Pharmacology Flashcards
1
Q
What is the 60/40/20 rule for body water?
A
60% of body weight is total body fluid
40% of BW is intracellular fluid
20% of BW is extracellular fluid
2
Q
What are the 2 compartments within ECF?
A
Intravascular—>blood (7% of BW/25% of ECF)
Extravascular—>interstitial fluid (75% of ECF)
3
Q
Where and how does diuretics work on? ICF or ECF? and it is equivalent to?
A
Force renal output—>shrink intravascular volume (ECF)—>decrease CO—>decrease BP
Equivalent to decrease Na intake
4
Q
Total body fluid increase or decrease as ones ages?
A
Decrease from 75% of BW to 50% (most shrinkage occurs in ECF)
5
Q
Is the osmolarity of ICF and ECF same or different?
A
Same
6
Q
What are the equations for BP or CO?
A
BP = TPR x CO CO = HR x SV
7
Q
How large are the CO going through kidneys/RBF/RPF/GFR?
A
20% of CO perfuses the kidneys
1/2 of RBF is RPF
20% of RPF is GFR (125 ml/min)—>filtration fraction (FF)
8
Q
Is there urine production if RBF is zero?
A
NONE
9
Q
What happened when you drink a lot of water or sodium?
A
ECF expands—>increase renal output of water and sodium
10
Q
In healthy individual, renal output of Na matches?
A
Dietary intake of Na
11
Q
Edema is a shift of fluid from ___ to ___?
A
Intravascular to extravascular
12
Q
Hydrostatic pressure does? oncotic pressure does?
A
Push fluid out of the capillaries/push fluid into the capillaries
13
Q
The ultrafiltrate of glomerulus has similar composition to plasma except?
A
Without protein
14
Q
What is the equation for excretion? and what is the fraction of excretion of water and Na(FEwater/FEsodium)?
A
Excretion = filtration - reabsorption + secretion
1%
15
Q
___ and ___ of kidney are impermeable to water, which results in?
A
Thin and thick ascending limb—>reabsorb solute w/o water—>dilute the tubular fluid (osmolarity decreases)
16
Q
___ drives the solute transport and maintain the counter current multiplication
A
Thick ascending limb
17
Q
The clearance rate of ___ is the GFR? and it is similar to endogenous __?
A
Inulin (amount filtered = amount excreted)/creatine
18
Q
What does it mean when FEwater > or
A
> 1%—>positive water balance
negative water balance
19
Q
Fractional reabsorption is = ?
A
1 - FE
20
Q
Is sodium ever secreted in the kidney?
A
Never
21
Q
Aldosterone increase __ reabsorption and ___ secretion?
A
Na/K
22
Q
We have normally a high or low K diet? which results in?
A
High K diet/aldosterone secretes K into the tubule
23
Q
How does hypokalemia happens during alkalosis?
A
Proton comes out of the cells and K goes into the cell—->increase K secretion in kidneys
24
Q
The faster the flow through the collecting duct, the ___ of the rate of secretion of K into the tubule
A
Higher
25
If creatine excretion is going up, what does that tell you about the GFR?
It is going down (kidney is sick)
26
Reabsorption of Na increases or decreases as Na goes from Loop of Henle to the Collecting duct? and what happens if a diuretics is used?
Decrease/diuretics blocks Na reabsorption--->different part of the tube will try to compensate by reabsorbing more Na
27
Na reabsorption is coupled with ___ in the late distal tubule and early collecting duct?
K secretion
28
Diuretics (non K sparing) cause hyper/hypokalemia?
Hypokalemia
29
What drives the Mg and Ca from the tubular fluid into the blood at thick ascending limb of loop of Henle? what if you block the Na/K/Cl channel with a diuretics?
```
The positive (+7) voltage difference in the tubular fluid created by the Na/K/Cl channel--->push Mg and Ca out of the tubular fluid
Increase Mg and Ca in the tubular fluid for excretion
```
30
What does it mean when U/P (urine osmolarity over plasma osmolarity) >1 or
>1--->urine is hypertonic--->free water clearance is negative--->kidney is retaining water
urine is hypotonic--->free water clearance is positive--->kidney is eliminating water
31
ADH increases when plasma osmolarity rises or falls?
