2Pharm I Flashcards
Rank diuretics from most to least potent:
Loop
Thiazides
Carbonic anhydrase inhibitors (very mild)
Potassium sparing
What is the most common cardiovascular disease whose prevalence increases with age?
Hypertension
Individuals at 55 years old with NORMAL BP have a ___% lifetime risk for developing hypertension
90%
Hypertension contributes to what 2 categories of disease?
Coronary artery disease
Cerebral artery disease
*heart and brain
What are 3 categories of hypertension?
Essential (idiopathic - 90%)
Secondary (identifiable)
Malignant (5%, retinal/renal damage)
BP intervention LESS THAN 60 yrs:
BP intervention OVER 60:
140/90
150/90
AHA/ACC recommend lifestyle changes if Systolic is what range?
Diastolic?
140-159
90-99
What are the 3 basic ways to reduce overall blood pressure?
Reduce peripheral resistance
Reduce cardiac output
Reduce blood volume
How do most diuretics work?
Block Na+ reabsorption
Which then blocks water
In the US _____ are the first line of drugs in hypertension treatment
Diuretics
What was the first class of diuretics (no longer used b/c of toxicity)?
Mercurials
What is the first choice, and most commonly prescribed class of diuretic?
Thiazides (benzothiazides)
What do Thiazides block in the kidney?
2 things
Blocks Na+ reabsorption in Proximal and Distal tubules
Carbonic anhydrase (this decreases H+ availability for exchange with Na+)
With Thiazides, what is the problem in losing Na+ in the distal/proximal tubules?
K+ is also lost (hypokalemia)
When taking Thiazides, if sodium intake increases, ________ is exacerbated.
Potassium loss
Why are a lot of Diabetics not on Thiazides?
Hyperglycemia is side effect
Hypokalemia, Hyponatremia, Hypomagnesaemia, loss of carbonate, hyperuricemia, Hyperglycemia, elevated cholesterol, triglycerides, weakness, no boner.
What am I?
Thiazide diuretic
According to lectures, 2 thiazide drugs we need to know:
Hydrochlorothiazide (Microzide)
Chlorothiazide (Diuril)
What is the most powerful class of diuretic?
Loop
3 effects of Loop Diuretics
Major volume loss
Electrolyte imbalance (Na+ and K+ loss)
Ototoxicity
Loop diuretics block the _______ symporter
Na/K/Cl
Hyponatremia, hypokalemia, hyperglycemia, hypocalcemia, hyperuricemia, NEPHROTOXICITY, ototoxiciy, GI distress, CNS effect
What am I?
Loop diuretic
From lecture, 2 loop diuretics we need to know:
Ethacrynic acid (Edacrin)
Furosemide (Lasix)
What 2 classes of drugs cause the Lichenoid Drug Rxn?
Thiazide and Loop diuretics
What class of diuretic competes with aldosterone?
Where does that competition take place?
Potassium sparing diuretics
Distal renal tubules
Potassium sparing diuretics save K+ and ____.
They increase ___ and ____ excretion
H+
Na+ and Cl-
2 potassium sparing diuretics:
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Adverse effects of Potassium sparing diuretics: Hyperkalemia, and what 4 other things?
Gynecomastia in males
Breast tenderness in young women
Menstrual irregularities
Decreased libido in males
What mild diuretic is now used mostly for glaucoma, and as an adjunctive therapy for congestive heart failure?
Carbonic anhydrase inhibitors
One carbonic anhydrase inhibitor we need to know:
Acetazolamide (Diamox)
What drug is used in emergencies to decrease blood volume?
Which to we need to know?
Osmotic diuretics
Urea (Ureaphil)
What diuretic is rarely used - but treats hypochloremic stated and metabolic alkalosis in the ER?
*produced a lot of chloride
What preparation do we need to know?
Acidifying Agents
Ammonium chloride
Caffeine is a _______ that inhibits tubular reabsorption of Na+ by inhibiting _______ in the ______
Xanthine
ADH
Bowman’s capsule
Most diuretics cause ________ and many cause ______
Xerostomia
Aphthous stomatitis
T/F
Use of NSAIDS for greater than 3 weeks can decrease diuretic effectiveness
True
T/F
Many pts take potassium supplements to counteract the K+ loss from diuretics but this is contraindicated in case of severe renal impairment
True
Potassium supplements (salts) are contraindicated with what?
