This next section will cover the CVP curriculum on common medications utilized in the heart catheterization lab. My name is Michael Templehoff. I'm an interventional cardiologist at Ohio Health in Columbus, Ohio, and completing this project with the assistance of RRT Tech Michelle Clark. What we have done in this compilation of slides and presentation is arranged medications according to their indication for antiarrhythmias, inotropes, vasopressors, anticoagulation, and sedative medications. This first slide covers very commonly utilized medications, particularly with adenosine. Adenosine can be used through an IV infusion with the doses as listed above, and when providing this medication, it is noteworthy to remain cognizant of the rhythm as adenosine works primarily on atrial tissue, not on ventricular tissue, to induce AV block by working on the A1 receptors. Additionally, adenosine has affinity for A2A receptors, causing arterial vasodilatation and may cause transitory drops in blood pressure. And also, by being an agonist for A2B receptors in the bronchial trees, can induce bronchospasm, which if does occur, can be rather profound, but is quickly resolved with discontinuation of the IV infusion. However, can have profound bronchoconstriction, requiring reversal with low-dose epinephrine. Adenosine in low doses can be given also through IC administration, intracoronarily, with also the caveat that it can induce AV block, particularly if administered directly into the right coronary artery. And as such, it is recommended that the dose to the right coronary artery is half of the dose to the left coronary circulatory. Atropine, a well-known antiarrhythmic with Yvonne Williams class of 3, working on essentially all the sodium and potassium and calcium channels, is a very strong antiarrhythmic utilized in multiple settings, including ACLS, atrial fibrillation, with the dosing as listed above. Atropine, for the administration to correct symptomatic bradycardia, often utilized during intervention of the right coronary artery, where the Gerald Biesel reaction of a hypervagal response limiting sympathetic output can induce a bradycardic response during PCI intervention of the right coronary artery. It is important to note the maximum total dose of atropine of 3 mg. Isopryl, a beta agonist in an infusion administration, can be given during heart catheterization. Oftentimes these patients are brought to the catheterization lab with isopryl, who are then getting treated with Pacemaker. Lidocaine, the second go-to antiarrhythmic for people in refractory ventricular tachycardia, does have a propensity to work better with ischemic myocardium. It is noted that lidocaine toxicity has a higher propensity amongst patients who have liver failure and hepatic vein congestion. Moving on to the next slide, where we will review inotropes and vasopressors, starting with dibutamine, commonly utilized for any mechanical complications associated with cardiogenic shock or PCI. Dibutamine has a relatively fast onset of action, and a rather prolonged offset of action of approximately 8 minutes can induce arrhythmias and also cause hypotension as it does mediate beta-2 receptors causing peripheral vasodilatation. Secondly, dopamine, less utilized in the cath lab for treatment of cardiogenic shock, as one study did demonstrate in comparison to norepinephrine, a higher rate of arrhythmias and, perhaps worse, major adverse cardiovascular events for patients initiated on dopamine versus levofed for all types of shock, including cardiogenic shock. Epinephrine, we're all very familiar with, utilized in ACLS settings for push and also can be used in IV infusions. During cardiac arrest, ACLS pushes of epinephrine works primarily on alpha receptors, causing rather profound and abrupt vasoconstriction. IV infusions works on beta and alpha receptors, causing both vasoconstriction and slight inotropic and chronotropic potentiation. Glycerin, a vasodilator, utilized judiciously for refractory angina. Levofed, or norepinephrine, as previously discussed, very favorable profile, mostly as a alpha agonist of 90% of its properties, an additional 10% with beta agonist properties, a very slight inotropic agent. And then, finally, vasopressin as an add-on agent to vasopressors for patients who are requiring additional hemodynamic support during cardiogenic shock or hypotensive episodes. This next slide reviews anticoagulants and antiplatelet agents commonly used in the heart catheterization lab by Valerudin and Geomax. Initially having promise of having lower bleeding risk profile compared to heparin. However, some of this has not proven to bear in the more recent clinical trials. By Valerudin, it is advantageous compared to heparin in that there is no impurities, no necessarily to check ACTs to confirm the appropriateness of anticoagulation. It is dosed appropriately according to renal function. However, there has been a slight increase of very acute stent thrombosis with utilization of by Valerudin and is often cost prohibitive in comparison to heparin. Next, cangrelor, an IV P2Y12 inhibitor, has a niche indication and utilization for PCI patients who are intubated do not have a per oral status and can be utilized and successfully utilized, particularly with its very quick onset of action of approximately three minutes with an offset of action within eight minutes and full recovery of platelet function within two hours. Therefore, favorable in the sense of patients going to emergent bypass surgery can be turned off on the way to the OR suite with decreased bleeding risk. IV heparin we're all aware of and use quite commonly. And finally, tyrofiban 2b3a inhibitor, which is a small molecule 2b3a as opposed to an antibody 2b3a. 2b3a such as tyrofiban can be utilized with patients with poor renal function, is dosed with an infusion, and does not associate with profound thrombocytopenia, which has been known and associated with antibody type of 2b3a inhibitors. And finally, the last slide reviewing sedative medications commonly used within the heart catheterization lab. First is ramazakam or flamazenil is to reverse benzodiazepine-induced respiratory depression in patients who may have received high doses of Versed. It is noted to be used in dose intervals one dose every minute up to four maximum doses. Additionally, Narcan for reversal of fentanyl or opioid-induced respiratory depression. And finally, utilization of propofol should be noted to be used in caution for patients who have a depressed ejection fraction as it does have negative inotropic effects. However, it is favorably used due to its rather rapid onset of action and rapid offset of action. Both Michelle and I want to thank you for your attention and interest in reviewing common medications utilized within the heart catheterization lab. Of course, this does not cover all of the medications which are utilized in the cath lab, but does address the most commonly used medications and ones that all of us should have a strong familiarity with as they are often utilized during complex heart intervention and oftentimes in urgent situations where relying on references and such may preclude a timely administration of medications. Again, thank you for your time and attention.

heart catheterization lab

medications

antiarrhythmias

inotropes

vasopressors