chronic, Hypertension, Hypertensive Crisis,
Tachycardia, Angina
CONTRA- First 2 trimesters of pregnancy, Hypersensitivity to verapamil or other calcium channel
INDICATION blockers, Cardiogenic shock, Congestive heart failure, Symptomatic hypotension, Sick
sinus syndrome (unless permanent pacemaker in place), 2°/3° AV block (unless
permanent pacemaker in place)

SIDE EFFECT Hypotension, fetal hypoperfusion, Headache, Gingival hyperplasia, Constipation,

Dizziness , Dyspepsia Nausea, Edema , Rash , Increased liver enzymes , Sleep
disturbance , Dyspnea
 Hydralazine
DOSE 5-10 mg via slow IV inj, may repeat after 20-30 minutes if necessary;
or 200-300 mcg/min via continuous IV infusion, adjust individually
according to response to usual maintenance dose of 50-150 mcg/min.
Alternatively, give 20-40 mg via IV push or IM inj then repeat if
necessary.
ROUTE Intramascular, Oral, Parenteral
INDICATION Hypertensive emergency , Congestive heart failure, Hypertension

CONTRAINDICATION Idiopathic SLE and related diseases, severe tachycardia, heart failure
with high cardiac output (e.g. thyrotoxicosis), myocardial
insufficiency due to mechanical obstruction (e.g. aortic or mitral
stenosis, constrictive pericarditis), isolated right ventricular failure due
to pulmonary hypertension, dissecting aortic aneurysm, CAD, mitral
valvular rheumatic heart disease, porphyria.
SIDE EFFECT Significant: Anginal attacks, ECG changes, peripheral neuritis.
Rarely, skin rash, febrile reactions, change in blood count.
Cardiac disorders: Tachycardia, palpitation.
Gastrointestinal disorders: Gastrointestinal disturbances, diarrhoea,
nausea, vomiting.
Metabolism and nutrition disorders: Anorexia.
Musculoskeletal and connective tissue disorders: Arthralgia, joint
swelling, myalgia.
Nervous system disorders: Headache, dizziness.
Vascular disorders: Flushing, hypotension.
Potentially Fatal: SLE-like syndrome (prolonged use, particularly
doses exceeding 100 mg daily), systemic vasculitis.
 ANTI-COAGULANTS IN PREGNANCY
DRUGS PRECONCEPTION EFFECTS OF PREGNANCY FETAL LACTATION
CONSIDERATIONS
Warfarin Discuss risk, and Depends on reason for use. In Teratogen. Does not enter
make plan for general, avoid use at period of Exposure between breastmilk as
pregnancy. greatest teratogenicity and 6 and 10 weeks highly protein
Depends on after 36 weeks. Maybe safe to associated with bound
indication for anti- use heparin as alternative embryopathy.
coagulation throughout pregnancy, but for Higher dose (>5
women with metal valves this mg/day) associated
may not provide sufficient anti with higher fetal risk
coagulation

Heparin Reassure safe in Safe in pregnancy. Increased Does not across Safe in
pregnancy renal clearance, may require placenta due to breastfeeding
increased dose. Monitoring of molecular size
Xa levels if therapeutic (rather
than prophylaxis is required) 146
 Aspirin (low dose)
DOSE Initial treatment: Loading dose: 150-300 mg

