B P9 C84 Cardiomyopathies Induced by Drugs or Toxins Flashcards
_____ is the most commonly used and abused substance across the globe.
Alcohol
Moderate drinking is considered up to:
1 drink per day in women
2 drinks per day in men
Binge drinking _____ is becoming an increasing problem.
4 drinks for women
5 drinks for men
In approximately 2 hours
Resulting in blood alcohol concentration to 0.08 g/dL or greater
Definitions of heavy drinking (Centers for Disease Control and Prevention [CDC]) include _____.
15 drinks or more per week for men
8 drinks or more per week for women
Ethanol is oxidized by the enzyme _____ into _____
Alcohol dehydrogenase
Acetaldehyde
Acetaldehyde is then oxidized into _____ by the enzyme aldehyde dehydrogenase
Acetic acid and Acetate
The deleterious effects of alcohol drinking depend on the:
Amount consumed
Duration of consumption
The amount of alcohol drinking to be considered an alcoholic is generally more than _____.
90 g/day of alcohol for 5 years or more
A 12-lead electrocardiogram (ECG) may show _____ (particularly during acute alcoholic intoxication), ____.
Sinus tachycardia
Nonspecific ST and T wave abnormality
RBBB and LBBB
Atrial and ventricular arrhythmias
The earliest echocardiographic abnormality in heavy alcohol drinkers is _____, present in at least 1/3 of asymptomatic patients.
Diastolic dysfunction
The histopathology of alcoholic cardiomyopathy is similar to dilated cardiomyopathy, except there is _____ in histologic sections in the former compared to the latter.
Lower myocyte count
In alcoholic cardiomyopathy, _____ were associated with poor prognosis.
(1) Atrial fibrillation
(2) Absence of beta blocker therapy
(3) QRS duration longer than 120 milliseconds
_____should be the first major component of treatment in alcoholic cardiomyopathy.
Abstinence of alcohol drinking
Patients who completely stop drinking alcohol may normalize their ejection fraction in _____.
1 year
Factors that were associated with the best recovery of ejection fraction in alcoholic cardiomyopathy included _____.
(1) Narrow QRS
(2) Beta blocker therapy
(3) Lack of use or need for diuretic therapy
The most common abnormality, and the one that needs more attention in the clinical setting of alcoholic cardiomyopathy, is _____.
Atrial Fibrillation
This syndrome describes patients who consume excessive alcohol on weekends and holidays, who then develop these arrhythmias a day or two later. It is more common in men than in women, occurs in patients with an apparently normal heart,and has a relatively benign prognosis.
Holiday Heart Syndrome
_____ drinking is associated with lower cardiovascular mortality, whereas heavy drinking leads to increased mortality.
Mild to moderate
_____ are determinants of malignant ventricular arrhythmias
Alcohol drinking + LBBB + decreased ventricular function
Metabolic effects of alcohol
Increased HDL
Reduced LDL
Favorable effect on Lp(a)
Moderate intake of beer enhances the _____ properties of HDL; thus it prevents lipid deposition in blood vessel walls.
Antioxidative
Severe alcohol consumption may increase _____ levels, blunting the beneficial effect of moderate alcohol drinking.
Triglyceride
Effects of alcohol in the CV system
Effects of low to moderate alcohol intake in the immune system:
Antioxidant and anti-inflammatory effects
Decrease inCRP and IL-6
Heavy drinking and binge drinking are associated with an _____ in inflammatory markers
Increase
After mild to moderate alcohol drinking, there is a _____ in platelet aggregation.However, binge drinking may have the opposite effect, which may account for the increase in cardiac events following binge drinking.
Mild-moderate: Decrease
Binge: Increase
_____ alcohol drinking, particularly wine, is associated with a decrease in cardiovascular risk
Mild
A “drink” is considered to be _____
12 ounces of beer
5 ounces of wine
1.5 ounces of hard liquor (mixed drink)
Mild alcohol drinking does not affect blood pressure. However, heavy alcohol drinking, which initially may cause _____, may later result in an increase in blood pressure.
