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Pharm 2 Flashcards

1
Q

Criteria for HTN

A

SBP +130
DBP +80
Taking Anti-HTN med

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2
Q

ISH criteria

A

SBP +140 and DBP -90

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3
Q

Humoral factors of TPR

A 
Constrictors:
Catecholamine
Angiotensin 2
Thromboxanes
Leukotrienes
Endothelin

Dilator:
Prostaglandin
Kinin
NO

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4
Q

Definitional function of Diuretic

A

Lower BP by depleting body of Na and reducing volume

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5
Q

Definitional function of Anti-adrenergic Agent

A 
Inhibits cardiac function (dec CO)
Reduce PVR (dec CO)
Increase venous pooling
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6
Q

Definitional function of Direct Vasodilators

A

Reduce BP by relaxing SM and dilate PVR

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7
Q

Definitional function of blocking production/action of angiotensin?

A

Reduce PVR and blood volume

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8
Q

Where do Acetazolamide elicit it’s function on the kidney?

A

Between glomerulus and PCT

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9
Q

Where do Osmotic Diuretics (Mannitol) elicit it’s function on the kidney?

A

Descending LoH

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10
Q

Where do Loop Diuretics (Furosemide) elicit it’s function on the kidney?

A

Ascending LoH

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11
Q

Where do K Spring elicit it’s function on the kidney?

A

CD

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12
Q

What has been shown to be the best tolerated HTN treatment class?

A

Diuretics

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13
Q

Diuretics are more effective at reducing BP when combined with?

A

ACEI

ARB

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14
Q

ACEIs reduce Angiotensin 2 which then causes a reduction in what five things?

A 
HANAS
Vascular SM
Aldosterone synthesis/release
Na reabsorption
HR
ADH release
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15
Q

Where is bradykinin found?

It is involved in the production of what two dilators?

A

Lungs
Smooth muscles
Blood vessels

NO and prostaglandins

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16
Q

ACEIs are used with PTs that have what five compelling indicators?

A

SC PHD

DM w/ protein
Post MI
HF
Stroke Hx
High CAD risk
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17
Q

ACEIs have reduced efficacy in African Americans but can become equally for all races/ethnicity efficient when combined with ?

A

CCB

Diuretic

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18
Q

What are the three clinical features/uses of ACEIs?

A

HTN
AfAm HTN
Renal insufficiency, reduces glomerular pressure

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19
Q

What is the Renal Trifecta of ACEIs?

A

Diuretics- inc Scr
NSAIDs- inc constriction in afferent arteriole
ACEI/ARBs- dilates efferent arteriole

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20
Q

Big two different side effects of DRI than other HTN meds?

A

Diarrhea

Sulfonamide component

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21
Q

DRI interactions include what 3?

A

ARB/ACEI
NSAID
Lithium

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22
Q

A1s are not used for monotherapy or first step therapy but can be combined with?

A

Diuretic
BB
ACEIs

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23
Q

Three big side effects of A1 blockers?

A

First dose syncope
Reflex tachycardia
Inhibited ejaculation

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24
Q

Which A1 blocker is more likely to cause edema in the PT and should be given with a diuretic?