Rises
32
What transporter is responsible for Na reabsorption in early distal tubule? and what blocks it?
Na-Cl cotransporter/thiazide diuretics
33
ADH acts on what parts of the kidney?
Late distal tubule and collecting duct
34
When you eat a lot of Na, your ADH is high or low?
Low
35
In the late distal tubule and collecting duct, increase ADH results in?
Increase Na reabsorption--->increase Na/K ATPase on the blood side of the luminal cell--->increase intake of K into the cell--->increase secretion of K out of the cell into the tubular fluid
36
Conductance equals to ?
1/resistance
37
Can AP opens an inactivated gate?
No
38
Which phase does the heart muscle contracts?
The plateau phase of the AP
39
What is the AP of pacemaker cells in the SA and AV node that is different from the rest of the heart muscle cells?
Slow response AP
40
Hypo/hyperkalemia causes hyper/depolarize?
Hypokalemia--->hyperpolarize (increase threshold)
| Hyperkalemia--->depolarize (decrease threshold)
41
Threshold potential depends on?
Resting membrane potential/Na current availability/cell size
42
Resting membrane potential depends on which ion?
K
43
What is the level of hyperkalemia affect the excitability?
Moderate--->increase excitability
| Severe--->decrease excitability (too much depolarization--->decrease K conduction)
44
What is effective/relative/functional refractory period?
Effective--->can't be stimulated with an AP
Relative--->can be stimulated but need a bigger AP
Functional--->combination of effective and relative
45
Heart muscle cells and pacemaker cells depends on what ions for AP?
Heart muscle cells--->Na
| Pacemaker cells--->Ca
46
Which cell has faster conduction speed, heart muscle or pacemaker cells?
Heart muscle cells
47
Sequence of conduction in the heart
SA node--->AV node--->purkinje fibers
48
Cardiac contract is dependent on?
AP duration
49
Tackycardia increases or decreases CO?
Decreases
50
Stretching sarcomere length increase ___ but over stretching causes?
Increase contractility/decrease in contractility
51
SV = ?
end diastolic volume - end systolic volume
52
Ejection fraction = ?
SV/EDV
53
How does diuretics work?
Increase urine output by decreasing active reabsorption of the solutes
Initial affect--->maintenance of the new baseline (body fights back)
54
Which kind of diuretics mimic diabetes insipidus? and how does it work?
Aquaretics--->decrease the ability of ADH to increase the water permeability of the late distal tubule and collecting duct
55
How does saluretics work?
Decrease solute reabsorption
56
How does osmotic diuretics work?
Raise osmolarity of tubular fluid--->oppose water reabsorption
57
What are diuretics used for?
HTN/edema/hyper or hypocalcemia or kalemia
58
Where is bicarb reabsorbed in the kidney?
Proximal tubule
59
What is the affect of loop diuretics on water regulation of the kidney?
Keeping the osmolarity of the urine close to that of the plasma--->decrease both + and - free water clearance--->takes the pt longer to get rid of/conserve water when he is volume overloaded/dehydrated
60
Thiazide diuretics only affect + or - free water clearance?
+
61
Which has a higher chance to cause hyponatremia, loop or thiazide diuretics?
Thiazide diuretics
62
What diuretics work on proximal tubule?
Carbonic anhydrase inhibitor/osmotic diuretics/aminophylline
63
Excess glucose is like what kind of diuretics?
Osmotic
64
What diuretics work on thick ascending limb?
Loop
65
What diuretics work on early distal tubule?
Thiazide
66
What diuretics work on late distal tubule/collecting duct?
K sparing/vaptans
67
How is bicarb and Na reabsorbed in the proximal tubule and what block this?
Na comes in and H+ goes out to the lumen--->bicarb + H+ becomes carbonic acid--->then disassociate into H2O and CO2--->CO2 comes into the cell and combine with water to form carbonic acid and then disassociate into H+ (goes out again) and bicarb--->bicarb is transported into the blood/carbonic anhydrase inhibitor (carbonic anhydrase facilitate the disassociation and association of bicarb and carbonic acid)
68
What is carbonic anhydrase does to ammonia excretion?
