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2. Cardiovascular > 6.5 - 6.12 > Flashcards

6.5 - 6.12 Flashcards

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1
Q

HF - digoxin (cardiac glycoside): mechanism?

A

Inhibit Na+/K+ ATPase (bind to K+ site).

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2
Q

HF - digoxin (cardiac glycoside): effects in cell?

A

Increase [Na]i, therefore, decrease Ca2+ extrusion by (Ca2+/Na+ exchanger).
Increase Ca2+ in SR.
Increase Ca2+ release per AP.

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3
Q

HF - digoxin (cardiac glycoside): side effects?

A

Affects all excitable tissues (Na+/K+ ATPase distribution) - anorexia, nausea, diarrhoea, drowsiness, may cause ventricular dysrhythmias (but used for atrial dysrhythmias!).

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4
Q

HF - digoxin (cardiac glycoside): causes of increased toxicity?

A

If low K+ - less competition for Na+/K+ ATPase - more digoxin binding.
If high [Ca2+]e, decreased gradient for Ca2+ efflux - more Ca2+ in cell.
If renal impairment.

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5
Q

HF - digoxin (cardiac glycoside): use?

A

Generally short term use only i.e. symptomatic relief, but not long term use/management of cardiac failure.

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6
Q

HF - digoxin (cardiac glycoside): use?

A

Generally short term use only i.e. symptomatic relief, but not long term use/management of cardiac failure.

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7
Q

ACE inhibitors: side effects?

A 
o	First-dose hypotension – if dose incorrect (high) -> significant reduction in BP.
	Individuals respond differently to different doses -> titrate i.e. start from low dose and increase to find effective dose.
o	Dry cough.
o	Loss of taste.
o	Hyperkalaemia (+ thiazide diuretic).
o	Acute renal failure.
o	Itching, rash, angio-oedema.
o	Foetal malformations.
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8
Q

ACE inhibitors: contraindications?

A

o Bilateral renal stenosis.
o Angioneurotic oedema.
o Pregnancy

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9
Q

ACE inhibitors: contraindications?

A

o Bilateral renal stenosis.
o Angioneurotic oedema.
o Pregnancy

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10
Q

HF - beta-adrenoceptor antagonists: side effects?

A

o Hypotension, fatigue (cardiac and B2-mediated (B2 = vasodilatory, interfere with ability to redistribute blood flow)).
o Bronchoconstriction (B2 block – contraindicated in asthma).
 Do not use cardiac selective beta blockers either!
• Selectivity is relative -> if dose too high, may block B2 despite selectivity for B1!
o Cold extremities (A1-mediated reflex – contraindicated in peripheral vascular disease).
o May cause and/or mask signs of hypoglycaemia – contraindicated in diabetes.

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11
Q

HF - beta-adrenoceptor antagonists: contraindications?

A

Asthma
Peripheral vascular disease.
Diabetes

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12
Q

HF: drugs affecting preload?

A

Venodilators (nitrates e.g. GTN).
Diuretics (frusemide (loop diuretic), thiazide diuretics).
Aldosterone receptor antagonists (e.g. spironolactone, K+ sparing).
Aquaretics - vasopressin receptor antagonists.

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13
Q

HF drugs affecting afterload?

A

Arterial vasodilators - not used often due to reflex tachycardia.

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14
Q

HF: drugs affecting preload AND afterload?

A

ACE inhibitors.
AT1 antagonists (ARBs).
B-adrenoceptor antagonists.

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15
Q

HF: examples of B-adrenoceptor antagonists?

A

Metoprolol – B1 antagonist

Carvedilol – B1 and A1 antagonist – also causes vasodilation to reduce afterload.

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16
Q

HF: examples of B-adrenoceptor antagonists?

A

Metoprolol – B1 antagonist

Carvedilol – B1 and A1 antagonist – also causes vasodilation to reduce afterload.

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17
Q

Hypertrophy is an increase in ___ of cells.

A

Size

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18
Q

___ cells use hypertrophy.

A

Permanent cells

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19
Q

Hyperplasia is an increase in ___ of cells.

A

Number

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20
Q

___ cells use hyperplasia.

A

Labile or stable cells.

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21
Q

Metaplasia is a ___ change in which one adult cell type is replaced by another adult cell type.

