Cariovascular pharmacology for primary care physician: cardiotonics, antiarrhytmics, vasodilatators Domina Petric, MD

digoxinum (Lanicor 0,25 mg tbl.) metildigoxinum (Lanitop 0,1 mg tbl.) 1.) Cardiotonic drugs digoxinum (Lanicor 0,25 mg tbl.) metildigoxinum (Lanitop 0,1 mg tbl.)

Digoxinum, metildigoxinum Indications: acute and chronic heart failure chronic heart failure with permanent atrial fibrillation supraventricular tachycardias (atrial fibrillation and undulation, paroxismal supraventricular tachycardia)

Digoxinum Fast oral saturation (if patient was not taking digitalis glycosides for two weeks): 0,5-0,75 mg at once per os 0,25 mg every 6-8 hours average dose during 24 hours is 1-1,5 mg

Slow oral saturation: 0,125-0,5 mg per os a day Maintenance dose: Digoxinum Slow oral saturation: 0,125-0,5 mg per os a day Maintenance dose: 0,25 mg per os a day

Metildigoxinum Fast oral saturation: 0,2 mg per os three times a day during 2 to 4 days Slow oral saturation (digitalisation): 0,4 mg per os a day during 3-5 days Maintenance dose is 0,15-0,2 mg a day.

Metildigoxinum Atrial fibrillation: 0,2-0,3 mg per os a day in one or two doses Heart failure: 0,2 mg three times a day during 1-5 days 0,15-0,2 mg a day is maintenance dose

Contraindications: hypersensitivity digitalis intoxication ventricular tachycardia or fibrillation AV block of II. or III. degree WPW syndrome, escpecially with atrial fibrillation

Contraindications: hypokalemia hypocalcemia hypomagnesemia hyperthrophic obstructive cardiomyopathy thoracal aorta aneurism

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2.) Antiarrhythmic drugs Ia fast sodium channel blockers depress fase 0 prolong repolarisation quinidine procainamide disopyramide

3.) Antiarrhythmic drugs Ib fast sodium channel blockers depress phase 0 selectively in abnormal/ischemic tissue, shorten repolarization  lidocaine, phenytoin, mexiletine 

Lidocainum for iv. application ventricular extrasystoles and tachycardias, especially after acute myocardial infarction 50-100 mg iv. during 2-3 minutes dose can be repeated after 5 minutes, if necessary maximum dose is 200-300 mg within one hour

4.) Antiarrhythmic drugs Ic fast sodium channel blockers markedly depress phase 0, minimal effect on repolarization flecainide, propafenone moricizine

Propafenonum 150/300 mg tbl. AV node tachycardia supraventricular tachycardia in patients with Wolff-Parkinson-White syndrome paroxysmal atrial fibrillation treatment starts in hospital (cardiologist)

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Lown-Ganong-Levine Syndrome short PR interval, normal QRS AliveCor.com

5.) Antiarrhythmic drugs II beta blockers decrease slope of phase 4 antihypertensive drugs

6.) Antiarrhythmic drugs III potassium chanel blockers amiodarone (prolongs phase 3; also acts on phases 1, 2, and 4) sotalol (prolongs phase 3, decreases slope of phase 4) ibutilide (prolongs phase 3) dofetilide (prolongs phase 3)

prevention of repetition of severe arrhythmias Amiodaronum 200 mg tbl. prevention of repetition of severe arrhythmias treatment is started in hospital conditions

7.) Antiarrhythmic drugs IV slow calcium channel blockers verapamil (prolongs phase 2) diltiazem (prolongs phase 2)

8.) Antiarrhythmic drugs V. variable mechanisms adenosine digoxin magnesium sulfate

9.) Vasodilatator drugs isosorbidi mononitras (20, 40, 60 mg tbl.) glyceroli trinitatis solutio isosorbidi dinitras

Isosorbidi mononitras Tablets are indicated for prevention of angina pectoris. Dose can vary from 30 mg up to 120 mg per os and it is taken at once in the morning! Titration of the dose can prevent headaches (30 mg for 2-4 days and then the augmentation of the dose up to maximum daily dose of 120 mg).

Contraindications: hypersensitivity shock, vascular decompensation myocardial infarction heavy heart operation in anamnesis cardiogenic shock severe hypotension (RRs<90 mmHg) severe anemia cerebrovascular insult in anamnesis

Interactions: Isosorbid mononitrate can not be applicated together with 5-phosphodiesterase inhibitors!

Glyceroli trinitatis solution for sublingual application Nitrolingual 0,4 mg/dose is indicated for: treatment of acute angina pectoris prophylaxis of angina pectoris before physical exertion treatment of acute myocardial infarction treatment of acute left ventricle failure prevention of coronary spasm (during coronary angiography)

Contraindications: hypersensitivity acute shock, hypotension (RRs<90 mmHg) hypertrophic obstructive cardiomyopathy elevated intracranial pressure severe anemia

Isosorbidi dinitras Tinidil 5 mg tbl. are indicated for: angina pectoris silent heart ischemia heart failure Maximum dose is 60 mg every six hours!

10. Ivabradinum (5 mg or 7,5 mg tbl.) symptomatic treatment of chronic stable angina pectoris when the heart rate is more than 70 bmp in patients that can not take beta-blockers or the beta-blockers are not enough chronic heart failure NYHA class II-IV with systolic disfunction in patients with synus rhythm and heart rate 75 bpm or more (≥75 bmp) with or without beta-blockers

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