7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Cardiac Pharmacology Heather Melrose, Jonas de Jong Contents Renin-Angiotensin-Aldosterone System Neural Control of the Cardiovascular System Sympathetic (Adrenergic) Nervous System Vasculature Heart Parasympathetic Nervous System Vasculature Heart Platelet/Clotting System Anti-coagulants Pharmacokinetics Common Drug-Drug Interactions References Cardiovascular disease including heart disease, arrhythmias and hypertension, is the leading cause of morbidity and mortality in the Western world. There are numerous devastating conditions affecting the heart and/or the vasculature, leading to high demand for cardiovascular drugs. This chapter focuses on some key therapeutic targets within the cardiovascular system and the drugs used to combat cardiovascular disease. Renin-Angiotensin-Aldosterone System The renin-angiotensin-aldosterone system (RAAS) is an important hormone-based pathway within the body that regulates fluid balance and thus systemic blood is activated by pressure. The system decreases in blood volume or pressure detected in two ways: a drop in blood pressure baroreceptors (pressure sensors) located in the carotid sinus or a drop in flow rate through the kidneys, detected by the juxtaglomerular apparatus. The body responds to these stimuli to effect a restoration in blood pressure via the actions of three hormones; aldosterone. renin, angiotensin Following the detected drop in blood pressure, the enzyme renin is released from specialised cells within the kidney. The substrate of renin is the inactive precursor of angiotensin I, angiotensinogen. Angiotensin I is then enzymatically converted by angiotensin converting enzyme (ACE) into angiotensin II, a hormone with various actions throughout the body that ultimately increase blood pressure, restoring fluid balance within the body. detected by and RAAS schematic Angiotensin II causes increases in blood pressure by actions at various sites: https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 1/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Adrenal Glands: Angiotensin II augments release of the steroid hormone aldosterone, which acts locally to augment sodium retention and potassium secretion from the kidney. The net effect of this is water retention, thus restoring fluid balance. Kidneys: Angiotensin II also increases sodium retention via direct actions on renal proximal tubules, as well as affecting glomerular filtration rate and renal blood flow. Cardiovascular System: Angiotensin II is a potent endogenous vasoconstrictor, causing resistance arteries and veins to constrict, raising blood pressure. Furthermore in both the blood vessels and the heart, prolonged increases in Angiotensin II encourage cell growth and resultant hypertrophy. Central Nervous System: In the brain, Angiotensin II acts on the posterior pituitary gland, stimulating release of antidiuretic hormone (ADH, also known as Arginine Vasopressin (AVP)). ADH increases water reabsorption in the renal collecting ducts. Angiotensin II also acts on the subfornical organ within the brain to cause increased thirst, encouraging water intake. Chronic activation of the RAAS system can lead to deleterious remodelling and increased inflammation in the heart, vasculature and kidneys, as well as hypertension and chronic kidney disease. Neural Control of the Cardiovascular System Sympathetic (Adrenergic) Nervous System The adrenergic nervous system is a vital component of many processes throughout the body, including the cardiovascular system. Circulating catecholamines (e.g. adrenaline and noradrenaline) bind to and activate adrenergic receptors on cell membranes. Adrenergic receptors are a class of G-protein coupled receptors that elicit a variety of tissue-specific effects and exist in several subtypes. Vasculature The predominant receptor subtype present in blood vessels is the a1-adrenergic receptor, activation of which by catecholamine binding causes activation of the phospholipase-C (PLC), inositol triphosphate (IP3), diacylglycerol (DAG) intracellular signalling pathway. This ultimately contraction, vasoconstriction and consequent increases in systemic blood pressure. results in myocyte Interaction between the sympathic and parasympathic nervous system and the heart Heart Although the heart is myogenic, that is the impetus