A

Prazosin

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25
A2 agonists work best when combined with one of two meds
Alternate MOA (diuretic and ACEI)
26
``` 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
27
Acronym for remembering the clinical uses of B Blockers?
MASH CH MPG
28
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 ```
29
Cardioselective (B1) BBs have less of an effect on what two PT issues?
Asthma | DM
30
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
31
Two low lipid solubility BBs | Two high lipid solubility
Low- Aten, Nado | High- Biso, Propran
32
BBs cautions acronym
``` DADS Love Sex DM Asthma Drug withdrawl Sex dysf. ```
33
BBs will have interactions with ? four?
B agonists Non-DHP CCBs NSAIDs Clonidine
34
Adverse effects of Mixed A1, NonSpec B | They should be used with caution in what 2?
Bradycardia Hypotension Caution: DM, bronchospastic Dzs
35
Which B1 blocker is for ophthalmics? | What NonSel is for ophthalmics?
Betax Tim
36
Caution using Reserpine in what two cases?
Asthma | Parkinsons
37
What type of CCB is more specific for the heart?
Non-DHP | DHP may cause compensative tachcardia
38
What type of PT are Non-DHPs preferred in?
Fast HR | Rate control in A-fib who can't tolerate BBs
39
Three uses of Verapamil?
Angina Supra V-tach Migraine/Cluster prophylaxis
40
What situation is Diltiazem used in?
Supra V-Tach (dec rate in A-fib/flutter)
41
CCBs are useful in PTs with what five predisposing issues?
``` PAADS PVD Asthma Angina DM Specific Arrhythmia ```
42
CCBs are used widely in what three situations?
HTN ISH More efficacious in AfAm HTN
43
CCBs should not be given during HF with what exception?
Amlodipine
44
DHPs have what adverse effects? | Non-DHPs have what adverse effects?
Peripheral Edema HOTN Nife- gingival hypertrophy Bradycardia Constipation
45
CCBs have what drug interactions?
Digoxin | BBs
46
What type of CCB can be combined with BBs?
DHP
47
DAVs are most effective when combined with what two classes?
Diuretics | BBs/sympatholytic agents
48
What are two adverse events that can happen from DAVs?
Inc plasma renin= Na/water retention | Angina pectoris/MI/CF from reflex cardiac stimulation
49
When is Hydralazine used?
Triple failure HTN emergency Pregnancy Class C
50
What med combinations are used to treat HTN and HF in AfAm PTs?
Hydralazine and Nitrates
51
When is Minoxidil used?
Max dose Hydralazine ineffective | PTs w/ renal failure and HTN that don't respond to Hydralazine
52
Elevated BP criteria Stage 1 HTN criteria Stage 2 HTN criteria
``` E= 120-129/<80 1= 130-139/80-89 2= +140/+90 ```
53
ASCVD is defined as Hx of what six issues?
``` MI Un/Stable angina Coronary revascularization Stroke TIA of atherosclerotic origin PAD ```
54
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
55
First line treatment of HTN includes what four classes?
Thiazides CCBs ACEIs ARBs
56
Black PT with HTN but NO HF/CKD/DM have an initial anti-htn plan that includes ?
Thiazide | CCB
57
What are the first line classes of Anti-HTN used for DM HTN?
Diuretic ACEIs ARBs CCBs
58
Adults that have stroke/TIA should have treatment from what four classes?
Thiazides ACEIs ARBs Thiazide/ACEI combo NOT CCBs
59
S/Sx of HTN Urgency?
Severe HA SOB Epistaxis Anxiety
60
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
61
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
62
HTN Emergency includes PTs at risk for imminent CV events that include three cases?
Severe HTN Stroke Intracranial aneurysm
63
What are the HTN Emergency drugs?
Dilators: Nitro*, Na Nitro*, Hydralazine*, Fenoldapam ACEI: Enalaprilat CCB: Nicardipine, Clevidipine Adrenergic Inhibs: Esmolol, Labetalol
64
Nitroglycerine is the DOC in PTs with what four conditions?
Ischemic HD MI HTN after bypass Acute pulmonary edema
65
What is considered the preferred agent to decrease preload in PTs with pulmonary congestion?
Nitroglycerine
66
What are the 3 adverse effects from Nitroglycerine?
HA/N/V and Inc ICP Methemoglobinemia- Ferric Fe3 PCV absorption
