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Pharm Exam II > Antihypertensive Drugs, Treatment of Angina, Arrhythmias, and CHF > Flashcards

Antihypertensive Drugs, Treatment of Angina, Arrhythmias, and CHF Flashcards

1
Q

Which 2 factors influence blood pressure

A

-cardiac output (CO)
-total peripheral vascular resistance (TPR)

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2
Q

What does the baroreceptor reflex control?

A

BP- it monitors and corrects changes in BP within seconds by altering cardiac output and peripheral vascular resistance

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3
Q

How do antihypertensive drugs work?

A

By affecting CO and TPR

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4
Q

What are the two categories of hypertension?

A
  1. Primary/essential HTN
  2. Secondary HTN
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5
Q

Secondary HTN

A

Attributed to an abnormality in the body (chronic kidney disease, renal stenosis, endocrine disorders)
<10% of HTN

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6
Q

Primary or Essential HTN

A

There is no clear cause
90% of HTN

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7
Q

What are possible causes of essential HTN

A

-diet
-stress
-genetic predisposition
-cigarette smoking
-alcohol abuse
-obesity

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8
Q

What is metabolic syndrome?

A

All the following characteristics together:
-impaired glucose metabolism
-hyperinsulinemia
-abdominal obesity

**associated with HTN

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9
Q

The drugs used to treat HTN

A

-diuretics
-sympatholytics
-vasodilators
-drugs that inhibit the renin-angiotensin system
-calcium-channel blockers

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10
Q

How do diuretics work?

A

They increase renal excretion of water and sodium which decreases fluid volume in the vascular system and helps to lower BP

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11
Q

What do we need to be aware of if a pt is taking diuretics?

A

That potassium is also excreted so they should be taking a potassium supplement or be getting blood levels drawn regularly to check levels

**low potassium will lead to arrhythmias and no energy

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12
Q

Types of Diuretics

A

-Thiazide diuretics: needs good kidney function, not good for geriatric population
-Loop diuretics: more potent than thiazide diuretics
-Potassium sparing diuretics: reduces the loss of potassium and prevents hypokalemia, not as potent

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13
Q

Adverse effects of diuretics

A

-fluid depletion
-electrolyte imbalance
-hyponatremia
-hypokalemia (thiadize and loop diuretics)
-orthostatic hypotension
-impaired glucose and lipid metabolism
-fatigue
-“up all night peeing”

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14
Q

How do sympatholytic drugs work?

A

they interfere with sympathetic discharge

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15
Q

Examples of sympatholytic drugs

A

-beta blockers
-alpha blockers
-presynaptic adrenergic inhibitors
-centrally acting agents

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16
Q

How do Beta-blockers work?

A

-They decrease HR and myocardial contraction force and cardiac output which lowers BP (antihypertensive)
-The work of the heart is decreased and thus the myocardial oxygen demand is decreased (angina)
-decreases effects of sympathetics nervous system which slows HR and controls HR (arrhythmias)

**typically used in combination with other antihypertensive meds

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17
Q

ending of beta blockers

A

-lol

Carvedilol
Propranolol
Metoprolol

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18
Q

Side effects of beta blockers

A

-excessive HR depression
-OH
-impair glucose and lipid metabolism
-depression
-fatigue
-GI disturbances
-allergic reactions
-blunted HR response with exercise
-bronchoconstriction in patients with asthma or other respiratory issues (taking nonselective beta blockers)

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19
Q

How do alpha blockers work?

A

They block the alpha-1 adrenergic receptors on vascular smooth mm which promotes a decrease in vascular resistance
-they also improve blood lipid profiles (decrease triglycerides and total cholesterol)

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20
Q

Adverse effects of alpha blockers

A

-reflex tachycardia: baroreceptor reflex may kick in when peripheral resistance drops and cause an increase in HR
-OH
-increase in cardiac disease and CHF: vasodilation increases blood volume and thus increases the workload on the heart
**those at risk for heart failure should avoid alpha blockers

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21
Q

How do presynaptic adrenergic inhibitors work?

