CV Meds and treatments Flashcards
Statins
Lovastatin, pravastatin, simvastatin, fluvastatin, pitavastatin
High intensity: atorvastatin, rosuvastatin
Inhibit HMG-CoA reductase -> decreased synthesis of cholesterol in liver
Best drugs to lower LDL
Side effects: muscle injury (depletes Coenzyme Q10, check CK level), hepatic dysfunction (check LFTs)
Ezetimibe
Impairs dietary and biliary cholesterol absorption at the brush border of the intestine
Lowers LDL - use if can’t tolerate statin
Side effects: myalgias and increased LFTs
Fibrates
Gemfibrozil, fenofibrate
Primary effect on TGs, mild increased of HDLs by 5-10%
reduce hepatic secretion of VLDL
Side effects: myositis, LFT elevation (caution mixing with statins)
Bile acid sequestrants
Cholestyramine (also used as adjunct for relapsing c. diff infection, binds c. diff toxin)
Colestipol
Colesevelam
Primary effect on LDL 10-20%, some A1c 0.5%
Side effects: GI (N, bloating, cramping, constipation), LFT elevation
Niacin
Primary effect on HDL
Side effect: uncomfortable facial flushing - prevent with pretreatment of aspirin or NSAIDs, take at night, better with time
Omega-3 fatty acids
Primary effect on TGs
S/E: fishy burp
Treatment of Stable Angina
B-blockers - decrease HR, contractility -> decreased O2 demand
CCB (diltiazem, verapamil, amlodipine) promote coronary and peripheral vasodilation, reduce contractility
Nitrates - peripheral venous dilation -> decreased preload, decreased O2 demand
-sublingual - acute sxs
Bb and CCB combined can cause heart block
Long acting nitrates with b-blockers for long term - risk nitrate tolerance
Treatment of acute coronary syndrome (unstable angina, MIs)
ABCs
MONA-B (caution Bb in HF, COPD, severe asthma)
Statin (atorvastatin 80 mg) before PCI
Antiplatelet: clopidogrel or ticagrelor
Anticoagulant: unfractionated heparin for PCI, enoxaparin for non-PCI pts
Manage Potassium above 4, magnesium above 2 to decrease risk of arrythmias
Fibrinolysis in MI
Only in STEMI, avoid in NSTEMI
Altaplase
Retaplase
Tenecteplase
Give within 12 hours (stroke 3-4 hours)
Aspirin MOA
COX -1 and -2 inhibitor
COX -1 inhibition inhibits thromboxane A2 - impairs platelet aggregation
ADP receptor blockers MOA
Clopidogrel, ticlopidine, prasugrel, ticagrelor
block P2Y12 receptor preventing platelet aggregation
Glycoprotein IIb/IIIa inhibitors MOA
abciximab, eptifibatide, tirofiban
inhibit platelet aggregation
Heparin MOA
activates antithrombin - anticoagulant
LMWH MOA
enoxaparin
Activates antithrombin - anticoagulant
Warfarin MOA
Vit K antagonist - inhibits clotting factors 10, 9, 7, 2, protein C and S “1972 diSCo”
Thrombolytics MOA
alteplase, reteplase, tenecteplase
convert plasminogen to plasmin
Long-term management of MI
Aspirin and/or clopidogrel (depends on stent)
B-blocker
ACE-i or ARBs
-all above decrease mortality
Potassium sparing diuretic - spironolactone
Statin
Exercise, smoking cessation, dietary modification
Treatment of Prinzmetal Angina
Smoking cessation
CCB first line - diltiazem
Nitrates
Avoid nonselective b-blockers (propranolol) and triptans
Aspirin used with caution and at low dose - inhibits prostacyclin
Action and primary use of dobutamine as a vasopressor
Action: Beta 1 agonist - increases HR and contractility = increased CO
