Pharm 2 Flashcards
Criteria for HTN
SBP +130
DBP +80
Taking Anti-HTN med
ISH criteria
SBP +140 and DBP -90
Humoral factors of TPR
Constrictors: Catecholamine Angiotensin 2 Thromboxanes Leukotrienes Endothelin
Dilator:
Prostaglandin
Kinin
NO
Definitional function of Diuretic
Lower BP by depleting body of Na and reducing volume
Definitional function of Anti-adrenergic Agent
Inhibits cardiac function (dec CO) Reduce PVR (dec CO) Increase venous pooling
Definitional function of Direct Vasodilators
Reduce BP by relaxing SM and dilate PVR
Definitional function of blocking production/action of angiotensin?
Reduce PVR and blood volume
Where do Acetazolamide elicit it’s function on the kidney?
Between glomerulus and PCT
Where do Osmotic Diuretics (Mannitol) elicit it’s function on the kidney?
Descending LoH
Where do Loop Diuretics (Furosemide) elicit it’s function on the kidney?
Ascending LoH
Where do K Spring elicit it’s function on the kidney?
CD
What has been shown to be the best tolerated HTN treatment class?
Diuretics
Diuretics are more effective at reducing BP when combined with?
ACEI
ARB
ACEIs reduce Angiotensin 2 which then causes a reduction in what five things?
HANAS Vascular SM Aldosterone synthesis/release Na reabsorption HR ADH release
Where is bradykinin found?
It is involved in the production of what two dilators?
Lungs
Smooth muscles
Blood vessels
NO and prostaglandins
ACEIs are used with PTs that have what five compelling indicators?
SC PHD
DM w/ protein Post MI HF Stroke Hx High CAD risk
ACEIs have reduced efficacy in African Americans but can become equally for all races/ethnicity efficient when combined with ?
CCB
Diuretic
What are the three clinical features/uses of ACEIs?
HTN
AfAm HTN
Renal insufficiency, reduces glomerular pressure
What is the Renal Trifecta of ACEIs?
Diuretics- inc Scr
NSAIDs- inc constriction in afferent arteriole
ACEI/ARBs- dilates efferent arteriole
Big two different side effects of DRI than other HTN meds?
Diarrhea
Sulfonamide component
DRI interactions include what 3?
ARB/ACEI
NSAID
Lithium
A1s are not used for monotherapy or first step therapy but can be combined with?
Diuretic
BB
ACEIs
Three big side effects of A1 blockers?
First dose syncope
Reflex tachycardia
Inhibited ejaculation
Which A1 blocker is more likely to cause edema in the PT and should be given with a diuretic?
Prazosin
A2 agonists work best when combined with one of two meds
Alternate MOA (diuretic and ACEI)
A2 agonist clonidine should be carefully used or avoided with what PTs? Should not be used with what class of med?
Geriatrics or depressed
TCA antidepressants
Acronym for remembering the clinical uses of B Blockers?
MASH CH MPG
Where are B2 receptors found and what kind of stimulation causes what type of response?
Bronchial tree, skeletal muscle, vessels, kidney liver
\+ = dilation and inc blood glucose - = restriction and dec blood glucose
Cardioselective (B1) BBs have less of an effect on what two PT issues?
Asthma
DM
When are ISAs considered?
BB ISAs should be avoided in what type of PT emergency?
PT needing BB but experience brady w/ normal BBs
MI
Two low lipid solubility BBs
Two high lipid solubility
Low- Aten, Nado
High- Biso, Propran
BBs cautions acronym
DADS Love Sex DM Asthma Drug withdrawl Sex dysf.
BBs will have interactions with ? four?
B agonists
Non-DHP CCBs
NSAIDs
Clonidine
Adverse effects of Mixed A1, NonSpec B
They should be used with caution in what 2?
Bradycardia
Hypotension
Caution: DM, bronchospastic Dzs
Which B1 blocker is for ophthalmics?
