cardio treatment notecards pt 1 Flashcards
rheumatic fever
• Strict _____ until the temperature returns to normal (without use of antipyretics), sedimentation rate, ECG and pulse also all return to normal
• _____:
o Reduce fever, relive joint pain and swelling
o Adults may require large dose
• _____
o Benzathine Penicillin 1.2 million units IM or procaine PCN 600,000 units IM daily for 10 days
o _____ may be substituted (40 mg/kg/day)
• Corticosteroids
o No proof that cardiac damage is prevented or minimized by steroids
o Short course (prednisone 40-60mg orally daily with tapering over 2 weeks) usually causes rapid improvement of the joint symptoms if salicylates are inadequate
bed rest
Salicylates
Penicillin
Emycin
dilated cardiomyopathy
• All patients regardless of etiology should be treated with _____ and _____
• Heart failure management
• Congestive symptoms: _____ and aldosterone antagonists
• Class II-IV HF: aldosterone receptor antagonist if LVEF is less than 35%
o Or in DM less than 40%
• CCB avoided unless afib or aflutter and need to control ventricular rate
• Control BP (systolic)
• _____ (angiotensin receptor-neprilysin inhibitor)
• Ivabradine if HR >70 and LVEF less than 35%. (do not replace other BBs)
• _____: second line med
• Blacks: hydralazine-nitrate combo and reduce salt intake
• CPAP in sleep apnea
• ICD (implantable cardioverter-defibrillator) is reasonable; LVAD (Left Ventricular Assist Devices)
• Anticoagulation for suitable candidates
• D/C ETOH if alcohol induced
ACEI BB diuretics Sacubitril/valsartan Digoxin
restrictive cardiomyopathy
- Little therapy is available for either causative conditions or the restrictive cardiomyopathy
- Severe cases: _____, _____, verapamil, _____
- Chemotherapy or bone marrow transplant (amyloidosis)
- Cardiac transplant
diuretics
beta blockers
ACEI
hypertrophic cardiomyopathy
• If hypertrophy is due to cardiac causes, treat the underlying cause
• _____ should be the initial medication in symptomatic individuals, especially when dynamic outflow obstruction is noted on the echocardiogram
o Slower heart rate assists with diastolic filling of the stiff LV
• _____ especially verapamil has also been effective in symptomatic patients
o Improved diastolic function but can increase outflow obstruction
• Disopyramide is also effective because of its negative inotropic (force/speed of contraction) effects as an addition
• _____ are frequently necessary due to the high LV diastolic pressure and elevated LA pressures
• Aggressively treat afib
• Nonsurgical septal ablation by injection of _____ into septal branches of the left coronary artery (controlled MI)
• _____ for patients with family history of unexplained syncope or sudden death
• Excision of part of the outflow myocardial septum or mitral valve replacement
• Cardiac transplant
Beta blockers CCBs Diuretics alcohol Implantable defibrillator
tako-tsubo cardiomyopathy
- Similar to any acute MI
- Long term therapy depends on whether LV dysfunction persists
- Most patient receive _____, _____ and _____ until the LV fully recovers
- Prognosis is good unless in-hospital complications such as mitral regurg, ventricular rupture or vtach
- Recovery is expected after a period of weeks-months
ASA
BB
ACEI
thiazides
EXAMPLES: Chlorthalidone, Hydrochlorothiazide
- Some experts recommend chlorthalidone over HCTZ because studies show that cardiovascular events less common than with HCTZ
- Also, BP, LDL were lower than with HCTZ
Method of Action:
• Initially lower bp by decreasing _____ and _____
• Chronic use: major effect is reduction of peripheral vascular _____
• Most of effect achieved at lower doses: ex: 12.5 or 25 mg HCTZ (hydrochlorothiazide)
• Chronic therapy: HCTZ every other day: no drop in efficacy
Indications:
• More potent in _____, _____, obese, smokers
• Decreases bone loss in older women at risk for osteoporosis
CI:
Side Effects
• _____ (uncommon at recommended doses)
• _____
• _____
• rash
• erectile dysfunction
• Increase serum _____ and may precipitate gout!
• Small increases in blood glucose, _____, LDLs and plasma insulin
• Relatively minor during long-term, low dose use.
• Slightly higher incidence of new onset DM
Misc.
• Diuretics as a single-drug therapy: control bp in 50% of pts, and can be used in combination with all other classes of drugs.
• Also good for lowering isolated or predominately systolic HTN
plasma volume cardiac output resistance. blacks older patients Hypokalemia hyponatremia hypomagnesemia uric acid triglycerides
ACE inhibitors
EXAMPLES: Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec, Epaned), Fosinopril (Monopril), Lisinopril (Prinivil, Zestril), Moexipril (Univasc), Perinopril (Aceon), Quinapril (Accupril)
Method of Action
• A good drug used as initial medication in mild-moderate HTN
• They inhibit _____
• Inhibit _____ degradation
• Stimulate _____ prostaglandins
• Reduce sympathetic nervous system activity
Indications
• More effective in younger _____
• Less effective in blacks and elderly
• Less effective in predominantly _____ hypertension
• Agents of choice in _____: they delay progression to end-stage renal dz
o Used in type II DM as well
• DOC in patients with _____, especially in combo with a diuretic
• Good in asymptomatic patients with reduced ejection fractions
CI Side Effects • Not many side effects • If your pt. has \_\_\_\_\_: severe hypotension & renal failure can occur • \_\_\_\_\_ in the elderly • COMMON: chonic, dry \_\_\_\_\_ • Dizziness • Skin rashes • Taste alterations (captopril)
Misc.
• As single therapy: control in only 40-50% of pts
• Use ACEIs in combo with diuretic & calcium channel blocker: POTENT!