-reflex vasodilation
Primary use: cardiogenic shock
Action and primary use of Norepi as a vasopressor
Action: alpha 1 agonist - vasoconstriction; beta 1 agonist - increased HR and contractility = increased CO
Primary use: septic shock
Action and primary use of epi as a vasopressor
Action: alpha 1, alpha 2, beta 1, beta 2 agonist
- low dose - beta 1 increased CO
- high dose - alpha 1 vasoconstriction
Primary use: anaphylactic shock; septic shock (2nd line)
Action and primary use of vasopressin (ADH) as a vasopressor
Action: weak vasoconstrictor
Primary use: 2nd line for septic shock or anaphylactic shock
Action and primary use of phenylephrine as a vasopressor
Action: alpha 1 agonist - vasoconstrictor, minimal effect on heart
- raises SVR, increases after load w/o increased contractility -> decreased SV and decreased CO
- risk arrhythmias
Primary use: 2nd link for septic shock
Action and primary use of Dopamine as a vasopressor
Action: low dose - Beta 1 agonist; high dose alpha 1 agonist
-renovasodilation - selective
Primary use:2nd line for cardiogenic shock or adjuvant pressor
Complications of prolonged norepinephrine as vasopressor
ischemia/necrosis of fingers and toes
mesenteric ischemia
renal insufficiency - decreased urine output
Best vasopressor for anaphylaxic shock
epi
best vasopressor for septic shock
norepi
best vasopressor for cardiogenic shock
dobutamine
Antiarrhythmic medication classifications
“No bad boy keeps clean” or “some block potassium channels”
Na channel blockers: IA, IB, IC
Beta blockers - II
K channel blockers - III
CCB - NDP - IV
Class IA antiarrhythmics
sodium channel blocker
Procainamide
quinidine
disopyramide
Use in supra ventricular or ventricular arrhythmias
Class IB antiarrhythmics
Sodium channel blocker
Lidocaine
Tocainide
mexiletine
Use in ventricular arrhythmias
Class IC antiarrhythmics
sodium channel blocker
Flecainide, propafenone
use: Afib, PSVT, Ventricular arrhythmias
Class II antiarrhythmics
betablockers
metoprolol
atenolol
propranolol
Afib, atrial flutter, MAT
Rate control of atrial tachy
Class III antiarrhythmics
K channel blockers
Amiodarone
sotalol
ibutilide
Rhythm control - afib, atrial flutter
Class IV antiarrhythmics
calcium channel blocker - NDP
diltiazem
verapamil
afib, atrial flutter
Amiodarone s/e
pulmonary fibrosis
liver toxicity
thyroid toxicity
Check PFTs, LFTs, TFTs
Drugs used in treating stable, asymptomatic vtach
amiodarone - first line
procainamide, sotalol
if fail -> synchronized cardioversion - if you shock on T wave -> vfib
Treatment for SVT
attempt vagal manuevers - valsalva, carotid massage
IV adenosine push - can use 2 rounds
Ventricular rate control:
Nondihydropyridine CCB - diltiazem
Beta-blocker - metoprolol
Side effects of adenosine
lasts a few seconds
Intense flushing sensation
CP
hypotension
ACLS meds for v-fib or unstable (pulseless) vtach
Shock/CPR
2 min
Repeat point Check rhythm Shock/CPR/epi 1 mg q3-5 min 2min check rhythm shock CPR Amiodarone 300 mg IV bolus (2nd dose 150 mg) Evaluate/tx reversible causes repeat
ACE inhibitors - drugs, mechanism, uses, s/e
Captopril
Enalapril
Fosinopril
Lisinopril
inhibit angiotensin converting enzyme -> less vasoconstriction
HTN Post MI CHF CKD DM - renal protective