ACE Inhibitors
5 classes of drugs used to lower BP:
Diuretics
Sympathetic blockers (alpha, beta)
ACE inhibitors
Angiotensis II receptor blockers (ARB’s)
Calcium channel blockers (CCB’s)
T/F
Beta blockers decrease cardiac output even though constrict vessels via beta2
True
Beta blockers decrease _______ secretion
Renin
Cardioselective beta blockers block ______ only
Beta1
A beta2 agonist is used for ________
Asthma
Beta1 receptors are in the _____
Beta2 receptors are in the ______
Heart
Lungs
2 cardioselective Beta Blockers (blocks Beta1 only):
2 noncardioselective Beta Blockers (blocks beta1 and beta2):
Beta1:
Atenolol (Tenormin)
Metoprolol (Lopressor, Toprol)
Beta2:
Nadolol (Corgard)
Propranolol (Inderal)
What class of drugs has side effects consistent with over-activity of the parasympathetic nervous system?
Beta blockers
*GI upset, xerostomia, orthostatic hypotension, sexual dysfunction, etc
4 contraindications to beta blockers:
Congestive heart failure
Asthma
Heart block
Diabetes
What receptors are located postsynaptically and produce vasoconstriction, increasing peripheral resistance when stimulated?
Alpha1
Alpha1 blockers produce ________
peripheral vasodilation
T/F
Alpha1 blockers have big effects on cardiac output and renal blood flow
False
*little effect
T/F
Alpha1 blockers are more effective when used with diuretics and/or beta blockers
True
Other than decreasing peripheral resistance, what is another effect of Alpha1 blockers?
Decrease urinary resistance
*benign prostatic hypertrophy
Alpha1 blocker =
Old men
3 adverse effects of Alpha1 blockers:
Orthostatic hypotension
CNS effects
Cardiovascular effects
3 Alpha1 Receptor blockers:
doxazosin (Cardura)
prazosin (Minipress)
tamsulosin (Flomax)
Women shouldn’t handle Flowmax, and its chief side effect in men is…
severe orthostatic hypotension
ACE inhibitors - inhibit Angiotensin Converting Enzyme how?
competitively
*prevents angiotensin I to angiotensin II conversion
Explain ACE Inhibitor pathway/mechanism:
blocks Angiotensin I - Angiotensin II
Low Angiotensin II increases Renin
Renin reduces Aldosterone secretion
Normally aldosterone does what in the kidneys?
retains Na+ and water
*so ACE Inhibitors will decrease Na/Water retention (pee free water)
What are the 2 primary beneficial effects of ACE Inhibitors?
Vasodilate
Decrease Blood Volume
What is the most widely prescribed ACE Inhibitor in the US?
lisinopril (Prinivil, Zestril)
2 ACE Inhibitors:
lisinopril (Prinivil, Zestril)
enalapril (Vasotec)
What are 2 side effects of ACE Inhibitors?
Chronic Dry Cough
Angioneurotic edema with first dose
What causes the Chronic Dry Cough associated with ACE Inhibitors?
Increased Bradykinin release in bronchial tree
Angiotensin Receptor Blockers, aka…
Angiotensin II Receptor Blockers
T/F
ARB’s block vasoconstrictor and aldosterone-secreting effects of Angiotensin II
Resulting in…
True
increased Renin, vasodilation, decreased Na/Water retention, and reduction in BP
What is often preferred over ACE inhibitors b/c the action is at the receptor and there are fewer side effects
*better tolerated
ARB’s
What may decrease the effectiveness of ARB’s?
NSAIDS
CNS, Upper respiratory infections, GI effects, cramps, angioedema, teratogenicity - what am I?
ARB’s
2 common ARB’s:
losartan (Cozaar)
valsartan (Diovan)
What is the new, expensive class of drugs for Hypertension?
Renin Inhibitor
*binds to Renin, decreasing levels of Angiotensin I - II - Aldosterone
Calcium Channel Blockers prevent Ca++ from entering…
slow channels
select voltage-sensitive areas
T/F
Calcium Channel Blockers relax coronary vascular smooth muscle and cause coronary vasodilation, increasing myocardial oxygen delivery
True
Calcium Channel Blockers are used for what 3 CV purposes?