What NonSel is for ophthalmics?
Betax
Tim
Caution using Reserpine in what two cases?
Asthma
Parkinsons
What type of CCB is more specific for the heart?
Non-DHP
DHP may cause compensative tachcardia
What type of PT are Non-DHPs preferred in?
Fast HR
Rate control in A-fib who can’t tolerate BBs
Three uses of Verapamil?
Angina
Supra V-tach
Migraine/Cluster prophylaxis
What situation is Diltiazem used in?
Supra V-Tach (dec rate in A-fib/flutter)
CCBs are useful in PTs with what five predisposing issues?
PAADS PVD Asthma Angina DM Specific Arrhythmia
CCBs are used widely in what three situations?
HTN
ISH
More efficacious in AfAm HTN
CCBs should not be given during HF with what exception?
Amlodipine
DHPs have what adverse effects?
Non-DHPs have what adverse effects?
Peripheral Edema HOTN
Nife- gingival hypertrophy
Bradycardia
Constipation
CCBs have what drug interactions?
Digoxin
BBs
What type of CCB can be combined with BBs?
DHP
DAVs are most effective when combined with what two classes?
Diuretics
BBs/sympatholytic agents
What are two adverse events that can happen from DAVs?
Inc plasma renin= Na/water retention
Angina pectoris/MI/CF from reflex cardiac stimulation
When is Hydralazine used?
Triple failure
HTN emergency
Pregnancy Class C
What med combinations are used to treat HTN and HF in AfAm PTs?
Hydralazine and Nitrates
When is Minoxidil used?
Max dose Hydralazine ineffective
PTs w/ renal failure and HTN that don’t respond to Hydralazine
Elevated BP criteria
Stage 1 HTN criteria
Stage 2 HTN criteria
E= 120-129/<80 1= 130-139/80-89 2= +140/+90
ASCVD is defined as Hx of what six issues?
MI Un/Stable angina Coronary revascularization Stroke TIA of atherosclerotic origin PAD
What equation is used to estimate a 10yr ASCVD risk?
ASCVD risk calculator is used to assess the need for ?
Pooled Cohort Equation
Statin therapy
First line treatment of HTN includes what four classes?
Thiazides
CCBs
ACEIs
ARBs
Black PT with HTN but NO HF/CKD/DM have an initial anti-htn plan that includes ?
Thiazide
CCB
What are the first line classes of Anti-HTN used for DM HTN?
Diuretic
ACEIs
ARBs
CCBs
Adults that have stroke/TIA should have treatment from what four classes?
Thiazides
ACEIs
ARBs
Thiazide/ACEI combo
NOT CCBs
S/Sx of HTN Urgency?
Severe HA
SOB
Epistaxis
Anxiety
Criteria and time goal for HTN Urgency
SBP +180/DBP +120 w/out end organ damage
Reduction over 24-48hrs w/ oral meds
Reduce MAP by no more than 25% in first 24hrs
Clonidine, Captopril, Labetalol
Criteria and time goals for HTN Emergency
SBP + 180/ DBP +120 with evidence of end organ damage with parenternal meds
WITHOUT Compelling Conditions:
MAP reduced by no more than 25% in first hours
To 160/100 within 2-6hrs
To normal in 24-48hrs
HTN Emergency includes PTs at risk for imminent CV events that include three cases?
Severe HTN
Stroke
Intracranial aneurysm
What are the HTN Emergency drugs?
Dilators: Nitro, Na Nitro, Hydralazine*, Fenoldapam
ACEI: Enalaprilat
CCB: Nicardipine, Clevidipine
Adrenergic Inhibs: Esmolol, Labetalol
Nitroglycerine is the DOC in PTs with what four conditions?
Ischemic HD
MI
HTN after bypass
Acute pulmonary edema
What is considered the preferred agent to decrease preload in PTs with pulmonary congestion?
