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CPR Exam 1 > Drugs for IHD > Flashcards

Drugs for IHD Flashcards

1
Q

IHD is characterized by what

A

partial occlusion of the coronary artery

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2
Q

What is classic angina?

A

=angina of effort/stable angina

CP during stress or exertion, caused by occlusion of coronary artery d.t a athersclerotic plaque.

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3
Q

What is variant (prinzmetal) angina?

How do we get it

A

CP d.t episodes of vasoconstriction of coronary arteries that occur when resting, often genetically inherited.

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4
Q

What type of angina is the most common?

A

Classic angina/stable angina

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5
Q

Angina is caused by imbalance of what?

A

Oxygen demand of the heart and oxygen supply via the coronary arteries

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6
Q

When do we experience CP in angina?

A

When the demand of the heart is GREATER than what can be supplied.

HEART is THIRTSTTTTYYY for blood.

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7
Q

Our heart wants blood, but our coronary arteries are having a heart time suppling it, causing our heart to hurt => angina.

What are two ways to solve this problem?

A
  • 1. Decrease cardiac work => decrease myocardial O2 demand
  • 2. Increase blood flow via CA
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8
Q

Name the 4 nonsurgical/surgical approaches to increasing blood to the heart?

A
    1. CABG
    1. PTCA (percutaneous transluminal coronary angioplasty)
    1. Atherectomy: catheter with a sharp blade removes plaque
    1. Stent
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9
Q

What is the problem with atherectomy?

A

Risk of reocclusion

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10
Q

What type of stent is preffered?

A

Drug eluting stent: stent that is covered with an antiproliferative medication, to prevent blockage in the future.

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11
Q

Vasodilators can be use to increase coronary blood flow and treat what kind of angina?

A

Variant (Prinzmetal angina) => relieves vasospasm => increases flood flow to the area.

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12
Q

Vasodilators shoud NOT be used for what types of angina?

A
  1. Classic angina (athersclerotic angina)
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13
Q

Vasodilators should not be used for classic angina. Why?

A
  • Coronary steal phenomenon
  • Vasodilators will dilate normal BV.
  • BV with plaques, are, however, already maximally dilated. Thus, during excercise, vasodilators will SHUNT the little amount of blood passing the [plaque => ischemic tissue], and redirect it to the normal BV, which now is sending more blood than needed to NL tissue, which the ischemic tissue is getting even less.
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14
Q

Which vasodilator can cause coronary steal syndrome

A

Dipyramidole

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15
Q

What determines how much oxygen our heart needs?

A
  • 1. HR
  • 2. Contractility
  • 3. Preload
  • 4. Afterload
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16
Q

What causes the production of endogenous NO?

A

ACh, Bradykinin, Substance P or mechanical stress on the endothelial cell => makes NO => acts on smooth muscle by + GC (Guanylyl cyclase) => vasodilation

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17
Q

Describe the role of organic nitrates (nitroglycerin) in maintaining vascular tone?

A
  • Organic nitrate is metabolically activated by thiol (ADH2) => NO activates GC (guanylyl cyclase) in vascular smooth muscle–> ↑ cGMP –> ↑ PKG (protein kinase G), which does 2 things:
  • Dephosphoylates Myosin-LC –> smooth m. relaxation
  • Open K+ channel => hyperpolarization and decreased Ca+ influx
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18
Q

Pharmacokinetics of Nitrovasodilators

First Pass Metabolism (amount of drug that reaches systemic circulation d/t some lost during absorption by gut wall and liver):

Administration:

A
  • First Pass Metabolism: Significant, d/t high amount of nitrate reductase in the liver
  • Administration: Sublingual, buccal or transdermal bc oral route decreases bioavailablity, thus, given though other mechanisms
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19
Q

Which nitrate is a poor substrate of nitrate reductase in the liver and therefore has higher bioavailability?

A

Isosorbide mononitrate

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20
Q

What is the crucial for the activation of nitrates to release NO?

