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Medicine Phase 2a CVS > Pharmacology > Flashcards

Pharmacology Flashcards

1
Q

Symptomatic treatment of congestion in heart failure

A

Diuretics (usually loop)

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2
Q

1st line pharmacological treatment of heart failure

A

ACE inhibitors and Beta Blocker therapy

Low dose and slow uptitration

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3
Q

Pharmacological management of heart failure

A

a. First line: ACE inhibitors and beta blocker therapy
Low dose and slow uptitration
b. Aldosterone antagonists
c. ACE-I intolerant: Angiotensin receptor blocker
d. ACE-I and ARB intolerant: Hydralazine/nitrate combination
e. Consider digoxin or ivabradine

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4
Q

What is ANP and BNP

A

Atrial natriuretic peptide - atria

B-(brain) natriuretic peptide - ventricles

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5
Q

What causes release of natriuretic peptide hormones

A

Stretching of atrial and ventricular muscle cells
Raised atrial or ventricular pressures
Volume overload

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6
Q

Main effects of natriuretic peptide hormones

A

Increase renal excretion of sodium (natriuresis) and water (diuresis)
Relax vascular smooth muscle (except efferent arterioles of renal glomeruli)
Increased vascular permeability

Inhibit the release or actions of:
Aldosterone, angiotensin II, endothelin, anti-diuretic hormone (ADH)
Counters RAAS

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7
Q

What metabolises cardiac natriuretic peptides

A 
Neutral Endopeptidase (NEP, Neprilysin)
NEP inhibition increases levels of natriuretic peptides
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8
Q

Example of Neprilysin inhibitor - how does it work

A

Sacubitril

Inhibits neutral endopeptidase, increasing levels if natriuretic peptides. NPs reduce pressure on heart

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9
Q

Example of angiotensin II blocker

A

Valsartan

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10
Q

Examples of beta-blockers in heart failure

A

Carvedilol
Bisoprolol
Metoprolol

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11
Q

Effects of nitrates

A

Arterial and venous dilators
Reduction of preload and afterload
Lower BP

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12
Q

Main uses of nitrates

A

Ischaemic heart disease (angina)

Heart failure

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13
Q

Examples of nitrates

A

Isosorbide mononitrate
GTN spray
GTN infusion

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14
Q

Describe chronic stable angina

A 
Anginal chest pain
Predictable
Exertional
Infrequent
Stable
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15
Q

Describe unstable angina/acute coronary syndrome (NSTEMI)

A

Unpredictable
May be at rest
Frequent
Unstable

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16
Q

Describe ST elevation myocardial infarction

A

Unpredictable
Rest pain
Persistent
Unstable

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17
Q

Management of chronic stable angina

A
  1. Antiplatelet therapy
  2. Lipid-lowering therapy = Statins
  3. Short acting nitrate = GTN spray for acute atack
  4. FIRST LINE TREATMENT = Beta blocker or Calcium channel blocker
  5. If intolerant then switch
  6. If intolerant then combine
  7. If intolerant or uncontrolled, consider monotherapy or combinations:
    Long acting nitrate
    Ivabradine (inhibits If current)
    Nicorandil (K channel activator)
    Ranolazine (inhibits late inward sodium current)
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18
Q

Management of chronic stable angina. Examples of drugs for:

  1. Antiplatelet therapy
  2. Lipid-lowering therapy
  3. Short acting nitrate
A
  1. Antiplatelet therapy - Aspirin or Clopidogrel (if aspirin intolerant)
  2. Lipid-lowering therapy - Statins (simvastatin, atorvastatin)
  3. Short acting nitrate - GTN spray
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19
Q

Management of chronic stable angina: if intolerant to Beta blocker and Calcium channel blocker combined

A

Consider monotherapy or combinations with:
Long acting nitrate
Ivabradine (inhibits If current)
Nicorandil (K channel activator)
Ranolazine (inhibits late inward sodium current)
(Co-morbidities may determine which therapy)

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20
Q

*Management of acute coronary syndromes (NSTEMI and STEMI)

A
  1. Pain relief
  2. Dual antiplatelet therapy
  3. Antithrombin therapy
  4. Consider Glycoprotein IIb-IIIa inhibitor (high risk cases)
  5. Background angina therapy
  6. Lipid lowering therapy
  7. Therapy for LVSD/heart failure as required

Most patients will undergo invasive management with coronary angiography and revascularisation (angioplasty or CABG)

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21
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Pain relief

A

GTN spray

Opiates - diamorphine

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22
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Dual antiplatelet therapy

A

Aspirin
PLUS:
Ticagrelor or Prasugrel or Clopidogrel

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23
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Antithrombin therapy

A

Fondaparinux

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24
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Consider Glycoprotein IIb-IIIa inhibitor (high risk cases)