Hypertension
Angina
Arrhythmias
Calcium’s role in muscle contraction - it binds ______
which turns on ______
which phospholrylates ________
so that it can better bind ______ and produce muscle contraction
calmodulin
myosin kinase
myosin
actin
3 Calcium Channel blockers:
amlodipine (Norvasc)
nifedipine (Adalat, Procardia)
verapamil (Calan)
verapamil (Calan) has major effects on the ______
nifedipine (Procardia) has more of an effect on _______
heart
blood vessels
What Calcium channel blocker is (most) associated with gingival hyperplasia?
What % have the responder gene that results in hyperplasia from this drug?
nifedipine (Procardia)
33%
T/F
Good oral hygiene will limit the extent and severity of a lesion due to a Calcium Channel Blocker
True
Why are Centrally Acting Antihypertensives used less often?
Less tolerated
clonidine (Catapres) is a centrally acting antihypertensive that is a ______ Agonist, that activates _____ neuron, which decreases _______
Alpha2
Inhibitory
Sympathetic outflow
Xerostomia, Parotid gland swelling/pain, Dysgeusia:
clonidine (Catapres)
*Centrally acting antihypertensive
What class of drug blocks granular uptake and storage of norepinephrine (decreasing sympathetic activity due to lack of neurotransmitter supply)
Catecholamine Release Blockers
2 Catecholamine Release Blockers:
reserpine (Serpasil)
guanethidine (Ismelin)
Antihypertensive meds react with general anesthetics and CNS depressants by enhancing _______
hypotention
Antihypertensive meds have a _____ response to vasoconstricting drugs
potentiated
*this why use epi w/ caution, take BP prior to locals
T/F OTC sympathomimetics (like cold capsules) counteract antihypertensive therapy
True
Use of NSAIDS longer than _____ may decrease effectiveness of diuretics, beta blockers, and ACE inhibitors
3 weeks
T/F
Nicotine constricts blood vessels and increases BP
True
With Antihypertensive meds, prevent sudden changes in _____ with pts.
impregnated gingival retraction cord (vasopressors) is ______
Rebound hypertension develops when agents withdrawn, which happens often in men b/c ____ is severe
posture
contraindicated
impotence
Diuretics make you _____ potassium
ACE Inhibitors and ARB’s make you ______ potassium
lose
gain (increase)
According to published guidelines, what 4 factors should be addressed when managing CV disease?
*HTN, obesity, and cholesterol…
Lifestyle
Obesity
Cholesterol
Risk assessment
The Risk Assessment portion of managing DV disease includes what 3 tiers?
Lifestyle changes
Drugs for under 60 140/90, over 60 150/90
Drugs for 160/100 + BP
The primary indication for diuretics is _______
or life threatening edema (loop diuretics) or renal failure (osmotic diuretic - urea)
Hypertension
All Hypertension drugs have what 4 side effects?
Xerostomia
Weakness/fatigue
Sexual impotence/libido in men
Fake lichen planus
Antihypertensive meds have what drug interactions that are significant in dentistry?
(4 things)
Epinephrine
Vasoconstrictors
General anesthetics/CNS depressants
Prolonged analgesics, sedatives, and tranquilizers (CNS)
Use of NSAIDS longer than ____ weeks may decrease effectiveness of some diuretics, beta blockers, and ACEi
3 weeks
3 precautions to take during dental procedures when treating Hypertensive pts:
Fainters/Fallers (orthostatic hypotension)
Compliance
NSAID popping - diuretics don’t work as well
What is the term for pain when the heart becomes Anoxic?
Angina
T/F
Angina is an ischemic heart disease, often involving the coronary arteries, and is greater if there is Hx of MI
True
Angina can be brought on by triggers, but absent that the pain occurs most often when?
Nighttime
Typical angina (exertional) is caused by the _____ arteries causing ischemia
coronary
If the demand exceeds available oxygen, then necrosis occurs =
myocardial infarction
Typical angina is ______
Atypical angina (variant), aka….
extertional
Prinzmetal’s
Normally there are Beta2 receptors in coronary arteries, in Prinzmetal’s angina there are more _____ receptors
Alpha 1
*causes vasoconstriction w/ epinephrine
Variant (Prinzmetal’s) angina shows an elevated ______ segment on an EKG that is not present in normal angina
S-T
Nitrites and Nitrates work on endothelial cells to produce______ that cause ______ via _______
nitric oxide
***arterial/venous vasodilation
relaxation of all smooth muscle
T/F
Nitrates/NItrites produce vasodilation and increase venous return to the heart
False
*decrease venous return
Why do NItrates/Nitrites cause headache?
vasodilation is intense and fast
Other than headache, what are 5 side effects of Nitrites/Nitrates?
