Cardiovascular Flashcards
Exam2
ACE Inhibitor MOA?
ACE inhibition -> decreased angiotensin 2 -> dilated blood vessels -> decrease blood volume -> prevent/reverse pathological changes in heart d/t angiotensin 2 & aldosterone -> reduces cardiac afterload / increases cardia output
ACE inhibition -> increased bradykinin -> vasodilation -> promotes cough & angioedema
ACEi -> aldosterone inhibition -> dilation of renal blood vessels -> allows for sodium & water excretion -> decreases edema / decreases preload (venous return) -> prevents/reverses cardiac structure changes // slows/delays renal disease in diabetic nephropathy
ACE Inhibitor Indications?
Hypertension, heart failure, MI, diabetic (and non-) nephropathy, prevention of MI/Stroke/Death in pts at high cardiovascular risk
ACE Inhibitor Adverse Effects?
First dose hypotension <- widespread vasodilation <- lowered angiotensin 2 <- ACE inhibition
Cough: persistent, dry, nonproductive cough
ACE inhibition -> increased bradykinin -> cough & angioedema
Hyperkalemia:
ACE inhibition -> inhibition of aldosterone release -> increased potassium retention in kidneys
Acute kidney injury:
In those w bilateral renal artery stenosis (or stenosis in artery to a solitary kidney) bc their kidneys -> increased renin release -> increased levels of angiotensin 2 -> maintain glomerular filtration // inhibition of ACE interrupts the compensatory mechanism
Risk of hypoglycemia:
ACEi -> increased insulin uptake in muscles -> hypoglycemia
Renally adjusted
Increases lithium levels
What drugs are used for hypertension?
thiazide diuretic
ACEi
ARBs
Beta-blockers
Aplha1-blockers
CCB
Centrally acting alpha2-agonists
Vasodilators
What drug is a thiazide diuretic?
Hydrochlorothiazide
What drug is an ACEi?
Lisinopril
What drug is an ARB?
Losartan
What drugs are CCBs?
Dihydropyridine: Amlodipine
Non-dihydropyridine: Diltiazem
What drug is a beta-blocker?
Metoprolol
What drug is an Alpha1-blocker?
Prazosin
What drug is a centrally acting alpha2-agonist?
Methyldopa
What drug is a vasodilator?
Hydralazine
What drug is an aldosterone receptor antagonist?
Spironolactone
What drug is a loop diuretic?
Furosemide
What drug is a SGLT2i?
Dapagliflozin
Examples of causes of secondary hypertension?
Cushing’s syndrome
Pheochromocytoma
Medications
Lifestyle
What is the difference between primary and secondary hypertension?
Primary/essential hypertension: no identifiable cause
Secondary hypertension: secondary to identifiable cause
At what BP range are meds recommended versus lifestyle changes?
“elevated” 120-129 / less than 80: lifestyle change
HTN stage 1: 130-139 / 80-89: meds
HTN crisis: higher than 180 / 120: IV meds, emergent
Treatment of HTN goal?
BP maintenance at < 130 / < 80
Going lower can cause profound hypotension d/t being used to higher BP
Main part of diagnosing HTN?
Repeated BP readings above 130/80
(White coat syndrome)
Recommended sodium consumption?
<2300mg / day
<2.3g / day
What are lifestyle changes for managing HTN?
Reducing sodium intake
Diet: fruits/veggies, low fat/cholesterol
Lower alcohol
Increase exercise
Smoking cessation
Weight loss
Maintain potassium / calcium intake
First line agents for HTN?