A

Inhibit the release of norepinephrine from the persynaptic terminals which decreases sympathetic excitation of the heart and peripheral vascular resulting in decreased BP

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22
Q

Adverse side effects of presynaptic adrenergic inhibitors

A

-bradycardia
-arrhythmias
-drowsiness
-GI disturbances: nausea, vomiting, diarrhea

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23
Q

How do centrally acting agents work?

A

Inhibit sympathetic discharge from the brainstem by acting on central receptors which causes a decrease in cardiovascular stimulation and BP

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24
Q

Adverse side effects of centrally acting agents

A

-dry mouth
-dizziness
-sedation

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25
Q

How do Vasodilators work?

A

Drugs that vasodilate the peripheral vasculature cause a decrease in peripheral resistance which decreases BP

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26
Q

Side effects of vasodilators

A

-reflex tachycardia
-dizziness
-OH
-weakness
-nausea
-fluid retention
-HA

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27
Q

How does the Renin-Angiotensin System work?

A

It is a system that regulates vascular tone as well as sodium and water balance in the body
-rennin is an enzyme produced in the kidneys that is released into the blood stream when BP decreases
-angiotensinogen is a peptide within the bloodstream
-angiotensin I: a biproduct of when renin and antiotensinogen contact each other in the blood
-angiotensin I is transformed into angiotensin II by angiotensin converting enzyme
-angiotensin II: a potent vasoconstrictor

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28
Q

What are the different renin-angiotensin system inhibitors?

A

-ACE inhibitors (angiotensin converting enzyme)
-ARBs (angiotensin II receptor blockers)
-Direct renin inhibitors

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29
Q

How do ACE inhibitors work?

A

Inhibits the enzyme that allows angiotensin I to be converted into angiotensin II- allows for vasodilation and a decrease in BP

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30
Q

How do ARBs work?

A

Angiotensin II receptor blockers block the actual receptor where angiotensin II would bind to allow vasoconstriction to occur- allows for vasodilation and decrease BP

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31
Q

How do direct renin inhibitors work?

A

they inhibit renin’s ability to convert angiotensinogen to angiotensin I- allows for vasodilation and decrease BP

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32
Q

Adverse effects of renin-angiotensin system inhibitors

A
  1. ACE inhibitors:
    -allergic reaction- skin rash
    -persistent dry cough
    -angioedema- rashes, welts, burning/itching skin, face swelling, difficulty breathing
    -hyperkalemia
  2. ARBs:
    -same as above expect dry cough
  3. Direct renin inhibitors:
    -dry cough
    -GI problems
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33
Q

How do calcium channel blockers work?

A

They block the calcium entry into the vascular smooth mm cells which blocks the contractile process and leads to vasodilation and decrease vascular resistance
-allows for an increase in coronary blood flow which increases myocardial oxygen supply

**originally developed to treat angina and cardiac arrhythmias

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34
Q

Adverse side effects of calcium channel blockers

A

-excessive vasodilation: swelling in feet and ankles
-OH
-abnormalities in HR: too fast or too slow

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35
Q

Stages of HTN

A

-Normal: <120/<80
-Pre-hypertensive: 120-139/80-89
-Stage 1: 140-159/90-99
-Stage 2: >159/>99

36
Q

What are the initial drugs of choice for those with stage 1 or stage II HTN?

A

-thiazide diuretic
-calcium channel blocker
-ACE inhibitor or ARBs

**using 2 of these is a more aggressive and better first approach

37
Q

PT considerations for patients on HTN meds

A

-be aware of OH and hypotension
-avoid activities that cause widespread vasodilation: whirlpool and Hubbard tanks
-be aware that exercise will cause further vasodilation
-beta blockers will cause a blunted HR response to exercise (use RPE!)
-encourage patients with be compliant with HTN meds

38
Q

Why does angina Pectoris occur?

A

The supply of oxygen to the heart is insufficient to meet myocardial demands at a specific point in time, then lactic acid accumulates and the painful symptoms occur

39
Q

Drugs to treat angina pectoris

A

-organic nitrates
-beta blockers
-calcium channel blockers

40
Q

Examples of organic nitrates

A

-Nitroglycerin
-Isosorbide dinitrate
-Isosorbide mononitrate

41
Q

How do organic nitrates work?

