CAD And HF Flashcards
Angina can lead to
MI, CHF, arrhythmias
At rest
Coronary BF
% CO
%02 extracted from myocardial tissue beds
70 ml/min/100g
5% co
70%
Coronary bf at exercise
Coronary bf alteration
CO demand increase, what also increases
2-4x
4-7x
Preload, hr, contractility
When coronary arteries fill
What perfusion pressure to LV is
Diastole
DBP-LVEDP
Factors that increase myocardial 02 demand 4
Tachycardia, high afterload, high preload, increased contractility
What increases myocardial 02 supply
6
Hgb conc, 02 sat, bradycardia, inc DBP, low normal preload, decreased contractility
CAD
Hr goal, indicated, contra/cautious use
Slow
BB and CCB
Isoproterenol, dobutamine, ketamine, pancuronium
CAD goals
Preload goal
Indicated
Contraindicated
Low normal
Ntg and diuretics
Volume overload
CAD goals
Afterload goal
Indicated
Contra/caution
High normal
Phenylephrine
Nitroprusside, high dose volatile agent
CAD
Contractility goal
Indicated
Contra
Normal to decreased
BB, CCB, high dose volatile
Contra: epi, dopamine
Stable angina tx
A- ASA, antianginals (nitrates, Ccb, bb) B- BP control C- cholesterol, no cigs D- diet, dm E- edu, exercise
Organic nitrates
What they do
3 ex
Inc conc NO in smooth muscle
Ntg, isordil, imdur
Organic nitrates
What they do to veins and arteries, cv fx
Isordil DOA
Relax venous capacitance vessels and large coronary arteries to decrease preload and ventricular wall tension. Decrease demand, inc supply
6 hrs
Ntg routes
6
SL: tab, spray
Oral
Topical: ointment, patch
IV
NO signal pathway through
Glutathione and glutathione s transferase to NO
Nitrate MOA
Release NO after metab. Activate guanylate cyclase, inc cGMP, inc protein kinase G
Where nitrate signaling cascade ends
Dephosphorylation of myosin light chains, sequesters intracellular Ca, vessel relaxes
Anti angina actions of nitrates
Reduces 02 consump (dec preload thru vasodilation, dec afterload thru arterial dilation)
Dilates collateral vessels serving ischemic areas, attentuates spasms, inc rate of relaxation like NO
NTG
Metabolism
1/2t
90% degraded by liver to inactive metabolites.
E 1/2 1.5 min IV
SL and transdermal bypasses 1st pass and liver
Ntg
SE
HA
Postural hypotension
Methomoglobinemia (high iv dose and liver disease)
Nitrate tolerance
About, do what
Limits efficacy. Tolerance to AE.
Have intervals w no use, remove path at night. Oral siorbine: long t 1/2 w low levels
Nitrate drug interac
3
What happens
Tx
Viagra, cialis, levitra
Inhib phosphodiesterase, breaks down cGMP
Additive effect. Tx phenylephrine
Beta adrenergic antag
Overall effect
Indic
Favorable 02 supply and demand balance
Prevents unstable and stable angina
Beta adrenergic antag
What it does to heart itself
Dec 02 demand by dec CO. Dec catechol inc in SA ndode and AV node- HR dec. Improves diastolic filling time to inc supply, CO drop more dramatic w activity than rest
BB Use primarily what Improves survival in who Dont do what Avoid in what
B1 selective, metoprolol and atenolol
CAD
D/c suddenly
Variant angina
BB
SE 6
Depression, insomnia, masks hypoglycemia signs in DM, exercise intolerance, bronchospasm asthmatics
CCB L type
Action (MOA)
Bind to A1 subunit of l type channel in mode 0 when channel wont respond to depolarization stimula
CCB Effect at SA AV Muscle Coronary vasculature
Dec hr,
Dec conductivity and hr
Dec contractility
Dilates vessels and arterioles
CCB
AE 5
AV block, cardiac failure, HA, constipation, hypotension
Dihydropyridines
3 ex
What they are
May cause what
Amlodipine, nifedipine, nicardipine
More selec for ca ch than vasculature than non-dihydropyridines
Reflex tachycardia
Non dihydropyridines
2 ex
More selec for
More at risk for, avoid what
Verapamil and dilt
Ca ch in heart
Heart block, avoid use of BB
Asa
Role, MOA
Plt activation contributes to thrombus formation
Antiplatelet activity imp CAD
ASA
Inhib what
Duration
Dose
Irreversible inhibited TxA2, lifespan of plt 10 days, 80 mg
Unstable angina
4 drugs you would use
Antianginals, heparin or asa, hpIIb/a agonists like integrillin, plavix
STEMI tx
Surgery, streptokinase, tPA
Plavix
MOA
Indic
Irreversible plt ADP receptor a antag
All ACS pts w ASA allergy
Reduces recurrent coronary events
Plavix
Caution w what
Combo w ASA/GPIIb/a inc risks of major bleeding. May still usein some pts
GP IIb/IIIa inhib
3 ex
Indic
Reapro, integrillin, aggrastat
Reduce risk mi in unstable angina and urgent revasc w nstemi
Tx acute angina
Nitrates, bb, Ccb
Tx unstable angina
Nitrate, bb, Ccb, aspirin or plavix, hepatic or thrombolytics, glyco II/III inhib
Tx variant angina
Nitrates and Ccb
Systolic dysfunc
EF < ___%
Causes
40
CAD
