Cardio - Pharm (Part 1: Antihypertensives & Antianginal therapies)

Question 1

What are the 3 major conditions treated by antihypertensive therapy?

Answer 1

(1) Primary (essential) hypertension (2) Hypertension with CHF (3) Hypertension with Diabetes mellitus

Question 2

What 4 drugs are used as antihypertensive therapy in Primary (Essential) hypertension?

Answer 2

(1) Diuretics, (2) ACE inhibitors, (3) angiotensin II receptor blocks (ARBs), (4) calcium channel blockers

Question 3

What 4 drugs are used as antihypertensive therapy in CHF?

Answer 3

(1) Diuretics, (2) ACE inhibitors/ARBs, (3) Beta-blockers (compensated CHF), (4) Aldosterone antagonists

Question 4

What 5 drugs are used as antihypertensive therapy in Diabetes mellitus?

Answer 4

(1) ACE inhibitors/ARBs, (2) calcium channel blockers, (3) diuretics, (4) B-blockers, (5) alpha-blockers

Question 5

When must Beta-blockers be used cautiously with regard to CHF, and when are they contraindicated?

Answer 5

In decompensated CHF; in cardiogenic shock

Question 6

What should you remember about the potential effects of ACE inhibitors/ARBs in diabetic patients?

Answer 6

ACE inhibitors/ARBs are protective against diabetic neuropathy

Question 7

For what condition are the following drugs used: Diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers?

Answer 7

Primary (Essential) hypertension

Question 8

For what condition are the following drugs used: Diuretics, ACE inhibitors/Angiotensin II receptor blockers (ARBs), beta-blockers (compensated CHF), aldosterone antagonists?

Answer 8

Hypertension with CHF

Question 9

For what condition are the following drugs used: ACE inhibitors/ARBs, calcium channel blockers, diuretics, beta-blockers, alpha-blockers?

Answer 9

Hypertension with Diabetes mellitus

Question 10

What are 3 examples of dihydropyridine calcium channel blockers? What are 2 examples of non-dihydropyridine calcium channel blockers?

Answer 10

Amlodipine, Nimodipine, Nifedipine (Dihydropyridine); Diltiazem, Verapamil (Non-Dihydropyridine)

Question 11

What is the mechanism of calcium channel blockers, and what effect does this have?

Answer 11

Block voltage-dependent L-type calcium channels of cardiac and smooth muscle & thereby reduce muscle contractility

Question 12

In terms of their effects on vascular smooth muscle, how do the following calcium channel blockers compare: amlodipine, diltiazem, nifedipine, verapamil?

Answer 12

Vascular smooth muscle - amlodipine = nifedipine > diltiazem > verapamil

Question 13

In terms of their effects on heart, how do the following calcium channel blockers compare: amlodipine, diltiazem, nifedipine, verapamil?

Answer 13

Heart - verapamil > diltiazem > amlodipine = nifedipine; Think: “Verapamil = Ventricle”

Question 14

For what 3 conditions are dihydropyridine calcium channel blockers used clinically? Which dihydropyridine calcium channel blocker is the exception? For what is that particular one used, and why?

Answer 14

Dihydropyridine (except Nimodipine): Hypertension, Angina (including Prinzmetal), Raynaud’s phenomenon; Nimodipine: Subarachnoid hemorrhage (prevents cerebral vasospasm)

Question 15

What are 7 toxicities associated with calcium channel blockers (i.e., amlodipine, nimodipine, nifedipine, diltiazem, and verapamil)?

Answer 15

(1) Cardiac depression, (2) AV block, (3) peripheral edema, (4) flushing, (5) dizziness, (6) hyperprolactinemia, & (7) constipation

Question 16

What is the mechanism of hydralazine? What effects does it have on arterioles versus veins? What effect does this have on afterload?

Answer 16

Increases cGMP –> smooth muscle relaxation. Vasodilates arterioles > veins; afterload reduction

Question 17

In what 3 conditions/settings is hydralazine used clinically? How is it frequently administered, and why?

Answer 17

(1) Severe hypertension, (2) CHF; (3) First-line therapy for hypertension in pregnancy, with methyldopa; Frequently coadministered with Beta-blocker to prevent reflex tachycardia

Question 18

What is the first-line therapy for hypertension in pregnancy?

Answer 18

Hydralazine - First-line therapy for hypertension in pregnancy, with methyldopa;

Question 19

What are 6 toxicities of hydralazine?

Answer 19

(1) Compensatory tachycardia (contraindicated in angina/CAD), (2) fluid retention, (3) nausea, (4) headache, (5) angina. (6) Lupus-like syndrome

Question 20

What are 5 drugs commonly used in hypertensive emergency?

Answer 20

Commonly used drugs include (1) Nitroprusside, (2) Nicardipine, (3) Clevidipine, (4) Labetalol, and (5) Fenoldopam

Question 21

What condition is Nitroprusside used to treat clinically? What is its length of action?

Answer 21

Hypertensive emergency; Short acting

Question 22

What is the mechanism of Nitroprusside? What is a potential toxicity associated with this drug?