for contraction is self-initiated, the output of the heart is influenced by the central nervous system. The net effect of the sympathetic system on the heart is to increase cardiac output. The adrenergic receptors found in the heart belong to the -receptor subfamily and include 1 and 3 receptors. Catecholamine binding to 1-receptors in the heart causes increases in cardiac output via a number of mechanisms: positive chronotropic effects, positive inotropic effects increased automaticity and conduction in both ventricular myocytes and the atrioventricular (AV) node. However 3-receptor activation antagonises these actions, producing a negative inotropic effect and providing an inbuilt control system within the heart. https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 2/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Prolonged increase catecholamine levels in the circulation (e.g. when secreted from adrenal tumours or times of stress) can lead to chronic cardiovascular problems such as hypertension and arrhythmias. Parasympathetic Nervous System The parasympathetic system relies on the binding of the neurotransmitter acetylcholine (Ach) to muscarinic receptors, and has various roles throughout the body. Vasculature Although blood vessels do express muscarinic receptors, they do not receive cholinergic innervation; however application of exogenous Ach results in a swift and profound vasodilation. Heart Activation of muscarinic receptors (M2-subtype) in the heart by Ach released from the vagus nerve causes a reduction in cardiac output via opposite effects to adrenergic stimulation: negative chronotropic effects and decreases in AV node conduction as well as decreasing the force of atrial contractions. Platelet/Clotting System Platelets (also known as thrombocytes) are small cells lacking nuclei that are responsible for haemostasis, or blood clotting. Damage or injury leading to blood loss and exposure of extracellular collagen fibres is detected, activating platelets. Once activated, platelets become adhesive, sticking to both the damaged vessel wall and each other, forming a clump of cells, or clot , helping to dam the vessel leak. They then begin to secrete cytokines that encourage invasion of fibroblasts present in the surrounding tissue which form a more permanent patch, either by creating healthy tissue, or depositing extracellular matrix to form a scar. Platelet activation and inhibition operates through surface receptors on platelets. Feedback loops enhance platelet activation (e.g. ADP released by platelets increases platelet activation, through the ADP receptor) There are several conditions in which abnormal clotting can be damaging to the body; excess clotting can lead to vascular blockage and less commonly, deficient clotting can lead to excess blood loss, for example in haemophilia. To combat these diseases, there are drugs that modulate the clotting process. ischaemia or stroke; Anti-coagulants Drugs that prevent clotting (anti-coagulants) are important in those with an increased risk of clotting-mediated damage such as a stroke or ischaemia. As well being an analgesic and anti-pyretic, Aspirin is an anti-thrombotic agent given in low doses to those at risk of damage from clotting (e.g. following a heart attack). Aspirin s anti-coagulant actions come from its suppression of key pro-clotting factors such as prostaglanding and thromboxanes via irreversible inactivation of the PTGS cyclooxygenase enzyme. This suppression of factors such as thromboxane A2 reduces platelet aggregation and thus prevents clot formation. https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 3/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology P2Y12 inhibitors such as clopidogrel exert their anti-coagulant effect via inhibition of the P2Y12 subtype of the platelet ADP receptor. By blocking P2Y12, these drugs prevent activation of platelets and the formation of the fibrin network needed for clotting. Drugs such as abciximab and tirofiban prevent clotting via inhibition of the glycoprotein IIb/IIIa receptor preventing both platelet activation and aggregation. Pharmacokinetics When administering drugs to a patient, it is crucial to know several facts about the drug in order to maximise efficacy and minimise side-effects/toxicity. These include information about what dose is effective, how