Thiazide diuretics
ACEi
ARBs
CCBs
Drugs that aid in HTN & heartfailure
ACEi
Aldosterone antagonist
ARB
Beta blocker
CCB- DHP
Diuretic
Drugs that aid in HTN and recurrent stroke prevention
ACEi
Diuretic
Drugs that aid in HTN and risk of CAD
ACEi
Beta blocker
CCB
Diuretic
Drugs that aid in HTN & post-MI
ACEi
Aldosterone antagonist
Beta blocker
Drugs that aid in HTN & diabetes
ACEi
ARBs
Beta blocker
CCB
Diuretic
Drugs that aid in HTN & CKD
ACEi
ARBs
Drugs that are safe to aid HTN in pregnancy
Labetalol
Nifedipine
Methyldopa
Drugs for HTN that are contraindicated in pregnancy
ACEi
ARBs
Direct renin inhibitors
All teratogenic
Thiazide diuretics- MOA
Prevents re-absorption of sodium in distal renal tubules
Promotes urinary excretion of sodium, water, potassium, hydrogen
Calcium, glucose, uric acid sparing
Thiazide diuretics- adverse effects
Photosensitivity - wear sunscreen
Electrolyte disturbances- hypokalemia, hypomagnesemia, hyponatremia, hypercalcemia
Orthostatic hypertension
Gout
Contains sulfa moiety (cross-reactivity w sulfa antibiotics is low)
ARBs Indications?
HTN
Heart failure
diabetic nephropathy
MI
Prevention of:
MI
Stroke
Death for high risk of cardiovascular events
ACEi and ARBs: main difference?
ARBs have lower risk of coughing or hyperkalemia
ACE are first choice, ARBs if not tolerated
ARBs MOA?
Prevents angiotensin 2 from binding to receptor -> decreased vasoconstriction -> vasodilation -> increased blood flow -> decreased BP //
decreased aldosterone -> decreased re-absorption of sodium and water -> decreased blood volume -> decreased BP
ACEi: Contraindications?
Idiopathic/hereditary angioedema
Coadministration within 36hours with a neprilysin inhibitor (ex. sacubitril)
ARBs: side effects?
Acute kidney injury
Hyperkalemia
First-dose hypotension
Fetal injury
Angioedema (less than ACEi)
Monitor:
Serum potassium (palpitations, irregular heart beat)
Renal function (BUN/Cr/urine output
CCBs: MOA?
CCB block calcium from entering heart muscle -> vasodilation -> decreased contractility -> reduced HR
Effects calcium has on the heart?
Increased calcium influx into the heart -> increased vasoconstriction / contraction
More calcium = constriction & contraction
What is a dihydropyridine (DHP) CCB?
Acts mostly on blood vessels
Amlodipine
DHP CCB: side effects?
Flushing
Peripheral edema
First-dose hypotension
Gingival hyperplasia - advise to floss regularly
Hyperglycemia
Headache
(Amlodipine)
What drug is a nondihydropyridine?
Acts on heart and blood vessels
(Diltiazem- CCB)
NDHP CCBs: Indications?
Arrythmias
Angina
HTN
(Diltiazem)
Main difference between NDHP and DHP?
Non-dihydropyridine: affects heart AND blood vessels (Diltiazem)
Dihydropyridine: affects only blood vessels (Amlodipine)
NDHP CCBs: MOA
Blocks calcium channels in vessels -> vasodilation -> decreased BP
Blocks calcium channels in heart -> increases relaxation -> increases vasodilation -> increases coronary perfusion
Blocks calcium channels at SA node -> decreases HR
and heart -> decreases AV node conduction -> decreases dysrhythmias
(Diltiazem)
NDHP CCB: side effect?
Constipation d/t CCB in GI
Peripheral edema/flushing d/t vasodilation
Bradycardia d/t CCB at SA node
Hyperglycemia
Heart failure
Gingival hyperplasia- floss regularly
Avoid grapefruit juice & st. John’s Wort d/t inhibition of drug metabolism -> increased drug levels
Contraindicated with heart failure or EF<40%
(Diltiazem- less potent than verapamil)
DHP CCB: Indications?
Angina- vasospastic
HTN
(Amlodipine)
What drug is a beta blocker?
Metoprolol
Beta blocker- MOA?
Beta blocker -> blocks beta 1(heart/kidneys) -> decreases HR, contractility, cardiac output, inhibits renin release
Beta blocker -> blocks beta 2 (lungs, pancreas, arteriolar muscle) -> peripheral vasoconstriction (decrease blood flow to extremities) / bronchoconstriction (caution w/ asthma)
Decreases HF risks, decreases BP, decreases risk of sudden cardiac death
(Metoprolol)
(Metoprolol succinate for HF- beta 1 selective)
Beta blockers- side effects?