Nitroglycerine
What are the 3 adverse effects from Nitroglycerine?
HA/N/V and Inc ICP
Methemoglobinemia- Ferric Fe3
PCV absorption
Na Nitropursside is used in what type of ADHF?
Warm and Wet
What is the DOC for most HTN and Emergencies?
What are the three exceptions?
Sodium Nitroprusside
Except:
CKD, Hepatic Failure, Aortic Dissection
What drug is used for inpatient management of short term severe HTN?
Fenoldopam
Nicardipine is used in PTs with what types of issues?
Intracerebral hemorrhage Acute ischemic stroke HTN encephalopathy Pre/Eclampsia Acute RF Sympathetic Crisis Perioperative HTN
What drug has a long half life but contains a strong cerebral/coronary dilator effect?
Nicardipine
Enalaprilat use is avoided for PTs with what two issues?
DHF
Acute MI
When is Esmolol used?
Severe tachycardia
Inc CO
Severe post-op HTN
Esmolol use is avoided in PTs with what 3 issues?
DHF
BB
Bradycardia
What drug has no pharmacokinetic drug interaction due to being metabolized in RBCs?
Esmolol
When is Labetalol use preferred?
CAD Acute Dissection End stage renal Dz Acute intracerebral hemorrhage Ischemic stroke MI
Heart responds to increased demand in what 3 ways?
Chronotropy- inc rate
Inotropy- inc force
Pre/After Load
Preload is determined by ?
After load is determined by?
Venous return and LV end diastolic volume
Ventricular wall tension and systemic VR
CO equation
MAP equation
SBP is largely determined by ?
DBP is largely determined by?
CO= HR x SV
MAP= CO x SVR
CO
TPR
Define Dystolic Dysfunction
Define Systolic Dysfunction
HRpEF- LVEF >50%
HRrEF- LVEF <40%
What is the most frequent cause of HFrEF?
Ischemia or Blood Restriction
Ischemic HD- 50-60%
HTn 30-40%
HFpEF is what type of heart issues?
HFrEF is what type of issue?
P= restricted ventricle filling from inc stiffness, M/T valve stenosis or pericardial Dz
R= dec contractility from dec mass, dilated myopathies or hypertrophy
What are the eight Neuro-Hormones of HF?
Epi/NorEpi- constrict, contribute to remodeling
Angiotensin 2- constrict, stimulates remodeling
Aldosterone- retention, produces interstitial cardiac fibrosis
ADH- inc absorption, inc pressure
BNP- inc due to stretch response of ventricles
Endothelin- constrictor of coronary vessels
A-TNF- inflammatory cytokine
Bradykinin-
Define Hypertonic
Define Hypotonic
per- outer Na concentration greater than insiide of cell
po= outter Na concentration is less than inside cell
Define Tubular Reabsorption/Secretion
Absorb- nephrons return substances to blood, from lumen to blood in PCT and CD
Secrete- from blood to lumen to maintain acid/base balance in PCT
Tubular reabsorption and secretion occurs where?
Nephron
Kidneys receive __ % of CO and consume _& of total O2 intake
20-25%
7%
What is the best overall index of kidney function?
GFR
Calculated from SCr using MDRD
What is used to estimate GFR?
CrCl, estimated renal function based on a formula from 24hr collection
Tends to exceed true GFR by 10-20%
Normal CrCl levels/
Normal: 90-140
Healthy male: 125
Healthy female: 125
In what part of the kidney are organic solutes reabsorbed by specific transport systems?
PCT
60-70% of all Na is reabsorbed
Organic acid and base secretory systems secrete waste products into what part of the kidney?
PCT
What process happens in Desc LoH?
Water flows out due to outside osmolality is greater
Na is retained due to lack of active transporters here
What process happens in the AscLoH?
Active reabsorption of Na K and Cl by NaK transporters
25-30% of Na reabosrbed here
What type of effect do Loop Diuretics have in the LoH?
