Flashcards in 2Pharm I Deck (254):
Rank diuretics from most to least potent:
Carbonic anhydrase inhibitors (very mild)
What is the most common cardiovascular disease whose prevalence increases with age?
Individuals at 55 years old with NORMAL BP have a ___% lifetime risk for developing hypertension
Hypertension contributes to what 2 categories of disease?
Coronary artery disease
Cerebral artery disease
*heart and brain
What are 3 categories of hypertension?
Essential (idiopathic - 90%)
Malignant (5%, retinal/renal damage)
BP intervention LESS THAN 60 yrs:
BP intervention OVER 60:
AHA/ACC recommend lifestyle changes if Systolic is what range?
What are the 3 basic ways to reduce overall blood pressure?
Reduce peripheral resistance
Reduce cardiac output
Reduce blood volume
How do most diuretics work?
Block Na+ reabsorption
(Which then blocks water)
In the US _____ are the first line of drugs in hypertension treatment
What was the first class of diuretics (no longer used b/c of toxicity)?
What is the first choice, and most commonly prescribed class of diuretic?
What do Thiazides block in the kidney?
Blocks Na+ reabsorption in Proximal and Distal tubules
Carbonic anhydrase (this decreases H+ availability for exchange with Na+)
With Thiazides, what is the problem in losing Na+ in the distal/proximal tubules?
K+ is also lost (hypokalemia)
When taking Thiazides, if sodium intake increases, ________ is exacerbated.
Why are a lot of Diabetics not on Thiazides?
Hyperglycemia is side effect
Hypokalemia, Hyponatremia, Hypomagnesaemia, loss of carbonate, hyperuricemia, Hyperglycemia, elevated cholesterol, triglycerides, weakness, no boner.
What am I?
According to lectures, 2 thiazide drugs we need to know:
What is the most powerful class of diuretic?
3 effects of Loop Diuretics
Major volume loss
Electrolyte imbalance (Na+ and K+ loss)
Loop diuretics block the _______ symporter
Hyponatremia, hypokalemia, hyperglycemia, hypocalcemia, hyperuricemia, NEPHROTOXICITY, ototoxiciy, GI distress, CNS effect
What am I?
From lecture, 2 loop diuretics we need to know:
Ethacrynic acid (Edacrin)
What 2 classes of drugs cause the Lichenoid Drug Rxn?
Thiazide and Loop diuretics
What class of diuretic competes with aldosterone?
Where does that competition take place?
Potassium sparing diuretics
Distal renal tubules
Potassium sparing diuretics save K+ and ____.
They increase ___ and ____ excretion
Na+ and Cl-
2 potassium sparing diuretics:
Adverse effects of Potassium sparing diuretics: Hyperkalemia, and what 4 other things?
Gynecomastia in males
Breast tenderness in young women
Decreased libido in males
What mild diuretic is now used mostly for glaucoma, and as an adjunctive therapy for congestive heart failure?
Carbonic anhydrase inhibitors
One carbonic anhydrase inhibitor we need to know:
What drug is used in emergencies to decrease blood volume?
Which to we need to know?
What diuretic is rarely used - but treats hypochloremic stated and metabolic alkalosis in the ER?
*produced a lot of chloride
What preparation do we need to know?
Caffeine is a _______ that inhibits tubular reabsorption of Na+ by inhibiting _______ in the ______
Most diuretics cause ________ and many cause ______
Use of NSAIDS for greater than 3 weeks can decrease diuretic effectiveness
Many pts take potassium supplements to counteract the K+ loss from diuretics but this is contraindicated in case of severe renal impairment
Potassium supplements (salts) are contraindicated with what?
5 classes of drugs used to lower BP:
Sympathetic blockers (alpha, beta)
Angiotensis II receptor blockers (ARB's)
Calcium channel blockers (CCB's)
Beta blockers decrease cardiac output even though constrict vessels via beta2
Beta blockers decrease _______ secretion
Cardioselective beta blockers block ______ only
A beta2 agonist is used for ________
Beta1 receptors are in the _____
Beta2 receptors are in the ______
2 cardioselective Beta Blockers (blocks Beta1 only):
2 noncardioselective Beta Blockers (blocks beta1 and beta2):
Metoprolol (Lopressor, Toprol)
What class of drugs has side effects consistent with over-activity of the parasympathetic nervous system?
