NS, CV and renal pharmacology Flashcards
What is the treatment for second and third degree heart block?
Emergency treatment required - Atropine (IV) or Isoprenaline (IV)
Class I Anti-arrhythmic drugs
Sodium channel blockers
Class II anti-arrhythmic drugs
Beta blockers
Class III anti-arrhythmic drugs
K+ channel blockers/Prolong A.P duration
Class IV anti-arrhrhymic drugs
Calcium channel blockers
What are the differences between Class Ia,b and C anti-arrhythmic drugs?
Differences due to recovery/unbinding of drugs
What is the main affect of Class I anti-arrhrhymic drugs?
Block Na+ channels to decrease phase 0 - depolarisaiob
Dysopyramide
Sodium channel blocker (Class 1A anti-arrhythmic drug) used to treat ventricular arrhythmias
Lidocaine (IV)
Sodium channel blocker (Class 1b anti-arrhrhymic drug) used in treatment prevention of ventricular tachycardia and fibrillation during and immediately after myocardial infarction
Flecainide
Sodium channel blocker (Class 1c anti-arrhrhymic drug) used to prevent paroxysmal atrial fibrillation and recurrent tachyarrythmias associated with abnormal conduction pathways
Amiodarone, sotalol, Bretylium
K+ channel blockers, prolong A.P depolarisation
What is Amidarone used to treat?
Tachycardia associated with WPW syndrome
What is Sotalol used to treat?
used in paraxysmal supraventricular dsyrthmias and suppresses ventricular ectopic beats, and short runs of ventricular tachycardia
outline the mechanism of CCB’s
act on L-type channels, shorten the plateau of the AP and reduce the force of contraction. Reduced Ca2+ entry reduces after depolarisation and thus suppresses premature ectopic beats
Veramapil
CCB
Diltiazem
CCB
outline the side effects of CCBs?
bradycardia, negative inotropic effect, constipation (verapamil), hypotension (diltiazem)
Loop diuretics, site of action
Act on thick ascending limb (TAL) of loop of Henle to inhibt Na+/K+/Cl-
Furosemide, Butetamide
Loop diuretics
Thiazides site of action
Distal tubule
Why might thiazides be preferred over loop diuretics?
Thiazides are less powerful than loop diuretics so preferred in treating uncomplicated hypertension. In contrast to loop diuretics thiazides reduce Ca2+ excretion and so is favourable in elderly patients
Thiazides mechanism of action
Bind to the Cl- site of distal tubular Na+/Cl- cotransport system inhibiting its action causing natriuresis with loss of Na+ and Cl-, results in reduced blood volume.
Clinical uses of thiazide diuretics
Hypertension, mild heart failure (loop diuretics preferred), severe resistant oedema, nephrogenic diabetes insipidus
Adverse effects of loop diuretics and thiazides
hypotension, gout, hypokalemia (caues dysrhythmias, increased digoxin toxicity and hyperglycaemia)
Potassium sparing diuretics- site of action
Act exclusively on distal parts of nephron: collecting tubule and collecting duct
Aldosterone antagonist - mechanism of action
Competitive inhibtion of intracellular aldosterone receptors, decreases the numbre of luminal Na+ channles and decreases number of basolateral Na+-K+-ATPases. This inhibits Na+ retention and K+ secretion
Spironolactone
Potassium sparing diuretic - aldosterone antagonist
Na+ channel blockers - mechanism of action
Inhibit Na+ re-absorption by blocking lumenal sodium channels and decreasing K+ excretion
Triameterene, Amiloride
Potassium sparing diuretic - Na+ channel blockers
Clinical uses of potassium sparing drugs
used with K+ losing diuretics, heart failure, primary aldosteronism (conns syndrome), resistant essential hypertension, secondary hyperaldosteronism caused by hepatic cirrhosis complicated by ascites
Osmoitic diuretics - site of action
Main effect is exerted on parts of the nephron that are FREELY permeable to water: proximal tubule, descending limb of the loop and collecting tubules
Osmotic diuretics - mechanism of action
Increase filtrate osmolairty, passive water reabsoprtion is reduced by the presence of non reabsorbable solute within the tubule
Clinical use of Osmotic diuretics
Used in emergency treatment of acutely raised intraocular or intracranial pressure
Clinical uses of carbonic anhydrase inhibitors
Glaucoma, altitude sickness, little use as a diuretic drug due to rapid tolerance
What is nephrotic syndrome?
Increased permeability of the glomerular basement membrane to proteins leading to proteinuria. Increases volume of interstitial fluid leading to tissue swelling and activation of RAAS.
Treatment of glomerular nephritis
Antihypertensive, loop diuretic, immunosuppresive
Consquences of glomerular nephritis
Acute renal failure, chronic renal failure, dialysis or transplantation
Acute Kidney Injury
Abrupt reduction in kidney function resulting in failure to maintain fluidm electrolye, and acid-base homeostasis. Decreased urine production and fluid-electrolyte imbalance.
