Cardiovascular Flashcards

Question

Cardiac Glycoside- Digoxin: Monitoring and Patient Education

Answer 1

Monitoring: - Diagnosis of toxicity is based on both clinical & lab data - Toxicity commonly occurs with serum levels greater than 2 mg/mL - Monitor Potassium levels (it can cause high potassium) Patient Education: - Take at same time each day - Do not double dose - Monitor for signs of toxicity - Take pulse, hold for HR less than 60 or greater than 100 bpm

Answer 2

Regardless of the strength of a stimulus, the cell cannot be depolarized

Answer 3

Stronger-than-normal stimulus can induce depolarization

Answer 4

State of the cardiac cell which determines depolarization Damaged heart cells may maintain a constant rate of refractoriness or may not be refractory at all

Answer 5

Lengthen the duration of action potential (slows HR)

Answer 6

Shorten the duration of action potential

Answer 7

Minimally increase action potential

Answer 8

Reduce adrenergic activity in the heart Sotalol: considered a class II and III drug

Answer 9

Prolong effective refractory period and reduce speed of conduction Amiodarone

Answer 10

Block influx of calcium, reduce contractility (negative inotropism), decrease SA and AV code conduction Significantly reduce afterload but little effect on preload Verapail, diltiazem, bepridil

Answer 11

Various types include nonspecific beta antagonists, selective beta antagonists, and those with or without intrinsic sympathomimetic activity (ISA) - In post-MI patients, cardioselective agents without ISA are preferred - Some are used as antiarrhythmics - Drugs with ISA may help avoid a decrease in cardiac output (CO) and HR. May be preferred for patients who experience bradycardia with other BBs More effective in African Americans & older patients BBs may not be abruptly withdrawn, because it will increase beta receptor sensitivity No longer first-line HTN drug choice

Answer 12

Class III antiarrhythmic Onset of action: oral- 2 days to 3 weeks Duration of action: 7 to 50 days Excreted in feces, 1% urine Dosing: watch out for use in grapefruit juice - Ventricular arrhythmias: 800-1600 mg BID for 1-3 weeks, then decreased to 300-400 mg BID, maintenance 400 mg/day

Answer 13

ADRs: - Thyroid, neurological, blue skin discoloration, bradycardia, lung damage not evident until advance Many drug interactions

Answer 14

Monitoring: - Potassium, blood urea nitrogen (BUN), creatinine, therapeutic drug levels - ECG Patient Education: - Take exactly as prescribed; do not double dose - Be aware of food-drug interactions - Monitor HR for regularity of rate and rhythm - Monitor BP at home

Answer 15

HA, orthostatic hypotension w/ potential for syncope & tachycardia (direct extensions of therapeutic vasodilation) HA may be severe & persists in up to 50% of patients Hypotension may lead to decrease in diastolic filling pressure & tachycardia may lead to decrease in diastolic filling time, which may lead to myocardial ischemia, arrhythmias, and rebound HTN Contact dermatitis can occur with transdermal patches

Answer 16

Concurrent use with vasodilators or with erectile dysfunction drugs sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) contraindicated Additive hypotension with antihypertensives, alcohol, BBs, CCBs

Answer 17

Clinical Use: - Acute angina attack (use NTG) - ----sublingual NTG, a short-acting form, 0.4-0.6 mg every 5 minutes for up to 3 doses - Stable or Predictable angina (use isosorbide): - ----Isosorbide dinitrate: 10-40 mg orally 2-3 times daily; sustained-release form 40-80 mg daily - ----Isosorbide mononitrate: dosing is 20 mg BID - ----Eccentric scheduling to avoid development of tolerance

Answer 18

Take the drug exactly as prescribed - Eccentric dosing schedule is separated by 7 hours because of need to have nitrate-free period - Take at 7 to 8 am and 2 to 3 pm rather than "usual" twice daily regimen - A nitrate-free interval of 10-12 hours is needed If anginal symptoms occur at night, have a daytime nitrate-free interval Storage of NTG - Adhere to the expiration date on bottle, usually 6 months - Do not open bottle frequently or keep bottles of tabs nest to body (e.g., in a shirt pocket)