*GI upset, xerostomia, orthostatic hypotension, sexual dysfunction, etc
4 contraindications to beta blockers:
Congestive heart failure
What receptors are located postsynaptically and produce vasoconstriction, increasing peripheral resistance when stimulated?
Alpha1 blockers produce ________
Alpha1 blockers have big effects on cardiac output and renal blood flow
Alpha1 blockers are more effective when used with diuretics and/or beta blockers
Other than decreasing peripheral resistance, what is another effect of Alpha1 blockers?
Decrease urinary resistance
*benign prostatic hypertrophy
Alpha1 blocker =
3 adverse effects of Alpha1 blockers:
3 Alpha1 Receptor blockers:
Women shouldn't handle Flowmax, and its chief side effect in men is...
severe orthostatic hypotension
ACE inhibitors - inhibit Angiotensin Converting Enzyme how?
*prevents angiotensin I to angiotensin II conversion
Explain ACE Inhibitor pathway/mechanism:
blocks Angiotensin I - Angiotensin II
Low Angiotensin II increases Renin
Renin reduces Aldosterone secretion
Normally aldosterone does what in the kidneys?
retains Na+ and water
*so ACE Inhibitors will decrease Na/Water retention (pee free water)
What are the 2 primary beneficial effects of ACE Inhibitors?
Decrease Blood Volume
What is the most widely prescribed ACE Inhibitor in the US?
lisinopril (Prinivil, Zestril)
2 ACE Inhibitors:
lisinopril (Prinivil, Zestril)
What are 2 side effects of ACE Inhibitors?
Chronic Dry Cough
Angioneurotic edema with first dose
What causes the Chronic Dry Cough associated with ACE Inhibitors?
Increased Bradykinin release in bronchial tree
Angiotensin Receptor Blockers, aka...
Angiotensin II Receptor Blockers
ARB's block vasoconstrictor and aldosterone-secreting effects of Angiotensin II
increased Renin, vasodilation, decreased Na/Water retention, and reduction in BP
What is often preferred over ACE inhibitors b/c the action is at the receptor and there are fewer side effects
What may decrease the effectiveness of ARB's?
CNS, Upper respiratory infections, GI effects, cramps, angioedema, teratogenicity - what am I?
2 common ARB's:
What is the new, expensive class of drugs for Hypertension?
*binds to Renin, decreasing levels of Angiotensin I - II - Aldosterone
Calcium Channel Blockers prevent Ca++ from entering...
(select voltage-sensitive areas)
Calcium Channel Blockers relax coronary vascular smooth muscle and cause coronary vasodilation, increasing myocardial oxygen delivery
Calcium Channel Blockers are used for what 3 CV purposes?
Calcium's role in muscle contraction - it binds ______
which turns on ______
which phospholrylates ________
so that it can better bind ______ and produce muscle contraction
3 Calcium Channel blockers:
nifedipine (Adalat, Procardia)
verapamil (Calan) has major effects on the ______
nifedipine (Procardia) has more of an effect on _______
What Calcium channel blocker is (most) associated with gingival hyperplasia?
What % have the responder gene that results in hyperplasia from this drug?
Good oral hygiene will limit the extent and severity of a lesion due to a Calcium Channel Blocker
Why are Centrally Acting Antihypertensives used less often?
clonidine (Catapres) is a centrally acting antihypertensive that is a ______ Agonist, that activates _____ neuron, which decreases _______
Xerostomia, Parotid gland swelling/pain, Dysgeusia:
*Centrally acting antihypertensive
What class of drug blocks granular uptake and storage of norepinephrine (decreasing sympathetic activity due to lack of neurotransmitter supply)
Catecholamine Release Blockers
2 Catecholamine Release Blockers:
Antihypertensive meds react with general anesthetics and CNS depressants by enhancing _______
Antihypertensive meds have a _____ response to vasoconstricting drugs
*this why use epi w/ caution, take BP prior to locals
OTC sympathomimetics (like cold capsules) counteract antihypertensive therapy
Use of NSAIDS longer than _____ may decrease effectiveness of diuretics, beta blockers, and ACE inhibitors
Nicotine constricts blood vessels and increases BP
With Antihypertensive meds, prevent sudden changes in _____ with pts.
