Pharm #9 - Acute CHF Drugs

Question 1

NITRATES (nitroglycerin/ nitroprusside)

• MOA
• Indications (2) and clinical effect

Answer 1

• reduce preload by causing vasodilation of venous capacitance vessels
• reduce after load

3- decrease filling pressures, decrease arterial blood pressure

Question 2

NITRATES (nitroglycerin/ nitroprusside)

• adverse effects (4, 1 main)
• contraindication 1

Answer 2

adverse:

• hypotension
• relfex tachy
• methemglobinemia
• nitrate tolerance**

contra:
- systemic hypotension

Question 3

Nisertide

• MOA
• indication 1 + Clinical effect (2)

Answer 3

MOA: activates vascular smooth muscle and renal BNP receptors
- raise cGMP levels in VSMC and renal epithelial cells

Indication:
- acutely decompensated CHRONIC CHF in hospitalized patients

Clinical: vasodilation (afferente arteriole) to increase GFR, induce natriuresis and vasodilation

Question 4

Nisertide

• adverse effects (2)
• contra (2)

Answer 4

• hypotension
• ventricular arrhythmias

Contra: reduced LV filling pressures
- systemic hypotension

Question 5

B- Agonists (isoproterenol, dopamine, dobutamine, NE)

• MOA
• 2 indications / 3 clinical effects

Answer 5

MOA:
- stimulates cardiac beta receptors to increase cAMP

1. low cardiac output due to acute CHF
2. cardiogenic shock

Clinical:

1. increase HR
2. Increase contractility
3. increase CO

Question 6

B- Agonists (isoproterenol, dopamine, dobutamine, NE)

• adverse effects 3
• 2 contra

Answer 6

1. arrhythmias
2. increased O2 consumption
3. Angina & vasoconstriction(NE)

Contra

• ventricular arrhythmias
• severe peripheral vascular disease

Question 7

Digoxin:

• MOA
• indication (2)
• clinical 2

Answer 7

MOA:
- partially inhibits Na/K ATPase increasing reverse mode Na/Ca exchange and increasing SR Calcium!!!

Indications:

• acute CHF
• atrial fibrillation with rapid ventricular response

Clinical:

• increased contractility
• decreased AV node conduction velocity

Question 8

Digoxin:

Side effects 2 major , 2 others

contra (2)

Answer 8

• Arrhythmias
• heart block

anorexia, nausea/vomiting

1. History of Ventricular tachycardia / ventricular fibrillation
2. hypokalemia

Question 9

Phosphodiesterase inhibitors (name 2)

MOA
Indication
Clinical (3)

Answer 9

Inamrinone
Milrinone

Moa: inhibit degradation of cAMP in cardiomyocytes –> increasing cAMP in cardiac muscle
- inhibit degradation of cGMP in vascular smooth muscle inducing vasodilation

Clinical (3)

• increased contractility
• vasodilation
• increased cardiac output

Question 10

Phosphodiesterase inhibitors (name 2)

Side effects 2

Answer 10

Inamrinone
Milrinone

1. arrhytmias
2. hypotension

Question 11

Nitrates

• name 3

Answer 11

nitroglycerin

• isosorbide dinitrate
• erythrityl tetra nitrate

Question 12

Nitrates (nitroglycerin, isosorbide dinitrate, erythrityl tetranitrate)

MOA
indications (3 types of \_\_\_)

Answer 12

MOA: reacts with cysteinyl resides in vessel wall to increase the concentration of nitric oxide in vascular smooth muscle cells
= vasodilation in capacitance vessels (veins)

Indications

1. exertional angina
2. variant angina
3. unstable angina

Question 13

Nitrates (nitroglycerin, isosorbide dinitrate, erythrityl tetranitrate)

adverse effects -4
contra 1

Answer 13

• orthostatic hypotension
• reflex tachycardia
• HA
• nitrate tolerance

Contra: systemic hypotension

Question 14

Ca Channel blockers

• nifedipine
• nicardipine
• verapamil
• diltiazem

MOA
Indication

Answer 14

Block L type C achannels in VSMC and cardiac myocytes
= vasodilation and decreased contractility

Indication:

• exertional angina
• variant angina
• unstable angina

Clinical effect: prevents episodes of exercise induced vasospastic angina

Question 15

Ca Channel blockers

• nifedipine
• nicardipine
• verapamil
• diltiazem

Adverse effects 4 (1 for nifedipine specifically)
Contra 3

Answer 15

Adverse

• bradycardia
• heart block
• CHF
• hypotension & peripheral edema
• REFLEX TACHY in NIFEDIPINE

Contraindication:

• advanced heart block
• CHF
• systemic hypotension

Question 16

B - Blockers
( propranolol, nadolol, atenolol, metoprolol, carvedilol)

MOA
Indications 3
Clinical effect - 1

Answer 16

MOA: block B receptors in cardiac myocytes to reduce contractility

Indications:

• exertional angina
• unstable angina
• post MI prophylaxis

Clinical effect:
- prevent exercise induced myocardial ischemia

Question 17

B - Blockers
( propranolol, nadolol, atenolol, metoprolol, carvedilol)

• adverse effects - ALOT
• contraindication (4)

Answer 17

Adverse:

• bronchospasm
• peripheral vasospasm
• bradycardia
• CHF
• Heart block
• depression/fatigue
• BLOCK INSULIN INDUCED HYPOGLYCEMIA
• impotence

Contra:

• heart block
• ACUTE CHF
• insulin dep. diabetes mellitus
• COPD

Question 18

RANALAZINE

MOA (?)
Indication

Answer 18

MOA: inhibit fatty acid beta oxidation in cardiac myocyte mitochondria

Indication: patients with chronic stable angina unresponsive to other agents
- now approved for EXERCISE INDUCED ANGINA

Question 19

RANALAZINE

• adverse effect
• contraindicated

Answer 19

prolong QT interval

Contra: long QT syndrome & use with other drugs that prolong QT

Question 20

Ivabradine

MOA
Indication

Answer 20

MOA:
- block If current in SA nodal fibers

• indication: chronic stable angina

Question 21

Ivabradine

• adverse 3
• contraindication 2

Answer 21

adverse:

• bradycardia
• heart block
• luminous phenomenon

Contra:

• sick sinus syndrome
• use with calcium channel blockers verapamil or dilitiazem

Question 22

Which dog is contraindicated for use with - use with calcium channel blockers verapamil or dilitiazem

Answer 22

IVABRADINE

• block If current in Sa nodal fiber and prevent exercise induced MI