A

Reduce VIA thiol (ADH2) => releases NO from nitrates

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21
Q

Which vessels are most sensitive => least sensitive to Nitrates?

A

Nitrates dilates vein and large artries BEST

Veins > large arteries > Small arteries and arteroles

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22
Q

What is the major effect of nitrates?

A

Relaxes vascular smooth muscle by:

  • Dilates veins**:
    • increases venous capitance
    • reduces pre-load => decreases O2 demand
    • => treats stable angina
  • With higher concentrations, dilates coronary arteries:
    • reduces afterload
    • stops spasm
    • => treats variange angina
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23
Q

Nitrous oxide has effects beyond just vasodilation, describe some of the inhibitory effects.

A
    1. Inhibits platelet aggregation
    1. Does not cause coronary steal phenomenon
24
Q

Major overall effect of nitrates is a decrease in?

A

Myocardial O2 demand

25
The development of **tolerance** to **Nitrates** is associated with what 4 events?
* 1. **Deplete thiol compounds,** needed to metabolize NO * 2. I**ncreased generation of superoxide radicas (O2-)**, which reacts with NO to make **H2O2**, depling NO. * 3. Reflex **activation of sympathetic NS** (=\> tachycardia and decrease coronary BS) * 4. **Hold in Na+ and water**
26
The development of tolerance to Nitrates is associated with what 4 events?
27
Increased amount of **superoxide radical** depletes tissues of what?
**NO**
28
**Nitrates** can come in short-acting formulants and long-acting formulants. What are the **short acting nitrate**s, ROA, and what are they used for?
**Short acting nitrate**s are used to **relieve angina attack** * 1. **Nitroglycerin** (**sublingual** or **spray**) * 2. **Isosorbide dinitrate** (**sublingual** or **spray**)
29
**Nitrates** can come in short-acting formulants and long-acting formulants. What are the **long acting nitrates,** ROA, and what are they used for?
* **Long-acting nitrates** are used to **PREVENT attacks** * **​1. Nitroglycerin (oral, ointment or a patch)** * **2. Isosorbide dinitrate (oral)** * **3. Isosorbid mononitrate (oral)**
30
What are **4 adverse effects** associated with **Nitrates**?
* 1. **HA** * 2. **Orthostatic hypotension** (BP falls when standing up) * 3. **Increased sympathetic activation** (tachycardia and increased contractility) * 4. In**creased renal Na+ and water reabsorption**
31
Why are **nitrates** **contraindicated if ICP** is elevated?
**Meningeal vessel**s can **DILATE**
32
**Nitrate drugs s**hould not be taken with what?
Drugs for **ED**: 1. **Sildenafil,** 2. **Vardenafil** 3. **Tadalafil**
33
Why **not** to take **nitrate drugs** with **drugs for ED**
ED drugs inhibit PDE-5 =\> i**ncrease cGM**P =\> 1. Dramatic d**rop in BP** 2. Can cause **MI**
34
What are the **3 non-cardioactive (dihydropyridines) calcium channel blockers** used in **angina**?
1) Amlo**dipine** 2) Nife**dipine** 3) Nicar**dipine**
35
What are the **2 cardioactive calcium channel blockers** used in angina?
* **1. Diltiazem** * **2. Verapamil**
36
MOA: **dihydropyridine calcium-channel blockers**
Act mainly on **peripheral vasculature** and indirectly **cause the heart not to work as hard :)** * 1. **Dilate peripheral arterioles** * 2. **Decrease PVR** =\> **decrease afterload** =\> **decrease BP**
37
