CV1-pharmcases Flashcards
where do you find beta 1 receptors?
heart
you have 1 heart and two lungs—good way to remember
where do you find beta 2 receptors? what happens when they are antagonized?
in myocardium centered around the SA and AV nodes
also in the lungs
when antagonized decreased HR and conduction
metopolol succinate is a _________ acting beta blocker
metopolol succinate is a LONG acting beta blocker
Case: 55 year old man with diffuse pericardial chest pressure on exertion occurring once every 3 months. COPD. HTN. DOC?
what does this drug do?
DOC: nitroglycerin sublingual, vasodilation causing decreased cardiac preload of heart
DOC2: ASA
what is stable angina?
it has predictability, when activity of the heart increases the demand of O2 goes up
you get chest pain or angina because there isn’t enough O2 getting to the heart.
this is an issue of supply and demand
if a patient takes nitoglycerin tab and is still having pain after 5 minutes what do you need to do?
you need to call 911, get them to a ED
what is the maximum amount of nitroglycerin you can take in an emergency?
take nitroglycerin every 5 minutes for a max of 3 times
either way you need to call 911 after the first attempt if the chest pain doesn’t go away
who gets aspirin? what is the next DOC if they have an ASA allergy or if they have santras triad?
ALL patients get aspirin!!!
if allergic, give clopidigrel!!
selective beta blockers are preferred for patients with COPD or asthma over non selective beta blockers because…..
Beta 2 receptors are in the lungs, so you don’t want to stimulate them
the beta 1 selective drugs only target the heart and you don’t have to worry about it reflecting the lungs in asthma and COPD pts
USE BETA 1 SELECTIVE DRUGS FOR COPD/ASTHMA
what two effects does nitroglycerin have?
venodilation causing decreased BP
decrease of heart preload
what effect does beta blockers have on the heart? (3)
decreases heart contractability and HR by decreasing workload
what happens if a patient is on both a BB and nitro?
nitro can cause tachycardia, but the BB prevent it from manifesting so you don’t get a increased heart rate
who needs a BB?
anyone who has had a MI
what three drugs should you think of when someone says a patient has stable angina?
ASA, BB, nitroglycerin
what do you want to order as a diagnostic test for stable angina?
stress test
figure out what is going on in the heart when they experience this pain
what do you want to make sure you do when you take a nitroglycerin tab?
SIT DOWN
causes venodilation which can cause a person to get dizzy and light headed….sit down!!!!
Case: a 55 year old man with precordial chest pain 2-5x a week with exertion. HTN. Obescity. DOC? (3)
DOC: nitroglycerin tab
DOC: metoprolol tartate (slow titrate up)
DOC ASA
refer this pt and get them a stress test
what is isosorbide dinitrate? how is the maximum amount a person should be on it in 24 hours?
long acting nitroglyceride
don’t want a pt being on it longer than 8-12 hours a day!! they can develop TACHPHYLAXIS meaning, the more they are on it, the less it will work!!!
metoprolol succinate does what in post MI patients?
it is the only drug to DECREASE MORTALITY AND MORBIDITY IN POST MI PATIENTS
this was the only drug that was tested of the selective B1 beta blockers, so it is unknown if metoprolol tartrate has the same effect, this is the shorter acting selective B1 beta blocker
what is the only drug to decrease morbidity and mortality in post MI patients?
metoprolol succinate, selective beta blocker
what is the dosing regimen for nitroglycerin?
.4 mg every 5 mins x3 max
always call 911 after the first dose
what should a cardiac patient do to decrease future risks or someone with high BP?
switch to DASH DIET….so a substitute salt thats like salt, but not as good hahah
How can chronic hypertension effect the heart? aka what can it lead to?
what is something important you always want to check?
can lead to long term organ damage like…
left ventricular hypertrophy
always do fundascopic to check AV nicking, sclerosis
case: a 57 year old woman with pericardial chest pain on exertion 2-3 times a week. asthma. HTN. tabacco.
DOC?
DOC: nitrogylcerin sublingual or isosorbide binitrate
DOC2: B1 selective beta blocker (atenolol, metoprolol)
DOC3: ASA
at what dosing does a beta blocker become less effective?
100 mg
might want to consider a different agent at this point, esp asthma/COPD pt
what are two main side effects that you will see with nitroglycerin?
dizzy and weak= from drop in BP
SEVERE headache= from heart racing
what should you never use nitroglycerin with?
