Quiz 2 Flashcards

Question

Stepped Care Approach

Answer 1

The stepped-care approach to HTN is based on the patient’s response to therapy. A patient’s therapy may be “stepped up” if non-responsive or “stepped down” if the patient shows signs of good BP control over time. Step I: lifestyle changes Step II: lifestyle changes and drug therapy Step III: continue lifestyle changes, increase drug dose or substitute another drug or add a second agent from a different drug class Step IV: add a second or third drug or a diuretic

Answer 2

1. Diuretics 2. sympatholytics( Andrenergic Anatagonists) beta-adrenergic blockers alpha 1 blockers alpha/beta blockers centrally acting Alpha 2 Agonist ``` 3. Other ACE inhibitors ARBs Calcium Channel Blockers Direct Acting Vasodilators ```

Answer 3

``` MOA: Block the sympathetic nervous system Beta adrenergic receptors ↓ HR ↓ force of contraction Slows conduction through the AV node ``` ``` Therapeutic Uses: Angina Pectoris HTN Cardiac dysrhythmias MI Heart failure ``` ``` Adverse Effects: Bradycardia ↓ cardiac output Precipitation of heart failure AV heart block Reflex tachycardia Bronchoconstriction inhibition of glycogenolysis ``` end in -OLOL

Answer 4

Nonselective beta adrenergic antagonist (Beta1 and beta2) ``` ↓ HR, ↓force of ventricular contraction and slow impulse conduction through the AV node, suppress secretion of renin (Beta1) Bronchoconstriction (Beta 2) Inhibits glycogenolysis (Beta 2) -Breakdown of glycogen to glucose -Most detrimental to diabetics ``` Lipid soluble- crosses membranes easily - well absorbed - widely distributed - hepatic metabolism - excreted in urine Drug Interactions: - Calcium Channel Blockers - Insulin

Answer 5

Cardioselective (Beta 1 only)!!! Therapeutic Uses: HTN, heart failure and MI Hepatic metabolism;Renal excretion Adverse Effects: Bradycardia, ↓ CO, AV block, rebound tachycardia with abrupt discontinuation

Answer 6

MOA:Block alpha receptors on blood vessels Therapeutic Uses: Essential Hypertension ``` Adverse effects: Orthostatic Hypertension Reflex tachycardia Nasal congestion Inhibition of ejaculation ```

Answer 7

Alpha/Beta Blocker Blocks beta 1 and beta 2 and selective alpha 1 Alpha blocking cause peripheral vasodilation Beta blocking prevents reflex tachycardia

Answer 8

( -DINE) | -DOPA

Answer 9

MOA: Inhibits sympathetic nervous system response and reduces sympathetic outflow from the CNS ↓ HR, BP, vasoconstriction and vascular resistance Severe rebound HTN if discontinued

Answer 10

- Displaces norepinephrine from storage sites | - Drug of choice for pregnant women with HTN

Answer 11

``` Angiotensin I (naturally causes): Little biologic activity ``` Angiotensin II (naturally causes): - Vasoconstriction - Release of aldosterone - Alteration of cardiac and -vascular structure Renin (naturally causes): -Catalyzes the formation of Angiotensin I -Released in response to decreased BP, blood volume, plasma sodium content, or renal perfusion pressure Angiotensin-Converting Enzyme (ACE) - Located on luminal surface of blood vessels - Catalyzes angiotensin I to angiotensin II **ACE can act on other substrates so it is also known as bradykinin RAAS- Regulates BP! -Vasoconstriction ( within minutes -hours) -Renal Water retention ( vasoconstriction decreases GFR; Stimulate release of Aldosterone) aldosterone- RETAINS NA+ and water

Answer 12

MOA: Suppress formation of angiotensin II - Dilate blood vessels - Reduce blood volume - Prevent or reverse pathologic changes in the heart and blood vessels mediated by angiotensin II and aldosterone ``` Therapeutic Uses: HTN Heart failure MI Diabetic and non diabetic nephropathy Prevention of MI, stroke, and death in patients with high CV risk Diabetic retinopathy ``` ``` Significant adverse effects: #1 persistent dry Cough -Hyperkalemia -First dose hypotension -Renal failure -Angioedema ``` ACE Inhibitors contraindicated in 2nd and 3rd trimesters Drug Interactions: - Diuretics - Antihypertensive agents - Drugs that raise potassium levels - Lithium - NSAIDs Administration- PO without regard to meal

