Week 2 (Exam 1) Flashcards
Who would you avoid giving Flecainide to?
Patients with preexisting ventricular tachyarrhythmias
Patients with previous MI
Patients with Ventricular Ectopic Rhythms
Nicardipine MOA
Slow Calcium entry blocker into Cardiac/SM
Does not change serum [Ca]
STEMI vs NSTEMI etiology
STEMI is complete occlusion of coronary vessel
NSTEMI is partial occlusion or complete w/ collateral circulation
Sotalol Clinical Use and Adverse Effects
Class 2 and Class 3 activities
Treats life-threatening ventricular arrhythmias
Maintains sinus rhythm for patients with A Fib
Adverse: Cardiac Depression, Torsade
Pt has postive stress test
Proceed to invasive coronary angiography
Adenosine MOA
Activates Gi-Coupled GPCR A1 Adenosine Channel
Enhances K+ Current and Inhibits Ca and Funny
Causes Hyperpolarization and suppression of APs
Inhibits AV conduction and Increased Refractory Period
4 drugs commonly used to treat Aortic Dissection
Labetalol, Esmolol, Nitroprusside, Nitrocardipine
b-Blockers
Dofetilide Clinical Use
Class 3 drug that maintains sinus rhythm after cardioversion in patients with A Fib
What happens if you combine Digitalis Glycosides?
Increased Bradycardia
Uses for Nitroprusside
Immediate lowering of blood pressure
Reduces bleeding during surgery
Treats Acute Congestive Heart Failure
Benazepril
Ace Inhibitor for HTN
Captopril MOA
ACE Inhibitor
Acute Pericarditis Treatment
NSAIDs (Indomethacin) and Colchicine (for 3 mos)
Carvedilol MOA
A- and (non-selective) B-Blocker
Amiodarone Clinical Use and MOA
Class 3 Agent
Blocks K+ Channels and Prolongs QT and APD uniformly
Blocks Inactivated Na+ Channels (and some Ca+)
Adrenolytic (causes bradycardia)
Used for V Tach and A Fib
Adverse Effects of Class 4 Drugs
Verapamil can make you constipated
Cardiac stuff: AV Block, -Inotropy, SA arrest, hypotension
What side effect are old people especially susceptible to when taking Esmolol?
Bradycardia (dosage reductions might be necessary)
Do not use Nitroprusside:
For Compensatory Hypertension
In its without enough brain blood, near death, b12 deficient, anemic, renal diseased, hypovolemic
Bisoprolol MOA
B1-Selective b-Blocker
Where are the cells in the heart that feature Fast Action Potential?
Atrial and Ventricular Cardiac Myocytes
Purkinje Fibers
Indications for Bisoprolol
Angina, A Fib / Flutter, HF, HPTN
How are Class 1c and Class 3 agents used for cardioversion / rhythm control in A Fib?
1C: Na block reduces retrograde conduction
2: K block keeps cells in their refractory period
Posterior Heart MI Leads and Artery
Leads: V1, V2, V3 Tall R and Depressed ST
70% Right Dom (PDA from RCA)
10% Left Dom (PDA from LCx)
20% Codominant (PDA from RCA and LCx)
Indications for Losartan
Treat HTN, to Lower BP in its above 6 years old
Reduce Risk of Stroke
Diabetic Nephropathy withy high creatine, proteinuria
Spironolactone MOA
Aldosterone Antagonist
Contraindications of Spironolactone
Hypokalemia
Addison’s
Concomintant use of Eplerenone
Verapamil and Diltiazem Clinical Use and MOA
The Class 4 Agents
Ends and Prevents Paroxysmal Supreventricular Tach
Controls Ventricular Rate in A Fib and Flutter
Contraindication for Stress ECG
Patients with baseline ECG abnormalities
Labetalol Adverse Effects
Dizziness, Scalp Tingling, Lightheadedness, Headache, GI, Stuffy Nose
Disopyramide MOA and Effects
1A Antiarrhythmic with antimuscarinic effects
Good with Recurrent Ventricular Arrhythmias
QT prolongation, Torsade
Negative Inotropy, causing heart failure
Atropine-like symptoms
Black Box warning for ACE Inhibitors / Angiotensin II receptor Blockers
Fetal Toxicity, Death
Most myocarditis patients present with one of 3 patterns…
New Onset or Worsening Heart Failure
Cardiac Conduction Abnormalities
Acute Myocardial Infarction
5 Drugs for PSVT episode prevention
Ca Blockers: Verapamil and Diltiazem
b-Blockers: Metoprolol, Atenolol, Propranolol
Septal Heart MI Leads and Artery
Leads V1 and V2
LAD
Labetalol MOA
Decreases Peripheral Vascular Resistance
What is Benazepril closest to pharmacologically?