Inhibits co-transporter and reduces positive potential causing increased urine output of cations and NaCl
What is the most efficacious of the diuretic class?
Loop
What events occur in DCT?
10% of Na reabsorption
Ca reabsorption occurs here
What types of drugs work in the CD?
Na channel blockers
Aldosterone antagonists
ADH is AKA and made where?
Where do they elicit their effects on the kidney?
Arginine Vasopressine
Peptide hormone made in Posterior Pituitary
CD and vessels
Activated collection ducts causes what effect?
Activation of vessels in kidneys cause?
CD= less water in urine Vessel= inc arterial pressure
How does the body detect if if more water needs to be retained?
Hypothalamus senses Na changes in plasma
What are the four mechanisms that regulate release of ADH
Hypovolemia
HOTN
Inc osmolality
Angiotensin 2
Normal Serum Na levels
Hypertonic = ?
Hypotonic = ?
135-145
Hyper= +145
Nypo= -135
What are the two clinical uses of CAIs?
What is the pharmacokinetic info of this?
Open Angle Glaucoma
Mtn Sickness
Total excretion by PCT
What are two big adverse reactions of CAIs?
Hyperchloremic Metabolic Acidosis
Stones- alkaline environment causes risks to increase 10x
Contraindication, caution and interaction of CAI use?
Cirrhosis
COPD
Cyclosporine trough extension=nephro/neurotoxicit
When are Osmotic Diuretics used?
Treatment of oliguric phase of acute RF
Reducing ICP
Loop diuretic use can lead to possible drug interactions with what class?
NSAIDs
What situations are Loop Diuretics used?
Acute pulmonary edema
Acute RF
HyperK/Ca
Anion OD
What three types of PTs would Loop Diuretics not be used?
Anuric
Severe Electrolye disturbance
Sulfonamide sensitivity (Except Etharynic Acid)
What are the adverse drug interactions when using Thiazides?
ACEIs
Digoxin
Lithium
NSAIDs
Spironolactone is the diuretic of choice in ? PT types
Hepatic cirrhosis
Nephrotic syndrome
Potassium sparing diuretics are contraindicated for PTs w/?
PUD
Pregnancy
What are the five general cautions for diuretic therapies?
Digitalis toxicity Lithium toxicity Hyperglycemia Hyperuricemia Allergic reactions
Avoid starting BBs in PTs with what two conditions?
Volume overload
Recent decompensation
BBs are added to PTs with HF when HF Sx are ____ and _____ and should not be prescribed to PTs w/ ?
Stable
Euvolemic
Not prescribed w/out diuretic to PT with Hx of fluid retention
How fast are BBs in HF PTs increased and aimed to achieve target dose?
Increase every 2 wks
Aim to achieve @ 8-12wks
What is a further/added benefit for HF PTs that are using Carvedilol?
Decreases SVR/afterload allowing for:
Improved LV function, exercise tolerance and NYHA classifications
What are the Short and Intermediate goals of diuretic therapy?
Short: Dec JVD, pulmonary congestion and peripheral edema
Inter: dec Sx, Inc exercise tolerance
What is the Goal of Diuretic Therapy?
Red/Eliminate S/Sx of fluid retention as assessed by JVD or edema
Diuretics should be used in combo with what 3 classes?
ACEI
ARB
BB
HF PT with fluid overload needs to have what issue taken care of first before addressing any other issues?
Overload relieved with diuretics
When are Loop Diuretics best used?
Quick reduction of fluid overload
Short time frame
GFR below 30/kidney impaired
What type of diuretic is best for mild reduction or regular management of HTN?
Thiazide/like
What drug can be used and useful for absence seizures secondary acidosis?
Acetazolamide
What is the DOC for lithium induced nephrogenic diabetes insipidus
Triamterene
What type of diuretic is reserved and used as an add-on therapy for HF PTs refractory to loops?
