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Medical Pharmacology Exam 3 > Treatment of Coronary Heart Disease > Flashcards

Treatment of Coronary Heart Disease Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the 3 examples of nitrates that are used to treat heart disease?

A

Nitroglycerine
Nitroprusside
Isosorbide dinitrate

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2
Q

What is the mechanism by which nitrates cause vasodilation? What is the mitochondrial enzyme involved in nitroglycerin formation of Nitric oxide?

A

Lead to nitric oxide formation, which activates cGMP with dephosphorylates the myosin light chain, leading to vasodilation
- mtALDH=mitochondrial aldehyde dehydrogenase

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3
Q

What are the 2 types of vessels that are relaxed in response to nitrates? Why not all vessels?

A
  • Large arteries, veins

- Large and small arteries have different enzyme pathways for vasodilation

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4
Q

Which of the nitrates forms nitric oxide completely Non-enzymatically?

A

Nitroprusside

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5
Q

In addition to relaxation of vessels, what is another mechanism by which nitrates act to treat heart disease?

A

Block platelet aggregation

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6
Q

Which of the nitrate undergoes a significant first pass hepatic metabolism? Which undergoes minimal first pass hepatic metabolism?

A

significant - nitroglycerin

minimal - isosorbide mononitrate

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7
Q

What nitrate drug is a prodrug for isosorbide mononitrate? Which is the two (drug / prodrug) has a longer duration of action

A

isosorbide dinitrate

isosorbide mononitrate

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8
Q

Which nitrate drug has a duration of action heavily dependent on formulation?

A

Nitroglycerin

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9
Q

What is the major reason for diminished response (nitrate tolerance) when using nitrates? How can this be addressed?

A

Impaired biotransformation

Interrupt therapy for 8-12 hrs

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10
Q

Headaches, orthostatic hypotension, dizziness, flushing, syncope are all side effects of _ class of drugs.

A

Nitrates

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11
Q

How can reflex tachycardia from nitrates be addressed?

A

Add a beta blocker

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12
Q

What type of drug is contraindicated in patients who use nitrates? Why?

A

Phosphodiesterase inhibitors

Excess cGMP, hypotension

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13
Q

What are the 2 indicated uses for phosphodiesterse 5 inhibitors?

A

Erectile dysfunction

Primary pulmonary hypertension

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14
Q

What are the 3 examples of phosphodiesterase 5 inhibitors available? What molecule in increased when using these drugs?

A

Sildenafil
Tadalafil
Vardenafil
cGMP

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15
Q

What is the interaction between nitrates and phoshodiesterase 5 blockers?

A

nitrates increase cGMP, which causes vasodilation

PDE5 cycles cGMP to GMP, inhibiting PDE5 leads to too much cGMP, too much vasodilation

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16
Q

Among the PDE5 inhibitors, which has the longest time to onset? Which has the shortest? Which is indicated for daily use?

A

Longest - sildenafil
Shortest - Tadalafil
Daily use - Tadalafil

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17
Q

Besides nitrates, what other drug class can cause hypotension when combined with PDE5 inhibitors?

A

Alpha receptor blockers

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18
Q

Sudden loss of hearing, increased vision loss, blurred vision and loss of blue/green discrimination are side effects associated with what drug class? What is responsible for the side effects of this drug class?

A

PDE5 inhibitors

Excess cGMP

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19
Q

How do beta antagonist improve heart function?

A

Inhibit the sympathetic NS

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20
Q

What is the effect of beta 1 blockade? Beta 2?

A

beta 1 - reduced HR and contractility, reduced renin

beta 2 - Increased vasoconstriction (usually counters alpha 1)

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21
Q

What is a population that should not use beta 2 blockers?

A

Asthmatics

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22
Q

Cardioselective beta blockers are likely functioning at what receptor subtype?

A

Beta 1 receptors

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23
Q

What are the 4 examples of beta 1 selective antagonists provided?

A

Acebutolol
Atenolol
Esmolol
Metoprolol

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24
Q

What are the 4 examples of non-selective beta Blockers provided?

A

Nadolol
Pindolol
Propranolol
Timolol

25
Q

Among the beta blockers, which 2 have intrinsic sympathomimetic activity?

A

Acebutolol

Pindolol

26
Q

What drug class is associated with bronchospasm, worsened type 2 diabetes, Hypoglycemia and hyperlipidemia?

A

Beta blockers

27
Q

Impotence, sleep disturbance, cold extremities and myocardial depression is associated with what class of drugs?

A

Beta blockers

28
Q

Beyond asthmatics, people what what 2 other diseases should avoid beta blockers?

A

peripheral vascular disease

insulin dependent diabetes

29
Q

While beta blockers prolong survival in patients with

compensated heart failure by decreasing MVO2, what aspect of these drugs may worsen heart failure?

A

Their negative ionotropic effects

30
Q

Regarding beta blockers, what is the rebound phenomenon? What is the mechanism? How can it be avoided?

A
  • worsening ischemia with abrupt discontinuation of drugs
  • upregulation of beta receptors
  • gradual tapering of drug dosage
31
Q

When calcium channel blockers are used for treatment of heart disease, what is the channel subtype targeted? What is the mechanism of these drugs?