long the drug remains active in the body, how quickly it is broken down/removed from the body, and how easily the body can absorb/use that drug. The following table details these pharmacokinetic properties and how they are calculated: Standard units (Abbreviation) Property Description Formula Dose Amount of active drug given to patient mg (D) Drug Specific (From clinical studies) Concentration Amount of drug in a given plasma volume g/ml (C) = D / Vd The concentration of drug needed to elicit a response halfway between zero and maximal responses. y = bottom + (Top-Bottom)/(1+ [x/EC50] Hill Coefficient) EC50 g/ml (EC50) The theoretical volume the drug would occupy if distributed uniformly throughout the tissues to elicit the current plasma concentration. Volume of Distribution L (Vd) D / C Elimination Constant (Rate) The rate at which the drug is removed from the body. h-1 (Ke) ln(2) / t1/2 or CL / Vd 100 (AUC (po) D (iv))/(AUC (iv) D (po)) no units as expressing a fraction (f) AUC = Area under curve po = oral intravenous administration administration How much of the administered dose is available for actual use by the body. Bioavailability iv = The maximum (Cmax) / minimum (Cmin) plasma drug concentration reached following drug administration g/ml (Cmax or Cmin) Identified via direct measurement of plasma C Cmax or Cmin The time it takes for a drug to reach Cmax following administration Identified via direct measurement of plasma C over time tmax h (tmax) The time it takes for a drug to reach half its original concentration Half-life h (t1/2) ln(2) / Ke The volume of plasma cleared of the drug over a set time Drug Clearance l/h (CL) Vd x Ke or D / Area under curve Common Drug-Drug Interactions It is important to be aware of the interactions that can occur between concomitantly administered drugs, as they may effect efficacy and/or toxicity, or produce adverse side effects. Such interactions could for example affect drug absorption, drug bioavailability or efficacy, or combine to produce unwanted metabolites, as well as possibly having effects on clinical analyses. If a combination of two drugs decreases the effect of one or both of them, the interaction is termed an antagonistic effect; however if, conversely, a combination of two drugs enhances the effect of one or both of them, the interaction is termed a synergistic effect. Drugs that act on the cardiovascular system are high in interactivity, which is an issue as cardiovascular patients normally receive more than one drug. Some common drug drug interactions related to cardiovascular drugs are listed below: https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 4/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Drugs that drug action Drugs that drug action Drug Diuretics Antiarrhythmics Macrolide antibiotics Cholestyramine Neomycin Keto- and intraconazole Calcium antagonists Cyclosporine, indomethacin HMG CoA reductase inhibitors Benzodiazepines Amiodarone Verapamil Rifampicin Antacids (liquid) Digoxin Furosemide Amiodarone Sulfa Macrolide and quinolone antibiotics NSAIDs Azathioprine Phenobarbitone Carbamazepine Dexamethasone Prednisolone Rifampicin Vitamin K Raloxifene Warfarin Rifampicin Caffeine Methylxanthines Phosphodiesterase inhibitors Statins Calcium channel blockers Warfarin Proton pump inhibitors Clopidogrel NSAIDs Phenytoin Colesevelam Furosemide NSAIDs Probenecid Calcium channel blockers Indomethacin Antacids ACE Inhibitors Amiodarone Calcium channel blockers Diltiazem Phenoxybenzamine Phenobarbital Rifampicin Cimetidine Antacids (liquid) NSAIDs -blockers Amiodarone Verapamil Fibrates Amprenavir Diltiazem Nevirapine Rifampicin Statins There are several mechanisms by which drugs are broken down by the body, usually via degradation by enzymes. One common family of enzymes involved in drug metabolismis the cytochrome P450 (CYP) family; a large, diverse group of enzymes that encourage oxidation of a variety of substrates, both endogenous (e.g. steroid hormones) and exogenous (e.g. toxins and drugs). CYP enzymes account for up to 75% of drug metabolism, aiding some drugs to form their active compounds but mostly deactivating drugs into inactive metabolites to be excreted. CYP enzymes can influence drug actions in several ways; they can increase drug metabolism (either increasing action via formation of the active by- product