Cardiovascular Drugs Flashcards
1
Q
What are the 2 Classes of Inotropes
A
- Receptor Dependent
2. Phosphodiesterase inhibitors
2
Q
Normal Myocardial Cell
A
In the body we have circulating hormones ex:(norepi &epi) these hormones stimulate Beta 1 receptors-contribute to production of Adenyl Cyclase-combines with ATP (fuel for the cell)-to produc cAMP (2nd messenger system within the cell, helps facilitate movement of CA into the cell.
3
Q
- Receptor Dependent Inotrope?
A
Stimulates the Beta 1 receptor sites on the cell. Ex: Dobutamine
4
Q
Down Regulation of the Beta 1 Receptors
A
Some patients that are in shock have high levels of norepi & epi circulating and the Beta 1 receptors get overloaded. So CO & CI drop and they are started on Dobutamine. This could create Down Regulation of the Beta 1 receptors. (ask for Milronine )
5
Q
- Phosphodiesterase Inhibitor
A
Shuts down the phosphodiesterase as a result we have more cyclic AMP availabel and more CA goes into the cell causing an increase in CO and CI.
*Milronine has nothing to do with the beta 1 receptors
6
Q
Where are Beta 1 receptors found:
A
Primarily in the heart
7
Q
What does Beta 1 stimulation produce?
A
- increase in HR (+chronotropic effect)
- increase in contractility (+Inotropic effect)
- increase conduction velocity through AV node (+Dromotropic effect)
8
Q
Where are Beta 2 receptors found?
A
Found in the lungs and peripheral arterioles
9
Q
What does Beta 2 stimulation Produce?
A
- Relaxation of smooth muscle
- Vasodilation (peripheral)
- Bronchodilation
10
Q
Where are Alpha 1 receptors found?
A
Lungs and peripheral arterioles
11
Q
What does stimulation of Alpha 1 receptors produce?
A
*constriction of smooth muscle (vasoconstriction)
*
12
Q
Where are Dopaminergic Receptors found ?
A
Renal, mesenteric vascular beds
13
Q
What does stimulation of the dopaminergic receptors produce?
A
*Vasodilation
14
Q
Dopamine
A
- Is an immediate precursor of norepinephrine
- Neurotransmitter in central and peripheral nervous system
15
Q
Effects of Dopamine?
A
- Decrease aldosterone secretion in adreanal cortex. (less Na & H2O reabsorption so UO will
increase) - Inhibits thyroid stimulating hormone and prolactin release. (can produce hyper or hypothyrodism)
- Inhibits insulin secretion
16
Q
Dopamine Range
A
2-10mcg/kg/min = increase contractility (beta effect) >10mcg/kg/min = vasoconstriction (Alpha effects)
17
Q
Dopamine Indications?
A
- Shock state
- Cardiogenic
- Septic
- Post Cardiac Surgery
18
Q
Dopamine Side Effects?
A
- N/V
- Tachyarrhythmias
- Supraventricular and ventricular
- Profound vasoconstriction
19
Q
Dobutamine
A
- Synthetic Catecholamine directly stimulates
- Beta 1 receptors- increasing myocardial contractility that will increase HR
- Beta 2 Vasodilation
- Alpha 1 vasoconstriction
- Inotropic effect
- May drop MAP slightly
20
Q
Dobutamine Indications?
A
- CHF
- Shock States
- Septic
- Stress testing
21
Q
Dobutamine side effects?
A
- increase HR
- Dysrhythmias, ventricular & supraventricular
22
Q
Dobutamine dosage
A
- 5-20mcg/kg/min
* **Never administer in an alkaline solution such as sodium bicarbonate.
23
Q
Epinephrine Cardiac Effects
A
- Has dose dependent effects*
- Mediated through Beta receptors.
