Module 5 Cardiac Flashcards
What is the BP goal for >60 with no chronic kidney disease (CKD) or diabetes?
<150/90
BP goal for <60?
<140/90
BP goal for >18 with CKD or diabetes?
<140/90
Initial tx for HTN per JNC8?
Individualized; Can be ACE, ARB,CCB or diuretic
What is the preferred diuretic?
Chlorthalidone, which is in the thiazide class
What is the recommended initial tx in blacks?
Thiazide diuretic or CCB.
First step for treating hypertension is ______________ unless BP is _________.
Lifestyle modifications; 160/100
Diuretics - Actions
Action takes place on different parts of the renal tubule. Blocks active reabsorption of Na and Chloride.
Increases: Urinary Na excretion, which increases water excretion.
Decreases: extracellular fluid and/or plasma volume
Acute effect: decreases stroke volume and cardiac output; Chronic effect: Decreased TPR, peripheral vascular resistance with normal CO , by unknown mechanism
Thiazide Diuretics - Side Effects
hypokalemia, dehydration, hyperuricemia, impaired glucose tolerance
Thiazide Diruetics - Contraindications
gout, renal failure, hypersenstiviity to sulfonamides
*May worsen diabetes
Angiotensin Converting Enzyme (ACE) Inhibitors : Actions
Inhibit ACE, which is responsible for converting angiotensin I to angiotensin II; also inhibits the degradation of bradykinin (kinin II) and increases the synthesis of vasodilating prostaglandins. The result is vasodilation, decreased blood volume, and prevention or reversal of pathologic changes in the heart and blood vessels mediated by angiotensin II and aldosterone.
Angiotensin Converting Enzyme (ACE) Inhibitors : Side Effects
Nonproductive cough
Angioedema
Angiotensin Converting Enzyme (ACE) Inhibitors : Contraindications
Patients taking K+ sparing diuretics
Renal artery stenosis
Pregnancy- teratogenic effects
Angiotensin receptor blockers: Actions
- ARBs block the actions of angiotensin II in blood vessels, the adrenals, and all other tissues.
- ARBs are similar to ACE inhibitors in that they cause vasodilation, suppress aldosterone release, promote excretion of sodium and water, reduce blood pressure.
Angiotensin receptor blockers: Side Effects
BIrth defects, angioedema
Angiotensin receptor blockers: Contraindications
pregnancy
Calcium channel blockers: Actions
Inhibit the movement of calcium ions across the cell membrane. Results in decreased myocardial contractility (negative ionotropic force), slowed rate of ventricular contractions, coronary artery dilation, peripheral arterial dilation, and reduced peripheral resistance. They work by blocking the movement of calcium into the cell membranes of the cardiac and smooth muscle.
Calcium channel blockers: Side Effects
Can cause reflex tachycardia- (use beta blocker in combination to control this). Bradycardia
Causes peripheral edema, primarily in lower extremities
Are not to be used with patients who are in heart block.
Contribute to acid reflux as they inhibit contraction of LES.
Multiple drug-drug interactions
**• Because of their cardiosuppressant effects, verapamil and diltiazem can cause bradycardia, partial or complete AV block, and exacerbation of heart failure.
• Beta blockers intensify cardiosuppression caused by verapamil and diltiazem.
Calcium channel blockers: Contraindications
Heart block
Beta Blockers: Actions
Achieve their effects by competing for adrenergic receptor binding sites. Prevent epinephrine from activating the heart causing a decrease cardiac output by decreasing the rate, contractility, and conduction velocity of the heart. Peripheral vascular resistance is decreased; mechanism is unknown. May decrease sympathetic activity & ventricular remodeling- used in stable heart failure patients
Beta Blockers: Side Effects
Bradycardia Postural hypotension Fatigue & dizziness Worsens asthma: Blocking of beta receptors may cause bronchial constriction. Selective beta 1 blockers have less risk, as they mainly affect heart- metoprolol & atenolol. Noncardioselective are propranolol & nadolol May worsen depression Sexual dysfunction Increase serum triglycerides
Beta Blockers: Contraindications
May mask effects of hypoglycemia & inhibit glycogenolysis, therefore not recommended for diabetes
Not recommended in heart block, COPD, asthma, bradycardia or severe heart failure
Avoid with PVD
Caution with exercise enthusiasts
Direct -acting vasodilators (relax vascular smooth muscle): Actions
Cause arteriolar smooth muscle relaxation. Reserved for severe or essential hypertension
Direct -acting vasodilators (relax vascular smooth muscle): Side Effects
Edema & tachycardia
Direct -acting vasodilators (relax vascular smooth muscle): Contraindications
CAD & rheumatic hd
Alpha Blockers: Actions
Work on alpha receptors & block primarily norepinephrine causing vasodilation.
Alpha Blockers: Side Effects
Dizziness Orthostatic hypotension Palpitations Bradycardia Edema
Alpha Blockers: Contraindications
Cardiovascular disease
Concomitant use of selective phosphodiesterase type 5 (PDE5) inhibitors, ie. tadalafil(Cialis) & vardenafil (Levitra)
Utilize one antihypertensive drug for __________. If not at goal either ___________or ________________.
(per JNC8)
one month; increase dose; add a second agent.
What is DASH diet?
Heart healthy diet with sodium restriction.
Which lifestyle change has the largest effect on reducing BP?
Weight loss and next is DASH diet
Natural products that elevate BP?
