CV2 pharm lectures Flashcards
what are the systolic and diastolic readings for normal BP?
stystolic: 120/80
what are the systolic and diastolic readings for prehypertension?
systolic 120-140
diastolic: 80-90
what are the systolic and diastolic readings for HTN stage 1?
systolic 140-160
diastolic: 90-100
what are the systolic and diastolic readings for HTN stage II?
systolic: >160
diastolic: >100
what are the systolic and diastolic readings for isolated SYSTOLIC HTN?
systolic >140
diastolic
what are the systolic and diastolic readings for isolated DIASTOLIC HTN?
systolic 90
what are the systolic and diastolic readings for mixed HTN?
systolic >140
diastolic >90
most common
what is the biggest predictor of cardiovascular risk?
in patients
greatest predictor is HTN!!
if
what is felt to be the most accurate gage of measurement for BP when dx someone with HTN?
home BP measurements
ambulatory BP measurements
new wave of thinking that these more accurately reflect their actual BP than the one you take in the office
if someone is measuring their home BP, what are the three ways doing these measurements they could qualify for HTN?
- 24 average BP of 130/80 (aka add them all up and average)
- awake average BP of 135/85
- asleep average BP of 120/70
what is considered a HTN EMERGENCY? (this is difference than urgency)
a diastolic BP >120 with end organ damage (aka CKD, retinopathy, LVH)
what is considered HTN URGENCY?
a diastolic BP>120 WITHOUT end organ damage and asymptomatic
at what systolic BP should you treat a patient under 60?
140 mmHg systolic
at what systolic BP should you treat a patient over 60?
150 mmHG systolic
despite the age rules for tx of systolic HTN…..what what are the two rules that override this and indicate treatment for a patient?
- DBP>90 mmHg AFTER trial lifestyle modifications
2. BP of 160/100 or higher START THESE PTS ON 2 DRUGS at the SAME time
if a ELDERLY patient has a BP of over 160/100 what are the treatment recommendations? what are you trying to prevent?
START ON TWO DRUGS, just like you would for a non elderly patient
for elderly: need to decrease the doses of both drugs and uptitrate them slowly….trying to prevent against ACUTE HYPOTENSION!!
what are the four clinical pearls to keep in mind about diuretics when treating HTN?
- low Na diet, high K diet (this is what you want to pt to have)
- start with a low dose and titrate up
- watch for K+ depletion and HYPOvolemia
- DOC for mild to moderate HTN
what is the DOC for mild to moderate HTN?
dieuretics
what are the two most common diuretics used to treat HTN? what is the relationship between the two?
DOC1: thiazide HCTZ
DOC 2: thiazide like: Cholthalidone
typically start with HCTZ, if it doesn’t work, switch to Cholthalidone because it is twice as potent as HCTZ
what do you need to keep in mind about the thiazide (HCTZ) and thiazide like diuretics (chlorthalidone) drugs?
going beyond their maximum dose doesn’t increase the effectiveness
how many times stronger is chlorthalidone than HCTZ?
twice as strong!!
what is a K sparing diuretic Triamtrene used for HTN? do you use this alone to treat HTN?
in conjunction with a thiazide
too weak to use on its own
do you typically use loop diuretics to treat HTN? why?
not as much anymore because they aren’t good to use long term
they also INTERACT WITH OTHER ANTI HTN MEDS…so not a good thing if you are trying to treat a pt with HTN. better to start with thiazide or thiazide like diuretic!!
do you typically use BB to treat HTN?
not as much now unless the pt has had a MI….
….ACE, ARB, and even CCB are more effective, so we like to use these first unless the pt has had a MI
although we don’t use BB as much for HTN, what added benefit does Carvedilol have in regards to Tx of HTN?
also blocks NE so it has an additive effect of lowering BP
what are the 3 effects that BB have on the heart?
lower HR
lower SV
lower systemic vascular resistance by decreasing renin/angiotensin II
what are 3 clinical pearls to keep in mind about BB?
- caution in patients with pulmonary disorder
- cardio protective in post MI pts
- many uses including anxiety, headache, PTSD, panic disorders
what is the MOA of ACE inhibitors?
prevent the conversion of angiotensin I to angiotensin II by inhibiting the angiotensin converting enzyme
what are the 3 effects the ACE inhibitors have on the body?