S/E: Cough (increased bradykinin) Angioedema Renal insufficiency - small bump BUN/Cr d/t decreased GFR Hyperkalemia
Teratogenic - kidney damage
ARBs drugs, mechanism, uses, s/e
Candesartan
Losartan
Valsartan
Inhibit angiotensin receptors
HTN Post MI CHF CKD DM - renal protective
S/E:
Angioedema - less frequent than ACE
Renal insufficiency - small bump BUN/Cr d/t decreased GFR
Hyperkalemia
Teratogenic - kidney damage
CCBs - dihydropyridines; drugs, mechanism, uses, s/e
amlodipine
felodipine
nifedipine
blocks Ca2+ channels in vascular smooth muscle -> vasodilation
HTN
prinzmetal angina
esophageal spasm
migraine prophylaxis
S/E: Peripheral edema HA Constipation GERD
CCBs - nondihydropyridines drugs, mechanism, uses, s/e
Diltiazem
Verapamil
Blocks Ca2+ channels in the heart -> reduced CO and HR
HTN
Afib and SVT
Migraine ppx - verapamil
S/E: Peripheral edema HA Constipation GERD Bradycardia
Thiazide diuretico drugs, mechanism, uses, s/e
Chlorthalidone
HCTZ
Reduce intravascular volume initially
Vasodilation
HTN
Volume overload - CHF, CKD
S/E: hypokalemia hyponatremia hypercalcemia sulfa allergy
B-blockers drugs, mechanism, uses, s/e
Beta 1 - first half of alpha
Atenolol
bisprolol
Metoprolol
Nonselective - last 1/2 of alpha
Propranolol
Alpha1/beta: carvedilol, labetalol
Block beta-adrenergic receptors
- decrease myocardial contractility, HR, and CO
- decreased renin-> vasodilation
HTN
CHF: reduced mortality - bisprolol, carvedilol, metoprolol ER
CAD
Propranolol: hyperthyroidism, essential tremor, migraine pax, social anxiety
S/E: Bronchoconstriction - nonselective -contra in asthma/COPD reduced HDL Increased TG Mask symptoms of hypoglycemia Slight increased risk of stroke
Alpha blockers drugs, mechanism, uses, s/e
Doxazosin
Prazosin
Terazosin
Block alpha1-adrenergic receptors -> vasodilation
Relax smooth muscle in vessel and urethra
HTN
BPH
S/E:
orthostatic htn with first dose
rebound htn when stop
Arterial vasodilators drugs, mechanism, uses, s/e
Hydralazine
minoxidil -> hypertrichosis (hair growth, aka rogaine)
relax vascular smooth muscle - arteries, arterioles
HTN
male pattern baldness
S/E:
reflex tachycardia
Drug induced lupus - anti-histone ab - hydralazine
Aliskiren
direct renin inhibitor
Clonadine
alpha 2 receptor agonist -> decreased BP by inhibiting NE release
S/E: rebound HTN xerostoma dizziness sedation
AVOID
JNC8 - initial drugs used in CKD pts
ACE-i/ARB - renal protective
JNC8 - initial drugs used in blacks without CKD
thiazide or CCB
JNC8 - initial drugs used in non-blacks without CKD
thiazide or CCB
ACE-i/ARB
Antihypertensives safe in pregnancy
“Hypertensive moms love nifedipine”
Hydralazine
Methyldopa (1st line)
Labetalol (1st line)
Nifedipine, amlodipine, felodipine
Antihypertensives unsafe in pregnancy
Teratogenic: ACE/ARB, aliskiren
Cause kidney damage
Patient has HTN, CHF and/or post MI drugs of choice:
ACE/ARB
B-blockers
Aldosterone antagonist - spironolactone, eplerenone
BPH + HTN - drugs of choice
Alpha blockers - prazosin, doxazosin, terazosin
Migraine + HTN drugs of choice
b-blocker, CCB
HTN + COPD or Asthma drugs to avoid
avoid b-blockers
HTN + CHF + peripheral edema drugs to avoid
avoid CCBs - cause edema
HTN + gout drugs to avoid
diuretics
