ACUTE CARE CARDIOLOGY

SUMMARY Pharmacotherapy Plans

Acute Decompensated Heart Failure (ADHF)
Diuretics, Vasodilators, Inotropics
1- LOOP DIURETIC (IV furosemide) + fluid & Na restriction
2- If diuretic resistance:
Increase furosemide up to 200 mg IV then
Add THIAZIDE DIURETIC oral (hydrochlorothiazide, metolazone) or IV (chlorothiazide in
case of GI edema & reduced oral absorption) then
Continuous furosemide IV infusion
3- Still symptomatic &/or decreased renal function, add a VASODILATOR (Nitroprusside,
Nesiritide, IV nitroglycerin)
Nitroprusside (1st choice), not in renal or hepatic impairment to avoid thiocyanate or
cyanide toxicity
Nesiritide, preferred than IV nitroglycerin in mild warm & wet ADHF because IV
nitroglycerin dose requires dosage titration by a catheter
4- If PCWP > 15 mmHg, cold (wet or dry) ADHF or low output syndrome, give an INOTROPIC
(dobutamine, milrinone)
Dobutamine, if hypotensive
Milrinone, if a -blocker was/is given

ARRHYTHMIAS
1- Tachycardia with a pulse
Unstable: O2 + ABC + DCC
ABC = airway, breathing, circulation. DCC = direct current cardioversion.
Stable: O2 + ABC + ECG
Narrow QRS complex atrial arrhythmia
*Regular rhythm (supraventricular or sinus tachycardia)
VAGAL MANEUVER + IV ADINOSINE
*Irregular rhythm (atrial fibrillation or flutter)
Mentioned in the previous lecture
-BLOCKER or CCB + anticoagulant then class I or III antiarrhythmic
Wide QRS complex ventricular arrhythmia (VT)
1- IV ANTIARRHYTHMIC
Procainamide contraindicated in HF
Amiodarone safe in HF
Lidocaine contraindicated in 3rd degree AV block
2- If drug therapy fails DCC

2- Premature ventricular contractions

If symptomatic -BLOCKERS
Avoid class Ic antiarrhythmics in post-MI premature ventricular contractions (mortality)

3- Ventricular tachycardia (VT)

Non-sustained VT
Asymptomatic no therapy
Symptomatic -BLOCKERS if unresponsive AMIODARONE or SOTALOL
Sustained VT
Unstable DCC if DCC refractory then AMIODARONE
Stable
PROCAINAMIDE (CI in HF)
LIDOCAINE (used if VT + MI)
AMIODARONE, -BLOCKER, or PROCAINAMIDE (if CAD + repetitive VT)
Polymorphic VT (Torsade de Pointes TdP)
WITHDRAW QT-PROLONGING MEDICATIONS (haloperidol, pentamidine,
sulfamethoxazole-trimethoprim, promethazine, tricyclic amine antidepressants
TAA)
CORRECTION OF Mg2+ & K+
Unstable: DCC with sedation
Stable: IV Mg2+
LIDOCAINE (used if TdP + MI)
Pulseless VT/VF
CPR/DCC + EPINEPHRINE/VASOPRESSIN + AMIODARONE or LIDOCAINE

4- Pulseless electrical activity (PEA) or asystole

CPR no DCC + EPINEPHRINE/VASOPRESSIN
Add ATROPINE (if HR < 60 beats/minutes or slow PEA)

Acute Coronary Syndrome (ACS)

ACS = UA, NSTEMI, STEMI
Unstable Angina, Non-ST-segment Elevation Myocardial Infarction, ST-segment Elevation
Myocardial Infarction

Initial management
1- UA, NSTEMI:
Conservative: MONA (Morphine + O2 + Nitroglycerin "spray, SL then IV" + Aspirin or
other antiplatelets/anticoagulants) or
Invasive (PCI): Balloon &/or Stent
2- STEMI:
Conservative: MONA + oral or IV -BLOCKERS + add THROMBOLYTICS if not
contraindicated (ideally within 30 min) + control arrhythmias if any
Invasive (PCI) within 90 min:
** If no prompt PCI in 90 min continuous FIBRINOLYSIS if not contraindicated
** High-risk patients when PCI is not immediately available Facilitated PCI = full- or
half-dose FIBRINOLYSIS &/or GP IIb/IIIa inhibitor then PCI
** If shock, severe HF, &/or pulmonary edema, persistent ischemia Rescue PCI = PCI
after failed thrombolysis
3- In the first 24 hr.:
Add oral ACEI if pulmonary congestion or EF 40%
Give CCB (verapamil, diltiazem) if -blockers are contraindicated or recurrent
ischemia after -blockers and nitrates

Antiplatelets/Anticoagulants/Thrombolytics

Initial conservative strategy:

Antiplatelets ASA + CLO or ASA + CLO + EPTIFIBATIDE/TIROFIBAN
Anticoagulants ENOXAPARIN or UFH or FONDAPARINUX
Initial invasive strategy:
Antiplatelets ASA + CLO &/or IV GP IIb/IIIa inhibitor
Anticoagulants ENOXAPARIN or UFH or BIVALIRUDIN (in case of HIT) or
FONDAPARINUX

*ASA = Aspirin, CLO = Clopidogrel, UFH = UnFaractionated Heparin, HIT = Heparin Induced
Thrombocytopenia, GP = GlycoProtein

Long-Term Management (post-MI as CAD)

MI or UA
1- Oral -BLOCKERS + oral ACEI + STATINS
2- Add ALDOSTERONE RECEPTOR BLOCKERS (if HF or DM, not if CrCl<30ml/min or
K>5mEq/L)
3- WARFARIN instead of clopidogrel with or without aspirin (in high CAD risk & low
bleeding risk if clopidogrel is contraindicated)

Antiplatelets: aspirin (ASA=Acetyl Salicylic Acid), clopidogrel, warfarin, GP IIb/IIIa

inhibitors (abciximab, ebtifibatide, tirofiban)
Anticoagulants: UFH, LMWH (Low Molecular Weight Heparins = enoxaparin, daltiparin),
fondaparinux, bivalirudin
Thrombolytics: alteplase, reteplase, tenecteplase, streptokinase

Pulmonary Arterial Hypertension (PAH)

CCB, vasodilators
1- Supportive care:
O2 + DIURETIC (if edema or ascitis) + ANTICOAGULANT (warfarin) + immunization for
influenza & pneumococcus
2- Initial therapy:
- Acute vasoreactivity testing If ve don't give CCB or vasodilators & move
to the next step (mostly prostanoids)
If +ve then
- Oral CCB (diltiazem in tachycardia, amlodipine or nifedipine in bradycardia) +
Class II or III without poor hemodynamics:
Oral ERA or PDEI + reassess in 6 months:
Satisfactory condition: continue therapy
Unsatisfactory condition:
Improved from baseline add second oral drug from other class (if the patient
on ERA add a PDEI)
Unchanged from baseline switch drug classes
Worsened functional class add/switch to PROSTANOIDS

Class III with poor hemodynamics or IV

Continuous PROSTANOID + reassess in 6 months:
Satisfactory condition: continue therapy
Unsatisfactory condition: the infusion (if tolerable) &/or add oral agent

ERA = Endothelin Receptor Antagonists, oral (non-selective bosentan, selective

ambrisentan)
PDEI = PhosphoDiEsterase Inhibitors, oral (sildenafil)
Prostanoids = prostacycline analogues infusion (IV epoprostenol, SC treprostinil, inhaled
iloprost)

Hypertensive Crises
1- HYPERTENSIVE URGENCY Oral
Give one or more of the following according to the condition & contraindications (CI =
ContraIndicated)
Captopril CI in pregnancy, renal artery stenosis
Clonidine CI in severe carotid artery stenosis
Minoxidil CI in angina, HF. Caution in altered mental status
Nifedipine CI in severe aortic stenosis, coronary artery or cerebrovascular disease
Labetalol avoided in acute HF, asthma
2- HYPERTENSIVE EMERGENCY IV
Give one or more of the following according to the condition, contraindications & the target
organ damage
Avoid nitroprusside in renal, hepatic failure
Avoid -blocker = esmolol & labetalol in acute HF, asthma
Avoid nicardipine in angina/MI, acute HF
Avoid nitroglycerin in cerebral events
Hydralazine mostly used in pregnancy (eclampsia)
Avoid ACEI = enalaprilat in pregnancy, renal artery stenosis
Fenoldopam = dopaminergic agonist, avoid in glaucoma

(Hypertension crises + target organ damage)

Renal failure fenoldopam, nicardipine
Sympathomimetic intoxication labetalol + nitroglycerin (avoid unopposed -blockade)
Eclampsia hydralazine, labetalol, Mg
Acute MI nitroglycerin + -blocker
Acute HF nitroglycerin, nitroprusside, ACEI, diuretic (if pulmonary edema)
Acute aortic dissection labetalol, nitroprusside + -blocker
Subarachnoid hemorrhage labetalol, nicardipine
Cerebral vascular accident nitroprusside, labetalol
Hypertensive encephalopathy nitroprusside, labetalol, fenoldopam, nicardipine

NOTES
ADHF
1- Inotropics: dobutamine & milrinone
HF -blocker ADHF HF
dobutamine milrinone Inotropic agent ADHF
no inotropic effect -blockade dobutamine = -agonist

ARRHYTHMIAS
2- Vagal Maneuver = carotid artery massage or pressing baroreceptors activation
similar to the effect of hypertension vagal (parasympathetic) activation HR rapid
stop of tachycardia
3- -blockers in premature ventricular contraction decrease the HR to allow the
ventricles to wait for the atrial signals instead of simultaneous ventricular contraction
4- Tachyarrhythmias 4 types:
Tachycardia with a pulse, premature ventricular contraction
ORAL

