Cardiac Pharmacology Flashcards by Lila van Breugel

Commonly used hypertensives are the ABCD’s which are?

A - Angiotensin converting enzyme inhibitors and Angiotensin receptor blockers
B - Beta Blockers
C - Calcium Channel Blockers
D - Diuretics

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Commonly used classes of anti-anginal drugs

Beta blcokers, calcium channel blockers and nitrovasodilators (and diuretics have small role)

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Glycerol Trinitrate

is a nitro-vasodilator which is usually applied sublingualy in acute angina attacks. It is vascular selective and may cause reflex tachycardia and hypotension. Can develop tolerance

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Viagra

Phosphodesterase inhibitors which breaks down cGMP and causes vasodilation. Can cause cardiovascular collapse

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calcium channel blockers

Block L type coltage gated calcium channels - reduces ca entry into vascular cells. Vasodilation greater in arteries than veins

Verapamil, dilitiazem, nifedipine, amliodipine in that order of cardioselectivity

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Verapamil

Cardio selective

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Nifedipine

Vascular selective (can cause reflex tachycradia)

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Calcium channel blockers indications

Angina (reduce cardiac oxygen demand), hypertension, tachyarrhythmias (SVT)

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Adverse effects calcium blockers and contraindications

bradycardia, cardiac depression

Contraindications: heart failure, beta blockers

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beta-blockers

propanolol (beta 1 and 2), atenolol (beta 1), metropolol (beta 1 selective)

Decrease sympathetic drive to heart and inhibit renin release

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beta - blocker indications

angina (decreased cardiac oxygen demand), hypertension, post MI, arrhythmias, clinically stable heart failure

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beta blocker adverse effects

bronchoconstriction, decreased heart contractility, bradycardia, depression and sedation, masking hypoglycaemia

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unstable angina medications

Dipyridamol: increases adenosine and is a vasodilator and anti-platelet drug

Aspirin: Antiplatelet

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Heart failure treatment

lifestyle changes
Diuretics (reduce workload by lowering TBL)
Angiotensin RAS inhibition (ARB/ACEi) (reduce workload by lowering TBL)
Beta blockers (reduce workload by lowering HR)
Digoxin (increase cardiac contractility)
Dobutamine (beta agonist to increase cardiac contractility)

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Dogoxin MOA

Inhibits Na/K ATPase and therefore increase myocardial intracellular calcium. Increased contractility and decreased O2 use

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Digoxin indications

heart failure, cardiomyopathy, atrial arrhythmias but not ventricular

Digoxin AE

narrow safety margin
long half life
arrhythmia, anorexia, nausea/vomitting, diarrhoea, visual distrurbances, agitation
Vagal Stimulation: bradycardia, possible AV block, high dose arrythmias

Digoxin Interactions

Diuretics (thiazides/loop reduce K)
Sympathomimetic drugs (arrhythmias)

Digoxin Toxicity

Fall in Potassium levels or rise in calcium levels

Dobutamine

beta 1 adrenoreceptor agonist

Increases cardiac contractility and cardiac output

Used limed IV and susceptible to desensitisation (already have downregulation in CHF)

Treatment of CHF

Decrease cardiac workload via

beta blockers
diuretics (loop diuretics > thiazides)
Angiotensin RAS inhibition

Increase Cardiac Contractility via
- +ve ionotrope (digoxin or dobutamine (beta 1 agonist)

Thiazide diuretics

Names: hydrochlorothiazide, indapamide

MOA: Act in distal tubule on sodium/chloride transporters and increases calcium reabsorption

Indications: Mild to moderate HT, oedema in mild to moderate CHF or renal/hepatic disease and diabetes insipidus

AE: hypokalaemia, hyperglycaemia, hypercholesterolaemia, digoxin toxicity,

Loop diuretics

Names: Frusemide

MOA: Acts in thick ascending limb of loop of Henle, has greatest diuretic effect

Indications: acute pulmonary oedema, CHF, liver cirrhosis, renal failure (hypertension), treating drug overdose

AE: Hypokalaemia, hypercholesterol and glycaemia, ototoxicity and nephrotoxicity, hypovolaemia

Potassium Sparing Diuretics

Names: Spirinolactone, eplernone, amlioride

MOA: either antagonist to aldosterone or block sodium channels. Sodium leaving drives in potassium

Indications: with loop/thiazide to prevent hypokalaemia, additional benefit in heart failure

ACE inhibitors

end in -pril Blocks conversion of angiotensin 1 to 2 and hence blocks RAAS and decreases water retention Indications: hypertension, heart failure, preserve renal function in diabetes (nephropathy) AE: dry cough due to bradykinin (also broken down by ACE), hypotension (start low dose), hyperkalaemia Contra: pregnancy, bilateral renal artery stenosis, less effective in African

ARB's

end in- sartan Block angiotensin 2 receptors and cause vasodilation Same indications as ACEi but for those intolerance to ACEi due to no dry cough More expensive`

Beta blockers

end in -olol Non selective: propanolol (beta and alpha), carvedilol (also blocks alpha) Selective: atenolol, nebivolol AE: cold extremities (b2), brochoconstriction (b2), mask hyperglycaemia Indication: hypertension, heart failure (late), antiarrrhythmic, anti-ischemic, angina

Steps in heart failure

1. lifestyle changes 2. diuretic or ACEi 3. Combine different classes or increase dose of 1 4. Add 3rd class e.g digoxin 5. Add 4th class e.g. beta blocker, potassium sparing

Anti-arrhythmics

Class 1: lignocaine IV (blocks fast NA current), used ventricular arrhythmias Class 2: beta blockers, used in A fib and flutter and post MI Class 3 K channel blocker, hyperpolarizes and prolongs refractory period Class 4: Calcium channel blockers (used a fib) Digoxin: inhibts NA/K pump, blocks AV conduction Adenosine: hyperpolarises cells, used in supraventricular tachycardia

Lipid lowering agents

- statins - fibrates - cholesterol absorption blockers

Statins

inhibit HMG CoA reductase and stop conversion of acetyl CoA to cholesterol in liver Improve endothelial function and plaque stabilisation unrelated to LDL but still occur Used in hypercholesterolaemia AE: GI disturbances, insomnia, rash

Fibrates

Name: gemfibrozil, fenofibrate Stimulate lipoprotein lipase Mainly used in hypertriglyeridaemia, slows diabetic retinopathy AE: GI, liver disease

Cholesterol absorption inhibitors

Bile acids binding resins e.g. colestipol and cholesyramin (rarely used anymore) Ezetimibe: inhibits cholesterol absorption in intestine. Add on to statin AE: greasy stool

New lipid lowering

Propeptin convertase subtilism, type 9: degrades LDL receptors