PDE-5 inhibitor sildenafil AKA viagra
this can can lead to a massive decrease in BP and lead to a MI
NEED TO BE 24 hours apart!!!!!!!!!!! KNOW IT
selective beta blockers block _____of the heart and ______
Beta 1 blockers block the CONDUCTION the heart and SLOW IT DOWN!!
what are selective beta blockers drugs usually used for and what are nonselective beta blockers drugs usually used for?
use selective beta blockers for the heart because thats where the B1 receptors are, selective beta blockers only go for B1
use nonselective beta blockers when you are dealing with more generalized issues like anxiety because nonselectives effect both the B1 and B2 receptors
what is the gold standard for coronary artery disease?
angiography via cardiac cath
what do you need to be careful if you have a patient who has had trauma?
need to be careful and cautious about prescribing them a vasodilator because if they are bleed or have internal bleeding it could cause them to bleed a lot more
can make both hemmorages and bleeds worse
explain syndrome X
look at the vessels of a woman and they look completely clear and then all of the sudden they have a massive MI
we can’t figure out what causes it, it just happens and we don’t know why
Case: a 60 year old lady takes almodipine 10 mg but has gotten 1+ pitting edema in legs about a week after starting drug. DOC?
what do you need to rule out?
DOC: switch almodipine for selective beta blocker! (atenolol, metoprolol)
DOC: ASA
want to get a BNP to confirm that it isn’t heart failure!! need to rule this out
what lab value can you use to measure heart failure?
BNP
what is a SE of almodipine?
EDEMA, don’t need to put them on a dieuretic, just change the drug and then you will see the edema go away
of the calcium channel blockers, which ones can be used in angina and hypertension (no arrhythmia)? (1 class, two drugs)
dihydropridines (DCCB):
- amlodipine
- nifedipine
of the calcium channel blockers which ones can be used in angina, hypertension, AND ARRYTHMIA(afib/aflutter)?
nondihydropyridine (NDCCB)
diltiazem
verapamil
amlodpine is a …..
dihydropyridine
what are the two main SE of amlodipine?
headache and edema
case: 75 year old lady with angina every 3 weeks with exertion. Now it is happening every few days and has new sinusitis with airway obstruction. COPD. CDK3. HTN. ALLERGY.
DOC (4). what do you NEVER us for this.
pts are very delicate with comorbid disorders, and sinusitis might be the thing that tips the scale and compromises her heart, so you need to treat it
DOC: augmentin, amoxicillin
DOC: amlodipine
DOC: Nitroglycerin PRN
DOC: oxygen
*****NEVER USE AFFRIN IN SINUSITIS IN
If patients have angina and are taking drugs for asthma/COPD that are LABA or SABA, what do you need to do?
you need to switch them to an anticholingeric drug like ipratropium or tiotropium or umeclidium because these drugs effect the B2 receptors in the lungs, and you don’t want to antagonize these if you are already having heart issues.
if a patient has CKD, what type of diuretic should they be on? what are the three drugs?
loop diuretics
- furosemide
- torsemide
- ethrcrynic acid
what is the drug class for nitroglycerin?
vasodilator: nitrates
what is the MOA of nitroglycerin/isosorbide?
smooth muscle dilation of the arteries and veins
what is the indication for nitroglycerin?
angina, congestive heart failure
what is the drug class for isosorbide?
vasodilators nitrates
what is the indication for isosorbide dinitrate?
FREQUENT stable angina
CHF
what are the 3 side effects of nitroglycerin?
HA
Hypotension
tachycardia
what are the contraindications for isosorbide dinitrate/nitroglycerin? (3)
hypersensivity
head trauma
severe dehydration
which med should you not mix with isosorbide dinitrate/nitroglycerin?
PDE-5 inhibitors aka sildenafil….viagra!!
what are the four SE of isosorbide dinitrate?
