Cardio Treatment Drugs Flashcards
Group 1 patients (primary PHTN)
Primary Pulmonary Hypertension (PHTN)
i. Bosentan (endothelin-A receptor antagonist, oral, causes vasodilation)
ii. Sildenafil, tadalafil (phosphodiesterase type 5 inhibitor, increases cGMP =
pulmonary artery relaxation)
iii. Prostacyclin analogues and prostacyclin receptor antagonist
- Epoprostenol: given IV
Rheumatic fever Treatment
a. Bedrest
b. Antibiotics (oral penicillin V)
c. Salicylates (Aspirin): reduce fever and relieve joint pain and swelling
d. Corticosteroids: improvement of joint arthritis
Acute coronary syndrome
Prehospital drug therapy
- Administer oxygen if saturation is less than 90%
- Analgesia – IV morphine or metoclopramide
- Low-molecular-weight heparin to prevent clot formation
- Dual antiplatelet therapy (loading dose): aspirin and P2Y12 inhibitor (usually clopidogrel)
- Nitrates – IV or sublingual
- Consider β-blockers if hypertensive or tachycardic.
- If the patient is not in heart failure or cardiogenic shock, give β-blockers.
- If they are, give ACEI (so long as they are not hypotensive).
Acute coronary syndrome
Hospital therapy
For STEMI :
Long-term aspirin,
ACEI,
β-blockers,
nitrates and high-dose statins
Infective endocarditis
Treatment
Treatment – antimicrobial therapy
a. Penicillin-susceptible oral streptococci = penicillin
b. Penicillin-resistant oral streptococci = amoxicillin/ceftriaxone with aminoglycoside, clinda
c. Beta-hemolytic streptococci = amoxicillin/ceftriaxone with aminoglycoside, clindamycin
d. Staph aureus = methicillin, oxacillin
e. MRSA =
vancomycin
f. Gram-negative HACEK bacteria = ceftriaxone, quinolones
g. Fungi = amphotericin B, fluconazole
Secondary prevention
of the myocardial infarction
a. For those diagnosed with a manifest vascular disease or patients who have already suffered
a cardiovascular event it is especially important to start a secondary prevention drug
therapy besides introducing lifestyle changes and controlling the risk factors. The aim is to:
i. Slow down progression of atherosclerosis
ii. Stabilization of existing plaques can
iii. plaque regression
b. Platelet-aggregation inhibitors – lifelong low-dose aspirin or dual antiplatelet therapy
(aspirin/clopidogrel18 for example)
c. β-blockers – unless contraindicated
d. Statins
e. ACEIs/ARBs
i. Aldosterone antagonists (with ACEI) in patients with heart failure, LVEF <40% or DM
Mitral insufficiency
Medical therapy
a. Diuretics, βB, and ACEI may help improve symptoms and reduce the rate of progression
b. Anticoagulation therapy is indicated in patients with AF
Mitral stenosis
Medical therapy
a. Diuretics, βB, digoxin or heart rate-regulating CCB can improve symptoms.
b. Anticoagulation indicated in patients with AF
Heart failure treatment
- Decreased preload: diuretics, ACEIs, ARBs, and veno-dilators
- Decreased afterload: ACEIs, ARBs, and arterio-dilators
- Increased contractility: digoxin, beta agonists, PDE III inhibitors
o Ionotropes are more beneficial in management of acute CHF
- Decreased remodeling of cardiac: ACEs, ARBs, spironolactone, beta blockers
o ACEs, ARBs, and spironolactone can improve survival in CHF by decreasing aldosterone
levels while beta blockers reduce the activity of SNS on the heart thereby also improving
survival.
Heart failures
Line treatment
a. First line
i. Begin loop diuretics to treat volume overload (thiazides may be added)
ii. ACEI – reduce preload and afterload (if patient does not tolerate give ARBs)
iii. Add β-blocker once the patient is stable on ACEI (Class II-IV; Class I if HTN or post-
MI)
iv. Aldosterone antagonists (spironolactone, eplerenone)
b. Second line
i. Ivabradine – if still symptomatic after highest dose of β-blocker given, or EF < 35%
and after MI (Class II-IV)
ii. Hydralazine – EF < 40% or ACEI are not tolerated (Class III-IV)
- Arteriolar specific, acts through nitric oxide and reduces afterload
- Usually combined with nitrate for heart failure (nitroglycerin or isosorbide
dinitrate)
iii. Angiotensin receptor-neprilysin inhibitor – administered as valsartan-sacubitril combination
iv. Digoxin
c. NOTE
i. Improve prognosis: ACEI, aldosterone antagonists, and β-blockers (decrease cardiac
remodeling)
ii. Improve symptoms: diuretics and digoxin
d. Contraindicated drugs
i. NSAIDS, Calcium channel blockers, antidepressants
Toxic heart deteriorations, primary heart tumors
Treatment
Cancer treatments which can cause cardiac toxicity
a. Chemotherapy
i. Anthracyclines (doxorubicin) – used to treat a multitude of cancers such as leukemia, lymphoma, sarcomas as well as bladder, bone, breast, kidney and other
cancers.