or decreasing action by metabolism of the active drug) or their action can be inhibited by drugs that compete for access to the CYP enzymes active site, preventing the normal interaction between drug and enzyme. Many drugs https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 5/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology exert their interactions with other drugs viainterference with the CYP system. For example, if Drug A is metabolised by CYP and Drug B inhibits CYP activity, co-administration will result in a decreased bioavailability of Drug A. In humans there are 18 families and 43 subfamilies of the CYP group of enzymes, which target different substrates. Some CYP enzymes important in cardiovascular medicine, their cardiovascular-drug substrates and some of their interactions are shown in the table below: Enzyme Substrates (e.g.) Inhibitors (e.g.) Inducers (e.g.) Clopidogrel Propranolol Warfarin Moclobemide Chloramphenicol Many anti-convulsants (Valproate) Proton pump inhibitors (Omeprazole) Rifampicin Carbamazepine Prednisone CYP2C19 Donepezil Statins (Atorvastatin) Ca-channel blockers (Nifedipine) Amiodarone Dronedarone Quinidine PDE5 Inhibitors (Sildenafil) Kinins Caffeine Eplerenone Propranolol Salmeterol Warfarin Clopidogrel Protease inhibitors (Ritonavir) Macrolides (Clarithromycin) Chloramphenicol Nefazodone Some Ca-channel blockers (Verapamil) Cimetidine Some azole anti-fungals (Ketaconazole) Grapefruit juice Some anti-convulsants (Carbamazepine) Baribiturates (Phenobarbital) St. John s Wort Some reverse transcriptase inhibitors (Efavirenz) Some Hypoglycaemics (Pioglitazone) Glucocorticoids Modafinil CYP3A4 Fluvastatin Angiotensin receptor II agonists (losartan) Warfarin Torasemide Some azole anti-fungals (Fluconazole) Amiodarone Antihistamines (Cyclizine) Chloramphenicol Fluvastatin Fluvoxamine Probenecid Sertraline Rifampicin Secobarbital CYP2C9 -blockers (Propranolol) Class I anti-arrythmics (Flecainide) Donepezil SSRIs (Fluoxetine) Quinidine Sertraline Terbinafine Amiodarone Cinacalcet Ritonavir Antipsychotics (Haloperidol) Antihistamines (Promethazine) Metoclopramide Ranitidine Mibefradil Rifampicin Dexamethasone Glutethimide CYP2D6 In addition to drug-drug interactions, the actions of many drugs are also affected by food or drink. For example, care should be taken with alcohol consumption with many kinds of drugs, as it can put stress on the liver which is already working hard to metabolise drugs in the body. Grapefruit juice too can cause issues, as it is known to inhibit CYP3a. For more information of interactions between drugs and food/drinks see this guide: General Use of Medicine (http://w ww.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicin e/GeneralUseofMedicine/UCM229033.pdf) https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 6/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Cardiovascular Drugs Examples (generic name) Typical Dosage Guidelines / Class of Indication Drug Type Indications Side Effects (Prevalence %) :Anti-hypertensives Mild gastro-intestinal disturbances, pancreatitis, hepatic encephalopathy, postural hypotension, temporary increase in serum-cholesterol and triglyceride concentration, hyperglycaemia, acute urinary retention, electrolyte disturbances, metabolic alkalosis, blood disorders, hyperuricaemia, visual disturbances, tinnitus and deafness, and hypersensitivity reactions (including rash, photosensitivity, and pruritus). Furosemide: 20-40mg once daily Oedema Diuretics Furosemide Hypertension in symptomatic (NYHA class II-IV) HF and LVD: Class IC [1] Furosemide: 40-80mg once daily Resistant Hypertension Hypertension: Class IA [2] Hypotension (2.4%), renal impairment, persistent dry cough, angioedema, rash pancreatitis, upper respiratory- tract symptoms (2-10%), gastro- intestinal symptoms (1-2%), altered liver function tests, cholestatic jaundice, hepatitis, fulminant hepatic necrosis and failure, hyperkalaemia (2%), hypoglycaemia, blood disorders including thrombocytopenia, leucopenia, neutropenia, headache (3%), dizziness (2-12%), fatigue, malaise, taste disturbance, paraesthesia, bronchospasm, fever, serositis, vasculitis, myalgia (3%), arthralgia, positive antinuclear antibody, raised erythrocyte sedimentation rate, eosinophilia, leucocytosis, and photosensitivity. Hypertension symptomatic class LVD: Class IA [1] in (NYHA II-IV) HF and Captopril: 12.5mg twice daily Hypertension Hypertension in diabetics: Class IA [3] Post STEMI: Class IA [4] Diabetic Class IC [2] patients: ACE Inhibitors Captopril, Monopril Captopril: 12.5mg 3 times daily Heart Failure Symptomatic (NYHA class II-IV) HF: Class IA; Acute heart failure with ACS: Class IA [1] Captopril: 6.25mg once daily Prophylaxis Following MI Captopril: 75- 100mg once daily Diabetic nephropathy Hypertension: Class IA [2] Gastro-intestinal disturbances (<3%), dizziness (14%), angina, palpitation, oedema, dyspnoea, headache (14%), malaise, urticaria, pruritus, rash; Losartan: 50mg once daily in Hypertension diabetics: Class IA [3] Hypertension Angiotensin Receptor Blockers Losartan, Candesartan Losartan: 12.5-150mg daily Left ventricular hypertrophy LVH: Class IB [4] Diabetic nephropathy Losartan: 50mg daily Alpha Blockers Prazosin, Doxazosin Drowsiness, hypotension (notably postural hypotension) (10-70% initially), syncope (1%), asthenia, dizziness, depression, headache (8- 18%), dry mouth, gastro-intestinal disturbances, oedema, blurred vision (<5%), intra-operative floppy iris Prazosin: 1- 10mg 2-3 times daily Hypertension Congestive Heart Failure Prazosin: 4- 20mg daily https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 7/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology syndrome, rhinitis (<4%), erectile disorders (including priapism), tachycardia and palpitations (7-14%), gastrointestinal side-symptoms (4-5%), hypersensitivity reactions including rash, pruritus and angioedema. Gastro-intestinal disturbances (2-4%); bradycardia, heart failure, hypotension, conduction disorders, peripheral vasoconstriction, bronchospasm, dyspnoea; headache, fatigue, sleep disturbances (2-5%), paraesthesia, dizziness (2-5%), vertigo, psychoses; sexual dysfunction; purpura, thrombocytopenia; visual disturbances; exacerbation of psoriasis, alopecia; rarely rashes and dry eyes. Raynaud s Syndrome Prazosin: 1- 2mg daily Beta Blockers Atenolol, Propranolol Atenolol: 25- 50mg daily Hypertension ACS: Class IIaB [2] Angina symptomatic class LVD: Class IA [1] in (NYHA II-IV) HF and Atenolol: 100mg once/twice daily Angina Arrhythmias Atenolol: 50- 100mg daily Atrial fibrillation: Class IA; Polymorphic VT: Class IB [4] Symptomatic (NYHA class II-IV) HF, LVD IA; and AF: Class Management of VA in HF: Class IA [1] SVT: Class IIbC; Wide QRS-complex tachycardia of unknown origin: Class Sinus IIIC; tachycardia: Class IC; tolerated Poorly AVNRT with haemodynamic Class intolerance: IIaC; Recurrent symptomatic AVNRT: IC; Class Documented PSVT with only dual AV- nodal pathways or single echo beats demonstrated during electrophysiological study and no other identified cause of arrhythmia: Class IC; well Infrequent, AVNRT: tolerated Focal Class IB; tachycardia: junction Class IIaC; Nonparoxysmal junctional tachycardia: IIaC; WPW Class Syndrome: Class IIaC; AVRT, poorly tolerated: Class IIbC; infrequent Since or episode(s): AVRT https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 8/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology IIaB; Acute Class treatment of Focal Tachycardia: Atrial Class IIaC; therapy Prophylactic for AT: Class IC; AF (Poorly tolerated): Class IIaC; AF (Stable flutter): Class IC; Prophylaxis of SVT during pregnancy: Class IIaB [5] Atenolol: 50- 200mg daily Migraine Gastro-intestinal disturbance (2-11%); hypotension (1-5%), oedema (7-29%), vasodilatation, palpitation; headache (7-35%), dizziness (3-27%), lethargy (4-6%), asthenia (10-12%); less commonly tachycardia (<1-7%), syncope (<1%), chills, nasal congestion, dyspnoea (<3%), anxiety, sleep disturbance (<2%), vertigo (<3%), migraine, paraesthesia, tremor (1-8%), polyuria, dysuria, nocturia, erectile dysfunction (<2%), epistaxis, myalgia, joint swelling, visual disturbance (<2%), sweating (<2%), hypersensitivity reactions (<1%); rarely anorexia, gum hyperplasia, mood disturbances, hyperglycaemia, male infertility, purpura (<1%), and photosensitivity reactions (<1%); also reported dysphagia, intestinal obstruction, intestinal ulcer, bezoar formation, gynaecomastia, agranulocytosis, and anaphylaxis; Hypertension in symptomatic (NYHA class II-IV) HF and LVD: Class IA [1] Nifedipine: 20-30mg once daily Hypertension Calcium Channel Blockers Nifedipine, Verapamil, Diltiazem Nifedipine: 5- 20mg 