- decrease arteriolar resistance
- increase venous capacity
- increase cardiac output
what do you need to monitor particularly close when a patient is taking ACE inhibitor? (2 things)
creatine levels
K levels, can cause HYPERkalemia and K retention!
what patients do you want to consult their nephrologist before prescribing an ACE inhibitor?
pts on hemodyalysis
what SE is contraindicated to take a ACE inhibitor?
angioedema, this can be life threatening so if it i happened once on an ACE inhibitor you should’ have it again
what is the name of the angiotensin receptor blocker drug used for HTN?
losartan
prevents angiotensin from binding to SM
what is the name of the direct renin inhibiting drug used for HTN?
aliskren
of the CCB which one has a short halflife and can cause hypotension so it isn’t used as much?
Nifedipine
what calcium channel blocker can cause a positive ANA and COOMBS test?
nifedipine
explain the properties of dihydropyridines in respect to their ability to cause vasodilation and contractility/conduction?
they are POTENT vasodilators
they have little to no effect on contractility or conduction
explain the properties of nondihydropyridines in respect to their ability to cause vasodilation and contractility/conduction?
less potent vasodilators
they have a greater DEPRESSIVE effect on contractilitiy and conduction
think about it, this is why they are used for arrhythmia*
should you use grapefruit juice with CCBs?
absolutely not!!
it effects CYP34A and can cause the CCB concentration to INCREASE!! making the effects more than you want!
why do you need to education patients about dental care when taking verapamil?
because it can cause gingival hyperplasia, so you want to include dental education
which drugs do you NOT want to use in HEART FAILURE?
don’t use the nondihydropyridines
- verapamil
- diltiazem
what are two strange SE of the direct acting vasodilator hydralazine?
- can cause LUPUS esp in WHITE PEOPLE
2. increase growth of hair
when is hydralazine used in an emergency?
DOC for HTN emergency in pregnant women usually due to PREECLAMPSIA or PREEXISTING HTN
what is the name of the drug that is a alpha blocker?
prazosin
what is the MOA of prazosin?
selective alpha 1 blocker that relaxes smooth muscle in arteries, veins, and prostate
what do you NOT want to take with the alpha 1 blocker prazosin?
PDE5 inhibitor like viagra
can cause dangerous hypotension
what is another use of the alpha 1 blocker prazosin and why?
used for benign prostatic hypertrophy since alpha 1 receptors are found here
what is an interesting thing that prazosin can cause in the eye?
FLOPPY IRIS SYNDROME
worry about this if pt is going to get lense replacement
what is the name of the two central acting alpha 2 agonists? where do they act and what do they decrease the release of?
clonidine
methyldopa
these act in the brain/CNS and decrease the release of NE
what are the 3 SE of clonidine and methyldopa you should be aware of?
- rebound HTN
- depression and mood alteration
- H2O retention
what is clonidine is often included as a part of what protocol?
ETOH detox protocols
what are the three indications for clonidine?
- hypertension
- ADHD
- narcotic addiction
what are two major contraindications for clonidine?
pre-existing CNS depression
SEVERE CAD
what are the 6 HMG-COA reductase inhibitors?
atorvastatin lovastatin pravastatin rosuvastatin simvastatin fluvastatin
what are the two strongest HMG-COA reductase inhibitors?
strongest: atorvastatin
2nd strongest: rosuvastin
how to HMG-COA reductase inhibitors decrease lipid panel?
decrease LDL, Triglycerides
Increase HDL
what is the best drug to decrease the combo of LDL/Tri?
ATORVASTATIN
when should you take atorvastatin?
at night!
what are the two bile sequestrian drugs?
cholestyramine
colestrevelam
how is the lipid panel effected by bile acid sequestriants?
decrease LDL
may increase tri
what are the two fibric acids?
gemfibrazil
fenofibrate
how do fibric acids effect the lipid panel?
decrease TRI
increase HDL
what is the drug under the nicotinic acid?
niacin
what does niacin do to the lipid panel?
decrease TRI with minimal LDL lowering
increase HDL
what is the cholesterol absorption inhibitor? and what dose it lower?
exetimibe lowers LDL
what does the omega fatty acid 3 increase and decrease?
increases LDL
decreases TRI
what does the PCSK9 inhibitor do? what does it lower?
increases functioning of the LDL receptors in the liver
decreases LDL
when does the most cholesterol synthesis take place? w
at night
why is it suggested that you take atorvastatin at night?
because this is when the most lipid synthesis occurs!
for primary prevention….what are the qualifications for high intensity statin therapy?
LDL >190 AND family history
for primary prevention…what are the qualifications for moderate intensitiy statin therapy? what is the exception that would pump this pt up to high intensity therapy?
LDL 70-190 AND diabetes AND 40-70 years old
EXCEPTION: if a patient has this AND 10 year risk >7.5% then bump them up to high intensity
what is the over arching rule for mod to high intensity therapy with statins?
