Objectives Effects of CV Drugs on Hemodynamics: Which Drug When? Robin Donohoe Dennison, DNP, APRN, CCNS, CNE describe the hemodynamic effects of select CV drugs select the appropriate CV drug in a clinical situation explain rationale for use of one drug over another drug copyright Robin Donohoe Dennison 2015 Heart Rate Palpable Pulse by fluids by diuretics, venous vasodilators Herlihy, 2007 treatment of cause antidysrhythmics I: procainamide, quinidine, lidocaine II: beta-blockers III: amiodarone, ibutilide, dofetilide IV: calcium channel blockers Misc: adenosine, digoxin vagal maneuvers cardioversion overdrive pacing defibrillation treatment of cause parasympatholytics: atropine sympathomimetics: epinephrine pacemaker Volume Pressure by vasopressors by arterial vasodilators, IABP Optimal preload Preload RV: RAP LV: LAP (PAOP) Normal but suboptimal Understretched Optimal Overstretched venous vasodilators: morphine; NTG diuretics ACE inhibitors or ARBs crystalloids: NS, LR colloids: albumin, hetastarch, dextran blood and blood products 1
arterial vasodilators: NTP, NTG > 1 mcg/ kg/min; hydralazine ACE inhibitors or ARBs IABP RV specifically oxygen pulmonary vasodilators: aminophylline, epoprostenol (Flolan), bosentan (Tracleer), nitric oxide Afterload RV: PVRI LV: SVRI vasopressors: phenylephrine, norepinephrine, dopamine, vasopressin beta-blockers calcium channel blockers Contractility RV: RVSWI LV: LVSWI cardiac glycosides: digoxin sympathomimetics: dobutamine PDE inhibitors: milrinone Inotropic Agents Cardiac glycosides: digoxin Sympathomimetic (adrenergic) agents Epinephrine Dopamine Dobutamine Phosphodiesterase inhibitors Inamrinone Milrinone Hemodynamic effects of inotropic agents Drug CO/CI MAP PAOP SVR Heart rate Digoxin Dobutamine or Dopamine Inamrinone/ Milrinone Sympathomimetics Inotropes Drug Alpha Beta 1 Beta 2 Phenylephrine ++++ 0 0 Norepinephrine ++++ ++ 0 Epinephrine ++++ ++++ ++ Dopamine +++ +++ + Dobutamine + ++++ ++ Isoproterenol 0 ++++ ++++ chronic LVF acute LVF calcium channel blocker toxicity beta-blocker toxicity end-stage refractory LVF a. Dobutamine b. Milrinone c. Digoxin d. Glucagon e. Calcium 2
Vasodilators Vasodilators Venous dilators to decrease preload Arterial dilators to decrease afterload Vasoactive effects of selected drugs DRUG ARTERIES VEINS Morphine sulfate no yes Effects of calcium channel blockers Nitroglycerin (Tridil) only if > 1 mcg/kg/min yes Hydralazine (Apresoline) yes no Minoxidil (Loniten) yes no Fenoldopam mesylate (Corlopam) yes no Clevidipine butyrate (Cleviprex) yes no Milrinone (Primacor) yes yes Nicardipine (Cardene) yes yes Nifedipine (Procardia) yes yes Nesiritide (Natrecor) yes yes Nitroprusside (Nipride) yes yes Phentolamine (Regitine) yes yes Prazosin (Minipress) yes yes Type of Calcium Channel Blocker Dihydropyridine type (e.g., nifedipine) Diphenylalkylamine type (i.e., diltiazem) Benzothiazepine type (i.e., verapamil) Coronary Arterial Dilation Peripheral Arterial Dilation AV Nodal Depression SA Nodal Depression + +++ 0 0 0 + ++ + + Effect on LV Contractility Copyright Dennison, R. D. (2013). Pass CCRN! (4 ed). Philadelphia: Elsevier. eclampsia hypertension with neurologic injury need for afterload reduction in acute MI benign prostatic hypertrophy hypertension after vascular surgery cerebral vasospasm autonomic dysreflexia heart failure coronary artery spasm renal hypoperfusion Vasodilators a. Nifedipine (Procardia) b. Nitroglycerin (Tridil) c. Labetalol (Normodyne) d. Phentolamine (Regitine) e. Fenoldopam mesylate (Corlopam) f. Hydralazine (Apresoline) g. Carvedilol (Coreg) h. Clevidipine (Cleviprex) i. Nitroprusside (Nipride) j. Doxazosin (Cardura) 3
