Cardiovascular and Neurological Conditions: A Review

Posted on Mar 24, 2025 in Pharmacy

Angina

Substernal pain caused by insufficient perfusion of the myocardium.

Angina Types

  • Stable: Oxygen demand exceeds supply, usually brought on by physical exertion.
    • Drug therapy: SL NTG, BB, or LA nitrate
  • Variant: Oxygen supply decreases due to vasospasm, may occur at rest.
    • Calcium channel blocker
  • Unstable: Oxygen supply decreases as demand increases; secondary to atherosclerotic plaque rupture within the coronary artery.
    • Combination e.g. CCB + BB

Drugs Used in Angina Pectoris

Vasodilators

Nitrates

Short, intermediate, long-acting.

Isosorbide dinitrate, isosorbide mononitrate, nitroglycerin.

Calcium Blockers

Cardiac depressants.

  • Dihydropyridine (-idine)
  • Non-dihydropyridine
    • Verapamil, diltiazem

Beta Blockers

-olol

Misc

Ranolazine

Other

Other antihypertensives, statins, and anticoagulants.

Nitrates

Nitroglycerine

  • IV
    • O: Immediate
    • D: minutes
  • SL
    • O: 1-3 min
    • D: 30-60 min
    • Acute/prevent chest pain
    • Keep in original container
    • Call 911 5 min after 1st dose
  • Ointment
    • O: 20-60 min
    • D: 4-8 hr
  • Patch
    • O: 40-60 min
    • D: 8-24 hr
    • Remove at night

Interaction w/PDE5 inhibitors (Viagra/sildenafil). Space 24-48 hours. Hypotension.

SE: HA, dizzy, ortho hypotension, flush.

Long-acting should be dosed for 10-12 nitrate-free interval.

Isosorbide DN

  • Oral
    • O: 20-40 min
    • D: 4-6 hr
  • Oral ER
    • O: 30 min
    • D: 12 hr
    • 7am, noon, 5pm

Isosorbide MN

  • Oral
    • O: 30-60 min
    • D: 6-8 hr
  • Oral ER
    • O: 30-60 min
    • D: 12 hr

Ranolazine

Inhibits late Na channels, decrease Ca concentration.

Increase exercise capacity 30 sec.

Combined with inadequate standard therapy.

No effect on BP/HR.

SE: constipation, HA, dizzy, nausea.

Interactions:

  • 3A4 inhibitor (ketoconazole)
  • Metformin 850 max if max Renexa
  • Digoxin recheck level

Acute Coronary Syndrome

Antiplatelet

  • ASA
  • P2Y12 inhibit (Clopidogrel)
  • DAPT s/p PCI

Anticoagulant

  • Heparin IV

Chest pain/antihypertensive

  • BB lower MVO2
  • Nitroglycerine IV vasodilate
  • Morphine vasodilate
  • ACEi or K-sparing diuretic
  • High intensity statin (atorvastatin)
  • Stabilize plaque, pleiotropic

Arrhythmia

Antiarrhythmic Classification

I: Na channel

Ia: Prolong repolarization
  • Afib, v. arrhythmia
  • Eg procainamide
  • Quinidine SE: GI, cinchonism, hypotension, digoxin, thrombocytopenia
  • Prolongs QTc; maintain K, Mg
  • Can cause torsades de pointes
Ib: Short repolarization
  • V. arrhythmia
  • Lidocaine SE: CNS depression/stim, concurrent use of tocainide or mexiletine cause additive CNS tox
  • More effect on fast HR
Ic: no effect on repolarization
  • AV nodal reentry, WPW arrhythmias, v. arrhythmia
  • Flecainide, Propafenone
  • Do not use in pts with CVD 2/2, prolong QTc
  • Can cause CAST proarrhythmia
  • Negative inotropic effect

II: anti-sympathetic (BB)

  • Afib, Aflutter, v. arrhythmia
  • Sotalol has class III activity
  • Decrease excitatory effects of sympathetic NS
  • Prolongs refractory period
  • Slow HR
  • Slow conduction through myocardium

III: K+ influx

Amiodarone
  • ½ life 40 days
  • Afib/flutter, V. arrhythmia
  • SE: sinus bradycardia, torsades de pointes
  • CNS tox: ataxia, dizzy, fatigue, p. Neuropathy, tremor
  • Lung: pulmonary fibrosis
  • Liver: monitor LFTs
  • Thyroid: hyper or hypo
  • Eye: yearly exam, cornea deposits
  • Skin: photosensitive, blue-grey discoloration
  • GI: constipation
Interactions:
  • Inhibits CYP3A4, 2C9, 2D6, p-glycoprotein
  • Warfarin, cyclosporine, statins, digoxin
Dofetilide
  • Afib/flutter
  • Reserved for refractory pts
  • QTc prolongation; only started/stopped inpt
  • Tikosyn REMS registration
Contraindications
  • QTc > 440
  • Crcl <> 440
  • Crcl <>5 or SrCr >2.5
  • 25-50 mg/day