3 times daily Raynaud s Syndrome Nifedipine: 5- 20mg 3 times daily Angina in symptomatic (NYHA class II-IV) HF and LVD: Class IIaA [1] Angina (prophylaxis) Anti-Arrhythmics Class I (sodium channel blockers) Flecainide, Lidocaine, Procainamide Ventricular Arrhythmias Flecainide: 50-100mg twice daily Sustained VT and VF: Class IIbC [4] Oedema, pro-arrhythmic effects (1- 13%); dyspnoea; nervous-system side- effects including dizziness, asthenia, fatigue, fever; visual disturbances (13- 28%); rarely pneumonitis, hallucinations, depression, confusion, amnesia, dyskinesia, convulsions, peripheral neuropathy; also reported gastro-intestinal disturbances (1-4%), anorexia, hepatic dysfunction, flushing, syncope, drowsiness, tremor, vertigo, headache, anxiety, insomnia, ataxia, paraesthesia, anaemia, leucopenia, thrombocytopenia, corneal deposits, tinnitus, increased antinuclear antibodies, hypersensitivity reactions (including rash, urticaria, and photosensitivity), increased sweating. Pre-excited SVT/AF: Class IB; Wide QRS- complex tachycardia of unknown origin: Lidocaine (Class IIbB) / Procainamide (Class IB); Wide QRS- complex tachycardia of unknown origin with LVD: Class IB; Focal tachycardia: junction IIaC; WPW Class IIaC; Syndrome: poorly AVRT, tolerated: IIaC; Single infrequent AVRT or episode(s): Class IIbC; Acute treatment Atrial of Focal Class Tachycardia: https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 9/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology Prophylactic IIaC; therapy for AT: Class (Stable IIaC; AF flutter): Class IIbA; Prophylaxis of SVT during pregnancy: Class IIbB [5] Class II (Beta blockers) (See above) (See above) (See above) (See above) Sustained VT and VF: Class IIaC; Polymorphic VT: Class IC [4] Management of VA in IA; Class HF: Prevention of VA in HF: Class IIbB [1] SVT: Class IIBC; Wide QRS-complex tachycardia of unknown origin: Class QRS- IB; Wide complex tachycardia of unknown origin with LVD: IB; AVNRT Recurrent unresponsive to beta blocker or calcium- channel blocker and patient not desiring RF ablation: Class junction IIbC; Focal Class tachycardia: WPW IIaC; IIaC; Syndrome: AVRT, poorly tolerated: Class IIaC; infrequent Since or episode(s): AVRT Class IIbB; Acute treatment of Focal Tachycardia: Atrial IIaC; Class Prophylactic therapy for AT: Class IIaC; AF tolerated): (Poorly Class IIbC; AF (Stable flutter): Class IIbC; Prophylaxis of SVT pregnancy: during Class IIIC [5] Gastro-intestinal disturbances (2- 20%)), taste disturbances, hepatic disturbances (up to 50%); bradycardia; pulmonary toxicity (1-17%); tremor (9- 59%), sleep disorders; hypothyroidism (5-10%), hyperthyroidism (5-10%); reversible corneal microdeposits (up to 98%); phototoxicity, persistent slate- grey skin discoloration (1-7%), injection-site reactions; less commonly onset or worsening of arrhythmia, conduction disturbances, peripheral neuropathy (1-105) and myopathy; very rarely sinus arrest, bronchospasm, ataxia (2-37%), benign intracranial hypertension, headache, vertigo, epididymo-orchitis, impotence, haemolytic or aplastic anaemia, thrombocytopenia, rash, hypersensitivity including photosensitivity (2-20%), anaphylaxis on rapid injection, hypotension (10- 30%), respiratory distress syndrome, sweating, and hot flushes Class Class III (Potassium channel blockers) Amiodarone: 200mg 2-3 times daily Amiodarone, Sotalol Ventricular, Arrhythmias Class IV (Calcium (See above) (See above) (See above) (See above) https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 10/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology channel blockers) SVT: Class IIbC; WPW Syndrome: Class IIIC; AVRT, poorly tolerated: Class IIIC; Since or infrequent AVRT episode(s): Class IIIC; Prophylaxis of SVT during pregnancy: Class IC [5] Gastro-intestinal disturbances (vomiting, diarrhoea, anorexia, abdominal pain) (25%); arrhythmias (up to 50%), AV conduction disturbances (50%); nervous system disturbances (dizziness, apathy, confusion, headache, fatigue, weakness) (25%); blurred or yellow vision; rash, eosinophilia, depression, anorexia, intestinal ischaemia and necrosis, psychosis, gynaecomastia on long-term use, and thrombocytopenia. Acute: 0.75- 1.5mg over 24 hours; Maintenance: 125-150 g daily Supra-ventricular Arrhythmias Symptomatic (NYHA class II-IV) HF: Class IIbB Digoxin (NYHA Symptomatic