Blood pressure = Sympathomimetics Vasopressors Drug Alpha Beta 1 Beta 2 Phenylephrine ++++ 0 0 Norepinephrine ++++ ++ 0 Epinephrine ++++ ++++ ++ Dopamine +++ +++ + Dobutamine + ++++ ++ Isoproterenol 0 ++++ ++++ Hormone: Vasopressin Antidysrhythmics Antidysrhythmics blocks potassium channel blocks beta receptors blocks calcium channel blocks sodium channel blocks reentry a. Class I b. Class II c. Class III d. Class IV e. Miscellaneous 4
Diuretics Diuretics heart failure hypertension oliguria rhabdomyolysis glaucoma metabolic alkalosis intracranial hypertension cirrhosis a. Thiazide b. Loop c. Osmotic d. Aldosterone antagonists e. Carbonic anhydrase Digoxin Dobutamine Dopamine 3-5 mcg/kg/min Dopamine 5-10 mcg/kg/min Dopamine >10 mcg/kg/min Fluid challenge Furosemide Milrinone Nesiritide Nitroglycerin Nitroprusside Phenylephrine Propranolol Vasopressin a. Increased heart rate b. Decreased heart rate c. Increased preload d. Decreased preload e. Increased afterload f. Decreased afterload g. Increased contractility h. Decreased contractility Case Study ST segment elevation in V 1 = septal injury Pathologic Q waves and ST segment elevation in V 2 through V 5 = acute anterior MI ST segment elevation in V 6 = lateral injury 5
PCI successful with reperfusion of IRA (LAD) BP 86/56 mm Hg MAP 66 mm Hg HR 118 bpm RA 8 mm Hg PA 44/26 mm Hg PAOP 22 mm Hg CO 3 liters/minute CI 1.3 liters/min/m 2 SV 25 ml/beat SVR 1680 dynes/sec/cm -5 PVR 160 dynes/sec/cm -5 DO 2 I 259 ml/min/m 2 References Bockenstedt, T. L., Baker, S. N., Weant, K. A., & Mason, M. A. (2012). Review of vasopressor therapy in the setting of vasodilatory shock. Adv Emerg Nurs J, 34(1), 16-23. Cooper, B. E. (2008). Review and update on inotropes and vasopressors. AACN Advanced Critical Care, 19(1), 5-13; quiz 14-15. Dennison, R. D. [2013]. Pass CCRN! [4 ed]. Philadelphia: Elsevier. Hays, A. J., & Wilkerson, T. D. (2010). Management of hypertensive emergencies: A drug therapy perspective for nurses. AACN Advanced Critical Care, 21(1), 5-14. References Oba, Y., & Lone, N. A. (2014). Mortality benefit of vasopressor and inotropic agents in septic shock: A bayesian network meta-analysis of randomized controlled trials. Journal of Critical Care, 29(5), 706-10. Ndefo, U. A., Erowele, G. I., Ebiasah, R., & Green, W. (2010). Clevidipine: a new intravenous option for the management of acute hypertension. Am J Health Syst Pharm, 67(5), 351-360. Improving vasopressor safety (2014).. Fredericton: Nurses Association of New Brunswick. Sviri, S., Hashoul, J., Stav, I., & van Heerden, P. (2014). Does high-dose vasopressor therapy in medical intensive care patients indicate what we already suspect? Journal of Critical Care, 29(1), 157-60. Which of the following would be appropriate to decrease preload? (more than one may be correct) a. Cleviprex b. Nitroprusside c. Nicardipine d. Nitroglycerin Which of the following is an advantage of dobutamine over dopamine as an inotropic agent? (more than one may be correct) a. less tachycardia b. decrease in preload and afterload c. less proarrhythmogenesis d. less propensity for hypotension 6