Week 3- Drug Management of Cardiac Disease P1 and P2 Flashcards
1
Q
The heart must carefully balance energy synthesis with immediate energy needs. Why?
A
Inability to do so can result in reduced cardiac function and/or cardiac pathology.
2
Q
What are the (3) main drug strategies to IMPROVE cardiac function?
A
- ) Directly increase cardiac contractility.
- ) Reduce workload of the heart i.e. reduce myocardial contractility and O2 demand.
- ) Increase myocardial blood flow.
3
Q
What are (3) ways we can reduce the workload of the heart? Are they direct or indirect?
A
- ) Reduce contractility (direct)
- ) Reduce afterload (indirect)
- ) Reduce preload (indirect)
4
Q
What are 2 ways we can increase myocardial blood flow?
A
- ) Increase blood flow.
2. ) Manage hemostasis.
5
Q
PART 1: DIRECTLY INCREASE CARDIAC CONTRACTILITY
A
PART 1: DIRECTLY INCREASE CARDIAC CONTRACTILITY
6
Q
- What is the purpose of inotropic agents?
- What are the (2) types and the difference between them?
A
- Inotropic agents are used to alter the force of the hearts contractions.
- Positive inotropic agents (increase force of contraction), Negative inotropic agents (decrease force of contraction).
7
Q
When are positive inotropic agents used?
A
- In instances where there is sudden low CO.
- Only used in inpatient settings, and only those who have S/Sx of low CO.
- PT most likely on hold with these patients.
8
Q
Name the (3) most common positive inotropic agents.
A
- Dopamine
- Dobutamine
- Milrinone
9
Q
Dopamine:
- Natural catecholamine that acts as precursor to __________.
- The hemodynamic effect is _______ dependent.
- When is it usually used?
A
- norepinephrine (NE)
- dose dependent
- Usually used in severe HF and reserved for patients with moderate hypotension.
10
Q
Dopamine Dose Dependent:
- Describe low-dose effects of dopamine.
- Describe mod-dose effects of dopamine.
- Describe high-dose effects of dopamine.
A
- Low-dose = renal/splanchnic vasculature dilation enhancing diuresis (urination).
- ***Mod-dose = enhance cardiac contractility and HR.
- High-dose = increase afterload through peripheral vasoconstriction.
11
Q
- Is Dobutamine or Milrinone used to improve end organ perfusion i.e improves MAP?
- Is Dobutamine or Milrinone used in the management of pulmonary hypertension?
A
- Dobutamine
- Milrinone
12
Q
- What is the purpose of Digitalis?
- Is it toxic? What is a sign of toxicity?
A
- Used to treat impaired cardiac contractility (positive inotropic effect) typically caused by HF.
- Is toxic, patients are hospitalized while dosage is adjusted. (yellow hues sign of toxicity)
13
Q
Digitalis:
- Increased ____ influx into the myocytes.
- Increases the ______ refractory period, decreasing ventricular responses. (antiarrhythmic)
- Can cause reflex stimulation of the vagus nerve, which leads to a decrease in what?
A
- Ca2+
- AV node
- decrease in HR and contractility
14
Q
PART 2: REDUCE WORKLOAD OF THE HEART, i.e. REDUCE MYOCARDIAL CONTRACTILITY AND O2 DEMAND
A
PART 2: REDUCE WORKLOAD OF THE HEART, i.e. REDUCE MYOCARDIAL CONTRACTILITY AND O2 DEMAND
15
Q
What are (3) ways we can reduce the workload of the heart?
A
- ) Directly reduce contractility.
- ) Reduce afterload.
- ) Reduce preload.
16
Q
B1 Receptor Agonists:
- Response when stimulated?
- Clinical use?
- Impact on cardiac work?
A
- ↑HR, ↑Contractility
- Treat severe cardiac decompensation.
- INCREASES workload of the heart.
17
Q
B1 Receptor Antagonists:
- Response when stimulated?
- Clinical use?
- Impact on cardiac work?
A
- ↓HR, ↓Contractility
- Treat compromised/diseased hearts.
- DECREASES workload of the heart, reduces functional capacity.