Vasodilation
The _____ in tobacco smoke is known to stimulate the sympathetic nervous system, which results in an increase in heart rate, blood pressure, heart contractility, and coronary vasoconstriction
Nicotine
Metabolic effects of nicotine:
Lowers HDL cholesterol
Increases triglyceride levels
Induces endothelial dysfunction
E-cigarettes consist of a liquid cartridge that typically contains _____ and may contain nicotine at various doses (including very high doses
Propylene glycol
Vegetable glycerin
Although e-cigarettes do not contain tar or generate carbon monoxide as do tobacco cigarettes, when the e-liquid is heated the results may include formation of _____, which result in reactive oxygen species and inflammation that can contribute to an acceleration of atherosclerosis and clotting.
Formaldehyde,
Acetaldehyde
Acrolein
One study suggested that e-cigarettes were more effective than standard, already approved nicotine replacement therapies for smoking cessation. However, the AHA recommended using e-cigarettes for smoking cessation only as a last resort. They recommended:
Behavioral support
Nicotine patches
Bupropion
Varenicline
The typical victim is a young male who has been using e-cigarettes (vaping) within days to weeks of the illness.The patients present with respiratory distress including shortness of breath, cough, chest pain, fever, fatigue and gastrointestinal symptoms including nausea, vomiting, and diarrhea.The patients are often hypoxic
E-cigarette or vaping product use associated lung injury (EVALI)
The exact cause of EVALI remains to be determined. Of note, over 80% of cases included use of _____.One leading theory suggested by the CDC is that contaminants such as _____ oil, which is often used to dilute THC, may be responsible for EVALI.
Tetrahydrocannabinol (THC)
vitamin E acetate oil
Other than _____, there is no specific treatment, as yet, for EVALI other than supportive measures and hospitalization if needed
Stopping vaping
COCAINE
In general, the intravenous and inhaled (i.e., smoked) routes have a very rapid onset of action (_____) and short-lived (_____) duration when compared with the mucosally absorbed (e.g., oral, nasal [i.e., snorted], rectal, vaginal) routes.
Seconds, 30 mins
When cocaine is given systemically, it blocks the presynaptic reuptake of _____, thereby producing an excess of these neurotransmitters at the site of the postsynaptic receptor
NE, Dopamine
Cocaine induces vasoconstriction in normal coronary arteries but exerts a particularly _____ vasoconstrictive effect in diseased segments. As a result, cocaine users with atherosclerotic coronary artery disease probably have an especially high risk for an ischemic event after cocaine use.
Marked
Cocaine-induced coronary arterial vasoconstriction results primarily from the stimulation of coronary arterial alpha-adrenergic receptors because it is reversed by _____(an alpha-adrenergic antagonist) and exacerbated by _____ (a beta-adrenergic antagonist)
Reversal: Phentolamine
Exacerbated: Propranolol
The _____ combined with a _____ due to coronary artery vasoconstriction explains various ischemic events temporally related to cocaine use.
Increase O2 demand
Decrease in blood supply
Chief complaint in cocaine abusers presenting to emergency departments
The risk of MI increases up to 24-fold in the first hour after cocaine abuse
Chest pain
The current American College of Cardiology (ACC)/AHA guidelines recommend that stable patients with cocaine-related chest pain should be observed for at least _____ hours
12 hours
Patients with recent cocaine intake with ECG evidence of persistent ST-segment elevation that is nonresponsive to nitrates should be directly referred for ______
Immediate use of aspirin and clopidogrel is recommended because of the increased platelet aggregation and increased coronary thrombosis
Coronary angiography, for consideration for possible angioplasty and stent implantation
Both the 2008 and 2012 ACC/ AHA scientific statements recommend the use of _____ stents in cocaine users.
Bare-metal
_____ have been shown to reverse cocaine-induced coronary vasoconstriction in the controlled set- ting of the cardiac catheterization laboratory and are used to manage cocaine-induced chest pain
Nitrates
Phentolamine (an alpha-receptor blocker)
Verapamil (a calcium channel blocker)
Although beta blockers represent an essential therapy in the mitigation of hyperadrenergic states and are known to reduce myocardial oxygen demand, the use of beta blockers in the setting of cocaine-induced vasoconstriction is still debated because of the concern that β1/β2-blockade might lead to _____, resulting in coronary artery vasoconstriction
Unopposed alpha-stimulation
ACC/AHA guidelines recommend against using beta- blockers in the setting of acute coronary syndromes with signs of _____ (class III, Level of Evidence: C) unless patients are receiving a vasodilator.
Acute cocaine intoxication
The 2012 AHA/ACC guidelines endorse the use of nonselective beta blockers in patients with _____, provided the patients are treated with a vasodilator (Class IIb, Level of Evidence: C).
