Presented by

Dr. Subrata KumarD.card Student

UCC, BSMMU

Cardiac catheterization laboratory is a lab in a hospital where different types of cardiac procedure are performed routinely.

Common procedure includes: Coronary angiogram, Percutaneous coronary intervention, Peripheral angiogram, PTMC, TPM,PPM implantation, Right & left heart cahteterization, Carotid angiogram, Aortogram, LV graphy,RV graphy etc.

Different drugs are used in different time of

procedure.

Those drugs have many other indications,

mechanism of action and adverse effects.

Here commonly used drugs are discussed

briefly with main focus on their use in cath

lab.

Class Ib antiarrhythmic drug.

Fast Na+ channel blocker with shortening of

action potential.

Indicated in ventricular arrythmias,

sympathetic & different types of peripheral

nerve block, regional & surface

anesthesia,painful haemorrhoides etc.

Mainly used as local anesthetic agent in

cath lab.

1% (10mg/ml) Injection is ideal.

Here 2% Injection is used.

50ml vial; 1ml contains 20mg lidocaine.

12-15 ml Injection is instilled at and around the approach area.

In ventricular arrythmias eg. Resistant VT,VF,

50-100mg (2.5-5ml) IV bolus within 2 minutes followed by a maintenance dose of 12 ml/hr in first ½ hour, 9ml/hr for next 2 hrs & then 6 ml/hr for 24-48 hrs.

Adverse effects:

Dizziness, Drowsiness,Confusion, Respiratory

depression,Convulsion,Anaphylaxis.

Hypotension,Bradycardia & Cardiac arrest.

Anticoagulant or anti thrombotic drug used for rapid anticoagulation.

Unfractionated heparin (UFH) & Low molecular weight heparin (LMWH) are commonly used clinically.

In cath lab UFH is mainly used.

UFH has more anti-thrombin (IIa) activity ,it also inhibits Xa, XIa & other factors associated with intrinsic coagulation pathway. Thus inhibits thrombin induced platelet aggregation.

Used during primary or elective PCI, in

different thromboembolism, Pulmonary

embolism, DVT, Peripheral arterial

embolism/PVD, Cardiopulmonary bypass

etc.

5ml vial, 1ml contains 5000 IU heparin.

Dose in most cases: 100 IU/kg ie. 1ml IV stat

followed by 1000 IU/hr for 24 hour.

In Cath lab,1ml heparin is diluted with

500ml NS in a bowl.

This hepainized saline is used for

washing/flushing of insturments,

intracoronary flushing after giving

intracoronary Heparin,GTN or Eptifibatide.

0.5ml heparin is diluted with 2ml NS in a

syringe; Given in intracoronary route after

vascular access sheath is fixed.

During PCI, 2 ml (10000 IU) heparin is given

after passing of PTCA guidewire.

Adverse effects:

Heparin induced thrombocytopenia and

thrombosis syndrome (HITTS), bleeding,

bruising,epistaxis,hematoma,hypersensitvity

raction ,nausea,vomiting,constipation,

osteoporosis,alopecia etc.

Organic nitrate which is converted to

NO,that stimulate guanylate ccyclase

enzyme which in turns synthesize cGMP,

eventually resulting dephosphorylation of

myosin light chain of vascular smooth

muscle fibre. Subsequet Ca++ release

causes smooth muscle relaxation &

vasodilatation.

Dilates both vascular bed with venous

predominant effect.

Decreases both preload & afterload,also

reduces both systolic & diastolic BP.

Used as vasodilator & anti-antiginal drug in

effort angina,UA,CSA,NSTEMI,hyprtensive

crisis etc.

Has oral tablet,sublingual spray,IV infusion

form.

10 ml ampoule; 1ml contains 5mg (5000 µg)

GTN.

For IV infusion, 1amp mixed with 40ml 5%

DA & infuse @ 5 µg/min or 0.3ml/hr. Can be

increased by 0.3ml/hr every 10 min.

Max dose 200-250 µg/min (12-15 ml/hr).

