Week 3- Drug Management of Cardiac Disease P1 and P2 Flashcards
The heart must carefully balance energy synthesis with immediate energy needs. Why?
Inability to do so can result in reduced cardiac function and/or cardiac pathology.
What are the (3) main drug strategies to IMPROVE cardiac function?
- ) Directly increase cardiac contractility.
- ) Reduce workload of the heart i.e. reduce myocardial contractility and O2 demand.
- ) Increase myocardial blood flow.
What are (3) ways we can reduce the workload of the heart? Are they direct or indirect?
- ) Reduce contractility (direct)
- ) Reduce afterload (indirect)
- ) Reduce preload (indirect)
What are 2 ways we can increase myocardial blood flow?
- ) Increase blood flow.
2. ) Manage hemostasis.
PART 1: DIRECTLY INCREASE CARDIAC CONTRACTILITY
PART 1: DIRECTLY INCREASE CARDIAC CONTRACTILITY
- What is the purpose of inotropic agents?
- What are the (2) types and the difference between them?
- 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).
When are positive inotropic agents used?
- 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.
Name the (3) most common positive inotropic agents.
- Dopamine
- Dobutamine
- Milrinone
Dopamine:
- Natural catecholamine that acts as precursor to __________.
- The hemodynamic effect is _______ dependent.
- When is it usually used?
- norepinephrine (NE)
- dose dependent
- Usually used in severe HF and reserved for patients with moderate hypotension.
Dopamine Dose Dependent:
- Describe low-dose effects of dopamine.
- Describe mod-dose effects of dopamine.
- Describe high-dose effects of dopamine.
- Low-dose = renal/splanchnic vasculature dilation enhancing diuresis (urination).
- ***Mod-dose = enhance cardiac contractility and HR.
- High-dose = increase afterload through peripheral vasoconstriction.
- 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?
- Dobutamine
- Milrinone
- What is the purpose of Digitalis?
- Is it toxic? What is a sign of toxicity?
- 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)
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?
- Ca2+
- AV node
- decrease in HR and contractility
PART 2: REDUCE WORKLOAD OF THE HEART, i.e. REDUCE MYOCARDIAL CONTRACTILITY AND O2 DEMAND
PART 2: REDUCE WORKLOAD OF THE HEART, i.e. REDUCE MYOCARDIAL CONTRACTILITY AND O2 DEMAND
What are (3) ways we can reduce the workload of the heart?
- ) Directly reduce contractility.
- ) Reduce afterload.
- ) Reduce preload.
B1 Receptor Agonists:
- Response when stimulated?
- Clinical use?
- Impact on cardiac work?
- ↑HR, ↑Contractility
- Treat severe cardiac decompensation.
- INCREASES workload of the heart.
B1 Receptor Antagonists:
- Response when stimulated?
- Clinical use?
- Impact on cardiac work?
- ↓HR, ↓Contractility
- Treat compromised/diseased hearts.
- DECREASES workload of the heart, reduces functional capacity.
What are (2) drug classes used to directly reduce contractility of the heart?
- B1 Antagonists
- Ca+ Channel Blockers
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?
- heart
- “beta-blockers”
- reducing
- Non-speific Beta Blockers have + effect on heart, but - effect on bronchial smooth muscle.
How do we typically identify B1 Antagonists (“beta-blockers”)?
-lol
What are some common AE of B1 Antagonists (“beta-blockers”)? (4)
- 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).
What is the biggest thing we should be mindful of when treating patients who are on B1 Antagonists?
REDUCED PEAK HR
-HRmax = 164-0.7*age
Ca+ Channel Blockers:
- Reduces _____ flux into myocytes.
- ____ contractility and energy demands on the heart.
- Also ↓ _____.
- Ca+
- ↓
- CO
What are the (3) main AE of Ca+ Channel Blockers?
Results in peripheral vasodilation leading to:
- Decreased BP
- Dizziness
- Bradycardia
What are (4) drug classes used to reduce afterload?
- A1 Blocker
- Direct Vasodilators
- B1 Blocker
- Centrally Acting Agents
- When thinking about reducing afterload, think ___!!!
- ↑ radius = __ resistance
- BP!!!
- ↓
What is the purpose of A1 Blockers?
Decrease BP by preventing norepinephrine from tightening muscles in the walls of small arteries/veins.
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)
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.
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
What is the function of Direct Vasodilators?
Act directly on smooth muscle cells to cause relaxation. (↑r)
What specific Direct Vasodilator is most commonly known for its effects on hair growth?
