Review Deck Flashcards
better for pregnancy drugs?
Labatalol, methyldopa, nifedipine
Cause Angioedema 10 times more frequently in African American’s
ACE-I’s.
which thiazides like diuretics and CCB’s for hypertension (CHLORATHIAZONE?)
African american’s
Diabetes with PROTEINuria - than you need to be on an
ACE-I
which drugs protect the kidney via the RAAS system for AA’s w/ microalbuminuria?
ACEI’s and ARBs
when Renin goes up it increases BP. In our blood pressure management we have water retention and increased salt so we try to stop this process
RAAS System - juxtaglomeruluar cells cause renin release, maculodensal cells monitor sodium and cause salt and water retention
Water pills (like hydrochlorthiazide) cause hyponatremia and hypokalemia and ** hypercalcemia - makes you thrombogenic and more likely to form a clot - why does this matter with thiazides?
if I have high cholesterol the water pill is going to INCREASE my lipids and the potential that I form a dangerous clot
Cliff Claven:
MI - subendocardial ischemia (inside of heart damaged as opposed to transmural death) Non- STEMI=subendocardial ischemia which is only part of the heart and STEMI is transural
Not yet
Angina - constriction of the heart or CHEST DISCOMFORT - Stable vs unstable?
PM angina?
unstable is either first time with chest pain, chest pain different than baseline, or past chest pain that doesn’t go away at rest… unstable we treat like STEMI…
Stable angina is no change in baseline…
Printz Metal Angina is like a spasm that happens in the PM between 0000 and 0500 ish and they have normal vessels when they go to the catch lab… associated with Reynauds and treated with a CCB.. unlike STABLE OR UNSTABLE Angina where CCB is the last resort for treatment because they effect the pump (preload and afterload also) lots of side effects
Heart failure - the pump is either not contracting appropriately (preserved ejection fraction AKA diastolic)… or reduced ejection fraction (Systolic) which implies the heart doesn’t have enough pump (MI or disease). ____ (this drug) KEY IN BOTH (BUT more in preserved to keep potassium in the heart)
SPIRONOLACTone
what are our goals in diastolic vs systolic ADHF?
For systolic our goal is to improve contractility, for diastolic our goal is to spare amount of blood heading to the right of the heart
45 y/o male with rapid relief of chest pain - stable angina - __ ___ ___ - provides rapid relief in recurrent angina attacks - faster than IV or nitro patch -
nitro SUBLINGUAL tablet
STAY AWAY FROM CLASS B AND CLASS C IN LIFE AND ON THE TEST… EXTENSIVE SIDE EFFECT PROFILES!!!!
47 y/o male intentional digoxin overdose - Pulse 50 bpm - 3rd degree heart block - serum potassium is normal - SE’s: yellowish vision, causes heart blocks, etc. (on most exams if a drug in a list caused a heart block it’s usually digoxin) In addition to antiarrythic agents which is the most appropriate treatment?
Digoxin Immune FAB (digibind) IV (MUST BE IV)
5 y/o history of dry cough - which drug were they treated with to cause it?
Choices:
Losartan, remopril, Digoxin (non specific), Verapamil (CCB non DHP), Bisoprolol? (Beta blocker) -
Obviously we would chose Remopril because it’s the only ACEI
PT is on the following: Hydrochlorizide (water pill) terazosin (alpha blocker) aspirin, Diltiazem (CCB non DHP), losartan (ARB), also suffering from bradycardia - THE DRUG MOST LIKELY TO CAUSE BRADYCARDIA?
CCB most likely to cause bradycardia so Diltiazem - REMEMBER THAT CCB’s work at the AV NODE - IF IT EFFECTS AV OR SA NODE WRITE IT OUT***WHICH ONES WHERE BECAUSE THAT IS A LOT OF THE EXAM!!!
THERE WILL BE TEST QUESTIONS ON WHICH ONES EFFECT SA vs AV node
take a look and add a CARD HERE**
Creatine elevated and proteinuria which drug MUST you be on?
ace-I followed by an ARB are DOCs
Cliff craven: this means we are in kidney damage or failure - proteinuria is earliest sign of kidney failure - how do we preserve kidney function?
what ‘s the only reason a BUN is low?
BUN is elevated?