RAAS system bradykinin vasodilating whites systolic Type I DM CHF bilateral renal artery stenosis Hyperkalemia cough
ARBs
EXAMPLES: Eprosartan, Olmesartan, medoxomil, valsartan, telmisartan, losartan, candesartan, irbestartan
Method of Action
• New agents appear to be as effective as ACEIs in reducing bp
Indications
-Use for pts who develop _____ with ACEIs
CI
Side Effects
• Do not cause cough and only infrequently cause skin rashes
• There is a risk of hypotension and _____ failure in pts with bilateral renal stenosis and _____
cough
renal
hyperkalemia
Beta-blockers
-olol
MOA:
• decrease the _____ and cardiac output
• decrease _____ release
• Neutralize reflex tachycardia caused by vasodilators
Indications:
• work better in patients with high plasma renin activity: younger _____ patients
• Work well in patients with angina pectoris, chronic previous MI, stable congenital heart failure, pts with migraines and physical manifestations of anxiety
• Beta blockers (traditional) not ideal for _____
CI:
• Depress HDL cholesterol
• Traditionally CONTRAINDICATED in pts with _____
o Recent evidence makes this controversial
• Use CAUTIOUSLY with Type I DM since they can mask sxs of _____
• Careful with Peripheral Vascular Dz in pts with rest pain and nonhealing ulcers
side effects:
• Non-selective block B2 receptors in bronchi and vasculature (not good for _____)
• Some are lipid-soluble: they do cross blood-brain barrier and cause _____ changes
• All exacerbate bronchospasm
• All depress sinus node and A-V conduction
• All cause nasal congestion
• They may cause Raynaud’s phenomenon
• Also CNS symptoms with nightmares, excitement, depression & confusion
• Fatigue, lethargy & impotence MAY occur
heart rate renin white monotherapy unstable CHF hypoglycemia asthmatics central nervous system
CCBs
EXAMPLES: Verapamil (Calan, Verelan) and diltiazem (Cardizem, Tiazac)
Dihydropyridine CA+ channel blockers: nifedipine, nicardipine, isradipine, felodipine, amlodipine, nisoldipine
Method of Action
• Cause peripheral _____
• Less reflex tachycardia and fluid retention than other vasodilators
• Effective as single drug therapy in 60% of patients
Indications
• Better than beta blockers or ACEIs in _____ and the _____
CI
• Verapamil (Calan, Verelan) and diltiazem (Cardizem, Tiazac) should be combined cautiously with Beta-Blockers because of their potential to depress _____ conduction and sinus node automaticity & contractility
• Higher rates of heart failure and myocardial infarction, especially in diabetics!!
Side Effects • headache • peripheral edema • bradycardia • constipation
Misc.
CA+CBS
• Negative inotropic effects
• Might cause or exacerbate _____ in pts with cardiac dysfunction
• Only CCB safe in severe heart failure: amlodipine (Norvasc)
vasodilation blacks elderly AV heart failure
Alpha-Adrenoceptor Antagonist
EXAMPLES: Prazosin, terazosin, doxazosin
Method of Action
• Block _____ alpha receptors
• Relax _____
• Reduce BP by lowering peripheral vascular resistance
• Effective as single drug tx in some patients
• Increase HDLs and REDUCE total cholesterol
Indications
• Don’t use as first agents to treat HTN: EXCEPT in men with symptomatic _____!
CI
Side Effects
• Marked _____ and syncope after the 1st dose (small, at bedtime)
• Postdosing palpitations, HA, nervousness
• No adverse effect on serum lipids
• Long term therapy: tachyphylaxis (marked DECREASE in effectiveness)
Misc.
• Higher degree of heart failure and stroke compared to diuretics
postsynaptic
smooth muscles
prostatism
hypotension
HTN summary
• Black All Ages:
o First Line: _____ or _____
• All Others <55 years
o First Line: _____ or _____; _____; _____
• All Others > 55 years
o First Line: _____ or _____
• Diabetics
o Treat to <130/80; _____ should be part of the treatment
• CKD
o Treat to <130/80; Thiazide to Loop _____; _____ Inhibitors
CCB
diuretics
ACE
ARB
CCB
diuretic
CCB
diuretic
ACE
diuretics
ACE
hypertensive emergency
• In most situations, appropriate control of BP is best achieved using combinations of _____ or _____ plus _____ or _____
nicardipine
clevidipine
labetalol
esmolol
secondary HTN
• Lifestyle modifications o \_\_\_\_\_ diet (high fruits, vegetables, low-fat dairy, low in saturated/total fats) o \_\_\_\_\_ reduction o Reduced ETOH consumption o Reduced \_\_\_\_\_ intake o Gradually increase activity o \_\_\_\_\_ cessation • For pharm drugs see drug charts
• Pheochromocytoma (PPP)
o Preoperative management: nonselective alpha blockage best initial therapy (PHEnoxybenzamine or PHEntolamine) 1-2 weeks followed by beta blockers or CCB to control pressure prior to surgery
o DO NOT initiate therapy with beta blockers
o Management: complete _____
• Renal vascular HTN (renal artery stenosis) (CURRENT)
o Options include medical management, angioplasty with or without _____, and surgical bypass.
o Antihypertensive meds
DASH weight salt smoking adrenalectomy stenting
heart failure
o Optimal management
_____
_____ (ARBS if ACEI is not tolerated)
_____ (started after patient is stable on ACEI)
Remain symptomatic:
• Mineralcorticoid (_____) receptor antagonists
• _____
If still symptomatic, add low dose _____
Diuretic ACEI BB aldosterone sacubitril/valsartan digoxin
