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Medicine Phase 2a CVS > Pharmacology > Flashcards

Pharmacology Flashcards

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1
Q

Symptomatic treatment of congestion in heart failure

A

Diuretics (usually loop)

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2
Q

1st line pharmacological treatment of heart failure

A

ACE inhibitors and Beta Blocker therapy

Low dose and slow uptitration

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3
Q

Pharmacological management of heart failure

A

a. First line: ACE inhibitors and beta blocker therapy
Low dose and slow uptitration
b. Aldosterone antagonists
c. ACE-I intolerant: Angiotensin receptor blocker
d. ACE-I and ARB intolerant: Hydralazine/nitrate combination
e. Consider digoxin or ivabradine

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4
Q

What is ANP and BNP

A

Atrial natriuretic peptide - atria

B-(brain) natriuretic peptide - ventricles

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5
Q

What causes release of natriuretic peptide hormones

A

Stretching of atrial and ventricular muscle cells
Raised atrial or ventricular pressures
Volume overload

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6
Q

Main effects of natriuretic peptide hormones

A

Increase renal excretion of sodium (natriuresis) and water (diuresis)
Relax vascular smooth muscle (except efferent arterioles of renal glomeruli)
Increased vascular permeability

Inhibit the release or actions of:
Aldosterone, angiotensin II, endothelin, anti-diuretic hormone (ADH)
Counters RAAS

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7
Q

What metabolises cardiac natriuretic peptides

A 
Neutral Endopeptidase (NEP, Neprilysin)
NEP inhibition increases levels of natriuretic peptides
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8
Q

Example of Neprilysin inhibitor - how does it work

A

Sacubitril

Inhibits neutral endopeptidase, increasing levels if natriuretic peptides. NPs reduce pressure on heart

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9
Q

Example of angiotensin II blocker

A

Valsartan

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10
Q

Examples of beta-blockers in heart failure

A

Carvedilol
Bisoprolol
Metoprolol

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11
Q

Effects of nitrates

A

Arterial and venous dilators
Reduction of preload and afterload
Lower BP

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12
Q

Main uses of nitrates

A

Ischaemic heart disease (angina)

Heart failure

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13
Q

Examples of nitrates

A

Isosorbide mononitrate
GTN spray
GTN infusion

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14
Q

Describe chronic stable angina

A 
Anginal chest pain
Predictable
Exertional
Infrequent
Stable
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15
Q

Describe unstable angina/acute coronary syndrome (NSTEMI)

A

Unpredictable
May be at rest
Frequent
Unstable

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16
Q

Describe ST elevation myocardial infarction

A

Unpredictable
Rest pain
Persistent
Unstable

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17
Q

Management of chronic stable angina

A
  1. Antiplatelet therapy
  2. Lipid-lowering therapy = Statins
  3. Short acting nitrate = GTN spray for acute atack
  4. FIRST LINE TREATMENT = Beta blocker or Calcium channel blocker
  5. If intolerant then switch
  6. If intolerant then combine
  7. If intolerant or uncontrolled, consider monotherapy or combinations:
    Long acting nitrate
    Ivabradine (inhibits If current)
    Nicorandil (K channel activator)
    Ranolazine (inhibits late inward sodium current)
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18
Q

Management of chronic stable angina. Examples of drugs for:

  1. Antiplatelet therapy
  2. Lipid-lowering therapy
  3. Short acting nitrate
A
  1. Antiplatelet therapy - Aspirin or Clopidogrel (if aspirin intolerant)
  2. Lipid-lowering therapy - Statins (simvastatin, atorvastatin)
  3. Short acting nitrate - GTN spray
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19
Q

Management of chronic stable angina: if intolerant to Beta blocker and Calcium channel blocker combined

A

Consider monotherapy or combinations with:
Long acting nitrate
Ivabradine (inhibits If current)
Nicorandil (K channel activator)
Ranolazine (inhibits late inward sodium current)
(Co-morbidities may determine which therapy)

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20
Q

*Management of acute coronary syndromes (NSTEMI and STEMI)

A
  1. Pain relief
  2. Dual antiplatelet therapy
  3. Antithrombin therapy
  4. Consider Glycoprotein IIb-IIIa inhibitor (high risk cases)
  5. Background angina therapy
  6. Lipid lowering therapy
  7. Therapy for LVSD/heart failure as required

Most patients will undergo invasive management with coronary angiography and revascularisation (angioplasty or CABG)

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21
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Pain relief

A

GTN spray

Opiates - diamorphine

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22
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Dual antiplatelet therapy