Thiazide/Like
What are the four loop diuretics?
Bumetanide
Furosemide
Torsemide
Ethacrynic Acid
What is a clinical benefit of K Sparing diuretics?
CHF benefits
Inhibits cardiac remodeling
Potassium sparing diuretics should be used in combo with what drugs?
ACEIs/ARB
BBs
Potassium sparing diuretics are recommended for PTs with what specific type of HF?
Class 2-4
Stage C w/ LVEF 35% or less
Class 2 should have Hx of CV hospitalization or inc BNP levels
Spironolactone is a potent inhibitor of what protein?
Eplerenone is metabolized by which pathway?
P-glycoprotein
CYP3A4
Ionotropic agents are mostly used in the treatment of ____ with the exception of ____
ADHF
Digoxin
Long term use of positive inotropics may be harmful thus are not recommended for PTs that have ?
With ? exception
HF Sx and reduced LVEF
Palliation for PTs w/ end-stage Dz who can’t be stabilized with standard treatment
Digoxin can be beneficial at reducing hospitalizations in PTs with ? HF
Not recommended for ? use?
HFrEF
Ventricular rate control in HF
What is the antidote for Digoxin?
Digoxin Immune FAB
Dopamine is generally avoided in treatment of ADHF except for when?
Systemic HOTN
Cardiogenic shock
What inotropic agent drug has no adrenergic effect allowing it to be useful in PTs using BBs?
Milrinone
Two similarities between HF ACEI, ARBs, BBs, and Aldosterone Antagonists
Dec morbidity
Dec hospitalization
Define Pulmonary Capillary Wedge Pressure
Indirect estimate of L atrial pressure
Norm: 8-12
CHF optimal: less than 18
How is Cardiac Index determined?
CI=CO/BSA
Determined by HR and SV
Cilostazol inhibits phosphodiesterase 3, which is the same MOA as what other drug?
Milrinone
How do drug interactions occur in the kidneys with PTs on Loop Diuretics?
Prostaglandins synth’d in kidney inhibits Na/ADH in CD
NSAIDs w/ Loop= interfered activity
What is the sequence of Loops from highest to lowest risk of ototoxicity?
Ethacrynic Acid
Furosemide
Bumetanide
Torsemide
What type of diuretic may be beneficial in treating kidney stones?
Thiazides
Used in hypercalciuria to unmask hyperCa from other causes
What diuretic can be used as an ADH substitute for Diabetes Insipidus PTs?
Thiazides
How long does it take for Thiazide HTN effects and diuretic effects to set in?
HTN: 1-3 wks
Diuretic: immediately
What drugs can be used for intracranial bleeding?
First- Nimo
Second- Nicar
What are the baroreceptors of the body and where are they located?
Juxtoglomerluar
Afferent
Decreased CO causes what results?
Inc Pre/Afterload
SNS acivation
RAAS activation
Ventricular hypertrophy
Signs of HF?
Rales Edema S3 gallop Cool extremeties JVD BNP
All PTs with HFrEF and any Sx are recommended to be on ?
ACEIs, BBs
Long term combo- BB and diuretic
PTs with LVentricular dysfunction bu NO Sx of HF need to receive?
ACEI
What are the adverse effects of ACEIs and ARBs?
Taste Cough/Angioedema HOTN Hyper K Inc SrCr
What do ACEI PTs need to be monitored for?
K
SrCr
BUN
Baseline and 2wks
ACIEs and ARBs interact w/ ? drugs?
K sparing diuretics
K supplements
Renal trifecta
What class of med has proven to be superior to ACEI at HF doses?
ARBs
When is Sacu/Val prescribed?
Reduce CV death and hospitalization for HF in PTs with Class 2-4HF
Alternate to ACEI/ARB
Only studied w/ EF <35%
What are the contraindications of Sacu/Val?
