Cardio Conrad Fischer Medquest Pharm Flashcards
ACE (-)’rs - target is where in the body?
lung
SE of ACEIs
cough
hyperkalemia
bradykinin
Use of ACEIs and mech of dec mortality in said disease?
HTN
CHF w/ systolic dysfxn (Dec EF) - will (-) LV remodeling + dilation, control afterload
MoA of AGII
leads to VC of arterioles –> afterload
This or inc K+ –> (+) rel of aldosterone from ZG “Zona Aldosterona”
Aldos @ prox tubule = retain Na, rel K+
Can you use ACEIs in DB?
if just DB alone - NO
DB + HTN/ proteinuria (chronic kidney disease) = YES
Define proteinuria range where ACEIs in DB would be necessary?
30-300 mg - microalbuminemia
Sx of Conn Syndrome
HTN and dec K+
( bc of retention o f Na and release of K due to aldos)
Mech of dry cough due to ACEIs
inc bradykinin –> kallikrein = dry cough
What leads to ACEIs intolerance? Switch to which Rx if this occurs?
Bradykinin - causes VD and pro-inflammatory –> angioedema, dry cough
If occurs - give ARBs instead (-sartan)
Bradykinin actions
Bradykinin (+) B2R –> dec endothelium dep, inc NO –> angioedema
Inc PGE2/cGMP –> VD, loss of natriuresis
Tx of Angioedema
Ecallantide
Icatibant
Which substances/Rx work on Aff art vs eff art of glomerulus?
Afferent:
Normally, VD caused by PGI2 & PGE2
(-) NSAIDs (leading to VC)
Efferent:
VC caused by AGII, NE - maintains GFR when renal perfusion dec
ex/ Bilateral renal a stenosis
How to know if swelling is allergic rxn or angioedema?
There’s no itching with angioedema
63 yr old female w/ Hx of HTN. Has palpitations, EKG shows Afib w/ HR of 125.
What is next course of action?
If < 1d, do nothing
>2 d - long term anticoagulants
If still doesn’t resolve, slow HR w/ BB, CCB, & Digoxin
What are the indications of cardioversion in this pt?
If hemodynamically unstable
Sx/ chest pain ( dec perfusion)
SOB (can’t get blood out of lungs)
confusion (dec brain perfusion)
dec BP
Which CCB can be used in this pt?
Only verapamil and diltiazem
-dipines can inc HR bc of reflex tachy
Which BB can be used in the Afib pt?
usually B1R (-)’rs - metoprolol
What is the target HR to reduce down to?
<100
Use of Propranolol
Thyroid storm
stage fight
essential tremor
Migraine prophylaxis - BB > 3mo to (-) next attack
portal HTN - dec freq of bleed
CCB like verapamil and diltiazem used for what arrythmias?
Can only slow HR if atrial arrythmia, SVT
bc (-) AV node in pathological conditions
if sinus rhythm issue, don’t slow HR
SE of CCB
dec BP
constipation ( (-) smooth musc)
peripheral edema (VD)
AV block
SE of BB
ED
dyslipidemia
depression (dec NE, Dopamine)
SE of Digoxin
INC K+ ( (-) Na/K ATPas)
atrial arrythmia w/ variable block
diarrhea (most common)
If a pt has 2 or more of the following, what Rx do you give?
CHF
HTN
Age > 75
DB
Stroke Hx
give anticoagulants
>48 hr, inc risk of clot/embollus
When is warfarin used to (-) stroke?
if valvular issues - like valvular Afib
-dipines used for?
HTN - will dec mortality, causes VD arterioles
CAD - if can’t use BB, will not dec mortality
pulm HTN - relax heart if hypertrophic cardiomyopathy
(-) vasospasm - Raynauds, SAH, Prinzmetal
What do you give in case of chronic dec in O2 in lungs?
chronic hypoxia –> VC lungs. Give O2
Rx of Primary Pulm HTN
1) PDE5 (-)’rs = sildenafil, vardenafil, todalafil
2) Bosentan - endoth -R (-)’r
3) PGI2 = VD - Epoprostenol, Iloprost, (-) platelet aggregation
+ R. heart catherization and see what works
MoA and use of Spironolactone & Eplerenone
Aldos-R (-)’r - retain Na and excrete K+
use: CHF - dec preload, dec mortality in systolic dysfxn
also anti-androgenic - PCOS, acne, hirsuitism
Ascites - best initial Rx as a diuretic
Adrenal hyperplasia/Aldos producing adenomas
Which Rx dec mortality in CHF?
