Exam 2 Drugs Flashcards
Hydrochlorothiazide
chlorthalidone
metalozone
indapamide
thiazide diuretics
Furosemide
Torsemide
Bumetanide
Ethacrynic Acid
Loop Diuretics
Amiloride
Triamterene
Potassium-Sparing diuretics
Nifedipine
Amlodipine
Calcium Channel Blockers (Dihydropyridine)
Verapamil
Diltiazem
Calcium Channel Blockers (Non-dihydropiridine)
Captopril Enalapril Fosinopril Lisinopril Perindopril Quinapril Ramipril Trandolapril
ACE Inhibitors (“-opril”)
Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmesartan Temisartan Vaslartan
ARBs (“-sartan”)
Doxazosin
Prazosin
Terazosin
Alpha-1 Antagonists (“-zosin”)
Clonidine
Methyldopa
Guanfacine
Guanabenz
Alpha-2 Agonists
Reserpine
Peripheral Sympathetic Inhibitor
Isosorbide dinitrate/hydralazine
Hydralazine
Minoxidil
Direct Vasodilators
Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin
Statin
Alirocumab
Evolocumab
PCSK9 Inhibitor (cholesterol) - other treatments
Lovaza
Vascepa
Epanova
Omtryg
Omega 3 Fatty Acids (fish oil) - other cholesterol treatment
Digoxin - Method of Action
Use in Heart Failure (sometimes)
MOA: + inotropic effects (heart beats harder); decreases hospitalization, DOES NOT decrease or improve HF progression
ACE-I pharmacological use
blocks creation of angiotensin II
ARBs pharmacological use
blocks angiotensin II’s receptor
Fondaparinux
Xa Inhibitor (indirect)
Apixaban
Rivaroxaban
Xa inhibitor (direct)
Bivalirudin
Desirudin
Aragatroban
Dabigatrin
Direct Thrombin inhibitors
Amiodarone
Dofetilide
Ibutilide
Propafenone
Pharmacological Cardio Conversion
Dabigatran
Rivaroxaban
Warfarin
Apixaban
Anticoagulants
Aspirin
Dipyridamole
Antiplatelets
Clopidogrel
Prasugrel
Ticagrelor
Cangrelor (IV)
P2Y12 Inhibitor - reduces platelet activation/aggregation
Abciximab
Eptifibatide
Tirofiban
Glycoprotein lIb/IIIa Receptor Inhibitor
Alteplase
Reteplase
Tenecteplase
Fibrinolytics (fibrin-specific)
Streptokinase
Urokinase
Fibrinolytics (nonfibrin-specific)
Nitroglycerin
Short-acting nitrate (angina)
Nitroglycerin ER
Isosorbide dinitrate
isosorbide mononitrate
Long-acting nitrates
this diuretic used in Edema and Heart Failure, works on loop of henle, and can be used even in poor renal function (decreases renal vascular resistance, increased renal blood flow)
Loop Diuretics
this diuretic used commonly in Hypertension; decreases BP by increasing sodium and water excretion by the kidneys (decreases blood volume)
Thiazide Diuretics
This diuretic is good for RESISTANT hypertension; they increase NaCl excretion, decrease K+ secretion), diminishing cardiac remodeling in heart failure
Aldosterone antagonists
spironolactone
eplerenone
Adverse effects of potassium sparing diuretics
HyperK; decrease or D/C K+ supplements and avoid high potassium foods
Spironolactone
Eplerenone
Aldosterone antagonists (diuretic)
Types of Diuretics?
Thiazide, Loop, Potassium Sparing, Aldosterone Antagonists
Aspirin MOA?
inhibits COX (cyclooxygenase)
Types of antiplatelets
aspirin, dipyridamole, P2Y12 inhibitors, Glycoprotein IIa/IIIb inhibitors
when to use fibrinolytics?
Acute Coronary syndrome if PCI is too far away, in ischemic stroke, in VTE
treatment for acute stroke; give within 3 hours after onset to reverse symptoms
Alteplase (fibrinolytics)
how do potassium sparing diuretics work?
inhibit sodium transport at late distal and collecting ducts
dihydropiridines vs. nondihydropyridines (CCB)
dihydropyridines have greater affinity for peripheral vasculature calcium channels (legs), while nondihydropyridines have affinity for both peripheral and cardiac calcium channels (not just legs)
DO’s and DONT’s of using nondihydropyridines (CCBs)
DONT use if EF is low; use for angina, Afib, HTN (blocks cardiac conduction through AV node, has vasodilating properties)
Which dihydropyridine (CCB) is safe for reduced EF?
Amlodipine
Verapamil
Diltliazem
Non-dihydropyridine (CCB)
Nifedipine
Amlodipine
dihydropyridine (CCB)
method of action ARBs?
block angiotensin II from binding to angiotensin receptor (RAAS)
Aliskren
Direct Renin Inhibitor (antihypertensive) - less common. MOA: directly inhibits renin
Doxazosin
Prazosin
Terazosin
Alpha-1 Antagonists (antihypertensive) - less common. MOA: add-on treatment, NOT monotherapy due to a risk for increase in cardiovascular events
Clonidine
Methyldopa
Guanfacine
Guanabenz
Alpha-2 agonists (antihypertensives) - less common. MOA: reduces sympathetic outflow, enhances parasympathetic activity
1st line medication for hypertension in PREGNANCY?
methyldopa - alpha 2 agonist. Labetalol ok too
Reserpine
peripheral sympathetic inhibitors. MOA: reduces sympathetic tone and peripheral resistance, depletes NE from nerve endings. (anti-hypertensive) - not tolerated well
isosorbide dinitrate/hydralazine
hydralazine
minoxidil
Direct Vasodilators (antihypertensive) - MOA: relaxes smooth muscle in arterioles, activates baroreceptors.
best time to prescribe direct vasodilators? (antihypertensive)
Resistant hypertension, but also ADD diuretics and BB (causes reflex tachycardia)
Blood pressure definition?
BP = CO x PVR
(CO: cardiac output)
PVR: peripheral vascular resistance
role of angiotensin II in Heart failure?
increases systemic vascular resistance, increasing BP. ALSO, potentiates release of NE, inducing vascular hypertrophy = cardiac remodeling
ACE-Inhibitor function?
blocks conversion of angiotensin I –> angiotensin II
ARB function?
blocks receptors of angiotensin II
CONTRAINDICATIONS for ACE-I/ARB?
pregnancy, renal artery stenosis (ACE can cause decline in renal function)
function of nitrates in HF?
venous dilation = reduced preload
function of hydralazine in HF?
direct arterial smooth muscle relaxation = reduce AFTERLOAD
Purpose of Beta Blockers in HF?
block influence of SNS (NE) at beta adrenergic receptors, improving EF and reducing hospitalizations
Do you give BB with volume overload?
NO! wait until euvolemic and initiate a low-dose
Aldosterone impact on HF? Why are aldosterone antagonists important for treating HF?
Aldosterone is responsible for sodium and water retention, electrolyte abnormalities. ALDOSTERONE ANTAGONISTS are important because ACE-I do not suppress production/release of aldosterone
Importance of antiplatelets (aspirin and warfarin) in Heart Failure?
Bad valves can cause stasis blood, endothelial dysfunction, hypercoagulability increasing risk of thromboembolic events
importance of Aspirin in HF?
reduces risk of stroke (embolism)
importance of anticoagulant in HF?
prevents blood clots, especially in LV dysfunction and prosthetic valves
Role of Digoxin in HF?
Positive inotropic effects = heart beats harder (increases intracellular Na by binding to Na and K pumps)
Restoration baroreceptor sensitivity
if AFib too, use to slow HR
DOES NOT decrease progression of HF, but has a role in decreasing hospitalizations due to HF
Risks of Digoxin
high risk of toxicity; monitor electrolytes
Heart failure with PRESERVED LVEF also known as?
diastolic HF - impaired ventricular relaxation and filling; EF not affected
How to manage ACUTE heart failure episode?
FIRST: manage congestion and hypoperfusion:
congestion: IV diuretic (furosemide) & IV vasodilators (nitro)
hypoperfusion: positive inotropes to make heart beat faster (dobutamine)
What are the 4 groups that need a statin?
- Established ASCVD
- LDL > 190
- Diabetic, age 40-70, LDL 70-189
- Nondiabetic, age 40-75, LDL 70-189, 10 year risk >7.5%
What do statins do?
inhibit MHG-CoA reductase, responsible for cholesterol synthesis
Atorvastatin
Fluvastatin
Lovastatin
Pravastatin
Statins
Low intensity statins?
Lovastatin
Pravastatin
(10-20 mg)
Moderate intensity statins
all of them…(40 mg)
reduces LDL by 30-50%
high intensity statins
Atorvastatin
Rosuvastatin
(40-80 mg)
reduces LDL by 50%
Adverse effects of statins
constipation, abdominal pain
Severe: myopathy, rhabdo, elevated liver function tests
Treatment for hypercholesterolemia?
1st: LIFESTYLE TREATMENT
then statins
If NOT using statin for high cholesterol, other options?
Ezetimibe PCSK9 inhibitor Nicotinic Acid Fibric acid derivatives Omega 3 fatty acids
MOA ezetimibe?
inhibit cholesterol absorption in small intestine and prevents delivery to liver. used post CV event.
Alirocumab
Evolocumab
PCSK9 inhibitor : used in combo with statin. Binds to LDL receptor and prevents its degradation–> longer breakdown and excretion of LDL. NEW, so don’t be the first!
Type of antihypertensive to use for resistant HTN?
Alpha-2 agonists
How to D/C clonidine? (Alpha-2 agonist)
Avoid severe rebound HTN. Taper B.B. first, wait several days, and then taper clonidine
What to do if INR >10?
Vitamin K! Takes 24 hours to see effects
INR >4 , under 10 - what do you do?
Hold warfarin until therapeutic
How long does warfarin take to be eliminated?
5-7 days
fondaparinoux (indirect Xa inhibitor) MOA?
Accelerates antithrombin (binds to AT)
Warfarin MOA? When to use?
Vitamin K antagonist
Treatment of VTE and stroke prevention in Afib
How to dose warfarin
Start it in combo w/ heparin, because it’s effects take 5-7 days. D/C warfarin 5 days before surgery and restart 12-24 hours post-op
Fondaparinoux MOA
SubQ; indirectly inhibits Xa in coagulation cascade - no effect against thrombin
Binds to Antithrombin
Contraindications and cautions of Fondaparinoux
CrCl<30 (rental impairment)
Hypersensitivity, thrombocytopenia
CAUTION in elderly (bleeding)
Apixaban and rivaroxaban MOA?
Inhibit Xa directly; bind reversible to Xa and prevent thrombus formation
Things to know about direct Xa inhibitors
Shorter 1/2 life than warfarin, missed doses more serious, no labs to measure effectiveness, no antidotes
Which anticoagulant to use with patient who has Heparin induced thrombocytopenia(HIT)?
Direct thrombin inhibitors
Bivalirudin, aragatroban
Drug of choice for RAPID anticoagulation?
Infractioned heparin
True or false: UFH dissolves a formed clot.
False! Prevents propagation and growth
UFH is eliminated enzymatically in low doses and renally in high doses (true or false)
True
What is HIT?
Heparin-induced thrombocytopenia- when platelets drop by >50%; discontinue UFH / LMWH immediately!!! Switch to direct thrombin inhibitors or fondaparinoux
Dalteparin
Enoxaparin
LMWH
LMWH MOA?
Prevent growth of formed thrombus, inhibits thrombin (factor IIa and factor Xa)
Is LMWF safe in treating pregnancy?
Dalteparin
Enoxaparin
Yes- does not cross placenta
Are nitrates done first at ER?
No- they relieve angina but they do not change outcomes
Adverse effects of P2Y12 Inhibitors?
bleeding, TTP (thrombotic thrombocytopenic purpura) (clopidogrel), dyspnea, bradyarrhythmias
How to dose P2Y12 inhibitors post-procedure
start immediately, continue for 2 weeks to 12 months
What Antiplatelet do you Rx for patient with poor CYP2C19 metabolizers?
Prasugrel or Ticagrelor; Clopidogrel is converted to active form by CYP2C19, so won’t be as effective in these patients
What do you do with antiplatelet meds for person who is having surgery?
WITHHOLD for 7 days to decrease chances of uncontrolled bleeding
When to use GP lib/llla?
for antiplatelet therapy; specifically when P2Y12 inhibitor are not adequate OR in large thrombus burden - not recommended if patient is on fibrinolytics or bivalrudin (bleed risk)
Role of thrombolytics?
break up life-threatening thrombus
Types of Antiplatelets
Aspirin
Dipyridamole
P2Y12 Inhibitors
GP lib/llla receptor inhibitors
Which drug is considered 1st line therapy in ACS?
fibrin-specific (Alteplase, Reteplase, Tenecteplase); opens greater percentage of infarcted arteries
Contraindications for Fibrinolytics
for use in NSTE-ACS and if too much time has passed since the cardiac event
Fibrinolytics in VTE?
Streptokinase, Urokinase, Alteplase - use for treatment in VTE ONLY IF shock, hypotension, massive DVT w/ limb gangrene
If PCI is too far away, what do you do?
use fibrinolytics - FIRST LINE (fibrin-specific)
HTN treatment >140/90 blacks?
Thiazide diuretic OR CCB
HTN treatment >140/90 white/nonblack?
ACE-I/ARB (or thiazide/CCB)
HTN treatment for >140/90 in patients with CKD
Add ACE-I/ARB, even in African Americans.
Guidelines for starting TWO Hypertensive drugs?
systolic >20mmHg or diastolic >10mmHg
What are the types of direct cardioversion? DCC
unstable (emergency- shock) and stable (medication)
sedate before electrical cardioversion
When thinking Rate vs Rhythm control, which do we try and achieve first?
RATE! - be careful with amiodarone, works like K blocker, CCB, BB - last ditch effort
When can you consider DCC?
w/ Afib lasting <48 hours
When is Delayed cardioversion considered?
in patients with Afib >48 hours; MUST anticoagulate for 3 weeks PRIOR to conversion and continue for 4 weeks AFTER as well.
Treatment for PCI (including time)
preferred treatment, within 90 min!
Dual antiplatelet therapy: ASA + P2Y12, anticoagulate w/ UFH
Treatment for Fibrinolysis
within 30 min! do if PCI not available. Dual antiplatelet therapy (ASA + clopidogrel P2Y12), and Anticoagulate with IV UFH
Two factors to address in acute heart failure episode
congestion and hypoperfusion, use
IV diuretics, IV vasodilators, Dobutamine (positive inotropes)
Purpose of amiodarone
treat Afib and ventricular arrhythmias
Factors that describe stage B HF
Previous MI, LV remodeling, low EF, valvular disease (but no symptoms)
Treat w/ ACEI + BB
Factors describing stage A HF
risk factors: HTN, smoking, lipids, DM, lack of exercise
Treat w/ ACEI
Stage C HF
Symptoms! DOE, edema, SOB, fatigue
Treat w/ ACEI, BB, Diuretic
ACE-I and renal function
ACE-I can cause renal insufficiency, and is CONTRAINDICATED in bilateral renal stenosis, however it can be beneficial chronically
Nitrates reduce _______ and hydralazine reduces ___________
preload, afterload
when do you initiate beta blockers in HF?
wait until patient is euvolemically stable (volume overload + BB = worsening effects)
When to use nondihydropyridines vs dihydropyridines
nondihydros - angina and AFib
dihydros - peripheral vasodilation
in acute HF exacerbation, we give IV diuretics, IV vasodilators, and IV positive inotropes (dobutamine)…why?
IV dobutamine - increases cardiac contractility, makes heart pump harder
IV vasodilators - rapidly decreases arterial tone
IV diuretics - decrease blood volume/fluid
CCB Method of Action?
Relaxes arterioles by blocking calcium from entering cell
True or False: Rechallenging statins in those who experience rhabdomyolysis is okay, but wait 2-4 weeks
FALSE! If patient has rhabdo from a statin, DO NOT rechallenge that same one! In other cases, where patient simply does not tolerate, re-challenging is ok, but wait 2-4 weeks.
Safest CCB to use in reduced EF?
Amlodipine
Why do we take a baseline CK when prescribing statins?
Need to have a baseline INCASE patients complain of myopathy, muscle pain, weakness, brown urine (signs of rhabdo)
True or False: Rechallenging statins in those who experience rhabdomyolysis is okay, but wait 3-4 weeks
FALSE! If patient has rhabdo from a statin, DO NOT rechallenge that same one! In other cases, where patient simply does not tolerate, re-challenging is ok.
Statins metabolized by which enzyme?
CYP450s
Quinidine
Procainamide
Disopyramide
Class 1A Na channel blockers (antiarrhythmic class)
-intermediate potency
Lidocaine
Mexilitine
Class 1B Na channel blockers (antiarrhythmics)
-lowest potency
Flecainide
Propafenone
Class 1C Na channel blockers (antiarrhythmics
-greatest potency
Class 2 antiarrhythmics?
Beta Blockers
Class 3 antiarrhythmics?
Potassium channel blockers
Amiodarone Dofetilide Dronedarone Ibutilide Sotolol
which anticoagulants bind the Von Willebrand factor in the coagulation cascade?
heparin
Adenosine MOA
Direct AV node inhibition; drug of choice for PSVT
Uses for anticoagulation
Prevention of stroke, VTE, thrombus formation (Afib, procedures), thromboembolism (PE)
Types of Anticoagulants
Warfarin Xa Inhibitors Direct Thrombin inhibitors Heparin LMWH
What is the importance of aPPT in UFH dosing?
adjust dose based on the aPPT; should be 1.5-2.5x control aPPT value
What do you do if there is HIT or thrombosis while patient is on UFH?
D/C immediately and switch to direct thrombin inhibitors OR Fondaparinoux
Dalteparin
Enoxaparin
LMWH
Which anticoagulants have antidotes, and what are they?
Protamine –> LMWH
Vit K –> warfarin
Praxbind –> direct thrombin inhibitors
which antiarrhythmics are IV form?
Class 1A and 1B Na channel blockers
Which antiarrhythmics are PO?
Class 1C Na channel blockers
Where in conduction system do BB affect rhythm?
Blocks conduction at AV node
does Amiodarone have a long or short 1/2 life?
EXTREMELY long (antiarrhythmic)
common side effects and severe side effects of Amiodarone
hypotension, sinus bradycardia (acts like all classes of antiarrhythmics)
pulm toxicity, hepatotoxicity, hypo/hyperthyroidism, exacerbated arrhythmias
Which antiarrhythmics slow conduction at AV node?
BB and CCB (class 2 and 4)
Why are we cautious with verapamil + digoxin?
verapamil (CCB) can mess with concentration of digoxin (digoxin has low therapeutic index, so small changes can cause large effects)
Which antiarrhythmic causes DIRECT AV nodal inhibition?
Adenosine
Which antiarrhythmic drug is 1st line choice in treating PSVT?
Adenosine
How can you tell if your patient has digoxin toxicity?
CNS effects(psychosis confusion), GI effects (nausea, vomiting), Visual disturbances (green halos around objects), new cardiac arrhythmias
How to monitor for digoxin toxicity
Look for HypoK, HypoMg
which drugs provide 24 hour protection for angina?
BB and CCB
door-to-needle time for Alteplase in stroke?
60 minutes
