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Pharmacology > Cardiac > Flashcards

Cardiac Flashcards

1
Q

What sort of drug is digoxin?

A

Cardiac glycoside

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2
Q

What are the indications for digoxin?

A

AF or atrial flutter (although beta blocker or calcium channel blocker generally preferred)
3rd line treatment in severe heart failure

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3
Q

What is the mechanism of action of digoxin?

A

Negatively chronotropic and positively ionotropic
AF - Increases parasympathetic (vagal) tone, reducing frequency of transmission to AVN.
HF - inhibits sodium potassium pump, increasing cellular sodium. Extrusion of calcium requires low Intracellular soduim, so causes this to accumulate increasing contractile force

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4
Q

What must you be aware of in digoxin?

A

Narrow therapeutic window
Can be proarrhythmic
Contraindicated in 2nd degree heart block, intermittent complete heart block, patients in risk of ventricular arrhythmias.
Dos should be reduced in renal failure
Effected by electrolyte disturbances (including hypokalaemia)

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5
Q

What type of drugs are ramipril, lisinopril, perindopril

A

Angiotensin converting enzyme inhibitors

ACE inhibitors

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6
Q

What are the indications for starting ACE inhibitors?

A 
Hypertension (1st or 2nd line treatment)
Chronic heart failure (1st line treatment)
Iscaemic heart disease 
Diabetic nephropathy 
CKD with proteinuria
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7
Q

What is the mechanism of action of ACE inhibitors?

A

Block the action of angiotensin converting enzyme, which prevents the production of angiotensin II, which is a potent vasoconstrictor and stimulates aldosterone secretion. This resulted.y reduces peripheral vascular resistance and promotes sodium and water secretion in the kidney.

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8
Q

Why are ace inhibitors given in CKD

A

Their vasodilator effect on the glomerular arteries, which reduces interglomerular pressure and slows the progression of CKD

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9
Q

What are some key side effects of ace inhibitors? E.g. ramipril and lisinopril

A

Persistent dry cough (bradykinin not inactivated)
Hypotension (vasodilation)
Hyperkalaemia (low aldosterone so potassium retention)
Risk of renal failure (loss of glomerular pressure due to vasodilation, worse with renal artery stenosis which struggle to retain glomerular filtration)
Angioedema/anaphylactic reactions

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10
Q

What are the contraindications for ACE inhibitors (e.g. ramipril, lisinopril)?

A

Renal artery stenosis
AKI
Pregnancy
Breastfeeding

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11
Q

What type of drugs are furosemide and bumetanide?

A

Loop diuretics

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12
Q

What is the mechanism of action of furosemide and bumetanide?

A

Work on ascending limb of loop of henle, where they inhibit the sodium postassium 2chloride cotransporter. This has a very potent diuretic effect and increases urinary losses of sodium, potassium and chlorine.
Also have vasodilator effect on capacitance veins.

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13
Q

What are the indications for loop diuretics such as furosemide or bumetanide?

A

Acute pulmonary oedema
Fluid overload in heart failure
Symptomatic treatment of fluid overload in other oedematous states e.g. renal Disease or liver failure.

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14
Q

What are the potential side effects of loop diuretics?

A

Dehydration and hypertension.
Low electrolyte states (including low magnesium, calcium and hydrogen indirectly)
Hearing loss, tinnitus (similar transporter in ear)

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15
Q

What are the contraindications of loop diuretics?

A

Hypovolemia, dehydration, hepatic encephalopathy (hypokalaemia can worsen this),hypokalaemia, hyponatraemia, gout (can inhibit uric acid secretion)

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16
Q

What sort of drug is amiloride?

A

Potassium sparing diuretic

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17
Q

What are co-amilofruse and co-amilozide?

A

Combinations of amiloride with furosemide (loop) and hydrochlorothiazide (thiazide) diuretics

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18
Q

What might be an indication for amiloride (potassium sparing diuretic)?

A

Treatment of hypokalaemia arising from loop or thiazide diuretics, as part of combination therapy

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19
Q

What might be used as an alternative to potassium sparing diuretics?

A

Aldosterone antagonist e.g. spironolactone

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20
Q

What are the contraindications of potassium sparing diuretics e.g. amiloride?