ACEIs, ARBs, BB, and Aldos-R (-)’rs
How to replace mineralocorticoids?
Fludrocortisone
SE of Spironolactone/Eplerenone
inc K
Spironolactone - gynecomastia
Acetazolamide - MoA and use?
MoA - (-) HCO3- resorption
Use for mountain sickness, alkalosis
Propranolol use in Pheo - use what first?
start with alpha (-)’n - Phenoxybenzamine, Phentolamine, then BB
SE of any BB?
B2 (-)’n ?
Any BB - dec HR, BP, Inc K+ ( bc RAAS (-)’n)
B2R (-)’n - bronchospasm, ED, hypoglycemia (glycogen breakdown)
34 yr old female @ ER w/ palpitations
SVT @ 160 bpm, no response to vagal maneuvers (carotid massage)
What Rx to give?
Adenosine
MoA of Adenosine
Opens K+ channels –> hyperpol
if not responsive to Inc CN X of carotid massage
dec Ca currents, and AV node conduction
slows sinus rate
SE of Adenosine
transcient asystole <5s
bronchospasm (if hyper responsive airway)
If SVT not fixed with Adenosine?
Digoxin
MoA of Aspirin
irreversible acetylates COX
(-) PG (TXA2), (-) plat activation and aggregation
Uses of Aspirin
- Acute Coronary Syndrome
- Stroke/TIA - aspirin or clopidogrel
- PAD
- dec fever
- Inflammatory arthritis - ex/ Jarisch Herxheimer rxn
- Esst’l thrombocythemia
- Kawasaki
- arthritis, gout
In Acute coronary syndrome, MI/unstable angina
post stent, post bypass
Use which Rx?
Use 2 Rx
dipyridomole too weak on its own, need aspirin too
In stroke/ TIA, use which Rx?
aspirin OR clopidogrel
In essential thrombocytopenia, when to use which rx?
if they bleed - use hydroxyurea
if they clot - use aspirin
SE of Aspirin
- bleed (platelet aggregation), esp w/ vWF deficiency
1 dose can (-) platelet for a week. - (-)’n of PGE2 —> peptic ulcers, renal insuff, VCaff
- asthma –> nasal polyps w/ LT synthesis issues
- intoxication –> tinnitus (salicylism)
- In toxic amounts –> metabolic acidosis, destroys mitoch - lactic acidosis.
Use of Dipyridamole
cardiac stress test for obstruction
should inc flow w/ thallium
combine w/ aspirin for brain - stroke/TIA, periph art disease
MoA of Dipyridamole
(-) platelet PDE = Inc cAMP = VD (-) (+)'n of platelets (+) cGMP = VD
PDE normally breaks down cAMP
SE of dipyridamole
bleed
headache (VD)
Ex of ADP-R (-)’r
Clopidogrel
Prasugrel
Ticlopidine
Ticogrelor
Uses of ADP-R (-)’r
1 in heart issues
acute coronary syndrome
stenting
give 1 w/ aspirin
Diff between ADP-R (-)’rs
Clopidogrel - used only in brain, if aspirin not tolerated.
Ticlopidine - SE/ TTP, neutropenia
Prasugrel - inc efficacy, more bleeding, never used in brain
Ticagrelor - reversible, doesn’t need to be activated.
MoA of Cilastazol
antiplatelet PDE III (-)’rs - inc cAMP
reversible platelet aggregation
arterial VC
Use of PDE (-)’r
Periph art disease - VD, esp in femoral bed
Claudication from vascular disease - do dipyridimole stress test
SE of PDE (-)’r
VD –> dizzy, edema, vertigo, headache
use of aspirin, clopidogrel + exercise
better > pentoxifylline
72 yr old pt on ramipril, metoprolol, spironolactine, furosemide, dev dry cough, which Rx to stop?
stop ACEIs, used ARBs
major SE of ACEIs/ ARBs , how to treat?