Answer 19

Hydralazine and Minoxidil There are NOT used as first line HTN Minoxidil is more potent vasodilator and has more dramatic compensator response These drugs act by direct relaxation and dilation of arteriolar smooth muscle, decreasing peripheral vascular resistance

Answer 20

ADRs: related to compensatory responses in the sympathetic nervous system & RAAS- tachycardia, increased cardiac contractility & output, sodium & water retention, HA Drug interactions: additive effects with other antihypertensive; NSAIDs may decrease their effect Dosing: - HTN: hydralazine 25-100 mg QID; max dose 200 mg/day

Answer 21

Most patients should return for follow-up & adjustment of meds at monthly intervals or until the BP goal is reached. Serum potassium & creatinine should be monitored at least one to two times per year After BP is at goal & stable, follow-up visits can usually be at 3-6 month intervals Co-morbidities such as HF, associated diseases such as diabetes, and the need for lab tests influence the frequency of visits Other CV risk factors should be monitored & treated to their respective goals, and tobacco avoidance must be promoted vigorously Low-dose aspirin therapy should be considered only when BP is controlled because of increased risk of hemorrhagic stroke when BP high

Answer 22

Atherosclerosis is a major cause of CAD Lipoproteins: all contain triglycerides (TGs), phospholipids, & cholesterol - Low density (LDL), high density (HDL), very low density (VLDL), TGs Exogenous pathway: involves absorption of lipids via intestine Endogenous pathway: lipids originate from liver

Answer 23

- Block synthesis of cholesterol in liver by competitively inhibiting HMG CoA reductase activity - Decreases levels of LDL by 25-65% - Modest decreases in TGs (10-40%) and very modest increases in HDL (5%-17%) may occur - Pregnancy: old category X; fully contraindicated

Answer 24

- All statins (except fluvastatin & rosuvastatin) are metabolized at least in part by CYP3A - CYP3A inhibitors may increase statin concentrations - --Verapamil, diltiazem, azole antifungals, erythromycin, fluoxetine, nefazodone, protease inhibitors - CYP3A inducers may decrease statin concentrations - --Rifampin, phenytoin, phenobarbital - Statins may also interact with other CYP channel substrates; for example cyclosporine

Answer 25

Common: HA, myalgia, fatigue, GI intolerance, flu-like symptoms Myopathy: occurs in 0.2-0.4% of patients, some agents more likely - Reduced by using lowest effective dose; cautiously combining statins with fibrates; avoiding drug interactions Increase in liver enzymes NOT ENOUGH to warrant frequent lab tests - Active liver disease is a contraindication; occurs in 0.5-2.5% of cases & is dose-dependent; serious liver problems are rare; manage by reducing dose or stopping until levels return to normal

Answer 26

Start with lower dose & increase, as needed, according to LDL response; absolute levels of LDL not as closely monitored now Rosuvastatin most potent: 5-20 mg daily Atorvastatin next most potent (Best ADR profile): 10 mg/day initially, increase no fewer than 2-4 weeks Simvastatin: 20-40 mg/day Lovastatin: (IR) 20 mg/day, (ER) 40-60 mg Provastatin: 40 mg/day; pediatric dosing for children 8-13 years: 20 mg/day Doses often are given traditionally in evening/bedtime May need to decrease dose occasionally: when adding potentially interacting drug; profound drop in LDL

Answer 27

Monitoring: - Lipid levels in 4-6 weeks then ever 3-4 months until controlled - LDL levels guide dose increases - LFTs before starting therapy & 3-6 months later only if suspected issues or underlying hepatic issues Patient Education: - Lifestyle changes (diet, exercise)

Answer 28

Inhibition of cholesterol synthesis Decreased triglyceride synthesis Inhibition of lipolysis in adipose tissue Decreased production of VLDL/increased clearance Increased plasma & hepatic lipoprotein lipase (LPL) activity Effects on lipids - Decreases total cholesterol (TC), LDL, TGs - Increases HDL

Answer 29

Effective TG-lowering drugs that modestly lower LDL & raise HDL for only some patients Work for patients with very high TG levels, such as patients with type 2 diabetes & with familial dysbetalipoproteinemia These drugs do NOT produce substantial reduction in LDL, so are not appropriate as initial or monotherapy

