Beta Blockers (Stable Angina CAD) Flashcards

1
Q

MOA Beta Blocker Class

A
Lower myocardial o2 demand
-reduce ischemic time
-↓ HR
-↓BP and workload
-↓contractility
slower rates improve venous perfusion and ventricular filling
-Slow PR interval
-Slow ventricular rate
-Reduces Renin output
-Decreased RAAS activity

all BB have dose related b1/b2 activity

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2
Q

Indications for Beta Blockers

A

Preferred when tolerated

Best data for reducing CV events!

Good for open angle glaucoma (↑outflow and drainage)

Perioperatively in high risk pts undergoing non cardiac surgery

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3
Q

Metabolism of Beta Blockers

A

Short half life*

Hepatic metabolism* (hepatic failure might not tolerate BB at therapeutic doses)

Rapidly absorbed

Large volume of distribution

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4
Q

Contraindications of BB

A

relatively CI in COPD
Renal insufficiency* increased toxic effect
Caution in pts with pulmonary dz
Pts with pulm dz can tolerate in low doses
Caution in DM-masks hypoglycemia

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5
Q

BB outcome benefits

A
  • ↓mortality in htn pts with recent MI
  • ↑survival in htn pts after stroke
  • ↑exercise tolerance!! (initially difficult) 25-50% tolerate doses
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6
Q

BB DI

A

DI BB with verapamil or diltiazem
Nonselective: carvedilol (post mi, LV dysfunction, heart failure); labetalol, nadolol, sotalol, timalol

Selective: metoprolol (heart failure or post MI), biosprolol (heart failure or LV dysfunction), atenolol, esmolol, nebivolol

ISA and partial agonism are not clinically important

*fyi bb can mask thyroid strome or thyrotoxicosis (vtach)

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7
Q

Considerations of BB

A

TAPER!!! To prevent rebound
-takes 2-4 weeks for full effect but will see bp decrease in 24 hrs

B1 selective (can still block B2 at high doses)

B2: bronchioles and peripheral vascular tissue for vasodilation; unopposed alpha constriction

Monitor: HR, BP, EKG, Physical function

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8
Q

Metoprolol MOA

A
Selective B1 Blocker
↓inotropy
↓chonotropy
↓cardiac work
↓MV02
(reduced selectivity in higher doses)
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9
Q

Metoprolol indications

A

Asthma
COPD
LIVER dz (little protein binding)

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10
Q

Metroprolol considerations

A

Adjusted to bp, hr, ekg (minimum sbp 90, minimum hr 50)

  • most frequently used BB
  • *evidence for reducing CV events in pts with HTN, HF, LVF, CAD
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11
Q

Bisprolol MOA

A
Selective Beta Blocker
↓inotropy
↓chonotropy
↓cardiac work
↓MV02
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12
Q

Bisprolol indications and meteabolism precautions

A

I: HF pts with HTN

M: Adjust in pts with renal dysfunction bc long half life
50% of dose is excreted unchanged

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13
Q

Bisprolol SE and

Considerations

A

Can precipitate decompensated HF if used in UNSTABLE pts with stage III/IV HF

Evidence based BB in HF pts with HTN

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14
Q

Carvedilol MOA

A

1.nonselective BB
2. alpha 1 blocker***
(= less rebound tachycardia)
↓renin output
↓inotropy
↓chonotropy
↓cardiac work
↓MV02

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15
Q

Carvedilol indcation

Metabolism

A

I:HF

M: Extensive hepatic metabolism: CYP2D6
Adjusted to bp, hr, ekg (minimum sbp 90, minimum hr 50

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16
Q

SE of Carvedilol

A

Less rebound tachycardia!! Following hypotension

17
Q

Considerations of Carvedilol

A

*Evidence in HF, reducing MI

might reduce smooth muscle infiltration in vascular remodeling, limit free radicals, reduce lipid peroxidation

18
Q

Propranolol MOA

A
Nonselective
Lipophilic 
↓inotropy
↓chonotropy
↓cardiac work
↓MV02
19
Q

Propranolol indications

A

h/a prophylaxis with CAD
-Short acting*
1-2 hr onset and lasts 6-12 hrs

-Long Acting* slower onset and lasts 24-27 hrs and even longer in liver dz*

20
Q

Propranolol metabolism

A

high 1st pass metabolism (CYP2D6/1A2)

highly protein bound (90%)
Adjusted to bp, hr, ekg (minimum sbp 90, minimum hr 50)

21
Q

Nadolol MOA

A
Nonselective
↓inotropy
↓chonotropy
↓cardiac work
↓MV02
22
Q

Nadolol Metabolism

A

Non-metabolized: 45 hr duration in pts with renal failure—dose adjust!

23
Q

Nadolol SE

A

Can cause bronchoconstriction in large dose

↓hepatic blood flow with beta2 blockade

24
Q

Nadolol Considerations

A

OK in Liver Dz

Adjusted to bp, hr, ekg (minimum sbp 90, minimum hr 50)

25
Atenolol MOA
``` Selective B1 Blocker ↓BP ↓HR ↓inotropy ↓chonotropy ↓cardiac work ↓MV02 ```
26
Atenolol Indications
Asthma COPD Liver dz (little protein binding and limited hepatic met)
27
Atenolol considerations
↓BP ↓HR but no CV outcomes in HTN with CAD or HF little hepatic metab.
28
Labetalol MOA
1.Nonselective BB (R isomer) 2.Selective alpha 1 blockade (S) ↓ renin output
29
Labetalol Metabolism
Alpha:beta is 1:3 oral vs 1:7 IV | Adjusted to bp, hr, ekg (minimum sbp 90, minimum hr 50)
30
Labetalol SE
less rebound tachycardia in alpha1!
31
Esmolol indications
Perioperative use in HTN, myocardial Ischemia, thyrotoxicosis, VT
32
Esmolol Metabolism
ultra short acting!! For perioperative use*** 2-10 min onset, 10-30 min duration Has ester linkage for rapid hydrolysis by RBCs
33
Nebivolol MOA
Most selective B1 antagonist with endothelium derived nitric oxide dependent vasodilation ↓HR, BP SVR
34
Nebivolol metabolism
12%bioavailable *protein binding 98% met by CYP2D6 half life 10-12 hrs nml or 32 hrs in poor met
35
Nebivodol contraindications
reduce dose in child pugh class B pts Reduce dose in CrCl
36
Nebivodol SE
no hyperglycemic or lipid issues like other BB!!
37
Nebivodol Contraindications
No role in angina Reduces hospitalizations of elderly pts with HF