10 year global risk score >7.5% and 40-70 years old!!
what is secondary hyperlipidemia prevention?
when you give someone a statin because they have hyperlipidemia and history of heart disease….trying to prevent progression
in someone with hx of heart disease and hyperlipidemia what intensity statin do you use?
what is the one exception to this?
high intensity statin
exception: if 75 and older drop down to moderate dose
what is the rule of 6 that you see with atorvastatin?
as you increase the dose you get decreased lipid reduction….lowest dose is most effective
how much do you expect high intensity statin to reduce LDL by?
50%
what is the dosing of atorvastatin and rousuvastatin that are considered high dose statin therapy?
atrovastatin high intensity: 40-80 mg
rousuvastatin high intensity: 20-40 mg
how much do you expect a moderate intensity statin to decrease LDL by?
30-40%
this is accomplished by all statins in lower doses
what are the two statins you use as high intensity statins?
atorvastatin and rousuvastatin
what are two of the most important SE of atorvastatin?
myopathy and rhabdomyolysis
what drug do you not want to use with atorvastatin?
dabigitran
what do you need to monitor when taking atorvastatin?
CK
can you drink grapefruit juice with any of the statins? what is the one exception?
NOPE CYP450/CYP34A baby
one exception: pravastatin
what do you need to be concious in when giving lovastatin?
don’t use it in those with EGFR
what is the only statin that is NOT METABOLIZED BY CYP34A?
pravastatin
what does long term use of bile sequestriants cholestyramine and colesevelam cuase?
decreased folate absorption
what is one random and beneficial SE of the bile sequestriant colesevelam?
modestly lowers BS in T2DM
what is the most effective triglyceride lowering agent?
fibrinic acid!!!! (Gemfibrazil and fenofibrate)
what do you need to be particulally mindful of for medicationswhen prescribing a fibrinic acid like gemfibrazil and fenofibrate in a patient? (2)
don’t combine with clopidigrel
also increases the effects of WARFARIN so may need to decrease the dose
fibrinic acids gemfibrazil and fenofibrate lower triglycerides what percent? how long does it take to accomplish this?
20-50%
3-4 weeks
what are the side effects you see with niacin (nicotininc acid B3) 3 of them!
itchying, flushing, blurred vision
what is important to consider prescribing to a patient who experiences flushing from niacin?
have them take ASA 30 mins before taking the med to prevent flushing!
what does niacin (nicotinic acid B3) increase in meds?
increase effects of HMG-CoA statins
who should you avoid using niacin in? 2
alcoholics, PVD
what does the cholesterol absorption inhibitor exetimibe interact with?
fibrates
what allergy are omega 3 contra indicated in?
fish allergy
what are three side effects of taking omega 3
change in taste, flu type illness, angina
what drugs do you not want to combine with omega 3?
anticoagulants
WHAT IS THE MAIN INDICATOR FOR THE NEW MONOCLONAL ANTIBODY PCSK9 INHIBITOR EVOLOCUMAB?
HOMOZYGOUS FAMILIA HYPERCHOLESTEROLEMIA
explain how evolocumab works?
human monoclonal antibody that binds to proptein convertase sk9 and inhibits the degredation of LDL receptors on the liver so that more can absorb the LDL to be degraded
how is evolocumab administered?
SQ
what are the three side effects of evolocumab?
nasopharyngitits, gastroenteritis, URI
what are the three drugs under the class 1 antiarrythmics?
1a: procainamide
1b: lidocaine
1c: flecainide
what is the 1a class 1 antiarrythmic? AP duration?
procainamide, prolongs AP duration
what is the 1b class 1 antiarrythmic? AP duration?
lidocaine, shorten AP duration
what is the 1c class 1 antiarrythmic? AP duration?
flecainide, no effect on AP
of the class 1 drugs which can cause QT prolongation and hypotension?
procainimide
which drug causes a METALIC taste and should not be used in bronchospasm?
lidocaine
which drug in class 1 has a significant proarrythmia effect?
flecainimide
what are the class II drugs made up of?
Beta blockers
what are three things you need to be concious of when using a beta blocker?
hypotension, masks hypoglycemia, bradycardia
what is the most frequently used antiarrythmic?
amiodarone
what do you need to be careful of when using amiodarone?
extreme pulmonary toxicity
what is the class 3 antiarrythmic?
amiodarone
what is the class 4 antiarrythmics consist of?
Nondihydropyridines Verapamil and diltiazem
which is the drug that is used in stress testing? why?
ADENOSINE
it increases the BF in normal arteries but not stenotic arteries so it makes the difference more noticeable
