Pharm Ischemic Heart Disease Flashcards
Nitrates
- examples
- indications
- MOA
Examples:
- Nitroglycerin (Nitrostat, Nitroquick)
- Isosorbide dinitrate (Isordil)
- Isosorbide mononitratae (Imdur)
- Transdermal patch (NitroDur)
Indications:
- acute angina
- chronic angina
- CHF
MOA:
- nitrates decrease the O2 demand of the heart by:
1. decreasing arteriolar and venous tone (systemic and coronary)
2. decrease preload
3. decrease afterload
4. incrase O2 supply to the heart
4. decrease BP
Short Acting Nitrates
- when do you use these?
- how are they taken?
- used fro immediate relief of acute anginal sx.
- sublingual nitro tablets or spray, repeat in 3-5min if needed x3. Not great advice for everyone, requires a lot of patient education. Best advice is to take one and call 911.
Nitroglycerin
- SE
- CI
SE: -HA -Dizziness -Hypotension -Flushing **Passing out. CI: -Hypotension -Aortic Stenosis -Severe volume depletion -acute RV infarction (rely on high preload during this time) -Hypertrophic cardiomyopathy -Recent meds for ED (Viagra, Levitra, Cialis)
Long acting nitrates
- first line monotherapy? Why or why not?
- how long does the blood need to be free of free nitrates/day?
- examples
- Not used as first line, usually used as and add on to other anti-angina drugs. This is because over time tolerance is developed to this medication and it no longer works, so we save this for last.
- The blood needs to be free of free nitrates for 8-10hrs/day.
Examples:
- Isosorbide dinitrate(Isordil)
- Isosorbide mononitrate (Imdur)***
- Transdermal patch (NitroDur)
Beta Blockers
- examples
- Indications
- SE
- MOA
Examples:
- Metoprolol (Lopressor, Toprol)
- Bisoprolol (Zebeta)
- Atenolol (Tenormin)
- Carvedilol (Coreg)
Indications:
- HTN
- Tachycardia
- CHF
- Ischemic Heart disease
- -NSTEMI (non-elevated ST elevation MI)
- -STEMI
- -Unstable/Chronic Angina
SE:
- Bradycardia
- Lethargy
- GI disturbance
- CHF
- Decreased BP
- Depression
MOA:
- negative inotrope and chronotrope
- decreases HR, force of contraction, AV conduction rate.
What is first line therapy for treatment of chronic angina?
-beta blocker
What is the only anti-anginal agent proven to prolong life in patients with CAD post MI?
- beta blockers!!!
* most common: Metoprolol (Lopressor)
Beta Blockers
- CI
- caution
- severe bronchospasm
- bradyarrhythmias
- decompensated heart failure (in midst of acute exacerbation)
- may worsent with Prinzmetals angina d/t leaving alpha 1 receptors unopposed. (normally, alpha and beta try to balance one another out, if you block the betas the alphas party b/c the betas are gone, this makes angina worse)
Cautions:
- mask hypoglycemia sx (tachycarida, sweating, confusion)
- abrupt withdrawl (3 days)
Calcium Channel Blockers
- examples
- indications
- MOA
examples: Dihydropyridines: -Amlodipine (Norvasc) -Nifedipine (Adalat, Procardia) Nondihydropyridines: -Diltiazem (Cardizem) -Verapamil
Indications:
- HTN
- Tachycardia
- Chronic Angina
- Coronary vasospaasm
- Peripheral vasospasm
MOA:
- Calcium channel blockers decrease myocardial O2 demand by:
1. decrease preload
2. decrease heart rate (verapamil, diltiazem)
3. decrease blood pressure
4. decrease contractility (Verapamil, diltiazem)
5. increase O2 supply
6. cause coronary artery vasodilation
Which of the Ca2+ channel blocker medication is only approved for use in CHF? WHY?
-Dihydropyridines; Amlodipine (Norvasc)
Why:
-it does not have the negative inotropic(contractility) or chronotropic(rate) effects that the other calcium channel blockers have.
SE of Calcium CHannel Blockers
- HA
- Edema
- Constipation
- Hypotension
- Dizziness
- Bradycardia (nondihydropyridines; cardizem & verapamil)
- CI to nondihydropyridines (verapamil, cardizem)
- CI for all calcium channel blockers
- systolic CHF d/t lower EF
- AV block or bradycardia.