In cath lab,0.2 ml (1000 µg)dissolved with

9.8 ml NS from where 1ml solution is taken in

each several syringe.

1ml dissolved GTN is given after PTCA

balloon inflation to dilated the blood

vessels during PCI. Several injections may

be needed accordingly.

Side effects:

Hypotension, headache,facial flushing,light

headedness,syncope,tachycardia,methe

moglinemia,nitrate tolerance etc.

Contraindications:

Acute Inferior MI with RV involvement,

HOCM, Use of Sildenafil or related

drugs,cardiac tamponade or constrictive

pericarditis etc

Gp IIb/IIIa Inhibitor (Anti-platelet drug)

Abciximab, Eptifibatide & Tirofiban are so

far used drugs. Eptifibatide is most

commonly used. All are IV form.

These drugs inhibit one of the platelet

integrin adhesion receptors technically

known as the αIIβ3 receptor. Thus they

block the final step of platelet activation &

cross linking by fibrinogen & vWF.

Indicated in primary or elective PCI,

UA/Non-STEMI with plan of invasive

strategy.

100ml vial, 1ml contains 0.75 mg

eptifibatide INN.

Dose is 180 mcg/kg IV bolus ( A second

dose is given 10 minutes after first dose )

followed by maintenance dose of 2

mcg/kg/min.

Infusion should continue until hospital

discharge or initiation of CABG, upto 72

hours.

In case of renal impairement ( CrCl <

50ml/min) maintenance dose may

reduced to 0.5-1 mcg/kg/min.

In our center during PCI,5-10 ml eptifibatide

is given slowly via intracoronary route

followed by heparinized saline flush.

Adverse effects:

Bleeding including ICH, pulmonary/GI

hemorrhage, thrombocytopenia,

hypotension, hypersensitivity reaction.

Several anti-platelet drugs are used in cath

lab namely clopidogrel & prasugrel.

Clopidogrel:

ADP receptor antagonist. It irreversibly

inhibit P2Y12 platelet receptor, thereby

prevents P2Y12 induced Gp IIb/IIIa

activation which is essential for platelet

aggregation.

Available as 75mg oral tablet.

Indicated in ACS,CVD,PVD for reduction of

atherosclerotic/thromboembolic events.

Usual dose is 75 mg daily but in case of

ACS with or without PCI and also before

PCI 300mg loading dose is indicated.

For prevention of post-stent thrombosis,

continue 75mg daily for at least 12 months.

Adverse effects include bleeding,

neutropenia, GI upset, Gastric irritation,URTI

etc

Prasugrel:

It is a novel third generation ADP receptor

blocker, irreversibly inhibit the P2Y12

receptor at the same site of clopidogrel.

But it has enhanced hepatic conversion to

the active form & is about 5-9 times more

potent than clopidogrel achieving greater

platelet inhibition than 600mg of

clopidogrel.

Available as 5mg & 10mg oral tablet.

Indicated in acute coronary syndrome, patients undergoing PCI, prevention of thromboembolic events including stent thrombosis,CVD.

Usual dose is 10 mg daily, in case of PCI preparation 60mg loading dose is indicated.

Caution should be taken in case of old age (>75 years) & low body weight (<60kg) because of the increased chance of bleeding.

Adverse effects include bleeding, TTP,

anaemia, hypertension, hypotension, atrial

fibrillation, bradycardia, GI upset,

headache,back pain, rash, peripheral

edema etc.

An inotrope is an agent that alters the

energy or force of muscular contraction.

Positive inotropes increase the force of

contraction whereas negative agents

decrease it.

Commonly used positive inotropes include

dopamine,dobutamine,adrenaline,nor

adrenaline,isoprenaline,digitalis etc.

Metoprolol,bisoprolol,carvedilol,verapamil,

diltiazem ,quinidine are few examples of

negative inotropes.

Catecholamine like agent, the precursor of

noradrenaline & releases nor epinephrine

from the stores of nerve endings in the

heart. In the periphery is overridden by

dopaminergic DA2 receptor causing

vasodilatation .