Decrease ammonia excretion--->causes hepatic encephalopathy
69
Which loop diuretics does not have a sulfamoyl group?
Ethacrynic acid
70
How does the body counter the increase of Na excretion created by diuretics?
Decrease GFR (decrease filtering load of Na)
71
How does hypokalemia happens with loop diuretics?
Late distal tubule and collecting duct trying to compensate for excess Na in the tubular fluid by reabsorbing Na--->increase K secretion--->hypokalemia
72
Thiazide decrease or increase Ca reabsorption and results in?
Increase/prevent Ca stone in the tubules
73
What is the pathology of nephrogenic diabetes insipidus?
Collecting duct and late distal tubule fail to response to ADH
74
What does Li do to the distal tubule and the collecting duct? what is used to treat that?
Make them fail to response to ADH (like diabetes insipidus)/K sparing--->might need to decrease Li dosage
75
Why do loop and thiazide diuretics cause hyponatremia?
Decrease + free water clearance
76
Response to volume contraction/expansion happen only at what part of the kidney?
Distal tubule and collecting duct
77
Where in the kidney do amiloride and triamterene secreted into the tubular fluid?
Proximal tubule
78
High or low Na diet is needed for spironolactone to work?
Low Na diet--->volume contracted--->ADH is released
79
Does the activity of spironolactone depends on GFR/tubular secretion and con.?
No (act inside of the cell)
80
Can we use diuretics for renal disease and nephrotic syndrome? and what should we be aware?
Yes/need to increase dose of diuretics
81
Hypokalemia can be an indication for ___ and ___?
Renal artery stenosis/hyperaldosteronism
82
Should you treat a younger HTN pt more aggressively or conservatively?
Mosre aggressively
83
HTN can causes LV hypertrophy, which is called ___?
End organ disease
84
What are the 5 factors associated with cardiac disease?
Smoking/diabetes/cholesterol/family history/HTN
85
How does alpha receptor decreases BP?
Alpha receptor--->vasoconstriction
| Block alpa--->decreases peripheral resistance
86
What are the 3 factors that stimulate renin release?
Low CO/low volume/sympathetic tone (NE and epi)
87
Potency of diuretics in descending order?
Loop>thiazide>K sparing
88
What causes the dry cough from ACEI?
Bradykinin (prevent breakdown)
89
Why can't you use dihydropyridine Ca channel blocker for anti-angina?
It causes reflex tachycardia--->increase O2 demand--->worsen angina
90
Couple Ca channel blocker with ___ to lessen leg edema
Diuretics
91
Which Ca channel blocker decrease HR/AV node conduction/contractility?
Non-dihydropyridine
92
Primary mechanism of beta blockers?
Reduce CO
93
For otherwise healthy pt with HTN, give what first?
ACEI--->get cough--->switch to ARB
94
For obese pt with HTN, give what first?
Thiazide
95
Is the airway obstruction reversible for asthma? and it is driven by TH_ cells?
Yes/TH2
96
Are allergen is only type of substance that can cause asthma?
No, cold air and exercise can also cause asthma
97
Beta 2 binds to Gs or Gi protein?
Gs
98
Most beta 2 agonist is a mix of R and S isomer, which isomer exerts beta 2 agonist effects?
R
99
How is long acting beta 2 agonist long acting?
Highly lipid soluble and binds to a 2nd site
100
How does paradoxical bronchospasm occurs?
Prolonged use of beta 2 agonist
101
Which M receptor is responsible for the effect of antimuscarinic agents on COPD?
M3
102
What is the first line treatment for chronic stable COPD?
Tiotropium
103
What is the mechanism of methylxanthine?
Inihibit breakdown of cAMP--->increase intracellular cAMP--->bronchodilation
104
Roflumilast mechanism?
Inhibit PDE4--->prevent neutrophil migration
105
When to use anti-inflammatory corticosteroid for COPD? what is the risk for?
