HF, CAD, Angina Antiarrythmics Flashcards
Angina pectoris and goal of frug therapy
Sudden pain beneath the sternum, when oxygen supply to the heart is insufficient to meet oxygen demand
Goals:
- Prevent MI and death
- Prevent myocardial ischemia and angina pain
Three families of antianginal agents
Organic nitrates
Beta blockers
CCB
Oxygen demand is based on these three things
Heart rate , MI contractility , intramyocardial wall tension ( preload/ afterload)
Oxygen supply needs 2 things
Myocardial blood flow
Myocardial perfusion only in diastole
Chronic stable angina
Tx: increase oxygen supply and demand
By :
Organic nitrates, BB, CCB
Education: always avoid risk factors
Variant Angina
Coronary artery spasm
Want to reduce incidence and severity
TX: increase cardiac oxygen supply
With : CCB, nitrates
Organic nitrate: Nitroglycerin
Isosrbide mononitrate and isosorbide dinitrate
Vasodilator vascular smooth muscle and decreases o2 demand
Adverse : HA, orthostatic hypotension, reflex tachycardia
Contraindications: Viagra, Cialis
Tolerance : drug holidays
Wean and taper
Uses: rapid onset used for acute prophlyaxis and ongoing angina
Beta blocker
Decrease cardiac oxygen demand
Propanolol and metoprolol
Adverse: bradycardia, asthmatic effects
Calcium channel blockers
Block calcium channels in vascular smooth muscle
Reduces after-load and cardiac demand
Used for stable and variant angina
Adverse: hypotension, HF, AV block
Ranolazine ( ranexa)
Antianginal agent and anti-ischemic
Adverse: tornadoes due to QT prolongation
Prevention of MI
For pt with chronic stable angina:
- anti-platelet drugs:
- ASA 81
- Plavix 75
- cholesterol drug
- ACE for people with CAD and DM
If nitro not working
- add beta blocker
- add CCB
- refer to cards
Systolic HF signs
Left sided HF
Right sided HF
Heptoslpenomegly ( palpate spleen and liver)
JVD, peripheral edema
Impaired EF
Diastolic HF
HF with preserved LV ejection fraction
Pulmonary congestion
JVD, peripheral edema
Increased left atria pressure leas to a fib
Heart failure definition
Progressive, fatal
Characterized by left ventricular dysfunction, right sided engorgement, reduced cardiac output , insufficient tissue perfusion , signs of fluid retention
Treatment goals for HF
To relieve symptoms , reduce morbidity and mortality , improve QOL, decrease preload and afterload
Improve contractility and decrease HR
Drugs for HR ( overview)
Diuretics , RAAS inhibitors, beta blockers, digoxin, dopamine, hydralazine
Thiazide diuretics
Produce mild to moderate diureses with early state HF
Decreases preload / after load
Decreases pulmonary and peripheral edema
Precaution : ineffective in pt with low GFR
Adverse: hypokalemia
High ceiling loop diuretics
Drug of choice in pts with moderate to severe HF
Lasix, bumex, demaex
Adverse: hypokalemia, dig toxicity , ototoxicity, hyperglycemia
Potassium sparing diuretics
Aldosterone blocker and diuretic that works on distal tubule
Used to counteract K loss
Use cautiously in pt prescribed ACE inhibitors and ARB’s = hyperkalemia
Drugs that inhibit the RAAS
ACE, ARBS, beta blocker , hypertensive drugs, aldosterone inhibitors
ACE inhibitor
Angiotensin - converting enzyme
- dilation of venous and arteriolar
Adverse: hyperkalemia, cough, angioedema
Do not give in pregnant women
Give ARB if cough is not tolerable
ARB’s
ARB’s improve LV ejection fraction, reduce HF symptoms, increase excerise tolerance, decrease hospitalizations, enhance QOL
ARBS do not increase levels of Kinins like ACE do
Drugs that end in SARTAN
Drugs approved form HF :
Atacand, Diovan, Cozaar
Aldosterone antagonist
Spironolactone
Added it in standard HF therapy in patients with moderately severe symptoms
Beta blockers
Protects from excessive sympathetic stimulation
Slows progression of HF
Improves LF function
Protect against dysrhythmias
Adverse: fluid retention, fatigue, bradycardia
Meds: Corey, Toprol XR, Zebeta
Cardiac Glycoside : Digoxin
Does not prolong life and no longer 1 st line
Only improves cardiac output
Adverse : cardiac dysrhythmias , hypokalemia
Caution in elderly
Takes 6 days for the drug level to reach plateau
Under 2 ng/ml = therapeutic
Digoxin toxicity
Long half and narrow therapuetuc window makes it high risk for toxicity
Signs: yellow/green halo , confusion bradycardia,
Management of heart failure :
Stage A,
A = reducing risk factors
Management for HF : stage B
B = goal to prevent symptomatic HR add ACE or ARB
Management for HF stage C
- Relieve pulmonary and peripheral congestive symptoms
- Improve function capacity and QOL
- Slow cardiac remodeling and progression of LV dysfunction
- Prolong life
Use drugs
Avoid : CCB, NSAIDS, ASA, antidysrhytmic drugs
Management of HF stage D
Marked symtoms of HF
Repeated hospitalization
Best solution : heart transplant
Management : control fluid retention,
Don’t use beta blacker = high risk of worsening HF
Antidysrhythmic Drug overall thoughts
All have potential for serious adverse effects
Virtual all drug that treat dysrhythmias can also cause dysrhythmias
Most uses in primary care have other indication
Consult cardiology on these drugs
Geriatrics and antiarythmics
With age comes decrease conduction fibers which predisposes them to benign arrhythmias
Treatment brings more ADR
Amiodarone and dig have decreased clearance and increased half life
Monitor CrCL and hepatic FX
Pediatrics in antiarytmics
Congenital heart defects put those patients at higher risk to develop arrhythmias , HF, and heart valve infection
No long term studies effectiveness of any of the drugs
Pregnant and lactation for AA
Drugs are excreted in breast mike
Dronedarone - CAT X
Most cat C
Key points to anticoagulants
Anticoagulants affect various stages in the clotting cascade whereas anti-platelet affects components in platelet aggregation
Monitoring parameters on heparin and warfarin