18
Q
What are (2) drug classes used to directly reduce contractility of the heart?
A
- B1 Antagonists
- Ca+ Channel Blockers
19
Q
B1 Antagonists:
- Affect the _____ primarily.
- Are called “___________”.
- Have negative chronotropic/inotropic effects thus __________ workload of the heart.
- What is the difference between Non-specific Beta Blockers and Cardioselective Beta Blockers?
A
- heart
- “beta-blockers”
- reducing
- Non-speific Beta Blockers have + effect on heart, but - effect on bronchial smooth muscle.
20
Q
How do we typically identify B1 Antagonists (“beta-blockers”)?
A
-lol
21
Q
What are some common AE of B1 Antagonists (“beta-blockers”)? (4)
A
- Bronchoconstriction (becomes problem in those with pulmonary disease i.e. cor pulmonale).
- Can cause excessive depression of cardiac function (too much of a good thing).
- OH
- Depression, lethargy, and sleep disorders (long term use).
22
Q
What is the biggest thing we should be mindful of when treating patients who are on B1 Antagonists?
A
REDUCED PEAK HR
-HRmax = 164-0.7*age
23
Q
Ca+ Channel Blockers:
- Reduces _____ flux into myocytes.
- ____ contractility and energy demands on the heart.
- Also ↓ _____.
A
- Ca+
- ↓
- CO
24
Q
What are the (3) main AE of Ca+ Channel Blockers?
A
Results in peripheral vasodilation leading to:
- Decreased BP
- Dizziness
- Bradycardia
25
What are (4) drug classes used to reduce afterload?
- A1 Blocker
- Direct Vasodilators
- B1 Blocker
- Centrally Acting Agents
26
- When thinking about reducing afterload, think ___!!!
| - ↑ radius = __ resistance
- BP!!!
| - ↓
27
What is the purpose of A1 Blockers?
Decrease BP by preventing norepinephrine from tightening muscles in the walls of small arteries/veins.
28
Alpha 1 Receptors:
- Located on ________ _______ muscle.
- Stimulation causes smooth muscle contraction and results in ____________.
- Blockade results in smooth muscle relaxation, _________ and decreased TPR.
- vascular smooth muscle
- vasoconstriction (↓r)
- vasodilation (↑r)
29
What is TPR/SVR?
Total Peripheral Resistance/ Systemic Vascular Resistance
| -The resistance to blood flow offered by all of the systemic vasculature beds to blood flow.
30
What are some common AE of A1 Blockers?
- Systemic drug = systemic effects
- Reflex tachycardia secondary to hypotension
- OH
- Edema of LE, syncope, and SOB
- Weakness, N/V
31
What is the function of Direct Vasodilators?
Act directly on smooth muscle cells to cause relaxation. (↑r)
32
What specific Direct Vasodilator is most commonly known for its effects on hair growth?
Minoxidil
33
B1 Antagonists (Beta-Blockers):
- Mainstay of anti-HTN therapy.
- May produce a general decrease in sympathetic tone or outflow thus _______ vascular smooth muscle contraction.
- Decrease _____ release from kidney → decreased amount of angiotensin II → decreased blood volume.
- HOWEVER, these drugs act primarily on the ______.
- reducing
- renin
- heart
34
- What are the (2) biggest AE of Beta-Blockers?
| - How do we estimate HRmax of patients on Beta-Blockers?
- Bradycardia, Dizziness
| - 164-(0.7*age)
35
What is the function of Centrally Acting Agents?
Inhibit sympathetic outflow from the brainstem.
36
Centrally Acting Agents:
- __ HR, Contractility, TPR
- Act like __ _________
- Often given with a diuretic
- ↓
| - A2 antagonists
37
What are common AE of Centrally Acting Agents?
- Dry mouth
- Dizziness
- Drowsiness
- Hypotension
38
What are the (4) drug classes used to reduce preload?
- Diuretics
- ACEi (Ace inhibitors)
- ARBs (Angiotensin II Receptor Blockers/Antagonists)
- Aldosterone Antagonists
39
What is the purpose of Diuretics?