Postural hypotension and syncope
Flush/Rash
tachycardia/increased peripheral resistance (due to sympathetic reflex)
methemoglobin
decrease oxygen carrying in large doses
T/F
There is rapid onset to Nitrites/Nitrates and also rapid tolerance, which is why there is usually a 12 hrs on 12 hrs off schedule
True
What is the fastest onset Nitrite/Nitrate preparation?
Amyl nitrate snorted
Nitroglycerin is considered a “rescue” drug and is often in emergency kits
True
Why is nitroglycerine stored in a small brown vial?
Photosensitive
T/F
Nitroglycerin is very caustic and leaves a sublingual burn
True
What is the longer duration option for nitroglycerin?
Patch (up to 12 hours)
Two Nitrites/Nitrates we need to know:
Isosorbide dinitrate (Isordil)
Isosorbide mononitrate (Imdur)
Beta blockers decrease cardiac ______, which decreases oxygen demand and decreases Angina
output (afterload)
inotropic:
chronotropic:
force
timing
T/F
Beta blockers have negative chronotropic and inotropic effects
True
Pts with a history of MI will always be taking_______
beta blockers
Beta blockers cause vasodilation
False
Beta blockers are contraindicated for some forms of congestive heart failure and ________
Variant/Prinzemetal’s Angina
Why are beta blockers often combined with diuretics?
Prevent sodium retention
Cardioselective agents are preferred for insulin-dependent diabetics and _______
Asthmatics
What does epinephrine do if the pt is taking a beta blocker?
Won’t stimulate the heart
Will vasoconstrict Alpha1 receptors
Non-selective Beta blockers enhance what response to epinephrine?
What does this response entail? (2 things)
Pressor
hypertension, reflex bradycardia
T/F
It’s ok to use epi with cardioselective beta blockers
True
T/F
Epinephrine dilates large vessels/muscles
Epinepherine constricts small vessels/muscles
True
If a pt is on heart meds, it’s most likely a Beta blocker - what 2 things do you ask?
Are you a diabetic?
Asthma?
Inotropic effect of Calcium Channel blockers:
Negative
Some Ca++ channel blockers cause smooth muscle relaxation (vasodilation) where?
Coronary arteries
2 Calcium channel blockers that have a negative inotropic effect:
verapamil
diltiazem
Ca++ channel blocker that vasodilates coronary arteries:
amlodipine
Calcium channel blocker that vasodilates peripherally:
nifedipine
nicardipine
What 2 things to limit in visit from pt on anti-anginals?
Extent of procedures/visit
epinephrine
If a pt is on an Antianginal, consider local aneshtetics without _____
vasoconstrictor
What are the practical side effects of antiarhythmic drugs?
Arrhythmic manifestations
Most Antiarrhythmics prolong _______
others affect the ______ system
Prolong
electrical
Cardiac arrhythmias produce abnormalities of the heartbeat and all denote something wrong with the _________ system
They are caused by disease, cardiac injury, or drugs
electrophysiologic
Arrhythmias result from abnormal impulse ______, abnormal impulse ______, or a combination of the two
formation
conduction
The type of arrhythmia that begins at the nodal level can be Supraventricular, Vetricular, or ______
Ectopic foci (preempt SA/AV node)
When the His Purkinje system is cut in half and atria/ventricles work independently it is know as a….
Heart Block
Antiarrhythmic medications ____ parts of the heart that are beating abnormally
Depress
What are 3 pharmacologic effect of antiarrhythmic medications?
Change slope of depolarization
Raise threshold for depolarization
Alter conduction velocity
Antiarrhythmic meds work on one or more of the _____ transmembrane phases of the cardiac cycle
5
What are the 3 areas of the heart that have pacemaker activity?
SA node (main)
AV node
Purkinje fibers
The spontaneous opening and closing of K+ channels is what drives _______
automaticity
Where is Effective Refractory Period longer - pacemaker areas or myocardial cells?