Answer 30

Dosing: - Gemfibrozil: 600 mg BID - Micronized Fenofibrate: 67 mg QID, max 201 mg - Clofibrate: 2 g daily in divided doses ADRs: - nausea, diarrhea, cholelithiasis, phototoxicity Drug Interactions: - Increased risk of hepatotoxicity and/or myalgias with concurrent statins and/or niacin - Protein-binding displacement (e.g., warfarin)

Answer 31

Monitoring: - Lipid levels in 4-6 weeks, then every 3-4 months until controlled - LDL levels will drop when triglycerides drop - LFTs before starting and PRN Patient Education: - Take as directed - ADRs: constipation & flatulence - Lifestyle changes (diet & exercise)

Answer 32

By promoting an increase in bile acid excretion, they enhance conversion of cholesterol to bile acids by the liver & increase uptake of LDL Bind with cholesterol in the intestine and are NOT metabolized by liver Excreted in bound form in feces May use with patient with active liver disease Lower TC, LDL, and TG, and increases HDL, in theory

Answer 33

Strong record of efficacy & safety Most useful for patients with moderately elevated LDL levels & low coronary heart disease (CHD) risk profile Patients who are not able to reduce their LDLs with lifestyle modifications Can be used together with fibrates

Answer 34

ADRs: - GI- constipation, bloating, abdominal pain, unpleasant taste & texture; HA - Reduced folate levels with long-term use Dosing: - Initial dose: one packet mixed with juice; never swallow in dry form Drug Interactions: - Interfere with absorption of other medications

Answer 35

Monitoring: - Lipid levels - Bowel issues Patient Education: - Taken with meals mixed with 4-6 oz of fluid - Other drug absorption impaired if taken at the same time - ADRs: constipation, may need stool softeners - Lifestyle changes (diet & exercise)

Answer 36

- No longer approved by FDA for use in lipid management - Previous touted effects on lipids (lower TC, LDL, TG, & elevate HDL) - Increased risk CV events if taken at doses to change lipids. Adverse events STRONGER than any benefit - OTC doses are not sufficient to lower LDL (flush-free have no CV effect) - Does not raise enough of the HDL to counter the increase in CV events without evidence of benefit - No evidence (yet) that actually increasing HDL is helpful

Answer 37

- Selectively inhibits intestinal absorption of cholesterol & related phytosterols - Has been shown to reduce TC, LDL, & TG while increasing HDL-C - No good outcome data yet, but most effective in combination with statin - Dosing: 10 mg/day - Pregnancy category C; not for children younger than 10 years of age

Answer 38

- HCTZ, chlorthalidone, indapamide, metolozone - High dose therapy (HCTZ greater than 50) has increased risk of hypokalemia, increase in uric acid levels, and serious CV outcomes; use in combination vs. pushing high doses - Watch with patients with hyperlipidemia

Answer 39

Potential for cross-sensitivity with sulfa Furosemide, bumetanide, torsemide

Answer 40

Often used in combination with thiazide to reverse low potassium effect Triamterene, Spironlactone, Eplerenone (Inspra) Eplerenone (Inspra)- next generation aldosterone agent - Potassium sparing, selective aldosterone blocker

Answer 41

Hypotension, decreased GFR, hypokalemia/hyperkalemia, electrolyte abnormalities, metabolic alkalosis, hyponatremia

Answer 42

Major CYP3A4 substrate - Decreased effects with NSAIDs - Drug effects increase with grapefruit juice, azoles, CCBs - Increases effects of ACEI, ARB, BB, potassium replacement Cost: - Approximately $110 to $125/month without superior outcomes

Answer 43

Monitoring: - BP, HR, edema, weight gain, dyspnea, cough, urine output - Prior to initiating therapy- BUN, creatinine, electrolytes (sodium, potassium, calcium, magnesium), uric acid, & glucose levels - Ongoing monitoring of electrolytes Patient Education: - Take as directed early in day if there are urination issues - Do not skip or double dose - Monitor weight - Must drink fluids!!