Lesson 2

Question 1

what is the difference between exertional angina and variant angina

Answer 1

exertional angina: obstruction of coronary vessels by artherosclerotic plaque. (brought on by exertional
activitiy
variant angina- spasms of vascular smooth muscle leading to the heart which temporarily narrow the artery, usually does not progress to an MI, more pain, usually occurs at rest

Question 2

what are the three drug classes used to treat exertional angina?

Answer 2

Nitrites
beta blockers
calcium channel blockers

Question 3

what are the determinants of myocardial oxygen demand ?

Answer 3

heart rate
heart muscle contractility
preload
afterload

Question 4

what are the two cardiac calcium channel blockers

Answer 4

Diltiazem
Verapimil
they mimic B-blockers by reducing heart rate and contractility

Question 5

what are signs of exertional angina?

Answer 5

pressure, squeezing, burning, tightness in chest, pain behind breastbone, radiating pain in arms shoulders, neck, jaw, throat, back, indigestion or heart burn, nausea fatigue, shortness of air, sweating, light headed, weak

Question 6

what are the 2 drug classes used to treat variant angina?

Answer 6

Daily nitroglycerine

Calcium Channel Blockers

Question 7

why are some patients instructed to provide themselves with a daily nitrate free interval?

Answer 7

some patients will experience partial or complete nitrate tolerance when using multiple dosing or use of long acting formulations

Question 8

which nitrate formulations are used to treat acute attacks?

Answer 8

sublingual tablets or spray and topical ointment (15-30 min)

rapid onset of 1-2 minutes

Question 9

which nitrates are used prophylactically?

Answer 9

transdermal patches, sustained release tablets isosorbide dinitrite and isosorbid monontire tablets

Question 10

what are nitrite transdermal patches used for?

Answer 10

used prophylactically or to reduce frequency of anginal attacks
they provide a steady release over 24 hours

Question 11

what is the mechanism of action of Nitrates?

Answer 11

Nitrates are venous dilators. they are converted to NO that relaxes vascular smooth muscle
Nitrate decrease preload, decrease afterload, decrease oxygen demand, and increase blood flow to deep myocardial muscle

Question 12

what is the adverse affects of Nitrates?

Answer 12

flushing , venous pooling (peripheral edema), hypotension, ORTHOSTATIC HYPOTENSION, acute headache, dizziness

Question 13

what effects do nitrates, CCB and Beta BLockers have on exercise tolerance?

Answer 13

decreased exercise tolerance

Question 14

which medications should a person with stable exertional angina be given?

Answer 14

B-blocker-prophylactically prevent attacks and increase M/M
daily nitroglycerine tablet/ or CCB
SL nitroglycerine for acute attacks
antiplatelet therapy (asprin) to reduce stroke risk
statin to lower cholesterol

Question 15

which medications should patients with variant angina be prescribed?

Answer 15

CCB or daily nitro
SL nitro for acute attacks
may or may not use antiplatelet drugs or statins

Question 16

ejection fraction

Answer 16

fraction of blood that is pumped out of the left ventricle with each heart beat compared to the total amount of blood delivered to the left ventricle
normal EF = 55-70%
can indicate dysfunctions of the heart
use an echocardogram to measure

Question 17

diastolic heart failure

Answer 17

most common in elderly females with hypertension and diabetes

• left ventricle is ejecting most of the blood it is receiving, but it isn’t receiving as much as it should
• normal or even elevated EF
• some ventricular hypertrophy

Question 18

systolic heart failure

Answer 18

caused by MI or coronary artery disease

• left ventricle is unable to empty as much blood as it should with each contraction
• low EF <40%
• reduced contractility and ventricular hypertrophy

Question 19

class 1 heart failure

Answer 19

asymptomatic

• no limit to PA
• can PA without fatigue, palpitation dyspnea or angin

Question 20

class 2 heart failure

Answer 20

symtomatic with moderate activity

• comfortable at rest
• ordinary {A results in fatigue palpitation, dyspnea or angina pain

Question 21

class 3 heart failure

Answer 21

symptomatic with mild actiivity

• comfortable at rest
• less than ordinary PA results in fatigue, palpitation, dyspnea, angina

Question 22

class 4 heart failure

Answer 22

symptomatic at rest

• limit to PA
• any PA causes discomfort

Question 23

in patients with chronic HF which medications exacerbate or make it worse?