67
Na Nitropursside is used in what type of ADHF?
Warm and Wet
68
What is the DOC for most HTN and Emergencies? | What are the three exceptions?
Sodium Nitroprusside Except: CKD, Hepatic Failure, Aortic Dissection
69
What drug is used for inpatient management of short term severe HTN?
Fenoldopam
70
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 ```
71
What drug has a long half life but contains a strong cerebral/coronary dilator effect?
Nicardipine
72
Enalaprilat use is avoided for PTs with what two issues?
DHF | Acute MI
73
When is Esmolol used?
Severe tachycardia Inc CO Severe post-op HTN
74
Esmolol use is avoided in PTs with what 3 issues?
DHF BB Bradycardia
75
What drug has no pharmacokinetic drug interaction due to being metabolized in RBCs?
Esmolol
76
When is Labetalol use preferred?
``` CAD Acute Dissection End stage renal Dz Acute intracerebral hemorrhage Ischemic stroke MI ```
77
Heart responds to increased demand in what 3 ways?
Chronotropy- inc rate Inotropy- inc force Pre/After Load
78
Preload is determined by ? | After load is determined by?
Venous return and LV end diastolic volume | Ventricular wall tension and systemic VR
79
CO equation MAP equation SBP is largely determined by ? DBP is largely determined by?
CO= HR x SV MAP= CO x SVR CO TPR
80
Define Dystolic Dysfunction | Define Systolic Dysfunction
HRpEF- LVEF >50% | HRrEF- LVEF <40%
81
What is the most frequent cause of HFrEF?
Ischemia or Blood Restriction Ischemic HD- 50-60% HTn 30-40%
82
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
83
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-
84
Define Hypertonic | Define Hypotonic
per- outer Na concentration greater than insiide of cell po= outter Na concentration is less than inside cell
85
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
86
Tubular reabsorption and secretion occurs where?
Nephron
87
Kidneys receive __ % of CO and consume _& of total O2 intake
20-25% 7%
88
What is the best overall index of kidney function?
GFR | Calculated from SCr using MDRD
89
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%
90
Normal CrCl levels/
Normal: 90-140 Healthy male: 125 Healthy female: 125
91
In what part of the kidney are organic solutes reabsorbed by specific transport systems?
PCT | 60-70% of all Na is reabsorbed
92
Organic acid and base secretory systems secrete waste products into what part of the kidney?
PCT
93
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
94
What process happens in the AscLoH?
Active reabsorption of Na K and Cl by NaK transporters | 25-30% of Na reabosrbed here
95
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
96
What is the most efficacious of the diuretic class?
Loop
97
What events occur in DCT?
10% of Na reabsorption | Ca reabsorption occurs here
98
What types of drugs work in the CD?
Na channel blockers | Aldosterone antagonists
99
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
100
Activated collection ducts causes what effect? | Activation of vessels in kidneys cause?
``` CD= less water in urine Vessel= inc arterial pressure ```
101
How does the body detect if if more water needs to be retained?
Hypothalamus senses Na changes in plasma
102
What are the four mechanisms that regulate release of ADH
Hypovolemia HOTN Inc osmolality Angiotensin 2
103
Normal Serum Na levels Hypertonic = ? Hypotonic = ?
135-145 Hyper= +145 Nypo= -135
104
What are the two clinical uses of CAIs? | What is the pharmacokinetic info of this?
Open Angle Glaucoma Mtn Sickness Total excretion by PCT
105
What are two big adverse reactions of CAIs?
Hyperchloremic Metabolic Acidosis | Stones- alkaline environment causes risks to increase 10x
106
Contraindication, caution and interaction of CAI use?
Cirrhosis COPD Cyclosporine trough extension=nephro/neurotoxicit
107
When are Osmotic Diuretics used?
Treatment of oliguric phase of acute RF | Reducing ICP
108
Loop diuretic use can lead to possible drug interactions with what class?
NSAIDs
109
