CV1-PharmChart Flashcards
what are the 2 drugs that are vasodilator: Nitrates
Isosorbide Dinitrate
Nitroglycerin
MOA of Isosorbide Dinitrate
Smooth muscle dilation of arteries and veins
Class of Isosorbide Dinitrate
Vasodilator: Nitrates
Indication of Isosorbide Dinitrate
frequent stable angina
SE with Isosorbide Dinitrate
Headache, hypotension, tachycardia, re-bound HTN
Common Dx-Dx interaction of ALL vasodilators: Nitrates
PDE-5 inhibitors
What is important to remember time wise about Isosorbide Dinitrate
want a 6-12 hour of nitrate free interval DAILY!
Drug class of Nitroglycerin
Vasodilator: Nitrates
MOA of Nitroglycerin
Smooth muscle dilation of the arteries and veins
Indications of Nitroglycerin
Angina, CHF
What forms does Nitroglycerin come in
and what are the two most important SE:
SL spray
SL or buccal tablet
topical
IV
SE: headache, dizzyness
What is it important to remember about storage of Nitroglycerin (2 things)
kept in a glass bottle to help minimize moisture
kept in dark container because sensitive to sunlight!
What are the four Vasodilator: Calcium Channel Blockers?
- Dihydropyridine: Amlodipine
- Dihydropyridine: Nifedipine
- NonDihydropyridine: Dilitiazem
- NonDihydropyridine: Verapam
Is Amlodipine a nonDihydropyridine or Dihydropyridine?
Dihydropyridine
MOA of Amlodipine
Vasodilation due to blocking calcium channels in vascular smooth muscle and myocardium
Indications of Amlodipine
Angina
HTN
Common SE of Amlodipine (2)
Peripheral edema
ELDERLY HYPOTENSION
Dx-Dx interactions of Amlodipine and Nifedipine
Grapefruit juice
what can Amlodipine be used instead of
Beta Blockers
Is Nifedipine a Dihydropyridine or nonDihydropyridine
Dihydropyridine
MOA of Nifedipine
Vasodilation due to blocking calcium channels in vascular smooth muscle and myocardium
Indications of Nifedipine
Angina
HTN
sound familiar?
Common SE of Nifedipine (3)
Palpitations
peripheral edema
ELDERLY HYPOTENSION
what is Nifedipine most likely to do?
Most likely to produce hypotension
is Diltiazem a Dihydropyridine or nonDihydropyridine
nonDihydropyridine
MOA of Diltiazem
Dilate coronary arteries and decrease myocardial oxygen demands
indications of Diltiazem (5)
1) Angina
2) HTN
3) A FIB
4) A FLUTTER
5) PSVT
SE of Diltiazem
Edema
what has the contraindications of both Bradycardia and SSS if no pacer
Nondihydropyridine’s
Diltiazem and Verapamil
What can you not use in combo with Diltiazem
Not for combo use with Beta blockers
What increased the half life of Diltiazem
half life increased in cirrhosis
is Verapamil a nondihydropyridine or dihydropyridine
nondihydropyridine
MOA of Verapamil
Dilate coronary arteries and decrease myocardial oxygen demands
sound familiar?
indications of Verapamil (3)
PSVT
A fib
A flutter
SE of Verapamil (1)
Gingival hyperplasia
Dx-Dx interactions with Verapamil
Grapefruit juice
What can you not use Verapamil in combo with
Beta Blockers
it will decrease nodal conduction!
What are the selective (B1) beta blockers
- Metoprolol Tartrate/ Metoprolol succinate
2. Atenolol
MOA of Metoprolol Tartrate/ Metoprolol succinate
Selective B1 adrenergic receptor inhibitor
Indications of selective (B1) beta blockers
Angina
HTN
hemodynamically stable MI
SE of selective (B1) beta blockers (6)
- fatigue
- sleep disturbance
- depression
- bradycardia
- rebound angina/hypertension
- hypotension
Contraindications for selective (B1) beta blockers (4)
- bradycardia
- heart block
- uncompensated heart failure
- severe depression
What can high doses cause in selective (B1) beta blockers
High doses can lose B1 selectivity
what do you do Post MI or in compensated HF with selective (B1) beta blockers… what about when stopping?
up titrate slowly
when stopping? down titrate slowly
which Beta blocker drug has an increase absorption with food?