Creatinine is HIGH?
what ‘s the only reason a BUN is low? LIVER FAILURE**
BUN is elevated? Liver damage
Creatinine is HIGH*** Kidney failure
—-if you do a Chem 7 it shows up with CREATINE and BUN - males should have higher creatinine
69 y/o AA in stage 3 with NYHC level 3 (issues at rest) reduced ejection fraction failure - 39%, currently taking ACE-I with BB, with daily dose of loop diuretic - ejection fraction continues to drop - which of the following would you add to decrease morbidity?
ANSWER = combination of two drugs to treat BIDIL = hydralizine +isosorbide dinitrate… any patient with ACE-I and BB with reduced ejection fraction need to add something else to get this goal.. if you’re adding something else it is most likely BIDIL and in this case hydralizine + isosorbide dintrate (BIDIL)
—— other options were adding stuff that he’s already on
Lupus SE’s?
Procainimide (has a lupus like SE’s… so does Hydralazine)
32 y/o F with diabetes, comes in for blood pressure and pregnancy check - what do you treat her routine hypertension… which drug will you use to treat her routine HTN?
methyldopa for ROUTINE…. if it was URGENT what would we use? Labetolol… later flash card explains why
NEVER use Lisinopril, Losartan, Beta blockers (other than Labatalol) OR Hydrochlorthiazide in these patients:
in a pregnant patient - will kill the baby!!!
No Lisinopril, Losartan, BB’s other than Labateolol, or Hydrochlorothiazide
Don’t use BB’s in pregnancy (other than )
labateolol
62 y/o patient in heart failure - Px meds with benefit for cardiac remodeling and mortality - class of drug recommended first line?
ACE-I is always first
retinopathy… patient has papilledema and blurry vision?
HTN EMERGENCY
Secondary HTN: one cause that you can’t use ACE-I….
renal artery stenosis!
Concomitant Diseases:
Each with at least one question this exam
– Diabetes Mellitus with Albumineria – Secondary Stroke Prevention – Chronic Kidney Disease (CKD) – Stable Ischemic Heart Disease (SIHD) – Heart Failure
• In adults with Diabetes Mellitus (DM) and hypertension
– Antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal of ?
– All first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective
– ACE inhibitors or ARBs may be considered in the presence of?
< 130/80 mm Hg
albuminuria
• Remember that Beta Blockers can mask DM, worsen Asthma, and disturb lipid metabolism
____ is also indicated for secondary stroke prevention, alone or in combination with aspirin,
though combination therapy may not be more effective and increases the risk of bleeding. _____ is also used to prevent thrombosis in patients with intermittent claudication, chronic arterial occlusion, atrioventricular shunts or fistulas, open heart surgery, and sickle cell anemia.
Clopidogrel
Straining to urinate - enlarged prostate with High blood pressure - any of the zosins will work, but (____ is MOST EFFECTIVE to treat both) -
____ has othrostatic hypotension on FIRST DOSE - all people who have alpha blocker you must give the 1st dose in the clinic
Doxazosin most effective for both
terazosin has orthostatic hypotension
Hypertensive emergency with hx of ischemic heart disease, kidney, and liver disease - treat with what and why?
NITROGLYCERIN due to short half life and you can titration to effect (not metabolized in the liver)
Only time you use esmolol -
aortic dissection - high doses arterial dialation low dose is veinous dialation - ripping and tearing in chest think ESMOLOL
What BB’s are recommended for HF with a reduced ejection fraction - #1 BB’s, ACEI’s, Aldosterone antagonist (spiro), and loop diuretic for symptoms
Hint this BB has alpha and beta blocker -
carvedilol - #1 drug used to treat heart failure ADHF
when you’re old you don’t want alpha response, but you do when you’re young (you want metoprolol because it’s beta selective)
what is NITROPRUSSIDE CI’d in?
It’s metabolized in the liver (cyanide) and if there is a liver disease you cannot take NITROPRUSSIDE
when you’re old you don’t want ___ response, but you do when you’re young
you want metoprolol because it’s beta selective in olds
Patients over 60 with ischemic heart disease or heart failure should still be prescribed beta-blockers for heart failure and angina. … ____ is a good choice, as it is inexpensive and proven to reduce mortality in patients with a history of MI or heart failure.
Metoprolol
61 y/o M with reduced ejection fraction - stage 3 - chronic stable angina - currently on lisinopril (ACE-I), also on BIDIL (hydralizine, nitro) and he’s also on NITRO by itself, which drug is he missing?