A

Severe renal impairment, hyperkalaemia, volume depletion. Do not use in combination with potassium supplements.

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21
Q

What sort of drugs are bendroflumethiazide, indapamide, chlortalidone?

A

Thiazide diuretics

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22
Q

What are the indications for thiazide diuretics?

A

Alternative first line treatment for hypertension where calcium channel blocker is unsuitable
Add on treatment for hypertension (after ca channel blocker and ace inhibitor)

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23
Q

What is the mechanism of action of thiazide diuretics?

A

Inhibits the sodium chlorine cotransporter in the distal convoluted tubule of the nephron. This prevents reabsorption of sodium and it’s osmotically associated water.

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24
Q

What are the contraindications for thiazide diuretics?

A

Hyponatraemia, hypokalaemia, gout

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25
Q

What type of medications are bisoprolol, atenolol, propranolol, metoprolol and sotalol?

A

Beta blockers

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26
Q

What are the indications for starting beta blockers?

A

Ischaemic heart disease (first line treatment to improve symptoms of angina and ACS)
Chronic heart failure
Atrial fibrillation (first line treatment to reduce ventricular rate and maintain sinus rhythm)
Hypertension (when initial therapy hasn’t worked)

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27
Q

What is the mechanism of action of beta blockers?

A

Via blocking Beta1 receptors, they reduce the force of contraction and speed of conduction in the heart, reducing myocardial work an O2 demand, improving prognosis.
Prolongs refractory period of AVN. Should be started slowly.

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28
Q

What are contraindications for beta blockers?

A

Asthma (could cause bronchospasm)
Heart block
Haemodynamic instability
Hepatic failure

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29
Q

What are the potential side effects of beta blockers?

A

Fatigue, cold extremities, headache, GI disturbances, sleep disturbances, impotence in men

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30
Q

What sort of drugs are tamsulosin, doxazosin and alfuzosin?

A

Alpha adrenoreceptor blockers

Alpha blockers

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31
Q

What are the indications for alpha blockers e.g. tamsulosin, doxazosin?

A

First line medical option to improve symptoms in benign prostatic hyperplasia
Add on treatment in resistant hypertension (where other treatment such as ca channel blockers, ace inhibitors and thiazide diuretics are insufficient)

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32
Q

What is the mechanism of action of alpha blockers?

A

Usually highly selective for alpha 1receptor, which is found in smooth muscle (including blood vessels and urinary tract). Blockade of this receptor causes relaxation in such, vasodilation and reduced resistance to bladder outflow

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33
Q

What are the contraindications for alpha blockers?

A

Postural hypotension

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34
Q

What are the side effects of alpha blockers?

A

Postural hypotension, dizziness, syncope. Usually particularly prominent after the first dose.

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35
Q

What sort of medications are losartan, candesartan, irbesartan?

A

Angiotensin receptor blockers

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36
Q

What are the indications for angiotensin receptor blockers e.g. losartan, candesartan?

A

Generally used when ace inhibitors are not tolerated
Hypertension
Chronic heart failure
Ischaemic heart failure
Diabetic nephropathy and chronic kidney disease with proteinuria

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37
Q

What is the mechanism of action of angiotensin receptor blockers?

A

Block the action of angiotensin II on the AT1 receptor, thereby preventing vasoconstriction and stimulation of aldosterone secretion. Reduces peripheral vascular resistance, reducing afterload and BP. Dilates efferent glomerular arteriole slightly reducing intraglomerular pressure and slowing CKD. Promotes sodium and water excretion.

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38
Q

What are the side effects of angiotensin receptor blockers?

A

Hypotension, hyperkalaemia, renal failure (particularly those with renal artery stenosis)
No risk of cough as no effect on bradykinin unlike ace inhibitors.

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39
Q

What are the contraindications for angiotensin receptor blockers ?

A

Renal artery stenosis, AKI, CKD
Pregnancy or breastfeeding
Other potassium elevating medications

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40
Q

What is the indication for adenosine?

A

First line diagnostic and therapeutic agent in supraventricular tachycardia SVT

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41
Q

What is the mechanism of action of adenosine?

