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Pharm Block 2 Anti-As and Angina Flashcards

1
Q

What are the 3 ions that regulate the heart?

A

Na K Ca

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2
Q

What are the names of the five AP phases?

A 
Upstroke
Early-fast repolarization
Plateau
Repolarization
Diastole
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3
Q

Arrhythmias can result from one of what three issues?

A 
Abnormal Automaticity (impulse formation)
Abnormal Impulse Conduction- development of short-circuit pathway
Re-Entry Phenomenon- impaired conduction
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4
Q

How do antiarrhythmics exert their effect on the heart?

A

Inhibits K channels to widen AP causing prolonged QT interval

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5
Q

Excessive prolongation of QT interval can results in ?

A

Torsades de Pointes- ventricular tachyarrhthmia

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6
Q

QT interval prolongation is usually caused by ? but can be caused by what three things?

A

Drug induced

Can be from ischemia, hypoK, genetics

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7
Q

Torsades de Pointes typically occurs when QT intervals exceed what time and can be caused by ?

A

> 500 milliseconds

Hypo K, Mag, drugs

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8
Q

Define Supraventricular arrhythmias

A

Originate in Atria and AV nodes

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9
Q

What type of arrhythmia can lead to HF or ischemic stroke?

A

A-Fib

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10
Q

Define Re-Entrant rhythm

A

Atrial flutter- signals travel in circle and not across the atria

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11
Q

Define PSVT

A

HR above 100 bpm originating superior to ventricles when atria contract prematurely

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12
Q

Define PACs and what type of arrhythmia are they?

A

Transient ryhthm when extra beat originates in atria

PSVT

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13
Q

What can cause PVCs to develop?

A

Structural HD
Electrolyte imbalance
ETOH
Stimulants

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14
Q

CAST was tested with what two meds?

A

Encainide

Flecainide

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15
Q

What is the most common classification of antiarrhythmic drugs and what are they based upon?

A

Vaughn-Williams System

Effect on Purkinje fibers

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16
Q 
Supra/Ventricular arrhythmias are treated with what class of drugs?
Ventricular arrhythmias are treated with what class of drugs?
A

Class 3
Class 1A
Class 1C

Class 1B

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17
Q

Supraventricular arrhythmias are treated with what drugs?

A

Adenosine
Digoxin
Verapamil

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18
Q

Stress induced arrhythmias are treated with what class of drugs?

A

Class 2: BBs, propranol, atenolol

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19
Q

What classes of drugs are used for Rate, Rhythm or Both control?

A

Class 1- rhythm
Class 2- rate
Class 3- both (rate- Am, So, Dr)
Class 4- rate

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20
Q

What drug was the prototype of Class 1A drugs?

What is the most frequently used 1A drug?

A

Quinine

Procainamide

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21
Q

What happens if Quinidine is given in high doses?

A

Cinchonism

Can exacerbate myasthenia gravis

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22
Q

Procainamide is the 2/3 choice drug for ventricular arrhythmias associated with MI after what two drugs have been used?

A

Lidocaine

Amiodarone

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23
Q

What two drugs can produce the Lupus macular-like rash?

A

Hydralazine

Procainamide

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24
Q

Disopyramide has what added benefit on top of it’s Class 1A effects?