He needs to be on a BETA BLOCKER = carvedilol
47 yo/ M with Stage I hypterenstion, which med do we start -
ALWAYS start with hydrochlorthiazide or chlorithalidone and build from there (HMMMM WHAT ABOUT AN ACE-I?)
Which vasodialator is a Human BNP type - caused diuresis - heart failure - better for warm and wet decompensated heart failure (reduced ejection fraction) -
nesiritide (only with BNP)
Increase urine output by inhibiting NA and CL in the Distal tubule -
metalozone
Major side effect of sprinalactone -
gynecomastia
You have an 57 yo AA with a history of uncontrolled diabetes, elevated BP and tried lifestyle modification he has BP of 150/88 with ALBUMINERIA, which drugs start with?
Hydrochlorothiazide, BB, Losartan (ARB), CCB, or Vasodilator?
- you can use hydrochlorothiazide but not here (not in protein in urine), but instead CHOOSE losartan (we choose ARB over ACE-I because ACE-I not offered, usually ACE first) * DON’T PICK YOUR ANSWER BEFORE READING ALL THE OPTIONS*
COPD requires meds for his angina attacks.. .which drug do we want? -
NOT beta blocker - instead we want verapimil because COPD is R side dheart problem (non DHP and someone with pulmonary condition)
Will cause Torsades De Pointes - lengthened qT over 500 we are worried- which drugs cause this?!?
- look at this slide Zpack will cause lengthening - TDP also caused by: Sotalol, Amiodarone, Quinidine, (all class IA's), Macrolide ABX (Zpak), ONdansetron, granisetron, Antidepressents, antipsychotics, sumatriptan
metoprolol DOC for long Qt
DOC for prolonged QT?
Metoprolol
This drug causes ototoxicity?
- furosemide betusomide etc the loops
emergency situation - everyone starts with water pill, than CCB, and ACE and ARB if they have porteinuriea especially for African Americans
Not exactly sure the context here…
Glaucoma probably BB’s before…
Loop diuretics
DCT and thiazides - SE’s
hyperglycemia, hypokalemia, hypercalcemia, and hyperlipidemia
Stage 2 - need two drugs -
water pill (hydrochlorithiazide or chlorothalidone) and ACEI or ARB
Clonidine initially for
urgent HTN
HTN Emergency classifications?
Stroke LOC Memory loss Crushing chest pain Damage to eyes or kidneys aortic dissection Angina (unstable chest pain) Pulmonary edema preeclampsia
HTN urgency classifications?
severe headache
SOB
Nosebleeds
severe anxiety
Urgent vs emergent on this exam - emergency think Blurred vision is…
emergency
DOC for Eclampsia -
nifedipine
Pheochromocytoma DOC -
BB’s phentoelamine
Nitro is always the best vasodilator…
Nitroprusside -SE =
cyanide
lupus
Hydralizine and procainamide
Head injury drug of choice -
mannitol
MOST POTENT Loop - lasts longer and longer half life
Most used, because it’s the cheapest - mind SE’s of loops OTOTOXICITY
Butanimide - most potent
Furosemide - cheap so most used
best with reduced ejection fraction
Spiro and Epler. -
Ace/Arb - BB - Diuretic - for all patients in
ADHF
can be used with decreased GFR
Metalozone
can be used with decreased GFR
Metalozone
A fib with a ventricular response like Ventricular Tachy can be treated by?
Digoxin -
LIST ALL THE A-FIB TX DRUGS HERE**
NOT DONE YET OBVI
Warm / dry - DOC?
Warm / wet - DOC?
Cold / wet DOC? (same as cold and dry)
Warm / dry - candesartan and captopril
Warm / wet - vasodilator and diuretics (nitro)
Cold / wet Milrineon - PED5 inhibitior for Cold/Wet
Quinidine major SE?
- Cinchonism
QT lengthening - worried about greater than 500 can we give Procainamide
NO!!! all the class IA’s cause QT lengthening
Decrease QT intervals
BB’s
210/120 - slight headache and anxiety - HTN classification?
Urgent- have 24 hours to decrease BP
25% decrease in MAP for urgent or emergent?
BOTH… urgent 25% MAP in 24 hrs, emergent for one that doesn’t have a BIG three issue over the first hour, then to 160 over next 2-6 hours followed by back to normal in 24-48 hrs
Angina - rapid relief
sublingual nitro
PFT Polumnary function test, Thyroid (Hypo/Hyper), bluish tilt to skin, baseline every 6 months for lung and liver, 90 days for thyroid
Amiodarone -
Ramopril - 138/88 atherosclerotic 10 year is 13% w/o any other comorbidities - start him on?
water pill and if that’s not available go to CCB like amlyodpine and ACEI
Why don’t we add CCB’s with BB’s?