Inc K+ — use hydralazine + nitrates
SE of hydralazine
drug induced lupus [(+) ANA]
hypotension
Ex of GPIIb/IIIa (-)’rs
Abciximab
Tirofiban
Eptifibatide
Lomifiban
Orbofiban
Use of GPIIb/IIIa (-)’rs
percutaneous coronary interventions
In a cath lab, bc IV only. (-) coronary a from occluding, (-) platelets
in addition to aspirin + clopidogrel
Disease with defective GPIIb/IIIa - R?
Glanzmann Thrombosthenia
SE/ of GPIIb/IIIa (-)’rs
bleed, thrombocytopenia
MoA of GPIIb/IIIa (-)’rs
(-) fibrinogen and vWF binding to receptor on platelet
stops platelets from binding to endothelial lining and to each other
(-) the homeostatic plug (primary clot)
Diff between GpIIb/IIIa & GpIb - R? Defective in which diseases?
GpIIb/IIIa - helps platelets stick together w/ fibrinogen & vWF
defective in Glanzmann
GpIb - platelet sticks to endothelium vWF,
defective in Bernard Soulier - 1 B
vWF def - use what test?
In the presence of ristocetin, blood with adequate vWF clots normally. Blood that’s deficient in vWF or has defective vWF won’t clot.
ex of Thrombolytics
tPA
Anistreplase
Streptokinase
Alteplase
Tenecteplase
How soon after stroke/chest pain is thrombolytics useful?
w/in 12 hours post chest pain
<3-4 hours for a stroke
How much time from door to balloon/angiplasty?
90 min, if longer, go to thrombolytics
CI of Thrombolytics
any risk of bowel/brain bleed - risk of bleeding, cerebral tumor, head trauma, or BP > 110
If chest pain and BP > 110, and you correct BP, can you give thrombolytics
Yes
Does Guaiac pos stool considered CI for thrombolytics
No, but black or red stool is CI for thrombolytics
MoA of thrombolytics
-ase - enzymes that degrade plasminogen –> plasmin
Plasmin degrades fresh fibrin
Fibrin is stabilized by
soft clot is just fibrin, but is solidified with thrombin, and FXIIII
FXIII - is clot stabilizing factor
Sudden SOB w/ clear lung means?
PE
What lab parameter inc with thrombolytics
D-dimer INC
bc fibrin degradation product = d-dimers
(fibrin isotrimer –> 2 D shaped dimers)
Digoxin is used in?
HF, atrial arrythmia
MoA of Digoxin
(-) Na/K ATPase -
Na stays in, Ca cant leave cell bc does so with Na/Ca anitport –> Inc Ca (+) ionotropy
SE of Digoxin
GI (cholinergic) - n/v, diarrhea
arrythmia - atrial tachy w/ variable block
confusion - encephalopathy
INC K+
What effect does Digoxin have on BP?
no effect on BP, so can be used for HR control
What cardiac parameter of CHF does digoxin improve?
CO,
In case of SVT, how does Digoxin help?
will not convert Afib –> sinus, but will slow ventricular rate
EKG signs of Afib/flutter?
no p waves
irreg irreg R-R intervals
Tx of Digoxin tox
Digibind (Digoxin antibody)
Fondaparinux MoA, when used?
FX (-)’r , used if HIT rxn, binds directly to antithrombin III, INC (+)’n to target it
Fondaparinux used in what diseases?
DVT, PE
(-) DVT in hip and knee replacements
Highest rate of DVT seen in what surgery? and why?
ankle replacement
longest period of immobility
MoA of Amiodarone?
class III anti-arrythmics.
(-) K+ channels - prolongs APD, extends refractoriness
also (-) inactivated Na & Ca channels, (-) abnormal automaticity
Use of Amiodarone
- Vtach/ Vfib - used in addition to defibrillator + vasopressors
- Afib - maintain sinus rhythm
- Prolonged QT syndrome - has BB effect, slowing heart will inc coronary filling –> dec ischemia –> dec all arrythmias
SE/ of Amiodarone
pulmonary fibrosis (dec FEV1/FVC) corneal deposits, blue-grey skin
68 female with SOB w/ min exertion from CHF, EF = 28%
which rx provide a mortality benefit?