Act directly on kidneys to increase water/Na+ excretion. This increased diuresis helps to decrease blood volume i.e. preload.
40
What are the (3) types of Diuretics?
- Loop Diuretics
- Thiazide Diuretics
- Potassium Sparing Diuretics
41
- Which diuretic acts on the distal convoluted tubules to inhibit Na+ reabsorption?
- Which diuretic acts on the ascending limb of the Loop of Henle, inhibits the reabsorption of Na+ and Cl-, and has a loss of K+?
- Which diuretic interferes with the Na/K exchange mechanism in the distal convoluted tubules and is less effective at producing diuresis but spares K+?
- Thiazide Diuretics
- Loop Diuretics
- Potassium Sparing Diuretics
42
Rank the (3) diuretics by AE.
Loop > Thiazide > Potassium Sparing
43
Loop diuretics are used more for _________ than __________.
diuresis than hypertension control
44
What are some common AE of Diuretics? (4)
- Fluid depletion (OH, ↑TPR, activate renin-angiotensin system)
- e- imbalance (hyponatremia/hypokalemia)
- OH/Falls precaution
- Urinary incontinence
45
What is the purpose of ACEi?
Blocks the conversion of angiotensin I to angiotensin II.
46
Angiotensin II:
- ________ walls of arterioles.
- Stimulates ____ reabsorption in the kidneys.
- Stimulates _______ release from adrenal cortex, causing kidneys to retain Na+/water.
- What is the net effect of angiotensin II?
- constricts
- Na+
- aldosterone
- vasoconstriction, fluid retention, INCREASED AFTERLOAD
47
What are the (3) net effects of ACEi?
- Decreased vascular smooth muscle tone (vasodilation)
- Inhibition of aldosterone secretion (reduced Na+ and H2Oresorption/water resorption in kidney and reduced blood volume)
- Decreased renin activity/production
48
- Are ACEi well tolerated?
| - What are the AE?
Yes, generally well tolerated.
- Allergic reaction
- GI discomfort
- Dizziness
- Chest pain
- Persistent cough
- Weakness
49
How do we typically identify ACEi?
-pril
50
How do ARBs (Angiotensin II Receptor Antagonists) work?
Block renin-angiotensin-aldosterone system.
51
How do we typically identify ARBs?
-artan
52
What is the purpose of Aldosterone Antagonists?
Block aldosterone binding sites and causes reabsorption of sodium by the kidneys, which encourages water loss, which decreases BP.
53
PART 3: INCREASE MYOCARDIAL BLOOD FLOW
PART 3: INCREASE MYOCARDIAL BLOOD FLOW
54
What are the (2) ways we can increase myocardial blood flow?
- Increase blood flow.
| - Manage hemostasis.
55
- What (1) drug class can be used to increase blood flow?
| - What is the purpose of them?
- Nitrates
- Drugs that work more directly at the level of the heart and act as a relaxant of coronary smooth muscle. They act quickly to bring about coronary dilation.
56
- Venodilator: ↓ venous return and ↓ _________
| - Arteriodilator: ↓ ________
- preload
| - afterload
57
Organic Nitrates are used in the treatment of angina and produce a general _________ (not specifically a coronary artery dilation).
-vasodilation
58
Organic Nitrates MOA:
- ___ in preload/afterload → ___ in cardiac work and hence ___ in MVO2 (cardiac oxygen use).
- ↓ in MVO2 is more important than the increased ___ availability
- Can a tolerance to nitroglycerin be developed?
- ↓, ↓, ↓
- O2
- Yes, but can be reversed rapidly by short term withdrawal.
59
What are the ways nitroglycerin can be delivered? (4)
- Oral
- Sublingual
- Buccal
- Transdermal patches
60
Nitroglycerin Patches:
- NOT effective ________.
- Must be changed every ___hrs.
- Change where patch is applied to avoid skin rash.
- Always use it even if you feel well.
- Don't suddenly stop using it.
- Don't "______ ___".
- Dispose of used patches carefully.