A

They convert nitric oxide within the vascular smooth mm which then causes vasodilation of the smooth mm throughout the body- this allows for a decrease in the amount of work the heart must do so the myocardial oxygen demand decreases

42
Q

Administration of Nitroglycerin

A

Given for both the prevention and treatment of angina
-can be taken orally, buccally, sublingually, transdermally, or via IV

43
Q

What is the most common and best route for nitroglycerin?

A

Sublingual- placed under the tongue and drug is rapidly absorbed through the oral mucosa into the systemic circulation
-therapeutic effect begins within 2 minutes
-avoids first pass effect of liver

44
Q

Adverse effects of organic nitrates

A

-HA
-dizziness
-OH

45
Q

Why are some patients with angina prescribed an anticoagulant?

A

because angina is usually associated with some coronary artery occlusion, thus an anticoagulant will help to prevent coronary arteries from becoming completely blocked and causing an MI

46
Q

Stable Angina

A

The myocardial oxygen demand greatly exceeds oxygen supply
-often called exertional angina: occurs with a certain level of activity

47
Q

Treatment for stable angina

A

-beta blockers
-calcium channel blockers
-nitrates

48
Q

What are the first drugs used for the long term management of stable angina?

A

Beta blockers- they decrease the workload of the heart
-must be taken daily to prevent episodes
-calcium channel blockers are used if beta blockers aren’t tolerated

49
Q

Treatment of acute angina

A

Nitroglycerin

50
Q

What is variant angina?

A

When the oxygen supply to the myocardium decreases because of coronary artery vasospasm
-can be triggered by environmental and emotional stimuli

51
Q

What is used to treat variant angina?

A

Calcium channel blockers are more effective
-nitrates used if those are ineffective

52
Q

What is the most severe form of angina?

A

Unstable angina- initiated by sudden rupture of atherosclerotic plaques within the coronary arteries and results in a decrease of myocardial oxygen supply

53
Q

Which two things are within the category of Acute Coronary Syndromes?

A

-Unstable angina
-MI

54
Q

Which drugs are essential for preventing unstable angina to progressing into an MI?

A

anticoagulants and antiplatelet therapy

**anticoagulants are given in the early stages of unstable angina

55
Q

Which drugs are used for the management of unstable angina?

A

-ACE inhibitors
-statin drugs

56
Q

Concerns for PT with those with angina

A

-make sure they have their nitroglycerin tablets with them
-be aware of cardiac limitations
-HR will be blunted- adjust workloads carefully
-at risk for hypotension

57
Q

What things can result in arrhythmias?

A

-electrolyte imbalance
-metabolic imbalances
-toxicity to drugs
-autonomic influences
-cardiac diseases
-genetic factors

58
Q

What are the three basic abnormalities that will cause an arrhythmia?

A
  1. Abnormal impulse generation: normal rhythm of SA and AV nodes has been disrupted
  2. Abnormal impulse conduction: impulses through myocardium has been disrupted (heart blocks)
  3. Simultaneous abnormalities of impulse generation and conduction: combo of above
59
Q

Classes of Arrhythmic Drugs

A

-Class I: sodium channel blockers
-Class II: beta blockers
-Class III: drugs that prolong repolarization
-Class IV: calcium channel blockers

60
Q

How do sodium channel blockers work?

A

They bind to sodium channels in various tissues which inhibits the channels and decreases the membrane excitability and normalizes the rate of firing

61
Q

What are the different categories of Class I drugs?

A

Sodium Channel Blockers
-Class IA
-Class IB
-Class IC

62
Q

What is the pro-arrhythmic effect?

A

A side effect of anti-arrhythmic drugs by actually increasing rhythm disturbances (another arrhythmia can be triggered while trying to treat another one)

63
Q

Side effects of sodium channel blockers

A

-pro-arrhythmic effect
-dizziness
-visual disturbances
-GI problems

64
Q

How do drugs that prolong repolarization work?

A

They delay repolarization of cardiac cells which lengthens the time interval between action potentials and ultimately slows and stabilizes HR

65
Q

what is the most widely used anti-arrhythmic drug?

A

Amiodarone
-has properties of class I, II, and III drugs
-controls many types of arrhythmias

Side effects:
-pulmonary toxicity
-thyroid problems
-liver damage

66
Q

Which types of arrhythmias do class III drugs treat?