0. 005-0.02 mcg/kg/min = increase HR, +Inotropic effects; vasodilation (decrease SVR)
24
Q
Epinephrine Vascular Effects
A
Mediated through alpha receptors at high doses: increase SVR; increase BP, renal artery vasoconstriction
25
Epinephrine Beta 2 stimulation
Bronchodilation
26
Epinephrine Alpha effects
With higher infusion rates = 1mg IVP (ACLS situation) short 1/2 life 2 min
27
Epinephrine Indications?
- Lower output state
- Cardiac Arrest
- Shock States
- Asthma
- Anaphylaxis
28
Epinephrine Side Effects?
- Restlessness, fear
- Tachyarrhythmias
- Severe HTN
- Cardiovascular Accident
- Hypokalemia
- Hypophosphotemia
29
Norepinephrine
Low Doses - Beta Stimulation
| High Doses - Alpha stimulation
30
Norepinephrine Dosage?
Start 0.5-0.10mcg/kg/min or 2-4mcg/min and titrate up
31
Norepinephrine Indications?
- Hypotension
- Cardiogenic Shock
- GI lavage (mix up to 16mg in 30-50ml of NS, inject in NGT don't leave down must aspirate but by washing the superficial lining of the stomach it can vasoconstrict to reduce bleeding
32
Norepinephrine side effects?
- Tachyarrhythmias
- HA
- Tremors
- Restlessness
- Severe HTN
33
Norepinephrine Contraindications?
- Renal and mesenteric thrombosis
34
Phenylephrine (Neo-Synephrine) Effects?
- Effects are primarily vascular
* increase SBP, DBP, PAP
* Coronary & Renal Vasoconstriction
- Indirectly releases norepinephrine from storage sites
- At large doses, could stimulate Beta 1 receptors, causing an increase in HR
- Can cause reflex bradycardia-mediated through vagus nerve.
35
Phenylephrine Dosage?
100-180mcg/min to achieve desired effect
Maintenance Dose 40-60mcg
Pressor effect / Immediate 1/2 life lasts 15-20min
36
Phenylephrine Side Effects?
- Vasoconstriction
- Hypertension
- Bradycardia
37
Vasopressin
- Antidiuretic Hormone
- Larger Doses
* Alpha stimulator causing vasoconstriction
* Does not have negative effects on myocardium
38
Vasopression Dosage?
ACLS 40 units- Do not repeat
| Infusion: 0.03 or 0.04units/min
39
Milronine
- Phosphodiesterase Inhibitor
- Positive Inotrope
- Minimal Vasodilating Effects
40
Milronine Dosage?
Loading Dose: 50mcg/kg undiluted over 10min
Infusion Dose: Start at 0.5mcg/kg/min and increase in increments of 0.375mcg/kg
Max Infusion 0.75mcg/kg/min
41
Milronine Indications?
- Low CO
- Acute CHF
- Cardiomyopathy
42
Milronine Side Effects ?
- Arrhythias (vfib, vtach)
- HA (tylenol may not help lowering rates may help)
- Tremors
- Thrombocytopenia
- Hypokalemia
- Hypotension
- Angina Pectoris
43
Nitroglycerin
- Direct Vasodilator
- Systemic & Pulmonary venodilation - decreases RV & LV aferload
- LV & RV filling pressures
- decreases aortic impedence
- coronary artery dilation (improvement of ischemic zone, dilates vessels around ischemic zone)
- May raise threshold for vent fib, makes it harder to fibrilate.
44
Nitroglycerin Dosage?
Start 10mcg/min
| - No upper limit of infusion
45
Nitroglycerin Indications?
- CP r/t myocardial ischemia
- decrease preload
- decrease afterload
46
Nitroglycerin Side Effects?
- Hypotension
- HA
- Nitrate tolerance
47
Nitrate Tolerance
Occurs when a pt has been exposed to nitrates continuously over several days.
48
Using Nitrates over several days may cause?
Chronic vasodilation-activation of the Renin angiotensin system-production of super oxcides-inactivation of endogenous & exogenous nitric oxide.
* therefore 12 hour window- fee time is important
49
Super oxide?
A super oxide block endogenous and exogenous nitic oxide.