Ginseng, yohimbe, mahaung, and black licorice
Which classes work on the sympathetic nervous system?
Anti-adrenergics: Alpha Blockers, Beta Blockers, and centrally acting drugs.
Calcium Channel Blockers
Which class works on vascular tone?
Vasodilators
Which classes work on vascular volume?
Diuretics, ACE, & ARB
Goal of antihypertensive therapy?
Reduce cardiovascular and renal morbidity and mortality.
Which diuretics produce the greatest diuresis?
High ceiling (LOOP diuretics) which work in the loop of henle
Loop Diuretics: Side Effects
Hypokalemia Hyponatremia Hypocalcemia Hypomagnesemia Orthostatic hypotension Dehydration Hearing loss (reversible)
Loop Diuretics: contraindications
anuria, hypersensitivity to sufonylureas, hepatic coma, severe electrolyte depletion
Which diuretic works when the GFR is low?
Loop
Hypokalemia caused by diuretics is a special problem for patients taking _________________.
Digoxin; Hypokalemia and Hypomagnesium can cause cardiac arrhythmias
Loop diuretics (high ceiling) can cause hypotension by decreasing ______________ and relaxing _________________.
blood volume; venous smooth muscle
Thiazide diuretics work in the _____________.
distal convoluted tubule.
Common thiazides
Hydrochlorthiazide, Chlorthalidone
Thiazide diuretics may be beneficial for people with ________________. Why?
Osteopenia; decreased calcium excretion
Do loop diuretics decrease or increase calcium?
decrease calcium reabsorption - bad for pt with osteopenia
Common Loop diuretics
Furosemide (Lasix)
Bumetanide (Bumex)
How do Potassium sparing diuretics work?
directly or indirectly block sodium-potassium “exchange” in the distal convoluted tubule.
Risk with K sparing diuretics? (Spironolactone, Triamterene)
Hyperkalemia
K sparing diuretics should not be used with…
K supplements, and cautiously with ACEs, ARBs, and direct renin inhibitors
Where are beta 1 receptors?
Predominate in cardiac tissue (cardioselective)
Where are beta 2 receptors?
Bronchial and vascular smooth muscles, as well as liver.
Should beta blockers be given after an MI?
Beta blockers should be given for 2 to 3 years after a heart attack. The two most effective beta-blockers that improve CV outcomes are carvedilol and metoprolol ER.
Which beta blocker should be avoided?
Atenolol
Differentiate between selective and nonselective beta blockers.
Although both receptors affect blood pressure, those which are cardioselective (Beta 1 receptors) have reduced risk of bronchoconstriction and gluconeogenesis in the liver. (Example: B 1 selective: Metoprolol (Lopressor), atenolol Nonselective:, Timolol (Betim), Propranolol (Inderal).
Alpha and Beta Blockers are _________________.
Peripheral adrenergic receptor blockers
Centrally acting adrenergic receptor drugs: Action
block neurotransmitters that activate the sympathetic nervous system. These drugs affect the vasomotor center in the brain by limiting the sympathetic outflow to the heart and blood vessels. They are typcially used in combination with other antihypertensives.
Example: methyldopa (Aldomet®) & clonidine (Catapress).
Can beta blockers be stopped suddenly?
No, they must be tapered.
What drug is a B2 agonist?
Terbutaline - mimics the sympathetic nervous system; promotion of norepinephrine release, blockade of norepi uptake, and inhibition of norepi breakdown.
What does activation of alpha 1 receptors cause?
Vasoconstriction & mydriasis; (peripheral alpha 2 activation of minimal significance, but activation in CNS has useful effects)
What are alpha 1 agonists used for? Adverse effects?
Hemostasis, nasal decongestion, and elevation of BP. Hypertension and local necrosis.
Activation of beta 1 (cardiac) receptors increases ___________, ____________, & ___________.
heart rate, for of cardiac contraction, conduction through the AV node.
Beta 1 agonists are used to treat (3): The adverse effects are (3):
heart failure, AV block, and cardiac arrest; tachycardia, dysrhythmias, and angina.
Beta 2 agonists are used to treat _________ & ___________. The adverse effects are:
asthma & PTL; hyperglycemia & tremor
Benefits of alpha blockers:
The alpha blockers have the benefit of lowering LDL cholesterol and elevating HDL. The alpha blockers may also improve insulin sensitivity. These drugs also relax the smooth muscles surrounding the prostate which relieves constriction of the urethra which facilitates urination.
ACEIs slow the progression of _____________ & _________________.
renal disease and heart failure.
ACE inhibitors are used to treat:
hypertension, heart failure, myocardial infarction (MI), and nephropathy, both diabetic and nondiabetic. In addition, they are used to prevent MI, stroke, and death (from cardiovascular causes) in patients at high risk for a cardiovascular event.
What can reduce the effectiveness of ACEIs?
NSAIDs
What does calcium do in the heart?
• In the heart, calcium entry increases heart rate, atrioventricular (AV) conduction, and myocardial contractility, and hence calcium channel blockade has the opposite effects.
Central alpha 2 receptor agonists should be used in conjunction with a _____________
diuretic
Difference between DHP CCB and other CCB?
DHP drugs do not affect the cardiac conduction system, and thus are not used for cardiac arrhythmias. (Procardia, Norvasc)
-olol
beta blocker
-sartan
ARB
-pine
CCB
-pril
ACEI
-azosin
Alpha 1 blocker
