Cardio Meds-lecture Flashcards
(215 cards)
1
Q
what is the basic pathophysiology of IHD/CHD
A
imbalance between cardiac oxygen needs and supply.
2
Q
Acute therapy for chronic stable angina
A
Nitroglycerin
3
Q
Are beta blockers used for long term or short term therapy for chronic stable angina
A
long term
4
Q
Class of nitroglycerin
A
Vasodilator
5
Q
Indications for nitroglycerine
A
angina
CHF
6
Q
MoA for nitroglycerine and Isosorbide Dinitrate (Isordil)
A
dilates arteries and veins by acting on the smooth muscle
7
Q
Contraindications for nitroglycerine and Isosorbide Dinitrate (Isordil)
A
Head trauma
severe dehydration
and obviously allergy
8
Q
PDE-5 inhibitors are a known dx-dx for what?
A
Nitro and Isosorbide Dinitrate (Isordil)
9
Q
There are many formulations for nitro. Name some
A
Sub lingual spray Sub lingua or buccal tab topical IV (glass bottle (?) vaporizes)
10
Q
What do you use Isosorbide dinitrate (Isordil) for?
A
frequent stable angina, CHF
11
Q
These meds dilate arteries and veins by relaxing the smooth muscle around them
A
Nitroglycerine and Isosorbide Dinitrate (Isordil)
12
Q
Nitroglycering and Isosorbide Dinitrate (Isordil) are both vasodilators, which one is long acting and which is short acting?
A
Nitro-short
Isosorbide Dinitrate-long
13
Q
Off-label use for Isosorbide Dinitrate (Isordil)
A
esophageal spastic disorders
14
Q
How long should the nitrate-free interval be when using Isosorbide Dinitrate (Isordil)
A
8-12 hours
15
Q
What are the 2 Dihydropyridine (DHP) Ca++ channel blockers?
A
Amlodipine (Norvasc)
Nifedipine (Adalat)
16
Q
What kind of Ca++ blocker are Diltizem and Verapamil?
A
Nonhydropyridines (NDHP)
17
Q
Can you use Dihydropyridine CCB to treat HTN?
A
Yes
Primary indication: Angina
18
Q
How do the dihydropyridine CCBs work?
A
Cause vasodilation by blocking Ca++ channels in vascular smooth muscle. Any med ending in -dipine is a DHP and only affects peripheral vasculature. (But ppt says they also act on myocardium.)
19
Q
Side effect seen in elderly with Nifedipine (Adalat) and Amlodipine (Norvasc)
A
Hypotension
20
Q
What do patients need to avoid while on Ca++ channel blockers?
A
Grapefruit Juice
21
Q
Contraindications for Nifedipine (Adalat) and Amlodipine (Norvasc). (DHP meds)
A
Just allergy
22
Q
Side effects of Nifedipine (Adalat) and Amlodipine (Norvasc)
A
DHPs
Nausea
Palpitations
Peripheral Edema
Elderly-hypotension
23
Q
What do we use PDE-5 inhibitors for? Give an example.
A
Erectile dysfxn. viagra (Sildenafil)
24
Q
pregnancy category for most angina meds
A
C
Aspirin and Atenolol: D
Plavix: B
25
Of Amlodipine and Nifedipine, which is more likely to cause hypotension?
Nifedipine
26
What does it mean for a med to be in the class Non-dihydropyridine?
It blocks the Ca++ channels in the heart rather than the periphery.
27
Indications for NDHPs
```
Diltiazam and Verapamil are used for:
Angina
HTN
PSVT
A fib
A flutter
```
28
MoA of NDHPs
Diltaziam and Verapamil dilate coronary arteries and decrease myocardial oxygen demands
29
What class is Diltiazem (Cardizem)?
Non-dihydropyridine Calcium Channel Blocker
30
Side effects of Diltiazem (Cardizem)?
Headache, edema, dyspepsia
31
Side effects of Verapamil (Calan)?
Headache, gingival hyperplasia, constipation, fatigue
32
Don't give Diltiazem (Cardizem) or Verapamil (Calan) to people with...
Bradycardia, Sick Sinus Syndrome with no pacer.
33
Do you need to monitor LFT's, BP, and chest pain with Verapamil (Calan)?