Sacubitril-neprilysin

  • Neprilysin + ATII blocker
  • Allow 36 hr washout of ACEi
  • Use in pts w/chronic sx and lower EF
  • Reduce if eGFR <>70
  • Reduce if eGFR <>70
  • Reduce if eGFR <>35 and HR >70
  • Dose adjusted based on HR 2.5-7.5
  • Take w/food
  • Useful in pts intolerant of BB
  • SE: HTN, bradycardia, afib, visual disturbance, angioedema
  • Intxns: 3A4, CCBs, nondihydropyridine
  • Monitor HR, BP, EKG

Acute HF Exacerbations

  • Diuretics e.g. furosemide
  • Acute renal failure: hold ACEi/ARB
  • Maintain BB

Phosphodiesterase Inhibitors

Milrinone

  • Increases force of contraction
  • IV, typically short-term
  • SE: HoTN, HA, v.arrhythmia

IV Agents for Severe HF

Dobutamine

  • 2-20
  • B-receptor agonist
  • Pro-arrhythmic, increase HR, ischemia

Milrinone

  • 0.375-0.75
  • Vasodilator
  • Improve pulmonary HTN
  • Pro-arrhythmic
  • Taken with BB

Nitroglycerine

  • 10-500
  • Anti-ischemic, vasodilator, limited by vasc HA
  • Rapid tolerance

Nitroprusside

  • 10-500
  • Thiocyanate accumulation in renal failure
  • Provoke ischemia
  • Vasodilator, ICU only

Parkinson’s Disease

2+ of Tremor at rest, rigidity, akinesia/bradykinesia, postural instability.

Early sx: fatigue, coordination, reduced arm swing, limp or tremor, soft voice, depression.

Parkinson’s Drugs

Levodopa

  • Best for resolving sx
  • IR: empty stomach, ~30 min
  • SR: with food, ~60 min, 30% less bioavailable
  • SE: ortho HoTN, syncope, dizzy, confuse, somnolence, EPS, hallucinations, dyskinesia, N/V, hematologic, paresthesia, cramps, blepharospasm, urine, resp
  • on/off phenomenon or wearing off (drug holiday not recommended)
  • Intxn: Phenytoin, TCA (HTN), MAO Is and antiHTN (orthostasis), iron salts

Carbidopa

  • Decrease peripheral breakdown of L-dopa

Amantadine

  • Alone in early stages, decrease L-dopa induced dyskinesia
  • 100mg w/breakfast, then 100 w/breakfast + lunch, 400 max
  • SE: ortho HoTN, insomnia, depressions, hallucinations, xerostomia
  • 1-2 week holiday after 4-8 week b/c tachyphylaxis
  • Withdrawal encephalopathy

Anticholinergics

  • Best for young pts w/tremor and min rigid/bradykinesia
  • SE: constipation, xerostomia, dry skin, dysphagia, confusion, memory
  • E.g. Benztropine, diphenhydramine

BB alternative

  • Antihistamine SE: drowsy, thick bronchial secretions, appetite, HA, xerostomia, blurry vision, N/V, decreased urination
  • E.g. diphenhydramine, benztropine

Dopamine Replacement

  • SE: nausea, ortho HoTN, confusion, dizzy, hallucination, dyskinesia, blepharospasm
  • E.g. carbidopa-levodopa

Dopamine Agonist

  • Treat tremor, rigidity, bradykinesia
  • Vs. L-dopa: less effective/motor SE, more neuro SE, long ½-life, no diet effect
  • SE: N/V, ortho HoTN, confusion, dizzy, hallucination, leg cramps, impulse control, somnolence, dementia, constipation, peripheral edema

E.g. Pramipexole, ropinirole

MAO-B inhibitors

  • Improve sx, maybe neuroprotective
  • E.g. rasagiline, selegiline
  • SE: Cardio, CNS, derm, GI, GU, NMS, ocular
  • Intxns: >20/day HTN crisis w/tyramine, CI with meperidine, caution w/serotonergics

COMT inhibitors

  • Improve and prolong levodopa effects

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