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Drugs used in treating cardiovascular diseases Flashcards

1
Q

Common CV conditions requiring drug therapy

A

Hypertension
Ischaemic heart disease and other atheromatous diseases
Heart failure
Arrhythmia

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2
Q

Hypertension

A

Most cases asymptomatic and 95% cases are ‘essential’ hypertension e.g. no secondary cause
CV morbidity and mortality can be < significantly by BP reduction

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3
Q

How can CV morbidity and mortality be reduced?

A

by BP reduction

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4
Q

Early detection of hypertension allows

A

Most effective risk management and treatment of hypertension

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5
Q

End organ damage in hypertension

A

Brain
Heart
Kidney: renal failure
Eyes: hypertensive retinopathy

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6
Q

End organ damage in hypertension: brain

A

Thrombotic, thromboembolic and haemorrhagic stroke, multi-infarct dementia, hypertensive encephalopathy

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7
Q

End organ damage in hypertension: heart

A

LVH, LV failure, coronary artery disease

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8
Q

Major risk factors for cerebrovascular atherosclerosis

A 
Hypertension increases risk by x5-10
Smoking x2
Diabetes x2
Hyperlipidemia x1.5
Obesity x1.5
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9
Q

Prognosis of hypertension

A

Related to level of systolic and diastolic BPs
Related to age, sex and other risk factors such as hyperlipidaemia and diabetes
Worse if there is evidence of end-organ damage
Improved with antihypertensive therapy

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10
Q

Non-pharmalogical treatment of hypertension

A 
Weight reduction
< salt intake
< fat intake
< alcohol intake
Exercise
Smoking cessation
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11
Q

Common antihypertensive drugs

A 
Thiazide diuretics
ACE inhibitors 
Angiotensin II receptor antagonists
Beta blockers
Calcium channel blockers
Alpha blockers
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12
Q

Thiazide diuretics

A 
Inhibit reabsorption of NaCl in proximal and early distal tubules of nephron
Cheap and recommended for first line use
Bendroflumethiazide 
Metolazone
Thiazide-related compounds
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13
Q

Renin-angiotensin system

A

Learn diagram

Regulates salts and fluid?

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14
Q

ACE inhibitors mechanism

-example

A

Inhibit conversion of angiotensin I to angiotensin II

e.g. ramipril < MI, stroke, CV death

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15
Q

Angiotensin receptor blocker

A

Acts on AT-1 receptor

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16
Q

Sprionolactone

A

Acts on aldosterone

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17
Q

Angiotensin II receptor antagonists (ARBs)

A

Similar effects to ACE inhibitors but do not influence bradykinin degradation so do not cause dry cough

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18
Q

Examples of ARBs

A

Losartan, valsartan, candesartan, irbesartan

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19
Q

Beta blockers (beta-adrenoreceptor antagonists)

A

< heart rate, BP and cardiac output

Variable selectivity for cardiac beta 1 receptors (which mediate sympathetic action)

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20
Q

Side effects of beta blockers

A 
Fatigue
Hypotension
Cold peripheries
Bronchospasm
Impotence
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21
Q

Sympathetic and Parasympathetic action on heart and vessels

A

Symp > force and rate of heart contractions
-beta-1 receptors of heart mediate sympathetic action
-B-blockers can have adverse effects on vascular supply to the legs as sympathetic system increasing vasoconstriction in arterioles
Parasymp opposite

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22
Q

Calcium channel antagonists

A

Vasodilators - < systemic vascular tone

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23
Q

Main types of calcium channel antagonists

A 
Two main types:
Verapamil and diltiazem
-cause bradycardia, inhibit AV node conduction, negative inotropes
Amlopidine, larcanipidine ... dipine
-may cause a reflex tachycardia
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24
Q