class II-IV) HF, LVD and AF: Class IB; Acute HF with AF and VT: Class IC [1] 62.5-125 g daily Heart Failure Anti-platelet Drugs Prevention in AF: Class IC; Prevention in diabetic patients: IIaB [2] Bronchospasm (10-30% in asthmatics); gastro-intestinal irritation (up to 83%), gastro-intestinal haemorrhage (occasionally major), also other haemorrhage (e.g. intracranial (0.5%), subconjunctival), chest pain (8.3%), oedema (4.5%), hypertension (4.3%). Prevention Symptomatic class AF: Class IIA [1] in (NYHA II-IV) HF and Prevention of thrombotic cerebro- or cardio-vascular disease in Prevention hypertensive patients with CV events: Class IA; Prevention in hypertensive patients without CV history but renal with reduced function/high risk: Class IIbA [3] 75mg once/day Aspirin Post-MI: Class Ia [3] 300-600mg every 4-6 hours as necessary Pain / pyrexia Clopidogrel Prevention of thrombotic events (esp. when warfarin not tolerated) 75mg once/day Prevention in diabetic patients: IIaB; Primary and secondary prevention of stroke: Class IB [2] Dyspepsia (5.2%), abdominal pain (5.6%), diarrhoea (4.5%); bleeding disorders including gastro-intestinal (2.0%) and intracranial (0.4%), nausea (3.4%), vomiting, gastritis, flatulence, constipation, gastric and duodenal ulcers, headache (7.6%), epistaxis (2.9%), dizziness (6.2%), paraesthesia, leucopenia, decreased platelets (very rarely severe thrombocytopenia), eosinophilia, rash (4.2%), pruritus (3.3%), vertigo, colitis, pancreatitis, hepatitis (<1%), acute liver failure, hypertension (4.3%), chest pain (8.3%), oedema (4.1%), vasculitis, confusion, hallucinations, taste disturbance, cough (3.9%), fatigue (4.8%) stomatitis, Prevention Symptomatic class AF: Class IIA [1] in (NYHA II-IV) HF and of Acute coronary artery syndrome: Class IB; phase https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 11/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology bronchospasm, interstitial pneumonitis, pyrexia (2.2%), blood disorders including thrombocytopenic purpura (5.3%), agranulocytosis, neutropenia (0.04%) and pancytopenia and hypersensitivity-like reactions (<0.1%)including fever, glomerulonephritis, arthralgia, Stevens-Johnson syndrome, toxic epidermal necrolysis, lichen planus. Non-cardioembolic cerebral events: Class IA [3] ischaemic 300mg daily initially then 75mg once/day Acute myocardial infarction Post STEMI: Class IA [4] 300mg daily initially then 75mg once/day Acute coronary syndrome ACS: Class IIaC [2] Haemorrhage (11.3%) (including gastro-intestinal (1.5%) and intracranial), haematoma, haematuria, hypertension (7.5%), hypotension (3.9%), headache (5.5%), back pain (5.0%), dyspnoea (4.9%), nausea (4.6%), dizziness (4.1%), cough (3.9%), fatigue (3.7%), chest pain (3.1%), arrhythmias including atrial fibrillation (2.9%) and bradycardia (2.9%), rash (2.8%), pyrexia (2.7%), oedema (2.7%), diarrhoea (2.3%), hypercholesterolaemia/hyperlipidaemia (7.5%), anaemia, rash,hypersensitivity reactions including angioedema (0.06%), thrombocytopenia (0.06%), thrombotic thrombocytopenic purpura. Prevention in Symptomatic (NYHA class II-IV) HF and AF: Class IIA [1] Prevention of thrombotic events. 60mg bolus then 5-10mg once daily Acute coronary syndrome: Class [3] phase of artery IB Prasugrel Dyspnoea (13.8%), haemorrhage, bruising; nausea (4.3%), vomiting, diarrhoea (3.7%), hypertension (3.8%), hypotension (3.2%), back pain (3.6%), abdominal pain, dyspepsia, gastritis, dizziness (4.5%), chest pain (3.7%), headache (6.5%), cough (4.9%), rash, pruritus, fatigue (3.2%), constipation, arrhythmias including atrial fibrillation (4.2%), paraesthesia, confusion, hyperuricaemia, raised serum creatinine (7.4%), vertigo. Prevention in Symptomatic (NYHA class II-IV) HF and AF: Class IIA [1] Prevention of thrombotic events. 