A

Reversible

The new cell type can be protective against injury in new environment, or have no added benefit.

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22
Q

Stimulus for metaplasia is generally a ___

A

Altered environment

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23
Q

Hyperplasia and metaplasia are ___ division whereas neoplasia is ___ division.

A

Hyperplasia/metaplasia - controlled.

Neoplasia - uncontrolled/dysregulated.

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24
Q

In hyperplasia/metaplasia, gene ___ is altered, but in neoplasia there are gene ___

A

Hyperplasia/metaplasia - gene expression is changed.

Neoplasia - gene mutations!

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25
Hyperplasia/metaplasia is benign but neoplasia may be benign or ___
Malignant
26
Atrophy is a ___ in cell or organ size (opposite of hypertrophy)
Decrease
27
Atrophy is ___ unless accompanied by cell death and fibrosis
Reversible. | But cell death and fibrosis are irreversible!
28
Myocardial hypertrophy may be ___ or ___, and ___ or ___
Physiological or pathological, and concentric or eccentric.
29
Concentric hypertrophy is caused by increased ___
Pressure e.g. in valve stenosis or systemic hypertension.
30
In concentric hypertrophy, there is in increase in mean myocyte ___
Diameter
31
In eccentric hypertrophy, there is in increase in mean myocyte ___
Length
32
Eccentric hypertrophy is caused by increased ___
Volume e.g. in valve regurgitation, shunt/wall defect, cardiac failure.
33
Eccentric hypertrophy is caused by increased ___
Volume e.g. in valve regurgitation, shunt/wall defect, cardiac failure.
34
Normal LV thickness is ___ and normal RV thickness is ___
Normal LV less or = to 15 mm. Normal RV less or = to 5 mm. Important for diagnosis of concentric hypertrophy.
35
Normal heart weight in women is ___, and in men is ___
Women less than 400 g | Men less than 500 g
36
Normal heart weight in women is ___, and in men is ___
Women
37
Microscopic features of myocardial hypertrophy
Enlarged, rectangular (box-shaped) nuclei. Bi-nucleated myocytes. Increased connective tissue, collagen.
38
In right HF, blood pressure in ___ veins increases, leading to "___" liver - haemorrhage and necrosis in middle of lobules
Hepatic | Nutmeg
39
Acute rheumatic fever is due to infection by ___
Strep. pyogenes
40
Degenerative aortic valve involves ___ calcification
Dystrophic! Nodules of calcium and fibrosis in valves. Valves may be thickened or fused leaflets.
41
Myxomatous mitral valve
"Floppy" -> prolapse and regurgitation. Thickened bulging/ballooning valve. Inherited or related to connective tissue disease.
42
Congenital bicuspid aortic valve
Predisposed to degenerative calcific changes. | May cause stenosis or regurgitation.
43
Infective endocarditis
Vegetations - soft nodules (c.f. hard nodules of calcium) affected area looks disrupted, chewed/eaten, but rest of valve is normal.
44
Key outcomes of clinical trials: relative (2 outcomes) and absolute (2 outcomes) measures of intervention effect?
Relative: relative risks, hazard ratios. Absolute: absolute risk/rate reduction, number needed to treat. Also survival analysis.
45
To deal with confounding, use ___
Randomisation
46
To deal with information bias, use ___
Blinding
47
To deal with selection bias, use ___
Intention to treat analysis - assume that subjects remained in their allocated group, regardless of cross-overs.
48
Intention to treat analysis always ___-estimates the treatment effect
Under-estimates | Conservative
49
Intention to treat analysis always ___-estimates the treatment effect
Under-estimates | Conservative
50
Hazard is an ___ rate
Instantaneous | Measured in longitudinal studies with close follow up - adjusted as outcomes occur!
51
Survival analysis is a plot of ___/___ vs. ___
A plot of hazard or survival (1 - hazard), vs. time. | Note - survival = avoidance of event (not always death!).
52
Hazard RATIO is a ratio of hazard(___):hazard(___)
Ratio of hazard(intervention) : hazard(control).
53
Hazard ratio applies to the ___ period of follow up
