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Small Animal Cardiology > Cardiac Pharmacology > Flashcards

Cardiac Pharmacology Flashcards

(75 cards)

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1
Q

What are the effects of angiotensin converting enzyme (ACE) inhibitors?

A 
Balanced vasodilation
Reduce aldosterone release
Reduced glomerular capillary pressure 
Prevent angiotensin II mediated myocardial fibrosis and remodelling
Anti-adrenergic effects
Reduce vasopressin release 
Reduce endothelin release
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2
Q

What is aldosterone escape?

A

Despite adequate ACE inhibition, aldosterone levels may increase due to the stimulation of aldosterone release from the adrenal cortex by other mechanisms

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3
Q

How do you block aldosterone escape?

A

Aldosterone antagonism eg: Spironolactone

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4
Q

What are the targets of drug therapy in congestive heart failure?

A
  1. Counteracting oedema and effusions
  2. Counteracting neuro-endocrine activation
  3. Counteracting vasoconstriction
  4. Improving cardiac output
  5. Counteracting high sympathetic drive
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5
Q

What drugs can you use to counteract Odense and effusions?

A

Diuretics - furosemide

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6
Q

Furosemide

A

Loop diuretic
Oral administration for daily use
IV Administration for emergency (also venodilator when given IV)
Once patient is stable titrate does to effect

Ask owners to monitor response by monitoring respiratory rate

Side effects: pre-renal azotaemia, hypokalaemia

Should not be used on its own in the long term - ACE inhibitor

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7
Q

What do you need to monitor in patients on furosemide?

A

Urea and creatinine

K+, Na+, Cl-

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8
Q

When is furosemide contraindicated?

A

Renal failure

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9
Q

Why might diuretic resistance occur?

A

GI tract oedema
Furosemide resistance - tubular hypertrophy
Concurrent NSAID therapy

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10
Q

What should you do if diuretic resistance is occurring?

A

Increase dose of furosemide - 3 mg/kg TID max dose
Introduce other diuretics
- Torasemide - very potent but high risk of AKI
- Spironolactone
- Amiloride / hydrochlorothiazide
- Hydroflumethiazide / Spironolactone

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11
Q

Spironolactone

A

Weak potassium sparing diuretic
Aldosterone antagonist
(prilactone)
Significantly increases survival in CHF

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12
Q

Hydrochlorothiazide

A

Thiazide diuretic that acts on the DCT

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13
Q

Amiloride

A

K+ sparing diuretic acts on the PCT

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14
Q

Where are diuretics definitely contraindicated?

A

Pericardial effusion - patients have low blood pressure due to cardiac tamponade

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15
Q

How else can you treat effusions?

A

Thoracocentesis to drain pleural effusion
- obtain a sample for testing

Abdominocentesis - only in patients with serve respiratory compromise as protein rich exudate

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16
Q

What drugs can you use to counteract neuro-endocrine activation?

A

Angiotensin converting enzyme inhibitors

Aldosterone antagonists - Spironolactone

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17
Q

What are the effects of ACE inhibitors?

A 
Balance vasodilators
Reduces cardiac remodelling
Reduces aldosterone release 
Reduces sympathetic activation
Reduces vasopressin release 
Reduces endothelin release 
Increases the vasodilators bradykinin and prostaglandin 
Reduces the risk of glumerular hypertension
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18
Q

What are the benefits of ace inhibitors?

A

Increased quality of life and survival time
Slows down progression to DCM
Reduces wall thickness in HCM

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19
Q

Name the 4 ace inhibitors used in practice.

A

Benazepril
Enalapril
Ramipril - highest levels in the tissues
Imidapril - liquid preparation

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20
Q

What ace inhibitors are licensed?

A

Dog - all 4

Cat - none! Benazepril is licensed in for CKD so use this under the cascade

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21
Q

What are the side effects of ace inhibitors?

A 
Hypotension 
Renal impairment 
Hyperkalaemia
Anorexia
Diarrhoea 
Vomiting 
Cough
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22
Q

When are ace inhibitors contraindicated?

A

Hypotension animals on high doses of furosemide

Aortic stenosis - aortic outflow tract obstruction

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23
Q

What drug combinations are indicated to prevent aldosterone escape and Hyperkalaemia?

A

Spironolactone + furosemide + ace inhibitors

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24
Q

How can you unload the failing heart?

