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Cardiology > Pharm for ischemic heart disease > Flashcards

Pharm for ischemic heart disease Flashcards

1
Q

Nitrates class?

A
  • nitroglycerin (nitrostat, Nitroquick)
  • isosorbide dinitrate (Isordil)
  • isosorbide mononitrate (Imdur)
  • transdermal patch (nitrodur)
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2
Q

Indications for Nitrates use?

A
  • acute angina
  • chronic angina
  • CHF
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3
Q

MOA of nitrates?

A
  • decrease O2 demand of heart
  • decrease arteriolar and venous tone
  • decrease preload and decrease afterload (at higher doses)
  • cause vasodilation
  • increases O2 to the heart
  • decreases BP
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4
Q

In what diseases is preload increased?

A
  • hypervolemia
  • regurgitation of cardiac valves
  • heart failure
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5
Q

In what diseases is afterload increased?

A
  • HTN and vasoconstriction

increased after load = increased cardiac workload

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6
Q

What are short acting nitrates used for?

- dosage?

A
  • immediate relief of anginal sxs
  • sublingual nitro tablets or spray: 0.4 mg and repeat in 3-5 minutes if needed (up to 3)
  • pain lasting more than 20 minutes should go to ED via EMS
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7
Q

What are the most common SEs from nitrates?

A
  • HA
  • dizziness (from lowering BP)
  • Hypotension
  • flushing
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8
Q

CIs to nitrates?

A
  • hypotension
  • aortic stenosis
  • severe volume depletion
  • acute RV infarction
  • hypertrophic cardiomyopathy
  • recent meds for ED: sildenafil (viagra), vardenafil (levitra), tadalafil (Cialis)
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9
Q

When are long acting nitrates used?

A
  • added to B blockers or CCBs to control stable angina (not first line because you want to save nitrate for when angina can’t be controlled by other meds, don’t want to become tolerant)
  • limited by development of tolerance
  • need a nitrate free interval for 8-10 hours a day
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10
Q

Types of long acting nitrates?

A
  • isosorbide dinitrate (Isordil)L 5-40 mg BID to TID
  • Isosorbide mononitrate (Imdur - most common) 30-120 QD to BID
  • transdermal patch (NitroDur): 0.1, 0.2, 0.4, 0.6 mg/hr (low dose for people with hypotension)
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11
Q

B blockers class?

A
  • metoprolol (Lopressor, toprol)
  • bisoprolol (zebeta)
  • atenolol (tenormin)
  • carvedilol (coreg)
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12
Q

Indications for B blockers use?

A
  • HTN
  • tachycardia
  • CHF
  • ischemic heart disease
    NSTEMI
    STEMI
    unstable angina
    chronic angina
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13
Q

B blockers are first line therapy for tx of what?

A
  • tx of chronic angina
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14
Q

MOA of B blockers?

A
  • blocks b receptors in heart causing a decrease in HR, decrease in force of contraction, decrease of AV conduction
  • only antianginal agents that have been demonstrated to prolong life in pts with CAD post MI
  • most commonly used is Metoprolol
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15
Q

B blocker CIs

A
  • severe bronchospasm (asthmatics)
  • bradyarrhythmias
  • decompensated heart failure (in midst of acute exacerbation)
  • may worsen Prinzmetal’s (variant) angina due to leaving alpha 1 receptors unopposed
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16
Q

Caution in B blocker use

A
  • they may mask sxs of hypoglycemia (tachycardia, diaphoresis) - so caution in diabetics
  • abrupt withdrawal may precipitate tachycardia, HTN crisis, angina or MI so it must be tapered off slowly (especially high doses) to prevent these sxs
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17
Q

Drugs in CCB class?

A

Amlodipine (Norvasc)
Nifedipine (Adalat, Procardia)
DIltiazem (Cardizem)
Verapamil

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18
Q

Indications for CCB use?

A
  • HTN
  • tachycardia
  • chronic angina
  • coronary vasospasm
  • peripheral vasospasm
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19
Q

MOA of CCBs?

A
  • decrease O2 demand
  • decrease preload
  • decrease HR (verapamil and diltiazem)
  • decrease BP
  • decrease contractility (verapmil, diltiazem)
  • increase O2 supply
  • cause coronary vasodilation
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20
Q

2 different subclasses of CCBs?

A
  • dihydropyridines:
    Amlodipine (Norvasc) - can be used in HF
    Nifedipine (Adalat, Procardia)
  • Nondihydropyridines:
    Diltiazem (Cardizem), and Verapamil
    (have neg chronotropic rate and neg inatropic effect)>
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21
Q

Common SEs of CCBs?

A
  • HA
  • edema
  • constipation
  • hypotension
  • dizziness
  • bradycardia (nondihydropyridines)
22
Q

CI for nondihydropyridines?

A
  • systolic CHF: b/c low EF

- AV block or bradycardia

23
Q

CI for all CCBs?

A
  • caution when using in pt’s with peripheral edema or hx of hypotension (elderly), multiple drug interactions - metabolized by the liver (use caution)
24
Q

What are anti platelet drugs function?

A
  • interfere either with platelet adhesion and/or aggregation

goal: prevent initial clot formation

25
Q

Fxn of fibrinolytic agents?

A
  • degrade fibrinogen/fibrin

goal: eliminate already formed clots

26
Q

Fxn of anticoagulants?

A
  • inhibit clotting mechanism, goal: prevent progression of thrombosis
27
Q

What are the antiplatet agents?

A
  • aspirin
  • clopidogrel (plavix)
  • prasugrel
  • Ticagrelor
  • acute situations IV:
    Abiciximab and Eptifibatide
28
Q

MOA of aspirin?