Whole! | Like a weight average of all hazard across whole period of follow up.
54
If hazard ratio for CHD is 1.29 in a study comparing HRT vs. placebo, what is the interpretation?
Compared to placebo, combined HRT group had a 29% relative increase in likelihood of CHD over this period of follow up.
55
Clinical trials - most interventions reduce risk/rate of outcome. Measure reduction using ___
RR - RATIO of rates b/w intervention and control arms. | AR - DIFFERENCE of rates b/w intervention and control arms.
56
NNT is number needed to treat to prevent outcome in ___
One person!
57
NNT is calculated by 1 divided by ___
Absolute rate reduction. | I.e. inverse of absolute rate reduction = NNT.
58
When interventions increase risk/rate of outcome, NNT may be __
Negative
59
If NNT is negative, can use ___
NNH - i.e. number needed to harm. | Same as NNT but change to positive.
60
Definition of health by WHO
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” – Constitution of the World Health Organisation, 1948
61
Definition of health by WHO
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” – Constitution of the World Health Organisation, 1948
62
In countries where the income gap between rich and poor is ___, health and social problems are worse.
Bigger gap -> worse health and social problems.
63
Stages of epidemiological transition?
* Stage 1 – most of population = 65. | * Stage 4 – more people > 65 AND less people
64
Primary health care
"Essential health care" that is based on scientifically sound and socially acceptable methods and technology.
65
The acronym ___-___ is a list of techniques for selective primary health care.
``` GOBI-FFF • Growth monitoring • Oral rehydration solution • Breast feeding • Immunisation • Female education • Family planning/spacing • Food supplementation ```
66
K+ is reabsorbed in the ___ and is secreted in the ___
Reabsorption in proximal tubule. | Secretion in distal tubule and collecting ducts.
67
Most NaCl is reabsorbed in the ___
Proximal tubule (60-70% NaCl reabsorbed in proximal tubule. 20-30% NaCl reabsorbed (and water) in loop of Henle. 5-10% NaCl reabsorbed in distal tubule. Remaining NaCl reabsorbed in collecting duct.)
68
Most NaCl is reabsorbed in the ___
Proximal tubule (60-70% NaCl reabsorbed in proximal tubule. 20-30% NaCl reabsorbed (and water) in loop of Henle. 5-10% NaCl reabsorbed in distal tubule. Remaining NaCl reabsorbed in collecting duct.)
69
Main drugs that act on kidney are ___
Diuretics
70
4 classes of diuretics
Loop diuretics. Thiazide diuretics. Potassium-sparing diuretics. Osmotic diuretics.
71
Loop diuretics (e.g. frusemide) are the ___ powerful and act on the ___ of the Loop of Henle
Most powerful! -> Torrential urine flow. | Thick ascending limb of loop of Henle
72
Loop diuretics (e.g. frusemide) inhibit the ___/___/___ carrier into cells.
The Na+/K+/2Cl- carrier - reabsorbs all these ions together. | Reabsorption -> water to transfer due to hypertonic interstitium.
73
Loop diuretics - by inhibiting reabsorption of Na+/K+/2Cl- in ascending loop of Henle, there is more Na+ ___
Distally | Therefore, there is less reabsorption of water distally too! I.e. even more excretion of water.
74
Pharmacokinetics of loop diuretics
Well absorbed from gut (onset
75
Pharmacokinetics of loop diuretics
Well absorbed from gut (onset
76
Main adverse effect of loop diuretics
K+ loss from DISTAL TUBULE | So usually prescribed with K+ supplement or potassium-sparing diuretic
77
Thiazide diuretics are ___ powerful
Moderately, less effect than loop diuretics
78
There are ___ thiazides and thiazide-___ diuretics
True (e.g. bendrofluazide, hydrochlorothiazide) and thiazide-like (indapamide).
79
Main adverse effects of loop diuretics
K+ loss from DISTAL TUBULE, and metabolic alkalosis! Because of more Na+ distally, stimulates aldosterone-sensitive sodium pump to increase Na+ reabsorption in exchange of K+ and H+ which are excreted!!!
80
There are ___ thiazides and thiazide-___ diuretics
True (e.g. bendrofluazide, hydrochlorothiazide) and thiazide-like (indapamide).
81
Thiazide diuretics act on the ___ ___ ___ and this is why it has less effect than loop diuretics