Answer 13

Only ACE inhibitor give in IV form

Answer 14

MOA: Prevents angiotensin II from binding to receptors in many tissues, thus blocking the vasoconstricting and aldosterone-secreting effects of angiotensin II -Decreases peripheral vascular resistance Does not cause” ACE cough” or hyperkalemia ``` Therapeutic Uses: HTN Heart failure MI Diabetic nephropathy Stroke prevention Prevention of MI, stroke, and death in patients with high CV risk Diabetic retinopathy ``` Adverse Effects: - Angioedema - ARB’s contraindicated in 2nd and 3rd trimesters - Renal failure Administration: Available PO and can be administered with or without food

Answer 15

-Antagonists MOA:Prevent calcium from entering the cells Treatment of : HTN, angina, and cardiac dysrhythmias Examples: *Verapamil (Calan) Blocks Ca channels in blood vessels and in the heart *Diltiazem (Cardizem) Inhibits calcium ion influx, reduce afterload ``` Direct effects: ↓arterial pressure ↓HR ↓AV nodal conduction ↓force of contraction ↑coronary perfusion Reflex responses ``` Indirect effects: Barroreceptor activated Increased firing of sympathetic nerves to the heart Direct and indirect negate each other Drug interactions with Beta blockers

Answer 16

Inhibits calcium ion influx -Vasodilating effects on coronary and peripheral arterioles -Does not slow AV node conduction but can cause cardiosuppression in toxic doses Used for angina and HTN Adverse effects : Flushing Dizziness Reflex tachycardia Common adverse effects for oral preparations: GI: constipation, nausea CV: HA dizziness Monitor and treat adverse effects supportively Overdose: IV calcium chloride or calcium gluconate

Answer 17

Hydralazine (Apresoline) MOA: ↓Peripheral resistance Adjunct with other antihypertensives Adverse effect: -Lupus like syndrome -Reflex tachycardia Combined with beta blockers or clonidine to prevent reflex tachycardia from vasodilation -Fluid retention Combined with a diuretic to offset fluid retention from ↑ production of angiotensin II Drug Interactions: Beta blockers

Answer 18

Nitroprusside (Nitropress) ``` Used to treat: hypertensive crisis (DBP>120) ``` MOA:Directly relaxes vascular smooth muscle, Dilates veins more than arteries ↓ preload and afterload ↓ BP dramatically IV use only MUST use a pump Protect from light Monitor BP

Answer 19

Nonselective adrenergic agonist: Stimulates all alpha and beta receptors ``` Many therapeutic uses, such as: Cardiopulmonary arrest Ventricular fibrillation Anaphylactic shock Asthma ``` Adverse effects: stimulation of all receptors are common. CNS and cardiac adverse effects are the most common and may be the most serious.

Answer 20

Catecholamine and a precursor to NE - Vasopressor used in treating shock - IV administration only in acute care settings - Invasive monitoring, pump Adverse effects: CV system effects - Stimulation of alpha-1, beta-1 and dopamine receptors is dose dependent - Weight based dosing IMPORTANT Correct hypovolemia first Contraindications: Pheochromocytoma Uncorrected tachyarrhythmias V-fib

Answer 21

Alpha-1 stimulant Potent vasoconstrictor Avoid IV extravasation Pharmacotherapeutics include: Vascular failure Hypotension Shock states Topical pharmacotherapeutics: - Nasal decongestant (sudafed) - Pupil dilation (mydriasis)

Answer 22

Nonselective beta-2 stimulant. Pharmacotherapeutics include: Congestive heart failure Various types of shock Hypoperfusion ``` Inhaled pharmacotherapeutics include: Asthma Bronchitis Emphysema Adverse effects are primarily related to cardiac stimulation ```

Answer 23

Heart is unable to pump sufficient blood to meet the metabolic demands of the tissues KEY: Not every patient has signs of systemic or pulmonary congestion ``` Can be: Progressive Ventricular dysfunction Reduced CO Insufficient tissue perfusion Signs of fluid retention ``` ``` Causes: Chronic HTN MI Coronary Artery Disease Valvular disease Congenital heart disease Dysrhythmias Aging myocardium ```

Answer 24

Physiologic adaptations to reduced cardiac output ``` Cardiac dilation ↑ sympathetic tone ↑ HR, ↑ contractility, ↑ venous tone, ↑ arteriolar tone H20 retention and ↑ blood volume Natriuretic peptides ```