NICM: htn, valvular disease, etoh, thyroid disease, cardiotoxic drugs
Diastolic dysfunc
Impaired ___
2 causes
Filling
Cardiomyopathies
Incomplete relaxation of LV during ischemia (myocytes need ATP to relax)
HF manifestations
Dyspnea: DOE, orthopnea, PND
Fatigue, fluid retention
NYHA
Class I
Class II
No symp w ordinary activity
Symp w ordinary activity, slight limitation
NYHA classification
Class III
Class IV
Symp w less than ordinary activity, marked limit
Symp w any activity, also at rest
Physio drug goals
Reduce ___: 3
Reduce ___:3
Preload: diretics, aldosterone antag, venodilators
Afterload: ACEi, BB, vasodilator
Physio drug goals
Increase ___: 3
Inotropy: cardiac glycosides, sympathomimetic amines, phosphodiesterase inhib
CHF goals
HR: __ to ___
Drugs:
Contra:
Normal to elevated
Dopamine and dobutamine
BB (high doses)
CHF goals
Preload
goal: ___, indicated, contra
Normal
IVF if decreased
NTG (if now preload), thiopental
CHF goals Afterload
Goal, indic, contra
Low
ACE, ntp, amrinone
Phenylephrine
CHF goals contractility
Goal, indic, contra
Increased
Dopamine, dobutamine, epi, amrinone
C: high dose inhaled agents and high dose BB
Diuretics
Consider __ before giving
No evidence of __ benefit w __ or __ diuretics
Preload
Mortality, thiazide, loop
Diuretics
__ ones most commonly used
3 ex. Inhibit what. Inc excretion of what
Loop
Furosemide, bumetanide, torsemide
Inhib na k 2 cl cotransporter in loop of henle. Excrete na, k, water
Diuretics Distal tubule: 5-10% \_\_ excretion 2 drugs 2 that spare k Lose effectiveness when what
Na
Thiazides, zaroxolyn
Spironolactone, eplerenone
Creat <30 ml/min
Diuretics
Loop: 20-25% __ excretion
Na
Spironolactone
How it acts
K sparing, competitive antagonist at aldosterone receptor
Dec k/na exchange in distal tubule and collecting duct of nephron
Spironolactone
Inc mortality or not
Monitor what w ACE
Decreases mortality
Monitor k, both decrease k excretion
Aldactone SE
Gynecomastia and impotence from inhibiting androgen and mineralcorticoid receptors
Inspa
What is is comp to aldactone
Also an aldosterone antagonist. More selective- less SE
NTG
CV effects
Inc venous capacitance, reduces venous return to heart. Dec myocardial o2 demand. Alleviates ischemia, improves diastolic relaxation and improves LV compliance
Ntg
Caution in these pts
Dont decrease preload too much
ACEi
Actions
Reverses RAA vasoconstriction and vol retention. Reduces afterload which increases SV, inc GFR , inc natiuresis/diuresis. Dec preload. Mortality benefit
ARB
Comparison to ACE
Similar hemodynamics, no bradykinin related vasodilation so less preload reduction. Mortality benefit. May be additive when used w ACEI
B blockers
Benefits r/t
Inhib renin release. Attenuates signaling from catecholamines and prevents ACS.
B blockers
Dont use in who
Benefit
Acute decompensated HF
Mortality benefit
Hydralazine and isorbide initiate
Action
Use when
Benefit
Vasodilator.
When pt doesnt tolerate ACEi
Mortality dec only in African Americans
What is bidil, why its useful
Hydralazine (arterial dilator) and isorbide dinitrate (venodilator).
Digoxin
Action
Na k adenosine triphosphate inhib. Dec SNS outflow, inc PNS outflow. Dec conduction, inc av refractory period. Dec hr/preload/afterload. Inc ca. Dec na abs
Digoxin
Therap level
Onset
Half life
0.5-1.2
30-60 min
36 hrs, takes 7 days to reach steady state serum conc
Digoxin
Excretion
AE
Antidote
90% really excreted
Hypokalemia, av block, ventricular ectopy
Digibind/fab
Digoxin
Pharm interactions
Inc risk av block w bb
Bb and ccb decrease contractility
Abx inc absorption
Digoxin
Drugs that inc levels and how
Verapamil, quinidine, amio. Affect Vd and/or renal clearance
Dobutamine
Action
Stim B1, inc contractility. Stim B2- arterial vasodilation, dec afterload. Short term tx acute HF
Phosphodiesterase inhib
Do what on cell level
Inhib degradation of cAMP and cGMP in cardiac myocytes and vascular smooth muscle
Phosphodiesterase inhib
Cardiac effects
Inc contractility w little inc in 02 demand. Arterial and venous dilation dec after and preload. Mild bronchodilation. Improved diastolic relaxation.
Pde inhib
Good in OD of what
Beta blocker
Amrinone
Cv effects
Inc CO and LV EF
Dec LVEDP and wedge pressures.
HR inc slightly, BP dec slightly
Amrinone
1/2 life
Excretion
AE
6 HRS
Renal, unchanged
Hypotension and thrombocytopenia. May cause arrhythmias from inc ca
Milrinone
Comp to amrinone
E 1/2
Excretion
Less tachycardia and thrombocytopenia
2.7 hrs
80% excreted unchanged in kidneys
Milrinone
Long term use shows what
No improvement of M and M. May increase it. More helpful for pulm htn management