All ACEIs and ARBs
BB - not all of them
Spironolactone/Eplerenone
Hydralazine AND nitrates ( only if both, nitrates on their own do not dec mortality)
Which BB provide a mortality benefit in CHF?
metoprolol
carvedilol
bisoprolol
T or F Ionotropic rx reduce mortality
F - Ionotropic Rx do not dec mortality
ex/ Dobutamine
Amrinone/Milrinone
When giving BB for CHF, what do you add if ischemia also involved
Ranolazine - used in ischemia, CAD
MoA of Ranolazine?
Na channel (-)’r
(-) Ca overload, leading to ischemia bc inc contraction + O2 consumption
What anti-arrythmic rx (-) phase IV
IVabradine - inc late INa
Pt w/ CAD by stress test, No DB/HTN, no smoking
Inc LDL = 3 mo
What does the pt have? What Rx ?
Acute Coronary Syndrome
give Statins
What do we give in chronic angina? Which dec mortality the most?
statins (best to dec mortality) - esp atorvastatin, rosuvostatin
niacin (dec LDL, inc HDL)
cholestyramine (dec LDL)
1 SE of Statin?
Liver issues ( measure LFTs)
Rhabdomyositis not as common
Normal LDL levels
<70-100
Try to get it <100, especially if CAD, or equivalent like disease DB, peripheral art disease, or stroke
<70 if multiple comorbidities
At what LDL level do you start statins?
def give statins if LDL \> 130 usually yes if \> 70-100
Man with metastatic cancer w/ DVT
Woman w/ metallic heart valve on routine care
Which rx?
Warfarin
#1 strongest indicator for warfarin use = metallic heart valve #2 - valvular Afib
MoA of Heparin
(+) Antithrombin - (-) all of the clotting cascade, esp IIa, Xa
When is IV Heparin the ans?
Use IV Heparin for surgical procedure bc of short t1/2
What test is used to follow Warfarin use/Heparin use?
Warfarin - measure PT/INR 2-3
Heparin - meaure PTT
SE of Heparin
bleed
HIT (allergic rxn)
Mech of HIT , what Rx to switch to?
HIT is not dose dep
IgG vs heparin bound platelet factor 4
test for Ab or serotonin related assays
Stop heparin and switch to Fondaparinux
Warfarin (-) which factors
Factors 2, 7, 9, 10
Which anticoags safe in pregnancy
heparin, LMWH
all heparins are safe in pregnancy, monitor with PTT
32 yr old woman in 3rd trim pregnancy
HTN, edema, proteinuria, pre delivery
67 year old man has torsades post MI, hemodynamically stable
Best rx?
MgSO4
will (-) seizure and dec BP in preeclampsia
(-) fetal arrythmia on Torsades
How does MgSO4 work?
Mg competes for Ca for active sites on smooth m in arterioles and uterine smooth m. Dec smooth m contractions = venodilate
Ventricle cells under catecholamine stress less likely to respond w/ autonomic depol
SE of Mg2+
musc weakness
loss of reflexes
diarrhea ( why we use milk of Mg) - osmotic retention of fluid
severe - resp paralysis
31 year old female at ER w/ palpitations. Short PR interval –> SVT
when given diltiazem/adenosine, pt had vtach
What does this pt have?
if diltiazem/ adenosine make it worse - it’s WPW
EKG sign of WPW?
delta wave, short PR
Best initial Rx of WPW?
procainamide (Ia)
amiodarone (III)
Which Rs is the WRONG ans for WPW
Digoxin
CCB
Adenosine
b/c by (-)’g Normal conduction = Inc Abnormal conduction system
Why do disopyramide + quinidine do not work as well on WPW?
They do not work as well on ventricular arrythmia, exclusively atrial
How to definitively treat WPW?
cauterize accessory pathway - radiofreq catheter ablation