Side effects of calcium channel antagonists

A 
Oedema
Flushing
Headache
Dizziness
Hypotension
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25
Alpha blockers and others
A variety of other vasodilators are used to treat hypertension: - alpha blockers: doxazosin, indoramin - hydralazine - methyldopa (can be used in pregnancy)
26
Alpha blockers and others: side effects
Hypotension Headache Tachycardia Oedema
27
Thiazide diuretics side effects
Side effects include electrolyte disturbance, rash and postural hypotension
28
Most commonly used thiazide diuretic
Bendroflumethiazide most commonly used thiazide
29
Thiazide diuretic used for severe congestive heart failure
Metolazone used in combination with loop diuretics
30
Thiazide related compounds
chlorthalidone, indapamide
31
Side effects of ACE inhibitors
Relatively infrequent side effects except for dry cough - hypotension - rash - hyperkalaemia - renal failure (especially in presence of renal artery stenosis) - angioedema - ageusia
32
Ischaemic heart disease
Atherosclerosis of coronary arteries may lead to stenosis and arterial thrombosis Spectrum of presentations from stable angina to acute coronary syndromes – unstable angina and myocardial infarction – to heart failure and sudden death
33
Progression of atherosclerosis to arterial thrombosis
Normal --> fatty streak --> (clinically silent) fibrous plaque --> athero-sclerotic plaque (can happen with age and can cause angina, transient ischemic attack and claudication/ PAD) --> plaque rupture/ fissure and thrombosis This can lead to MI/ ischemic stroke / critical leg ischemia/ CV death
34
Anti-anginal drugs
Beta blockers Nitrates Calcium channel blockers Potassium channel activators
35
Relative contraindications of beta-blockers
asthma, uncontrolled heart failure, bradycardia
36
Anti-anginal drugs: beta blockers
Lower myocardial oxygen demand by < HR, BP and myocardial contractility May exacerbate cardiac failure (need to be introduced slowly) and peripheral vascular disease (claudication), and cause bronchospasm
37
Abrupt withdrawal from beta blockers as anti-anginal drugs
may lead to arrhythmia, worsening angina or myocardial infarction
38
Anti-anginal drugs: nitrates | -how do you take them
Oral, sublingual (GTN tabs/spray), buccal, transdermal and intravenous forms used commonly
39
Anti-anginal drugs: nitrates | -action
Symptomatic relief of angina Produce nitric oxide at endothelial surface leading to vascular smooth muscle relaxation and arteriolar and venous dilatation < myocardial oxygen demand (lower preload and afterload) and increase myocardial oxygen supply (coronary vasodilatation)
40
Side effects of anti-anginal drugs: nitrates
Headache Flushing Postural hypotension
41
Anti-anginal drugs: calcium antagonists
Lower myocardial oxygen demand by < BP and myocardial contractility and < myocardial oxygen supply by dilating coronary arteries
42
Anti-anginal drugs: calcium antagonists | -when to avoid
Verapamil and diltiazem should be avoided in heart failure
43
Anti-anginal drugs: Potassium channel activators
Nicorandil Arterial and venous dilating properties No problems with tolerance as seen with nitrates
44
Anti-anginal drugs: Potassium channel activators | -side effects
Can cause mucocutaneous ulceration | -relegated to second-line therapy
45
Anti-platelet drugs: action
Inhibit platelet aggregation and arterial thrombus formation, thus preventing heart attack, stroke and CV death
46
Anti-platelet drugs: aspirin
blocks platelet cyclo-oxygenase (COX1) and the production of thromboxane A2, a platelet activating substance
47
Anti-platelet drugs: clopidogrel, prasugrel and ticagrelor
platelet ADP (P2Y12) receptor inhibitors; used alone or, more often, in combination with aspirin
48
Anti-platelet drugs: dipyridamole
Mainly used in combination with aspirin to prevent stroke
49
Bleeding time in healthy volunteers treated with ticagrelor +/- aspirin -in Lancet bleeding time (s)
Non antiplalet treatment: 150 +/- 54 Ticagrelor 250 +/- 77 Ticagrelor + aspirin: 541 +/- aspirin
50
Statins
Hydroxymethyl-glutaryl (HMG) CoA reductase inhibitors Lower LDL cholesterol and may increase HDL cholesterol < risks of MI stroke and CV death
51
Examples of statins
Simvastatin, pravastatin, atorvastatin, rosuvastatin, ...statin
52
Heart failure
imprecise term describing state that develops when heart cannot maintain adequate cardiac output or can do so only at the expense of an elevated filling pressure Associated with activation of RAS axis and sympathetic nervous system
53
How do pulmonary and/ or peripheral oedema develop?
due to high atrial pressures and salt/water retention caused by impaired renal perfusion and secondary aldosteronism
54
Drug treatment for chronic heart failure
Diuretics ACE inhibitors Beta Blockers Aldosterone antagonists
55
Diuretics for treatment of heart failure
Thiazides K-sparing Loop diuretics -strongest *more powerful than those used for hypertension* *synergistic effects of combining all diuretics*
56
Thiazides for treatment of heart failure
Inhibit active exchange of Cl-Na in the cortical diluting segment of the ascending loop of Henle Acts on cortex
57
K-sparing diuretics for treatment of heart failure
Acts on cortex Inhibit reabsorption of Na in the distal convoluted and collecting tubule
58
Loop diuretics for treatment of heart failure
Inhibit exchange of Cl-Na-K in the thick segment of the ascending loop of Henle Acts on medulla
59
Aldosterone inhibitors
Spironolactone Eplerenone -competitive antagonist of the aldosterone receptor -acts on myocardium, arterial walls, kidney -tackle salt and water retention -prevent potassium level from going too low -may reduce fibrosis in the myocardium
60
Tacharryhthmias
Abnormal rapid heart rhythms Different types depending on origin in heart of abnormal electrical activity including: -atrial fibrillation (AF) or atrial flutter with rapid ventricular rate response -supraventricular tachycardia (SVT) -ventricular tachycardia (VT)
61
Digoxin (digitalis)
Most often used to treat AF and heart failure Glycoside drug Blocks Na+/ K+ ATPase --> Ca++ > vagal tone - slows conduction in atrial fibrillation
62
Oral antiarrhythmics
Drugs for controlling tachyarrhythmia Class Ia,b,c – disopyramide, flecainide, procainamide Class II – beta blockers Class III – amiodarone, dronedarone, sotalol Class IV – calcium antagonists (verapamil, diltiazem)
63
What can low potassium lead to?
Heart rhythm disturbance (arrhythmia)
64
Interaction between anticoagulants and antiplatelets
Both interact (antithrombotics) Both coagulation and platelet formation are driven by thrombin -if you block thrombin by one drug, will affect other pathway Higher bleeding risk if on both

Vascular System and Medical Emergencies (5 decks)

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