*different arrhythmias require ERP be longer/shorter
Pacemaker areas
In what 2 situations would you want to induce an arrhythmia with epi, isoproterenol (beta agonist) or hypokalemic diuretics?
Ventricular arrhythmias due to AV node block
Temporary heart block until pacemaker insertion
4 contraindications for Antiarrhythmics
Complete AV heart block
Congestive heart failure
Hypotension
Known hypersensitivity to drug
A partial heart block is when the _______ is not in sync
atria/ventricles
T/F
Indications for antiarrhythmic drugs are arrhythmia, flutters, fibrillations, tachycardias, ectopic arrhythmia, or digoxin induced arrhythmia
True
What are 4 Contraindications to Antiarrhythmics?
Complete AV block
CHF
Hypotension
Known hypersensitivity to drug
What are the 4 classes of Antiarrhythmics?
!a, 1b, 1c
2
3
4
Class Ia Antiarrhythmics:
3 drugs, 3 actions
1a (medium) = quinidine, (*procainamide, Pronestryl), (disopyramide, Norpace)
blocks Na conduction
Slows ERP
Slows AP
Class Ib Antiarrhythmics:
1 drug, 2 actions
FAST = lidocaine
blocks Na conduction
Decrease relative refractory period
Class Ic Antiarrhythmics:
(2 drugs, 2 actions)
***life threatening ventricular arrhythmias only
Slow = flecainide (Tambocor), propafenone (Rhythmol)
blocks Na conduction
conduction velocity
Quinidine can lead to what clinical manifestation?
Cinchonism
*from cinchona tree
Class II Antiarrhythmics:
1 drug, 1 class
propanolol
beta blockers
Class III Antiarrhythmics:
3 drugs, mechanism
amiodarone (Cordarone, Pacerone), bretyllium, sotalol
K+ channel blockers
***sotalol (Betapace) is nonselective beta crossover
Class IV Antiarrhthmics:
5 drug, mechanism
nifedipine, verapamil, diltiazem, adenosine, Digoxin (cardiac glycoside)
Calcium channel blockers
Describe cinchonism from quinidine:
nausea, vomiting, headache, TINNITIS
deafness, vertigo, visuals
FATAL arrhythmias
What is the site of action of cinchonism (quinidine)?
atrial tissues
If a patient is taking antiarrhythmics, what do we NOT give them?
What is ok to give them?
Atropine (may cause tachycardia)
Lidocaine solutions
***not the same lidocaine as anti-arrhythmic med
Prinzmetal angina is seen in ______ men most commonly
Japanese
Nitrites/Nitrates are _______ vasodilators
direct
T/F
CCB’s block calcium channels so that calcium trickles more slowly, decreasing the rate and strength of contractions
True
What two side effects of taking NItrites/Nitrates is accentuated with alcohol?
Syncope
Postural hypotension
What is the fastest acting Nitrite/Nitrate and how long does it last?
What is the second fastest?
Vaporole - (snort) onset 1 minute, lasts 3-15 minutes
Nitroglycerin - onset 1-3 minutes, half life 10 minutes
A Transdermal pouch can last up to ___hrs
12
What are the 2 long acting nitrates?
other than transdermal pouch
Isosorbide dinitrate (4-6 hrs)
Isosorbide mononitrate (1/2 life 4 hrs)
procainamide (Pronestyl) is a class Ia antiarrhythmic that has reversible _____ like syndrome in ___% of pts
(nickname: novacaine)
lupus
25%
Class Ib antiarrhythmics (lidocaine, phenytoin, mexiletine, tocainide) are are used to treat ______ arrhythmias
ventricular
4 class Ib antiarrhythmics:
lidocaine
phenytoin (Dilantin)
mexiletine
tocainide
amiodarone (Cordarone, Pacerone) contains iodine causing blue skin and may cause _____ disease
*Class III antiarrhythmic
thyroid
Digoxin is a Class IV antiarrhythmic that increases _____ and ______
intracellular Ca
contractility
T/F
atropine and isoproteronol treat Bradyarrhythmias
True
T/F
Potassium and Magnesium treat Ectopic Pacemakers
True
T/F
The vagal blocking effects of anntiarrhythmic drugs (anticholinergics like atropine) can act synergistically to lead to tachycardia
True
Congestive heart failure is the inability of the heart to provide the necessary ______
output
What do drugs target in CHF?