CI All Ca2+:
- pt w/ peripheral edema or hx of hypotension
- multiple drug interactions* caution* (cleared through the liver, CYP enzymes)
Define each of the following:
- Antiplatelet
- Fibrinolytic
- Anticoagulants
Antiplatelets: drugs interfere either with platelet adhesion and/or aggregation. (prevent initial clot formation)
Fibrinolytic: degrade fibrinogen/fibrin (eliminate formed clots)
Anticoagulants: inhibit clotting mechanism ( prevent progression of thrombosis)
Antiplatelets
- examples
- MOA
- absorption peak
Examples: Antiplatelet
- Aspirin
- Clopidogrel (Plavix)
- Prasugrel (Effient)
- Ticagrelor (Brilinta)
- Abiciximab (Reopro)
- EPtifibatide (Integrelin)
- last two are IV, used in setting of MI
MOA:
- inhibits cyclooxygenase that then inhibits the synthesis of thromboxane A2, a potent stimulator of platelet aggregation.
- irreversible platelet inhibitor
Absorption peak is 1Hr
Dosing Recommendations of Aspirin
- primary prevention of CVA/MI
- Secondary prevention of CVA/MI (already had one)
- Acute coronary syndrome (in the midst of having an MI)
Primary prevention: 81mg/day
Secondary: 325mg/day acutely(several months)
Acute syndrome: 325mg chewed x1
SE of Aspirin
-GI bleeding
(H2 Blockers or proton pump inhibitors may decrease gastritis and GI bleeding, also administer with food to decrease GI disturbnace)
- tinnitus at high doses
- resistance (dont metabolize and has no effect on platelet aggregation)
- allergy
How many days pre-op should you stop taking aspirin?
-4days
P2Y12 Antagonists
- examples
- MOA
- indications
Examples: Antiplatelet
- Clopidogrel (Plavix)
- Prasugrel (Effient)
- Ticagrelor (Brilinta)
MOA:
- inhibits the binding of fibrinogen to activated platelets by blocking P2Y12 receptor site, as a result the GP IIb/IIIa receptor is not activated. (which is the binding site for fibrinogen, von Willebrand factor)
- resulting in the blockage of platelet aggregation and prevention of thrombosis
P2Y12 Antagonists
- Indications
- do these require loading dose?
Indications:
- unstable angina
- NSTEMI/STEMI
- post intracoronary stent placement
- post stroke
- PVD
- no indication for primary prevention of MI/CVA unless the patient is allergic to aspirin
-yes, these drugs require a loading dose. Plavix has the slowest time to detection in the blood of all three medications
P2Y12
- SE
- not recommended in whom?
- reversible?
SE:
- bleeding**
- SOB w/ Ticagrelor
Not recommended in LOP. Greater than 75 or weigh less than 132lbs.
-No antidote for the reversal of the medication in the event of significant bleeding.
GPIIB/IIIA Antagonist
- examples
- Route of administration
- Indications
examples: Platelet Antagonists
- Abiciximab (Reopro)
- EPtifibatide (Integrelin)
Route: IV
Indication:
acute coronary syndrome, percutananeous coronary intervention
GPIIB/IIIA Antagonist
- onset of action
- reversible?
- SE
Onset: immediate
-yes Reversible, platelet function is restored to normal 4-8hrs after discontinuation of infusion
SE:
- bleeding
- thrombocytopenia (reversible once discontinuation of med_
- allergy
Anticoagulants:
- examples
- indications
Enoxaparin (Lovenox) (LMWH)
Heparin (UFH)
Bivalirudin (Angiomax)
- indications:
- acute MI situations only.
Heparin
- MOA
- what lab do we base our medication adjustments on?
- CI
- Adverse Effects
anticoagulant
MOA:
-activation of anti-clotting factors (especially ATIII)
-indirect thrombin inhibitor
-Base med adjustments on the PTT
CI:
-anaphylaxis and recent major surgery
Adverse effects:
-bleeding, hypersensitivity rxn, transaminitis, heparin induced thrombocytopenia (HIT)
