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Flashcards in Pharm Ischemic Heart Disease Deck (28)
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1

Nitrates
-examples
-indications
-MOA

Examples:
-Nitroglycerin (Nitrostat, Nitroquick)
-Isosorbide dinitrate (Isordil)
-Isosorbide mononitratae (Imdur)
-Transdermal patch (NitroDur)

Indications:
-acute angina
-chronic angina
-CHF

MOA:
-nitrates decrease the O2 demand of the heart by:
1. decreasing arteriolar and venous tone (systemic and coronary)
2. decrease preload
3. decrease afterload
4. incrase O2 supply to the heart
4. decrease BP

2

Short Acting Nitrates
-when do you use these?
-how are they taken?

-used fro immediate relief of acute anginal sx.

-sublingual nitro tablets or spray, repeat in 3-5min if needed x3. Not great advice for everyone, requires a lot of patient education. Best advice is to take one and call 911.

3

Nitroglycerin
-SE
-CI

SE:
-HA
-Dizziness
-Hypotension
-Flushing
**Passing out.
CI:
-Hypotension
-Aortic Stenosis
-Severe volume depletion
-acute RV infarction (rely on high preload during this time)
-Hypertrophic cardiomyopathy
-Recent meds for ED (Viagra, Levitra, Cialis)

4

Long acting nitrates
-first line monotherapy? Why or why not?
-how long does the blood need to be free of free nitrates/day?
-examples

-Not used as first line, usually used as and add on to other anti-angina drugs. This is because over time tolerance is developed to this medication and it no longer works, so we save this for last.

-The blood needs to be free of free nitrates for 8-10hrs/day.

Examples:
-Isosorbide dinitrate(Isordil)
-Isosorbide mononitrate (Imdur)***
-Transdermal patch (NitroDur)

5

Beta Blockers
-examples
-Indications
-SE
-MOA

Examples:
-Metoprolol (Lopressor, Toprol)
-Bisoprolol (Zebeta)
-Atenolol (Tenormin)
-Carvedilol (Coreg)

Indications:
-HTN
-Tachycardia
-CHF
-Ischemic Heart disease
--NSTEMI (non-elevated ST elevation MI)
--STEMI
--Unstable/Chronic Angina

SE:
- Bradycardia
-Lethargy
-GI disturbance
-CHF
-Decreased BP
-Depression

MOA:
*negative inotrope and chronotrope
-decreases HR, force of contraction, AV conduction rate.

6

What is first line therapy for treatment of chronic angina?

-beta blocker

7

What is the only anti-anginal agent proven to prolong life in patients with CAD post MI?

-beta blockers!!!
*most common: Metoprolol (Lopressor)

8

Beta Blockers
-CI
-caution

-severe bronchospasm
-bradyarrhythmias
-decompensated heart failure (in midst of acute exacerbation)
-may worsent with Prinzmetals angina d/t leaving alpha 1 receptors unopposed. (normally, alpha and beta try to balance one another out, if you block the betas the alphas party b/c the betas are gone, this makes angina worse)

Cautions:
-mask hypoglycemia sx (tachycarida, sweating, confusion)
-abrupt withdrawl (3 days)

9

Calcium Channel Blockers
-examples
-indications
-MOA

examples:
Dihydropyridines:
-Amlodipine (Norvasc)
-Nifedipine (Adalat, Procardia)
Nondihydropyridines:
-Diltiazem (Cardizem)
-Verapamil

Indications:
-HTN
-Tachycardia
-Chronic Angina
-Coronary vasospaasm
-Peripheral vasospasm

MOA:
-Calcium channel blockers decrease myocardial O2 demand by:
1. decrease preload
2. decrease heart rate (verapamil, diltiazem)
3. decrease blood pressure
4. decrease contractility (Verapamil, diltiazem)
5. increase O2 supply
6. cause coronary artery vasodilation

10

Which of the Ca2+ channel blocker medication is only approved for use in CHF? WHY?

-Dihydropyridines; Amlodipine (Norvasc)

Why:
-it does not have the negative inotropic(contractility) or chronotropic(rate) effects that the other calcium channel blockers have.

11

SE of Calcium CHannel Blockers

-HA
-Edema
-Constipation
-Hypotension
-Dizziness
-Bradycardia (nondihydropyridines; cardizem & verapamil)

12

-CI to nondihydropyridines (verapamil, cardizem)

-CI for all calcium channel blockers

-systolic CHF d/t lower EF
-AV block or bradycardia.

