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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
Q

The development of tolerance to Nitrates is associated with what 4 events?

A
    1. Deplete thiol compounds, needed to metabolize NO
    1. Increased generation of superoxide radicas (O2-), which reacts with NO to make H2O2, depling NO.
    1. Reflex activation of sympathetic NS (=> tachycardia and decrease coronary BS)
    1. Hold in Na+ and water
26
Q

The development of tolerance to Nitrates is associated with what 4 events?

A
27
Q

Increased amount of superoxide radical depletes tissues of what?

A

NO

28
Q

Nitrates can come in short-acting formulants and long-acting formulants.

What are the short acting nitrates, ROA, and what are they used for?

A

Short acting nitrates are used to relieve angina attack

    1. Nitroglycerin (sublingual or spray)
    1. Isosorbide dinitrate (sublingual or spray)
29
Q

Nitrates can come in short-acting formulants and long-acting formulants.

What are the long acting nitrates, ROA, and what are they used for?

A
  • Long-acting nitrates are used to PREVENT attacks
    • ​1. Nitroglycerin (oral, ointment or a patch)
    • 2. Isosorbide dinitrate (oral)
    • 3. Isosorbid mononitrate (oral)
30
Q

What are 4 adverse effects associated with Nitrates?

A
    1. HA
    1. Orthostatic hypotension (BP falls when standing up)
    1. Increased sympathetic activation (tachycardia and increased contractility)
    1. Increased renal Na+ and water reabsorption
31
Q

Why are nitrates contraindicated if ICP is elevated?

A

Meningeal vessels can DILATE

32
Q

Nitrate drugs should not be taken with what?

A

Drugs for ED:

  1. Sildenafil,
  2. Vardenafil
  3. Tadalafil
33
Q

Why not to take nitrate drugs with drugs for ED

A

ED drugs inhibit PDE-5 => increase cGMP =>

  1. Dramatic drop in BP
  2. Can cause MI
34
Q

What are the 3 non-cardioactive (dihydropyridines) calcium channel blockers used in angina?

A

1) Amlodipine
2) Nifedipine
3) Nicardipine

35
Q

What are the 2 cardioactive calcium channel blockers used in angina?

A
  • 1. Diltiazem
  • 2. Verapamil
36
Q

MOA: dihydropyridine calcium-channel blockers

A

Act mainly on peripheral vasculature and indirectly cause the heart not to work as hard :)

    1. Dilate peripheral arterioles
    1. Decrease PVR => decrease afterload => decrease BP
37
Q

CCB can treat both athersclerotic angina and variant angina. How?

A
  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 increase blood supply
    1. Dilates coronary arteries => relieves local spasm
38
Q

Which non-cardioactive (dihydropyridine) is the longest-acting?

A

AMLODIPINE (30-50 hours)

39
Q

Which non-cardioactive (dihydropyridine) is the shortest acting?

A

1. Nifedipine (4 hrs)

2. Nicardipine (2-4 hours)

40
Q

Which group of CCB’s are more potent vasodilators?

A

Non-cardioactive (dihydropyridines)

41
Q

Why is there less orthostatic hypotension as an AE when using CCB’s for angina?

A
  • Dihydropyridines CCBs affect arterioles more
  • Nitrates affect veins more.
42
Q

Which CCB’s lead to ↓ cardiac contractility and HR?

A
  • Cardioactive CCB’s (diltiazem and verapamil)
43
Q

Which CCB causes the greatest ↓ cardiac contractility, ↓ SA and AV node conduction?

A

Verapamil

44
Q

What are the major AE’s associated with cardioactive CCB’s?

A

1. Cardiac depression/arrest, acute HF

2. AV block and bradyarrythmia

45
Q

Adverse effects associated with the short-acting dihydropyridine CCB’s?

A

Vasodilation => Reflex sympathetic activation

46
Q

Nifedipine (immediate release) in should be used with caution in what patients?

Should use what type of dihydropyridine instead?

A
  • Pts with HTN => increase risk of MI
  • Slow-release or long-acting dihydropyridine are better tolerated.
47
Q

What are the 4 beta-blockers indicated in tx of angina?

A
  1. Metaprolol
  2. Nadolol
  3. Atenool
  4. Propanol

mNAP

48
Q

MOA of B-Blockers in treating Angina

A

Decrease myocardial O2 demand by

  1. Decrease HR => increase perfusion and the heart will need less o2 at rest and during XRCISE
  2. Decrease contractility
  3. Decrease BP => decrease afterload
49
Q

What are 5 AE’s associated with beta-blockers?

A
  1. -↓ CO
    • Bronchoconstriction
  3. - Impaired liver glucose mobilization
    • (↓ HDL and ↑ VLDL)
    • Sedation, depression
50
Q

Which drugs cause withdrawal sx?

Why?

A
  • B-blockers
  • Sympathetic hyperrresponsiveness
51
Q

CI of B-Blockers?

A

1. Asthma

2. Bradycardia

3. AV block

4. Peripheral vascular dise

5. Type 1 DB on insilin

52
Q

B-Blockers should be taken with what drugs?

A

Nitrates

53
Q

Why should B-Blockers should be taken with what Nitrates?

A
    1. Nitrates have reflex increase in HR: BB decrease
    1. Nitrates decrease EDV: BB increase
    1. Nitrates have reflex increase in contractility: BB have decrease
    1. Nitrates have decrease ejection time: BB have increase
54
Q

How do we treat variant angina?

Mangement is focused on ______

A
  • 1. Prevent episodes
    1. First drug of choice: CCB or, if contraindicated, LA-nitrate
55
Q

How do we treat stable (atherosclerotic) angina?

A
  1. Lower lipids, modify lifestyle, immediate release nitrates, antiplate therapy (aspirin)
  2. BB or al
56
Q

ALL OF THE FOLLOWING DRUGS MAY CAUSE ANGINA ATTACKS EXCEPT

A. ISOPROTERENOL

B. EPHEDRINE

C. PILOCARPINE

D. ATROPINE

E. PHENTOLAMINE

A

ASK; WILL IT INCREASE OXYGEN DEMAND VIA ONE OF THE 4 MECHANISMS.

CPR Exam 1 (19 decks)

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