Ischaemic (Coronary) Heart Disease & Chronic Heart Failure

Question 1

Drugs to use for Heart Failure (9 classes)

Answer 1

ACE inhibitors
Ag II Receptor Blockers
Sacubitril-Valsartan
Beta Blockers (Bisoprolol, Carvedilol, Metoprolol XL, Nebivolol)
Diuretics (Loop)
Mineralocorticoid receptor antagonists
Hydralazine
Ivabradine
Nitrates

Question 2

Nitrates Examples

Answer 2

For HF: Nitroglycerin (GTN)

For Angina:
Isosorbide mononitrate (ISMN)
Isosorbide dinitrate (ISDN)

Question 3

ISDN Administration & PK

Answer 3

Oral
Onset: 60min
Duration of action: 8h (IR), 12h (SR)

Question 4

ISMN Administration & PK

Answer 4

Oral
Onset: 30-45min
Duration of action: 6h (IR), <24h (SR)

Question 5

Nitroglycerin PK

Answer 5

Sublingual:
Onset 1-5min
Duration: 10-30min (immediate relief of angina)

Transdermal:
Onset: 30-60min
Duration: 7-10h (prevent angina)

Question 6

Nitrates MOA

Answer 6

Vasodilation of veins & arteries:
Veins – lower preload
Arteries – decrease afterload

Question 7

Nitrates ADR

Answer 7

Tachycardia due to baroreflex
Hypotension due to venodilation
Headache due to meningeal artery vasodilation

Question 8

Drugs to use for Coronary Heart Disease & Angina

Answer 8

Beta blockers
Calcium channel blockers
Ivabradine
Nitrates

Question 9

Beta Blockers for HF Names

Answer 9

Carvedilol
Bisoprolol
Metoprolol
Nebivolol

Question 10

Sacubitril-Valsartan MOA

Answer 10

During HF, brain natriuretic peptide (BNP) increases, promotes vasodilation, antagonizes RAAS. BNP broken down by neprilysin

Sacubitril - neprilysin inhibitor, prolongs BNP effects (good for HF)

But neprilysin also breaks down Ag II (bad for HF)

Valsartan - AT1 blocker, avoid negative effects of Ag II

Question 11

Sacubitril-Valsartan ADR

Answer 11

Hypotension
Hyperkalemia
Renal failure
Cough
Angioedema

Question 12

Ivabradine MOA

Answer 12

Pure heart rate lowering agent for angina pectoris
Also for chronic HF with systolic dysfunction, in patients with sinus rhythm with HR > 75bpm
Cardiac pacemaker current that controls spontaneous diastolic depolarisation in sinus node, regulates HR

Question 13

Ivabradine ADR

Answer 13

Visual problems: luminous phenomena, transient enhanced brightness in limited area of visual field
Bradycardia: dizziness, hypotension, fatigue, malaise

Question 14

Cardiac glycoside names

Answer 14

Digitalis - Digoxin

Question 15

Digitoxin vs Digoxin

Answer 15

Digitoxin: extensive M by liver, E in feces
Digoxin: not extensively M, 2/3 E unchanged in kidney

Question 16

Digitalis MOA

Answer 16

Inhibits Na-K exchange, increase Na
Increased Na leads to less Ca efflux, stronger systolic contraction

Question 17

Digitalis Effects

Answer 17

Mechanical:
Higher CO, higher carotid sinus firing, lower sympathetic activity/ higher CO, higher renal blood flow, lower renin release, lower Ang II –> lower preload & afterload

Electrical: Increase parasympathetic, lower AV conduction, increase PR interval, lower ventricular rate

Toxic: Increase intracellular Ca, tachycardia, fibrillation

Question 18

Digitalis Uses

Answer 18

Systolic dysfunction
Atrial fibrillation

Question 19

Digitalis ADR

Answer 19

Progressively more severe dysrhythmia: AV block, AF, VF
GIT: nausea, anorexia, vomiting
CNS: headache, fatigue, confusion, blurred vision

Question 20

Digitalis toxicity treatment

Answer 20

Discontinue cardiac glycoside therapy
Correct Mg/K deficiency
Antiarrhythmic drugs (if increase automaticity predominant - lidocaine, propranolol)
Digoxin antibody (FAB fragments, digibind)