Angioedema from previous ACEI/ARB
Conjunction with ACEI
Aliskiren in PTs with DM
What are the adverse effects of Sacu/Val?
HOTN
Hyper K
Cough/Dizzy
RF
What interactions will Sacu/Val have with other drugs?
ACEIs Aliskiren in DM PTs ARBs NSAIDs- renal impairments Lithium toxicity
Sacu/Val needs to be used in conjunction with?
K sparing diuretic
K supplements
Na substitute
What type of HF PTs are BBs given to?
2 or 3 B/C/D
Even if Asymptomatic/mild-mod
BB precautions for HF PTs?
DM
Asthma
Lipids
Withdrawls
Adverse effects of BB in HF PTs?
HOTN Dizzy Bradycardia Fatigue Sex Dysfuntion
What are the 3 BB HF meds?
Carvedilol- mised BB that dec SVR after load (better than metoprolol)
Meto/Biso- B1 sel
All PTs w/ Sx of HF receive ? med class?
Diuretic
IF evidence/Hx of retention is present
Diuretics in HF Pts should be used in ? combo?
ACEI/ARB
BB
Loop diuretic ceiling effects from small to large
F, T, B
What happens if HF PT has diuretic resistance?
Inc dose before frequency
IV
Second Diuretic with different MOA
Using Eplerenone and Spironolactone for HF PTs has what benefits?
Eliminates catecholamine potentiation
Dec BP
Blocks fibrotic actions on heart
What type of diuretic reduced M/M in PTs after MI w/ LVEF <40% w/ HF Sx and Diabetes
K sparing
Loop diuretics are specifically recommended in ? HF PT?
2-4 Stage C w/ HFrEF below 35% Stage 2 needs inc BNP or hospitalization record CrCl>30 K<5
Drug interaction sof K Sparing diuretics?
ACEIs, ARBs
CYP3A4 w/ eplerenone
When is Hydralazine used for HF?
Added to ACEIs and BB in AfAM w/ Class 3 or 4 HF
PT w/ Sx HFrEF and intolerant to ACE/ARB
How does Hydralazine and Isosorbide work together?
H- arterial dilator and enhances nitrate effect
I- stims nitric acid signaling, relaxes SM and reduces preload
Side effects of Na Prusside?
HOTN
Cyanide
Inc ICP
Nesiritide needs to be used with what adjunct?
Diuretic
Adverse effects of Nesiritide?
HOTN
Renal impairment- azotemia
When are inotropic agents allowed for long term use?
Palliation for PTs with end stage Dz who are unstabled with standard meds
Benefits of Digoxin
Inc force w/out inc O2 consumption
Imp Sx, exercise
NONE on mortality
When is Digoxin used in HF theapy?
Added to Diuretic, ACE/ARB, and BB for HF Sx
PTs on Digoxin need ? monitored?
ECG
Levels
SrE+
Urea, N, Creatinine
When is Dobutamine used?
What may develop after use?
Sel B1 w/ Small A1 and B2 for PTs unresponsive to dopamine for severe HF
Tachyplhylaxis
Adverse effects of Milrinone?
Arrhythmia
HOTN
Thrombocytopenia
When is Dobutamine considered?
When is Milrinone considered?
HOTN
PT on BB
HF recommendations fo NSAIDS, Corticosteroids, Non-DHPs, Minoxidil
Avoid
Lowest dose for shortest time
Only Amlodipine- angina and HTN from HF
Avoid
Avoid Metformin in HF Classes?
3 or 4
Recommendation for HF and Thiazolidinediones?
Avoid Piog/Rosig in 3 and 4
HF recommendation for DPP-4 inhibitor?
Caution with saxagliptin
Avoid Class 1 and 3 anti-arrhythmics in HF PTs w/ ? exceptions?
Amiodarone
Dofetilide
Sotalol
What is Cilostazol used for?
Claudication pain by inhib PDE3
Dont use in HF PTs