ROUTE Oral
INDICATION Unstable angina; Myocardial infarction; Transient ischaemic attack
CONTRA- Hypersensitivity to aspirin, salicylates and other NSAIDs; history of asthma
INDICATION attacks, angioedema, urticaria, or rhinitis precipitated by aspirin or other
NSAIDs. Nasal polyps associated with asthma; active or history of recurrent
peptic ulceration and gastrointestinal haemorrhage; haemorrhagic diathesis,
coagulation disorders (e.g. haemophilia, thrombocytopenia), severe cardiac
failure, gout. Severe renal and hepatic impairment. Children <16 years and/or
those who have or are recovering from chickenpox or flu-like symptoms.
Pregnancy (doses >100 mg daily during 3rd trimester) and lactation (during
long-term use and/or high doses). Concomitant use with methotrexate ≥15 mg
weekly
 Aspirin (low dose)
SIDE Significant: Bronchospasm, asthma attacks, hypersensitivity reactions, prolonged bleeding time;
EFFECT reduced uric acid excretion (low dose use); haemolytic anaemia (in patients with G6PD deficiency),
medication overuse headache (long-term use), salicylism (repeated use of large doses).
Blood and lymphatic system disorders: Rarely, thrombocytopenia, agranulocytosis, aplastic
anaemia.
Ear and labyrinth disorders: Reduced hearing ability, tinnitus, vertigo.
Gastrointestinal disorders: Dyspepsia, nausea, vomiting, diarrhoea, mild stomach pain, heartburn.
Hepatobiliary disorders: Hepatic insufficiency, hepatitis.
Investigations: Increased transaminases.
Nervous system disorders: Headache.
Renal and urinary disorders: Impaired renal function, Na and fluid retention, urate kidney stones,
haematuria.
Reproductive system and breast disorders: Rarely, menorrhagia.
Respiratory, thoracic and mediastinal disorders: Rhinitis, dyspnoea.
Skin and subcutaneous tissue disorders: Urticaria.
Potentially Fatal: Gastrointestinal bleeding, ulceration, and perforation. Rarely, Reye's syndrome,
serious skin reactions (e.g. Stevens-Johnson syndrome, erythema multiforme, toxic epidermal
necrolysis).
 Aspirin (low dose)
HEALTH • Instruct patients on symptoms of toxicity such as a ringing in the ears
TEACHING (tinnitus) or hearing loss, and unusual bleeding or bruising.
• Do not take aspirin with alcohol due to an increased risk of bleeding.
• Educate that aspirin has an antiplatelet effect. If the patient is taking another
anticoagulant, their risk of bleeding is increased. Teach the patient to monitor
for bruising and signs of bleeding, and to prevent the risk of injury.
• Keep out of reach of children to prevent poisoning.
• Aspirin needs to be discontinued 1 week prior to surgical and dental
procedures due to the risk of bleeding. Discuss with your healthcare provider
before discontinuing.
• Administer aspirin with food or milk to reduce the risk of GI irritation.
• Alert all providers that you are taking aspirin to prevent interactions.
• Do not break, crush, or chew extended-release, delayed-release, or enteric-
coated preparations.
 Warfarin
DOSE 1mg,3mg,5mg
ROUTE oral
INDICATION Mechanical heart valves , deep venous thrombosis & thromboembolism, atrial
fibrillation, cardiac valve replacement,
CONTRA- •Allergy to warfarin, Recent or planned surgery on the brain, spine, or eye,
INDICATION Large esophageal varices, Low platelet count, Pregnancy, except in women with
mechanical heart valves, Hemorrhagic tendencies or blood dyscrasias, Bleeding
tendencies associated with certain conditions, Kidney problems or risk of acute
kidney injury
SIDE EFFECT Bleeding problems, allergies, liver problems, low BP, swelling, paleness, fever,
HEALTH . Try to avoid NSAIDs (ibuprofen, naproxen) and aspirin for pain or
TEACHING inflammation as these can increase your risk for bleeding while on warfarin.
ANTICOAGULATION MTAC (ACMTAC) PROT
ANTICOAGULATION MTAC (ACMTAC) PROT
 Heparin (LWMH-Clexane/Enoxaparin)
DOSE 20mg OD , Weight -<50kg
40mg OD , Weight – 50 – 90kg
60mg OD , Weight 90 – 130 kg
80mg OD , Weight >130kg

ROUTE Subcutaneous

INDICATION Mechanical heart valves , atrial fibrillation , pulmonary aterial hypertension , congenital heart
disease , hypercoagulable
CONTRA- Hypersensitivity to enoxaparin , heparin , history of immune-mediated heparin – induced
INDICATION thrombocytopenia (hit),active clinically significant bleeding , recent haemorrhagic stroke ,
gastrointestinal ulcer

HEALTH Enoxaparin is a low molecular weight heparin (LMWH) with anticoagulant properties. It has
TEACHING minimal effect on the activated partial thromboplastin time (aptt) and has high anti-factor xa
activity. Its anticoagulant effects are mediated through antithrombin III resulting in
antithrombotic activities.
DRUGS IN PREGNANCY
CPG Heart

154
DRUGS IN PREGNANCY

155

CPG Heart
DRUGS IN PREGNANCY

156

CPG Heart
 157

CPG Heart
 158

CPG Heart
 159

CPG Heart
160
CPG Heart
161
 CONTRACEPTION IN PREGNANCY
 Effective contraception
- Permanent sterilization.
- Barriers methods as condom are useful in heart disease because of do
not have adverse effects.
- Oral contraceptives is best avoided in patients with ischemic heart
disease , valvular heart disease & pulmonary hpt. Risk of
thromboembolism , hypercoagulability and adverse lipid profiles
associated with pill.

162
 CONTRACEPTION IN PREGNANCY
 Effective contraception
- Intra- uterine device – low failure but for valvular and congenital lesions
limited by the risk of bacterial endocarditis. In those with prosthetic valve &
with a past history of endocarditis .
- implants and injectables are safe methods for those with heart disease.
• The use of iucd is an absolute contraindication. In those patient with
congenital & valvular lesions the IUCD may be used when other option
are limited.