Yes, same goes for the other NDHP (Diltiazem-Cardizem)
34
Which calcium channel blockers can you combine with a beta blocker?
Amlodipine (Norvasc)
35
Which calcium channel blockers can you NOT combine with a betablocker? Why?
Diltiazem (Cardizem)
Verapamil (Calan)
Will decrease nodal conduction
36
Is CHF a contraindication for Diltiazem (Cardizem) and Verapamil (Calan)?
Yes
37
What impact does cirrhosis have on Diltiazem (Cardiezem)?
Increases the half life
38
Class of Propranolol (Inderal)
Non-selective Beta Blocker
| Beta 1 and Beta 2
39
Class of Carvedilol (Coreg)
```
Non-selective Beta Blocker
Mixed alpha (1) and beta (1 and 2) receptor inhibitaion
```
40
Uses for Propanolol (Inderal)
Angina, HTN, Tachy-arrhythmias, essential tremore, migrane prevention, anxiety
41
Uses for Carvedilol (Coreg)
Angina (off-label), HTN, stable HF, stable post-MI
42
What side effects do BOTH non-selective beta blockers cause?
Fatigue, sleep disturbance, depression
43
Side effects of Carvedilol (Coreg) that arne't side effects of Propanolol (Inderal)
Bradycardia, rebound angina/hypertension, hypotension
44
Do beta blockers react with other drugs? Which ones?
A lot. Look it up.
45
What do we monitor on Beta blockers?
BP, chest pain, HR, LFT, eGFR
46
MoA of Propranolol (Inderal)
Blocks a1, b1, b2 and produces a reduction in myocardial oxygen demand
47
Hypersensitivity, bradycardia, and what else are contraindications for Carvedilol (Coreg)?
heart block, uncompensated HF, severe depression, bronchospasm, severe liver failure
48
Can you give Carvedilol (Coreg) to someone with asthma?
Probably not. It can cause bronchospasm
49
Can you give Beta Blockers (all kinds) to someone who has had an MI or has compensated HF?
Yes, but you need to titrate slowly
50
Can you drink alcohol while taking Propanolol (Inderal)?
no
51
What class is Metoprolol?
Selective beta blocker
52
Indications for Metoprolol and Atenolol (Tenormin)
Angina, HTN, hemodynamicaly stable MI
53
By how much do beta blockers reduce risk of second MI?
25%
54
How much of Atenolol (Tenormin) is excreted renally?
~50%
55
If you give someone high dose of Metoprolol (>100mg day), what happens?
Loses selectivity for B1.
56
Cardiac related contraindications for Atenolol (tenormin) and Metoprolol
bradycardia, rebound angina/hypertension, hypotension
57
Class of Ranolazine (Ranexa)
Na+ channel inhibitor. Anti-angina
| This is a new drug
58
Uses for Ranolazine (Ranexa)
Chronic Angina
59
MoA of Ranolazine
Inhibits inward sodium channel in inschemic cardiac cells during repolarization. This reduces Na+/Ca++ exchange which relaxes cardiac muscle -->reduces oxygen consumption
60
Is Diltiazem a CYP34A inhibitor?
yes
61
Can you give Ranolazine and Diltiazem at the same time?
No, Ranolazine dx-dx with CYP34A inhibors (diltiazem, erythromycin, verapamil)
62
Can you give cyclosporine with Ranolazine (Ranexa)?
Nope. dx-dx with P-glycoprotein and Ranolazine (Ranexa)
63
What do you monitor with Ranolazine?
BP, HR, eGFR, LFTs
64
What happens to serum levels in people with renal dysfunction when they take Ranalzine?
They increase
65
If someone has renal cirrhosis, can you give them Ranalzine?
No. not even a little.
66
Can you take Ranolazine with food? with juice?
food yes, but NOT with grapefruit juice.
67
Can you crush the Ranolazine pills and mix them in with apple sauce?
nope
68
Should Ranolazine be used for acute angina?
no it should not
69
What impact does Ranolazine have on heart rhythm?
prolongs QT interval
70
MoA for aspirin
COX-1 inactivation. Stops thromboxane A2 formation. TXA2 is needed for platelet aggregation and vasoconstriction.
71
Will aspirin give me a tummy ache?
