Cardiac Contractility/Positive Inotropic medications Flashcards

1
Q
  • LV End Diastolic Volume (EDV)-
A

amount of blood in left ventricle at the
end of diastole
* LV EDV = Preload

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2
Q
  • Afterload-
A

pressure heart has to overcome to eject blood
 Afterload = Systemic blood pressure

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3
Q
  • LV End Systolic Volume (ESV)-
A

amount of blood in left ventricle at the end
of systole

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4
Q
  • Stroke Volume (SV):
  • Ejection Fraction (EF):
  • Cardiac Output (CO):
A

SV= EDV – ESV (mL)
EF= SV/EDV X 100% (%)
CO= HR X SV (mL/min)

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5
Q

ionotrophy

A

the ability of the heart to contract

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6
Q

Positive Inotropic medications
(5)

A
  • Cardiac glycosides
  • Digoxin- inhibits Na-K ATPase
  • DOBUTamine- b1 adrenocepter agonist
  • Milrinone- phosphodiesterase inhibitor
  • Levosimendan- calcium sensitizer
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7
Q

Positive Inotropic medications
Digoxin
* Brand name: (3)
* MOA:
* Use: (2)

A

Digitek, Lanoxicaps, Lanoxin (available IV/PO)
inhibition of Na+-K+ ATPase/ vagal tone to heart
heart failure, atrial fibrillation (rate-control)

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8
Q

Positive Inotropic medications
Digoxin
ADRs (narrow therapeutic index medication):
(3)

A
  • Nausea, vomiting, diarrhea
  • Bradycardia/ heart block
  • Visual disturbances (green-yellow halo)
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9
Q

Positive Inotropic medications
Digoxin
Drug-Drug interactions:
(3)

A
  • Other drugs that cause bradycardia or hypokalemia
  • Increased levels with macrolide antibiotic
  • Increase risk of arrhythmia with adrenergic agonists or succinylcholine
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10
Q

Digoxin
— effects with – K+

A

increase
decrease

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11
Q

Positive Inotropic medications
Digoxin- Dental Implications
* Monitor …
* Increased — may make dental procedures,
such as taking radiographs or impressions difficult
* After supine positioning, …
* Use — with caution (adrenergic stimulation)
* Avoid ..
* — protocol

A

vital signs
gag reflex
have patient sit upright
for at least 2 minutes before standing to avoid
orthostatic hypotension (bradycardia)
vasoconstrictors
dental light in patient’s eye/offer dark glasses
Stress reduction

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12
Q

Positive Inotropic medications
DOBUTamine
* Brand name:
* MOA:
* Use: (2)

A

Dobutrex (only available IV)
b1- adrenergic receptor agonist
acute decompensated heart failure, cardiogenic shock

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13
Q

Positive Inotropic medications
DOBUTamine
ADRs:
(3)
* Drug-Drug interactions: none of significance
* Dental Implications: none

A
  • Increased heart rate and blood pressure
  • Arrhythmias
  • Chest pain
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14
Q

Positive Inotropic medications
Levosimendan
* Brand name:
* MOA:
* Use:

A

Simdax (not available in the U.S.)
Sensitize troponin to Ca2+ (inotropy) and KATP channel activation
in smooth muscle (vasodilation)
acute decompensated heart failure

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15
Q

Positive Inotropic medications
Levosimendan
* ADRs:
(3)
* Drug-Drug interactions: none of significance
* Dental Implications: none

A
  • Arrhythmias (ectopic beats, NSVT, VT)- supposedly less than DOBUTamine
  • Hypotension
  • Headache
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16
Q

Myocardial Oxygen Supply
Function of:
(2)

A
  1. Arterial O2 content
  2. Coronary blood flow
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17
Q
  1. Arterial O2 content
A
  • decreased anemia and hypoxia
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18
Q
  1. Coronary blood flow
A
  • decreased atherosclerosis and vasospasm
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19
Q

Myocardial Oxygen Supply is a function of

A

Heart Rate
Cardiac myocytes supplied with blood during diastole
increased Heart rate = dcereased time in diastole

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20
Q

Myocardial Oxygen Demand (MVO2)
MVO2Determinants
(3)

A
  1. Heart rate
  2. Myocardial contractility
  3. Myocardial wall stress
    * Preload
    * Afterload
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21
Q

Surrogate marker for MVO2

A

Double Product= HR X SBP

22
Q

SYMPATHETIC Nervous System
b1 adrenoreceptors
(5)

A
  • increased force of contraction
    (positive inotropic effect)
  • increased heart rate (positive
    chronotropic effect)
  • increased automaticity
  • Repolarization
  • Reduced cardiac efficiency
23
Q

PARASYMPATHETIC Nervous System
Muscarinic (M2) receptors
(3)