163
 COMPLICATION OF CARDIAC DISEASE IN
• Pregnancy
PREGNANCY
• *Risk is not increaased if symptoms
- Do not occur with exertion (class 1)
- Occur only with signifacant exertion (class II )

* Risk is increased symptoms

- Occur with mild exertion (class I )
- Occur with minimal or no exertion (class IV )
164
 COMPLICATION OF CARDIAC DISEASE IN
PREGNANCY
MATERNAL
1. Haemorrhage caused by hypertension
2. Cerebral/Pulmonary embolism
- As a result of slow blood flow causing blood clots in the brain / lungs
3. Acute cardiac failure
- Heart weakness on the right side
- As a result of blood congestion from the inferior & superior vena cava in
the lungs 165
 COMPLICATION OF CARDIAC DISEASE IN
PREGNANCY
4. Sub bacterial endocarditis (SBE)
- antenatal mothers with tooth decay, microorganisms from damaged teeth
can enter the heart through the circulatory system
5. Weak body defenses
6. Acute pulmonary
-as a result of the left atrium failing to function due to a narrow mitral valve
causing blood circulation to be unable to pump to the left ventricle and the
rest of the body, causing congestion in the lungs
7. Maternal shock is caused by a lack of oxygen in the blood and the heart166

cannot pump blood throughout the body.

 COMPLICATION OF CARDIAC DISEASE IN
PREGNANCY
FETUS
1. Intrauterine death (IUD) is caused by a lack of oxygen in the blood.
2. IUGR / Small gestation age (SGA) - heart failure due to increased
cardiac output causing less oxygen and nutrients to the fetus
3. Preterm baby- lack of oxygen supply stimulates the uterus to contract
and premature birth will occur
4. Congenital heart disease is a structural problem of the heart that exists
from birth such as tetralogy of fallot.
5. Fetal defects - side effects of drugs such as warfarin (teratogenic) 167
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Family planning
Contraception option:
• Contraceptive safety and risk has not specifically been examined in women with heart
disease . therefore , recommendations are extrapolated from studies in women without
heart disease.
 Barrier methods
• In general barrier methods (condom, diaphragms and cervical caps) do not pose a
health risk to the mother, but due to the high failure rates are not recommended to women
when the maternal risk of pregnancy related complication is high.
168
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Combined estrogen and progestin contraceptives
• This contraception have very good efficacy, but the estrogen component is associated with
a risk of arterial and venous thrombosis.
• Combined contraceptives should be used with caution in women with bile a flat
mechanical valves, atrial arrhythmias, prior thromboembolic events or unoperated atrial
septal defects.

169
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Progestin only contraceptives.
•Progestin only methods are not associated with a thrombosis risk and in many cases are
ideal for women with heart disease. However , the pill form has high failure rates and
should not be used in women in whom pregnancy is contraindicated.
•Some of the never forms of progestin only pill may be associated with lower failure
rates.

170
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Family planning
• Kaedah pembedahan
-BTL (bilateral tubal ligation)
-Vasectomy

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 HEALTH TEACHING OF CARDIAC DISEASE
2) Well balanced diet
IN PREGNANCY
I- Reduce sodium and increase potassium
•Selecting foods low in salt and sodium as well as high in potassium are key components to
healthy eating for cardiac patients.
•Excessive salt intake increases body fluid volume, impairing the body’s natural blood
pressure regulators.
•The recommended limiting sodium intake to between 1500mg and 2400mg per day. This
equal approximately 2/3 to 1 tsp of salt.
•Processed, overly salted prepared foods such as canned salted vegetables, fast food and
frozen pizza should also be omitted from your diet.
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•A low sodium and high potassium diet also reduces the effect of adrenaline on the body
 HEALTH TEACHING OF CARDIAC DISEASE
Ii- Fiber-rich diet
IN PREGNANCY
• A high fiber is effective in the prevention and treatment of many types of cardiac diseases.
• Water soluble fibers such as oat bran are of particular benefit in reducing cholesterol and blood
pressure.
Iii- Vegetarian an lifestyle
• National institutes of health(NIH) studies have found that vegetarians typically have lower
blood –pressure levels as well as a lower incidence of all cardiac disease.
• These studies determined that a standard vegetarian diet includes more fiber, complex
carbohydrate, potassium , magnesium, calcium, and vitamin c, and a in addition to a lower
intake of sodium.
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• All of these factors are believed to contribute to the prevention of cardiac episodes
 HEALTH TEACHING OF CARDIAC DISEASE
3) Prevention of infection IN PREGNANCY
• Infection often cause a pyrexia and tachycardia- which increase the cardiac output and put an
added strain on the heart.
• The infective organism can cause further damage in women with heart lesions by causing
endocarditis
• Advice about how identity respiratory, urinary, and vaginal infections and the necessary of
seeking treatment for these infection as quickly as possible.
• An early dental examination to detect and treat caries and gum disease, which will also
precipitate endocarditis
• Prophylactic antibiotic therapy is recommended for women who are at high risk of endocarditis.
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• All invasive procedure should be carried out using a strict aseptic technique and the number of
vaginal examination in labor should be kept to a minimum.
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
4. Sterilization