A

L type calcium channels

Decrease cytosolic calcium

32
Q

What are 2 calcium channel blockers that decrease HR? Which decreases cardiac contractility?

A

Diltiazem and Verapamil

verapamil

33
Q

How do calcium channel blockers increase O2 supply to the heart?

A

Dilate epicardial arteries (and stenoses)

Block vasospasm

34
Q

What are the 5 examples of dihydropyridines provided? Which is only used in subarachnoid hemorrhage?

A 
Nifedipine
Amlodipine
Felodipine
Nicardipine
Nimodipine (subarachnoid hemorrhage)
35
Q

In addition to heart disease and hypertension, what are 2 other uses of calcium channel blockers?

A

Supraventricular arrhythmias

Cerebral hemorrhage

36
Q

Between beta blockers and calcium channel blockers, which is more effective for secondary prevention following MI? Which calcium channel blocker should be avoided following acute MI?

A

Beta blockers more effectove

Avoid nifedipine

37
Q

Gingival inflammation and hyperplasia is associated with the use of _. Heart failure, brady cardia and heart block is associated with the use of what 2 drugs? Peipheral edema is associated with the use of what class of drug?

A

Nifedipine (other calcium channel blockers)
Verapamil and diltiazem
Didydropyridines

38
Q

Calcium channel blockers should be avoided in heart failure. If they have to be used, what 2 are the best candidates?

A

Amlodipine and felodipine (both newest)

39
Q

What are the 2 drug classes used to treat heart disease that inhibit the renin angiotensin system?

A

ACE inhibitors

Angiotensin receptor blockers

40
Q

When used to treat heart disease, what are the 2 effects of ACE inhibitors and Angiotensin receptor blockers

A

Slow CHD progression

Prevent secondary MI

41
Q

What is ranolazine? What is its effect on ATP production?

A 
Newest antianginal (introduced in 2006)
Shifts ATP production from fatty acid oxidation to glycolysis
42
Q

What are 3 advantages of ranolazine?

A

No negative ionotropic or chronotropic effecrs
Improved exercise tolerance
Minimal effects of HR and BP

43
Q

Ranolazine is reserved for what patient population?

A

Patients with chronic angina that are refractory to traditional antianginal agents

44
Q

For stable coronary heart disease, what is the treatment for acute attacks? What is used for chronic treatment?

A

Acute - Sublingual nitroglycerin

Chronic - Beta blockers, aspirin

45
Q

For unstable CHD, what are 3 treatments to reduce myocardial oxygen demand/prevent vasoconstriction?

A

Nitrates
Beta blockers
Calcium channel blockers

46
Q

For unstable CHD, what are 3 treatments to stabilize atherosclerotic plaques?

A

Statins
Antiplatelets therapy
Anticoagulants

47
Q

For unstable CHD, what are 3 (classes) of drugs used to prevent platelet aggregation?

A

– Aspirin
– Thienopyridines - ADP antagonist
– Glycoprotein llb/llla blockers

48
Q

For unstable CHD, what are 2 drugs used to limit thrombus formation?

A

– Heparin

– Thrombin inhibitors (hirudin, hirulog)

49
Q

For unstable CHD, what are 2 drugs used to prevent vasoconstriction?

A

– Nitrates

– Ca2+ channel blockers-vasospasm

50
Q

What is the major drug used to prevent progression of CHD and secondary MI?

A

RAS inhibitors

51
Q

Thienopyridines are used to prevent platelet activation. What are the 2 examples provided?

A

Prasugrel

Clopidogrel

52
Q

Thienopyridines require hepatic biotransformation. Why? What is their target receptor? What do they displace?

A

They are prodrugs
P2Y receptors
Irreversibly replace ADP

53
Q

What is the major side effect associated with clopidogrel?

A

Neutropenia

54
Q

Between clopidogrel and prasugrel, which is likely to cause more bleeding? Why? Which has the longer half life?

A

Prasugrel
Rapid absorption, near 100% metabolic activation, vs 15% for clopidogrel
Prasugrel (see second point)

55
Q

For the acute treatment of unstable CHD and MI, what is the MONA acronym?

A

Morphone,Oxygen, Notroglycerin and Aspirin

56
Q

– Rapid onset of action
– Easily titrated to achieve desired effect
– Brief duration of action if adverse effects
– No effects on cardiac contractility or conduction

These are all advantages of using _ in the acute treatment of unstable CHD / MI

A

Nitroglycerin

57
Q

What are the 2 interventional treatment for MI

A

PCI - Percutaneous Coronary Intervention

CABG - Coronary artery bypass graft

58
Q

What are 2 drugs that can be used on stents? What are their functions?

A

– Paclitaxel (Taxol®)-antimicrotubule antineoplastic
– Sirolimus (Rapamycin®)-inhibits cell cycle
progression

59
Q

What is microvascular angina? What causes it?

A
  • Angina or angina-like discomfort with exercise, ST-segment depression or other signs of ischemia
  • Microvascular (endothelial) dysfunction (normal coronary vessels)

Medical Pharmacology Exam 3 (13 decks)

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