Jill Pharm Flashcards
Tx goals in Ischemic Heart disease
Short term
Reduce or prevent symptoms of angina that limit exercise capability and impair QoL
Restore balance between supply and demand
Tx goals of ischemic heart dz
Long term
Prevent CHD events such as MI, arrhythmia, HF
Prevent morbidity and mortality
Classes of drugs in angina pectorals
Cardio selective beta blockers
Calcium channel blockers
Nitrates
First line maintenance therapy for stable angina
Beta blockers
MOA BB
Inhibit catecholamine neurotransmitters at B1 and B2 receptors
Lower HR and force of contraction, plasma renin activity
Prevent sympathetic response to exercise or stress
Increase coronary blood flow and decrease HR, contractility, wall tension
Beta blockers subtypes
Cardioselective - MC, decreased mortality, better in pts with HF, asthma, COPD, Dm
Non selective - no mortality data, worse for COPD/asthma/cough
BB use in therapy
Only anti-angina drug proven to prevent re-infarction and improve survival in pts with MI
NOT used in patients with vasospastic angina (can increase vasospasm)
What must be monitored in BB use?
HR (dc if <55bmp)
BP (dc if <115)
Nitrate usage and angina symptoms
Nitrates MOA
Converted to nitric oxide to cause venous dilation (some arterial)
Increase myocardial oxygen supply
Decrease in myocardial oxygen demand
Nitrate formulations
IV NTG (acute CP, HTN)
SL NTG (Acute CP)
Isosorbide dinitrate (chronic CP)
Isosorbide mononitrate (chronic CP)
NTG patch (chronic CP)
Side effects of nitrates
Tolerance (tachyphylaxis due to reduced C-GMP, can happen right away)
Headache
Flushing
Orthostasis
Nitrate drug interactions
PDE-5 inhibitors (pulmonary HTN and ED)
Contraindications for nitrates
PDE-5 inhibitors in past 24 hrs
Hypertrophic cardiomyopathy
Use with caution in aortic stenosis (decreased pre-load) and volume depletion
Monitoring in nitrates
BP, HR (may have hypotension, tachycardia)
SL PRN usage and CP
Sublingual nitroglycerin
Taken PRN (max 3 tabs or sprays 5 min apart over 15 min)
HA can mark potenentcy, sit down before placing under tongue and dont chew or swallow
Long acting nitrates
Isosorbide mononitrate - extended release, 1 per day
Isosorbide dinitrate - 2-3 times per day
Not PRN, given every day for stable angina (no acute episodes)
Calcium channel blockers MOA
Blocks calcium entry into vascular smooth muscle cells
Non-DHP = decrease HR and contractile force (verapamil, dilitiazem)
DHP = decrease smooth muscle tone vascular to decrease SVR (amlodipine, nifedipine, felodipine)
CCBS use and monitor
Use for stable angina when BB are CI or stopped bc of ADRs
Combo with BB when BB and nitrates are not enough
Monitor: HR, BP, PRN nitrate use, angina symptoms, edema, constipiation, rash
ranolazine (Ranexa)
Use/MOA
Inhibits late phase of sodium channel
Prolongs ventricular AP
Reduces ventricular tension
Decrease oxygen demand
NO EFFECT ON HR or BP
Chronic stable angina in combo therapy or inadequate response with other anti-angina agents
Side effects of Ranolazine
Constipation
Headache
Nausea
Dizziness
LOW DC RATE, avoid in pts with cirrhosis
Ranolazine drug drug interactions
D- digoxin A - azole derivatives N - non-DHP CCB G - grapefruit S- Simvastatin
Ischemic heart disease treatment goals
- Alteration of atherosclerosis via risk factor modification
- Provide symptomatic relief using pharm agents
Risk factor - post menopausal hormone replacement
Associated with lower CHD
HERS trial (no difference, increased thromboembolism issues)
Women’s health initiative (increases CHD, stroke, emboli events, breast cancer)
NOT recommended in primary or secondary prevention
Acute coronary syndromes
Treatment goal
Relieve chest discomfort