30% of the time is causes gastritis and dyspepsia.
Also monitor for melana
72
What is Samter's triad?
Aspirin-induced respiratory disease. In aprox 25% of asthmatics with nasal polyps, aspirin will increase asthma and allergy symptoms (watery eyes, itching, bronchospasm).
73
Average dose of ASA?
81 mg
74
What is the difference between MoAs of Diltiazem and Verapamil
Diltiazem is a benzothiazapine and acts on both peripheral vasculature as well as coronary vasculature. Verapamil impacts only coronary arteries.
75
Who's your FAST friend in heart failure???
Diuretics!!
76
What is heart failure? (In simple terms)
Heart can't keep up with all the work it's supposed to do. This creates a whole slew of systemic problems.
77
Primary goals of pharm therapy for heart failure
1. improve cardiac fxn2. reduce clinal symptoms3. reduce hospitalizations4. reduce risk of death
78
What will a patient with heart failure complain of?
Fatigued, weak, exercise intolerant.
79
How often does someone with heart failure pee?
A lot. And at night.Polyuria, Nocturia
80
What will lower extremities look like in HF?
Dependent edema d/t inadequate perfusion of tissue
81
What will the neck look like in HF?
jvd
82
What will you see on exam if the patient has HF
Dyspnea, inadequte pumping, orthopnea (SOB when lying flat), Post-nasal drip
83
Do diuretics cure HF?
No, they can quickly help decrease acute fluid load
84
What should you watch for when using diuretics?
Electrolyte imbalance, general dehydration
85
Why do diuretics work well as initial therapy?
They can help clear fluid while long-term controlling agents are on-boarding.
86
What is the most common diuretic used?
Furosemide (Lasix)
87
Which diuretic has IV and oral dosing equilants?
Torsemide
88
Which diuretics are sulfa meds?
Furosemide (Lasix)Torsemide (Demadex)
89
Which diuretic is a non-sulfa med?
Ethacrynic Acid (Edecrin) not used much
90
MoA for loop diuretics
Block reabsorption of Na+, K+ and Cl- in TAL (thick ascending loop) of henle and distal tubule. Water follows ions, so if the ions aren't absorbed, everything gets peed out.
91
Side effects of Loop Diuretics (Occurs in loop of Henley)
Electrolyte imbalance (esp hypokalemia-not enough K+)Orthostatic HypotensionDehydrationFurosemide has highest risk of these
92
If you're allergic to sulfa ABX, should you avoid sulfa diuretics?
No necessarily. No evidence that the allergies are related, but patients might be reluctant.
93
What can you look for that might indicate decreased profusion resulting from dehydration?
hypotension, orthostatic hypotension
94
How can you monitor the effectiveness of loop diuretics?
daily body weights
95
What should you monitor with loop diuretics?
Electrolytes, BUN, Creatinine clearance
96
Electrolyte imbalance and renal function changes are common when starting loop diuretics. When should we expect these to stabilize?
2-3 weeks, but continue to monitor even after that.
97
Indications for Furosemide, Torsemide, and Ethacrynic Acid
Edema d/t CHF, Renal failure, Hepatic failure, HTN
98
What effect do Loop Diuretics have on serum uric acid?
Furosemid, Torsemide and Ethacrynic acid can decrease then increase serum uric acid.
99
Major difference between Torsemide and Furosemide?
Torsemide has longer half life. 10-20 mg of Torsemide has about the same diuretic impact as 40 mg of Furosemide.
100
What happens when someone on Furosemide takes corticosteroids?
The steroids increase the impact of furosemide.
101
what is the outpatient weight loss target with loop diuretics?
~2 lbs per day. Once at dry weight, titrate down.
102
Can you use Nondihydropyridines for HF?
No, becasue of their cardiac impact
103
Can you use dihydropyridines for HF?
Yes. It's safe. Not the primary indication though. They have been shown to be safe in HF patients needing drug for angina or HTN.
104
What do you want to monitor with Furosemide and Ethacryinic Acid?
Serum ElectrolytesBUNCrClBPHearing if high dose therapy
105
What is anuria and which med is it a contraindication for?
Kidneys not making urine. Don't use Torsemide with anuria.