Pre-renal causes of AKI
Causes that decrease effective blood flow to the kidney e.g. reduced cardiac output - heart failure, MI, bradycardia. Drugs - ACE inhibitors, NSAIDS
Renal causes of AKI
Blockage of renal vasculature = uric acid crystals, cholesterol emboli, vasculitis, endothelial damage (blood clots). Glomerulonenephritis Interstitial nephritis
Post renal causes of AKI
Urinary tract obstruction, benign prostatic hypertrophy, cancers/tumours, stones, non-emptying bladder, crystal deposition
Disopyramide, procainamine, quinidine
Class 1a antiarrythmic drugs - sodium channel blockers. Intermediate dissociation rate, leading to moderate decrease in phase 0 and increased QRS and QT interval Used to treat AF (triggered by vagal overreactivity) and VT
lidocaine, mexiletine
Class 1b anti-arrhythmic drugs -sodium channel blockers. Fast dissociation rate, decreased AP duration and QT interval. Used to treat and prevent VT and VF immediatley after Myocardial infarction
Flecainide, Moncizine, propafenone
Class 1c anti-arrhythmic drugs, blocks with slow dissociation rate causing large decrease in phase 0, leading to increased QRS and QT interval. Used to treat AF and recurrentt tachycardias associated with adnormal conduction pathways and WPW syndrome
Class 1a anti-arrhythmic drugs side effects
Atropine like (urinary retention, dry mouth, blurred vision, constipation) and Quinide causes syncope (due to triggering torsades de pointes)
Class 1b anti-arrhythmic drugs side effects
CNS, drowsiness, disorientation and convulsions
Beta blockers mechanism
Block cardiac B1 adrenoreceptors to reduce sympathetic drive to the heart, decreasing heart rate
Propranolol
Non selective B antagonist, long acting, oral
Timolol
Non selective B antagonist, used to treat glaucoma (decreases AH formation)
Atenolol, bisoprolo, metoprolol
B1 Selective antagonist
Pindolol
B1 Selective partial agonist
Nevbivolol
B1 selective antagonist and also increases NO (leading to less fatigue, bradycardia,and impotence)
Labetalol
Mixed alpha/beta adrenergic antagonist
Carvedilol
Mixed Alpha1/beta antagonist
Clinical uses of beta blockers
Rate control in SVT, rate and rhythm control in AF and flutter, VT
Adverse effects of B blockers
Bronchospasm (caution in asthma), negative inotropic effect, bradycardia, fatigue, increased risk of hypoglycaemia (diabetics)
Sotalol, amiodarone, bretylium
Class 3 anti-arrhythmic drugs-prolong AP duration by prolong phase 3 by blocking K+ channels
Amidarone
K+ channel blocker. Also a modest Na+ and Ca2+ blocker and alpha adrenergic receptor antagonist and decreases cardiac B1 adrenergic receptor expression. When given orally has slow onset (up to 3 weeks) and a very long plasma half life
Amidarone side effects
thyroid abnormalities, corneal deposits, pulmonary disorders, skin pigmentation
Class 3 anti-arrhythmic drugs clinical uses
SVTs, WPW syndrome, ventricular tachycardias
Sotalol
Class 3 anti-arrhythmic also a non selective B blocker. Lacks the adverse ADRs seen in amidarone
Verapamil, Diltiazen
Class IV anti-arrhythmic drugs. Calcium channel blockers to slow down AVN conduction
Therapeutic uses of Class IV anti-arrhythmic drug
paroxsmal SVT, AF (but NOT if due to WPW)
Class IV anti-arrhythmic drug side effects
bradycardias, negative inotropic effect, constipation (verapamil), hypotension (more with diltazem)
Ist line treatment for hypertension <55 years
ACE inhibitor or angiotensin receptor AT1 blockers
Captopril, Enalapril
ACE inhibitors
ACE inhibitors effects
reduce TPR with little effect on HR or cardiac output
ACE inhibitors adverse effects
Dry cough (due to accumulation of bradykinin)
Losortan, Candesartan
Angiotensin receptor (AT1) blockers
?Why mgiht AT1 blockers be preffered over ACE inhibitors
NO dry cough - no bradykinin accumulation
Aliskiren
Renin inhibitor
Renin inhibitors
e.g. Aliskiren. reduces plasma renin activity by binding and inhibiting activity
Contraindication of RAAS inhibitors
In pregnancy (due to fetotoxicity)
Common ADRs of RAAS inhibitors
hypotension (with thiazides), hypersemsitvity (head & neck angioedema), hyperkalaemia
1st line hypertension treatment in African/Carribbean and elderly (>55 years)
Calcium channel blockers
Nifedipine, Amlodipine
CCB, dihydropines, act preferentially on vascular smooth muscle, use in hypertension and angina
Phenylalkylamines
Verapamil - CCB act on cardiac preferentially
Benzothiazepines
Diltiazem, CCB with an intermediate effect on cardiac and smooth muscle
ADRs of Calcium channel blockers
Postural hypotension, flushes/tremors (nifedipine), AV block and negative ionotropic effects (verapamil, diltiazem)
Treatment for hypertension when ACEi/CCBs do not work?
Also give patient diuretics
Treatment in resistant hypertension
B Blockers and alpha antagonists
Statins, fibrates, bile-acid binding resins
Lipid lowering drugs
Statins mechanism
inhibits HMG-CoA reductase (key enzyme in cholestrol production)
Simvastatin, Atorvastatin, Pravastatin
Statins