impregnated gingival retraction cord (vasopressors) is ______
Rebound hypertension develops when agents withdrawn, which happens often in men b/c ____ is severe
Diuretics make you _____ potassium
ACE Inhibitors and ARB's make you ______ potassium
According to published guidelines, what 4 factors should be addressed when managing CV disease?
*HTN, obesity, and cholesterol...
The Risk Assessment portion of managing DV disease includes what 3 tiers?
Drugs for under 60 140/90, over 60 150/90
Drugs for 160/100 + BP
The primary indication for diuretics is _______
(or life threatening edema (loop diuretics) or renal failure (osmotic diuretic - urea))
All Hypertension drugs have what 4 side effects?
Sexual impotence/libido in men
Fake lichen planus
Antihypertensive meds have what drug interactions that are significant in dentistry?
General anesthetics/CNS depressants
Prolonged analgesics, sedatives, and tranquilizers (CNS)
Use of NSAIDS longer than ____ weeks may decrease effectiveness of some diuretics, beta blockers, and ACEi
3 precautions to take during dental procedures when treating Hypertensive pts:
Fainters/Fallers (orthostatic hypotension)
NSAID popping - diuretics don't work as well
What is the term for pain when the heart becomes Anoxic?
Angina is an ischemic heart disease, often involving the coronary arteries, and is greater if there is Hx of MI
Angina can be brought on by triggers, but absent that the pain occurs most often when?
Typical angina (exertional) is caused by the _____ arteries causing ischemia
If the demand exceeds available oxygen, then necrosis occurs =
Typical angina is ______
Atypical angina (variant), aka....
Normally there are Beta2 receptors in coronary arteries, in Prinzmetal's angina there are more _____ receptors
*causes vasoconstriction w/ epinephrine
Variant (Prinzmetal's) angina shows an elevated ______ segment on an EKG that is not present in normal angina
Nitrites and Nitrates work on endothelial cells to produce______ that cause ______ via _______
relaxation of all smooth muscle
Nitrates/NItrites produce vasodilation and increase venous return to the heart
*decrease venous return
Why do NItrates/Nitrites cause headache?
vasodilation is intense and fast
Other than headache, what are 5 side effects of Nitrites/Nitrates?
Postural hypotension and syncope
tachycardia/increased peripheral resistance (due to sympathetic reflex)
decrease oxygen carrying in large doses
There is rapid onset to Nitrites/Nitrates and also rapid tolerance, which is why there is usually a 12 hrs on 12 hrs off schedule
What is the fastest onset Nitrite/Nitrate preparation?
Amyl nitrate snorted
Nitroglycerin is considered a "rescue" drug and is often in emergency kits
Why is nitroglycerine stored in a small brown vial?
Nitroglycerin is very caustic and leaves a sublingual burn
What is the longer duration option for nitroglycerin?
Patch (up to 12 hours)
Two Nitrites/Nitrates we need to know:
Isosorbide dinitrate (Isordil)
Isosorbide mononitrate (Imdur)
Beta blockers decrease cardiac ______, which decreases oxygen demand and decreases Angina
Beta blockers have negative chronotropic and inotropic effects
Pts with a history of MI will always be taking_______
Beta blockers cause vasodilation
Beta blockers are contraindicated for some forms of congestive heart failure and ________
Why are beta blockers often combined with diuretics?
Prevent sodium retention
Cardioselective agents are preferred for insulin-dependent diabetics and _______
What does epinephrine do if the pt is taking a beta blocker?
Won't stimulate the heart
Will vasoconstrict Alpha1 receptors
Non-selective Beta blockers enhance what response to epinephrine?
What does this response entail? (2 things)
hypertension, reflex bradycardia
It's ok to use epi with cardioselective beta blockers
Epinephrine dilates large vessels/muscles
Epinepherine constricts small vessels/muscles
If a pt is on heart meds, it's most likely a Beta blocker - what 2 things do you ask?