Fosinopril and Quinapril
NSTEMI ECG Crtieria
ST Depression 0.5mm or higher in 2 contiguous leads
T Wave Inversions more than 1mm in two with prominent R waves or R/S ratio more than 1
What 3 drugs would you use for Maintenance of Sinus Rhythm in A Fib patients with structural disease?
Sotalol
Amiodarone
Dofetilide
Adverse Effects of Procainamide
QT prolongation, Torsade de Pointe, Syncope
SLE, Hypotension
MOA of Benazepril
ACE inhibitor (Competes for Angiotensin I so it doesn’t cover to Angiotensin II)
What happens if you combine Nitroglycerin with Labetalol?
Additional Antihypertensive Effects
Caution nitroprusside use with patients:
with high Cyanide/Thiocyanate ratio (Congenital Leber’s Optic Atrophy, Tobacco Amblyopia)
with Acute Congestive Heart Failure
with Hepatic Impairment
with Head Trauma
1C anti arrhythmic MOA
Block NA channels and certain K Channels
Do Not Prolong AP, Just QRS
Esmolol MOA
Class 2 Anti-Arrhythmic
Competitively blocks b1 Adrenergics
Controls rapid heartbeats and high BP surrounding surgery or medical procedures
Cyanide (and Thiocyanate)
From breakdown of Sodium Nitroprusside, and following binding of oxyhemoglobin,
(also produces NO and Methaemoglibin)
What has a super potent effect when combined with Lisinopril?
Thiazide Diuretics: Exponential
Definitive Diagnosis of Myocarditis
Endomyocardial Biopsy
3 Black Box Warnings of Nitroprusside
Hypotension (ischemic injury, death)
Cyanide Toxicity
No Direct Inject (Dilute before infusion)
Dressler Syndrome
Pericarditis (immune-based) weeks to months after an MI
Inferior Heart MI Leads and Artery
Leads II III and aVF
RCA
Drug interactions with Furosemide
Makes Aminoglycosides (especially with impaired renal function) more Ototoxic
3 components of Angina Pectoris
Substernal chest pain or discomfort
Provoked by exertion or emotional stress
Relieved by rest and/or Nitroglycerin
Torsade etiology
Impaired K channels cause prolonged repolarization
Ibutilide Clinical Use and Adverse Effects
Class 3 Antiarrhythmic
Blocks rapid part of delayed rectifier K+ current
Restores sinus rhythm in A Fib
Adverse: QT prolongation, Ventricular Arrhythmias
Esmolol Clinical Use and MOA
rapid b1-blocker used in supra ventricular arrhythmias and those associated with myocardial infarction.
Used as adjunct to general anesthesia
Enalapril MOA
ACE Inhibitor
Nicardipine Metabolism
CYP3A4 Substrate
P-GP (MDR1) Substrate
Acute Chest Pain or Discomfort Dyspnea N/V Diaphoresis Fatigue
Acute Coronary Syndrome
1B Antiarrhythmic MOA
Block Sodium Channels Only
May Shorten AP
Class 4 Drug MOA
Block L-Type Ca+ Channels in pacemaker cells
Decrease phase 0 slope
Increase L-type Ca channel threshold potential
Labetalol Warnings and Precautions
Hepatic Injury
Cardiac Failure
Non-Allergic Bronchospasm
Nitroprusside Metabolism
1 Nitroprusside + 1 Hemoglobin -> 1 cyan-methoglobin + 4 CN- ions
Thiosulfate reacts with cyanide, then leaves via urine as thiocyanate
Why is hydroxychloroquine and Azithromycin dangerous to give everyone for COVID?
They cause QT prolongation and/or Torsade
2+ drugs causing QT combines cause Torsade and Fatal Ventricular Arrhythmias
New Cardiac Murmur in Embolic Disease (CVA)
Non-Bacterial Thrombotic Endocarditis (Marantic)
Often seen with Malignancy, often found on autopsy
Uh oh, you need to treat someone for cyanide poisoning after you gave them too much sodium nitroprusside. What do?
Give Sodium Thiosulfate: Increases rate of toxic cyanide processing
Why do b-blockers decrease Phase 0 of action potentials
Acts on Funny and T-Type Ca Channels
Treatment and management of stable angina
External Enhanced CounterPulsations (EECP) therapy
What drug do you use for Oral Anticoagulation in patients with A Fib and mechanical heart valves?