Metoprolol Tartrate/ Metoprolol succinate
MOA of Atenolol
Selective B1 adrenergic receptor inhibitor
when do you adjust the dose of Atenolol
Adjust dose in CKD (50% renally excreted unmetab)
Non-selective (B1 and B2) : Beta blockers
Propranolol
MOA of Propranolol
Adrenergic B1 and B2 receptor inhibitor
Reduction in myocardial oxygen demand
indications of Propranolol
Tachyarrhythmia
Essential Tremor
migraine Px
anxiety
the 3 SE of Propranolol
fatigue
sleep disturbance
depression
contraindications of Nonselective Beta blockers (6)
- Hypersensitivity
- Bradycardia
- Heart Block
- Uncompensated heart failure
- Severe depression
- Bronchospasm
what may increase or decrease concentration of Propranolol
Ethanol aka alcohol
what may Propranolol mask
may mask hypoglycemia
what do we have to know about HR relate to Propranolol
what about when stopping
titrate to HR 50-60 bpm or increase HR 20 bpm with exercise
when stopping: down titrate
when does the bioavailability increase in Propranolol and by how much
Bioavail increases x2 in elderly
drug class of Carvediliol
Beta blocker: Non selective (B1 , B2, Alpha 1)
MOA of Carvediliol
Mixed alpha beta receptor inhibition
indications of Carvediliol
angina (off label)
HTN
Stable HF
Stable Post MI
SE of Carvediliol (hint … youve seen this before)
- fatigue
- sleep disturbance
- depression
- bradycardia
- rebound angina/hypertension
- hypotension
when do you titrate slowly in Carvediliol
Post MI or Compensated HF
Anti-anginal Agent: Miscellaneous
Ranolazine
MOA of Ranolazine
Inhibits inward sodium channel in ischemic cardiac myocytes during repolarization thereby reducing Na+/Ca++ exchange which relaxes cardiac muscle and reduces myocyte oxygen consumption (proposed mechanism)
Indication of Ranolazine
CHRONIC ANGINA
SE of Ranolazine
HYPERHYDROSIS
also: constipation, HA, bradycardia, hypotension etc
Contraindications of Ranolazine (2)
- any degree of hepatic cirrhosis
2. concurrent strong CYP3A4 inhibitors or inducers
Common dx-dx interactions with Ranolazine
- CYP3A4 inhibitors (diltiazem, eythromycin, verapamil etc)
- P-glycoprotein inhibitors (cyclosporine)
- simcastatin (max dose is 20mg/day)
what do you NOT do with Ranolazine
SO NO CRUSH OR CHEW
what is Ranolazine not for?
not for acute episodes of angina
do not use Ranolazine with
grapefruit juice or st johns wort
how much is Ranolazine
AWP at full dose is $476.51
how do you dose Nitroglycerin?
Sublingually… if chest pain 1 tab every 5 min due to chest pain
3 pills max in 15 min.
you can also use it prophylactically
what is the drug class for asprin?
anti-platelet aggregation drug COX 1 inhibitor
what is the MOA of aspirin?
Irreversible inactivation (via acetylation) of cyclo-oxygenase (COX1)- inhibits synthesis of thromboxane A2 – prevents platelet aggregation & vasoconstriction by thromboxane A2
what is the indication for aspirin?
secondary prophylaxsis
especially with MI, CVA
what person of people experience gastritis with aspirin?
30%!!
what are the two contraindications for asprin?
nasal polyps
bronchospasm
what should you not take ASA with (2)
NSAIDS
other anticoagulants
what is one thing you want to monitor for a pt taking ASA?
melena
what do higher doses of ASA more than 325 mg do?
inhibit PGI2 (inhibits platelet aggreagation in vivo
what is the drug class for clopidigrel?
platelet ADP inhibitor
what is the indication for clopidigrel? (4)
secondary prevention
AMI
CVA
PAD
what is the MOA of clopidigrel?
irreversibly blocks ADP receptor on platelets preventing platelet/fibrinogen binding and platelet aggregation
what are the 3 negative effects experienced by those who take clopidigrel?
27% experience gastritis
abdominal pain
thrombocytopenia
what are the 4 drug interactions that interact with clopidigrel?
- antiplatelet/anticoagulant (increase)
- atorvastatin (decrease)
- macrolides abx (decrease)
- ginko biloba (increase)
Is clopidigrel used for ASA allergy?
why yes, yes it is
what is the dosing for clopidigrel?
