Unit 11 Cardiovasular Pt. 2 Flashcards
In the general nonblack population, including diabetics, initial anti hypertensive treatment should include :
Thiazide type diuretic, calcium channel blocker, angiotensin converting enzyme inhibitor or angiotensin receptor blocker.
According to JNC guidelines in the general population aged >60years Pharmacologic treatment should be initiated to lower systolic and diastolic pressure with a goal of :
SBP < 150
DBP < 90
Grade A recommendation
In the African American population, including diabetics, initial antihypertensive treatment should include
A Thiazide type diuretic or calcium channel blocker.
ACEIs or ARBs should not be combined with :
NSAIDS: lower response of hypertension to therapy
Potassium-sparing diuretics: can produce hyperkalemia
Diuretics and NSAIDs: lead to nephrotoxicity
Calcium channel blockers and CYP3A4 inhibitors can produce significant hypotension! What are these inhibitors
Antimicrobials and antidepressants
Erythromycin, Clindamycin, Ciprofloxacin, macrolides, azole antifungals, grapefruit juice, amiodarone.
(Hint: Note that erythromycin and Clindamycin are included but Azithromycin is not)
Beta blockers are metabolized by CYP2D6. Inhibitors can result in bradycardia, hypotension, or heart failure. These inhibitors are :
Some antidepressants, cimetidine, Benadryl, and amiodarone.
Calcium Channel blockers have the most significant interactions and can result in severe
Hypotension
When used together, Diuretics and NSAIDs carry the potential risk of :
Dehydration, reduced renal function, and unnecessary hospitalization.
Geriatric patients are at highest risk.
When hypertension is first diagnosed in pregnancy prescribe :
Methyldopa
Category B
African Americans have more difficult to treat Htn with higher BP and recommended therapy is :
CCBs or Thiazide Diuretics
Mechanism of action: Nitrates
Relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophospohate cGMP.
Reduce myocardial oxygen demand by decreasing preload.
Major dilation of venous bed.
Key components to risk reduction and prevention :
Hypertension, cigarette smoking, lipid abnormalities, diabetes mellitus, obesity/weight management, physical inactivity.
Nitroglycerin is very unstable. Loss in potency related to:
Heat, sun, temperature, expiration date
Glycosides such as Digoxin are indicated for :
Heart failure
Atrial fibrillation
Atrial flutter
Mechanism of action : Digoxin
Inotropic effect on cardiac cells.
Increased force of contraction of cardiac muscle.
Increases cardiac output.
Loop diuretics are given for
Fluid retention
Certain drugs can exacerbate heart failure and should be avoided if possible :
Calcium channel blockers
NSAIDs
Antiarrhythmic agents
Thiazolidinediones
Beta blockers are indicated for :
-olol
Htn, angina, chf, selected arrhythmias, migraine prophylaxis, MVP, alcohol withdrawal.
Mechanism of action : Beta blockers
Competitive blockade of b-adrenergic receptor.
Decreased heart rate and contractility.
Decreased BP, myocardial oxygen demand.
Avoid Beta blockers in:
African Americans, asthma, COPD, severe PVD, Raynaud’s phenomenon, depression, bradycardia, 2nd or 3rd degree heart block, hypoglycemia prone diabetics, and elderly.
Post MI for secondary prevention all patients should receive
Beta blocker therapy.
B-blockers have been shown to improve survival in post MI patients by reducing the incidence of sudden death.
Treatment of choice for chronic stable and unstable angina:
Beta blockers.
Indications for calcium channel blockers :
-dipine (Nifedipine, Verapamil, Diltiazem)
Hypertension, vasospastic angina, arrhythmias.
Off label use: Raynaud’s , stable angina
Mechanism of action: calcium channel blockers
Block inward movement of calcium through the slow channels of cell membranes causing:
Negative Inotropic and neg chronotropic effect, decreased cardiac output, decreased after load.
Works on 1.cardiac muscle, 2. conduction system (AV & SA), 3.vascular smooth muscle.
Treatment principle for chronic stable angina :
First line therapy: beta blocker and nitrate
Second line: if unable to tolerate b-blocker or symptoms are not controlled we’ll start long acting Diltiazem, Verapamil, Amlodipine, or Felodipine.
Calcium channel blockers are not recommended in treatment of :
CHF
Calcium channel blockers are recommended as safe for :
African Americans
Elderly patients
Patients with hyperlipidemia
Patients on NSAIDs
Patient education calcium channel blockers :
Don’t take with grapefruit juice !
Serum digoxin will need to monitored if pt is on dig
Indications for ACE Inhibitors:
-pril
HTN, CHF, Renal Impairment, post MI
Prolongs survival in: heart failure, coronary heart disease, acute MI
Slows progression of: chronic renal failure, diabetic neuropathy
Mechanism of action ACEIs:
Block angiotensin converting enzyme (ACE- responsible for conversion of angiotensin I to angiotensin II)
Angiotensin II receptors are blocked which blocks the potent vasoconstrictor and stimulus for aldosterone release from adrenal glands. This leads to less water absorption in distal renal tubule.
ACEIs also inhibit breakdown of bradykinin - possible reason for cough side effect.
ACEIs result in:
Decreases systemic vascular resistance
Decreased BP without changes in heart rate
Increased renal perfusion
Decrease renal vascular resistance: no change in GFR
Advantages of ARBs over ACEIs:
ARBs (angiotensin receptor blockers -artan)
No dry cough, decreased incidence of angioedema, second line tx. because of cost.
_________ should be given to all patients with a symptomatic or symptomatic heart failure.
ACEIs (-pril)
Reduces preload, after load, systemic BP and increases renal blood flow.
Also slow the progression of diabetic neuropathy.
Ace inhibitors should be avoided in :
Renal failure (can cause hyperkalemia)
Pregnancy (significant fetal risk)
Blacks (less effective monotherapy, must be used in comb with diuretic)
Use of potassium containing meds
(Monitor supine BP while titraing and watch for angioedema without urticaria)
Indications for antiarrhythmic agent:
Paroxysmal supraventricular tachycardia (PSVT)
Atrial fibrillation (A. Fib)
Premature ventricular contractions (PVCs)
Mechanism of action antiarrthymics
(Quinidine, lidocaine, amiodarone, dig, verapamil, B-blockers etc)
Decrease electrical irregularity
*all antiarrthymics have potential to cause arrhythmias.
Indications for diuretics:
Hypertension
CHF
Renal Failure
Cirrhosis
Treatment principles for diuretics:
Salt restriction
Thiazide: First line (HCTZ no greater than 25mg start small)
Loop: second line (Furosemide 40mg)
Other diuretics as needed for special conditions
