Cardiovascular Disorders Flashcards
When considering the use of pentoxifylline to treat intermittent claudication, all of the following is
true EXCEPT:
a) Recommended for patients with marked renal or hepatic dysfunction
b) It causes a lot of GI upset, so should be taken with food
c) 24 weeks of therapy followed by 8 weeks drug-free can decrease the need for the drug
d) It is very effective in mild claudication
e) It will increase the risk of bleeding if given with warfarin
D. It only produces marginal improvement in pain-free and maximal walking distance, so is not indicated for mild claudication (page 513, CTC, 7th edn). Pentoxifylline causes nausea, vomiting, dyspepsia, belching, bloating and flatulence; the incidence of these can be reduced by taking the medication with food. A drug-free period as exercise tolerance increases can reduce the need for pentoxifylline. It increases the effect of warfarin by an unknown mechanism, leading to an increased risk of bleeding.
A patient with a myocardial infarction, with preserved LV function and without any previous medical
conditions should be routinely started on all of the following medications EXCEPT:
a) Metoprolol
b) Ramipril
c) ASA
d) Simvastatin
e) Spironolactone
E. Among high risk patients, antiplatelet agents such as ASA, beta-blockers, ACE inhibitors and lipid-lowering therapies independently reduce the incidence of vascular events and have been shown to reduce mortality. Aldosterone antagonists should be considered in patients with significant LV dysfunction.
The most common side effect of nitrate therapy in the treatment of angina is:
a) Chest pain
b) Upset stomach
c) Muscle cramps
d) Headache
D. Headache is extremely common and can be severe due to the vasodilatory effects of the nitrate. Chest pain is a symptom of an angina attack and nitrates are taken to prevent these. Upset stomach and muscle cramps rarely occur with nitrates.
Which of the following is TRUE regarding the treatment of stable angina?
a) Organic nitrates should be prescribed with a nitrate-free interval of 4-6 hours to avoid the development of tolerance
b) Substitution with an ARB is reasonable if a patient that is prescribed an ACE inhibitor cannot tolerate it due to a cough
c) Verapamil and diltiazem are recommended for patients with LV systolic dysfunction
d) Beta-blockers are the agents of choice for patients with Prinzmetal’s angina
B. Organic nitrates should be prescribed with a nitrate-free interval of 10-12 hours to avoid the development of tolerance (page 568, CTC, 7th edn). Verapamil and diltiazem should be avoided for patients with LV systolic dysfunction (page 568, CTC 7th edn). Calcium channel blockers and nitrates are the agents of choice for patients with Prinzmetal’s angina (page 568, CTC 7th edn).
For a patient with Raynaud’s phenomenon, the following could be of value:
a) Avoid snowmobiling
b) Take nifedipine XL 30mg daily in the winter
c) Take nifedipine XL 30mg 30-60 min. before cold exposure
d) All of the above
e) None of the above
D. Patients with Raynaud’s phenomenon should be advised to avoid cold exposure and the use of vibrating tools; snowmobiling combines both of these factors. Calcium channel blockers (CCBs) are the first-line agents in treatment of this condition and reduce the frequency and severity of the attacks. A CCB can be taken either before cold exposure or on a regular basis during the winter months; daily use rather than prn will increase tolerance to the side effects.
All of the following antimicrobials should be given with caution, if at all, to a patient being treated
with warfarin for a deep vein thrombosis (DVT) EXCEPT:
a) Erythromycin
b) Fluconazole
c) Ciprofloxacin
d) Tetracycline
e) Clindamycin
E. Clindamycin does not interact with warfarin. All of the other agents potentiate the effects of warfarin, increasing the INR.
When treating DVT, warfarin is given at a dose to maintain an INR range of:
a) 0.5–1
b) 1–1.5
c) 1.5–5
d) 2-3
e) 4–5
D. The standard treatment is for an INR range of 2-3. An INR of 1.5-2 has been shown to be less effective than standard treatment (page 584, CTC, 7th edn). All of the other ranges listed are inappropriate target INR ranges.