300 mg loading, 75 maitenance
what are the three drugs in the Diuretics: Loop diuretics
- Furosemide
- Torsemide
- Ethacrynic Acid
MOA of Furosemide
Inhibits NA+, K+, Cl2, symporter in TAL of loop and distal tubule
Indications of Furosemide
Edema 2nd to CHF, kidney, liver failure
HTN
SE of Furosemide and Ethacrynic Acid (6)
- hypotension
- dehydration
- hyperglycemia
- increased then decreased uric acid
- electrolyte abnormalities
- jaundice
Contraindications of Furosemide
Hypersensitive to sulfa
DX-DX interactions of Furosemide
- Increases impact of anti-HTN meds and lithium
2. corticosteroids increase furosemide impact
what is the outpatient target with Furosemide
outpatient target 2lbs body weight loss/day to get to dry weight, then down titrate
MOA of Torsemide
Inhibits NA+, K+, Cl2, symporter in TAL of loop and distal tubule
Indications of Torsemide
Edema of cardia, renal and hepatic failure
HTN
SE of Torsemide
- Constipation
2. diarrhea
Contraindications of Torsemide
anuria
sulfa sensitivity
Dx-Dx interactions of Torsemide
Other K+ wasting drugs
2 things to monitor with Torsemide
k+
eGFR
how much Torsemide is equal to Furosemide
10-20mg Torsemide about equal to Furosemide 40mg
MOA of Ethacrynic Acid
Inhibits NA+, K+, Cl2, symporter in TAL of loop and distal tubule
indications of Ethacrynic Acid
Edema 2nd to CHF, kidney, liver failure
contraindications of Ethacrynic Acid and Dx-Dx interactions (2)
Contraindications: H/o of severe watery diarrhea with ethacrynic acid
Dx-Dx:
- Increase anti-HTN impact
- corticosteroids increase diuretic impact
what about outpatient target
outpatient target 2lbs body weight loss/day to get to dry weight, then down titrate
what are the 2 Diuretics: aldosterone Antagonists
- Spironolactone
2. Eplerenone
MOA of Spironolactone
Inhibit Na reabsorption by distributing the aldosterone-dependent NA+/K+ pump
Indications of Spironolactone
- Excessive aldosterone excretion or HF
- HTN
- hypokalema
- liver cirrhosis with edema or ascites
SE of Spironolactone
SJS
gynecomastia
amenorrhea
contraindications of Spironolactone
Addisons dx
K+>5.5
eGRF
monitoring Spironolactone
K+
what does K+ need to be below for Spironolactone
K+ needs to be below 5.5 in order to initiate
MOA of Eplerenone
- -> more specific aldosterone receptor antagonist in kidney, heart, blood vessels, brain
- -> reduces vascular and cardiac fibrosis
Indications of Eplerenone
- excessive aldosterone excretion
- heart failure
- HTN
- hypokalema
- liver cirrhosis with edema or ascites
Dx-Dx of Eplerenone
- K+ >5.5 (K must be below 5.5 to start)
2. eGFR
monitor with Eplerenone
K+
referring to Eplerenone
- what is it less likely to cause
- when do you reduce dose
- what to be cautious with?
less likely to cause gynecomastia
reduce dose for renal, hepatic insufficiency
caution in DM (hyperkalemia risk)
3 Vasodilators: ACE inhibitors
- Captopril
- Lisinopril
- Fosinopril
ok- so these are all the same so the next cards are for all three together
MOA of Vasodilators: ACE inhibitors
Competitive inhibitor of ACE preventing angiotensin I conversion to angiotensin II decreasing vasoconstriction by angiotensin II and decreases aldosterone secretion
Indications of Vasodilators: ACE inhibitors (4)
- HTN
- HF
- left ventricular dysfunction after MI
- DM neuropathy
SE of Vasodilators: ACE inhibitors (3)
cough
hyperkalmia
angioedema
Contraindications of Vasodilators: ACE inhibitors (3)
- Hx angioedema
- concurrent use of Aliskerin in DM patients
- bilat renal artery stenosis
Dx-Dx of Vasodilators: ACE inhibitors
don’t use with ARB’s, aliskerin
Pregnancy category of Vasodilators: ACE inhibitors
PG. D
TERTOGEN
AHHHH!