A

Class 3- K blocking, prolong repolarization

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25
Disopyramide is reserved for treatment of what type of PT?
Ventricular arrhythmia that are refractory/intolerant to Quinidine or Procainamide
26
Class 1B drugs have what effect on the electrical process?
Shortens Phase 3 repolarization
27
What are the 3 uses of Lidocaine? | When must the dose be adjusted?
Shortens V-tach with pulse Prevents V-tach after conversion Alternate for PVT/VF if amiodarone is not available Hepatic Dz and/or CHF
28
What is the least cardio toxic Na Channel blocker? When is it contraindicated? What can it interact with?
Lidocaine 3* block Amiodarone inc lidocaine levels
29
What is Mexiletine used in the treatment of? | What is it contraindicated in?
Ventricular arrhythmias associated with previous MI Off label- diabetic neuropathy 3* block
30
What is the MOA of Class 1C agents?
Slows conduction velocity w/ little effect on refractory period of Supraventricular/Ventricular arrhythmia
31
When are Class 1C drugs used?
PTs with normal hearts but have supraventricular arrhythmia
32
Avoid Class 1C drugs in what PTs?
Post MI | HF
33
Class 1C drugs have what effect on the electrical process?
Slows conduction velocity with little effect on refractory period
34
What Class 1C drug possesses negative ionotropic effects and can exacerbate HF?
Flecainide
35
What are the two uses of Flecainide?
Sinus rhythm maintenance of A-fib w/out structural HD | Life threatening V-tach, refractory
36
What are the 3 contraindications for Felainide?
HF VD CAD
37
What are the three uses of Propafenone?
Supraventricular arrhythmia w/out structural HD Rhythm control of A-fib/flutter Life threatening V-tach
38
What are the DOC in A-fib/flutter?
BBs
39
A-fib PTs should be started on what additional medication on top of the BB?
Anticoagulation
40
Of the anti-arrhythmic BBs, which one is non-selective?
Propranolol
41
What is Esmolol used for?
Intraoperative BP/HR control and acute arrhythmia
42
What drug has zero drug interactions due to being metabolized in RBCs?
Esmolol
43
What is the MOA of Class 3 drugs?
Prolong phase 3, refractory period in ventricle/supraventricle tissue
44
Amiodarone has what three effects?
BB Anti-angina Vasodilation
45
What is the DOC of PVT/VF
Amiodarone
46
What type of PTs is Amiodarone used in?
A-fib conversion Suppression of arrhythmias in PTs with implanted defibrilators Preferred agent for PTs with LVD/HF
47
What is the derivative of Amiodarone that doesn't contain iodine?
Dronedarone
48
What is the clinical use of Dronedarone | How is it's bioavailability increased?
Maintain sinus rhythm in A-fib/flutter w/ history of paroxysmal/persistent A-fib Taken with food
49
What is Sotalol used for?
Treatment of Supra/Ventricular arrhythmias in Peds | Maintenance of sinus rhythm in PTs with A-fib
50
What is the MOA of Ibutilide?
Class 3 that prolongs AP duration that slows sinus rat and AV conduction velocity
51
What is Ibutailide used for?
Rapid conversion of A-fib/flutter to normal sinus | More effective if onset is less than 90 days
52
What is Dofetilide used for?
Conversion of A-fib/flutter | Maintenance of sinus in PTs with arrhythmias lasting greater than a week
53
What effect do Class 4 drugs have on the SA and AV nodes?
Slows Ca conduction in AV (most important) | SA- Slow depolarization and decrease HR
54
What are Class 4 drugs beneficial against?
Atrial arrhythmias | Re-entrant supraventricular tachy
55
Which Non-DHP has grater action on the heart?
Verapamil
56
Which Non-DHP is more potent vasodilator than Verapamil?
Diltiazem
57
What is the MOA of Digoxin?
Cardiac glycoside, inhibits Na/K pump in cardiac membrane dec K and inc Na/Ca
58
What is the clinical effect of taking Digoxin?
Inc contractions | Stims Vagus nerve to slow SA/AV node and HR w/out increasing O2 demand
59
What drug is used to control ventricular rate with A-fib/flutter?
Digoxin
60
When is Digoxin used as an add on therapy for HF?
PTs failed to achieve Sx control
61
What is the MOA of Adenosine?
Inc K efflux Dec Ca influx Slows HR and AV conduction
62
What is Adenosine the drug of choice for?
Conversion of regular rhythm paroxysmal supraventricular tachycardia to sinus rhythm
63
What must every Adenosine administration be followed with? | What is the starting dose?
NaCl flush | 6mg
64
PTs taking what drug may not be responsive to Adenosine?
Theophylline
65
What is the most common arrhythmia? | Where is it a common comorbidity?
AFib | Valve HD or HF
66
For Torsades de Points, if they have it give ? | If they don't have it give?
Magnesium | BB
67
Define Atrial Flutter
Atrial rate 300
68