180mg bolus then 90mg twice daily Acute coronary syndrome: Class [3] phase of artery IB Ticragelor Vitamin K Antagonists 5-10mg initially then tailored to individual (usually 3- 9mg once daily at the same time) Haemorrhage, nausea, vomiting, diarrhoea, jaundice, hepatic dysfunction, pancreatitis, pyrexia, alopecia, purpura, rash, purple toes , skin necrosis (increased risk in patients with protein C or protein S deficiency) Prevention of thrombotic/ embolic events (esp. after prosthetic valve insertion) Warfarin Haemorrhage, nausea, vomiting, diarrhoea, jaundice, hepatic dysfunction, pancreatitis, pyrexia, alopecia, purpura, rash, purple toes , skin necrosis (increased risk in patients with protein C or protein S deficiency) Prevention of thrombotic/ embolic events (esp. after prosthetic valve insertion) 4mg initially, followed by 1-8mg daily Acenocoumarol Lipid-Lowering Drugs Statins Simvastatin, Atorvastatin Primary hyper- cholesterolaemia, combined hyperlipidaemia Simvastatin: 10-20mg once daily Dyslipidaemia: Class IA; Low HDL-C: Class IIbB; Elderly patients with CVD: IB; Elderly patients with no CVD but CV risk factors: IIbB; Type I diabetes: IC; Patients with CKD: IIaC; Transplant patients: Class Oedema (2.7%), abdominal pain (5.9%), nausea (5.4%), atrial fibrillation (5.7%), constipation (2.2%), gastritis (4.9%), diabetes mellitus (4.2%), myalgia (3.7%), headache (2.5%), insomnia (4.0%), vertigo (4.5%), bronchitis (6.6%), sinusitis (2.3%), https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 12/14 7/4/23, 12:41 AM Cardiac Pharmacology - Textbook of Cardiology IIaB; PAD: Class IA; HIV patients: IIaC [2] eczema (4.5%), urinary tract infection (3.2%) Hypertension diabetics: Class ACS: Class IA [3] in IA; Simvastatin: 40mg once daily Familial hyper- cholesterolaemia HeFH: Class IC [2] Prevention of cardiovascular events 20-40mg once daily Class IA [2] Gastro-intestinal disturbances including dyspepsia (19.6%), nausea (4%), abdominal pain (9.8%), diarrhoea (7.2%), vomiting (1.2%); headache (1.2%), fatigue (3.8%), vertigo (1.5%), eczema, rash (1.7%), atrial fibrillation (0.7%), pancreatitis, appendicitis, disturbances in liver function including hepatitis and cholestatic jaundice, dizziness, paraesthesia, sexual dysfunction, thrombocytopenia, anaemia, leucopenia, eosinophilia, bone-marrow suppression, myalgia, myopathy, myasthenia, myositis accompanied by increase in creatine kinase, blurred vision, exfoliative dermatitis, alopecia, and photosensitivity Low HDL-C: Class IIbB; Transplant patients (with HTG, low HDL-C): Class IIbC [6] Hyperlipidaemias of types IIa, IIb, III, IV and V Gemfibrozil: 0.9-1.2mg daily Gemfibrozil Fibrates Gastro-intestinal disturbance including diarrhoea (4.1%) and abdominal pain (3.0%); headache, fatigue (2.4%); myalgia, arthralgia (3.0%), sinusitis (3.6%), pharyngitis (2.3%), viral infection (2.2%), coughing (2.3%), hypersensitivity reactions including rash, angioedema, and anaphylaxis, hepatitis,pancreatitis, cholelithiasis, cholecystitis, thrombocytopenia, raised creatine kinase, myopathy, and rhabdomyolysis Primary and familial hyper- cholesterolaemia 10mg once daily Transplant patients (with high LDL-C): Class IIbC [6] Ezetimibe References 1. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, B hm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, K ber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, R nnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, and ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012 Jul;33(14):1787-847. DOI:10.1093/eurheartj/ehs104 | 2. 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DOI:10.1093/eurheartj/ehs092 | 4. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, Badano LP, Bl mstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van 't Hof A, Widimsky P, and Zahger D. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012 Oct;33(20):2569-619. DOI:10.1093/eurheartj/ehs215 | 5. Blomstr m-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW Jr, Stevenson WG, Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ, American College of Cardiology, American Heart Association Task Force on Practice Guidelines, and European Society of Cardiology Committee for Practice Guidelines. Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation. 2003 Oct 14;108(15):1871-909. DOI:10.1161/01.CIR.0000091380.04100.84 | 6. European Association for Cardiovascular Prevention & Rehabilitation, Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D, and ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. 2011 Jul;32(14):1769-818. DOI:10.1093/eurheartj/ehr158 | Retrieved from "http://www.textbookofcardiology.org/index.php?title=Cardiac_Pharmacology&oldid=2554" This page was last edited on 28 May 2015, at 08:41. Content is available under Attribution-NonCommercial-ShareAlike 3.0 Unported unless otherwise noted. https://www.textbookofcardiology.org/wiki/Cardiac_Pharmacology 14/14