A

Aspirin
PLUS:
Ticagrelor or Prasugrel or Clopidogrel

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23
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Antithrombin therapy

A

Fondaparinux

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24
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Consider Glycoprotein IIb-IIIa inhibitor (high risk cases)

A

Tirofiban
Eptifibatide,
Abciximab

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25
Management of acute coronary syndromes (NSTEMI and STEMI): Background angina therapy
Beta blocker Long acting nitrate Calcium channel blocker
26
Management of acute coronary syndromes (NSTEMI and STEMI): Lipid lowering therapy
Statins
27
Management of acute coronary syndromes (NSTEMI and STEMI): Therapy for LVSD/heart failure as required
ACE-inhibitor Beta-blocker Aldosterone antagonist
28
How can you classify antiarrhythmic drugs
Vaughan Williams classification
29
Describe the Vaughan Williams classification for anti-arrhythmic
Class I - sodium channel blockers Class II - beta adrenoreceptor antagonists Class III - Prolong the action potential Class IV - Calcium channel blockers
30
Vaughan Williams classification: Subtypes/Examples of Class I anti-arrhythmics (sodium channel blockers)
Ia - disopyramide, quinidine, procainamide Ib - lidocaine, mexilitene Ic - flecainide, propafenone
31
Vaughan Williams classification: Examples of Class II anti-arrhythmics (beta-adrenoreceptor antagonists)
Propranolol, nadolol, carvedilol (non-selective) | Bisoprolol, metoprolol (β1-selective)
32
Examples of non-selective beta-adrenoreceptor antagonists
Propranolol, nadolol, carvedilol
33
Examples of β1-selective beta-adrenoreceptor antagonists
Bisoprolol | Metoprolol
34
Vaughan Williams classification: Examples of Class III anti-arrhythmics (prolong the action potential)
Amiodarone | Sotalol
35
Vaughan Williams classification: Examples of Class IV anti-arrhythmics (calcium channel blockers)
Verapamil | Diltiazem
36
What is Digoxin
Cardiac glycoside | Inhibit Na/K pump
37
Main effects of Digoxin on the heart
Bradycardia (increased vagal tone) Slowing of atrioventricular conduction (increased vagal tone) Increased ectopic activity Increased force of contraction (by increased intracellular Ca)
38
True or False: | Digoxin has a narrow therapeutic range
True | Excess can cause: Nausea, Vomiting, Diarrhoea, Confusion
39
Is digoxin positively or negatively inotropic
Positively inotropic
40
Where is digoxin used
Used in atrial fibrillation (AF) to reduce ventricular rate response Use in severe heart failure as positively inotropic
41
What is function of Amiodarone
Prolong the action potential | Class III Anti-arrhythmic
42
Adverse effects of amiodarone on heart
QT prolongation | Polymorphic ventricular tachycardia
43
Adverse effects of amiodarone
``` Interstitial pneumonitis Abnormal liver function Hyperthyroidism / Hypothyroidism Sun sensitivity Slate grey skin discolouration Corneal microdeposits Optic neuropathy ``` Multiple drug interactions Very large volume of distribution
44
What is hypertension a risk factor for?
``` Stroke – ischaemic and haemorrhagic Myocardial infarction Heart failure Chronic renal disease Cognitive decline Premature death ``` Increases risk of atrial fibrillation
45
Each 2mmHg rise in systolic BP is associated with...
7% increased mortality from ischaemic heart disease | 10% increased mortality from stroke
46
What is clinical hypertension
140/90mmHg or higher
47
True or False: People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension
True
48
Mechanisms of BP control - targets for therapy
Cardiac output and peripheral resistance Interplay between RAAS and Sympathetic nervous system (noradrenaline) Local vascular vasoconstrictor and vasodilator mediators
49
Main clinical indications of Angiotensin Converting Enzyme (ACE) inhibitors
Hypertension Heart failure Diabetic nephropathy
50
Examples of ACE inhibitors
Ramipril Enalapril Perindopril Trandolapril
51
Main adverse effects of ACE inhibitors
Related to reduced angiotensin II formation: - Hypotension - Acute renal failure - Hyperkalaemia - Teratogenic effects in pregnancy Related to increased kinin production - Cough - Rash - Anaphylactoid reactions