106
Side effects of Torsemide?
constipation. diarrhea. Really? Both??
107
Remind me again what is unique about Ethacrynic Acid?
Non-sulfonamide
108
Drug category/class of Spironolactone (aldactone) and Eplerenone (inspra)
Aldosterone Antagonistaka Potassium Sparing Diuretics
109
MoA of Aldosterone Antagonists?
Spironolactone and Eplerenone: inhibit sodium reabsorption by disrupting aldosterone-dependent Na+/K+ pump. PEE MORE!Promote excretion of Na+, Cl-, and water. Retains K+. (Potassium sparing)
110
Aldosterone Antagonists are relatively weak diuretics. Why do we use them?
Their anti-aldosterone activity reduces cardiac fibrosis.
111
General GI/GU SEs of aldosterone antagonists
Hyponatremia, Diarrhea, amenorrhea, impotence, gynecomastia.
112
General Neuro SE's of aldosterone antagonists
Headache, Drowsiness
113
Monitoring in Aldosterone Antagonists
BUN, Electrolytes, Potassium (especially with spironolactone)
114
What do we specifically monitor with Spironalactone?
Potassium.But also: daily weights, BP, eGFR, gynecomastia
115
What does poor renal fxn put people at risk for if taking Spironolactone & Eplerenone?
Aldosterone Antagonists can cause hyperkalemia
116
Side effects specific to Spironolactone (Aldactone)
Ataxia, SJS, gynecomastia, amenorrhea, agranulocytosis (dec granulocytes, inc risk of infection), hepatotoxicity
117
Contra indications of Spironolactone
Anuria, Acute renal insufficency, hyperkalemia, addison's disease, low serum K+, low eGFR, K+supplements
118
If a patient has an eGFR below ____, you can't prescribe spironolactone.
30
119
If a patient has a serum K level above _____, you can't prescribe spironolactone.
>5.5 mEq/L
120
What drugs does Spironolactone interact with
Look it up. There are many.
121
Can the elderly and patients with diabetes take Spironolactone?
Yes, but monitor renal fxn and serum K very closely!
122
what is the outpatient weight loss target with loop diuretics?
~2 lbs per day. Once at dry weight, titrate down.
123
Which drugs are the Loop diuretics?
Furosemide, Torsemide, Ethacrynic Acid
124
Can you use Nondihydropyridines for HF?
No, becasue of their cardiac impact
125
Can you use dihydropyridines for HF?
Yes. It's safe. Not the primary indication though. They have been shown to be safe in HF patients needing drug for angina or HTN.
126
What do you want to monitor with Furosemide and Ethacryinic Acid?
Serum ElectrolytesBUNCrClBPHearing if high dose therapy
127
What is anuria and which med is it a contraindication for?
Kidneys not making urine. Don't use Torsemide with anuria.
128
Side effects of Torsemide?
constipation. diarrhea. Really? Both??
129
Remind me again what is unique about Ethacrynic Acid?
Non-sulfonamide
130
Drug category/class of Spironolactone (aldactone) and Eplerenone (inspra)
Aldosterone Antagonistaka Potassium Sparing Diuretics
131
MoA of Aldosterone Antagonists?
Spironolactone and Eplerenone: inhibit sodium reabsorption by disrupting aldosterone-dependent Na+/K+ pump. PEE MORE!Promote excretion of Na+, Cl-, and water. Retains K+. (Potassium sparing)
132
Aldosterone Antagonists are relatively weak diuretics. Why do we use them?
Their anti-aldosterone activity reduces cardiac fibrosis.
133
General GI/GU SEs of aldosterone antagonists
Hyponatremia, Diarrhea, amenorrhea, impotence, gynecomastia.
134
General Neuro SE's of aldosterone antagonists
Headache, Drowsiness
135
Monitoring in Aldosterone Antagonists
BUN, Electrolytes, Potassium (especially with spironolactone)
136
What do we specifically monitor with Spironalactone?
Potassium.But also: daily weights, BP, eGFR, gynecomastia
137
What does poor renal fxn put people at risk for if taking Spironolactone & Eplerenone?