Distal convoluted tubule. | Whereas loop diuretics act on more proximal areas!
82
Thiazide diuretics inhibit luminal ___/___ contransporter
Luminal Na+/Cl- cotransporter (reabsorbs Na+ and Cl- together).
83
Pharmacokinetics of thiazide diuretics
Orally active Excreted in urine - secreted to site of action! Slower onset and longer duration than loop diuretics.
84
Main adverse effects of thiazide diuretics
K+ loss from DISTAL TUBULE, and metabolic alkalosis! (Same as loop diuretics!) Also increased plasma uric acid -> gout.
85
K+-sparing diuretics have ___ diuretic effect, but are used in combination with K+ losing diuretics to prevent K+ loss.
Limited diuretic effects | But spares K+!
86
2 subclasses due to 2 different mechanisms of K+ sparing diuretics: ___ and ___/___
Spironolactone and triamterene/amiloride.
87
K+ sparing - spironolactone is a ___ receptor ___.
Aldosterone receptor antagonist
88
Aldosterone activates luminal ___ channels and stimulates the production of interstitial ___/___ pumps.
Activates luminal Na+ (reabsorb, into cell) channels | Increases production of interstitial Na+/K+ (sodium out of cell to interstitium, potassium into cell) pumps.
89
K+ sparing diuretics act on the ___ (most distal), this explains the limited effect of K+ sparing diuretics in water excretion.
Collecting tubules and ducts
90
Spironolactone reduces ___ of Na+ channels and reduces ___ of Na+ pumps.
Activation | Production
91
Spironolactone reduces ___ of Na+ channels and reduces ___ of Na+ pumps.
Activation | Production
92
Main adverse effects of spironolactone
Hyperkalaemia (if used alone, but rare, because generally used in combination with potassium-losing (loop/thiazide) diuretics).
93
Triamterene/amiloride inhibits luminal ___ channels in collecting tubules and ducts
Na+ channels
94
By inhibiting luminal Na+ channels, triamterene/amiloride inhibits Na+ ___ and K+ ___
Na+ reabsorption and K+ secretion (because K+ in other direction by a luminal K+ channel, as Na+ is reabsorbed).
95
Pharmacokinetics of triamterene and amiloride
``` Triamterene = well absorbed and fast onset Amiloride = poorly absorbed and slow onset ```
96
Osmotic diuretics are pharmacologically ___
Inert! | I.e. no active effects, filtered but NOT absorbed so pure osmotic effect!
97
Osmotic diuretics mainly affect water permeable parts of nephron: 3 areas
Proximal tubule. Descending limb of loop of Henle. Collecting tubules.
98
Osmotic diuretics reduce passive water ___
Reabsorption | C.f. other diuretics which change Na+ and inhibit the secondary water reabsorption
99
Osmotic diuretics are NOT very useful if there is ___ retention
Sodium/Na+ | Only has a significant effect on water reabsorption, and only a small reduction in Na+ reabsorption.
100
Osmotic diuretics are NOT very useful if trying to reduce ___ retention
Sodium/Na+ | Only has a significant effect on water reabsorption, and only a small reduction in Na+ reabsorption.
101
Osmotic diuretics are NOT very useful if trying to reduce ___ retention
Sodium/Na+ | Only has a significant effect on water reabsorption, and only a small reduction in Na+ reabsorption.
102
Heavy metals e.g. mercury, may cause kidney toxicity by:
Direct toxicity and vasoconstriction (limit blood supply -> toxic effects). Bind to nucleophilic groups (thiol groups) of proteins -> autoimmune state (due to Ab complex deposition?).
103
Antibiotics e.g. gentamicin, may cause kidney toxicity by:
Altered cell signalling -> altered [Ca2+]i -> impaired mitochondrial resp. -> cell injury! Site = apical membrane of proximal tubule. Note elimination is RENAL i.e. it is unchanged in the urine so it can exert its actions on kidneys easily (impair kidneys - reduce excretion - vicious cycle).
104
Antineoplastics e.g. cisplatin, may cause kidney toxicity by:
Forms highly reactive species to kill tumour cells - this may damage cells in kidney. Binds to nucleophilic cell components e.g. thiols in proteins. In distal tubule and collecting ducts!

2. Cardiovascular (6 decks)

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