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Therapeutics P2 Winter Semester > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Beneficial effects of increased preload due to Na/H2O retention

A

Optimize stroke volume via Frank-Starling mechanism

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2
Q

Detrimental effects of increased preload due to Na/H2O retention

A

Pulmonary/systemic congestion and edema; increased MVO2

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3
Q

Beneficial effects of vasoconstriction

A

Maintain BP in face or reduced CO; shunt blood from nonessential tissues to the heart

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4
Q

Detrimental effects of vasoconstriction

A

Increased MVO2; increased afterload decreases SV and further activates the compensatory responses

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5
Q

Beneficial effects of tachycardia and increased contractility (SNS activation)

A

Maintain CO

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6
Q

Detrimental effects of tachycardia and increased contractility (SNS activation)

A

Increased MVO2; shortened diastolic filling time; beta-receptor downregulation and decreased responsiveness; ventricular arrhythmias; increased risk of myocardial cell death

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7
Q

Beneficial effect of ventricular hypertrophy and remodeling

A

Maintain CO; Reduce myocardial wall stress; decreased MVO2

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8
Q

Detrimental effects of ventricular hypertrophy and remodeling

A

Diastolic and systolic dysfunction; risk of myocardial cell death and ischemia; risk of arrhythmias; fibrosis

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9
Q

Factors precipitating or worsening HF

A

AFib, Atrial flutter, inadequate therapy

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10
Q

Which medication classes are negative inotropes?

A

Antiarrhyhmics, BB, CCB, Itraconazole

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11
Q

What is asymptomatic rEF

A

No HF symptoms w/ EF<40%

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12
Q

What is HFrEF

A

HF symptoms with EF<40%

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13
Q

Should a patient withhold fluid if they are fluid overloaded?

A

Nope

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14
Q

Regular exercise (walking and cycling) should be ______ in all patients with stable HF. The need for cardiac rehab should be ____ in each patient.

A

Encouraged; assessed

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15
Q

Dynamic exercise (walking, biking, etc.) to increase HR to ____% of maximum for 20-60 minutes ____ times/week.

A

60-80%
3-5 times/week

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16
Q

How many grams of sodium should a HF patient consume a day?

A

2-3 grams

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17
Q

Why would a patient have a fluid intake restriction to <2 L/day?

A

-Hyponatremia (<130 mEq/L)
-If tx with diuretics is difficult in maintaining fluid volume

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18
Q

General measures for pts with HF

A

-Weight monitoring (and reduction) if necessary
-Non-drug and drug tx; sx of worsening HF
-Smoking cessation
-Immunizations
-Mx and replace electrolytes (esp K and Mg)
-Appropriate thyroid disease management
-Herbal products and nutritional supplements?

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19
Q

Which medication classes decrease intravascular volume?

A

Diuretics and SGLT2-i

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20
Q

Which medications increase myocardial contractility?

A

Positive inotropes

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21
Q

Which medications decrease ventricular afterload?

A

ACE-i, vasodilators, SGLT2-i

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22
Q

Which medications are a neurohormonal blockade?

A

ARNIs, BB, ACE-i, ARB, MRAs, SGLT2-i

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23
Q

Med class for Stage A HF

A

ACEi/ARB

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24
Q

Med class for Stage B HF

A

ACEi/ARB + BB

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25
Q

What stage would a previous MI or asymptomatic rEF be in?

A

Stage B

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26
Q

What stage is rEF with symptoms?

A

Stage C

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27
Q

5 therapies used as a basis for stage C HF

A

ACEi/ARB/ARNI
BB
SGLT2-i
AA
Loop diuretic

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28
Q

If there is a black patient who is persistently symptomatic on the tx for stage C, what should be used?

A

ISDN/Hydralazine

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29
Q

If a patient is intolerant to ACEi/ARB/ARNI, what should be used?

A

ISDN/Hydralazine

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30
Q

If a patient is persistently symptomatic on GDMT, what should be used?

A

Digoxin

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31
Q

Diuretics reduce hospitalizations. Do they have an impact of mortality or natural progression of HF?

A

Nope

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32
Q

Should patients who do NOT have symptoms of volume overload receive a diuretic? Why or why not?

A

NO; diuretics may cause electrolyte imbalance. They decrease blood volume which activates SNS and further perpetuates HF

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33
Q

Short-term diuretic benefits

A

Reduce fluid retention via decreased edema, pulmonary congestion and JVD by reducing preload and cardiac filling pressure

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34
Q

Long term benefits of diuretics

A

Reduces daily symptoms and improves the ability to exercise

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35
Q

MOA of diuretics

A

Increase Na+ and H2O excretion by reducing sodium reabsorption at a variety of sites in the nephron—>must get to their site of action to elicit a pharmacological response

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36
Q

Which diuretic classes are the most potent?

A

Loop and thiazide

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37
Q

Describe sequential nephron blockade

A

Block loop and DCT with diuretics

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38
Q

With prolonged loop diuretic tx, the cells in the DCT ___ (increase/decrease) their ability to extract sodium and water.

A

Increase (able to retain these well)

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39
Q

Loop diuretics block the absorption of which electrolytes?

A

Na and Cl

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40
Q

IV equivalent doses F, B, T, E

A

F 40 mg = B 1 mg=T 20 mg=E 50 mg

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41
Q

Who would benefit most from thiazide diuretics?

A

Pts with mild HF and small amount of fluid retention

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42
Q

When would a thiazide be added on to a loop diuretic?

A

In a patient who becomes resistant to single-drug tx

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43
Q

Adverse effects of loop and thiazide diuretics (fill in the blank with increase or decrease)
____ Mg
____K
____renal function
____Na
____Uric acid
____Ca

A

decrease
decrease
decrease
decrease
increase
increase or decrease

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44
Q

Numerous studies suggest that ACEi…

A

-Reduce symptoms
-Improve NYHA
-Improve clinical status
-Decrease hospitalizations
-Improve exercise tolerance
-Improve QOL

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45
Q

ACEi equivalent dosages

A

20 mg/d enalapril=
150 mg/d captopril=
20 mg/d lisinopril

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46
Q

If an ACEi is used and CrCl<30 ml/min, how much of the target dose should be used?

A

Half (1/2)

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47
Q

Why does the left ventricle have 2 division branches?

A

It has a larger muscle mass because it pumps against a higher pressure

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48
Q

How do open spaces in the left atrium become depolarized?

A

Each cell depolarizes the next cell and it spreads like a wave

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49
Q

(True/False) Arrhythmias will show up in ANY lead

A

True

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50
Q

(True/False) A 12-lead ECG is needed to detect an MI because it will not show up on all leads.

A

True

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51
Q

Faster heart rate = ___ (bigger/smaller) QT interval

A

Smaller

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52
Q

What is Torsades de Pointes?

A

Ventricular repolarization (QT) interval is too long

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53
Q

At what QT interval do we get worried because it is too long?

A

> 500 ms = >5 s

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54
Q

Drugs that may cause Torsades de Pointes

A

Antiarrhythmic agents
Antimicrobials
Antidepressants
Antipsychotics
Anticancer
Opioids

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55
Q

Which patients would we want to keep in the hospital when starting treatment on a QTc prolongating agent?

A

> 65 y/o
HFrEF or HFpEF
Electrolyte abnormality

56
Q

Main problem in sinus bradycardia

A

HR too slow (<60 bpm)

57
Q

Is there re-entry in sinus bradycardia?

A

NO

58
Q

Where is the problem in sinus bradycardia?

A

Sinus node

59
Q

Drugs that may cause sinus bradycardia

A

Digoxin
BB
CCB (non-DHP)
Amiodarone
Dronedarone
Ivabradine

60
Q

Symptoms of sinus bradycardia

A

Hypotension
Dizziness
Syncope

61
Q

Which patients should be treated for sinus bradycardia?

A

ONLY symptomatic patients

62
Q

First-line option for symptomatic sinus bradycardia

A

Atropine 0.5-1 mg IV (repeat q5min; max dose 3 mg)

63
Q

Options in sinus bradycardia if pt is unresponsive to atropine

A

Transcutaneous pacing
Dopamine
Epinephrine
Isoproterenol

64
Q

ADR of atropine

A

Tachycardia
Urinary retention
Blurred vision
Dry mouth
Mydriasis (dilated pupils)

65
Q

Medications for patients with symptomatic sinus bradycardia after heart transplant or spinal cord injury

A

Aminophylline
Theophylline

66
Q

Most common arrhythmia

A

AFib

67
Q

Issue on ECG for AFib

A

-Atrial activity is chaotic and disorganized
-Ventricular rate: 120-180 bpm
-Rhythm is irregularly irregular
-P waves are absent

68
Q

AFib
-Is there a P wave in front of QRS?

A

No

69
Q

AFib
-Is there a QRS after every P wave?

A

No; there are no p waves

70
Q

AFib
-What is the interval between R waves?

A

Irregularly irregular (No distinct pattern)

71
Q

BB for ventricular rate control in AFib

A

Esmolol, Propranolol, Metoprolol tartrate, Metoprolol succinate

72
Q

Starting dose of carvedilol in HF

A

3.125 mg BID x 2 weeks

73
Q

Starting dose of coreg CR

A

10 mg QD x 2 weeks

74
Q

Starting dose of metoprolol XL in HF

A

12.5-25 mg QD

75
Q

Dose conversion for switching from IR–>ER carvedilol

A

3.125 BID –10 QD
6.25 BID – 20 QD
12.5 BID – 40 QD
25 BID – 80 QD

76
Q

Meds used for tx of HFpEF

A

Entresto
Empagliflozin
Dapagliflozin

77
Q

Which channels should we avoid blocking in the heart?

A

hERG because that channel is important for repolarization

78
Q

Most drugs known to precipitate torsades de pointes should be avoided in patients with diagnosed ____

A

Congenital LQTS
-Genetic mutations (KCNQ1, KCNH2, SCN5A) cause long QT syndrome

79
Q

Can a patient with HFrEF be on entresto?

A

NO! It is contraindicated

80
Q

BB used in HF

A

Carvedilol
Metoprolol XL
Bisoprolol (not in US)

81
Q

What should you ensure before starting a HF patient on a BB?

A

That they are stable and euvolemic (no marked signs of fluid retention)

82
Q

BB monitoring

A

BP
HR
Edema/fluid retention (intensify diuretic if needed)
Fatigue/weakness

83
Q

Dosing of SGLT2 inhibitors in HF

A

Empagliflozin and dapagliflozin 10 mg PO QD

84
Q

eGFR to use dapagliflozin

A

Greater than or equal to 30

85
Q

eGFR to use empagliflozin

A

Greater than or equal to 20

86
Q

MOA of Digoxin

A

Inhibits Na+/K+ ATPase altering excitation-contraction-coupling

87
Q

Goal serum dig concentration

A

0.5-0.9 ng/mL

88
Q

Usual dosing range for Dig

A

0.125-0.25 mg QD

89
Q

Main ADR with Digoxin

A

Visual disturbances: halos, photophobia, altered color perception

90
Q

Name of soluble guanylate cyclase stimulator that decreases CV death and hospitalizations

A

Vericiguat

91
Q

Place of omega-3 polyunsaturated fatty acids in HF

A

As an ADJUNCT

92
Q

Place of antiplatelets in HF

A

Long-term tx with ASA is recommended for pts with HF AND IHD/CAD/ASCVD

93
Q

Should non-DHP CCB be used routinely in HF?

A

NO!

94
Q

Should DHP CCB be used routinely in HF?

A

Only for managing angina/HTN if not effectively managed with HF tx

95
Q

Lab assessments used to diagnose acute HF

A

Routine testing of Cr and K; BNP and NTproBNP - BNP>400 is closely associated with acute HF

96
Q

Hemodynamically unstable criteria

A

SBP<90 mmHg
HR>150 bpm
Lost consciousness
Ischemic chest pain

97
Q

It is expected that SC.r can increase as much as __% after initiating/increasing a SGLT2i

A

20

98
Q

Should a BB be stopped for a patient experiencing acute HF?

A

NO! –consider holding IF dobutamine is needed or the patient is hemodynamically unstable

99
Q

Should Dig be stopped in a patient experiencing acute HF?

A

NO! continue at the same dose to achieve serum dig concentration 0.5-0.9 ng/mL.

100
Q

Which 4 drug classes are beneficial in managing decompensation episodes?

A

Vasopressors
Vasodilators
Diuretics
Inotropes

101
Q

Hospitalized patients for acute HF should always be given ___ (IV/PO) equal to or exceed chronic daily dose and given as intermittent bolus.

A

IV

102
Q

If there is resistance to a diuretic in hospitalized patients, what should be done?

A

Na+ restriction (1.5 g/d)
H2O restriction (<2L)
Increase dose, rather than frequency, to ceiling
Combo tx (thiazides&loop)

103
Q

Ceiling effect dosing for IV furosemide

A

160-200 mg

104
Q

In which situations would a vasodilator be used in acute HF?

A

wet; stage 2 and 4

105
Q

What is the venodilator of choice?

A

NTG

106
Q

Arterial vasodilators are useful in patients with ___

A

Elevated SVR

107
Q

Pts with symptomatic hypotension ___ (should/should not) receive vasodilators

A

Should not

108
Q

Which classes are positive inotropes?

A

Beta agonists
PDE-3 inhibitors

109
Q

How long should a positive inotrope be used for?

A

72-96h or less

110
Q

When is milrinone preferred over dobutamine?

A

If SVR is high or BB use

111
Q

What sodium channel is only expressed in the heart?

A

Nav1.5

112
Q

Requirements for re-entry arrhythmia

A

-Multiple parallel pathways
-Unidirectional block
-Conduction time greater than effective refractory period (ERP)

113
Q

Does lidocaine help with ventricular arrhythmias, atrial arrhythmias, or both?

A

Ventricular

114
Q

Arrhythmias will show up in ___ (any/one) lead

A

Any

115
Q

MI will show up in ___ (any/one) lead

A

One; so need to use a 12-lead ECG

116
Q

Questions to ask when looking at an ECG

A
  1. Is there a P-wave in front of every QRS complex?
  2. Is there a QRS complex after every P wave?
  3. Is the interval between R waves all similar?
  4. What is the rate? (hint: every 5 bigger blocks=1 sec. In class, there are 6s intervals, so you would count the number of R waves and multiply by 10 to get bpm)
117
Q

At QTc interval length is there increased risk of Torsades de Pointes?

A

Greater than or equal to 500 ms (5 s)

118
Q

Sx of sinus bradycardia

A

Hypotension
Dizziness
Syncope

119
Q

Tx of sinus bradycardia

A

Atropine
-If unresponsive to atropine, use transcutaneous pacing, dopamine, epinephrine, or isoproterenol

120
Q

Tx of sinus bradycardia after heart transplant or spinal cord injury

A

Aminophylline
Theophylline

121
Q

Long-term tx of sinus bradycardia

A

Permanent pacemaker
-If not feasible, use theophylline

122
Q

(T/F) AFib medications should be given to patients with Stage 4 AFib.

A

False; this is permanent AFib and patients will NEVER be in sinus rhythm again

123
Q

What is the main cause of AFib?

A

Left atrial hypertrophy

124
Q

Etiologies of reversible AFib

A

Hyperthyroidism
Thoracic surgery (CABG, lung resection, esophagectomy, valve replacement surgery, sepsis)

125
Q

Where does blood normally pool in AFib?

A

Left atrial appendage; gets sucked into left ventricle and out aorta which causes a stroke

126
Q

Oral anticoagulants are recommended for AFib patients with what CHADsVASc score?

A

1 in men
2 in women

127
Q

In AFib, DOACs are preferred over warfarin except for patients with…

A

-Mechanical heart valve
-AF associated with heart valve disease (mitral valve stenosis)
-Warfarin or apixaban preferred if end-stage CKD (CrCl<15 mL/min) or on hemodialysis.

128
Q

Dofetilide dose for AFib

A

CrCl>60 : 500 mcg PO BID
CrCl 40-60: 250 mcg PO BID
CrCl 20-39: 125 mcg PO BID
CrCl<20: C/I

129
Q

Sx unique to supraventricular tachycardia

A

“Neck pounding” – blood flowing up to head

130
Q

Does SVT lead to a stroke?

A

NO; atria are still contracting so no blood is pooling

131
Q

Is there increased risk of HF or dementia with SVT?

A

Not if it is well managed

132
Q

MOA of premature ventricular complexes

A

Increased automaticity of ventricular muscle cells/Purkinje fibers

133
Q

Sx of PVC

A

Usually asymptomatic
Frequent/repetitive PVCs can result in palpitations, dizziness, light-headedness

134
Q

Most common etiology for ventricular tachycardia

A

MI

135
Q

Which drugs are not used with a history of prior MI

A

Flecainide
Propafenone

Therapeutics P2 Winter Semester (29 decks)

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