Answer 23

• use of negative inotropes (B blockers, verapamil, diltiazem etc)
• drugs that cause sodium or water retention such as NSAIDs , COX II inhibitors, corticosteroids, Rosiglitazone, estrogens/androgens

Question 24

common causes of Congestive Heart Failure

Answer 24

coronary heart disease (angina, palques, ischemia, hard arteries)
MI
uncontrolled hypertension
renal failure
dysrhythmias (brady, tachy)
age >65 years

Question 25

how does the body's compensatory mechanisms eventually worsen heart failure?

Answer 25

increase symp activity:

Question 26

what is the best class of drugs to give patients with systolic chronic heart failure

Answer 26

ACE-Inhibitors or ARBS

Question 27

list in order the drugs potentially used for systolic heart failure

Answer 27

ACE inhibitors/ ARBS Beta Blockers (could worsen HF and fluid acc.) Diuretics (loop recommended in HF) Sprironolactone (aldosterone blocker) vasodilators (used for patients who cannot tolerate ACE or ARB) Digoxin (last resort; used in patients that triple therapy isn't working well)

Question 28

digoxins's mechanism of action

Answer 28

- cardiac glycoside - positive inotrope: inhibits the Na+/K+ pump meaning intracellular Na+ increases, calcium in the cell increases. - has neurohormonal effects: decreased sympathetic NS, decreased HR

Question 29

inotrope

Answer 29

force of contraction

Question 30

chronotrope

Answer 30

heart rate

Question 31

digoxins therapeutic use

Answer 31

treats systolic CHF (as a last resort if triple therapy does not work a-fib

Question 32

digoxin ADR's

Answer 32

narrow therapeutic window - intertacts with beta blockers, diltiazem, verapamil - interacts with AV heart block - interacts with cytochrome P450 liver - antacids reduce oral absorption

Question 33

signs of Digoxin toxicity

Answer 33

nasea, vomiting, dizziness, headache, neuralgia, confusion, delerium, psychosis, loss of appetite blurred vision, haloes, photophobia, red-green or yellow green tinted vision -cardiac dysrhythmia -sinus bradycardia (PULSE LESS THAN 60 BPM)

Question 34

class of medications ending in tan

Answer 34

ARBs

Question 35

asprin mechanism of action

Answer 35

irriversable inhibitor of Cox- prevents platelet aggregation | -

Question 36

asprin therapeutic use

Answer 36

- prevents stroke / MI - pos acute coronary syndrome - post stent placement - secondary stroke prevention

Question 37

asprin ADRs

Answer 37

hypersensitive allergies, upset stomach/GI discomfort - GI ulcers - excessive bleeding - risk of clots with withdrawl

Question 38

what are the drug interactions of NSAIDs

Answer 38

- interactions with other NSAIDs - increased risk os GI ulcers/bleeding - may block antiplatelet benefits of asprin - other antiplatelet/anticoagulants both increase risk of bleeding

Question 39

class of medication that ends with grel

Answer 39

ADP inhibitors (antiplatelet drugs)

Question 40

dipyridamole + asprin therapeutic use and mechanism of action

Answer 40

secondary stroke prevention | -leads to accumulation of cAMP and cGMP, enhances antithrombotic potential of vascular wall

Question 41

common triggers of platelet activation

Answer 41

``` collagen epinephrine thrombin thromboxane A2 adenosine diphosphate ```

Question 42

list the three doses of aspirin that are considered to be low dose or cardiac dose

Answer 42

``` 81 mg (baby aspirin), regular or enteric coated 162 mg, regular or enteric coated 325 mg (single tablet of the regular strength) ```