HF, CAD, Angina Antiarrythmics

Question 1

Angina pectoris and goal of frug therapy

Answer 1

Sudden pain beneath the sternum, when oxygen supply to the heart is insufficient to meet oxygen demand

Goals:

1. Prevent MI and death
2. Prevent myocardial ischemia and angina pain

Question 2

Three families of antianginal agents

Answer 2

Organic nitrates
Beta blockers
CCB

Question 3

Oxygen demand is based on these three things

Answer 3

Heart rate , MI contractility , intramyocardial wall tension ( preload/ afterload)

Question 4

Oxygen supply needs 2 things

Answer 4

Myocardial blood flow

Myocardial perfusion only in diastole

Question 5

Chronic stable angina

Answer 5

Tx: increase oxygen supply and demand

By :
Organic nitrates, BB, CCB
Education: always avoid risk factors

Question 6

Variant Angina

Answer 6

Coronary artery spasm
Want to reduce incidence and severity

TX: increase cardiac oxygen supply

With : CCB, nitrates

Question 7

Organic nitrate: Nitroglycerin

Isosrbide mononitrate and isosorbide dinitrate

Answer 7

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

Question 8

Beta blocker

Answer 8

Decrease cardiac oxygen demand

Propanolol and metoprolol

Adverse: bradycardia, asthmatic effects

Question 9

Calcium channel blockers

Answer 9

Block calcium channels in vascular smooth muscle

Reduces after-load and cardiac demand

Used for stable and variant angina

Adverse: hypotension, HF, AV block

Question 10

Ranolazine ( ranexa)

Answer 10

Antianginal agent and anti-ischemic

Adverse: tornadoes due to QT prolongation

Question 11

Prevention of MI

Answer 11

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

Question 12

Systolic HF signs

Answer 12

Left sided HF
Right sided HF
Heptoslpenomegly ( palpate spleen and liver)

JVD, peripheral edema
Impaired EF

Question 13

Diastolic HF

Answer 13

HF with preserved LV ejection fraction

Pulmonary congestion
JVD, peripheral edema

Increased left atria pressure leas to a fib

Question 14

Heart failure definition

Answer 14

Progressive, fatal
Characterized by left ventricular dysfunction, right sided engorgement, reduced cardiac output , insufficient tissue perfusion , signs of fluid retention

Question 15

Treatment goals for HF

Answer 15

To relieve symptoms , reduce morbidity and mortality , improve QOL, decrease preload and afterload

Improve contractility and decrease HR

Question 16

Drugs for HR ( overview)

Answer 16

Diuretics , RAAS inhibitors, beta blockers, digoxin, dopamine, hydralazine

Question 17

Thiazide diuretics

Answer 17

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

Question 18

High ceiling loop diuretics

Answer 18

Drug of choice in pts with moderate to severe HF

Lasix, bumex, demaex

Adverse: hypokalemia, dig toxicity , ototoxicity, hyperglycemia

Question 19

Potassium sparing diuretics

Answer 19

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

Question 20

Drugs that inhibit the RAAS

Answer 20

ACE, ARBS, beta blocker , hypertensive drugs, aldosterone inhibitors

Question 21

ACE inhibitor

Answer 21

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

Question 22

ARB’s

Answer 22

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

Question 23

Aldosterone antagonist

Answer 23

Spironolactone

Added it in standard HF therapy in patients with moderately severe symptoms

Question 24

Beta blockers

Answer 24

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

Question 25

Cardiac Glycoside : Digoxin

Answer 25

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

Question 26

Digoxin toxicity

Answer 26

Long half and narrow therapuetuc window makes it high risk for toxicity Signs: yellow/green halo , confusion bradycardia,

Question 27

Management of heart failure : | Stage A,

Answer 27

A = reducing risk factors

Question 28

Management for HF : stage B

Answer 28

B = goal to prevent symptomatic HR add ACE or ARB

Question 29

Management for HF stage C

Answer 29

1. Relieve pulmonary and peripheral congestive symptoms 2. Improve function capacity and QOL 3. Slow cardiac remodeling and progression of LV dysfunction 4. Prolong life Use drugs Avoid : CCB, NSAIDS, ASA, antidysrhytmic drugs

Question 30

Management of HF stage D

Answer 30

Marked symtoms of HF Repeated hospitalization Best solution : heart transplant Management : control fluid retention, Don’t use beta blacker = high risk of worsening HF

Question 31

Antidysrhythmic Drug overall thoughts

Answer 31

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

Question 32

Geriatrics and antiarythmics

Answer 32

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

Question 33

Pediatrics in antiarytmics

Answer 33

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

Question 34

Pregnant and lactation for AA

Answer 34

Drugs are excreted in breast mike Dronedarone - CAT X Most cat C

Question 35

Key points to anticoagulants

Answer 35

Anticoagulants affect various stages in the clotting cascade whereas anti-platelet affects components in platelet aggregation Monitoring parameters on heparin and warfarin