A

Tirofiban
Eptifibatide,
Abciximab

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25
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Background angina therapy

A

Beta blocker
Long acting nitrate
Calcium channel blocker

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26
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Lipid lowering therapy

A

Statins

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27
Q

Management of acute coronary syndromes (NSTEMI and STEMI): Therapy for LVSD/heart failure as required

A

ACE-inhibitor
Beta-blocker
Aldosterone antagonist

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28
Q

How can you classify antiarrhythmic drugs

A

Vaughan Williams classification

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29
Q

Describe the Vaughan Williams classification for anti-arrhythmic

A

Class I - sodium channel blockers
Class II - beta adrenoreceptor antagonists
Class III - Prolong the action potential
Class IV - Calcium channel blockers

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30
Q

Vaughan Williams classification: Subtypes/Examples of Class I anti-arrhythmics (sodium channel blockers)

A

Ia - disopyramide, quinidine, procainamide
Ib - lidocaine, mexilitene
Ic - flecainide, propafenone

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31
Q

Vaughan Williams classification: Examples of Class II anti-arrhythmics (beta-adrenoreceptor antagonists)

A

Propranolol, nadolol, carvedilol (non-selective)

Bisoprolol, metoprolol (β1-selective)

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32
Q

Examples of non-selective beta-adrenoreceptor antagonists

A

Propranolol, nadolol, carvedilol

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33
Q

Examples of β1-selective beta-adrenoreceptor antagonists

A

Bisoprolol

Metoprolol

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34
Q

Vaughan Williams classification: Examples of Class III anti-arrhythmics (prolong the action potential)

A

Amiodarone

Sotalol

35
Q

Vaughan Williams classification: Examples of Class IV anti-arrhythmics (calcium channel blockers)

A

Verapamil

Diltiazem

36
Q

What is Digoxin

A

Cardiac glycoside

Inhibit Na/K pump

37
Q

Main effects of Digoxin on the heart

A

Bradycardia (increased vagal tone)
Slowing of atrioventricular conduction (increased vagal tone)
Increased ectopic activity
Increased force of contraction (by increased intracellular Ca)

38
Q

True or False:

Digoxin has a narrow therapeutic range

A

True

Excess can cause: Nausea, Vomiting, Diarrhoea, Confusion

39
Q

Is digoxin positively or negatively inotropic

A

Positively inotropic

40
Q

Where is digoxin used

A

Used in atrial fibrillation (AF) to reduce ventricular rate response
Use in severe heart failure as positively inotropic

41
Q

What is function of Amiodarone

A

Prolong the action potential

Class III Anti-arrhythmic

42
Q

Adverse effects of amiodarone on heart

A

QT prolongation

Polymorphic ventricular tachycardia

43
Q

Adverse effects of amiodarone

A 
Interstitial pneumonitis
Abnormal liver function
Hyperthyroidism / Hypothyroidism
Sun sensitivity
Slate grey skin discolouration
Corneal microdeposits
Optic neuropathy

Multiple drug interactions
Very large volume of distribution

44
Q

What is hypertension a risk factor for?

A 
Stroke – ischaemic and haemorrhagic
Myocardial infarction
Heart failure
Chronic renal disease
Cognitive decline
Premature death

Increases risk of atrial fibrillation

45
Q

Each 2mmHg rise in systolic BP is associated with…

A

7% increased mortality from ischaemic heart disease

10% increased mortality from stroke

46
Q

What is clinical hypertension

A

140/90mmHg or higher

47
Q

True or False:
People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension

A

True

48
Q

Mechanisms of BP control - targets for therapy

A

Cardiac output and peripheral resistance
Interplay between RAAS and Sympathetic nervous system (noradrenaline)
Local vascular vasoconstrictor and vasodilator mediators

49
Q

Main clinical indications of Angiotensin Converting Enzyme (ACE) inhibitors

A

Hypertension
Heart failure
Diabetic nephropathy

50
Q

Examples of ACE inhibitors

A

Ramipril
Enalapril
Perindopril
Trandolapril

51
Q

Main adverse effects of ACE inhibitors

A

Related to reduced angiotensin II formation:

  • Hypotension
  • Acute renal failure
  • Hyperkalaemia
  • Teratogenic effects in pregnancy

Related to increased kinin production

  • Cough
  • Rash
  • Anaphylactoid reactions
52
Q

Main clinical indications of Angiotensin II receptor blockers (ARBs)

A

Hypertension
Diabetic nephropathy
Heart failure (when ACE-I contraindicated)

53
Q

Examples of ARBs

A 
Candesartan
Valsartan
Losartan
Irbesartan
Telmisartan
54
Q

Main adverse effects of ARBs

A 
Symptomatic hypotension (especially volume deplete patients)
Hyperkalaemia
Potential for renal dysfunction
Rash
Angio-oedema