What situations are Loop Diuretics used?
Acute pulmonary edema Acute RF HyperK/Ca Anion OD
110
What three types of PTs would Loop Diuretics not be used?
Anuric Severe Electrolye disturbance Sulfonamide sensitivity (Except Etharynic Acid)
111
What are the adverse drug interactions when using Thiazides?
ACEIs Digoxin Lithium NSAIDs
112
Spironolactone is the diuretic of choice in ? PT types
Hepatic cirrhosis | Nephrotic syndrome
113
Potassium sparing diuretics are contraindicated for PTs w/?
PUD | Pregnancy
114
What are the five general cautions for diuretic therapies?
``` Digitalis toxicity Lithium toxicity Hyperglycemia Hyperuricemia Allergic reactions ```
115
Avoid starting BBs in PTs with what two conditions?
Volume overload | Recent decompensation
116
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
117
How fast are BBs in HF PTs increased and aimed to achieve target dose?
Increase every 2 wks | Aim to achieve @ 8-12wks
118
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
119
What are the Short and Intermediate goals of diuretic therapy?
Short: Dec JVD, pulmonary congestion and peripheral edema Inter: dec Sx, Inc exercise tolerance
120
What is the Goal of Diuretic Therapy?
Red/Eliminate S/Sx of fluid retention as assessed by JVD or edema
121
Diuretics should be used in combo with what 3 classes?
ACEI ARB BB
122
HF PT with fluid overload needs to have what issue taken care of first before addressing any other issues?
Overload relieved with diuretics
123
When are Loop Diuretics best used?
Quick reduction of fluid overload Short time frame GFR below 30/kidney impaired
124
What type of diuretic is best for mild reduction or regular management of HTN?
Thiazide/like
125
What drug can be used and useful for absence seizures secondary acidosis?
Acetazolamide
126
What is the DOC for lithium induced nephrogenic diabetes insipidus
Triamterene
127
What type of diuretic is reserved and used as an add-on therapy for HF PTs refractory to loops?
Thiazide/Like
128
What are the four loop diuretics?
Bumetanide Furosemide Torsemide Ethacrynic Acid
129
What is a clinical benefit of K Sparing diuretics?
CHF benefits | Inhibits cardiac remodeling
130
Potassium sparing diuretics should be used in combo with what drugs?
ACEIs/ARB | BBs
131
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
132
Spironolactone is a potent inhibitor of what protein? | Eplerenone is metabolized by which pathway?
P-glycoprotein CYP3A4
133
Ionotropic agents are mostly used in the treatment of ____ with the exception of ____
ADHF | Digoxin
134
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
135
Digoxin can be beneficial at reducing hospitalizations in PTs with ? HF Not recommended for ? use?
HFrEF Ventricular rate control in HF
136
What is the antidote for Digoxin?
Digoxin Immune FAB
137
Dopamine is generally avoided in treatment of ADHF except for when?
Systemic HOTN | Cardiogenic shock
138
What inotropic agent drug has no adrenergic effect allowing it to be useful in PTs using BBs?
Milrinone
139
Two similarities between HF ACEI, ARBs, BBs, and Aldosterone Antagonists
Dec morbidity | Dec hospitalization
140
Define Pulmonary Capillary Wedge Pressure
Indirect estimate of L atrial pressure Norm: 8-12 CHF optimal: less than 18
141
How is Cardiac Index determined?
CI=CO/BSA | Determined by HR and SV
142
Cilostazol inhibits phosphodiesterase 3, which is the same MOA as what other drug?
Milrinone
143
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
144
What is the sequence of Loops from highest to lowest risk of ototoxicity?
Ethacrynic Acid Furosemide Bumetanide Torsemide
145
What type of diuretic may be beneficial in treating kidney stones?
Thiazides | Used in hypercalciuria to unmask hyperCa from other causes
146
What diuretic can be used as an ADH substitute for Diabetes Insipidus PTs?
Thiazides
147
How long does it take for Thiazide HTN effects and diuretic effects to set in?
HTN: 1-3 wks Diuretic: immediately
148
What drugs can be used for intracranial bleeding?