Answer 22

Increase cGMP via direct release of NO; Can cause cyanide toxicity (releases cyanide)

Question 23

What condition is Fenoldopam used to treat clinically? What is its mechanism? What 3 major effects does it have?

Answer 23

Hypertensive emergency; Dopamine D1 receptor agonist - (1) coronary, peripheral, renal, and splanchnic vasodilation; (2) Decreased BP and (3) Increased natriuresis

Question 24

What other drug shares the same mechanism as nitroglycerin? What is their mechanism?

Answer 24

Isosorbide dinitrate; Vasodilate by increasing nitric oxide in smooth muscle, causing increase in cGMP & smooth muscle relaxation

Question 25

Again, what is the mechanism of nitroglycerin and isosorbide dinitrate? What effect does this have on arteries versus veins? What effect does this have on preload?

Answer 25

Vasodilate by increasing nitric oxide in smooth muscle, causing increase in cGMP & smooth muscle relaxation; Dilate veins&raquo_space; arteries; Decrease preload

Question 26

For what 3 conditions are nitroglycerin and isosorbide dinitrate used clinically?

Answer 26

(1) Angina, (2) Acute coronary artery syndrome, (3) Pulmonary edema

Question 27

What are 5 toxicities associated with nitroglycerin and isosorbide dinitrate?

Answer 27

(1) Reflex tachycardia (treat with Beta-blockers), (2) hypotension, (3) flushing, (4) headache, (5) “Monday disease” in industrial exposure: development of tolerance for the vasodilating action during the work week and loss of tolerance over the weekend results in tachycardia, dizziness, and headache upon reexposure

Question 28

What is the goal of antianginal therapy? What are the factors involved in achieving this goal?

Answer 28

Reduction of myocardial O2 consumption (MVO2) by decreasing 1 or more of the determinants of MVO2: end-diastolic volume, blood pressure, heart rate, contractility

Question 29

Do nitrates versus Beta-blockers affect afterload or preload?

Answer 29

Nitrates - Preload; Beta-blockers - Afterload

Question 30

What affect do nitrates have on the following factors associated with myocardial O2 consumption: (1) End-diastolic volume (2) Blood pressure (3) Contractility (4) Heart rate (5) Ejection time (6) MVO2?

Answer 30

(1) Decrease (2) Decrease (3) Increase (reflex response) (4) Increase (reflex response) (5) Decrease (6) Decrease

Question 31

What affect do beta-blockers have on the following factors associated with myocardial O2 consumption: (1) End-diastolic volume (2) Blood pressure (3) Contractility (4) Heart rate (5) Ejection time (6) MVO2?

Answer 31

(1) Increase (2) Decrease (3) Decrease (4) Decrease (5) Increase (6) Decrease

Question 32

What affect do nitrates and beta-blockers combined have on the following factors associated with myocardial O2 consumption: (1) End-diastolic volume (2) Blood pressure (3) Contractility (4) Heart rate (5) Ejection time (6) MVO2?

Answer 32

(1) No effect or decrease (2) Decrease (3) Little/no effect (4) Decrease (5) Little/no effect (6) Significant Decrease

Question 33

How do calcium channel blockers compare to nitrates and beta-blockers in terms of effect? Give a specific calcium channel blockers that relates to each.

Answer 33

Nifedipine is similar to Nitrates in effect; Verapamil is similar to Beta-blockers in effect

Question 34

What are 2 examples of partial Beta-agonists? In what clinical condition are they contraindicated?

Answer 34

Pindolol and acebutolol; angina

Question 35

What are 3 conditions for which non-dihydropyridine calcium channel blockers are used clinically?

Answer 35

Non-dihydropyridine: (1) Hypertension (2) Angina (3) Atrial fibrillation/flutter

Question 36

In what condition(s) is Hydralazine contraindicated, and why?

Answer 36

Toxicity: Compensatory tachycardia (contraindicated in angina/CAD)

Question 37

What adverse effect can nitroglycerin and Isosorbide dinitrate have on the heart? How is this treated?

Answer 37

Reflex tachycardia (treat with Beta-blockers)

Question 38

What 2 drugs are associated with “Monday disease” as a toxicity? Describe the disease and give its 3 symptoms.

Answer 38

Nitroglycerin, Isosorbide dinitrate; “Monday disease” in industrial exposure: development of tolerance for the vasodilating action during the work week and loss of tolerance over the weekend results in tachycardia, dizziness, and headache upon reexposure

Question 39

What are 4 determinants of myocardial O2 consumption (MVO2)?

Answer 39

Determinants of MVO2: end-diastolic volume, blood pressure, heart rate, contractility

Question 40

Give 2 examples of non-dihydropyridine calcium channel blockers. For which 3 conditions are non-dihydropyridine calcium channel blockers used clinically?

Answer 40

(1) Diltiazem (2) Verapamil; Non-dihydropyridine: (1) Hypertension, (2) Angina, (3) Atrial fibrillation/flutter