Bradyarrhythmia
Fatigue, insomnia
SOB/Bronchospasm- avoid starting if pt already experiencing
Rebound hypertension- if stopped abruptly
Avoid if pt is decompensated- more for Tx not for acute
Counsel on abrupt withdrawal d/t increased mortality and avoid rapid titrations d/t side effects
Hyperglycemia (masked Sx- tremors, palpitations, hunger, irritability)
Hyperkalemia
Increase cholesterol
Intensify adverse effects of diltiazem (NDHP CCB)
(Metoprolol)
Beta blocker- contraindications?
Bradycardia (HR < 45)
AV block without functioning pacemaker
Cardiogenic shock
Acute heart failure exacerbation
What drug is an Alpha1-Blocker?
Prazosin
What drug class is prazosin?
Alpha1-Blocker
Alpha1-blocker- MOA?
Blocks alpha1 receptors -> prevents norepinephrine binding -> vascular vasodilation -> dilation of arterioles/veins & relaxation of smooth muscle -> decreases BP
(Prazosin)
Alpha1-blocker- indications?
HTN- not first choice d/t hypotension
BPH- off-label
PTSD-related nightmares- off-label
Alpha1-blocker- side effects?
Orthostatic hypotension
Angina
Reflex tachycardia
Nasal congestion
Dizziness/drowsiness
Not first-choice for HTN
What drug is a Centrally Acting Alpha2-Agonist?
Methyldopa
What drug class is Methyldopa?
Centrally acting alpha2-agonists
Alpha2-agonist- MOA?
Stimulates alpha2 receptor (in brain) -> decrease sympathetic outflow (norepinephrine release) -> -> decrease SNS activity -> decreases peripheral resistance
renal vascular resistance
heart rate
blood pressure
(Methyldopa)
Alpha2-agonist- indication?
Hypertension
HTN in pregnancy
(methyldopa)
Alpha2-agonist- side effects?
Neurologic effects- depression at higher doses- can worsen depression or increase risk of suicidal ideation- counsel
Hemolytic anemia
Transient sedation w initiation or dose increase
Contraindicated w/ use of MAO inhibitors- counsel
What drug is a vasodilator?
Hydralazine
What drug class is hydralazine?
Vasodilator
Vasodilator- MOA?
Selective vasodilation of arterioles
(Hydralazine)
Vasodilator- side effects?
Reflex tachycardia
Increases intracranial pressure
Headache, dizziness, weakness/fatigue, increased blood volume
Not first-choice for HTN/HF
(Hydralazine)
What are some common causes for arrythmias?
MI
Electrolyte imbalances: decreased potassium or decreased magnesium
What are the classes of antiarrhythmics?
Class 2: beta blockers (Metoprolol)
Class 3: Potassium channel blockers (Amiodarone)
Class 4: NDHP if no HF (Diltiazem)
What drug is a potassium channel blocker?
Amiodarone
What drug class is Amiodarone?
Potassium channel blocker
Potassium channel blocker- side effects?
Hyper/hypothyroidism
Hepatotoxic
Optic neuropathy
Pulmonary toxicity
Bradycardia
Hypotension
Avoid grapefruit juice/ st.John’s Wort
Take with food (avoids GI upset)
Limit sun exposure
Long half-life (58days)
Correct hypokalemia, hypomagnesemia, hypocalcemia prior to starting
Contraindications:
Iodine sensitivity
(Amiodarone)
Amiodarone- indications?
Arrhythmias - not first-choice d/t toxicities
Potassium channel blocker- MOA?
Blocks potassium channels -> blocks repolarization of heart muscle -> prolongs AP
(Amiodarone)
Which cholesterol increases risk for ASCVD?
Increased LDL (bad cholesterol) or decreased HDL (good cholesterol)
What are some ASCVD events?
MI
Ischemic stroke
Transient ischemic attack
Coronary artery disease
What is the 10-year ASCVD score?