For severe COPD with frequent exacerbation/pneumonia
106
Steroid sensitivity can be restored with low dose of ?
Theophylline
107
Which way is better for delivery, metered dose or dry powder?
Dry powder (no need to coordinate)
108
What is the first line treatment for persistent asthma?
Inhaled corticosteroids
109
What to give for COPD and asthma exacerbation?
Corticosteroid/short acting beta 2 agonist/antibiotics for COPD
110
Shear stress on the coronary vessels causes vaso__?
Vasodilation
111
Is angiographic test a diagnostic test for heart ischemia?
No/test to show the presence of coronary narrowing
112
What happens to the extracellular K level during ischemia and how does it happens?
Extracellular K level goes up/increase K leak outwards during AP
113
What happens to the extracellular phosphate/lactate/fatty acid?
Increases (MI causes symp activation--->increase fatty acid)
114
What is systolic injury current (subendocardial injury) and what does that cause on EKG?
Shortening of AP in ischemic cells--->ischemic cells are more negative than normal cells--->positive current flow from normal cells to ischemic ones/ST depression on EKG
115
What is stress test used for and what is the goal?
Diagnosis of ischemia/85% of max HR
116
If baseline EKG is not normal then what should be added to diagnose ischemia?
Echo and nuclear tracers
117
If the pts can not exercise, what should you do to diagnose ischemia?
Use dobutamine (beta 1 agonist) to stimulate the heart like it is exercising/use vasodilator to create perfusion mismatch and then detect using radioactive tracer
118
Why clopidogrel is not used for long term use?
Stronger than aspirin--->more risk for bleeding (except for severe vascular disease pts)
119
Which antiplatelet drugs can be used for pt with liver dysfunction?
Ticagrelor
120
What is the box warning for ticagrelor?
Aspirin maintenance dose has to be under 100mg
121
Which substance does ACE help degrading?
Bradykinin
122
How does hyperkalemia caused by ACEI?
Decrease aldosterone
123
How does beta blocker causes decreased exercise tolerance?
Not be able to reach high HR and CO
124
Affect of nitrate on cardiac function?
Increase myocardial O2 supply/venous dilation--->decrease preload
125
Difference between the 1st and 2nd gen dihydropyridines?
1st gen has negative inotropic effect (decrease heart contractility) and reflex tackycardia/2nd gen does not have those (less reflex tacky)
126
Non-dihydropyridines have negative ___ effect
Inotropic (decrease contractility)
127
What is the definition of congestive heart failure?
Inability to pump blood at a rate that required to supply tissues (inability for the heart to keep up)
128
What are class I to IV of heart failure?
Class I--->pts with cardiac disease but w/o limitation in physical activity
Class II--->cardiac disease with slight limitation
Class III--->marked limitation
Class IV--->inability to carry out physical activities w/o discomfort
129
___ reduce readmission with chronic heart failure pts
Exercise
130
LV dysfunction w/o intervention will get?
Worse (cardiac remodeling)
131
What is responsible for cardiac remodeling of heart failure?
neurohormonal (e.g. NE/aldosterone/angiotensin II)--->target these to prevent heart failure
132
What are stage A and B of development of heart failure and how to manage?
Stage A--->high risk for HF w/o structural heart disease nor symptoms--->treat underlying conditions (use ACEI or ARB)
Stage B--->structural heart disease no symptoms of HF (ACEI or ARB)
133
What are stage C and D of development of heart failure and how to manage?
Stage C--->structure disease with HF symptoms (ACEI/diuretics/beta blockers)
Stage D--->refractory HF (hospice)
134
Main effect of ACEI?
Artery and vein dilation--->increase CO and exercise tolerance
135
CHF/LV dysfunction, first line treatment? what about ischemic heart disease?
ACEI/aspirin, beta blockers, statin
136
Mechanism and benefit of angiotensin receptor blockers over ACEI?
Block angiotensin II type 1 receptor (AT1)---->usually used to replace ACEI because of the cough
Inhibit angiotensin II's effect on symp tone--->dilate vessels
137
Treating HTN, use diuretics with combo of ___?