Ventricular tachycardia, pulseless electrical activity or asystole
..
DCC/CPR IV Medications
rhythm DCC >-- tachycardia HR
CPR = CardioPulmonary Resuscitation >-- asystole = no pulse or no HR

5- Antiarrhythmics mainly affect the RHYTHM

DCC ventricular arrhythmias sinus & atria
6- Antiarrhythmics are used for:
Conversion
+ Maintenance
7- Arrhythmias are ventricular or atrial
antiarrhythmics 4
AF Conversion, AF Maintenance, VT/VF Conversion, VT/VF Maintenance

AF
Conversion

VT/VF
Conversion

AF
Maintenance

Maintenance
of both AF &
VT

VT/VF
Maintenance

Amiodarone

Amiodarone

Quinidine

Amiodarone

Lidocaine

Dofetilide

Procainamide

Dofetilide

Procainamide

Mexiletine

Ibutilide

Lidocaine

Class Ic

Sotalol

Class Ia
(procainamide,
disopyramide)

Disopyramide

Class Ic
(propafenone,
flecainide)

8- Important notes on antiarrhythmics:

Safe in HF amiodarone, dofetilide
Safe post-MI dofetilide
Adjust the dose in renal dysfunction (based on CrCl) procainamide, lidocaine, dofetilide,
sotalol
(oral ( Must be initiated in the hospital sotalol, dofetilide
cinchonism (toxicity) Quinidine
Contraindications:
HF all antiarrhythmics except amiodarone & dofitilide
Post MI class Ia, class Ic
Asthma sotalol, propafenone
3rd-degree heart block amiodarone, lidocaine, mexiletine
QTc > 440 millisecond sotalol, dofetilide, ibutilide
CrCl < 20 ml/min sotalol, dofitilide
Glaucoma disopyramide
Hyperthyroidism amiodarone
Drug-drug interactions:
With digoxin quinidine, propafenone, flecainide, amiodarone (must digoxin dose)
Amiodarone several interactions: digoxin, warfarin, phenytoin, statins
Adverse Effects:
Lupus-like syndrome procainamide
CNS effects quinidine, lidocaine, mexiletine, amiodarone
ADHF disopyramide, propafenone, flecainide, sotalol
9- ECG = ElectroCardioGram
3 main parts in the "cardiac cycle"
P wave atrial depolarization (contraction)
QRS complex ventricular depolarization (contraction)
T wave ventricular depolarization (relaxation or dilatation)

10- Cardiac Enzymes: released in the blood circulation from the infracted myocardium
markers for acute MI
Creatinine Kinase (CK) subdivided into MM, MB, BB CK-MB is specific for cardiac
muscles
Troponins (Troponin I, Troponin T) structural components of the cardiac muscles more
specific than CK-MB
11- ICD = Internal (Implanted) Cardiac Defibrillator
Device put in the chest for automatic defibrillation (give DCC in VT/VF)
For patients receiving optimal chronic medications & reasonable survival expectation
..
survival expectations
alcoholic, smoker,etc
Primary prevention of sudden cardiac death
MI cardiac arrest ICD
* LV dysfunction after MI
* LVEF of 30-40% or less
* NYHA class II or III
Secondary prevention of sudden cardiac death
cardiac arrest
* Recurrent sustained VT post MI
* Normal or near-normal LVEF
Contraindications for ICD (severe cases & terminal illness)
!
Acute MI with VT, Acute VT after CABG (Coronary Artery Bypass Grafting), VF caused by
AF, NYHA class IV HF, Psychotic disorders

ACS
indications 353-352-351
3
12- Conservative or invasive?
Calculate TIMI score (Thrombolysis In MI) & risk of mortality details in p.349
13- PCI = PerCutaneous Intervension
Percutaneous transluminal coronary angiography (balloon)
Stent implantation bare-metal or medicated "siroliumus or paclitaxel"

PAH
14- Reassessment includes:
Functional class determination (not worsened)
6-minute walk test ( 380 m)
Right heart catheterization (CI 2.2 L/min/m2, mean pulmonary arterial pressure< 12mmHg)

15- Bosentan, ambrisentan teratogenic (if childbearing age, use 2 contraceptive

methods)
Bosentan severe drug interactions (with glyburide & cyclosporine)
Ambrisentan no drug interactions
16- Sildenafil contraindicated with nitrates
17- Epoprostenol rebound worsening if abruptly discontinued (t 1/2-6min prepared spare
should be kept available, unstable & requires reconstitution in sterile environment)
Treprostinil premixed, prefilled, longer half-life, injection site pain (use hot/cold packs or
topical analgesics & change the injection site every 3 days)
Inhaled Iloprost less systemic adverse reactions