Answer 25

``` ↓ exercise tolerance Fatigue SOB Tachycardia Cardiomegaly Pulmonary edema Peripheral edema hepatomegaly JVD Weight gain – fluid retention ```

Answer 26

Stage A -No symptoms, no structural or functional cardiac abnormalities -Do have associated behaviors HTN, CAD, Diabetes Stage B- No S/S but do have structural heart disease LV hypertrophy or fibrosis, LV dilation Stage C- Symptoms and structural heart disease Stage D- Advanced structural disease and severe symptoms

Answer 27

Diuretics - Thiazide diuretics - Loop diuretics - Potassium sparing diuretics ACE Inhibitors/ARBs: - Dilate arterioles - Dilate veins - Decrease release of aldosterone - Favorable effects on cardiac remodeling ``` Adverse effects on heart: Hypotension Hyperkalemia Intractable cough Angioedema ``` ***Diovan******* Only ARB approved for treating HF Similar to ACE without effects on cardiac remodeling ``` Beta Blockers: Carvedilol, metoprolol -Improve LV ejection fraction -protect the heart from excessive sympathetic stimulation -protect the heart from dysrhythmias -Increase exercise tolerance -Slow progression of heart failure ``` ``` ****Start doses low*** Adverse effects on heart: Fluid retention and worsening heart failure Fatigue Hypotension Bradycardia or heart block ```

Answer 28

Digoxin ( Cardiac Glycoside) Positive inotrope Inhibits sodium, potassium-ATPase → promotes calcium accumulation → augmentation of contractile force Potassium competes with dig for binding to sodium, potassium-ATPase → when potassium is low there is ↑dig binding → digoxin toxicity ↑ potassium there is inhibition of sodium, potassium-ATPase ↓ therapeutic response of digoxin ``` Benefits in Heart Failure: Increased cardiac output Decreased sympathetic tone Decreased heart rate Decreased afterload Reduced venous pressure Increased urine output ``` Narrow therapeutic window .5 - 2.0 Renal excretion ``` Adverse effects: Dysrhythmias Digoxin-induced dysrhythmias Noncardiac adverse effects Anorexia, nausea and vomiting Fatigue Visual disturbances ``` Drug Interactions: There are multiple drug interactions (p. 527, Burcham) Thiazides, loops - potassium Beta blockers, verapamil, diltiazem – decrease contractility Aminoglycosides, erythromycin, antacids – increase levels Captopril, alprazolam, amiodarone, diltiazem – increase digoxin by decreasing excretion Caution when patient is on multiple medications watch for signs of toxicity or subtherapeutic values ``` Routes po, SLOW IV Apical rate prior to administration Hold for <60 beats/minute Hold for change in rhythm Compliance is essential! ```

Answer 29

- Spironolactone (Aldactone) - Eplerenone (Inspra) Mechanism of Action: Block aldosterone receptors in the heart and on bld vessels Drugs reduce the effects of aldosterone – which go beyond Na and water retention ``` Harmful effects of aldosterone no the heart : Promotes myocardial remodeling Promotes myocardial fibrosis Activate SNS Promotes vascular fibrosis Promotes baroreceptor dysfunction ```

Answer 30

Nitroglycerine Used in acute care Venodilator Decreases pulmonary congestion Adverse Effects: Hypotension and resultant reflex tachycardia

Answer 31

Implantable cardioverter defibrillator Cardiac resynchronization therapy Exercise training

Answer 32

Teach patients signs of toxicity Teach patients to monitor for rate and rhythm Teach patients to monitor for signs of hypokalemia

Answer 33

Physiology Review: Classes of lipoproteins: -Six major classes of plasma lipoproteins -Three relevant to coronary atherosclerosis 1.Very-low-density lipoproteins (VLDLs) -AKA Triglycerides 2.Low-density lipoproteins (LDLs) -Cholesterol primary core lipid -Greatest contributor to . coronary heart disease (CHD) 3. .High-density lipoproteins (HDLs) Cholesterol as primary core lipid

Answer 34

-More than just deposit of lipids -Now considered primarily a chronic inflammatory process Infiltration of macrophages, T lymphocytes, and other inflammatory mediators In late stages of the disease inflammation weakens the atherosclerotic plaque leading to plaque rupture and then thrombosis SCreening and Risk Patients are screened for risk of developing ASCVD and considered for -statin treatment if they fall into one of the four different categories Cholesterol screening Every 5 years for adults older than 20 years

Answer 35

- Identifying CHD risk factors - Calculating 10-year CHD risk - Identifying CHD risk equivalents - Diabetes - Atherosclerotic disease other than CHD - Framingham risk score greater than 20% - dentifying an individual’s CHD risk category - Each type of dyslipidemia a patient has contributes independently to CHD risk

Answer 36

- Diet - Reduce intake of cholesterol and saturated fats - Minimize trans fat - Exercise 30-60 minutes on most days - Weight control - Smoking cessation

Answer 37

Statins Fibric Acid Derivatives Nicotinic Acid Bile Acid Sequestrants

Answer 38