ACEI or beta blockers
138
___ dose of aldosterone antagonist is used for class III and IV of CHF to reduce death
Low (because the side effect of hyperkalemia)
139
Eplerenone does not have side effect of ___ comparing with spironolactone?
Gynecomastia
140
Why is beta blockers used for reduction of mortality in CHF?
Anti arrhythmic/inhibit negative cardiac remodeling
141
Digoxin increases intracellular ___ and ___ level and has a ___ inotropic effect?
Na and Ca/positive
142
What is the toxic effect of digoxin?
Cardiac arrhythmia
143
When is digoxin used?
For pt who is admitted into the hospital and had a previous decompensation episode
144
What does diuretics aim to and does it inhibit negative cardiac remodeling?
Treat symptoms/no
145
Low dose dobutamine stimulate ___ receptor and high dose stimualte ___ receptor?
beta 2--->vasodilation/alpha--->vasoconstriction
146
What is the effect of milrinone similar to?
Dobutamine--->increase HR/contractility/vasodilation
147
Dobutamine and milrinone, which drugs develop tolerance?
Dobutamine
148
Management of acute decompensated heart failure?
Diuretics for symptoms, use inotropic to improve CO and symptoms but long term worsen outcomes
149
Which surface protein of chylomicron activates plasma lipoprotein lipase (or CPL) that hydrolyze chylomicron?
ApoCII
150
Where is VLDL produced and how it is degraded?
Endogenously produced by liver/hydrolyzed from VLDL to IDL to LDL (mainly cholesterol by now)
151
Which ligand on the surface of LDL is responsible for taking LDL back into the liver?
Apo B100
152
What are the 3 effects of free cholesterol in the hepatocyte recycled by the liver from LDL?
Decrease HMG CoA reductase--->decrease cholesterol synthesis
Increase ACAT--->for storage of cholesterol esters
Decrease LDL receptor--->decrease uptake of LDL
153
What is the enzyme used by HDL to get cholesterol from peripheral tissues and bring them back to liver?
LCAT
154
How does atherosclerosis plaque developed?
Endothelial damage (HTN)--->inflammation response--->LDL deposition--->LDL oxidation--->macrophages swallow LDL--->foam cells--->smooth muscle cell joins--->plaque
155
Serum cholesterol increases with __?
Age
156
3 major risk factors for atherosclerosis?
Age/BP/smoking (decrease HDL)
157
3 major factors that increase HDL level?
Estrogen/exercise/alcohol
158
How to manage pt with moderate high lipid level?
Lifestyle and diet change first
159
What is the mechanism of nicotinic acid?
Lower VLDL secretion from liver and increase HDL
160
Fibric acid derivatives enhance ___ that stimulate ___ clearance?
LPL (or CPL)/TG-rich lipoprotein (like VLDL/chylomicron)
161
Possible beneficial effects of statins?
Counteract osteoporosis/cardioprotective
162
Statin is given with __ to have synergistic effect?
Ezetimibe
163
Statin should not be given with ___ due to ___?
Fibrates/increased risk of myositis
164
Electrolyte imbalance causes ___ and ___ waves in ECG?
U and J
165
What are the 2 mechanisms of arrhythmia?
Automaticity and conduction
166
Where is the ectopic activity usually located in the heart?
Purkinjie
167
Which 2 phases do pacemaker cell AP lack?
phase 1 and 2
168
How does early afterdepolarization occur?
Inhibit K current/inhibit Na inactivation current/increase Ca current--->another AP might be generated after depolarization
169
What are the 2 triggered activity of abnormal automaticity?
EAD and DAD
170
What are the 2 major factors that decrease conduction velocity and cause arrhythmia?
Low Na current/increase gap junction resistance
171
What are the 3 general mechanism for cardiac arrhythmia?
Enhanced automaticity/triggered activity/reentry
172
What is reentry arrhythmia?
A propagating impulse fail to die out and travel back in a circular path to re-excite the heart after refractory period is ended
173
What is the concept behind class I anti arrhythmic drug?
