3.

2
Pharmacology: Vasodilators

Emmanouil S. Brilakis, MD, PhD

 PCI: the steps
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 Medication classes

1. Sedatives - Analgesics
Goals
2. Vasodilators
1. Prevent + treat
3. Contrast media
coronary spasm
4. Anticoagulants
2. Rx no reflow
5. Antiplatelets
3. FFR
6. Vasopressors - Inotropes
4. Prevent + treat radial
7. Antiarrhythmics
spasm
5. Rx hypertension
6. Rx pulmonary edema
  Nitroglycerin:
Medication classes IC: 50-300 mcg
IV: 10-200 mcg/min
SL: 400 mcg (0.4 mg)
1. Sedatives - Analgesics
2. Vasodilators 1. Prevent spasm
2. Rx no reflow • Nicardipine-Nitroprusside:
3. Contrast media 3. FFR IC: 100-300 mcg
4. Anticoagulants 4. Prevent + Rx radial spasm
5. Rx hypertension
5. Antiplatelets 6. Rx pulmonary edema
• Verapamil
Radial 2-3mg
6. Vasopressors - Inotropes IC: 1 mg
7. Antiarrhythmics
 Adenosine:
IC-RCA: 50-100 mcg
IC-LM: 200 mcg
Intragraft: similar to above
IV: 140 mcg/kg/min
 Angiography steps

1. Ensure good pressure waveform NTG dose

SBP>120 mmHg: 200 mcg
2. Test contrast injection SBP=100–120 mmHg: 100 mcg
3. IC nitroglycerin SBP<100 mmHg: 0-50 mcg

4. Optimally position patient – image receptor

– shields - operator
5. Assess pressure + ECG
6. Perform cineangiography
7. Assess pressure + ECG
8. Angiogram interpretation
PCI?
After nitro
Before NTG After NTG
Nitroglycerin “on a stick”
Courtesy Dr. Rick Nishimura
 Medication classes

 Nitroglycerin:
1. Sedatives - Analgesics
IC: 50-300 mcg
2. Vasodilators 1. Prevent spasm
2. Rx no reflow IV: 10-200 mcg/min
3. Contrast media 3. FFR
4. Anticoagulants 4. Prevent radial spasm SL: 400 mcg (0.4 mg)
5. Rx hypertension
5. Antiplatelets 6. Rx pulmonary edema
6. Vasopressors - Inotropes • Nicardipine-Nitroprusside:
7. Antiarrhythmics IC: 100-300 mcg

• Verapamil
Radial 2-3mg
IC: 1 mg
2.5 x 28 mm DES 2.75 x 12 mm DES
Severe chest
pain and ST-
segment
elevation!
What was done…

Treatments
• Aspiration
thrombectomy
• Adenosine
(3,000 mcg)
• Nicardipine 400
mcg
• Eptifibatide

Troponin I: 8.98 ng/mL

CK-MB: 53.5 ng/mL
 Approach to radial spasm
Do NOT pull!!
Intra-arterial / sublingual / SQ
Step 1 Vasodilators injection

Step 2 Sedation Moderate – propofol - general

Step 3 Warming arm

Step 4 Lubricious solution Rotaglide - Viperglide

Step 5 BP cuff in arm x 5 min

Step 6 Surgery
 Complications

1. Sedatives - Analgesics
2. Vasodilators
3. Contrast media
4. Anticoagulants
5. Antiplatelets
6. Vasopressors - Inotropes
7. Antiarrhythmics
 Hypotension
Prevention
• Do not give vasodilators if
hypotension, LVOT
obstruction, RV infarction
Treatment
• Normal saline
• Waiting
• Vasopressors
 Medication classes

 Adenosine:
1. Sedatives - Analgesics IC-RCA: 50-100 mcg
2. Vasodilators IC-LM: 200 mcg
3. Contrast media
Intragraft: similar to above
4. Anticoagulants
5. Antiplatelets IV: 140 mcg/kg/min
6. Vasopressors - Inotropes
7. Antiarrhythmics
Mahmood et al. Hellenic J Cardiol 2011;52:352–3
B
Complete heart block R on T Torsades

Adenosine administration

C
Defibrillation

Restoration of sinus rhythm

Mahmood et al. Hellenic J Cardiol 2011;52:352–3

 Aminophylline for RCA
atherectomy

250 mg IV over 10 minutes

No rebolus
Half-life=8 hours
  Nitroglycerin:
Medication classes IC: 50-300 mcg
IV: 10-200 mcg/min
SL: 400 mcg (0.4 mg)
1. Sedatives - Analgesics
2. Vasodilators 1. Prevent spasm
2. Rx no reflow • Nicardipine-Nitroprusside:
3. Contrast media 3. FFR IC: 100-300 mcg
4. Anticoagulants 4. Prevent + Rx radial spasm
5. Rx hypertension
5. Antiplatelets 6. Rx pulmonary edema
• Verapamil
Radial 2-3mg
6. Vasopressors - Inotropes IC: 1 mg
7. Antiarrhythmics
 Adenosine:
IC-RCA: 50-100 mcg
IC-LM: 200 mcg
Intragraft: similar to above
IV: 140 mcg/kg/min