50
Nitric Oxide?
- Nitic oxide enzyme released from endothelial lining of the blood vessels and is a potent vasodilator.
* **Nitroglycerin as its metabolized and is converted to nitric oxide, so eventually it stops working.
51
Sodium Nitorprusside
- Potent Vasodilator
balance effects on arterial and venous beds
- In 10% of pt's can increase pulmonary shunt
* Will see Spo2 and PO2 fall
- Can produce cononary steal syndrome
52
Sodium Nitroprusside Dosage?
0.25mcg-10mcg/kg/min
| Duration of action 1-5min
53
Sodium Nitropusside monitoring?lev
Long term monitoring (>48hours) should include serum thiocynate levels.
54
Critical Thyiocynate Levels
- >10g/dL significant
- If infusion rates 3mcg/kg/min are not associated with toxicity
- Poor renal function increases risk for thiocynate toxicity.Br
55
Nitropusside Indications
- Severe heart failure with increase SVR
- Mitral Regurgitation to decrease afterload
- Low CO syndrome with increase SVR
- Hypertensive Crisis
56
Nitropursside Contraindications?
- Use with caution in patients :
* Hypothyroidism
* Hepatic renal disease
57
Nitropusside Side Effects
- CNS
* Nervousness, Ataxia, HA
* Cardiac: Hyotension, palpitations
- Cyanide poisoning
58
Why is important to monitor serum thiocyanate levels:
Thiocyanate begins to act like cyanide. When someone dies of cyanide poisoning its usually because cyanide impairs the ability of oxygen molecules to go into the cells of the tissue.
59
Cyanide Poisoning Effects:
- Impaired tissue oxygenation
- confusion
- hyperreflexia
- convulsion
-
60
Antidote for cyanide poisoning?
Sodium thiosulfate
61
Nesiritide (Natrecor)
Brain Natriuretic Peptide
| - Identical to endogenous BNP
62
Nesiritide (Natrecor) Effects?
- Vasodilation
- Natriuresis
- Diuresis
Usually start with a bolus dose followed by infusion
- Do not infuse through same line as other meds.
- Monitor BP before administering and during
63
Nesiritide (Natrecor) Side Effects?
Hypotension
64
Natrecor is incompatible with?
- Insulin
- Lasix
- Bumex
- Heparin
* *Do no infuse through a hepain -coated catheter
65
Nicardipine (Cardene)
Calcium Channel Blocker
66
Nicardipine (Cardene) Indications?
- Hypertensive Crisis
| - Afterload Reduction
67
Nicardipine (Cardene) infusion rate?
5-15mg/Hr
| 1/2 life 15-45min: therefore avoid rebound HTN
68
Nicardipine Side Effects?
Hypotension
| Phlebitis
69
Beta Blocker Indications?
- AMI, only class of drug to show prevention of sudden cardiac death. Needs to be sarted while in the hospital and discharged on them.
- Attenuate ventricular remodeling
- Tachycardias (supraventricular,ventricular)
- Hypertension
,
70
Beta Blocker Side Effects?
- AV Block
- Sinus Bradycardia
-
71
Use Beta Blockers Cautiously with?
- Raynauds's disease (b/c blocks beta 2 receptors and will cause vasoconstriction.
- Insulin Dependent diabetes mellitis
72
Indications for Calcium Channel Blockers?
- HTN
- Supraventricular arrhythmias
- MI (rarely)
- Stemi, when beta blocker intolerant
- Some are stronger vasodilators, others are stronger AV blockers
73
Calcium Channel Blocker Side Effects?
Hypotension
74
Ace Inhibitors
```
Block Conversion (converting enzyme in the lung) of Angiotensin 1 to Angiotensin II
- They end with "pril"
```
75
Ace inhibitor indications?
- HTN
- MI(particular if EF is <40%
- CHF
76
Ache inhibitor Side Effects?
- Cough
- Angioedema (more common in female, more common in black females
- Renal Insufficiency