Reflex sympathetic output
T/F
Right sided heart failure will manifest in fatigue and edema while left side will be more acute and result in pulmonary congestion
True
T/F
With CHF you want to slow the heart and increase the contractile force
True
What is the drug of choice in treatment of CHF?
digoxin (Digitek, Lanoxin)
aka Cardiac Glycosides
Digoxin inhibits __________, resulting in more ________ inside the cell.
This has a positive ______ effect
Na/K pump
Ca
inotropic
Digoxin has a positive inotropic effect and a negative ______ effect due to directly suppressing ______
chronotropic
AV node
Digoxin has 3 mechanisms of action: positive inotropic effect through increased Ca, negative chronotropic effect by suppressing the AV node, and what else?
Diuresis
*pee excessively, decreasing venous return
The increased vagal output caused by cardiac glycosides (digoxin) can be blockes by ________
Atropine
T/F
Digoxin has a low therapeutic index and can lead to uncoordinated arrhythmias
True
Few drugs cause sensory side effects - which causes a green/yellowish aura?
Digoxin
T/F
azole antifungals and macrolides like clindamycin and azythromycin could increase digoxin in the system and increase risk for toxicity
True
What posture would you not want to put a pt with CHF in?
don’t recline fully - hard to breathe
T/F
It’s ok to do general anesthesia in a dental setting with a pt with CHF
False
*hospital only
What are 3 preparations of Bile Acid Sequestrants?
chelestyramine resin
colesevelan
colestipol
What decreases liver triacylglycerol synthesis necessary for VLDL production?
(decreases plasma LDL’s - used for MILDLY elevated cholesterol)
Nicotinic Acid (Niacin)
What is the side effect on Niacin?
facial flushing
What lowers plasma triglycerides and increases HDL by inhibiting cholesterol synthesis in the liver?
Fibric Acids
What are 3 Fibric Acids?
clofibrate
fenofibrate
gemfibrozil
The most popular/effective cholesterol inhibitors:
statins
HMG coA reductase inhibitors
HMG CoA reductase is the _____ step in the synthesis of ______
rate limiting
cholesterol
When can’t you take a statin?
Liver disease
***HMG CoA reductase inhibitors alter liver function
What is a side effect of statins?
HMG CoA reductase inhibitors
myalgias
**rhabdomyolysis - disintegration of muscle tissue
What 2 types of drugs promote myalgias in pts taking statins?
Macrolide antibiotics (erythromycin)
Azole antifungals
2 statins are combined with a drug that decreases intestinal absorption (only drug in class), what is the drug, and what are the combos?
ezetimibe
Vytorin - simvastatin + ezetimibe
Liptruzet - atorvastatin + ezetimibe
The therapeutic dose for Digoxin is _____% of the toxic dose, which is why every pt needs to be _______
50-60%
Titrated
Cardiac glycosides are used for what 3 conditions?
CHF
A-fib
flutter
Cardiac glycosides (digoxin) can cause bradycardia/arrhythmia, _____ effects from stimulation of chemoreceptor zones and vagal nucleus (parasymphathetic effects)
*what other parasympathetic effects?
GI
*nausea, vomiting, increased saliation, anorexia, diarrhea, ab pain
Other than a Green/Yellow aura, what are 3 other CNS effects of Digoxin?
Headache - edema
fatigue
visual
Retraction cords and local anesthetics often have ________, which is contraindicated for pts with CHF
vasoconstrictors
T/F
General anesthesia is dangerous for pts with CHF
True
Statins should be used in pts with CV disease aged 40-75 and have a ______% or higher risk of having heart attack within 10 years
7.5%
T/F
You can’t raise HDL without exercise
True
T/F
Statins shouldn’t be combined with additional cholesterol lowering drugs like niacin or fibrates
True
*don’t reduce heart attack/stroke risk
DVT =
deep vein thrombosis
What are 3 types of acute coronary syndromes caused by blood clots in coronary arteries?