Red Flags by condition and drug induced conditions: Dyslipidemia
NIACIN (IMMEDIATE-RELEASE NICOTINIC ACID)
- CI in severe PUD, uncontrolled hyperglycemia, severe gout, hepatic disease
Red Flags by condition and drug induced conditions: Dyslipidemia
STATINS HMG COA
CI in pregnancy, liver disease, ↑ alcohol consumption, caution in moderate-severe renal dysfunction
Red Flags by condition and drug induced conditions: Dyslipidemia
INT Statins HMG CoA Reductase Inhibitors
- Avoid w/CYP3A4 Inhibitors (Macrolides- clar, eryth, azith), Gemfibrozil, Grapefruit Juice, Azoles, Protease Inhib, Amiodarone, Cyclosporine, Calcium Channel Blockers (Non-dihydropyridine – VERAPAMIL, diltiazem)
Caution with Warfarin-
Pravastatin has least drug intx and Rosuvastatin have fewer drug intx
Red Flags by condition and drug induced conditions: Dyslipidemia
Drug that cause elevated Cholesterol (2ndary hyperlipidemia)
- Drugs: B-blockers (w/o intrinsic sympathomimetic, or alpha-blocking activity),
Corticosteroids, HAART (HIV), OCP\HRT, Thiazide diuretics
Condition: alcohol excess, chronic KD failure, Diabetes, Metabolic Sx, Excess wt, Hypothyroid, nephritic Syndrome, obstructive LV dz, Pregnancy
Red Flags by condition and drug induced conditions: Dyslipidemia
DRUGS INDUCED INCREASE IN CHOLESTEROL
Hypercholestrol
○ Progestins (found in BCP or HRT)
○ thiazide diuretics,
○ glucocorticoids, corticosteroids
○ β-blockers,
○ isotretinoin,
○ protease inhibitors,
○ cyclosporine,
○ mirtazapine,
○ sirolimus
Red Flags by condition and drug induced conditions: Dyslipidemia
DRUGS INDUCED INCREASE IN TRIGLYCERIDES
○ alcohol,
○ estrogens,
○ isotretinoin,
○ beta blockers,
○ glucocorticoids,
○ bile-acid resins,
○ thiazides;
○ asparaginase,
○ interferons,
○ azole
○ antifungals,
○ mirtazapine,
○ anabolic steroids,
○ sirolimus,
○ bexarotene
Red Flags by condition and drug induced conditions: Dyslipidemia
DRUG INDUCED DECREASE IN HDL
● low HDL
○ non-ISA β-blockers,
○ anabolic steroids,
○ probucol,
○ isotretinoin
○ progestins
Red Flags by condition and drug induced conditions: Dyslipidemia
Risks for Rhabdomyolisis
● statins (controversial)
● fibrates (gemfibrozil)
● recreational drugs (amph, cocaine, heroine, mdmd)
● diuretics - potassium levels
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
ACEI & ARBS & DIRECT RENIN INHIBITORS (Aliskiren)
CI in pregnancy + caution in women of child-bearing potential
Neither of these drug classes should be used together. They all act on reinin-angiotensin system (RAS)
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
INT ACE Inhibitors & ARBs
● ACEI + ARBs NOT to be used together in pts
● ESP in pts w/ Diabetic nephropathy, pts on NSAIDs(?)
● Additive hyperkalemia w/K+ sparing diuretics or supplements
● ↑ Renal dysfunction-KD failure and severe hypotension
● ↓ Clearance of Lithium (potentially toxic)
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
ACEI and metformin
Enhances hypoglycemic effect
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
Angiotensin Receptor Blockers (ARBs)
CI in pregnancy
Don’t combine with ACEi (same CIs as ACEi)
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
ß-BLOCKERS
○ CI in asthma, 2nd/3rd degree heart block,peripheral artery dz, heart block, bradycardia, chronic bronchitis, Raynaud’s
○ Caution in patients >60yoa
*In migraine section, atenolol is CI (in addition) in insulin-dependent diabetes
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
ß-Blockers
Avoid abrupt withdrawal, may precipitate ischemia
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
INT ß-Blockers
● Additive bradycardia & cardiodepression w/Digoxin, CCB-ND, amiodarone
● CYP2D6 Inhibitors may ↑ levels of propranolol and metoprolol
● Propanolol may ↑ serum levels of Rizatriptan
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
CCBS
Can worsen heart failure (cause edema), caution w/heart block in absence of pacemaker
Taper & withdraw gradually (expensive)
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
INT CCBs (Dihydropyridine – Amlodipine, Felodipine, Nifedipine XL)
● CYP3A4 Substrate – many potential interactions.
● Strong inhibitors: Azole antifungals, protease inhibitors, macrolides, quinidine
● Grapefruit juice may ↑ serum concentrations (marked increase w/felodipine)
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
INT CCBs (Non-Dihydropyridine – Diltiazem, Verapamil)
All listed above apply, with addition of:
o CCBs (ND) inhibit metabolism of Carbamazepine, cyclosporine, lovastatin, simvastatin (may need to ↓ dose)
o Rifampin induces metabolism of CCB-ND
o Additive negative inotropic effects w/amiodarone, ß-blockers and digoxin
Red Flags by condition and drug induced conditions: Hypertension or Heart Failure
INT DIGOXIN
Very narrow therapeautic window. Therap drug monitoring
Digoxin (.5 – 2.0 ng/ml)
○ Done after steady-state levels have been achieved (1- 2 weeks).
○ Used for CHF, SVT and Atrial Fibrillation.
● ↑ In serum levels from: Amiodarone, clarithromycin, cyclosporine, erythromycin, itraconazole, propafenone, quinidine, ritonavir, tetracycline, verapamil
● ↓ In serum levels from: Antacids, cholestyramine, colestipol, neomycin, rifampin, St.Johns, Sulfasalazine.
● ↑ Risk of bradycardia from: Amiodarone, ß-blockers, diltiazem and verapamil
ADVERSE EFFECTS- Anorexia, N/V, visual disturbance, fatigue, confusion, arrhythmia (older person w/flu-like Sxs or confusion, always suspect toxicity – measure serum)