Concerned when score is >7.5%
What enzyme synthesizes cholesterol?
HMG-CoA Reductase- the main target for statins
What is the main target for statins?
HMG-CoA Reductase- the enzyme that synthesizes cholesterol
What range is ideal for total cholesterol?
<200mg/dL
200-239mg/dL borderline
>240mg/dL high
What is primary prevention of ASCVD?
No history of ASCVD event, at risk
Increased LDL > 190
Age 40-75 > 7.5% 10-year CV risk
What is secondary prevention of ASCVD?
History of ASCVD event -> more likely for another
Age > 75: moderate intensity statin
Age < 75: high intensity statin
What drug is a statin?
Atrovastatin
What drug class is atrovastatin?
Statin
Statin- MOA?
Competitively inhibits HMG-CoA reductase -> decreased cholesterol synthesis ->
decreased LDL production
increased LDL receptor expression -> LDLs get pulled from blood by liver -> increased LDL excretion -> decreased overall cholesterol
mild increase in HDL
(Atorvastatin)
Statins- Indications?
Hyperlipidemia
Lowers risk of heart failure, MI & sudden death- primary and secondary prevention
(Atorvastatin)
Statins- side effects?
Myalgia (muscle pain)
Myopathy (muscle weakness/pain)- higher risk with higher log p (lipophilicity)
Rhabdomyolysis (muscles breaking down -> release creatinine kinase increasing level // monitor creatinine kinase to check this)
Headache
Rash
GI discomfort
Memory issues
Monitor LFTs and discontinue if severely low
CYP substrate- Avoid grapefruit juice to prevent accumulation effect
Try to take at night- when cholesterol synthesis is highest
(Atorvastatin)
What drug is a bile acid seqeusterant?
Cholestyramine
What drug class is cholestyramine?
Bile acid sequestrant
Bile acid sequestrant- indications?
Hyperlipidemia
Hypercholesteremia (high LDL)
Used commonly with statins or if statin-tolerant
(cholestyramine)
Bile acid sequestrant- MOA?
Non-digestible positive charge -> displaces chloride & binds to bile acids in GI -> form insoluble complex -> bile-acid bound LDL -> excreted in feces -> decreases LDL
(Cholestyramine)
Bile acid sequestrant- side effects?
Constipation/GI upset
Elevated triglycerides- don’t take if TG> 500
Teeth discoloration/erosion/decay of tooth enamel- counsel on dental hygiene
Don’t take if bowel obstruction
Other meds taken 1 hour before or 4-6hours after
Oral contraceptives/fat-soluble vitamins (A, D, E, K) 4 hours prior or 6-12 hours after
Can cause hemorrhage from lack of vit K
Swallowing dry can cause esophageal irritation- counsel to mix powder with fluid
(Cholestyramine)
Tiers of ASCVD therapy, what drug is high-, medium-, and low-intensity?
High: Atorvastatin 40-80mg, >50% lower
Med.: Atorvastatin 10mg, 30-50%
Low: Cholestyramine, 20% alone (40-60% combo w/ statin)
What drug is a fibric acid (fibrate) derivative?
Fenofibrate
What drug class is fenofibrate?
Fibrates derivative
Fibrates- indications?
High TG, ASCVD, high cholesterol
Third-line drug d/t interactions, side effects, etc.
(Fenofibrate)
Fibrates- MOA?
Activates PPAR-a in liver -> increased fat burned by liver -> increased breakdown of TG -> decreased TG
Activates PPAR-a in liver -> decreased bad fats produced by liver -> decreased TG
Increases HDL
Reduces cholesterol buildup in blood
Little to no effect on LDL
(Fenofibrate)
Fibrates- side effects?
GI discomfort- take with food to avoid (high fat meal for absorption)
Gallstones- contraindicated for preexisting gallbladder disease
Myopathy
Liver toxicity
AKI
Avoid grapefruit juice- accumulation effect
Can be cautiously combined with statin (except gemfibrozil)
(Fenofibrate)
What drug is a lipid lowering agent?