A

Agonist of adenosine receptors on cell surface, increasing resistance to depolarisation and reducing frequency of spontaneous deplolarisations. This slows the sinus rate, conduction rate and increases AVN refractory period, potentially breaking the reentry circuit, allowing normal SAN to resume control of heart rate (cardioversion). Duration of action is very short.

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42
Q

What are the side effects of adenosine?

A

Can induce bradycardia and asystole, which can be very unpleasant for patient, although effect is only brief.

43
Q

What are the contraindications for adenosine?

A

Hypotension, coronary ischaemia, heart transplant, decompensated heart failure - anything which might indicate patient won’t be able to tolerate transient bradycardic effects.
May induce bronchospasm in asthma or COPD

44
Q

What is the indication for amiodarone?

A

Tachyarrhythmias, such as AF, atrial flutter, SVT, VT, refractory ventricular fibrillation VF.
Generally used when other options are inappropriate

45
Q

What is the mechanism of action of amiodarone?

A

Blockade of sodium, calcium and potassium channels and antagonism of alpha and beta adrenergic receptors. This reduces spontaneous depolarisations, slows conduction velocity, and increases resistance to depolarisation including in the AVN. Interferes with AVN conduction.

46
Q

What are the contraindications for amiodarone?

A

Heart block
Severe hypotension
Active thyroid disease (amIODarone)
Potentially dangerous drug

47
Q

What are the indication for lidocaine?

A

First choice local anaesthetic

Antiarrhythmic drug in ventricular tachycardia VT and ventricular fibrillation VF

48
Q

What is the mechanism of action of lidocaine?

A

Blocks voltage gated sodium channels on cell surface. This prevents initiation and propagation of action potentials in nerves and muscle.
In heart reduces duration of action potential, slows conduction velocity and increases refractory period.

49
Q

What is the indication of flecainide?

A

Supraventricular tachycardia, AVNRT, WPW, AF,

Can be used for VT in some cases

50
Q

What is the mechanism of action of flecainide?

A

Acts on the His-Purkinje system mostly
Blocks sodium channel, slowing upstroke of cardiac action potential, and reduces contractility of the muscle.
Class 1 antiarrhythmic agent

51
Q

What are the contraindications of flecainide?

A

Previous MI of structural heart disease

52
Q

What sort of medications are glycerol trinitrate and isosorbide mononitrate?

A

Nitrates

53
Q

What are the indications for the use of short acting nitrates?

A

Acute angina and chest pain associated with acute coronary syndrome

54
Q

What is the indication for the use of long acting nitrates?

A

Prophylaxis of angina, where a beta blocker or calcium channel blocker are unsuitable or inefficient

55
Q

What would be an indication for IV nitrates?

A

Pulmonary oedema

Usually in combination with furosemide and oxygen

56
Q

What is the mechanism of action of nitrates?

A

They are converted to NO (nitric oxide). This increases cGMP synthesis, reducing Ca in vascular smooth muscles cells, causing them to relax. Relaxation of capacitance vessels reduces cardiac preload and left ventricle filling, reducing cardiac work and oxygen demand. Also reduces peripheral resistance and afterload.

57
Q

What are the contraindications of nitrates?

A

Severe aortic stenosis (risk of cardiovascular collapse)
Haemodynamic instability
Hypotension

58
Q

What type of drugs are amlodipine, nifedipine, diltiazem ans verapamil?

A

Calcium channel blockers

59
Q

What might diltiazem and verapamil (nondyhydropyridines) be used for?

A

To control cardiac rate in supraventricular arrhythmias, including supraventricular tachycardia, AF and atrial flutter
Relatively unselective for vasculature

60
Q

What might amlodipine and nifedipine (dihydropyridines) be used for?

A

First or second line treatment of hypertension, to reduce risk of MI, stroke and cardiovascular disease and death
Relatively selective for vasculature

61
Q

What might any calcium channel blocker be used for?

A

Control symptoms in people with stable angina, as an alternative to beta blockers

62
Q

What is the mechanism of action of calcium channel blockers?

A

Decrease calcium entry into cells, reducing its conc and therefore causing relaxation and vasodilation in arterial smooth muscle. Decreases myocardial contractility, reducting myocarial oxygen demand.
Suppresses cardiac conduction, particularly in AVN, slowing ventricular rate.

63
Q

What are the side effects of calcium channel blockers?

