Commonly Used Drugs In Cath Lab

1. Presented by
Dr. Subrata Kumar
D.card Student
UCC, BSMMU

2.  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.

3.  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.

5.  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.

6.  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.

7. Adverse effects:
 Dizziness, Drowsiness,Confusion, Respiratory
depression,Convulsion,Anaphylaxis.
 Hypotension,Bradycardia & Cardiac arrest.

8.  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.

9.  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.

10.  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.

11. Adverse effects:
 Heparin induced thrombocytopenia and
thrombosis syndrome (HITTS), bleeding,
bruising,epistaxis,hematoma,hypersensitvity
raction ,nausea,vomiting,constipation,
osteoporosis,alopecia etc.

12.  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.

13.  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.

14.  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.

15.  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

16.  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.

17.  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.

18.  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.

19.  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.

20.  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

21. 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.

22.  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.

23.  Adverse effects include bleeding, TTP,
anaemia, hypertension, hypotension, atrial
fibrillation, bradycardia, GI upset,
headache,back pain, rash, peripheral
edema etc.

24.  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.

25.  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.

26.  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

27. 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.

28.  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.

29. 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.

30.  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.

31.  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.

32. Adverse effects:
 Pulmonary fibrosis, DPLD, Hypo /
hyperthyroidism, corneal micro deposits.
 Elevated liver enzymes, jaundice, hepatitis,
hepatomegaly, peripheral neuropathy,
epididymitis, gynaecomastia etc.

33. 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.

34. 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

35. 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.

36. Iohexol:
 Iodine based non-ionic & low osmolality
contrast 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.

37. THANK YOU ALL