52
Main clinical indications of Angiotensin II receptor blockers (ARBs)
Hypertension Diabetic nephropathy Heart failure (when ACE-I contraindicated)
53
Examples of ARBs
``` Candesartan Valsartan Losartan Irbesartan Telmisartan ```
54
Main adverse effects of ARBs
``` Symptomatic hypotension (especially volume deplete patients) Hyperkalaemia Potential for renal dysfunction Rash Angio-oedema ``` Contraindicated in pregnancy Generally well tolerated
55
Main clinical indications of Calcium channel blockers (CCB)
Hypertension Ischaemic heart disease (IHD) - angina Arrhythmia (tachycardia)
56
Examples of CCBs
``` Amlodipine Felodipine Nifedipine Lacidipine Diltiazem Verapamil ```
57
Types of L-type CCBs
Dihydropyridines Phenylalkylamines Benzothiazepines
58
Main effects of Dihydropyridines (CCB)
Preferentially affect vascular smooth muscle | Peripheral arterial vasodilators
59
Main effects of Phenylalkylamines (CCB)
Main effects on the heart | Negatively chronotropic, negatively inotropic
60
Main effects of benzothiazepines (CCB)
Intermediate heart/peripheral vascular effects
61
Examples of Dihydropyridines (CCB)
Nifedipine Amlodipine Felodipine Lacidipine
62
Examples of Phenylalkylamines (CCB)
Verapamil
63
Examples of benzothiazepines (CCB)
Diltiazem
64
Adverse effects of calcium channel blockers
Due to peripheral vasodilatation (mainly dihydropyridines) - Flushing - Headache - Oedema - Palpitations Due to negatively chronotropic effects (mainly verapamil/diltiazem) - Bradycardia - Atrioventricular block Due to negatively inotropic effects (mainly verapamil) - Worsening of cardiac failure
65
Adverse effects specific to or mainly in Verapamil (calcium channel blocker)
Constipation (specific to verapamil) Worsening cardiac failure due to negatively inotropic effects Bradycardia and Atrioventricular block due to negatively chronotropic effects
66
Main clinical indications of Beta-adrenorecoptor blockers
Ischaemic heart disease (IHD) – angina Heart failure Arrhythmia Hypertension
67
Examples of Beta-adrenorecoptor blockers
``` Bisoprolol Carvedilol Propanolol Metoprolol Atenolol Nadolol ```
68
Beta-1 selective Beta-adrenorecoptor blockers
Metoprolol | Bisoprolol
69
Non selective Beta-adrenorecoptor blockers
Propranolol Nadolol Carvedilol
70
Main adverse effects of Beta-adrenoceptor blocker
Fatigue Headache Sleep disturbance/nightmares Bradycardia Hypotension Cold peripheries Erectile dysfunction Worsening of: Asthma (may be severe) or COPD PVD – Claudication or Raynaud’s Heart failure – if given in standard dose or acutely
71
Main clinical indications of Diuretics
Hypertension | Heart failure
72
Classes of Diuretics
Thiazides and related drugs (distal tubule) Loop diuretics (loop of Henle) Potassium-sparing diuretics Aldosterone antagonists
73
Examples of thiazide and related diuretics
Bendroflumethiazide Hydrochlorothiazide Chlorthalidone
74
Examples of loop diuretics
Furosemide | Bumetanide
75
Examples of potassium-sparing diuretics
Spironolactone Eplerenone Amiloride Triamterine
76
Main adverse effects of diuretics
``` Hypovolaemia Hypotension Hypokalaemia Hyponetraemia Hypomagnesaemia Hypocalcaemia Erectile dysfunction Raised uric acid (gout) Impaired glucose tolerance ```
77
Adverse effects of diuretics - effects mainly in loop diuretics
Hypovolaemia | Hypotension
78
Adverse effects of diuretics - effects mainly in thiazides
Erectile dysfunction | Impaired glucose tolerance
79
Example of α-1 adrenoceptor blockers
DOXAZOSIN
80
Examples of Centrally acting anti-hypertensives
Moxonidine | Methyldopa
81
Example of direct renin inhibitor
Aliskiren
82
Treatment of hypertension <55 years
ACEi or ARB ACEi or ARB + CCB ACEi or ARB + CCB +Thiazide-like diuretic (Resistance hypertension:) Consider addition of Spironolactone, high dose thiazide-like diuretic, Alpha blocker, beta blocker, (others)
83
Treatment of hypertension >55 years or Afro-Carribean any age
Calcium channel blocker ACEi or ARB + CCB ACEi or ARB + CCB +Thiazide-like diuretic (Resistance hypertension:) Consider addition of Spironolactone, high dose thiazide-like diuretic, Alpha blocker, beta blocker, (others)

Medicine Phase 2a CVS (17 decks)

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