Ezetimibe
What drug type is Ezetimibe?
Lipid lowering agent
Ezetimibe- indications?
high cholesterol
Adjunct to max statin
Monotherapy if statin intolerant
Ezetimibe- MOA?
Binds to NPC1L1 protein in small intestine -> inhibits cholesterol absorption -> decreases absorbed cholesterol -> decreases effects of dietary cholesterol
Ezetimibe- side effects?
Myopathy/rhabdomyolysis
Gallstones- when used w/ fibrates
Hepatotoxicity- when used w/ statins
Adjunct to max statin when high LDL
Monotherapy if statin intolerant
What is angina pectoris?
Sudden pain beneath sternum, common to radiate to left shoulder, left arm and jaw
Occurs when the heart isn’t receiving enough oxygen to meet the body’s demands
Secondary to atherosclerosis of coronary arteries
Can lead to MI, myocardial ischemia, anginal pain, death
What is chronic stable angina?
Triggered by physical activity, emotional excitement, large meals, cold exposure
Underlying cause: CAD
Treatment: decreasing cardiac oxygen demand <- vasodilation (only symptomatic relief)
What is an antianginal drug?
Nitroglycerin
What drug class is Nitroglycerine?
Antianginal agent
Nitroglycerin- indications?
Stable angina
Nitroglycerin- MOA?
Increases vasodilation -> decreases venous return -> decreases preload -> decreases oxygen demand
Nitroglycerine- side effects?
Headache- improves over time
Washout period from last doses of sildenafil & tadalafil: 24- and 48-hours (all vasodilatory)
Drug holiday to prevent tolerance
Don’t d/c abruptly- withdrawal effects/vasospasms
Nitroglycerine- doses allowed?
Repeat every 5 minutes, 3 doses max, call 911 if not alleviated
Open bottle mist be replaced 6months d/t patch deterioration
Beta blocker- indications?
Angina -first line for angina w/ effort (decreases cardiac oxygen demands)
Arrythmias (decreases HR / contractility)
HTN (decreases HR)
HF (metoprolol succinate)
(Metoprolol)
What drug is an injectable anticoagulant?
Enoxaparin
What drug class is enoxaparin?
Injectable anticoagulant
Enoxaparin- MOA?
Inactivation of clotting factors: thrombin and factor Xa -> -> decreases fibrin production -> clotting suppressed -> prevents thrombosis
Enoxaparin- side effects?
Hemorrhage
Spinal/epidural hematoma
Heparin-Induced thrombocytopenia (HIT)
Contraindicated for hx of HIT or uncontrolled active bleeding
Monitor PTT/Xa levels on heparin drip
Pork based
Short half-life: 1.5hours
From porcine products
What drug is a vitamin K antagonist?
Warfarin
What drug class is Warfarin?
Vitamin K antagonist
Warfarin- MOA?
Inhibits VKORC1 (enzyme that converts inactive vitamin K to active form) -> inactive vitamin K -> decreased production of vitamin K dependent clotting factors (SNTT) -> delayed anticoagulant effect
INR goal: 2-3
INR goal for mitral valve replace.: 2.5-3.5
Warfarin- side effects?
Hemorrhage/bleeding
Fetal harm
Overdoes- tx w/ vitamin K (takes some time, only works w/ functioning liver)
Narrow therapeutic index- monitor INR
Goal: 2-3
Warfarin- indications?
Anticoagulation
Preventing blood clots
VTE
What drug is a direct thrombin inhibitor?
Dabigatran
What drug class is dabigatran?
Direct thrombin inhibitor
Dabigatran- indications?
DVT/PE Tx- 5 days of parenteral anticoagulation & dabigatran
Stroke prevention w/ nonvalvular AFib
VTE prevention after knee/hip replacement surgery
Doesn’t need anticoagulation monitoring
few drug/food interactions
(Direct thrombin inhibitor)
Dabigatran vs. Warfarin?
Dabigatran has higher efficacy and lower incidence of bleeding
Dabigatran- MOA?