First- Nimo | Second- Nicar
149
What are the baroreceptors of the body and where are they located?
Juxtoglomerluar | Afferent
150
Decreased CO causes what results?
Inc Pre/Afterload SNS acivation RAAS activation Ventricular hypertrophy
151
Signs of HF?
``` Rales Edema S3 gallop Cool extremeties JVD BNP ```
152
All PTs with HFrEF and any Sx are recommended to be on ?
ACEIs, BBs | Long term combo- BB and diuretic
153
PTs with LVentricular dysfunction bu NO Sx of HF need to receive?
ACEI
154
What are the adverse effects of ACEIs and ARBs?
``` Taste Cough/Angioedema HOTN Hyper K Inc SrCr ```
155
What do ACEI PTs need to be monitored for?
K SrCr BUN Baseline and 2wks
156
ACIEs and ARBs interact w/ ? drugs?
K sparing diuretics K supplements Renal trifecta
157
What class of med has proven to be superior to ACEI at HF doses?
ARBs
158
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%
159
What are the contraindications of Sacu/Val?
Angioedema from previous ACEI/ARB Conjunction with ACEI Aliskiren in PTs with DM
160
What are the adverse effects of Sacu/Val?
HOTN Hyper K Cough/Dizzy RF
161
What interactions will Sacu/Val have with other drugs?
``` ACEIs Aliskiren in DM PTs ARBs NSAIDs- renal impairments Lithium toxicity ```
162
Sacu/Val needs to be used in conjunction with?
K sparing diuretic K supplements Na substitute
163
What type of HF PTs are BBs given to?
2 or 3 B/C/D | Even if Asymptomatic/mild-mod
164
BB precautions for HF PTs?
DM Asthma Lipids Withdrawls
165
Adverse effects of BB in HF PTs?
``` HOTN Dizzy Bradycardia Fatigue Sex Dysfuntion ```
166
What are the 3 BB HF meds?
Carvedilol- mised BB that dec SVR after load (better than metoprolol) Meto/Biso- B1 sel
167
All PTs w/ Sx of HF receive ? med class?
Diuretic | IF evidence/Hx of retention is present
168
Diuretics in HF Pts should be used in ? combo?
ACEI/ARB | BB
169
Loop diuretic ceiling effects from small to large
F, T, B
170
What happens if HF PT has diuretic resistance?
Inc dose before frequency IV Second Diuretic with different MOA
171
Using Eplerenone and Spironolactone for HF PTs has what benefits?
Eliminates catecholamine potentiation Dec BP Blocks fibrotic actions on heart
172
What type of diuretic reduced M/M in PTs after MI w/ LVEF <40% w/ HF Sx and Diabetes
K sparing
173
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 ```
174
Drug interaction sof K Sparing diuretics?
ACEIs, ARBs | CYP3A4 w/ eplerenone
175
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
176
How does Hydralazine and Isosorbide work together?
H- arterial dilator and enhances nitrate effect I- stims nitric acid signaling, relaxes SM and reduces preload
177
Side effects of Na Prusside?
HOTN Cyanide Inc ICP
178
Nesiritide needs to be used with what adjunct?
Diuretic
179
Adverse effects of Nesiritide?
HOTN | Renal impairment- azotemia
180
When are inotropic agents allowed for long term use?
Palliation for PTs with end stage Dz who are unstabled with standard meds
181
Benefits of Digoxin
Inc force w/out inc O2 consumption Imp Sx, exercise NONE on mortality
182
When is Digoxin used in HF theapy?
Added to Diuretic, ACE/ARB, and BB for HF Sx
183
PTs on Digoxin need ? monitored?
ECG Levels SrE+ Urea, N, Creatinine
184
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
185
Adverse effects of Milrinone?
Arrhythmia HOTN Thrombocytopenia
186
When is Dobutamine considered? | When is Milrinone considered?
HOTN | PT on BB
187
HF recommendations fo NSAIDS, Corticosteroids, Non-DHPs, Minoxidil
Avoid Lowest dose for shortest time Only Amlodipine- angina and HTN from HF Avoid
188
Avoid Metformin in HF Classes?
3 or 4
189
Recommendation for HF and Thiazolidinediones?
Avoid Piog/Rosig in 3 and 4
190
HF recommendation for DPP-4 inhibitor?
Caution with saxagliptin
191
Avoid Class 1 and 3 anti-arrhythmics in HF PTs w/ ? exceptions?
Amiodarone Dofetilide Sotalol
192
What is Cilostazol used for?
Claudication pain by inhib PDE3 | Dont use in HF PTs

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