- acutely
- 24hrs
- "double up"
61
- What do we do if blurred vision, dry mouth, skin rash, dizziness, or fainting occurs while treating patients who use Nitroglycerin Patches?
- What do we need to check frequently in these patients?
- Contact MD
| - BP
62
What (3) drug classes can be used to manage hemostasis?
- Thrombolytic agents
- Anticoagulants
- Antiplatelet agents
63
What is hemostasis?
Intrinsic process which causes bleeding to stop.
64
Describe the process of hemostasis in (3) steps.
1. ) VESSEL WALL INJURY triggers attachment and activation of platelets and and causes vasoconstriction.
2. ) PLATELETS become "sticky" and attach at area of vessel wall injury.
3. ) PLASMA FACTORS interact to convert fibrinogen to fibrin which helps to form a clot.
65
What is the purpose of Thrombolytic Agents?
Act by degrading a formed clot.
66
Thrombolytic Agents AE:
- _________ is the primary and most serious problem with these drugs.
- Be alert for S/Sx of ______________.
- No antidote
- GI distress
- Hemorrhage
| - heavy/unusual bleeding
67
What is the purpose of Anticoagulants?
Help to prevent/slow coagulation of blood i.e. formation of blood clots.
68
Anticoagulants:
- Are _____________.
- Commonly called _______ _________.
- Act by interfering with the proteins in your blood that are involved with the coagulation process (__________).
- preventative
- blood thinners
- (factors)
69
List of Anticoagulants. (5)
- Heparin
- Coumadin (Dicoumarol, Warfarin)
- Xarelto
- Eliquis
- Lovenox
70
Anticoagulants are used primarily to prevent what?
- Strokes, MI's, DVT/PE, Hx of clots/post surgery/inactivity, A.fib
- Anticoagulants are used if you're at risk for developing blood clots that could potentially block a blood vessel and disrupt the flow of blood around your body.
71
Anticoagulants AE:
- Excessive _________/__________
- Bruising, bloody stools, bleeding gums, blood in urine
- ___________ (decrease in thrombocytes or platelets)
- ____/_____ pain (bleeding into abdomen or joint)
- GI distress
- bleeding/hemorrhage
- thrombocytopenia
- back/joint pain
72
What are some special concerns for patients on anticoagulants? (4)
- Know why on anticoagulant.
- Avoid contact sports.
- DO NOT use with aspirin.
- Take special care brushing teeth and shaving.
73
Blood clot warning signs. (4)
- Swelling or pain in legs.
- SOB/Chest pain
- Sudden difficulty moving limb/side of body
- Difficulty speaking
74
What is the purpose of Antiplatelet Agents?
Prevent platelets from clumping together to form a clot.
75
Antiplatelets:
- _______ is the classic drug in the class.
- May also be called ________ ________.
- Aspirin
| - blood thinners
76
PART 4: OTHER DRUG CATEGORIES
PART 4: OTHER DRUG CATEGORIES
77
What (2) other drug categories are used to improve cardiac function?
- Antiarrhythmics
| - Statins
78
What is the purpose of Antiarrhythmics?
Antiarrhythmic medications prevent and treat abnormal heartbeats (arrhythmias). Problems with your heart's rhythm are caused by a disruption in the heart's electrical system.
79
What are the (3) mechanisms of cardiac arrhythmias?
1. ) Abnormal pulse generation (defects in SA/AV nodes)
2. ) Abnormal pulse conduction (AV block, Bundle Branch block)
3. ) Combination of the 2
80
What are the (4) classes of antiarrhythmic drugs?
- Class I: Na+ channel blockers
- Class II: Beta-blockers
- Class III: K+ channel blockers
- Class IV: Ca+ channel blockers
81
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85
What is the purpose of Statins?
Statins help to lower LDL levels.
86
Statins:
- Risk factor for ____ disease.
- _________ lowering drug.
- ________ atherosclerotic plaque.
- CV disease
- cholesterol
- stabilize
87
How do we typically identify hyperlipidemia agents?
-statin
88
What are the 2 biggest AE associated with statins?
Rhabdomyolysis (destruction of skeletal muscle)
-Patients complain of muscle pain.
Liver Failure