DON’t ADD CCB’s with BB’s - this causes heart block and possibly failure
Patient with bradycardia - hydrolchlorothiazide, verapmil and metoprolol… why do they have a heart block?
verapmil and metoprolol together cause the block (CCB with Beta Blocker)
Ejection % less than 39 % - ACEI and BB’s, which ACEI will decrease morbidity more below: Losartan, amlodipine, nitro, intresto, carvedilol, -
the answer is the CARVEDILOL not INTRESTO because INTRESTO is the last ditch
Joint pain and lupush like rash -
procainamide or hydralizine
PT 20 weeks pregnant, atherosclerosis risk of 11% - treat her with
METHYLODOPA
Spironolactone - remember we want K level of about 4-5.. if it’s over 5 we have a HIGH pottassium so….
DON’T USE IT!!!
Pt with ejection fracture HF 30%, patient on ARB and BB and diuretic, CR is fine (58 mL) , Potassium is 4, - here can you start spironoalactone?
YES
Enlarged prostate and HTN - doxazosin - main SE is
ORTHOSTATIC HTN on FIRST DOSE
Drop in BP, Blurry vision, heachache and angina - first drug you give them?
Nitro IV (isosorbide dinitrate, but not given by itself) (preload and afterload reductions) Listen to what he said about not taking HERE… DOUBLE CHECK NITRO VS ISOSORBITE DINITIRATE
Clonidine is for
HTN URGENCY - take a look at board photo
Never use NITRO like isosorbide dinitrate with
Cialis and Viagra
Amlodipine is fine with viagra, atenolol with viagra, Lasix with viagra, ACEI with viagra… just not things that effect preload like
NITRATES
AA’s for HTN management -
CCBs and Thiazides
AA’s with HF who are already on ACEI, BIDIL and hydralizine and spironalactone… what are they missing? w
ill put them on a BB - carvedilol is the alpha and beta blocker - always the answer
AA’s with HF you treat just like everyone else - on stage A you would stay with
CCB and thiazide, after structural deficiency then we switch to ACEI or ARB etc
Ethanacrinic acid (edericin) - best for
non sulfa
LONGEST ANSWER - if you don’t know on a test go with the longest answer
QT lengthening - dronedarone (Maltagg) if the pt has a QT interval greater than 500 we don’t want to use it, BECAUSE…..
the QT interval or going from Q to the T will lengthen further
PT with ramopril - check their potassium and about 2 -4 weeks post (serum creatinine and potassium so you can check GFR) ** any time starting patient on ACEI or ARB and CrCl is low ***
cool
write out Cockcroft Gault and male vs female
Female: 0.85 (140 - age) * body weight / ( serum creatinine x 72) - if a male DO NOT multiple by 0.85
30 y/o with significant injury and ICP (no SAH) -
mannitol
Patient with Ejection fraction under 40%, breast tenderness caused by?
spirolacterone would give epleronone
Patient that has atherosclerotic vascular disease of 16% with significant Albumineria, HTN 150/88, and patient has uncontrolled DM - must put on?
ACEI first if not effective then an ARB
Patient with Angina - pt has headaches - what is most likely causing it?
Nitro causes the headaches
Pt with heart failure - checkup treated with captopril, spiro, and digoxin, pottassium is 5.2 - caused by which medication ?
Spironolactone and the ACE-I both cause HYPERKALEMIA
BB’s cause hypokalemia
Pt with angina, stable, COPD - can use
CCB for stable angina
Pt with angina, stable, COPD - can use
CCB for stable angina
HTN Emergency - getting nitroglycerin** - how do we lower?
MAP 25% if no main 3 issues - if the do have aortic dissection lower to 120 systolic in 1st hour, but if preeclampsia or phechromocytoma down to 140 systolic int eh 1st hour - go for the one that’s in the middle of the range - rarely extreme high or low
Pt is taking macrolide and you add another med for heart failure - what are you concerned about for causing Torsades?