Optimize blood flow to infant or related artery
Prevent coronary occlusion
Prevent death
Acute drug therapy (8)
Analgesia Nitroglycerin Lidocaine Beta blockers Fibrinolytics Asa Heparin Mg
drugs NOTused during acute MI
Digoxin Nitroprusside CCB NSAID Enalapril Steroids
“Do Not Consider in aN Emergent Setting”
Morphine
DOC and MOA
DOC for acute management of pain with MI NOT RELIEVED WITH NG OR BB
Blocks sympathetic efferent discharge causing venous and arterial dilation
Morphine dose and monitor
1-5 mg IV q 5-15 min
Pain relief, allergic response, vitals (BP, HR, RR), CNS/respiratory depression
Can be reversed with NARCAN
Nitroglycerin in an acute setting
Relieves pain decreasing preload and oxygen demand
SL nitro first, then IV drip if pain persists (should have gotten SL in ambulance)
Avoid in BP <90, CI in cases of RV INFARCTION
Don’t use for more than 48hrs (unless persistent CP, HF, or HTN)
Oxygen in an acute setting
Indicated in patients with O2 Sat under 90– otherwise induce vasospasm
Given to pts with high oxygen demand
Don’t over do in COPD
Beta blockers in the acute setting
Actions
Immediate administration reduces the size of infarction via improving perfusion
Decreases further infarction, recurrent ischemia, reinfarction
Decreases mortality
Decrease ventricular arrhythmia
Administration BB acute setting
Oral in first 24 hrs to pts w/o CI
IV can be used, but not better (can cause HoTN)
No benefit if given prior to PCI
Titration to HR of 70 bpm
CI to BB in acute setting
Signs of HF
Bradycardia (<55bpm)
HoTN/cardiogenic shock
Greater than first degree AV block
ACTIVE asthma and bronchospasm
CCB in acute MI setting
symptom relief ONLY (after event normally)
NSTEMI (no relief despite max BB and nitrates — still choose morphine)
Pts with ACS, unable to tolerate BB
Typically in drugs that we avoid
Anti-coagulation during acute event
Stops propagation of clot and assists in preventing re-occlusion
unstable angina or NSTEMI - LMWH preferred or UFH
UFH is given in PCI bc less drug interactions
Alternative to heparin in anticoagulant tx in acute event
Fondaparinux (Arixtra)
Bilvalrudin (angiomax) - direct thrombin
Rivaroxaban (Xarelto)
ASA
MOA, ADR, CI
Block Cox1 and Cox 2 = Decreased thromboxane A2 formation
ADRS= GI bleed, hypersensitivity, bleeding
CI: EtOH use, high dose in CKD, children and teens, pregnancy
Thienopyridines
Plavix (CLopidogrel)
Prasugrel (Effient)
Ticagrelor (Brilinta)
Blocks activation of GP 2b/3a receptor, reducing platelet aggregation
Clopidigrel
Indications, brand, dosing
Plavix
MI/ACS (UA/NSTEMI/STEMI)
Stroke
PAD
Dosing: 75mg/day, 300-600mg loading dose
Plavix ADR
bleeding (esp. >70 or <60kg)
TTP
CKD can cause problems with serum [ ]
Poor metabolizers - genetic disorder causing ineffective breakdown
Prasugrel (Effient)
Indications and pharmacokinetics
ACS, CAD
C/i in patients older than 75 or history of stroke/TIA
No renal or hepatic adjustments needed but liver might be
Prasugrel Effient
Dose, BBW
Dose: loading 60mg, 5-10 daily
BBW: d/c in >75 yrs (fatal intercranial bleeding and uncertain benefit), hold 7+ days prior to six
Ticagrelor
Brand, indications, dose
Brilinta
ACS, CAD
Dose: 180 mg loading, 90 mg bid
Brilinta
ADR, BBW
Ticagrelor
ADR: increased bleeding risk, dypsnea, caution in gout
BBW: reduced efficacy with ASA use (low dose only), dc 5 days before sx, metabolized by liver, tablets crushed
IV GP 2b/3a
Used during PCI
Intense inhibition of platelet function
Fibrinolytics
late please
Activates plasminogen (converts plasmin)
Beneficial in limiting infarct size, improving LV function and reducing mortality
12-24 hrs of CP (significant ST elevation, invasive strategy is not option)
UFH/LMWH/fondaparinux