A

Ventricular arrhythmias: v-tach, v-fib, and supraventricular arrhythmias

67
Q

Side effects of class III drugs?

A

Initial increase in arrhythmias (pro-arrhythmic effect)

68
Q

why do calcium channel blockers help with arrhythmias?

A

Calcium entry plays a role in the generation of cardiac action potentials- by inhibiting the calcium influx into myocardial cells the excitability and conduction of cardiac tissue is altered
-they decrease the rate of SA node discharge and inhibit conduction velocity through the AV node

69
Q

What type of arrhythmia are class IV drugs useful in treating?

A

a-fib

70
Q

Examples of nonpharamcological treatment for arrhythmias

A

-pacemakers
-cardioverter defibrillators
-surgical electrode catheter ablation

**reduce long term complications and may be a more effective way to manage arrhythmias

71
Q

PT considerations for arrhythmia medications

A

-faintness and dizziness can be signs of cardiotoxic drug effects (a sign that further arrhythmias are developing)- REFER!
-hypotension can occur- monitor BP and HR

72
Q

What are the 2 primary goals of CHF drugs?

A
  1. improve myocardial contraction force (positive inotropic agents)
  2. decrease cardiac workload: by affecting the heart or peripheral vasculature or by controlling fluid volume
73
Q

Which drugs increase myocardial contraction?

A

Cardiac Glycosides: improves pumping action of the heart which increases cardiac output at rest and exercise

74
Q

Which drugs decrease cardiac workload?

A

-ACE inhibitors
-ARBs
-Beta blockers
-Diuretics
-Vasodilators

75
Q

What are the two types of cardiac glycosides?

A
  1. Digoxin - used in the US
  2. Digitoxin

**digitalis refers to both of these drugs

76
Q

How does Digitalis work?

A

Increases intracellular calcium concentrations which facilitates interaction between actin and myosin filaments in myocardial cells and decreases the symptoms of heart failure and number of hospitalizations
-it also has an inhibitory effect on the sympathetic nervous system: slows HR and slows impulse conduction through heart

77
Q

What is digitalis toxicity

A

A potentially fatal reaction to high doses of digitalis
Signs:
-GI disturbances
-CNS disturbances (drowsiness, fatigue, confusion, visual disturbances)
-Abnormalities in cardiac function
-toxicity increases V-fib and death can occur

78
Q

How is the Renin-Angiotensin System used for CHF?

A

The renin-angiotensin system is often activated in patients who have CHF which causes vasoconstriction and causes the heart to work even more- also stimulates aldosterone production which stresses the cardiovascular system more due to salt and water retention

79
Q

ACE inhibitors for CHF

A

Very successful in treating CHF when heart failure is due to reduced L ventricular function and decreases mortality in those with CHF
-early use of them can prevent or delay disease progression

80
Q

Why is it important for ACE inhibitors to inhibit aldosterone secretion?

A

Angiotensin II promotes aldosterone secretion which promotes water retention- this beneficial because it reduces fluid volume

81
Q

Which drugs are used if CHF patients cannot tolerate ACE inhibitors?

A

ARBs- are as effective as ACE inhibitors in treating heart failure and reducing mortality

82
Q

Why are beta blockers beneficial for CHF?

A

they lessen the increased sympathetic activity that occurs with CHF- also reduces mortality and morbidity associated with this disease
-used along with ACE inhibitors, digitalis, and diuretics to provide optimal treatment

83
Q

Purpose of Diuretics for CHF

A

Increases the excretion of sodium and water which decreases the amount of fluid the heart must pump which reduces the heart’s workload

84
Q

PT Implications for CHF patients

A

-watch for s/s of acute congestive heart failure
-watch for s/s of digoxin toxicity
-fatigue and weakness may be early signs of fluid and electrolyte imbalance
-watch those taking vasodilators for hypotension or postural hypotension

85
Q

Vasodilators for CHF

A

these drugs vasodilate peripheral vessels which reduces peripheral resistance- thus the amount of blood returning to the heart is decreased and the pressure against which the heart must beat against is reduced

Pharm Exam II (9 decks)

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