A
  • inhibits cox: this then inhibits synthesis of thromboxane A2, a potent stimulator of platelt aggregation
  • irreversible platelet inhibitor
  • prevents form. of clots by inhibition of platelet plug
  • rapid absorption with peak effects in 1 hr
29
Q

Dosing recommendations of aspirin and indication?

A
  • primary prevention of CVA/MI: 81 mg daily
  • 2nd prevention of CVA/MI: depends on other meds. acutely 325 mg daily for MI and CVA
  • acute coronary syndrome: 325 mg chewed x 1
30
Q

Is ASA beneficial in unstable angina?

A
  • study showed that aspirin lead to a 51% reduction in CV events
31
Q

Major SE of aspirin?

A
  • always assess for GI bleeding
  • H2 blockers or PPIs may decrease gastritis and GI bleeding
  • administer with food to decrease GI disturbance
  • Tinnitus at higher doses
  • Resistance
  • allergy
  • stop 4 days before surgery
32
Q

Class of P2Y12 antagonists of antiplatelet agents?

A
  • clopidogrel (plavix)
  • prasugrel (effient)
  • ticagrelor (brilinta)
33
Q

MOA of P2Y12 antagonists?

A
  • inhibit binding of fibrinogen to activated platelets by blocking the P2Y12 receptor site as a result the GP IIb/IIIa receptor isn’t activated
  • blocks receptor which is the binding site for fibrinogen, von WIllebrand factor and other ligands
  • resulting in blockage of platelet aggregation and prevention of thrombosis
34
Q

Indications for P2Y12 antagonists?

A
  • unstable angina
  • NSTEMI
  • STEMI
  • post intracoronary stent placement
  • post stroke
  • peripheral vascular disease
  • No indication for primary prevention of MI/CVA unless pt is allergic to aspirin
35
Q

P2Y12 drugs?

A
  • clopidogrel (plavix): 300-600 mg loading dose - detected within 2 hours, platelet function returns to normal about 5 days after discontinuation
  • prasugrel (effient): 60 mg loading dose: less than 30 minutes, platlet aggregation gradually returns to baseline values over 5-9 days after d/c
  • ticagrelor (Brilinta)
    180 mg loading doses: wthin 30 minutes, platelet fxn returns normal in 3 days
36
Q

SEs of P2Y12 inhibitors?

A
  • major: bleeding
  • prasugrel not recommended for 75 and older, or those who weigh less than 60 kg - (LOPs) - = increased bleeding risk
  • ticagrelor: 10-14% of pts = SOB first few days after initiating therapy
  • no antidote for reversal of medication in event of significant bleeding
  • some people have genetic variant and are resistant to clopidogrel
37
Q

GPIIb/IIa antagonists?

A
  • abciximab (Reopro)

- eptifibatide (integrelin)

38
Q

MOA of GPIIb/IIIa antagonists?

A
  • IV
  • used for acute coronary syndrome
  • during percutaneous coronary intervention
39
Q

Onset of GPIIb/IIIa antagonists?

A
  • immediate (IV)
  • platelet fxn is restored to normal 4-8 hrs after d/c of infusions
    (reversible)
40
Q

SEs of GPIIb/IIIa antagonists?

A
  • bleeding
  • thrombocytopenia: reversible once d/c meds (takes a couple of days)
  • allergy
41
Q

Anticoagulants class for acute situations (MI)?

A
  • enoxaparin (Lovenox - LMWH)
  • Heparin (UFH)
  • Bivalirudin (angiomax)
42
Q

MOA of Heparin?

A

activation of anticlotting factors (especially antithrombin III)

  • indirect thrombin inhibitor
  • rapid onset of action and short half life
  • dose adjusted by following aPTT
  • given IV for acute tx, (SQ use for DVT prevention in post surgical pts)
43
Q

CIs and complications of Heparin?

A
  • CIs: anaphylaxis and recent major surgery

- adverse effects: bleeding, hypersensitivity rxns, transaminitis, HIT

44
Q

MOA of Enoxaparin (Lovenox), indications

A
  • inhibits Xa and antithrombin III
  • indirect thrombin inhibitor
  • stronger inhibition of Xa than UFH
  • for use in MI pts: IV dose followed by SQ dose
45
Q

MOA of Bivalirudin (angiomax)

A
  • direct thrombin inhibitor
  • immediate onset of action
  • coagulation times return to normal about hour after d/c of infusion
  • IV infusion only
46
Q

Major SEs and CIs of Bivalirudin?

A
  • SE: bleeding

- CIs: allergy or recent major surgery or trauma

47
Q

Fibrinolytics class?

A
  • tPA (activase)
  • streptokinase (streptase)
  • Urokinase (Abbokinase)
48
Q

MOA of fibrinolytics?

A
  • convert plasminogen to plasmin to breakdown fibrin strands

- short activation times and short half lives

49
Q

Indications of fibrinolytics?

A

tx of existing clots:

  • MI
  • stroke
  • Massive PE (life threatening)
  • limb threatening ischemia
50
Q

SEs of thrombolytics?

A
  • massive life threatening bleeding
51
Q

Absolute CIs of thrombolytics?

A
  • previous intracranial bleeding at any time
  • CVA within last 3 months
  • closed head or facial trauma within 3 months
  • suspected aortic dissection
  • active bleeding diathesis
  • uncontrolled HTN: SBP greater than 180 and DBP greater than 100
  • known CV lesions
52
Q

Relative CIs of fibrinolytics?

A
  • current AC use
  • invasive or surgical procedure in last 2 weeks
  • prolonged CPR defined as more than 10 minutes
  • known bleeding diathesis
  • pregnancy
  • hemorrhagic or diabetic retinopathies
  • active peptic ulcer
  • controlled severe HTN

Cardiology (20 decks)

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