HA
hypotension
tachycardia
re-bound HTN
what is a off label use for isosorbide dinitrate?
esophageal spastic disorders
what formulations does nitroglycerin come in? (3)?
sublingual spray
sublingual tablet
buccal tablet
what is important about the storage needs for nitroglycerin? (2 things)
comes in a glass colored bottle to prevent photosensitization
it vaporizes or can dissolve if exposed to moisture
the last thing you want to do is reach for your nitro tab and it has disintegrated, so some people prefer the spray since less temperamental
explain how nitroglycerin and beta blockers have a synergistic relationship?
nitro can increase the HR and BB prevents the increase of the HR….most patients are on both of these so they work with each other
BB balances out the negative side effects of the nitro
BB decreases _________ and keeps them in the ______
BB decreases O2 DEMANDS and keeps them in the NEUTRAL ZONE
what should you not use in sinusitis if a patient has angina?
don’t use affrin because it is a vasoconstrictor, you don’t want to vasoconstrict your pts
Case: a 70 yr old man with ischemic heart disease. 2-3x chest pain a week controlled with a beta blocker. He recently started getting dizzy. Sitting his BP was 120/60 and standing dropped to 100/50. His HR is now 50. Metoporol 50mg BID.
DOC?
and if that doesn’t work DOC2?
orthostatic hypotension from BB use!!
DOC1: down titrate metoprolol
if HR doesn’t improve with less dosing, down titrate pt off metoprolol for 7-10 DAYS and switch to amlodipine
DOC2: amlopdipine
how long should a taper off metoporlol last?
7-10 days
which calcium channel blockers can cause HYPOTENSION IN THE ELDERLY?
the DIHYDROPYRIDINES
- amlodipine
- nifedipine
people who have angina are likely to have a lot of other things going on like CKD, so they might be good candidates for…..
ace inhibitors
explain why a person on Beta blockers might have issues with orthostatic hypotension and dizziness?
when this person stands up, his BP drops – normal response would be to increase HR, but beta blockers prevent adrenergic reaction with increasing HR – so because he is on the beta blocker, he is unable to increase his HR to maintain his BP causing orthostasis
case: 67 year old lady with progessive dependent edema exertional sob and nocturnal sob and dry cough over the last 6 weeks. HTN, COPD, CKD 3, angina. cholathriodone HTN, nitro angina, Salmetrol diskus COPD.
DOC? (2)
- DOC: lasix fursemide BID to reduce fluid and edema
- DOC2: need to change salmetrol because it decreases the effectiveness of diuretic so change to tiotropium
follow up in 5-7 days to check weight
how can COPD cause HF?
COPD can cause pulmonary hypertension causing HF
what do people on direutics need to do? what is goal weight loss?
MONITOR THEIR WEIGHT AT HOME, GOAL IS 2LBS LOSS A DAY
what do you worry about a side effect of furosemide (all loops)?
HYPOKALEMIA, HYPOTENSION, K depletion
when do you consider direutics?
stage 3 or 4 CKD
what direutic do you want to use in a patient with CKD either stage 3 or 4?
FUROSEMIDE!!!! LASIX
ONE OF MOST POTENT DIURETICS IN PT WITH RENAL INSUFFICIENCY-WORKS WITH FOLKS WITH 3 AND 4 CKD BETTER THAN ANY OF THE OTHER DIERETICS
During the day, when are the best times to take furosemide? if BID, how far part should they be taken?
ake 20 mg Ferocimide at 7am and then second dose and 20 mg 1pm because it has an effective time frame of about 6 hours.
By 7pm, warn off and she wont have to be getting up all night to go pee.
take them 6 hours apart
at what weight gain in 24 hours should you take furosemide if given to you “PRN”?
if you gain 3 lbs in 24 hours, pt should take a dose of furosemide
case 8: 70 year old lady with nocturnal dyspnea, orthopnea. she now sleeps sitting up in a chair with pitting edema billatreally. COPD. HTN. CKD 2. ACD. SULFA ALLERGY.
DOC
DOC ethacrynic acid
Most indicated dieuretic for someone with sulfa allergy even though studies have shown that people with sulfa allergies won’t have issues with direutics. the package says this though so everyone freaks out.
of the loop dieuretics which one is most indicated for someone with a severe sulpha allergy?
ethacryinic acid
what two loop direutics shouldn’t you use in sulpha allergy even though there is no evidence it can cause an issue?
furosemide
torsemide
when should you consider using the non sulfa loop direutic ethacrynic acid?
in someone who has anaphylaxis or SJS to sulfa
what aldosterone antagonist diuretic can cause SKS?
spirolactone
what are the two aldosterone anatagonist drugs that are K sparing?