• Women should be educated about the highly effective alternative options.

• Tubal ligation is associated with procedural risks in women with complex heart disease such
as fontan circulation or eisenmanger physiology and should only be done in centers with
expertise in this group of women.
5. Follow up care
• Mother will had a follow up under combined clinic every 2/52 until 30/52 gestation and
weekly thereafter until birth.
• At each visit , a mother is asked about cardiac symptoms and whether there is any limitation on
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her activities.
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
6) Pre conception counseling
• Discuss the impact of their heart condition on pregnancy well in advance of becoming pregnant.
• Discuss contraception, maternal and fetal risks of pregnancy and potential long term maternal
morbidity and mortality.

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 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Well balance diet
• Nutrition must be adequate in iron and folic acid to prevent anaemia and
increase cardiac workload.
• Sodium restriction.
• Increase dietary fiber can decrease the risk for constipation and reduce
heart workload.
• If patient taking a diuretic must increase dietary source of potassium to
decrease the risk for potassium deficiency.
• Refer dietitian form management of the dietary modifications with complex
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pharmacologic treatment.
 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
Prevention of infection
• Get early treatment if have symptoms of infection fever, flu or cough
• Hand hygiene
• Avoid crowded area
• Practice good personal hygiene

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 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
• Follow-up care
• Semua cardiac patient yang mengalami cardiac murmur perlu dirujuk ke
hospital untuk urgent echocardiography dan dirawat di combine clinic.
• Lawatan ke klinik antenatal ialah 2 minggu sekali sehingga 28 minggu
kemudian seminggu sekali sehingga bersalin.
• Notify klinik kesihatan selepas discaj untuk postnatal follow up.
• Mo/fms review di klinik kesihatan.
• Pastikan patient follow up dengan cardiac clinic.
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 HEALTH TEACHING OF CARDIAC DISEASE
IN PREGNANCY
• Pre-conception counseling
• Follow up TCA FMS @ clinic.
• Inform any potential risk that may affect their health and unborn baby such
as congenital malformations.
• Assist in decision making and plan their pregnancy monitoring to reduce
morbidity and mortality.
• Review and counsel about all medications for pregnancy risk include lab
testing, ecg, x-ray and assessment of stress or cardiopulmonary exercise
test. 180

• Educate patient about suitable contraception.

 REFERENCE
American Heart Association. (n.d.). Algorithms. cpr.heart.org.
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms

Cardiac Drug. (n.d.). MIMS. https://www.mims.com/malaysia/drug/search?

q=cardiac+drugs&mtype=brand&code=2a

Epomedicine. (2021, March 27). FDA Pregnancy Drug Risk Categories : Mnemonic |
Epomedicine. https://epomedicine.com/medical-students/fda-pregnancy-drug-risk-categories-
mnemonic/

Kedah State Health Department. (2019). OBSTETRICS AND GYNAECOLOGY PROTOCOL

STATE OF KEDAH 2019.

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 REFERENCE
Marshall, J. E., & Raynor, M. D. (2020). Myles Textbook for Midwives (17th ed., Vols. 361–
369). Elsevier.

Medical eligibility criteria for female sterilization | Family planning. (n.d.).

https://fphandbook.org/medical-eligibility-criteria-female-sterilization

Mehta, L. S., Warnes, C. A., Bradley, E. A., Burton, T., Economy, K. E., Mehran, R., Safdar,
B., Sharma, G., Wood, M. J., Valente, A. M., Volgman, A. S., & Biology, V. (2020).
Cardiovascular considerations in caring for Pregnant patients: A scientific statement from the
American Heart Association. Circulation, 141(23).
https://doi.org/10.1161/cir.0000000000000772

Ministry of Health Malaysia. (2016). CLINICAL PRACTICE GUIDELINE HEART DISEASE

2016. https://www.malaysianheart.org/files/583aacd86e27d.pdf
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THANK YOU!!!

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