Warfarin
Class 1A Anti-arrhythmic MOA
Block Na: Reduces Phase 0 Slope, Prolongs QRS
Block K: Prolong AP, Prolong QT
Suspect an aortic Dissection? Order…
CT Angiography
What counseling point would you be sure to make with a patient starting Lisinopril?
Don’t take NSAIDs
Adverse Effects of Adenosine
SOB, Bronchoconstricution, Chest Burn, AV Block, Hypotension
Contraindications for Captopril
Sulfur Allergy
Angioedema
Aortic Stenosis
Indications for Furosemide
Treatment of Edema associated with CHF, Cirrhosis, Renal Disease
Pulmonary Edema
What is responsible for the refractory period?
Voltage gated K+ channels
Nitroprusside MOA
NO: activates Guanylate Cyclase on Vascular SM,
Increasing intracellular cGMP, activating PKG, activating Phosphates, activating Myosin Light chains involved in muscle contraction, VASODILATION
Enalapril Indications
Diabetic Neuropathy
Stroke Prevention
CHF, Proteinurea, HPTN
Methaglobinemia as a side effect
From Nitroprusside
Adverse Effects of Esmolol
Bronchial Asthma
Bradycardia / hypotension
Cardiogenic shock, cardiac failure
Fetal Bradycardia in Pregnancy (even after stopped)
Extravasation
Hyperkalemia (especially with renal impairment)
What 5 drugs would you use for Maintenance of Sinus Rhythm in A Fib patients with minimal heart disease?
Flecainide Propafenone Sotalol Amiodarone Dofetilide
Labetalol Contraindications
Overt Cardiac Failure
Greater than First Degree Heart Block
Severe Bradycardia
Contraindications for Carvedilol
Bronchial Asthma
AV Block
Severe Bradycardia
Hepatic Impairment
Oral Anticoagulation in patients with A Fib and no mechanical heart valves
Dabigatran, Rivaroxaban, Edoxaban, Apixaban, Warfarin
Warnings associated with Carvedilol
Worse CAD upon cessation
Non-Allergic Bronchospasm
Masking Hypoglycemia, worsening Hyperglycemia
1st, 2nd, 3rd line treatments for Stable Angina Pectoris
- Aspirin, Betablocker, Nitro, Statin
- Increase b-Blocker, Add Ca Channel Blocker
- Optimize BB and Ca Blocker, Consider Ranolazine
Propafenone Clinical Use and MOA
1C Antiarrhythmic + some B-Blocking
For Supraventricular Arrhythmias w/out structural dz
Similar possible exacerbation as with Flecainide
Indications for Spironolactone
HF, Reduced Ejection Fraction, HPTN
Edema
Primary Hyperaldosteronism
Nicardipine to patients with b-Blockers
Titrate Slowly
Nicardipine interactions with Cyclosporine and Tacrolimus
Concomitant use increases plasma [cyclosporine or tacrolimus] because nicardapine inhibits hepatic microsomal enzymes (CYP3A4)
Why does the threshold of an AP get increased with b-blockers?
Effects L-Type Ca Channels
What happens if you have a STEMI patient at a Non-PCI capable hospital?
Transferwithin 120 Minutes OR:
Give Thrombolytics within 30 minutes, then transfer
Propanalol Clinical Use and MOA
B Blocker (Class 2) For Stress/Thyroid Storm Arrhythmias, A Fib / Flutter, Paroxysmal Supraventricular Arrhythmias, MI Arrhythmias
Distribution of labetalol
Crosses Placenta
Found in breast milk
4 Cardiac Tamponade Signs
Pericardial Friction Rub
Absent Y Descent on Jugular Veinous Waveforms, Pulsus Paradoxus
Hypotension + JVD + Muffled Heart Sounds
Clinical use of Adenosine
Conversion to sinus Rhythm in Paroxysmal Supaventricular Tach (IV)
Indications for Benazepril
HTN and Heart Failure Management
Metabolism of Labetalol
Conjugated to Glucuronide Metabolites, Ester Linkage Hydrolysis
55 - 60% is found in urine within first 24 hours of dosing
Crosses the Placenta
4 signs of Constrictive Pericarditis
JVD (Prominent x and y descents on waveform) Pulsus Paradoxus Kussmaul Sign (JVP doesn't decrease with inspiration) Pericardial Knock (cessation of ventricular filling)
What cardioversion drugs would you only use with a left ventricular ejection fraction 40% or higher?
Flecainide and Propafenone
Flecainide Clinical Use and MOA
1C Antiarrhythmic
Used in normal hearts with supra ventricular arrhythmias
Exacerbation in certain patients
Metoprolol MOA
B-1 Selective (cardioselective) Blocker
What should you try to avoid when giving Nicardipine to patients who sustained an acute cerebral infarct or hemorrhage?