Persistent hypertensive or tachycardia after cocaine use
High-risk features in a patient suspected of cocaine-related chest pain
Hemodynamic instability
Positive cardiac troponin
Recurrent chest pain
Cocaine has been implicated as a causative factor in 0.5% to 37% of cases of aortic dissection, with an average interval from cocaine use to the onset of symptoms of _____.
12 hours (range, 0 to 24)
Cardiac arrhythmias are a frequent finding in cocaine users presenting to the emergency department, including various atrial arrhythmias and ventricular arrhythmias such as _____.
Ventricular extrasystoles
Ventricular tachycardia
Ventricular fibrillation
Cocaine may affect the generation and conduction of cardiac impulses by several mechanisms.
(1) its sympathomimetic properties may increase ventricular irritability and lower the threshold for fibrillation.
(2) it inhibits action potential generation and conduction (i.e., it prolongs the QRS and QT intervals) as a result of its sodium channel–blocking effects. In so doing, it acts in a manner similar to that of a class I anti- arrhythmic agent.
(3) it increases the intracellular calcium concentration, which may result in afterdepolarizations and triggered ventricular arrhythmias.
(4) it reduces vagal activity, thereby potentiating its sympathomimetic effects
In individuals who use cocaine in temporal proximity to the ingestion of ethanol, hepatic transesterification leads to the production of _____, a unique metabolic by-product of cocaine.
Cocaethylene
In a study of 230 patients with a history of acute amphetamine and methamphetamine abuse and positive urine tests (mainly young males), the most common electrocardiographic findings were _____.
Sinus tachycardia
Prolonged QT interval,
Arrhythmia (supraventricular and ventricular)
Experimental studies showed that methamphetamine induces cardiac damage by increasing apoptosis (programmed cell death) in cardiomyocytes and reducing protein expression of _____ (a protein that is a mechanotransducer and is important in maintain- ing normal cardiac function)
Melusin
___ is the active component of marijuana that is responsible for its psychoactive properties;
THC
The cannabinoids in marijuana exert their effects by binding two cannabinoid receptors: cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2). CB1 and CB2 both belong to a superfamily of metabotropic G protein–coupled receptors. CB1 receptors are found pre- dominantly in neurons of the _____, whereas CB2 receptors are present in ____.
CB1: Brain
CB2: immune cells, vascular smooth muscle cells, and cardiac myocytes
The most commonly reported atrial arrhythmia in Marijuana use is _____, which was reported in 26% of published cases
Atrial Fibrillation
Marijuana inhalation results in increased myocardial oxygen demand in addition to :
Creation of reactive oxygen radicals
Endothelial dysfunction
Effects on human platelets
____ is another component of marijuana, but it lacks the psychoactive effect of THC. It has a favorable effect as a pain reliever, anti-inflammatory, and anxiety-relieving agent.
Cannabidiol (CBD)
Caffeine has sympathomimetic effects and increases cytosolic calcium concentration by _____.
inhibiting calcium reuptake in the sarcoplasmic reticulum
_____ due to energy drinks have been considered possible mechanisms by which MI occurred.
Coronary vasospasm and/or increased platelet aggregation
Opioid that is high risk for causing QT prolongation and ventricular arrhythmias, even at low doses
Methadone
Opioids that are intermediate in risk and may be more of a problem at higher doses.
Tramadol
Oxycodone
Fentanyl
Opioids that are lower risk and do not usually cause QT prolongation or torsades de pointes at routine dosing levels.
Morphine
Buprenorphine
A recent meta-analysis showed exposure to the heavy metals _____ was associated with increased cardiovascular disease including coronary artery disease and stroke.
Arsenic
Lead
Cadmium
Copper
However, this heavy metal was not associated with an increase in cardiovascular disease
Mercury
Heavy metal exposure (including exposure to _____) has been implicated as contributing to metabolic syndrome.
Cadmium
Lead
Mercury
Cadmium increases ______ and depletes natural _____. Exposure to this heavy metal has been associated with endothelial and smooth muscle dysfunction, hypertension, atherosclerosis, and diabetes.
Increase ROS
Depletes antioxidants
Although chelation therapy is one approach to removing cadmium, recent studies suggest that the antioxidants _____ may play a protective role in dealing with cadmium exposure
Curcumin
Tetrahydrocurcumin