Inhibits thrombin (in blood and bound to clots) -> prevents conversion of fibrinogen into fibrin (req. thrombin) -> decreases coagulation -> decreases VTE/PE/aFib
(Direct thrombin inhibitor)
What does thrombin do?
Converts fibrinogen into fibrin- essential for coagulation
Dabigatran- side effects?
Bleeding
GI discomfort
Can’t be crushed
Premature d/c can increase thrombotic events
What drug is a direct oral anticoagulant
Factor Xa inhibitor?
Rivaroxaban
What drug class is Rivaroxiban in?
Direct Oral anticoagulant (DOAC)
Factor Xa Inhibitor
Rivaroxaban- MOA?
Inhibition of factor Xa -> inhibits production of thrombin -> decreases coagulation
Rivaroxaban- indications?
DVT/PE Tx
DVT/PE prevention after hip/knee replace. surgery
Stroke prevention for those w/ aFib
Rivaroxaban vs. Warfarin?
Rivaroxaban is:
faster onset
fixed dose-consistent dosing
lower bleed risk
few drug/food interactions
No INR monitoring
Roxaroxaban- side effects?
Bleeding (less risk than Warfarin)
Doses >10mg taken w high fat food for increased absorption
Not safe in pregnancy
Avoid grapefruit juice
What drug class is sacubitril/valsartan?
Angiotensin receptor neprilysin inhibitor (ARNI)
Sacubitril/valsartan- MOA?
inhibits breakdown of BNP and blocks angiotensin -> increased vasodilation -> decreased cardiac workload
BNP- hormone that helps with loss of sodium/water and vasodilation
(ARNI)
Sacubitril/valsartan- indications?
Heart failure
(ARNI)
Sacubitril/valsartan- side effects?
Dizziness- reduce diuresis is management, chronic diuretic dose might be reduced 50%
Hyperkalemia
RAASi first choice- transition ACEi/ARBs to ARNI
ANGIOEDEMA- contraindication
If taking ACEi- need 36hr washout period prior to taking ARNI
(ARNI)
Sacubitril/valsartan compared to ACEi/ARBs
Both are anti-RAAS
ACEi/ARBs still used for HF and HFrEF
Cost difference
Sacubitril/valsartan- more hypotensive
What drug is a sodium glucose co-transporter 2 inhibitor (SGL2i)?
Dapagliflozin
What drug class is dapagliflozin in?
Sodium glucose co-transporter 2 inhibitor (SGL2i)
Dapagliflozin- indications?
HF
T2DM
CKD
Dapagliflozin- MOA?
Inhibits SGLT-2 in kidneys -> decreases SNS response -> decreases glucose & sodium reabsorption (kidneys) -> decreases plasma volume -> decreases cardiac workload
increases mild ketosis -> ‘sick’ myocardium prefers ketone metabolism -> cardiac muscle has more ‘food’ available
Can improve tolerance to MRAs & ARNI/ACEi/ARBs by decreasing hyperkalemia caused by them
(SGL2i)
Dapagliflozin- side effects?
Glucosuria- increased risk of UTI
Risk of yeast infection- proper urinary hygiene
Volume losses- decrease diuretics 50% & correct volume depletion prior to starting SGL2i
Increased urination/thirst
Euglycemic ketoacidosis
Necrotizing fasciitis risk
Contraindicated for dialysis
Control high blood sugar prior to starting
Euglycemic ketoacidosis d/t NPO
What drug is a mineralocorticoid receptor agonist (MRA)?
Spironolactone
What drug class is spironolactone in?
Mineralocorticoid receptor agonist (MRA)
Spironolactone- indications?
HF (HFrEF)
HTN
Spironolactone- MOA?
Antagonist of aldosterone receptors (in kidneys) -> decreases sodium & water retention & increase potassium retention // -> stops progression of myocardial scaring -> reverses remodeling
(MRA)
Spironolactone- side effects?
Risk of hyperkalemia- caution w/ CKD: stop K+ supp. / oral K+ binder- check levels
Gynecomastia
Abnormal uterine bleeding- post-menopausal
Check renal function
(MRA)