CI All Ca2+:
-pt w/ peripheral edema or hx of hypotension
-multiple drug interactions* caution* (cleared through the liver, CYP enzymes)

13

Define each of the following:
-Antiplatelet
-Fibrinolytic
-Anticoagulants

Antiplatelets: drugs interfere either with platelet adhesion and/or aggregation. (prevent initial clot formation)

Fibrinolytic: degrade fibrinogen/fibrin (eliminate formed clots)

Anticoagulants: inhibit clotting mechanism ( prevent progression of thrombosis)

14

Antiplatelets
-examples
-MOA
-absorption peak

Examples: Antiplatelet
-Aspirin
-Clopidogrel (Plavix)
-Prasugrel (Effient)
-Ticagrelor (Brilinta)
-Abiciximab (Reopro)
-EPtifibatide (Integrelin)
*last two are IV, used in setting of MI

MOA:
-inhibits cyclooxygenase that then inhibits the synthesis of thromboxane A2, a potent stimulator of platelet aggregation.
*irreversible platelet inhibitor

Absorption peak is 1Hr

15

Dosing Recommendations of Aspirin
-primary prevention of CVA/MI
-Secondary prevention of CVA/MI (already had one)
-Acute coronary syndrome (in the midst of having an MI)

Primary prevention: 81mg/day

Secondary: 325mg/day acutely(several months)

Acute syndrome: 325mg chewed x1

16

SE of Aspirin

-GI bleeding
(H2 Blockers or proton pump inhibitors may decrease gastritis and GI bleeding, also administer with food to decrease GI disturbnace)

-tinnitus at high doses
-resistance (dont metabolize and has no effect on platelet aggregation)
-allergy

17

How many days pre-op should you stop taking aspirin?

-4days

18

P2Y12 Antagonists
-examples
-MOA
-indications

Examples: Antiplatelet
-Clopidogrel (Plavix)
-Prasugrel (Effient)
-Ticagrelor (Brilinta)

MOA:
-inhibits the binding of fibrinogen to activated platelets by blocking P2Y12 receptor site, as a result the GP IIb/IIIa receptor is not activated. (which is the binding site for fibrinogen, von Willebrand factor)
-resulting in the blockage of platelet aggregation and prevention of thrombosis

19

P2Y12 Antagonists
-Indications
-do these require loading dose?

Indications:
-unstable angina
-NSTEMI/STEMI
-post intracoronary stent placement
-post stroke
-PVD
*no indication for primary prevention of MI/CVA unless the patient is allergic to aspirin

-yes, these drugs require a loading dose. Plavix has the slowest time to detection in the blood of all three medications

20

P2Y12
-SE
-not recommended in whom?
-reversible?

SE:
-bleeding**
-SOB w/ Ticagrelor

Not recommended in LOP. Greater than 75 or weigh less than 132lbs.

-No antidote for the reversal of the medication in the event of significant bleeding.

21

GPIIB/IIIA Antagonist
-examples
-Route of administration
-Indications

examples: Platelet Antagonists
-Abiciximab (Reopro)
-EPtifibatide (Integrelin)

Route: IV

Indication:
acute coronary syndrome, percutananeous coronary intervention

22

GPIIB/IIIA Antagonist
-onset of action
-reversible?
-SE

Onset: immediate

-yes Reversible, platelet function is restored to normal 4-8hrs after discontinuation of infusion

SE:
-bleeding
-thrombocytopenia (reversible once discontinuation of med_
-allergy

23

Anticoagulants:
-examples
-indications

Enoxaparin (Lovenox) (LMWH)
Heparin (UFH)
Bivalirudin (Angiomax)

-indications:
-acute MI situations only.

24

Heparin
-MOA
-what lab do we base our medication adjustments on?
-CI
-Adverse Effects

anticoagulant
MOA:
-activation of anti-clotting factors (especially ATIII)
-indirect thrombin inhibitor

-Base med adjustments on the PTT

CI:
-anaphylaxis and recent major surgery

Adverse effects:
-bleeding, hypersensitivity rxn, transaminitis, heparin induced thrombocytopenia (HIT)

25

Enoxaparin (Lovenox)
-MOA
-route of admin

Anticoagulant

MOA:
-inhibits Xa and ATIII
*indirect inhibitor of thrombin

Route:
used in MI, IV dose followed by SQ dose.

26

Bivalirudin (Angiomax)
-MOA
-Route of administration
-SE
-CI

MOA:
-direct thrombin inhibitor (IIa), immediate onset of action.

-IV infusion only

-SE: bleeding
-CI: Allergy or recent major surgery or trauma

27

Fibrinolytics
-aka
-examples
-MOA
-Indications

aka: Thrombolytics

exampleS:
-tPA: Alteplase (Activase); Reteplase (Retavase); Tenecteplase (TNKase)
-Streptokinase (Streptase)
-Urokinase (Abbokinase)

MOA:
-convert plasminogen into plasmin to break down fibrin strands.

Indications :
-MI
-Stroke
-MASSIVE PE
-Limb threatening ischemia

28

Fibrinolytics
-SE
-CI

SE:
-life threatening bleeding (LTB)
*check with hospital to use a checklist prior to administration.

CI:
ABSOLUTE:
-previous intracranial bleeding at any time
-CVA in last 3 mo
-Close head or facial trauma last 3 mo
-uncontrolled HTN greater than 180SBP and 100DBP

Relative:
-Current anticoagulant use
-invasive surgical procedure in last 2 wks
-pregnancy
known bleeding diathesis (predisposition)