A
  • Cardiac slowing
  • decreased automaticity
  • Inhibition of AV node
    conduction
24
Q
  • Organic nitrates-
A

increased myocardial O2 supply

25
* Calcium channel blockers-
increased myocardial O2 supply and decreased O2 demand
26
* b-adrenocepter antagonists-
decreased myocardial O2 demand
27
* Ranolazine-
improves angina w/o changing BP or HR
28
* Ivabradine-
not approved for angina in U.S.
29
Antianginal medications Organic nitrates * Forms: (4)
* Organic nitrates -Nitroglycerin - Isosorbide dinitrate/mononitrate * Sodium Nitroprusside
30
Antianginal medications Organic nitrates * Major side effects (5)
* Headache * Syncope/hypotension * Tachycardia * Tolerance * Methemoglobinemia
31
Antianginal medications Organic nitrates * Contraindicated with
PDE-5 Inhibitors
32
Antianginal medications Organic nitrates- Available products
* SL tablets * Spray * Intravenous * Ointment * Patch * Capsules * LA tablets * Isosorbide mononitrate (ISMN) * Isosorbide dinitrate (ISDN)
33
Immediate relief
* SL tablets * Spray * Intravenous * Ointment
34
Prevention
* Patch * Capsules * LA tablets * Isosorbide mononitrate (ISMN) * Isosorbide dinitrate (ISDN)
35
Antianginal medications Organic nitrates Isosorbide Mononitrate * Brand name: (2) * MOA: * Use: (2)
Imdur, Ismo Stimulate production of intracellular cGMP Angina and heart failure
36
Antianginal medications Organic nitrates Isosorbide Mononitrate ADRs: (4)
* Headache (common), flushing, dizziness, postural hypotension
37
Antianginal medications Organic nitrates Isosorbide Mononitrate Drug-Drug interactions:
* Increased effects with other vasodilator type medications
38
Antianginal medications Organic nitrates- Dental Implications * Monitor ... * --- protocol * After supine positioning, * Use --- with caution * --- available for acute angina attack
vital signs Stress reduction have patient sit upright for at least 2 minutes before standing to avoid orthostatic hypotension vasoconstrictors Sublingual nitroglycerin
39
Antianginal Medications Calcium Channel Blockers MOA:
Block calcium from entering cell through voltage sensitive “slow” L-type channels * Slow conduction in SA and AV node (non-dihydropyridine) *  heart rate * AV block * Vasodilatation of arterioles * Decrease arterial pressure and wall tension * Decrease myocardial contractility * Increase flow through areas of fixed coronary obstruction
40
Antianginal Medications Calcium channel blockers Amlodpine * Brand name: * MOA: * Use: (3)
Norvasc Dihydropyridine calcium channel blocker Angina, hypertension, also vasospastic angina
41
Antianginal Medications Calcium channel blockers Amlodpine ADRs: (6)
* Edema (common), dizziness, lightheadedness, hypotension, flushing, gingival enlargement (rare- but more common than non-DHP)
42
Antianginal Medications Calcium channel blockers Amlodpine Drug-Drug interactions: (2)
* Hypotension with sedatives, opioids, general and inhaled anesthetics * NSAIDS reduce blood pressure lowering effect
43
Antianginal Medications Calcium channel blockers- Dental Implications * Monitor ... * Consider ... * --- appointments * After supine positioning, * Use (2) with caution * Place on frequent recall to monitor for ---
vital signs stress reduction protocol Shorter have patient sit upright for at least 2 minutes before standing to avoid orthostatic hypotension vasoconstrictors and inhaled anesthetics gingival hyperplasia
44
Antianginal medications β-adrenoceptor blockers * Block sympathetic stimulation to the heart (4)
* Decrease heart rate * Decrease automaticity - block NE’s effects on Ca2+ channels * Slow conduction through AV node (increase refractory period)
45
Antianginal medications β-adrenoceptor blockers Prevent
ischemia * Decrease myocardial oxygen demand * decrease HR, decrease contractility, decrease SBP
46
Antianginal medications β-adrenoceptor blockers * Prefer ---acting b1 selective agents for angina
long
47
Antianginal medications β-adrenoceptor blockers Dental implications * Monitor ... * --- protocol * --- appointments * After supine positioning, * Use (2) with caution * Use -- effective dose of local anesthetics
vital signs (heart rate should be low) Stress reduction Shorter have patient sit upright for at least 2 minutes before standing to avoid orthostatic hypotension vasoconstrictors and inhaled anesthetics lowest
48
Antianginal Medications Ranolazine * MOA: (2)
* inhibits late inward sodium current (Ina) in ischemic myocardium  reduced myocardial wall tension and O2 consumption * At higher concentrations inhibits rapid delayed rectifier potassium current (Ikr)  prolonged action potential and QT interval
49
Antianginal Medications Ranolazine * Brand name: * MOA: * Use:
Ranexa Inhibition of late inward sodium current (Ina) Angina
50
Antianginal Medications Ranolazine * ADRs: (6)
* Bradycardia, hypotension, dizziness, QT prolongation, TdP, xerostomia
51
Antianginal Medications Ranolazine * Drug-Drug interactions: (1)
* Many due to CYP 450 3A4 metabolism
52
Antianginal Medications Ranolazine Dental implications: (2)
* Assess salivary flow as a factor in caries, periodontal disease, and candidiasis * Use vasoconstrictors and inhaled anesthetics with caution