A

Ankle swelling, flushing, headache, palpitations, constipation, bradycardia, heart block

64
Q

What are the contraindications of calcium channel blockers?

A

Poor left ventricular function, unstable angina, AV nodal conduction delay, severe aortic stenosis

65
Q

What are the indications for Warfarin?

A

To prevent embolic complications in…
DVT, PE, VTE
AF
Heart valve replacement (particularly mechanical, lifelong. Only short term post tissue)

66
Q

What do you use to prevent ARTERIAL thrombosis?

A

Antiplatelet agents e.g. aspirin, clopidogrel

67
Q

What is the mechanism of action of Warfarin?

A

Inhibits hepatic production of vitamin k-dependent coagulation factors and cofactors by inhibiting vitamin k epoxide reductase, preventing the active form of vitamin k being produced and utilised.

68
Q

What are the adverse effects of warfarin?

A

Bleeding
Form existing abnormalities e.g. peptic ulcers,minor trauma
Large excess may trigger spontaneous haemorrhage e.g. epistaxis

69
Q

Wha are the contraindications of Warfarin?

A

Patients at risk of haemorrhage - post trauma or in need of surgery
Liver disease (less able to metabolise drug)
Pregnancy
Cytochrome P450 inhibitors/inducers must be used with great care

70
Q

What is used to help determine what dose of Warfarin should be used?

A

INR. International normalised ratio

71
Q

What is an indication for heparin?

A

VTE (first line treatment of hospital in patients and initial treatment of PE and DVT)
Acute coronary syndrome

72
Q

What type of medications are unfractionated heparin, enoxaparin, delteparin, fondaparinux?

A

Anticoagulants

73
Q

What is the mechanism of action of heparin?

A

Unfractionated heparin inactivates factor Xa and thrombin
Low molecular weight heparin (e.g. delteparin and enoxaparin) work similarly but preferentially inhibit factor Xa, and have a more predictable effect and so don’t need laboratory monitoring

74
Q

What are the risks with heparin?

A

Risk of bleeding

Risk of heparin induced thrombocytopenia, less likely with LMWH than with UFH

75
Q

What are the contraindications for heparin?

A 
Clotting disorders
Severe uncontrolled hypertension
Recent surgery or trauma
Invasive procedures likely to be carried out soon
Renal impairment
76
Q

What might the indications for rivaroxaban be?

A

AF

VTE

77
Q

What might protamine sulphate be used for?

A

Heparin reversal

78
Q

What is the mechanism of protamine sulphate, used to reverse heparin?

A

Highly cationic peptide that binds to heparin molecules to form stable ion pair, which does not have cationic activity.

79
Q

What are the indications for aspirin?

A

Treatment of ACS and acute ischaemic stroke (rapid inhibition of platelet aggregation can reduce mortality)
Long term prevention of thrombotic arterial events in cardiovascular, cerebovascular and peripheral arterial disease.
To reduce the risk of thrombotic events in atrial fibrillation, where Warfarin and DOACs are contraindicated
To control mild to moderate pain and fever

80
Q

What is the mechanism of action in aspirin?

A

Inhibits COX (cyclooxygenase) to reduce production of pro-aggregatory factor thromboxane, reducing platelet aggregation and the risk of ARTERIAL occlusion. Occurs at low doses. Effect lasts lifetime of platelet as it doesn’t have a nucleus so cannot produce new COX.

81
Q

What are the risks of aspirin?

A

GI irritation, GI ulceration, haemorrhage, hypersensitivity and bronchospasm. Tinnitus at high doses. Fatal in overdose. Can trigger gout attack in patients with the disease .

82
Q

What are the indications for dipyridamole?

A

Cerebrovascular Disease (for secondary prevention of stroke, first line therapy following transient ischaemic attack and secondary for ischaemic stroke where clopidogrel is contraindicated)
To induce tachycardia during myocardial perfusion scan in the diagnosis of ischaemic heart disease.
Usually given in combination with aspirin

83
Q

What is the mechanism of dipyridamole?

A

Has both antiplatelet and vasodilatory effects.
Antiplatelet, increases cAMP in platelets which inhibits platelet aggregation
Blocks cellular uptake of adenosine, prolonging it’s effect on cells producing vasodilation

84
Q

What are the contraindications for dipyridamole?