Aldosterone Antagonists can cause hyperkalemia
138
Side effects specific to Spironolactone (Aldactone)
Ataxia, SJS, gynecomastia, amenorrhea, agranulocytosis (dec granulocytes, inc risk of infection), hepatotoxicity
139
Contra indications of Spironolactone
Anuria, Acute renal insufficency, hyperkalemia, addison's disease, low serum K+, low eGFR, K+supplements
140
If a patient has an eGFR below ____, you can't prescribe spironolactone.
141
If a patient has a serum K level above _____, you can't prescribe spironolactone.
>5.5 mEq/L
142
What drugs does Spironolactone interact with
Look it up. There are many.
143
Can the elderly and patients with diabetes take Spironolactone?
Yes, but monitor renal fxn and serum K very closely!
144
What class is Eplerenone
Aldosterone Receptor Antagonist (Potassium Sparing Diuretic)
145
If someone has excessive aldosterone excretion, you're likely to see (many things and ) hypertension. What are 2 meds that will directly block the aldosterone receptor and lower blood pressure?
Spironolactone and Eplerenone
146
Where will Spironolactone (Aldactone) block aldosterone receptors?
distal renal tubule and blood vessels
147
Where will Eplerenone (inspra) block aldosterone receptors?
kindey, heart, blood vessels, brain
148
Side effects of Eplerenone.
Hyperkalemia, hypertriglyceredemia, cough, diarrhea
149
Is Eplerenone more or less likely than Spironolactone to cause gynecomastia?
less likely
150
Where do beta blockers effect their impact?
Heart, kidneys. (beta 1)
151
When using Beta Blockers in heart failure, what labs do we need in order to monitor patients?
None, but all patients should have baseline labs (BMP, CrCl, electrolytes, renal function). Also monitor HR
152
What do beta blockers do?
Decrease HR
Decrease Stroke Volume
Decrease TPR (total peripheral resistance) by decreasing renin and angiontesin II
153
What Beta Blocker is non-selective and will go to B1, B2, A1
Carvedilol (Coreg)
154
When can you not prescribe Beta Blockers in HF? (6 answers)
```
Asthma
Symptomatic HYPOtension
HR under 60
PAD with resting limb ischemia
Second or third degree AV block
Evidence of fluid retention
```
155
Does metoprolol have the same dosing for angina and heart failure?
no, they are different.
156
Decreasing (or blocking) norepinephrine binding rate will have what effect on BP?
lower's BP
157
Can carvedilol (coreg) cause you to lose weight?
Actually, weight GAIN is a side effect and you should monitor for it.
158
Can you give Carvedilol (Coreg) to someone with COPD?
No, it is non-selective and will block B2 receptors causing bronchospasm
159
What is Inotropy?
Force of contraction
160
What do positive inotropes do?
Increase the force of ventricular contraction
161
What do negative inotropes do?
Decrease the force of ventricular contraction
162
What class is Digoxin?
Positive Inotropic Agent: *Cardiac Glycocides*
163
What ion does digoxin increase intracelularly and how does it do this?
Na+ and Ca++. It inhibits Na-K-ATPase pump in myocardial cells.
164
Will positive inotropic agents have an effect on HR?
They decrease HR by increasing vagal tone
165
4 EKG changes seen with Digoxin
```
Cardiac Glycocides can cause:
Prolong PR interval
ST seg depression
Inverted T wave
Short QT interval
```
166
Initial does for Digoxin
0.125 mg to 0.25mg
167
Should you give digoxin as a first line tx for HF?
No. it might induce arrhythmias (PVCs secondary to inc intracellular Ca++)
168
Can we combine Digoxin with Beta Blockers?
don't do it if possible
169
Side effects of Digoxin
```
Fatigue
Delirium
AV block
EKG changes
N/V/D
Visual disturbances
Toxic Psychosis
```
170
Indications for digoxin
Mild-moderate HF
| A-Fib rate control
171
Symptoms of digitalis toxicity
```
Confusion
Irregular pulse
Loss of appetite
N/V/D
Palpitations
Vision changes
```
172
Can you give Digoxin to someone with V-Fib, thyroid disease, or recent MI?
No
173
Class of Dobutamine
Positive Inotropic: Beta (adrenergic)-agonist
174
Where else have we used Beta-Agonists?
Pulmonology!! Although Dobutamine mainly affects Beta 1
175
Use for Dobutamine?