Dopamine stimulates the heart by both β1

and β2 adrenergic response.

Low dose mainly stimulates dopaminergic

receptors producing renal & mesenteric

vasodilatation.

Higher dose stimulates both β1 & β2

receptors along with dopaminergic

receptors causing heart stimulation & renal

vasodilatation.

Large dose stimulates α receptor causing

vasoconstriction.

Indicated in cardiogenic shock in coronary

artery disease or cardiac surgery, acute

heart faliure,hypotension etc

Dose:

5ml ampoule, 1ml = 40 mg dopamine

Renal: 2-5 mcg/kg/min

Cardiac: 5-10 mcg/kg/min

Vasoconstriction: 10-20 mcg/kg/min

Side effects:

Tachycardia, nausea, vomiting,

hypertension, anginal pain, ectopic beats

etc.

Synthetic analogue of dopamine which

stimulate β1>β2>α which gives potent

inotropic effect.

Due to β2 stimulation often there is fall of

diastolic blood pressure and hypotension.

So it is logical to use it simultaneous with

dopamine.

Indicated in acute on chronic refractory

heart failure, severe acute myocardial

faliure following AMI or cardiac surgery,

cardiogenic shock, excessive β blockade.

Dose:

5ml vial contains 250mg dobutamine.

2-15 mcg/kg/min

Renal: 1.5 ml/hr

Cardiac: 3ml/hr

Vasoconstriction: 6ml/hr

Side-effects:

Tachycardia, PVCs, HTN, dyspnoea, chest

pain, headache, nausea etc.

Class III anti-arrhythmic drug, prolongs cardiac action potential. It increases the refractory period in SA & AV node, slows the intra-cardiac conduction. It has also class Ia, II & IV anti-arrhythmic properties.

Has structural similarity with thyroxine as a 200mg tablet contains 75mg of Iodine.

As it has a low incidence of pro-arrhythmic effect, it is indicated both in acute life threatening arrhythmia as well as chronic arrhythmia suppression.

It is useful both in supraventricular and

ventricular arrhythmias.

Available in 100mg, 200mg oral tablet and

3ml IV injection .

Dose:

1 ampoule(150mg) IV bolus followed by a

maintenance dose of 3ml/hr in first 6 hours

& 1.5ml/hr in next 18 hours.

Adverse effects:

Pulmonary fibrosis, DPLD, Hypo /

hyperthyroidism, corneal micro deposits.

Elevated liver enzymes, jaundice, hepatitis,

hepatomegaly, peripheral neuropathy,

epididymitis, gynaecomastia etc.

Adenosine:

Mainly used in SVT

Dose: 1 amp (2ml/6mg) IV bolus followed

by a saline flash, repeat several doses

every 1-2 mins if no response.

Atropine:

Used in severe bradycardia

Dose: 1-2 amp (0.6-1.2 mg) every 3-10 mins

upto 5 amp to achieve HR at least 60/min.

Furosemide:

In cath lab, used to treat pulmonary

edema.

Dose: 0.5-1mg/kg (or 40mg) IV bolus over 1-

2 mins, may be increase upto 80mg if no

response.

For continuous infusion: 5 amp in 40ml NS @

2.5ml/hr

Diazepam:

For restless/anxious patient

Hydrocortisone:

1-2 vial (100-200mg) IV stat when patient is

shivering or suspected dye reaction.

Pantoprazole:

Potent proton pump inhibitor, less drug

interaction, so cardiac friendly.

Usually 1 vial (40mg) IV is given prior to PCI.

Povidone Iodine:

Iodine based broad spectrum antiseptic

solution used for antiseptic wash of

operative area.

Iohexol:

Iodine based non-ionic & low osmolalitycontrast agent helps to visualize coronary arteries & cardiac chambers clearly.

It is clear & colorless agent, excreted totally via kidney in almost unchanged form, so caution should be made in case of renal impairement patient.

100ml bottle/vial contains 350mg of iodine per ml.

50-150 ml solution is usually needed according to procedure variation.

THANK YOU ALL