Are you a diabetic?
Inotropic effect of Calcium Channel blockers:
Some Ca++ channel blockers cause smooth muscle relaxation (vasodilation) where?
2 Calcium channel blockers that have a negative inotropic effect:
Ca++ channel blocker that vasodilates coronary arteries:
Calcium channel blocker that vasodilates peripherally:
What 2 things to limit in visit from pt on anti-anginals?
Extent of procedures/visit
If a pt is on an Antianginal, consider local aneshtetics without _____
What are the practical side effects of antiarhythmic drugs?
Most Antiarrhythmics prolong _______
others affect the ______ system
Cardiac arrhythmias produce abnormalities of the heartbeat and all denote something wrong with the _________ system
They are caused by disease, cardiac injury, or drugs
Arrhythmias result from abnormal impulse ______, abnormal impulse ______, or a combination of the two
The type of arrhythmia that begins at the nodal level can be Supraventricular, Vetricular, or ______
Ectopic foci (preempt SA/AV node)
When the His Purkinje system is cut in half and atria/ventricles work independently it is know as a....
Antiarrhythmic medications ____ parts of the heart that are beating abnormally
What are 3 pharmacologic effect of antiarrhythmic medications?
Change slope of depolarization
Raise threshold for depolarization
Alter conduction velocity
Antiarrhythmic meds work on one or more of the _____ transmembrane phases of the cardiac cycle
What are the 3 areas of the heart that have pacemaker activity?
SA node (main)
The spontaneous opening and closing of K+ channels is what drives _______
Where is Effective Refractory Period longer - pacemaker areas or myocardial cells?
*different arrhythmias require ERP be longer/shorter
In what 2 situations would you want to induce an arrhythmia with epi, isoproterenol (beta agonist) or hypokalemic diuretics?
Ventricular arrhythmias due to AV node block
Temporary heart block until pacemaker insertion
4 contraindications for Antiarrhythmics
Complete AV heart block
Congestive heart failure
Known hypersensitivity to drug
A partial heart block is when the _______ is not in sync
Indications for antiarrhythmic drugs are arrhythmia, flutters, fibrillations, tachycardias, ectopic arrhythmia, or digoxin induced arrhythmia
What are 4 Contraindications to Antiarrhythmics?
Complete AV block
Known hypersensitivity to drug
What are the 4 classes of Antiarrhythmics?
!a, 1b, 1c
Class Ia Antiarrhythmics:
(3 drugs, 3 actions)
1a (medium) = quinidine, (***procainamide, Pronestryl), (**disopyramide, Norpace)
blocks Na conduction
Class Ib Antiarrhythmics:
(1 drug, 2 actions)
FAST = lidocaine
blocks Na conduction
Decrease relative refractory period
Class Ic Antiarrhythmics:
(2 drugs, 2 actions)
***life threatening ventricular arrhythmias only
Slow = flecainide (Tambocor), propafenone (Rhythmol)
blocks Na conduction
Quinidine can lead to what clinical manifestation?
*from cinchona tree
Class II Antiarrhythmics:
(1 drug, 1 class)
Class III Antiarrhythmics:
(3 drugs, mechanism)
amiodarone (Cordarone, Pacerone), bretyllium, sotalol
K+ channel blockers
***sotalol (Betapace) is nonselective beta crossover
Class IV Antiarrhthmics:
(5 drug, mechanism)
nifedipine, verapamil, diltiazem, adenosine, Digoxin (cardiac glycoside)
Calcium channel blockers
Describe cinchonism from quinidine:
nausea, vomiting, headache, TINNITIS
deafness, vertigo, visuals
What is the site of action of cinchonism (quinidine)?
If a patient is taking antiarrhythmics, what do we NOT give them?
What is ok to give them?
Atropine (may cause tachycardia)
***not the same lidocaine as anti-arrhythmic med
Prinzmetal angina is seen in ______ men most commonly
Nitrites/Nitrates are _______ vasodilators
CCB's block calcium channels so that calcium trickles more slowly, decreasing the rate and strength of contractions
What two side effects of taking NItrites/Nitrates is accentuated with alcohol?