SPIRONOLACTONE OR EPLERENONE (BOTH ANTI ALDOSTERONE DIRETICS) SO IF THE PT HAD LOW K, USE THESE INSTEAD
of the aldosterone antagonist diuretics, which one can cause male gynecomastia? so who do you not want to use this is?
Spironolactone can cause gynecomastica so avoid use in males
spironolactone can cause what in males? so which one is safter to use since it doens’t cause this?
spironolactone can cause gynecomastica
so use EPLERENON instead if they need K sparing drug
if you are a man who needs a diuretic that is K sparing, which on do you want?
eplerenone because it is K sparing and doesn’t cause gynecomastica
case 9: 70 year old man with onset of HF symptoms with preexisting CKD that was stage 4 with eGFR of 20 ml/min. HCTZ for HTN. 155/110.
2 DOC?
- DOC ACE inhibitor lisinopril or captopril for BP since isn’t regulated with HCTZ DOESN”T WORK FOR PEOPLE BELOW 30 ml/min. Take him off this
- DOC: put on furosemide to take off fluid
what are the four SE that make ACE inhibitors ( captopril, lisinopril, fosinopril) completely contraindicated?
- dry cough
- angiodema (swelling around the periorbital area that can go into the throat and cause breathing issues)
- billateral renal stenosis
- pregnancy
get them off ACE inhibitor next DOC is angiotensin 2 receptor inhibitor losartan!!!
if someone can’t take ACE inhibitors because they are contraindicated from SE (renal stenosis, pregnancy, angiodema, cough) what is the new DOC?
angiotensin 2 receptor blockers (ARBs)
LOSARTAN
which diuretic is equally effective if administered IV and oral and has the same dosage between the the two?
torsemide
what do loop direutics decrease reabsorption of?
sodium, chloride, and K….so watch electrolyte levels!
HCTZ rarely works for below what eGFR?
case 10: 68 year old man with dyspnea on exertion, nocturia, dry cough, and wheezing with headache last 2 weeks. CKD 3. HTN. ACD. chlorthalidoone HTN. AV nicking and diminished heart sounds. Lab show new eGFR of 20ml/min.
DOC 2
hypertension and heart failure
- DOC: take off chlorthalidone since not working, put on furosemide can use in CHF and CKD
- DOC2: put on low dose ACE inhibitor since still has high BP
what is the most potent diuretic for CHF and CKD?
FUROSEMIDE BECAUSE IT IS THE MOST POTENT FOR THIS POPULATION, ALSO HAPPENS TO BE THE CHEAPEST!
what do you need to monitor with furosemide? (3)
electrolytes, BUN, CrCl
what are three diseases that often coexist that can make it difficult to determine the culprit?
CKD, COPD, HF…not uncommon for people to have all three. WEIGHT, BP, CHEST XRAY, updating eGFR and CrCl are both important
what do ACE inhibitors prevent?
inhibitors prevent the conversion of angiotenion I to angiotension II decreasing vasoconstriction and aldosterone production
why do people have increased cough on ACE inhibitor?
increase in bradykinin being produced
40 mg of furosemide=_____mg of torsemide
10-20 mg torsemide, so torsemide is basically twice as strong as furosemide
case 11: 70 year old man with treated HF who is on vacation. 10 days ago he notices ankles are swollen and dry cough, has gained 7 pounts and can’t lie down comfortably. Hes been eating at a bunch of fancy restaurants. TNG. ASA. Atorvastatin. metoprolol. FUROSEMIDE 20 mg prn weight increase of 3 pounds. eGFR 35ml/min.
DOC 2?
change in dietary regulation with increased sodium exacerbating HF, BP is increased because of fluid overload
DOC1: increase furosemide
DOC2: if BP still doesn’t come down, consider adding calcium channel blocker since already on beta blocker
DOC3: once weight down start cardiac rehab
*since on vacation may want to use 25 mg twice daily instead of PRN with 3 lb weight gain if he is going to keep doing all the activites while on vacation, may want to keep in on the direutics scheduled so that way it doesn’t cause an exacerbation again
what is the goal of cardiac rehab?
people with a lot going on with HF, get them to cardiac rehab. goal is to increase the efficiency their muscles use oxygen so their muscles eventually cal for less O2.
when evaluating a patient who has SOB..what do you always want to consider?
