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Cardiac Drugs - Quick Reference                         See  Anticoagulation Rx  |  BP Medications

Adenosine (Adenocard) 6 mg IV bolus, may repeat at 12 mg IV bolus. for SVT, Narrow Complex Tachycardia or Wide Complex Tachycardia * Adverse effects: dyspnea, flushing, chest discomfort or pain. * Supply: 6mg/2mL vial * Duration: less than 1 minute.

Amiodarone (Cordarone) For Cardiac Arrest  life-threatening ventricular arrhythmia (Vent. fibrillation or pulseless Vent. tachycardia) - IV 300 mg bolus or 5 mg/kg in shock-refractory VF/pulseless VT; followed by unsynchronized defibrillation, additional 150 mg bolus may be given  in 3-5 min if serious arrhythmias recur. (Max dose 2.2 g/24 h IV) For unstable Vent. tachycardia or Supraventricular tachycardia: - IV load 150 mg over 10 min (15 mg/min), may repeat same dose as needed, then 1 mg/min x 6 hours, then 0.5 mg/min (about 540 mg IV/18 hr)  x 18 hours. Oral loading dose: 800-1600 mg PO daily for 1-3 weeks, reduce dose to 400-800 mg daily for 1 month when arrhythmia is controlled or adverse effects are prominent, then reduce to lowest effective dose, usually 200-400 mg daily.

Amrinone (Inocor) 0.75 mg/kg loading over 2-3 min, may repeat loading dose x1 30 min later prn, then 5-10 ug/kg/min. (Max: <10mg/kg/day) * Adverse risks: thrombocytopenia, arrhythmia, hypotension * Supply: 20 mL ampule of 5mg/mL

Atropine For Asystole or Pulseless Electrical Acitiry: 1 mg IV push, may repeat q3-5 min (Max 0.03-0.04 mg/kg) For Bradycardia: 0.5 - 1.0 mg IV q3-5 min as needed, max 0.04 mg/kg. * Tracheal dose:  2-3 mg in 10 mL NS. * Adverse risks: increased myocardial O2 consumption with tachycardia, ventricular tachycardia or fibrillation * Supply: 1 mg/10 ml, 0.5 mg/5 ml

Beta-blockers Propranolol (Inderal) usual dose 1 - 3 mg IV or at rate 0.5 - 1 mg/min to total dose of 0.15 - 0.2 mg/kg * Adverse risks: bradycardia, AV block, hypotension, mental depression, bronchospasm, etc. * Supply: 1mg/1mL ampule Esmolol 0.5 mg/kg over 1 min, followed by 0.05 mg/kg/min infusion, titrate the dose (Max: 0.3 mg/kg/min). Short half-life of 2-9 minutes. Labetalol 10 mg IV Push over 1-2 minutes, may repeat every 10 min (Max 150 mg) or 2 - 8 ug/min infusion Atenolol 5 mg slow IV over 5 minutes, may repeat IV slowly after 10 minutes; if tolerated well may start PO 50 mg bid Metoprolol 5 mg slow IV over 5 minutes, may repeat in 5 minutes (total dose 15 mg); if tolerated well may start PO 50 mg bid

Bretylium (Bretylol) 250 - 500 mg or 5 mg/kg IV bolus, may repeat in 5 min at 10mg/kg, then 1 - 2 mg/min infusion * Adverse risks: N&V, postural hypotension, bradycardia, increased PVC, dizziness * Supply: 500 mg/10 ml; add 1 gm to 100-250 mL D5W (10-4 mg/mL conc.)

Cardizem (Diltiazem) IV bolus for rate control of atrial fib/flutter. * Start 0.25 mg/kg IVP over 2 min (ave pt= 15-20mg dose), after 15 min if inadequate response, 0.35 mg/kg (ave pt = 20-25 mg dose) over 2 min; Infusion Rx start at 5 mg/h, range 10 - 15 mg/h., titrated to heart rate * Adversr risks: hypotension, arrhythmia, bradycardia, AV block, CHF, dizziness. * Supply: 5-10 mL vial of 5 mg/mL

Dobutamine (Dobutrex) start 2 - 3 ug/kg/min, increase by 2 - 3 ug/kg/min q10 - 15min IV infusion, optimal maintenance doses : 7.5 - 20 ug/kg/min (Max: 40 ug/kg/min) * Adverse risks: tachycardia, dysrhythmias, headaches, anxiety, tremors, etc. * Supply: 250 mg/20 mL vial; add 250 mg in 250-500 mL D5W (1000-500 ug/mL conc.) * Duration: 10 - 12 min

