lecture 3 Flashcards
_______are potent vasodilators that could cause reflex tachycardia
_______ decrease HR with some vasodilatory effect
DHP
NON- DHP (verapamil (diltiazem)
CCB MOA
block L type calcium channels
how do CCBs affect cardiac cells
Lead to decrease in chronotropy and inotropy
How do DHPs affect HR, contractility, conduction and vasodilation
Increase HR
decrease contractility
no effect on conduction
increase vasodilation
How does verapamil affect HR, contractility, conduction and vasodilation
decrease HR
GREATLY decreases contractility
GREATLY decreases AV node
Increases vasodilation
How does diltiazem affect HR, contractility, conduction and vasodilation
decrease HR
decrease contractility
decrease conduction
DO DHPs have a stronger vasodilatory effect in vasculature or heart
Much stronger vasodilatory effect
amlodipine brand name and dosing
Norvasc (5-10 mg)
Verapamil brand name and dosing
Isoptin, 60-90 mg TID-QID
diltiazem brand name and dosing
Cardizen, 80-120 mg TID
adverse effects of DHPs
DHPs- hypotension, flushing, dizziness, edema
adverse effects of non DHPs
non-DHP (verapamil, diltiazem)- hypotension, constipation, decreased myocardial contractility, Contraindicated in HF
monitoring parameters for CCBs
edema, BP
why are nitrates never used as monotherapy
Tolerance
how to avoid tolerance in nitrates
Nitrate free period of atleast 10-12 hrs
How does nitrate tolerance occur?
ALDH2 inactivation
How to use NTG patch
Put on in morning, take off at night (7 AM-7 PM)
on for 12-14 hrs, off for 10-12 hrs
How to use ISDN tabs
2-3 x a day
8 AM, 12 PM, 4 PM
10 mg
How to use ISMN tabs
2 X/day 7 hrs apart
8 AM and 3 PM
20 mg
ISMN SR tabs use
QD 8AM
30 mg
patient counseling nitrate patches
Apply patches between elbow and knee
clean, dry and hairless region
differet area each day
you can shower while wearing it
do not cut patch
wash hands before and after
counseling on NTG ointment
DO not rub or massage ointment
DO not cover area
what are the primary agents that cause vasodilator induced tachycardia
Nitrates and DHPs
Nitrates primary effect is on ______ and ______ (much more on _______)
pre load and afterload (much more on preload)
B blockers reduce
HR, contractility and BP
Nifedipine reduces
Preload and to a smaller extent afterload
does Ranolazine affect HR, contractility, afterload or pre load
no
How does Ranolazine work
Ranolazine inhibits Na channel and interrupts angina without affect HR, BP or afterload
Ranozaline brand name and dosing
Ranexa 500 mg ER tablets
When can ranolazine be used as 1st line tx
Only when BP/HR is too low for 1st line agents
ranolazine metabolized by
CYP3A4
What effect does ranolazine being metabolized by CYP3A4 cause
causes drug drug interaction. SHould not be used with pther strong 3A4 inhibitors or inducers
Name strong CYP3A4 inhibitors
Ketoconazole, itraconazole, protease inhibitors, clarithromycin
Name strong CYP3A4 inducers
carbamezapine, rifampin, st johns wort
how to adjust dose of ranolazine when taking with verapamil and diltiazem
500 mg BID
adverse rxns of ranolazine
Dose related increase in QT interval (should not be used with other QT prolonging drugs)
monoket
ISMN
Norvasc
amlodipine (QD)
when do we never use B blockers
if a patient has significant asthma. We can not use selective or non selective
what patients are B blockers specifically useful in?
Stable HF, history of MI
When to avoid B blockers? COntraindication?
Avoid in vasospastic angina
contraindicated in bradycardia (HR<50), high degree AV block or risk sinus syndrome
Which is first line? BB, CCB or nitrate
BB
If BB is contraindicated, what do we prefer to use
Non DHP CCBs
when do we use non DHP CCBs
- contraindication to B blockers
- unacceptable B blocker side effects
non DHP contraindications
HFrEF, bradycardia, high degree AV block or sick sinus syndrome
DHP contraindications
HFrEF (except amlodipine and felodipine)
Caution with nitrates
PDE 5 usage
clinical conditions that favor use of b blocker
Prior ACS/MI
HF, LVD, hyperthyroidism
name combo therapies
Nitrates + B blockers
DHP CCBs +B blocker
triple therapy (B blocker, nitrate and CCB)
WHat combo should be avoided? why?
B blocker and non DHP CCB sghould be avoided due to HR lowering
treatment algorithim of angina
-management of angina (use NTG)
-Is it vasospastic angina?
if yes (if BP<130/80 add nitrate, if BP>or=130/80 add CCB)
if no ( HR>60 use B blocker as 1st line and non DHP CCBs as second line)
If there is still angina
if BP<130/80 add ranolazine or nitrate
If BP >130/80 add DHP
treatment algorithim for risk factor modification
LSM
Vaccination
Aspirin or clopidogrel
ACE inhibitor
WHich NSAIDs should be used? which should be avoided
Select ibuprofen or naproxen as 1st alternative
avoid diclofenac
how to take ASA and NSAIDs
Take ASA 2 hrs before NSAID
What is a vasospasm
Ischemia associated with spasm.
Do vasospaqsm require plaque
no
Does vasospasm occur with or without exertion
At rest (no exertion)
symptoms of vasospasm
ST segment elevation
Mostly in early morning
Tx of vasospasm 1st line
CCB (1st line)
2nd line tx of vasospasm
Nitrate
What should we never use for vasospasms
B blockers