Define Atrial Fibrillation
Atrial muscles writhering dure to ectopic areas | Ventricle rate +140bpm
69
What are the five classifications fo A-Fib?
``` Paroxysmal Persistent Long standing Permanent Recurrent ```
70
_____ control is at least as good as _____ | ____ have more risk than ____ drugs
Rate, Rhythm | Rhythm more than rate
71
How are Rhythm control drugs chosen?
Based on disease state
72
Avoid Class __ and __ in HF PTs
1A and 1C
73
What three Class 3 drugs have a neutral effect on mortality in PTs with LVD post-MI?
Amiodarone Dofetilide Sotalol
74
Dronedarone is contraindicated in PTs with ___?
SxHF with recent decompensation requiring admission | NYHA Class 4
75
Avoid Class __ and ___ in acute MI | What two Class 3s can be used?
1A and 1C | Amiodarone and dofetilide
76
Avoid Class __ in PTs with structural HD?
1C
77
What is the goal of ventricular rate control?
Reduce Sx and prevent tachy-induced cardiomyopathy
78
What therapies have an effect on cardioconversion of AF?
BB CCBs Digoxin Amiodarone
79
Which BBs can be considered for PTs with stable HF?
Carvedilol Metoprolo Bisoprolol
80
Avoid BBs for ventricular rate control in PTs with what syndrome?
Wolff-Parkinson-White
81
Avoid Non-DHPs in ventricular rate control if what is present?
Concomitant Systolic dysfunction
82
Non-DHP CCB use for ventricular rate control may be preferred over BB in PTs with ?
COPD | Asthma
83
___ is ineffective for monotherpay for controlling ventricular rate in AF
Digoxin
84
When can Amiodarone be used for rate control in PTs with HF?
No accessory pathway
85
Amiodarone is not considered first or second line options for rate control after ?
BBs Non-DHPs CCBs Digoxin
86
PTs with any form of A-fib need to be evaluated on what criteria?
``` Anti-Coagulation Therapy Dabigatran Rivaroxaban Apixaban Warfin Edoxaban ```
87
When is aspirin use for angti-coagulation therapy?
No other problems and under 60y/o
88
What is considered first line for cardioconversion in AF for stable PTs?
Electrical
89
If PT is experiencing AF for more than 48hrs what needs to be considered/added?
Anticoagulation Less than 48hrs=1% More than 48= 15% More than 72= 30% rate of thrombus
90
What must be verified before converting a PT with a-fib? What is needed for pre-conversion care? What is needed for post-conversion care?
Absence of atrial thrombi Anticoagulation x 3wks Anticoagulation x 4wks
91
Cardioconversion of PTs with A-fib is contraindicated in PTs with what heart issue?
Structural HD
92
What Class 3 agent is used during cardioconversion for AF?
Amiodarone initiated for out-pt use after anti-coagulation
93
Amiodarone is useful for cardioconversion in PTs with A-fib and what two underlying issues?
Worlf-Parkinsons after 1C drugs have failed | Safe in HF
94
What two Class 3 drugs are safe for use in cardioconversion of A-fib in PTs with HF?
Amiodarone and Dofetilide
95
What is the DOC for Symptomatic Bradyarrhythmia?
Atropine
96
What is the DOC for Paroxysmal Supraventricular Tachy?
Adenosine, fastest onset and shortest duration of action
97
What is the sequence of DOCs for Acute Ventricular Tachy/Pulseless Fib?
``` Epi, followed by: 1st line antiarrhythmic- amiodarone Lidocaine Procainamide Empiric Magnesium ```
98
What is the DOC for Torsades de Pointes?
Magnesium IV in PTs with TdP and digitalis toxicity and hypomagnesium is present
99
Ischemic HD is AKA?
Coronary Heart Disease | Sx from imbalance of O2 demand and supply
100
What are the phases of Ischemic Heart Disease?
``` Asymptomatic Stable angina Progressive angina Unstable angina Non-STEMI STEMI ```
101
Define STEMI and what it indicates
Persistent ST elevations and release of biomarkers of necrosis Elevation indicates full thickness injury to muscle
102
Define Non-SEMI and what it's associated with?
Usually caused by atherosclerosis and associated with increased risk of cardiac death/MI Absence of elevation indicates lack of full thickness
103
Priority of Stable Plaque phase of Acute Coronary Syndrome | Priority of Unstable angina phase?
Control anginal Sx Prevent total occlusion
104
What is the priority during N/STEMI phases of ACS?
Prevent total occlusion, limit infarct size | Restore patency of infarcted artery, prevent arrhythmia/death
105
Define Chronic Stable Angina, it's AKA and treatment
Exertional/Classic angina Most common fro reduced coronary perfusion Rest, nitro, BB/CCB
106
Define Unstable Angina, it's AKA and treatment
Crescendo/Pre-Infarction Angina Episodes of small clots, PT may present with angina at rest Admit and treat
107
Define Variant Angina, it's AKA and treatment
Prinzmetal/Vasospasitc Coronary artery spasm caused by decreased blood flow to heart from coronary artery Nitro and CCB