What is the fastest acting Nitrite/Nitrate and how long does it last?
What is the second fastest?
Vaporole - (snort) onset 1 minute, lasts 3-15 minutes
Nitroglycerin - onset 1-3 minutes, half life 10 minutes
A Transdermal pouch can last up to ___hrs
What are the 2 long acting nitrates?
(other than transdermal pouch)
Isosorbide dinitrate (4-6 hrs)
Isosorbide mononitrate (1/2 life 4 hrs)
procainamide (Pronestyl) is a class Ia antiarrhythmic that has reversible _____ like syndrome in ___% of pts
Class Ib antiarrhythmics (lidocaine, phenytoin, mexiletine, tocainide) are are used to treat ______ arrhythmias
4 class Ib antiarrhythmics:
amiodarone (Cordarone, Pacerone) contains iodine causing blue skin and may cause _____ disease
*Class III antiarrhythmic
Digoxin is a Class IV antiarrhythmic that increases _____ and ______
atropine and isoproteronol treat Bradyarrhythmias
Potassium and Magnesium treat Ectopic Pacemakers
The vagal blocking effects of anntiarrhythmic drugs (anticholinergics like atropine) can act synergistically to lead to tachycardia
Congestive heart failure is the inability of the heart to provide the necessary ______
What do drugs target in CHF?
Reflex sympathetic output
Right sided heart failure will manifest in fatigue and edema while left side will be more acute and result in pulmonary congestion
With CHF you want to slow the heart and increase the contractile force
What is the drug of choice in treatment of CHF?
digoxin (Digitek, Lanoxin)
aka Cardiac Glycosides
Digoxin inhibits __________, resulting in more ________ inside the cell.
This has a positive ______ effect
Digoxin has a positive inotropic effect and a negative ______ effect due to directly suppressing ______
Digoxin has 3 mechanisms of action: positive inotropic effect through increased Ca, negative chronotropic effect by suppressing the AV node, and what else?
*pee excessively, decreasing venous return
The increased vagal output caused by cardiac glycosides (digoxin) can be blockes by ________
Digoxin has a low therapeutic index and can lead to uncoordinated arrhythmias
Few drugs cause sensory side effects - which causes a green/yellowish aura?
azole antifungals and macrolides like clindamycin and azythromycin could increase digoxin in the system and increase risk for toxicity
What posture would you not want to put a pt with CHF in?
don't recline fully - hard to breathe
It's ok to do general anesthesia in a dental setting with a pt with CHF
What are 3 preparations of Bile Acid Sequestrants?
What decreases liver triacylglycerol synthesis necessary for VLDL production?
(decreases plasma LDL's - used for MILDLY elevated cholesterol)
Nicotinic Acid (Niacin)
What is the side effect on Niacin?
What lowers plasma triglycerides and increases HDL by inhibiting cholesterol synthesis in the liver?
What are 3 Fibric Acids?
The most popular/effective cholesterol inhibitors:
HMG coA reductase inhibitors
HMG CoA reductase is the _____ step in the synthesis of ______
When can't you take a statin?
***HMG CoA reductase inhibitors alter liver function
What is a side effect of statins?
(HMG CoA reductase inhibitors)
****rhabdomyolysis - disintegration of muscle tissue
What 2 types of drugs promote myalgias in pts taking statins?
Macrolide antibiotics (erythromycin)
2 statins are combined with a drug that decreases intestinal absorption (only drug in class), what is the drug, and what are the combos?
Vytorin - simvastatin + ezetimibe
Liptruzet - atorvastatin + ezetimibe
The therapeutic dose for Digoxin is _____% of the toxic dose, which is why every pt needs to be _______
Cardiac glycosides are used for what 3 conditions?
Cardiac glycosides (digoxin) can cause bradycardia/arrhythmia, _____ effects from stimulation of chemoreceptor zones and vagal nucleus (parasymphathetic effects)
*what other parasympathetic effects?
*nausea, vomiting, increased saliation, anorexia, diarrhea, ab pain
Other than a Green/Yellow aura, what are 3 other CNS effects of Digoxin?