A

Ischaemic heart disease, aortic stenosis, heart failure as it causes vasodilation and tachycardia which can exacerbate these.
Increased risk of bleeding
Side effects relate to vasodilatory effects

85
Q

What are the indications for clopidogrel?

A

For treatment of ACS (where rapid inhibition of platelet aggregation can be beneficial)
To prevent occlusion of coronary artery stents
Long term secondary prevention of thrombotic arterial events in cardiovascular, cerebrovascular and peripheral arterial disease
Reduce the risk of intracardiac thrombus in AF where Warfarin and DOACs are contraindicated
Usually prescribed along with aspirin

86
Q

What is the mechanism of action of clopidogrel?

A

Prevents platelet aggregation by binding irreversibly to adenosine diphosphate ADP receptors on the surface of platelets. Acts synergistically to aspirin as this is irrelevant of COX pathway

87
Q

When should clopidogrel be used cautiously?

A

Renal and/or hepatic impairment

Requires metabolism by cytochrome P450 inhibitors so is effected by other drugs effecting such

88
Q

What sort of drugs are alteplase, streptokinase, reteplase?

A

Fibrinolytic drugs

89
Q

What are the indications for fibrinolytic drugs, such as alteplase?

A

Acute ischaemic stroke (if given within 4.5hrs of event onset improves chance of better outcome)
Acute ST elevation MI (reduce mortality if given within 12hrs)
Massive pulmonary embolism with haemodynamic instability

90
Q

What is the mechanism of action of fibrinolytic drugs?

A

Catalyse the conversion of plasminogen to plasmin, which acts to dissolve fibrinous clots as recanalise occluded veins.

91
Q

What are the contraindications for fibrinolysis?

A

Factors predisposing patients to bleeding
Intracranial haemorrhage, recent surgery or trauma, bleeding disorders, severe hypertension, peptic ulcers
Streptokinase cannot be given again as anti streptokinase antibodies may block its effect

92
Q

What are the indications for statins?

A 
Primary prevention of cardiovascular disease (at patients over 40 with a 10yr risk of over 20 percent)
Secondary prevention of cardiovascular disease (first line alongside lifestyle changes to prevent cardiovascular events in those already with evidence of disease)
Primary hyperlipidaemia (first line in conditions such as primary hypercholesterolaemia, mixed dyslipidaemia, and familial hypercholesterolaemia)
93
Q

What type of drugs are simvastatin, atorvastatin, pravastatin?

A

Statins

94
Q

What is the mechanism of action of statins?

A

Reduce serum cholesterol levels. Inhibit HMG CoA reductase, an enzyme involved in making cholesterol. Decrease cholesterol production in liver and increase clearance of LDL cholesterol. Mildly reduce triglycerides and increase HDL levels indirectly. Therefore slow atherosclerotic process

95
Q

What are the contraindications for statins?

A

Hepatic impairment, renal impairment (smaller dose needed), pregnancy, breastfeeding.
Can cause muscle aches and occasionally rhabdomyolysis. Can cause a a rise in liver enzymes.
Metabolised by CYP450, effects decreased by inhibitors of such.

96
Q

What is nicotonic acid used for?

A 
Lowering cholesterol (usually in addition to other methods)
Niacin deficiency
97
Q

What type of drug is bezafibrate?

A

Fibrate lipid lowering agent

98
Q

What is the mechanism of action of bezafibrate?

A

Agonist of receptor PPAR alpha, changing gene expression to result in better cholesterol levels, higher HDL and lower LDL levels.
Also known to help reduce insulin resistance

99
Q

Where is the metabolism of bezafibrate?

A

Hepatic

100
Q

What are the indications for ezetimibe?

A

Hypercholesterolaemia

In conjunction with statins, or alone where other medications are contraindicated. 2nd line therapy

101
Q

Where is ezetimibe metabolised?

A

Liver, beware hepatic disease

102
Q

What is the mechanism of action of nicotonic acid?

A

Decreases fat breakdown, reducing levels of free fatty acids

103
Q

What is the indication for Bivalirudin?

A

First line injectable anticoagulant post MI. Inhibits further thrombotic events

Pharmacology (9 decks)

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