Dopamine (Intropin) usually up to 20 ug/kg/min IV infusion; (Max 20-50 ug/kg/min) (1-2 ug/kg/min dopaminergic; 2-5 ug/kg/min inotropic; 5-20 ug/kg/min vasoconstriction Alpha1) * Adverse risks: tachyarrhythmia, GI upset, angina, excessive vasoconstriction. * Supply: 200 mg/5 mL; add 200 mg in/ 500 mL D5W = 400 ug/mL)

Epinephrine   For cardiac arrest:  IV 1 mg (10 mL in 1:10,000 solution) q3-5 min; followed each dose with 20 mL IV flush. For bradycardia or hypotension:  Epinephrine infusion 2-10 mcg/min (add 1 mg of 1:1000 to 500 mL NS, infuse at 1-5 mL/min) * Tracheal Dose:  2 - 2.5 mg diluted in 10 mL NS * Adverse risks: tachyarrhythmia & increased myocardial O2 use. * Supply: 1 mg/1 ml of 1:1000, 1 mg/10 ml of 1:10,000

Isoproterenol (Isusprel) For symptomatic bradycardia:  IV infusion 2 - 20 ug/min IV * B agent effects: inotropic, chronotropic, vasodilatation, bronchodilatation. * Usual dose 1 - 5 ug/min, up to 20 ug/min * Adverse risks: tachyarrhythmia, PVC & increased myocardial O2 use. * Supply: 1 mg/5 ml amp, may be added in 250-500 ml D5W = 4-2 ug/ml conc.

Lidocaine For cardiac arrest:  50 - 100 mg or 1 - 1.5 mg/kg IV bolus, may repeat 0.5 - 0.75 mg/kg in 5-10 min upto Max total 3mg/kg then 1 - 4 mg/min infusion ( 30-50 ug/kg/min) * Tracheal dose: 2-4 mg/kg * Adverse risks: CNS & myocardial depression, seizure * Supply: 100 mg/10 ml (1%), 100 mg/5 ml (2%); add 1 gm in 250 mL D5W = 4 mg/mL conc.

Nitroglycerin (Tridil) IV bolus 12.5-25 ug, usual IV infusion 10-20 ug/min.  IV infusion, start at 5 ug/min, then may increase at increment of 5 ug/min q3 - 5min till response seen. May give up to 80 - 160 ug/min if needed. * Adverse risks: hypotension * Supply: 1 amp=50mg/10ml added in 250 - 500 ml D5W

Nitroprusside (Nipride) for Hypertensive Crisis                                                                       See  Hypertensive Crisis   IV infusion begin at 0.1 ug/kg/min & titrate upward q3-5 min to desired effect up to 5 ug/kg/min). Ave dose 3 ug/kg/min, range 0.5 - 8 ug/kg/min (Max=800 ug/min) * Action occurs within 1-2 minutes. * Adverse risks: hypotension, N&V, headache, dizziness, restlessness, muscle twitching;    cyanide poisoning (check blood thiocyanate, >10mg/100ml is considered toxic, >20mg/100ml may be fatal. * Supply: 1 amp=50 mg, added in 500 ml = 100 ug/ml.

Procainamide (Pronestyl)    for Recurrent VF/VT - usually start @ 20 mg/min ( in urgent situations , up to 50 mg/min) till total of 1 g (Max: 17mg/kg) or hypotensive, or QRS >50% wider, or PVC suppressed; then maintenance dose 1-4 mg/min. * Adverse risks: hypotension, prolonged QRS & QT interval * Supply: 2 mL vial of 500mg/mL, 10 mL vial of 100 mg/mL; add 1 gm in 250 mL = 4 mg/mL

Verapamil (Isoptin) - IV infusion 2.5 - 5 mg IV bolus over 2 min, 2nd dose 5-10 mg, if needed, in 15-30 min.  Max dose 20 mg.   Alternative: 5 mg bolus q15 min to total dose of 30 mg.     0.075 - 0.15 mg/kg IV (usually about 5 - 10 mg IVP) * Adverse risks: bradycardia, AV block, hypotension, tachycardia, dizziness, etc. * Supply: 5mg/2mL, 10mg/4mL vial

Thrombolytic agents:                      See  Anticoagulation Rx   Thrombolytic agents TNKase (Tenecteplase) single IV bolus over 5-15 seconds; for patients <60 kg give 30 mg; 60-69 kg give 35 mg; 70-79 kg give 40 mg; 80-89 kg 45 mg; >90 kg give 50 mg   Reteplase (recombinant t-PA): given as two boluses, together with aspirin and I.V. heparin; as effective as t-PA Retavase (Reteplase) 10 U over 2 min; 30  min later give another 10 U  over 2 min   IV Anistreplase (Eminase) single IV bolus 30 units IV over 2- 5 min * Adverse risks: arrhythmia/conduction disorders (38%), hypotension (10%), bleeding * Supply: 30 units vial tPA = alteplase (Activase) 60 mg first hour (6-10 mg IV bolus over 1-2 min, then the rest over the first hour by infusion, followed by 20 mg over the second hr  by infusion, and 20 mg over the third hour. For PE: 100 mg infusion over 2 hours. as 15 mg IV bolus, then 50 mg (0.75mg/kg) over 30 min, then 35mg (0.50mg/kg) over 60 min. (Total dose <100mg) * Adverse risks: bleeding, arrhythmias. * Supply: 100mg. 50 mg, 20 mg vial   Streptokinase (Kabikinase, Streptase) 1.5 million units IV in 50 mL NS, infuse over 60 min for acute M (at 50 ml/hr)I; For PE or DVT: 250,000 u IV over 30 min, followed by 100,000 u/hr infusion for 24-72 hr. Streptokinase & I.V. or SC heparin: contraindicated in patients who have recently received a dose of streptokinase! * Adverse risks: bleeding, fever & chills, rare anaphylactoid reaction * Supply: 1.5 million u vial,250,000 u , 750,000 u vials. Streptokinase therapy is contraindicated in patients who have recently received a dose of streptokinase because of antibodies that form against the drug; these antibodies limit the efficacy of repeat doses and increase the risk of allergic reactions. It has been suggested that the drug not be readministered for at least 2 years. Combination therapy: a thrombolytic agent plus a glycoprotein IIb/IIIa inhibitor; not currently indicated GP IIb/IIIa inhibitors (Tirofiban/Aggrastat, Eptifibatide/Integrilin, Abciximab/Reopro)   Eptifibatide/Integrilin 180 mcg/kg IV bolus load, then 2 mcg/kg/min infusion for up to 72 hr.  If percutaneous coronary intervention (PCI) occurs during the infusion, continue infusion for 18-24 hr after procedure.   CONTRAINDICATION for t PA infusion Rx: Active internal bleeding CVA & TIA within 12 months. CNS tumor or AV malformation. Intracranial or intraspinal surgery or trauma within 2 months. General surgery, abrasive wounds or fracture < 2 wks, or hip surgery < 3 wks. Recent traumatic CPR resuscitation. GI bleeding < 3 months, liver failure, uremia. Pregnancy. Over 75 y.o. or serious advance illness, such as cancer. Hypertension systolic > 180 or, diastolic > 110 mmHg. SBE, acute pericarditis, high likelihood of left heart thrombus (eg. mitral stenosis with atrial fibrillation). Diabetic hemorrhagic retinopathy or other hemorrhagic opthalmic conditions. Septic thrombophlebitis or occluded AV cannula at seriously infected site. Patients on warfarin (Coumadin). Hemostatic defects as from severe liver or renal disease. TNKase (Tenecteplase) single IV bolus over 5-15 seconds; for patient <60 kg give 30 mg; 60-69 kg give 35 mg; 70-79 kg give 40 mg;  80-89 kg 45 mg; >90 kg give 50 mg

Anti-arrhythmic Agents: Class IA: Quinidine, Procainamide, Norpace (Disopyramide) - increase QRS & QT interval, decrease conduction velocity & automaticity, increse effective refractory period & action potential duration. Class IB: Lidocaine, Phenytoin (Dilantin), Mexiletine (Mexitil), Tonocard (Tocainide), Moricizine (Ethmozine) - phenytoin decreases QT interval, others may or may not;  decrease conduction velocity & automaticity, may decrease effective refractory period & action potential duration. Class IC: Flecainide (Tambocar), Propafenone (Rythmol), Encainide, Lorcainide Flecainide 300 mg PO for PSVT or atrial fibrillation conversion; maintenance 100-200 mg bid PO Propafenone (Rythmol) 150-300 mg bid PO - increase QRS & QT & PR interval, decrease conduciton velocity & automaticity, increase effective refractory period, may increase action potential duration. Class II:  Beta blockers as Propranolol (Inderal), Sectral (acebutolol), Esmolol - decrease QT interval, decrease conduction velocity  & automaticity, increase effective refractive period. Class III: Amiodarone (Cordarone) 200 mg, Sotalol (Betapace), Bretylium Amiodarone 200 mg tab, start high loading dose of 800 mg for a few days, then 400 mg/d Sotalol 80-160-240 mg tab.  Start 80 mg bid, up to 160 mg bid PO - increase QRS, QT, PR intervals, decrease conduction velocity & automaticity, increase effective refractory period & action potential duration. Tikosyn (dofetilide) 125 - 250-500 mcg cap  bid dose to convert persistent AF to normal sinus rhythm & for maintenance also. Class IV: Calcium blockers as verapamil, diltiazem - no change in QRS or QT interval, may or may not increase PR interval, no change in conductin velocity or automaticity, or effective refractory period, decrease action potential duration.

Antiplatelet Rx    Aspirin 81 - 325 mg/d Plavix/ clopidogrel 75 mg/d Thrombotic thrombocytopenic purpura can occur after the initiation of clopidogrel therapy, often within the first two weeks of treatment. Physicians should be aware of the possibility of this syndrome when initiating clopidogrel treatment.  (NEJM June 15, 2000 ) Ticagrelor 180-mg loading dose, 90 mg twice daily thereafter  Ticlid/ ticlopidine 250 mg bid

Anticoagulants:                                        See also Anticoagulation   Heparin 60 Units/kg (max 4000 units) IV bolus, then 12 units/kg/hr infusion (max 1000 u/hr) IV drip to maintain a PTT at 1.5 - 2.0 x control (~ 50-70 seconds). Enoxaparin/Lovenox (1 mg/kg SC q12h) - in pts receiving fibrinolysis for ST-elevation MI, treatment with enoxaparin throughout the index hospitalization is superior (9.9% vs 12% primary end point events) to treatment with unfractionated heparin for 48 hours, but is associated with an increase in major bleeding episodes (2.1% vs 1.4%).   NEJM April 6, 2006, Vol 354:1477   Fondaparinux  2.5 mg daily is similar to enoxaparin (1 mg/kg twice daily) in reducing the risk of myocardial ischemic events at 9 days, but it substantially reduces major bleeding & improves long term mortality & morbility. NEJM April 6, 2006, Vol 354:1464

Platelet Glycoprotein GP IIb/IIIa Receptor Antagonists or Inhibitors Integrilin /Eptifibatide   For acute coronary syndrome: 180 ug/kg IV bolus, then infusion of 2 ug/kg/min upto 72 hours, until discharge or CABG;   For percutaneous coronary interventions (PCI): 135 ug/kg bolus, then 0.5 ug/kg/min infusion for 24 h. ReoPro /Abciximab 0.25 ug/kg bolus, then 0.125 ug/kg/min infusion for 12 hours for before & during percutaneous coronary interventions Aggrastat /Tirofiban 0.4 ug/kg/min bolus for 30 min, then 0.1 ug/kg/min infusion for upto 72h for acute coronary synd. Refludan (lepirudin) for injection - The first direct thrombin inhibitor for anticoagulation in patients with HIT (heparin-induced thrombocytopenia). - Initial Dosage :Anticoagulation in adult patients with HIT and associated thromboembolic disease: 0.4 mg/kg body weight (up to 110 kg) slowly intravenously (eg, over 15 to 20 seconds) as a bolus dose, followed by 0.15 mg/kg body weight (up to 110 kg)/hour as a continuous intravenous infusion for 2 to 10 days or longer if clinically needed. Normally the initial dosage depends on the patient's body weight. This is valid up to a body weight of 110 kg. In patients with a body weight exceeding 110 kg, the initial dosage should not be increased beyond the 110 kg body weight dose (maximal initial bolus dose of 44 mg, maximal initial infusion dose of 16.5 mg/h

Magnesium sulfate For cardiac arrest: (for hypomagnesemia or torsades de pointes):  1-2 g (2-4 mL of 50% solution) diluted in 10 mL D5W IV push; if not in cardiac arrest, may give it over 5-60 minutes IV; follow with 0.5-1g/h IV to control torsades.

     
2006