Headache - edema
Retraction cords and local anesthetics often have ________, which is contraindicated for pts with CHF
General anesthesia is dangerous for pts with CHF
Statins should be used in pts with CV disease aged 40-75 and have a ______% or higher risk of having heart attack within 10 years
You can't raise HDL without exercise
Statins shouldn't be combined with additional cholesterol lowering drugs like niacin or fibrates
*don't reduce heart attack/stroke risk
deep vein thrombosis
What are 3 types of acute coronary syndromes caused by blood clots in coronary arteries?
Non-ST elevated MI (incomplete blockage)
ST elevated MI (complete blockage)
Stroke reduction benefits of antiplatelets improve when used in combo with aspirin
Aspirin causes _______ platelet aggregation
You should discontinue low dose aspirin therapy before dental treatment
*Stroke risk greater than bleeding
Discontinuing aspirin use Increases MI and adverse bleedings and has worse clinical outcomes than nonusers
Antiplatelet drugs used for short and long term stenting have ______ effects on platelets
4 antiplatelet drugs
ticlopidine (Ticlid) *canadian
Aspirin blocks _____, which blocks ______
clopidogrel prevents binding of ____ to collagen receptors thereby preventing platelet aggregation
What is used with aspirin and heparin to treat acute coronary syndromes?
fibrinogen receptor inhibitors
(platelet glycoprotein IIb/IIIa receptor antagonists)
3 platelet glycoprotein IIb/IIIa receptor antagonists (Fibrinogen Receptor Inhibitors)
Thienopyridines prevent the binding of _____ to collagen receptors which prevents platelet aggregation.
It requires ____ to form the clot
Percutaneous coronary intervention (stents) combined with antiplatelet therapy has numerous dental advisory guidelines, one being _____ risk of premature discontinuation.
Consult the cardiologist, and defer any procedure with significant bleeding risks until ______
thienopyridine therapy conclusion
After a DES is placed, wait ___ months for major intervention
__ months for normal stent
Leading up to a procedure the pt can go off Plavix, but must stay on ______
*restart Plavix right after procedure
**keep pt on 1 antiplatelet
Heparin inhibits _____ and ______
produces _____ anticoagulant effect
Factor Xa and IIa thrombin
Warfarin interferes with liver synthesis of ______
produced effect in _____ days
vitamin K dependent clotting factors
Warfarin inhibits what 4 vitamin K dependent clotting factors?
What 2 proteins?
2, 7, 9, 10
C and S
6 drugs that alter the efficacy of warfarin:
Any liver metabolism drug
Vita K (spinach)
Tylenol (enhances coagulation)
3 antagonists to Heparin and Warfarin:
NSAIDS cause _____ effects on platelets
Heparin can cause profound bleeding, what is the antidote?
Heparin and Warfarin can be overlapped 1-2 days
Warfarin has a mandatory blood test every 30 days b/c of low _____ indes
Many things throw off coumadin, _____ being one
There is no need to discontinue warfarin use prior to routine dental procedures even though it is associated with increased gingival bleeding and mouth ulcers
5 tests used to assess the effects of Heparin and Warfarin:
Bleeding time test
The International Normalized Ratio (INR) has a therapeutic range of ___ to ____
______ and warfarin significantly enhance anticoagulation
What causes the greatest number of drug interactions?
What is the direct Thrombin inhibitor?
*prodrug - converted in vivo to dabigatran
The advantages to dabigatron over warfarin is no monthly monitoring and less expensive
What is the antidote to dabigatran (Pradaxa)
Antithrombins drugs (not to be confused with Thrombin inhibitors) are _______ inhibitors
What are 3 Factor Xa inhibitors (antithrombins)
Hemorhage, no reversal agent, and loss of ____ function are the major risks to Factor Xa inhibitors (antithrombins)
When would Factor Xa inhibitors be used?
post op after total hip/knee
Factor Xa inhibitors stop coagulation by preventing _____ mediated effects, including cleavage of fibrinogen to fibrin, and activation of what 4 factors?
5, 8, 11, 13
2 thrombolytic clot busting drugs: