heart meds Flashcards
Nitroglycerin MOA
Forms free nitric oxide (NO) which activate guanylate cyclase (GC) to increase cGMP resulting in smooth muscle relaxation. Aldehyde dehydrogenase-2 (ALDH2) is the enzyme that releases the NO from organic nitrates. This enzyme can get depleted resulting in “nitrate tolerance” requiring nitrate holiday
NG ADR
Headache, syncope, hypotension, reflex tachycardia,
methemoglobinemia (increased affinity of hemoglobin for ferric iron versus ferrous iron)
NG dental implications
Xerostomia- normal salivary flow resumes upon discontinuation
Monitor for orthostatic hypotension
Isosorbide mononitrate
(ISMN) (Imdur) MOA
Forms free nitric oxide (NO) which activate guanylate cyclase (GC) to increase cGMP resulting in smooth muscle relaxation. Aldehyde dehydrogenase-2 (ALDH2) is the enzyme that releases the NO from organic nitrates. This enzyme can get depleted resulting in “nitrate tolerance” requiring a nitrate holiday.
long acting oral formulation
Isosorbide mononitrate ADRs
Headache, syncope, hypotension
Isosorbide mononitrate dental implications
none
Isosorbide dinitrate
(ISDN/Isodril) MOA
Forms free nitric oxide (NO) which activate guanylate cyclase (GC) to increase cGMP resulting in smooth muscle relaxation. Aldehyde dehydrogenase-2 (ALDH2) is the enzyme that releases the NO from organic nitrates. This enzyme can get depleted resulting in “nitrate tolerance” requiring a nitrate holiday. Intermediate-acting oral formulation
Isosorbide dinitrate ADRs
Headache, syncope,
hypotension
Isosorbide dinitrate dental implications
Xerostomia- normal salivary flow resumes
upon discontinuation
Sodium Nitroprusside
(Nitropress)
Only available in what form
IV form
Sodium Nitroprusside
(Nitropress) MOA
Direct donates a NO molecule, which activate guanylate cyclase (GC) to increase cGMP resulting in smooth muscle relaxation. Does not require ALDH2.
Does not exhibit tolerance
Sodium Nitroprusside
(Nitropress) ADRs
Severe hypotension, flushing, reflex tachycardia, methemoglobinemia, thiocyanate toxicity.
Thiocyanate can form in the parenteral fluid due to
exposure to light, product MUST BE PROTECTED form
light. This is more common with higher doses and longer durations of administration
Sodium Nitroprusside
(Nitropress) dental implications?
none
Ranolazine (Ranexa) MOA
Inhibition of late inward sodium current (Ina). Does not affect heart rate or blood pressure
Ranolazine (Ranexa) ADRs
QT prolongation, torsade de pointes, bradycardia,
hypotension, xerostomia
Usually does not affect hemodynamic parameters
Ranolazine (Ranexa) dental implications
Xerostomia- normal salivary flow resumes
upon discontinuation
Ivabradine (Corlanor) approval in US?
Not approved for angina in the United
States- only approved for HF
Ivabradine (Corlanor) MOA
Inhibited the If (funny) channel in the SA node resulting in a reduction in heart rate, without a change in blood pressure
Ivabradine (Corlanor) ADRs
Bradycardia, atrial fibrillation, phosphenes
Ivabradine (Corlanor) dental implications
none
b1 selective blockers
acebutolol
esmolol
atenolol
betaxolol
metopolol
nebivolol
Acebutolol (Sectral) MOA
exhibits what activity?
Competitively blocks β1 adrenergic receptors with little
to no effect on β2 adrenergic receptors.
Exhibits intrinsic sympathomimetic activity
Acebutolol (Sectral) ADRs
Bradycardia, hypotension, dizziness
B1 specific blockers dental implications
Cardio selective beta-blockers do not interact with local anesthetics.
NSAIDs can reduce antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days) is safe
Atenolol
(Tenormin) MOA
Competitively blocks β1
adrenergic receptors with little
to no effect on β2 adrenergic
receptors
atenolol ADRs
Bradycardia,
hypotension,
dizziness,
AV node block,
fatigue,
Raynaud’s phenomenon,
impotence
betaxolol MOA
Competitively blocks β1
adrenergic receptors with little
to no effect on β2 adrenergic
receptors
betaxolol ADRs
Bradycardia, hypotension, dizziness, AV node block, fatigue, impotence
Esmolol (Brevibloc)
Only available as?
Only available IV:
Short acting (t1/2= 5 mins
esmolol MOA
Competitively blocks β1
adrenergic receptors with little
to no effect on β2 adrenergic
receptors
esmolol ADRs
Hypotension, bradycardia,
infusion site reaction
metoprolol forms
(Lopressor)- immediate release
(Toprol XL)- extended release
metoprolol MOA
Competitively blocks β1
adrenergic receptors with little
to no effect on β2 adrenergic
receptors at doses < 100mg
daily
metoprolol ADRs
Bradycardia,
hypotension,
dizziness,
AV node block,
fatigue,
impotence
Nebivolol (Bystolic) MOA
also produces what effect?
Competitively blocks β1 adrenergic receptors with little to no effect on β2 adrenergic receptors.
**Also produces nitric oxide dependent vasodilation **
nebivolol ADRs
Bradycardia, hypotension,
dizziness, fatigue,
impotence
non selective B blockers
carteolol
penbutolol
pindol
propranolol
timolol
Carteolol
(Ocupress) only formulation
opthalmalic
carteolol MOA
Blocks both β1 and β2 adrenergic
receptors. Reduces intraocular
pressure
carteolol ADRs
Conjunctival hyperemia
(no systemic ADRs noted)
carteolol dental implications
none
Penbutolol
(Levatol) MOA
Blocks both β1 and β2 adrenergic receptors.
**Exhibits mild intrinsic sympathomimetic activity
penbutolol ADRs
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
penbutolol dental implcations
Xerostomia- normal salivary flow resumes upon discontinuation
Non-selective beta blockers may enhance the pressor response to epinephrine resulting in hypertension and bradycardia.
NSAIDs can reduce antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days) is safe.
pindolol MOA
Blocks both β1 and β2 adrenergic receptors.
**Exhibits mild intrinsic sympathomimetic activity **
pindolol ADRs
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
pindolol dental implications
Non-selective beta blockers may enhance the pressor response to epinephrine resulting in hypertension and bradycardia.
NSAIDs can reduce antihypertensive effects of beta blockers. Short-term use of NSAIDs (i.e. 3 days) is safe
Propranolol (Inderal LA)/ (Hemangeol) MOA
can work where else? how?
Blocks both β1 and β2 adrenergic receptor
Reduce portal pressure by producing splanchnic vasoconstriction
propranolol ADRs
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
propranolol dental implications
Non-selective beta blockers may enhance the pressor response to epinephrine resulting in hypertension and bradycardia.
NSAIDs can reduce the antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days)
is safe
timolol formulations
(Timoptic)- ophthalmic formulation
(Betimol)
timolol MOA
Blocks both β1 and β2 adrenergic
receptors.
Reduces intraocular pressure
timolol ADRs
Ophthalmic- burning eyes
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
timolol dental implications
Xerostomia- normal salivary flow resumes upon discontinuation
Non-selective beta blockers may enhance the pressor response to epinephrine resulting in hypertension and bradycardia
carvediolol formulations
(Coreg)- immediate release
(Coreg CR)- extended release
carvediolol MOA
Blocks both β1 and β2 adrenergic receptors.
Also blocks α1 adrenergic receptors.
Non-selective beta blockade with alpha blocking (β1 = β2 ≥ α1 > α2)
carvediolol and labetolol
carvediolol ADRs
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
carvediolol dental implications
Orthostatic hypotension, use caution when changing position.
NSAIDs can reduce antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days) is safe
Labetalol
(Trandate) MOA
Blocks both β1 and β2 adrenergic receptors.
Also blocks α1 adrenergic receptors.
The ratio of alpha to beta blockade is 1:3 following
oral administration
labetalol ADRs
Bradycardia,
hypotension,
fatigue,
dizziness,
impotence
labetalol dental implications
Taste disorder
NSAIDs can reduce antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days) is safe
Dihydropyridine Rx’s
all end in -pine
Amlodipine (Norvasc) MOA
Inhibits calcium ions influx through L-type or “slow”
calcium channels”
Selective for vascular smooth muscle
same as all -pine Rx
amlodipine ADRs
Reflex tachycardia, flushing, hypotension,
peripheral edema, gingival hyperplasia
Dihydropyridine Rx’s dental implications
Monitor of gingival
hyperplasia, usually
resolves upon
discontinuation
Clevidipine
(Cleviprex)
Only available as?
IV form
clevidipine MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
clevidipine ADrs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema
Gingival hyperplasia not reported probably due to shorter duration of administration
felidipine MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
felodipine ADRs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema,
gingival hyperplasia
Isradipine
(DynaCirc CR) MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
isradipine ADRs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema
Information is sparse as to whether isradipine causes
gingival hyperplasia
Nicardipine
(Cardene)
Available in?
PO and IV
formulations
nicardipine MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
nicardipine ADRs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema,
gingival hyperplasia
nicardipine dental implications
Xerostomia (normal salivary flow resumes upon discontinuation)
Monitor of gingival hyperplasia, usually resolves upon discontinuation
Nifedipine MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
nifedipine ADRs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema,
gingival hyperplasi
nifedipine ADR
Gingival hyperplasia (10%
incidence with doses of
30-100mg/day). Effects
present after 1-9 months
of treatment. Usually
resolves upon
discontinuation
nimodipine MOA
Inhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
nimodipine ADR
Reflex tachycardia,
flushing,
hypotension,
peripheral edema
No reports of gingival hyperplasia with nimodipine
nimodipine dental implications
Possibly gingival
hyperplasia- although no
known cases
nisoldipine MOA
nhibits calcium ions influx
through L-type or “slow”
calcium channels”
Selective for vascular smooth
muscle
nisoldipine ADRs
Reflex tachycardia,
flushing,
hypotension,
peripheral edema
Information is sparse as to whether nisoldipine causes
gingival hyperplasi
nisoldipine dental
Xerostomia (normal salivary flow resumes upon discontinuation)
Possibly gingival hyperplasia- information is sparse
Non-Dihydropyridine Rx
selective for myocardium
Diltiazem and vermapril
Diltiazem MOA
inhibits calcium ions influx through L-type or “slow” calcium channels”
Selective for myocardial calcium channels
Slows impulse conduction through the AV node
diltiazem ADRs
Constipation,
dizziness,
lightheadedness,
hypotension,
bradycardia,
gingival hyperplasia
diltiazem dental
gingival hyperplasia
usually resolves
upon discontinuation
Verapamil MOA
where are impulses slowed in the cardiac conduction?
inhibits calcium ions influx through L-type or “slow”
calcium channels”
Selective for myocardial calcium channels
Slows impulse conduction through the AV node
verapamil ADRs
Constipation,
dizziness,
lightheadedness,
hypotension,
bradycardia,
gingival hyperplasia
verapamil dental
gingival hyper
class Ia anti-arrhytmatics
moderate sodium channel blockers
Quinidine MOA
moderate na channel block
quinidine ADRs
abdominal pain and cramps, nausea, vomiting, diarrhea
Cinchonsim- “overdose” (symptoms include: ringing in ears, blurred vision, hearing loss)
Cardiac- QT prolongation
quinidine dental
May consider semisupine
chair position to minimize
GI distress if occurs
procainamide MOA
moderate Na blocker
procainamide ADRs
Lupus-like syndrome
Skin rash
QT prolongation
procainamide dental
dysguesia
dysopyramide MOA
moderate na blocker
dysopyramide ADRs
Anticholinergic-Dry mouth, constipation, urinary hesitancy
Cardiac- QT prolongation
dysopryamide dental
xerostomia- done with discontinuation
class Ib agents
weak na blockers
lidocaine
tocanide
mexilitine
phenytoin
lidocaine mech
weak na block
lido ADRS
Neuro- Agitation, anxiety, hallucinations, seizures
(toxic)
Bradycardia
lido dental
metalic taste
tocainide MOA
weak na block
mexilitine MOA
weak na block
mexilitine ADRs
GI- nausea, vomiting, heartburn
Neuro- dizziness, light-headedness, tremors, convulsion (toxic
mexitiline dental
Xerostomia- normal salivary flow resumes upon discontinuation
phenytoin MOA
weak na blocker
phenytoin ADRs
Ataxia, cardiovascular side
effects with IV
administration
phenytoin dental
Gingival hyperplasia is
common during the first 6
months of treatment
class Ic
strong na block
moricizine
flecainide
propafenone
moricizine moa
strong na block
flecainidea moa
strong na block
flecainide ADRs
Dizziness and visual disturbances
flecainide dental;
none
Propafenone moa
strong na block
propafenone ADRs
Unusual taste (3-23%)
Nausea/vomiting
Blurred vision (1-6%)
Dizziness
propafenone dental
unusual taste, also xerostomia a possibility
class III antiarrhytmatics
amiodarone
donfetilide
dronedarone
ibutilide
satalol
K channel block
amiodarone moa
K+ channel blocker
Also blocks Na+ and Ca2+
channels, B receptors
amiodarone adrs
eyes- blurred vision
Lungs- pulmonary fibrosis
Heart- hypotension (IV formulation)
Thyroid-hypo/hyperthyroidism
Liver- elevated LFTs
GI- nausea and vomiting
Skin-photosensitivity/blue skin
amiodarone denta;l
abnormal salivation and taste
donfetilide moa
k channel blocker
donfetilide adr
QT prolongation/Torsades de pointes
Minimal other ADRs
dronedarone moa
K+ channel blocker
Also blocks Na+ and Ca2+
channels, B receptors
Similar to Amiodarone
dronedarone adr
QT prolongation/Torsades de pointes
Elevations in serum creatinine
Acute hepatic failure inpost-marketing
ibutilide moa
k channel block
ibutilide adr
QT prolongation/Torsades
de pointes
salatol moa
K+ channel blocker
Also blocks both β1 and β2
adrenergic receptors
salatol adr
QT prolongation/Torsades de pointes
Bradycardia, hypotension, fatigue, dizziness
salatol dental
Related to beta blocking activity.
Non-selective beta blockers may enhance the pressor response to epinephrine resulting in hypertension and bradycardia
NSAIDs can reduce antihypertensive effects of beta-blockers. Short-term use of NSAIDs (i.e. 3 days) is safe.
positive ionotropic meds
digoxin
dobutamine
milrinone
levosemnderin
digoxin moa for HF and SV arrhythmias
Heart failure: inhibition of the sodium/potassium ATPase pump in myocardial cells resulting in an increase of intracellular sodium which promotes calcium influx via the sodium-calcium exchange pump
leading to increased contractility
Supraventricular arrhythmias: direct suppression of the AV node conduction to increase effective refractory period and decrease conduction velocity
digoxin adr
nausea, vomiting, diarrhea, bradycardia, heart block, visual disturbances
digoxin dental
increased gag reflex may make dental procedures, such as taking radiographs or impressions difficult
Avoid dental light in patient’s eye/offer dark glasses
dobutamine moa
Stimulates myocardial B1-adrenergic receptor. Results in increased contractily
dobutamine adr
increased heart rate and blood pressure,
arrhythmias, chest pain, localized phlebitis
milrinone moa
Selective phosphodiesterase -3
inhibitor (PDE3) in cardiac and
vascular tissue, resulting in
vasodilation and increased
contractility
milrinone adr
Decreased blood pressure,
arrhythmias, chest pain
levosimendan moa
Sensitize troponin to Ca2+
(inotropy) and KATP channel
activation in smooth muscle
(vasodilation
levosimendan uses
none, not available here
what adrs can we see with all nitrates
headache, syncope, hypotension
which nitrates can cause methemoglob
NG and Na nitroprusside
which nitrate can cause thioocyante toxicity
Na nitroprusside
which nitrates can cause xero
NG, iso dinitrate, ranolazine
which Rx can cause phosphenes
ivabradine
common adrs of all b blocks
hypo, dizzy, fatique
which b block can cause raynauds
atenolol
which b blockers can cause AV block
atenolol, betaxolol, metoprolol
which b blockers do not cause impotence?
acebutolol, esmolol, carteolol
which b blockers can cause xero
penbutolol, timolol
which b blocker can cause taste disorder?
labetalol
which b blocker can cause NO dependent vasodialtion
nebivolol
which b blocker exhibit mild intrinsic sympathomeitic activity
penbutolol, pindolol
which b blocker reduces portal pressure
propranolol, causes splanchnic vasoconstriction
dihydropyradine common adrs
reflex tachy, flushing, hypo, edema, ging hyper (usually)
which dihydropyradines may not have ging hyper
clevidipine, isradipine, nimodipine, nislodipine
which dihydropyradines may cause xero
nicardipine and nislodipine
what are the common adrs of non-dihydropyradines
constipation, lightheaded, dizzy, hypoten, bradycardia, ging hyper
which Rx may increase gag
digoxin
what rx should you avoid light in eyes
dogoxin and amiodarone
which class 3 drugs also block other channels/receptors
amiodarone and dronedarone
which class 3 drugs can cause QT prolong and TdP?
donfetilide, dronedarone, ibutilide, sotalol
which Rx can cause acute hepatic failure
dronedarone
which class I agents may alter taste
procainamide
lidocaine
propafenone
which class I Rx’s may cause xero?
disopyramide, mexilitine, propafenone