Short term management of cardiac decomposition
176
MOI of Dobutamine
Stimulates B-1 receptros, which Increase HR
| Increase contractility
177
Side effects of Dobutamine
paradoxical hypotension.
| Exacerbation of ventricular ectopy.
178
Contra indications of Dobutamine?
Allergy to sulfites (may contain sodium bisulfate).
Recent use of MOA inhibitors.
IHSS
179
Drug interactions
Sympathomemetics: stimulant compounds that mimic the effects of catecholamines (epi/norepi)
180
Monitor these while on Dobutamine
```
BP
HR
EKG
glucose
eGFR
urine output
```
181
how do you administer Dobutamine
IV
182
Class of Milrinone (Primacore)
Inotropic Agent-Phosphodiesterase Inhibitors (PDE-I)
| PDE-3 inhibitor
183
MoA for PDE-Is
Increase cAMP
184
Will PCP prescribe Milrinone?
No, should only be used under close supervision of a cardiologist.
Contra in post-MI pts.
185
We are studying 2 PDE inhibitors? What are they and which PDE do they each target?
Nitro PDE-5
| Milrinone PDE-3
186
What class is Nesiritide (Natrecor)
B-type Naturetic Peptide (BNP)
187
When to use Nesiritide
Acute decomp HF with dyspnea at rest or with minimal activity
188
What does Nesiritide do?
Decrease BP.
I don't understand the complicated MoA, so we'll stick with this
189
Contra for Nesiritide (Natrecor)
Cardiogenic shock, hypotension (SBP
190
Class of Aliskiren
Direct Renin Inhibitor
191
What does Aliskiren do?
Causes vasodilation.
Keeps renin from converting angiotensinogen to agiotensin I so that there is less converstion of angiotensin I to angiotensin II.
192
If someone is on Aliskiren and Furosemide, what are the interactions?
Aliskiren will decrease effect of Furosemide.
193
What do NSAIDs do when taken with Aliskiren?
NSAIDs decrease effect of Aliskerin
194
Class of Ivabradine (Corlandor)
SA node IF channel inhibitor
195
When to use Ivabradine (Corlandor)
Heart Failure (EF
196
MoA of Ivabradine
Inhibits funny current (If) in SA node. Prolongs diastolic depol which reduces HR.
197
What are the 4 types of diuretics?
ThiazideThiazide-likeK+ sparingLoop Diuretics
198
What type of med is the most commonly used for mild to moderate HTN?
diuretics
199
How should you start dosing a diuretic?
Start with low potency, monitor for tolerance/response
200
What are the 2 major dietary changes to recommend in HTN management?
Low Na+High K+
201
What are the warning signs of K+ depletion?
1. Weakness, fatigue (most common)2. Worsening diabetes control3. polyuria4. Arrhythmia5. Muscle cramps (severe)6. Psych changes
202
Should patients be aware of any developing symptoms of hypokalemia when starting a diruretic?
Yes. Warn them.
203
What electrolytes does HCTZ increase excretion of?
Na+Cl-
204
How does HCTZ work?
inhibits Na-Cl pump in distal convoluted tubule. This increases Na, Cl excretion
205
Side effects of HCTZ
Hypokalemia!!!anorexia, nausea, photosensitivity, QT prolongation, vertigo (rare)
206
If someone has sulfa allergies, can they still take HCTZ?
no
207
What could happen to blood sugar if someone on beta blocker and HCTZ?
hyperglycemia
208
How much NaCl is absorbed in nephron BEFORE it gets to distal convoluted tubule?
~90%
209
Chronic use of HCTZ can cause decrease excretion of what ion?
Ca++
210
What is necessary GFR for HCTZ to be effective?
30-40 or higher
211
Can HCTZ increase risk of gout?
yes, it increases serum uric acid
212
What class is Chlorthalidone?
thiazide-like diuretic
213
MoA of Chlorthalidone?
inhibits Na-Cl pump. increases excretion
214
Are the side effects the same for Chlorthalidone and HCTZ?
yes*Hypokalemia*, anorexia, nausea, photosensitivity, QT prolongation, vertigo (rare)
215
What is the major difference between HCTZ and Chlorthalidone?
Chlorthalidone is approximately twice as potent.