Systemic Hypotension
Fosinopril Indications
CHF, HTPN, Proteinurea
Does Not Contain Sulfhydryl
Mexiletine Clinical Use and MOA
1B Antiarrhythmic (oral lidocaine, basically)
Good on Ventricular arrhythmias, neuropathy
Tremor, blurred vision, nausea, lethargy
Quinidine MOA and Adverse Effects
1A Antiarrhythmic
Tachycardia from hypotension, QT prolongation, Torsade
GI effects
Tinnitus / hearing loss / delirium / vision disturbances
Thrombocytopenia, hepatitis, fever
EKG findings of Paroxysmal Supraventricular Tach (PSVT)
Narrow QRS, P Wave Inverted or Hidden by QRS
Adverse Reactions to Captopril
Abdominal Pain
Agranulocytosis
Alopecia
Anaphylactoid Rxns
Drug interactions with Spironolactone
Hyperkalemics: Hyperkalemia
Lithium: Toxicity
NSAIDs: Reduces effect of Aldosterone
ST elevation of 2mm or more, or New LBBB
This pt has a STEMI
Indications for Valsasrtan
HTN, to lower BP, Etc
Captopril Indications
HTN, CHF
Adverse Effects of amiodarone
AV Block and Bradycardia Fatal Pulmonary Fibrosis Hepatitis Photodermatitis Hypo/er-Thyroidism: failed thyroxine to triiodothyronine
Nicardipide interactions with Cimetidine
Increases Plasma [Nicardipine]
contraindications of beta-blockers
Asthma, Peripheral Vascular Disease, Raynaud’s, Type 1 Diabetics on Insulin, Bradyarrhythmias and AV conduction abnormalities, severe depression of cardiac function
Acute vs Subacute Infective Endocarditis
Acute: Staph Aureus on Normal Heart Valves
Subacute: On Damaged Heart Valves, Fatal above 6 wks
Contraindications for Furosemide
Anuria, Hx Hypersensitivity
Dual Antiplatelet Therapy
ASA and P2Y12 Inhibitor
Procainamide Clinical Use and MOA
Class 1A Antiarrhythmic along with SA / AV depression
Effective with sustained V Tach and MI arrhythmias
Beck’s Triad
Hypotension + JVD + Muffled Heart Sounds
This is Cardiac Tamponade
What happens if you combine Labetalol with Tricyclics?
Tremor
Half life of Esmolol
9 minutes
Who should you use caution with regarding Labetalol?
Nursing mothers: a small amount is excreted in milk
Pregnancy: faster metabolism of it
Geriatrics: Lower elimination
Classifications of Angina based on its 3 components
Typical: All 3 components
Atypical: 2/3
Non-Angina Chest Pain: 1
Lateral Heart MI Leads and Artery
Leads V5, V6 or I, AVL
LCx
Novel / Non-traditional risk factors for CAD
CKD
Proteinuria
Inflammatory States (HIV, RA, Psoriasis)
Nicardipine Contraindications
PATIENTS WITH ADVANCED AORTIC STENOSIS
Class 3 Drug MOA
Prolongs APD and QT uniformly
Lidocaine Clinical Use and MOA
1B Antiarrhythmic (IV only) Good on V Tach in acute myocardial ischemia Least toxic of all class 1s, maybe hypotension or neuro
Risk factors for young people having an Aortic Dissection
Marfan syndrome (or other CT disorders)
Syphilis
Cocaine or Meth
Trauma
Acute medical management of Aortic Dissection
Anti-Impulse Therapy to lower HR below 120
Nicardipine use in patients with Angina
Can worsen it with chronic oral therapy
can be induced in >1% of CAD patients
Pain pattern of Acute PEricarditis
Worse lying flat and relieved by sitting up and leaning forward
Anterior Heart MI Leads and Artery
Leads V2, V3, V4
LAD
Caution in using Nicardipine with patients who:
Have Heart Failure (-inotropic effects)
have Impaired Liver Function (where its metabolized)
have Impaired Renal Function (titrate gradually!)
are Geriatric
What are the two Angiotensin II blockers?
Valsartan and Losartan
What is blocked by b-blockers?
Epinephrine
Captopril Monitoring Parameters
BP
BUN
Na, K
What drug do you want to avoid in combination with Esmolol?
IV calcium channel blockers
Treat a hemodynamically stable Torsade de Pointe
Tx electrolyte abnormalities
Magnesium sulfate IV regardless of levels
Transveous Temporary Pacemaker or Isoproterenol IV
Black Box warning for Benazepril
Fetal Toxicity