**CCB** can t**reat both athersclerotic angina and variant angina**. How?
1. Treats **atherosclerotic angina** by **decreasing O2 demand​** 1. **​Dihydropyrimidines (amlodipine, nifedipine and nicardipine)** =\> dilating peripheral ***_arterilioles_*** =\> decrease PVR =\> decrease afterload =\> decrease BP 2. Cardioreactive CCBs (verapimil and cardioreactive CCBs) decrease contractility and HR 2. Treates **variant angina** by i**ncrease blood supply** 1. Dilates coronary arteries =\> relieves local spasm
38
Which **non-cardioactive (dihydropyridine) i**s the **longest-acting?**
**AMLODIPINE** (30-50 hours)
39
Which **non-cardioactive (dihydropyridine**) is the **shortest acting?**
**1. Nifedipine (4 hrs)** **2. Nicardipine (2-4 hours)**
40
Which group of **CCB's** are **more potent vasodilators**?
**Non-cardioactive (dihydropyridines)**
41
Why is there l**ess orthostatic hypotension** as an AE when using **CCB's** for angina?
* **_Dihydropyridines CCBs affect arterioles more_** * Nitrates affect veins more.
42
Which CCB's lead to **↓ cardiac contractility** and **HR**?
* **Cardioactive CCB's (diltiazem and verapamil)**
43
Which CCB causes the greatest **↓ cardiac contractility, ↓ SA and AV node conduction?**
**Verapamil**
44
What are the major AE's associated with **cardioactive CCB's?**
**1. Cardiac depression/arrest, acute HF** **2. AV block and bradyarrythmia**
45
Adverse effects associated with the **short-acting dihydropyridine CCB's?**
Vasodilation **=\> Reflex sympathetic activation**
46
**Nifedipine (immediate release) in** should be used with caution in what patients? Should use what type of dihydropyridine instead?
* Pts with **HTN** =\> increase risk of **MI** * **Slow-release** or **long-acting dihydropyridine** are better tolerated.
47
What are the **4 beta-blockers** indicated in tx of angina?
1. Metaprolol 2. Nadolol 3. Atenool 4. Propanol **mNAP**
48
MOA of **B-Blockers** in treating **Angina**
**_Decrease myocardial O2 demand by_** 1. **Decrease HR** =\> increase perfusion and the heart will need less o2 at rest and during XRCISE 2. **Decrease contractilit**y 3. **Decrease BP** =\> decrease afterload
49
What are 5 AE's associated with **beta-blockers?**
1. -**↓ CO** 2. - **Bronchoconstriction** 3. **- Impaired liver glucose mobilization** 4. - **(↓ HDL and ↑ VLDL)** 5. - **Sedation**, **depression**
50
Which drugs cause **withdrawal sx?** **Why?**
* **B-blockers** * **Sympathetic hyperrresponsiveness**
51
**CI** of **B-Blockers?**
**1. Asthma** **2. Bradycardia** **3. AV block** **4. Peripheral vascular dise** **5. Type 1 DB on insilin**
52
**B-Blockers** should be taken with what drugs?
**Nitrates**
53
Why should **B-Blockers** should be taken with what **Nitrates?**
* 1. Nitrates have reflex increase in **HR**: BB decrease * 2. Nitrates decrease **EDV**: BB increase * 3. Nitrates have reflex increase in **contractility**: BB have decrease * 4. Nitrates have decrease **ejection time**: BB have increase
54
How do we treat v**ariant angina**? Mangement is focused on \_\_\_\_\_\_
* **1. Prevent episodes** * 2. First drug of choice: **CCB** or, if contraindicated, **LA-nitrate**
55
How do we treat **stable (atherosclerotic) angina?**
1. Lower lipids, modify lifestyle, immediate release nitrates, antiplate therapy (aspirin) 2. BB or al
56
**ALL OF THE FOLLOWING DRUGS MAY CAUSE ANGINA ATTACKS EXCEPT** A. ISOPROTERENOL B. EPHEDRINE C. PILOCARPINE D. ATROPINE E. PHENTOLAMINE
ASK; WILL IT INCREASE OXYGEN DEMAND VIA ONE OF THE 4 MECHANISMS.

CPR Exam 1 (19 decks)

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