what do you watch for during first time dose of Vasodilators: ACE inhibitors
watch for first dose hypotension
Drug class of Losartan
Vasodilators:
Angiotensin 2 Receptor Blockers
ARB
MOA of Losartan
Selectively and competitively blocks AT1 and AT2 receptors
indication of Losartan
- HTN
- DM neuropathy
- stroke
- LVH
SE of Losartan
- hyperkalemia
- especially in people with T2DM:
- ->chest pain
- ->fatigue
- ->hypogycema
- ->diarrhea
- ->UTI
dx-dx interactions of Losartan
Aliskerin
ACEI
what increases with Losartan
incr excretion of uric acid
which drug is a Direct-Acting Vasodilators
Hydralazine
+
Isosorbide Dinitrate
MOA of
Hydralazine
+
Isosorbide Dinitrate
Direct-acting arteriolar vasodilators
Indication of
Hydralazine
+
Isosorbide Dinitrate
adjunct in HF esp. afro-americans
SE of
Hydralazine
+
Isosorbide Dinitrate
- Angina
- orthostatic htn
- SLE-like syndrome
contraindications of
Hydralazine
+
Isosorbide Dinitrate
Mitral valve rheumatic heart disease
Which drug is a
Positive Inotropic Agents:
Cardiac Glycoside
Digoxin
MOA of Digoxin
- Inhibits Na/K ATPase pump in myocardial cells promoting influx Ca++ leading to increased contractility
- direct suppressor of AV node decr ventricular rate
indications of Digoxin
Afib rate control
SE of Digoxin
- incomplete heart block may proceed to complete block
- digoxin toxicity
- SSS
Contraindications of Digoxin
- -> V-fib
- -> co-existing thyroid d/o
- -> recent MI
what is a list to remember in Digioxin and what kinda of effect is important to remember
BEERS list: cautious use in elderly
proarryhthmic effect
What drug is under the drug class
Positive Inotropic Agents:
B-agonists
Dobutamine
MOA of Dobutamine
Stimulates B1 adrenergic receptors increasing cardiac contractility and HR
little impact on B2 or alpha receptors
Indications of Dobutamine
Short-term management of cardiac decompensation
SE of Dobutamine
incr HR
paradoxical hypotension
exacerbation of ventricular ectopy
contraindications of Dobutamine
- allergy to sulfites
2. recent MAOI
Which drug is under the class
Positive Inotropic Agents:
Phosphosdiesterase
Inhibitors
Milrinone
MOA of Milrinone
Selective PDE inhibitor in cardiac and vascular tissue producing vasodilation and inotropic effects with little chronotropic activity
indications of Milrinone
Short-term IV therapy of acutely
contraindications of Milrinone
- -> AMI
- -> severe obstructive or pulmonic valvular disease
Drug class of Nesiritide
Miscellaneous:
Recombinant BNP
MOA of Nesiritide
Increases intracellular GMP in vascular smooth muscle cells and endothelium resulting in smooth muscle relaxation reducing pulmonary capillary wedge pressure (PCWP) and systemic arterial pressure
indication of Nesiritide
acutely decompensated HF with dyspnea at rest or with minimal activity
SE of Nesiritide
- -> Increase creatinine
- -> arryhthmias
contraindications of Nesiritide
cardiogenic shock
hypotension (SBP
drug class of Aliskiren
Miscellaneous:
Direct Renin Inhibitor
MOA of Aliskiren
Direct renin inhibitor preventing conversion of angiotensinogen to angiotensin I which reduces conversion to angiotensin II producing arteriolar vasodilation
indication of Aliskiren
HTN
Contraindications of Aliskiren
itraconazole
Dx-Dx interactions of Aliskiren (2)
- decr effect of furosemide
2. NSAIDs decr effect of Aliskerin
what do you not take with Aliskiren!!!!!
Not with grapefruit juice!
which drug just has the drug class Miscellaneous
Ivabradine
MOA of Ivabradine
Selective and specific inhibition of If SA node and prolonging diastolic depolarization and reducing HR
indications of Ivabradine
Stable HF with EF70 and who are on max tolerated doses of B-blocker or unable to take B-blocker
indications of Ivabradine (3)
- afib
- heart block
- phosphene
SE of Ivabradine
- SSS
- BP
“other category” Ivabradine
and what to avoid
Retinal Ih (similar to If) channel partial inhibition may account for phosphene
avoid grapefruit juice