Unstable angina
Non-ST elevated MI (incomplete blockage)
ST elevated MI (complete blockage)
T/F
Stroke reduction benefits of antiplatelets improve when used in combo with aspirin
True
Aspirin causes _______ platelet aggregation
irreversible
T/F
You should discontinue low dose aspirin therapy before dental treatment
False
*Stroke risk greater than bleeding
T/F
Discontinuing aspirin use Increases MI and adverse bleedings and has worse clinical outcomes than nonusers
True
Antiplatelet drugs used for short and long term stenting have ______ effects on platelets
Irreversible
4 antiplatelet drugs
ticlopidine (Ticlid) *canadian
clopidogrel (Plavix)
prasugrel (Effenet)
ticagrelor (Brilinta)
Aspirin blocks _____, which blocks ______
COX
Thromboxane A2
clopidogrel prevents binding of ____ to collagen receptors thereby preventing platelet aggregation
ADP
What is used with aspirin and heparin to treat acute coronary syndromes?
fibrinogen receptor inhibitors
platelet glycoprotein IIb/IIIa receptor antagonists
3 platelet glycoprotein IIb/IIIa receptor antagonists (Fibrinogen Receptor Inhibitors)
abciximab (ReoPro)
eptifibatide (Integrilin)
tirofiban (Aggrastat)
Thienopyridines prevent the binding of _____ to collagen receptors which prevents platelet aggregation.
It requires ____ to form the clot
ADP
Adenosine
Percutaneous coronary intervention (stents) combined with antiplatelet therapy has numerous dental advisory guidelines, one being _____ risk of premature discontinuation.
Consult the cardiologist, and defer any procedure with significant bleeding risks until ______
catastrophic
thienopyridine therapy conclusion
After a DES is placed, wait ___ months for major intervention
__ months for normal stent
12
1
Leading up to a procedure the pt can go off Plavix, but must stay on ______
Aspirin
*restart Plavix right after procedure
**keep pt on 1 antiplatelet
Heparin inhibits _____ and ______
produces _____ anticoagulant effect
Factor Xa and IIa thrombin
immediate
Warfarin interferes with liver synthesis of ______
produced effect in _____ days
vitamin K dependent clotting factors
4-5
Warfarin inhibits what 4 vitamin K dependent clotting factors?
What 2 proteins?
2, 7, 9, 10
C and S
6 drugs that alter the efficacy of warfarin:
Phenytoin
Phenobarbital
Any liver metabolism drug
Antibiotics
Vita K (spinach)
Tylenol (enhances coagulation)
3 antagonists to Heparin and Warfarin:
Vitamin K
Phenytoin
Phenobarbital
NSAIDS cause _____ effects on platelets
reversible
Heparin can cause profound bleeding, what is the antidote?
Protamine sulfate
T/F
Heparin and Warfarin can be overlapped 1-2 days
True
Warfarin has a mandatory blood test every 30 days b/c of low _____ indes
Therapeutic
Many things throw off coumadin, _____ being one
diet
*vita K
T/F
There is no need to discontinue warfarin use prior to routine dental procedures even though it is associated with increased gingival bleeding and mouth ulcers
True
5 tests used to assess the effects of Heparin and Warfarin:
INR
Bleeding time test
PT
aPTT
Intrinsic pathway
The International Normalized Ratio (INR) has a therapeutic range of ___ to ____
2-3
______ and warfarin significantly enhance anticoagulation
Acetaminophen
What causes the greatest number of drug interactions?
Warfarin
What is the direct Thrombin inhibitor?
dabigatran (Pradaxa)
*prodrug - converted in vivo to dabigatran
T/F
The advantages to dabigatron over warfarin is no monthly monitoring and less expensive
True
What is the antidote to dabigatran (Pradaxa)
idarucizumab (Praxbind)
Antithrombins drugs (not to be confused with Thrombin inhibitors) are _______ inhibitors
Factor Xa
What are 3 Factor Xa inhibitors (antithrombins)
apixaban (Eliquis)
fondaparinux (Arixtra)
rivaroxaban (Xarelto)
Hemorhage, no reversal agent, and loss of ____ function are the major risks to Factor Xa inhibitors (antithrombins)
kidney
When would Factor Xa inhibitors be used?
antithrombins
post op after total hip/knee
prevent stroke
Factor Xa inhibitors stop coagulation by preventing _____ mediated effects, including cleavage of fibrinogen to fibrin, and activation of what 4 factors?
thrombin
5, 8, 11, 13
2 thrombolytic clot busting drugs:
streptokinast (Streptase)
urokinase
What is the antidote for Tissue Plasminogen Activator (tPA)?
this is a clot forming IV drug = Retavase
Epsilon AminoCaproic Acid (Amicar)
*treats hemophilia, cerebral aneurysms