A

Arteriodilators
Venodilators
Mixed vasodilators

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25
What do arteriodilators do to unload the heart?
Redistribute the blood to the periphery, reducing mean arterial blood pressure and reducing afterload on the heart
26
Name some pure arteriodilators.
Amlodipine Hydralazine ACE inhibitors - Benazepril etc Pimobendan - mixed venodilator
27
When are arteriodilators useful / indicated?
Mitral valve disease Reduce regurgitant flow Reduce afterload Increase forwards stroke volume
28
How do venodilators work to unload the failing heart?
Diverts the blood away from the cardiopulmonary circuit Eg: IV furosemide
29
What are mixed vasodilators?
Ace inhibitors | Pimobendan (also a major positive inotrope)
30
What category of drugs increase contractility?
Positive inotropes - calcium sensitiser
31
Pimobendan
Sensitises the cardiac myocyte to calcium - positive inotrope Balanced venodilator - reduces myocardial work load Reduced risk of arrhythmias compared to other PDE inhibitors that increase intra-cellular calcium concentrations Given orally in a palatable tablet - must give 1 hour before feeding
32
What is the best protocol for dogs with DCM?
Pimobendan + diuretics + ace inhibitors + digoxin
33
How can you counteract sympathetic drive?
Digoxin | Beta blockers
34
When are beta blockers contraindicated?
Uncontrolled congestive heart failure | Poor contractility
35
What are the effects of digoxin?
Negative chronic rope Weak positive inotrope Reduces sympathetic tone and increases vagal tone = slows the rate of depolarisation through the AV node
36
Digoxin
Liquid elixir has between absorption than tablets Effects are seen in 6-8 hours Takes 5 days for plasma levels to reach a steady state
37
What monitoring is required with the use of digoxin?
Check the drug level after 7 days of treatment | Aim for low end of therapeutic range
38
What are the side effects of digoxin?
``` Borborygmi Depression Anorexia Vomiting and diarrhoea Cardiac arrhythmias ```
39
What patients are at a greater risk of digitoxicity?
``` Thin Obese Ascites Hypoproteinaemia Hypothyroidism Impaired renal function Dobermann Hypoxia / acidosis Hypokalaemia ```
40
How can you prevent digitoxicity?
Start at a low dose Dose to body surface area Never use loading dose Always check serum levels after 7 days If ventricular rate is still to high add in another drug - eg: diltiazem for AF
41
What is the optimal treatment for CHF?
``` Furosemide Benazepril / ace inhibitor Pimobendan Spironolactone (SPAF) ```
42
Which anti-arrhythmic drug should you use to treat ventricular tachycardia long term?
Mexiletine | Class 1b anti-arrhythmic - Na+ channel inhibitor
43
Which drugs should you combine to achieve the best control in atrial fibrillation?
Treat underlying CHF - due to atrial stretch in small animals Digoxin and diltiazem = chemical cardioversion +/- Beta blockers (never in CHF)
44
How should you treat sick sinus syndrome?
Propantheline, pheylpropylamine | = parasympatheticolyics
45
How can ventricular tachycardia be treated?
First - Lidocaine IV then CRI - class 1b ``` Esmolol / Sotalol (beta blocker - class 2 anti-arrhythmic) - Sotalol also has class 3 actions Mexilitine (Na channel blocker - class 1 anti-arrhythmic) Amiodarone (class 1, 2 and 3 (K+ channel blocker) actions) ```
46
How should you treat supra ventricular tachycardia caused by high vagal tone?
Vagal manoeuvres Verapamil / Diltiazem (Ca2+ channel blocker) Esmolol (beta blocker)
47
How should you treat supraventricular arrhythmias?
``` Diltiazem - class 4 anti-arrhythmic - calcium channel blocker Digoxin - class 5 anti-arrhythmic - cardiac glycoside ```
48
How should you treat pulmonary hypertension?
Slidenafil - PDE inhibitor - vasodilator Pimobendan - PDE inhibitor - venodilator Anti coagulation therapy
49
What nutraceuticals and dietary modifications can you make in CHF?
Omega 3 Taurine - cats with DCM Reduce Na+ in diet
50
How can you suppress a cough?
Opioids - codeine and butorphanol
51
What is a beneficial drug in pre-clinical mitral valve disease?
Pimobendan | Can delay onset of CHF by 15 months