108
What treatment plan applies to all PTs with chronic coronary artery disease and chronic stable angina?
``` ABCDE Aspirin/anti-anginal BB/BP Cigarette/cholesterol cessation Diet/Diabetes Education/exercise All to decrease cardiac load and inc blood flow ```
109
What treatment classes are available for angina?
``` BBs- first line for stable IHD Nitrates CCBs Na blockers (BB alternative) ACEI/ARB in PT with CV comorbidities Lipid lowering agents Anti-platelet ```
110
All angina PTs should be treated with ? or the alternative
Aspirin | Clopidogrel
111
How do BB help in angina PTs?
Dec O2 demand by decreasing catecholamines
112
What is the clinical use for BB with angina PTs? | What can be combined with it?
Long term chronic angina w/ Sx occurring more than once a day or during exertion Used with nitrates, avoid ISAs
113
____ class of drug is detrimental in rest or severe angina
ISAs
114
BBs should be avoided in what type of angina PT?
Prinzmetal, use CCBs
115
CCBs can be used for what type of angina PT?
Stable | Or those who can't tolerate BB/Nitrates due to adverse effects
116
What DHPs can be used in angina PTs?
Nifedipine- added HTN/Sx control, oldest/best studied and used agent in class Felodipine- HTN/Sx control Amlodipine- HTN Sx control when HF is present
117
NO dependent relaxation of vascular smooth muscle leads to ?
Endothelium dependent vasodilation | Inhibits coronary artery spasm
118
Spironolactone is more effective diuretic in what type of PTs?
2* Hyperaldosteronism- Hepatic Cirrhosis, Nephrotic syndrome Ascites PCOS
119
What is a benefit of using Milrinone?
Inhibits PDE3 | No direct adrenergic effect so safe for use in PTs on BBs
120
Using Nitrates for stable angina is useful in conjunction with what other two classes?
Non-DHP | BB
121
What form of nitrates are stable from hepatic breakdown and allow for long duration?
Isosorbide mononitrate
122
What are the adverse reactions of nitrates?
HA Inc ICP Methemoglobinemia
123
What is nitrates contraindicated to use with?
PDE5 inhibitors- can cause hypertrophic obstructive cardiomyopathy Inferior wall MI Aortic valve stenosis
124
WHat is the max dose of SL Nitro? | Don't use nitro tabs if they're older than ?
.4mg Max is 3 tabs in 15min, lasting more than 20min 6mon
125
Nitro is the DOC for what type of PT heart issue?
Preload reduction in PTs with pulmonary congestion
126
Transdermal patches are used for what types of angina and in conjunction with?
Chronic stable but must have nitrate free period daily | BBs
127
What form of nitrate is reserved for inpatient use when PTs require variable doseages?
Oinment
128
What is the clinical use of Isosorbide Dinitrate?
Prevent angina pectoris Sx in chronic stable angina w/ BBs Approved combo of ISDN/hydralazide in HF
129
What form of nitrate has the best bioavailability? What is this form used for? What step must be taken by the PT?
Mononitrate- ISMO at 100% Treating chronic stable angina w/ BBs BUT is not FDA approved 7hrs in between dose to prevent tolerance
130
What is the clinical use of Ranolazine?
``` Monotherapy for chronic stable angina if BBs were adverse/ineffective #3 in line added to CCBs, BBs or nitrates when traditional management is not effective ```
131
What are the adverse reaction of Ranolazine?
QT prolongation | Limit dose to 500mg BID
132
What are the three clues that indicate unstable angina?
Longer than 20min New onset/inc of angina Sudden development of SOB
133
How is NSTEMI angina medically managed?
Antiplatelets w/ aspirin and P2Y12 inhibitor +- glycoprotein 2b/3a inhibitor
134
What are the two types of inhibitors used in NSTEMI?
P2Y12- Clopidogrel- inhibits platelet activation/aggregation | Glycoprotein 3a/2b Inhib- prevents formation/aggregation
135
All PTs with NSTEMI ACS receive anticoagulation therapy with includes what four things?
``` Unfract. Heparin Low weight Heparin Foondaprinux Bivalirudin All prevent formation of fibrin and thrombus ```
136
How is PCI performedin PTs with UNSTEMI?
PIC w/ fibrinolytics
137
When are BB the first line drug?
PT after MI to dec PVCs
138
When are Non-DHPs the first line drug?
PT w/ Inc HR for rate | Rate control for A-Fib and can't tolerate a BB
139
A-Fib PTs need what two drugs?
BB | Anti-Coagluant
140
What is the first line drug for PVT/Fib?
Amiodarone
141
What is the first line drug for PSVT?
Adenosine
142
What is the DOC for Pinzmetal Angina?
DHP CCBs
143
What is the first line drug for lithium induced nephrogenic diabetes insipidous?
Triamterene | Thizide for only D Insip.
144
All HFrEF PTs get what class of drug unless CI?
ACEI

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