HX OF ANEMIA OF CHRONIC DISEASE, WANT TO GET H+H, CBC, TSH
SOB COULD BE ATTRIBUTED TO ACUTE ANEMIA IF PRESENT
when taking direutics patient should continue to drink….
the same amount of fluid they normally do
what is the MOA of loop dieuretics?
inhibits Na, K, and Cl symporter in the ascending loop of henry
what is the MOA of spirolactone and eplerenone?
aldosterone receptor antagonist in distal renal tubule and blood vessels
case 11a: 75 year old white male with HF and afib who presents today with a fall yesterday. he is still unsteady and afraid he will fall again. Furosemide 20mg. Metoprolol 100 mg daily. BP 120/80. HR 50. 10 pound weight loss.
DOC 2? what are two things you want to check?
bradycardia secondary to metoprolol
DOC: decrease metoprolol since 100mg is the max daily dose! try 75 mg and downtitrate to lowest effective dose
DOC: put on antiplatelet drug ASA since afib!
DOC get EKG and do orthostatic vitals
since taking high dose of metoprolol it could keep his HR low so that he can’t COMPENSATE, this in combination with the fact he is taking furosemide (dehydrated) could have caused HYPOTENSION Afib could also have contributed to the fall.
what you do orthostatic BPs you looking to see if the pressure….
drops with standing
12c: 70 y/o african american man with new heart failure, many years of HTN, smoker. edema, dyspnea at rest and is wheelchair bound with angina with any exertion. COPD, HF, obesity, HTN, osteoarthritis of the knee, angina. A MYRIAD OF DRUGS but lisinopril and ibuprofen
of interest. eGRF 20 mL/min.
DOC 2? who should he be seeing? what do you want to order for a test?
acute HF on top of chronic HF
DOC1: furosemide to decrease edema and CP
DOC2: want to get chest xray to determine how much is due to COPD and CHF
DOC3: STOP IBUPROGEN BECAUSE OF HIS eGFR!!
- follow up 3-4 days to check edema
- furosemide interaction with linsinopril and can cause hypotension so just be conscious and watch it
- should be seeing pulm and cardio
what drug can be given by cardiologists for end stage HF? what are the requirements for this drug?
Ivabradine
EF less than 35% and HR greater than 70%
when should you not use Ibuprofen?
CKD or hepatic diease
ivabradine can cause…
can cause visual disturbances
hydralazine and isosorbide dinitrate decrease……
afterload because it cause it is a direct arterial vasodilator
dieuretics and nitrates decrease….
PRELOAD
case 11b: a 28 year old african man who has consistently elevated BP of 160/90. has never been treated and is otherwise healthy
DOC 1 and if that doesn’t work?
DOC1: ACE inhibitor captopril
DOC2 if that doesn’t work: hydralazine + isosorbide dinitrate
after giving the ACE want to see him back in 2-3 weeks because african or black males can be LESS RENIN SENSITIVE OR DEPENDENT, so they may fail on ACE inhibitors
sometimes be best drug for them is HYDRALAZINE + isosorbide dinitrate even though a heavy hitter
what might african men fail on ACE inhibitor drugs/
because they are less renin dependent or sensitive so need to use another drug most likely hydralazine + isosorbide dinitrate (bidil)
what do kidneys release when the don’t think they are getting enough blood for blood volume?
renin
this increases angiotension and increase BV/BP
if you have CKD, you shouldn’t be taking ______ because it is extremely nephrotoxic
IBUPROPHEN
what drug is reccomended in the black population because it can decrease hospitalizations in pts with HF and HTN?
hydralazine and isosorbide dinitrate
aren’t responsive to the other drugs as much as this
what is the MOA of hydralazine + isosorbide dinitrate?
direct arteriolar vasodilator that decreases periphreal resistance causing dilation of SM and decrease BP
ivabdradine can cause what in the eye?
visual floaters ad periphreal vision changes
which drug is used as a adjunct in HF esp afro-american males?
hydralazine and isosorbide dinitrate
what ACE is on the $4 list?
lisinopril
salmoteral decreases the effectiveness of which drug?
looop direutics!
african americans don’t produce
angiotensin 1
what can hydralazine + isorbide dinitrate cause it whites?
lupus
dobutamine is what drug class
positive inotropic B-agonist drug
lisinopril and furosemide can cause….
HYPOTENSION when used together….so just watch out for this!!