52
What is the action of class 1 anti-arrhythmic?
Block Na+ channels 1a (intermediate Na+ channel blockers) - quinidine 1b (fast Na+ channel blockers) - lidocaine, mexilitine 1c (slow Na+ channel blockers) - encainide
53
What are class 2 anti-arrhythmics?
Beta blockers Propanolol, Esmolol, atenolol, Sotalol (but mostly class 3)
54
What are class 3 anti-arrhythmias?
K+ channel blockers ``` Amoiodarone - also has class 1 and 2 actions Sotalol - also a beta blocker class 2 ```
55
What are class 4 anti-arrhythmic drugs?
Calcium channel blockers Diltiazem Verapamil
56
What are class 5 anti-arrhythmics?
Direct nodal inhibition Digoxin Adenosine
57
How should you treat preclinical HCM?
Beta blockers - atenolol, Propanolol, emsomolol - reduce LVOT and SAM - slows heart rate and improves diastolic function - CI in CHF Pimobendan - Ca channel blocker Benazepril - ace inhibitor Diltiazem - positive lusiotrope = improves diastolic filling There is no evidence that any drug slows down the progression to CHF
58
How should you treat clinical HCM?
Furosemide Benazepril Clopidogrel and aspirin
59
How should you manage a case of dysponea due to life threatening oedema in a cat?
Oxygen cage in a darkened room Administer furosemide IV if a catheter can be placed, if not IM Sedation with methadone if very anxious Drain pleural effusion
60
How can you screen for HCM?
Annual screening by echo in breeding cats Pro BNP on blood or pleural effusion in CHF cases only
61
How should you manage feline DCM?
``` Furosemide Benazepril Pimobendan Digoxin Taurine ``` Warmth Humorous oxygen Drain pleural effusion
62
How should you treat feline aortic thromboembolism?
``` Methadone - pain Aspirin Clopidogrel Low molecular weight heparin Physio ``` Treatment for CHF: Spironolactone, Benazepril, Pimobendan, furosemide
63
What drug is particularly useful in HOCM? When there is a left ventricular outflow tract obstruction
Atenolol - decreases heart rate and increases diastolic filling time
64
Diltiazem
Class 4 anti-arrhythmic Calcium channel blocker Negative chronotrope - achieves best rate control on AF with digoxin Works quicker than digoxin which takes around a week to work
65
When are beta blockers contraindicated?
Uncontrolled CHF - sympathetic tone is maintaining cardiac output Diltiazem acts quicker in AF and is well tolerated
66
How can you treat supraventricular tachycardia due to an accessory pathway? (Wolff-Parkinson-White syndrome)
Ablate accessory pathway | Identified by delta waves on the ECG, notched QRS
67
What criteria should you use to decide to treat ventricular tachycardia?
Multiform Patient haemodynamically compromised HR rate over 200 R on T phenomemnon - high risk of progressing to V fib
68
What should you give only if IV lidocaine does not resolve ventricular tachycardia?
IV Amiodarone | Need to premedicate with steroids and anti-histamines first
69
How should you treat a bradyarrhythmia?
Rule out Hyperkalaemia / hypothyroidism Atropine response test - if vagally mediated, HR will double in 30-40 mins Anti-cholinergics - atropine, propantheline Beta agonists - terbutaline (beta 2) Xanthine derivatives - theophylline, aminothylline, etamiphyline Pacemaker
70
How should you initially treat hypertension?
Amlodipine - calcium channel blocker with just vascular effects
71
How can you protect the kidneys in hypertension?
Ace inhibitors - benazepril - reduce the GFR Angiotensin II receptor blockers - Telmisartan
72
How can you prevent FATE in cats?
Low dose aspirin Clopidogrel - FAT cat study - more effective at prevention Low molecular weight Heparin (don't need to monitor clotting time)
73
How should you treat pulmonary thromboembolism?
O2 therapy Clopidogrel Aspirin Low molecular weight heparin
74
How should you treat lungworm?
Fenbendazole (panacur) Milbemycin oxime (Milbemax) Moxidectin (with imidacloprid in advocate) - repeat in 30days Prednisolone - if pulmonary haemorrhage or very severe burden
75
How can you prevent lungworm?
Moxidectin or milbemycin q 4w

Small Animal Cardiology (9 decks)

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