Prolonged QT - decrease pottassium, decrease calcium, and decrease magnesium which together prolong QT - causes of prolonged QT = PMC, Potassium Magnesium Calcium
ADHF - warm to touch - already on carvidol, enalopril - could add
NITRO and Torsemide together
EVery heart failure in ADHF patient needs what?
BB’s and ACEI (ARBs), water pill, and could ADD? Nitro for acute decompensated
What works in the collecting duct?
Spironolactone
Patient needs to be anticoagulated - how long before Synchronized cardio version?
3 weeks before and 4 weeks after monitoring
Falsinopril - what do they block? -
ACE blocked, so block angiotensin I to Angiotensin II in the lungs Ototoxicity, hypokalemia, hypomagnesemia - loop diuretic
Torsemide works where?
It is a loop that works in the LOH
Always tell pt’s when you take NITRO do what for it to work?
take time off 12 hrs
This pt comes in and are having blurry vision nausea numbness and tinnitus - what are they being prescribed for their back pain and they are wearing a patch?
(lidocaine patch) - which cause prolonged QT intervals
Cinchonism - - equilibrium issues is Cinchonism (not synced up equilibrium)
Quinidine
pulseless vtac - tx? -
shock them and epi - then give them amiodarone at 300 mg - epi first then amiodarone
HF drugs never get this class of drug -
NSAIDs (motrin etc) - affects bradykinin and ACEI’s with NSAIDs no bueno
Which drug stimulates the vagus nerve?
Digoxin
Only one time you will use this drug (to prevent remodeling) to block the angiotensin receptors to decrease the RAAS system -
intresto (saccubitral and Valsartan)
You have a patient that you think was in Torsades - treat with?
2g of Magnesium
You decide to use drug that blocks alpha and beta and is nonspecific?
carvedilol
Pt that has bluish skin, blurry vision, hypotension, etc what caused it?
amiodarone caused
Class 3 - K channel blockers - remember that SOTALOL has class II and Class 3 - Contraindicated in a patient with
asthma due to beta blocking properties like B2
STEMI - start them on MONA… Aspirin - oxygen, nitro, morphine - if you can’t get to the Cath lab within 90 minutes?
Use fibrionolytic therapy within 30 minutes
If a patient is a diabetic, atherosclerotic disease is 16% they must be on 2 drugs?
ACEI and water pill
If you are having a DIGOXIN toxicity (affects vagus nerve) what will you see on an EKG?
Vagus nerve effects you will see bradycardia and heart blocks
PSVT DOC?
Adenosine -
Verapamil main SE?
constipation
Peripheral edema is ___ main side effect
CCB’s
K sparing blockers - amiodarone - SE’s
Pulmonary fibrosis, thyroid issues, blue skin, etc
Dronedarone our major SE?
GI issues as SE for DRONES - droning over toilet vomiting and diarrhea
Sotalol major Side effect?
signficant bradycardia
BB’s - esmolol only one given?
IV ONLY DRUG Propanol for migraines
is DOC for migraines
Candesartan
IB - lidocaine and mexisartan - decrease the
QT interval**
1A drugs all cause?
QT lengthening so we don’t use in HF - procainamide, Quinadine, Disopyramide
Warm and dry ADHF DOC?
Warm and wet ADHF DOC? V
Cold and dry ADHF (also COld and wet)?
Cold and wet ADHF DOC (same as Cold and dry)?
Warm and dry ADHF DOC? captopril and candesartan
Warm and wet ADHF DOC? Vasodilator nitroglycerin
Cold and dry ADHF (also COld and wet)? Milrinone
Cold and wet ADHF DOC (same as Cold and dry)? Milrinone
Lasix is usually DOC for
ADHF patients, Torsemide can be combined in nitro with patients in heart failure (you can use any but this one is helpful)
Where do potassium sparing drugs what are they?
Potassium SEAT works at the collecting ducts
Chlorathalidone and Thiazides work where and which has highest half life?
DCT and Chlorathalidone has longest half life
Pregnant with HTN URGENCY drug in house treatment we use? outpatient? -
LABEOLOL because it’s IV for in house to, But if outpatient we do methylodopa
45 yo Caucasian male which drug do we start them on?
Clonidine because it’s PO
ACIE we should always know?
Lisinopril is your most likely used ACEI
Do CCB’s prevent strokes?
NO
Nifedipine used for?
HTN preeclampsia
DOES your answer provide the entire STEM? READ EVERYTHING BEFORE YOU ANSWER especially answer choices, but at least ENTIRE STEM
We know dad.