Block the unidirectional block of reentry to a full block and break the circular path of reentry
174
Hyper or hypokalemia causes bradycardia?
Hyperkalemia
175
What does sick sinus syndrome cause?
Bradycardia
176
What is 1st/2nd/3rd degree AV block?
1st--->prolonged PR interval
2nd: not every P wave is followed by QRS
mobitz type I--->PR interval prolongs till QRS beat is dropped (Wenchebach)
mobitz type II--->constant PR interval prolongation
3rd--->complete block (ventricular pacemaker)
177
What is normal PR interval?
0.12 to 0.2 s
178
What is hemiblock?
Block of either left anterior or posterior fascicle of left bundle branch
179
What causes an inverted P wave?
Beat starts from AV node then travels back to SA node/may block a sinus beat and produce compensatory pulse
180
What can cause prolonged QRS?
Bundle block/conduction starts in either left or right ventricle
181
2/3 of supraventricular tachycardia is caused by ?
AV node reentry
182
Paroxysmal (sudden onset and termination) is characteristics of what kind of SVT?
Atrial or junctional
183
How to terminate AV node reentry SVT?
Vagal tone/adenosine/beta or Ca blocker
184
What is Wolff-Parkinson-White syndrome?
Special kind of SVT--->higher risk for sudden death/treat with amiodarone and procainamide
185
More than __ PVC is defined as ventricular tachycardia
3
186
Difference between spontaneous and sustained VT?
Spontaneous VT--->less than 30 sec
| Sustained VT--->more than 30 sec
187
What is torsades de pointes and how does it occur?
It is a polymorphic VT---->long QT syndrome/caused by EADs via inhibition of K current (caused by many drugs)
188
What is catecholamine induced polymorphic VT and what causes it and how do we treat it?
It is a one kind of PVT/defect in Raynodine receptor causes Ca overload--->DADs/beta blocker
189
How does CPVT usually triggered?
Exercise induced
190
What is atrial flutter?
Rapid atrial rate/e.g. every 4 P waves follows 1 QRS/saw tooth pattern
191
When is atrial flutter dangerous?
When it causes Wolff-Parkinson-White syndrome
192
How to manage chronic A fib?
Anticoagulant and rate control of ventricles
193
What are ventricular flutter/fib what do they look like on ECG?
lethal/dysfunctional ventricular contraction/no QRS or T on ECG--->just up and down waves
194
What does torsades de pointes ECG look like?
A sin wave
195
What are class I anti-arrhythmic drugs? and which one is the strongest?
Block Na--->thus phase 0/Ic is the strongest
196
What is special about class Ib anti-arrhythmic drug?
Block Na in ischemic tissues--->treat arrhythmia caused by ischemia
197
Sotalol induces ____ strongly?
LQT
198
Quinidine may increase ___ and interact with ___ ?
AVN transmission/Digoxin (displace it--->increase free Digoxin level)
199
Which class Ia drug causes lupus like syndrome?
Procainamide
200
Lidocaine is used for what kind of arrhythmia?
Ventricular fib/tachy
201
What is the oral version of lidocaine?
Mexiletine
202
Beta blockers decrease mortality in ___ pts?
CHF/MI
203
Sudden withdraw of beta block in angina pt may cause?
MI
204
What anti-arrhythmic drugs are strong proarrhythmic?
Class Ic and Class III
205
Class III drugs are mainly used for ? (except for amiodarone)
Atrial arrhythmia because of their induction of ventricular arrhythmia
206
Don't use amiodarone for ___ pt?
Pregnant
207
Which drug causes blue gray skin?
Amiodarone
208
What other drugs interact with Digoxin like Quinidine?
Class IV
209
What antiarrhythmic drugs are contraindicated in AV block pts?
Beta blockers/Ca channel blockers/Digoxin
210
Adenosine does not work on ___?
Atrial arrhythmia
211
What are the first line treatment for acute and chronic A fib/flutter/SVT?
Non dihydropyridine/beta blocker/digoxin
212
What is given for unsustained VT and sustained VT?
Beta blocker/amiodarone or ICD
213
What is given for V fib?
Amiodarone or ICD