Contraindicated in pregnancy
Generally well tolerated

55
Q

Main clinical indications of Calcium channel blockers (CCB)

A

Hypertension
Ischaemic heart disease (IHD) - angina
Arrhythmia (tachycardia)

56
Q

Examples of CCBs

A 
Amlodipine
Felodipine
Nifedipine
Lacidipine
Diltiazem
Verapamil
57
Q

Types of L-type CCBs

A

Dihydropyridines
Phenylalkylamines
Benzothiazepines

58
Q

Main effects of Dihydropyridines (CCB)

A

Preferentially affect vascular smooth muscle

Peripheral arterial vasodilators

59
Q

Main effects of Phenylalkylamines (CCB)

A

Main effects on the heart

Negatively chronotropic, negatively inotropic

60
Q

Main effects of benzothiazepines (CCB)

A

Intermediate heart/peripheral vascular effects

61
Q

Examples of Dihydropyridines (CCB)

A

Nifedipine
Amlodipine
Felodipine
Lacidipine

62
Q

Examples of Phenylalkylamines (CCB)

A

Verapamil

63
Q

Examples of benzothiazepines (CCB)

A

Diltiazem

64
Q

Adverse effects of calcium channel blockers

A

Due to peripheral vasodilatation (mainly dihydropyridines)

  • Flushing
  • Headache
  • Oedema
  • Palpitations

Due to negatively chronotropic effects (mainly verapamil/diltiazem)

  • Bradycardia
  • Atrioventricular block

Due to negatively inotropic effects (mainly verapamil)
- Worsening of cardiac failure

65
Q

Adverse effects specific to or mainly in Verapamil (calcium channel blocker)

A

Constipation
(specific to verapamil)
Worsening cardiac failure due to negatively inotropic effects
Bradycardia and Atrioventricular block due to negatively chronotropic effects

66
Q

Main clinical indications of Beta-adrenorecoptor blockers

A

Ischaemic heart disease (IHD) – angina
Heart failure
Arrhythmia
Hypertension

67
Q

Examples of Beta-adrenorecoptor blockers

A 
Bisoprolol
Carvedilol
Propanolol
Metoprolol
Atenolol
Nadolol
68
Q

Beta-1 selective Beta-adrenorecoptor blockers

A

Metoprolol

Bisoprolol

69
Q

Non selective Beta-adrenorecoptor blockers

A

Propranolol
Nadolol
Carvedilol

70
Q

Main adverse effects of Beta-adrenoceptor blocker

A

Fatigue
Headache
Sleep disturbance/nightmares

Bradycardia
Hypotension
Cold peripheries

Erectile dysfunction

Worsening of:
Asthma (may be severe) or COPD
PVD – Claudication or Raynaud’s
Heart failure – if given in standard dose or acutely

71
Q

Main clinical indications of Diuretics

A

Hypertension

Heart failure

72
Q

Classes of Diuretics

A

Thiazides and related drugs (distal tubule)
Loop diuretics (loop of Henle)
Potassium-sparing diuretics
Aldosterone antagonists

73
Q

Examples of thiazide and related diuretics

A

Bendroflumethiazide
Hydrochlorothiazide
Chlorthalidone

74
Q

Examples of loop diuretics

A

Furosemide

Bumetanide

75
Q

Examples of potassium-sparing diuretics

A

Spironolactone
Eplerenone
Amiloride
Triamterine

76
Q

Main adverse effects of diuretics

A 
Hypovolaemia
Hypotension
Hypokalaemia
Hyponetraemia
Hypomagnesaemia
Hypocalcaemia
Erectile dysfunction
Raised uric acid (gout)
Impaired glucose tolerance
77
Q

Adverse effects of diuretics - effects mainly in loop diuretics

A

Hypovolaemia

Hypotension

78
Q

Adverse effects of diuretics - effects mainly in thiazides

A

Erectile dysfunction

Impaired glucose tolerance

79
Q

Example of α-1 adrenoceptor blockers

A

DOXAZOSIN

80
Q

Examples of Centrally acting anti-hypertensives

A

Moxonidine

Methyldopa

81
Q

Example of direct renin inhibitor

A

Aliskiren

82
Q

Treatment of hypertension <55 years

A

ACEi or ARB
ACEi or ARB + CCB
ACEi or ARB + CCB +Thiazide-like diuretic
(Resistance hypertension:) Consider addition of Spironolactone, high dose thiazide-like diuretic, Alpha blocker, beta blocker, (others)

83
Q

Treatment of hypertension >55 years or Afro-Carribean any age

A

Calcium channel blocker
ACEi or ARB + CCB
ACEi or ARB + CCB +Thiazide-like diuretic
(Resistance hypertension:) Consider addition of Spironolactone, high dose thiazide-like diuretic, Alpha blocker, beta blocker, (others)

Medicine Phase 2a CVS (17 decks)

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