ii. Cyclophosphamide – an alkylating agent used in chemotherapy
b. Targeted therapy – monoclonal antibodies (trastuzumab), tyrosine kinase inhibitors
(sunitinib), and antimetabolites (clofarabine)
c. Radiation therapy – radiation may damage blood vessels which then find its way to the heart.
Heart failure with preserved ejection fraction
Treatment
Treatment – few therapeutic options are available and none which improve prognosis. Treatment is
symptom based
a. Diuretics for volume overload
b. Salt and fluid restrictions (and daily weight monitoring)
c. ACEI, ARBs, β-blockers are often used to help symptoms
d. Antihypertensive and diabetic treatment should be reviewed and optimized
e. Patients who also have AF should receive anticoagulant treatment as well
Medication group for these conditions:
- Sinus tachycardia
- Atrial fibrillation/flutter
- Paroxysmal supraventricular
tachycardia - AV block
- Ventricular tachycardia
- Premature ventricular
complexes - Digitalis toxicity
Gestational HTN
Treatment
β-blockers and Calcium channel blockers
i. ACEI/ARBs and diuretics are contraindicated
Aortic insufficiency
Treatment
a. In patients who suffer from heart failure or hypertension, ACEI or ARBs and βB are useful
b. Patients who are not candidates for surgical treatment may also find the above useful
Name the drug line treatments hypertension
1st line
First-line drugs
a. ACEI/ARB (lisinopril, enalapril; losartan, valsartan)
i. Preferred for patients with diabetes mellitus or renal disease
ii. Side effects: increase K+
iii. DO NOT USE TOGETHER
iv. DO NOT GIVE TO PREGNANY PATIENTS
b. Thiazide diuretics (hydrochlorothiazide)
i. Preferred for salt-sensitive patients and those with isolated systolic HTN
ii. Side effects: reduce K+ and Na+
; increase glucose and cholesterol
c. CCB (nifedipine)
i. Side effects: headache, constipation, GERD
Name the drug line treatments hypertension
2nd line
Second-line drugs
a. β-blockers (propranolol, metoprolol)
i. Contraindicated in patients with aortic regurgitation
ii. Side effects: broncostriction and increased triglycerides
b. Loop diuretics (furosemide)
i. Used in patients with heart failure or CKD
ii. Side effects: decrease K+ and Na+, increase glucose and cholesterol
c. Aldosterone antagonists – in patients with primary hyperaldostronism
d. Direct renin inhibitors – DO NOT USE WITH ACEI/ARBs
e. Alpha-1 blockers – in patients with pheochromocytoma
f. Direct arteriolar vasodilators – use in pregnancy
Steps of pharmacological treatment
Hypertension
(1) Initial pharmaceutical treatment involves the combination of an ACE-inhibitor or ARB with a
calcium antagonist or a diuretic (A+C/D)
(2) The second step of therapy involves the combination of an ACE-inhibitor or ARB with a calcium
antagonist AND a diuretic (A+C+D)
(3) The third step of therapy involves the previous step plus 1 extra hypertensive compound
(spironolactone or other diuretics, beta-blocker, alpha-blocker)
– Beta blocker should be administered in case of any cardiac disorders
Hypertension
Combinations
a. No two drug classes that act separately on the RAS should be used in combination.
b. Some fixed combinations are available
i. ACEI with CCB – Tarka (trandolapril/verapamil)
ii. ACEI with Thiazides – Zestoretic (lisinopril/hydrochlorothiazide)
iii. ARBs with CCB – Exforge (valsartan/amlodipine)
iv. ARBs with Thiazides – Hyzaar (losartan/hydrochlorothiazide)