``` Prototype: lovastatin (Mevacor) Highly effective and the most prescribed class of antilipids ``` Increase high-density lipoproteins (HDL) Decrease low-density lipoproteins (LDL), total cholesterol, very low-density lipoproteins (VLDL), and plasma triglycerides Competively inhibit HMG-CoA reductase Pregnancy category: X ``` Atorvastatin (Lipitor) Rosuvastatin (Crestor) Simvastatin (Zocor) Fluvastatin (Lescol) Pravastatin (Pravachol) ```

Answer 39

Adverse effects: Elevated liver enzymes may occur with lovastatin and all other antilipid drugs. -Monitoring LFTs is essential. -Myopathy – injury to muscle tissue may occur. -Monitor CK (creatinine kinase) at baseline, repeat if symptoms (muscle aches, weakness) occur Metabolized via the hepatic enzyme CYP3A4: All drugs and substances (such as grapefruit juice) that inhibit this pathway may decrease metabolism and increase serum drug concentration.

Answer 40

Lower triglyceride levels and increase HDL cholesterol Unlike the statins, effect on LDL cholesterol can be either to lower it slightly or to increase it slightly Gemfibrozil (Lopid) Clofibrate (Atromid-S)

Answer 41

Niacin -Reduces triglycerides -Reduces LDL cholesterol I-ncreases HDL cholesterol ``` Adverse effects: GI Upset Facial flushing Intense flushing of face neck and ears occurs in most patients Usually subsides several weeks ``` Can reduce by administering ASA 325 mg prior to taking Niacin

Answer 42

Second- or third-line therapy Bind with the bile acids in the intestine to make them non-reabsorbable then excrete them: The lowered bile acid level prompts cholesterol to be used to make more bile acid. Cholestyramine (Questran) Colestipol (Colestid) Risk of hyperchloremic acidosis. Poor palatability, many GI adverse effects

Answer 43

Stable Angina- predictable- usually upon exertion Unstable Angina- unpredictable chest pain Prinzmetal’s (variant ) Angina - happens when a pt is at rest, typically between midnight and 5 am

Answer 44

Prototype agent: nitroglycerin MOA: Relaxes vascular smooth muscle -Dilates both arterial and venous vessels: Venous dilation decreases peripheral resistance, thus decreasing BP. -Arteriolar dilation reduces systemic vascular resistance and arterial pressure, thus reducing afterload. -Decreases myocardial oxygen consumption -Redistributes blood flow in the heart, improving circulation to ischemic areas Tolerance to the vascular and antianginal effects may develop. Minimize by: Starting with as small a dose as possible Removing the NTG (paste or transdermal patches) from the patient for 8-10 hours usually at night

Answer 45

Acute angina: -Sublingual (SL) -Transmucosal T-ranslingual spray ``` Chronic recurrent angina: -Topical - NTG paste -Transdermal – NTG patch -Translingual spray T-ransmucosal or oral sustained-release - ``` Significant hypertension: Administer IV

Answer 46

Assess the patient’s BP and pulse prior to administration of nitrates. Acute care: IV access established Have the patient sit or lie down before taking NTG for acute pain. Repeat SL NTG every 5 minutes for up to three doses; assume myocardial infarction (MI) if no pain relief. Monitor for hypotension and reflex tachycardia. Common adverse effect: Headache.

Answer 47

Loses potency with exposure to: - Light - Humidity - Heat - Plastic IV bags of fluid Sublingual NTG requires replacement every 3 months

Answer 48

Nitroglycerine: - Isosorbide Mononitrate (Imdur, Monoket) . Sustained and immediate release - Isosorbide Dinitrate (Isordil) . Sustained and immediate release

Answer 49

Prevent stimulation of the beta receptors of the heart Slow the heart rate, depress atrioventricular (AV) conduction, decrease CO, and reduce BP, resulting in decreased oxygen demand Metoprolol Propranolol

Answer 50

Inhibit calcium from moving across cell membranes Slow the heart rate, depress impulse formation (automaticity), and slow the velocity of conduction, resulting in decreased oxygen demands of the heart Diltiazem (Cardizem) Verapamil Used in chronic stable angina when the patient cannot tolerate beta blockers or nitrates, or if the symptoms are not adequately controlled while on these therapies Drug of choice for Variant (Prinzmetal’s) angina

Answer 51

Acronym: MONA These therapies do not decrease oxygen demands on the heart, but slow down the progression of coronary artery disease or prevent/treat complications that may arise with angina.