Minoxidil
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
- 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)
What is the function of Centrally Acting Agents?
Inhibit sympathetic outflow from the brainstem.
Centrally Acting Agents:
- __ HR, Contractility, TPR
- Act like __ _________
- Often given with a diuretic
- ↓
- A2 antagonists
What are common AE of Centrally Acting Agents?
- Dry mouth
- Dizziness
- Drowsiness
- Hypotension
What are the (4) drug classes used to reduce preload?
- Diuretics
- ACEi (Ace inhibitors)
- ARBs (Angiotensin II Receptor Blockers/Antagonists)
- Aldosterone Antagonists
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.
What are the (3) types of Diuretics?
- Loop Diuretics
- Thiazide Diuretics
- Potassium Sparing Diuretics
- 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
Rank the (3) diuretics by AE.
Loop > Thiazide > Potassium Sparing
Loop diuretics are used more for _________ than __________.
diuresis than hypertension control
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
What is the purpose of ACEi?
Blocks the conversion of angiotensin I to angiotensin II.
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
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
- Are ACEi well tolerated?
- What are the AE?
Yes, generally well tolerated.
- Allergic reaction
- GI discomfort
- Dizziness
- Chest pain
- Persistent cough
- Weakness
How do we typically identify ACEi?
-pril
How do ARBs (Angiotensin II Receptor Antagonists) work?
Block renin-angiotensin-aldosterone system.
How do we typically identify ARBs?
-artan
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.
PART 3: INCREASE MYOCARDIAL BLOOD FLOW
PART 3: INCREASE MYOCARDIAL BLOOD FLOW
What are the (2) ways we can increase myocardial blood flow?
- Increase blood flow.
- Manage hemostasis.
- 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.
- Venodilator: ↓ venous return and ↓ _________
- Arteriodilator: ↓ ________
- preload
- afterload
Organic Nitrates are used in the treatment of angina and produce a general _________ (not specifically a coronary artery dilation).
-vasodilation
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.
What are the ways nitroglycerin can be delivered? (4)
- Oral
- Sublingual
- Buccal
- Transdermal patches
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”
- 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
What (3) drug classes can be used to manage hemostasis?
- Thrombolytic agents
- Anticoagulants
- Antiplatelet agents
What is hemostasis?
Intrinsic process which causes bleeding to stop.
Describe the process of hemostasis in (3) steps.
- ) VESSEL WALL INJURY triggers attachment and activation of platelets and and causes vasoconstriction.
- ) PLATELETS become “sticky” and attach at area of vessel wall injury.
- ) PLASMA FACTORS interact to convert fibrinogen to fibrin which helps to form a clot.
What is the purpose of Thrombolytic Agents?
Act by degrading a formed clot.
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
What is the purpose of Anticoagulants?
Help to prevent/slow coagulation of blood i.e. formation of blood clots.
Anticoagulants:
- Are _____________.
- Commonly called _______ _________.
- Act by interfering with the proteins in your blood that are involved with the coagulation process (__________).
- preventative
- blood thinners
- (factors)
List of Anticoagulants. (5)
- Heparin
- Coumadin (Dicoumarol, Warfarin)
- Xarelto
- Eliquis
- Lovenox
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.
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
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.
Blood clot warning signs. (4)
- Swelling or pain in legs.
- SOB/Chest pain
- Sudden difficulty moving limb/side of body
- Difficulty speaking
What is the purpose of Antiplatelet Agents?
Prevent platelets from clumping together to form a clot.
Antiplatelets:
- _______ is the classic drug in the class.
- May also be called ________ ________.
- Aspirin
- blood thinners
PART 4: OTHER DRUG CATEGORIES
PART 4: OTHER DRUG CATEGORIES
What (2) other drug categories are used to improve cardiac function?
- Antiarrhythmics
- Statins
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.
What are the (3) mechanisms of cardiac arrhythmias?
- ) Abnormal pulse generation (defects in SA/AV nodes)
- ) Abnormal pulse conduction (AV block, Bundle Branch block)
- ) Combination of the 2
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
1
1
1
1
1
1
1
1
What is the purpose of Statins?
Statins help to lower LDL levels.
Statins:
- Risk factor for ____ disease.
- _________ lowering drug.
- ________ atherosclerotic plaque.
- CV disease
- cholesterol
- stabilize
How do we typically identify hyperlipidemia agents?
-statin
What are the 2 biggest AE associated with statins?
Rhabdomyolysis (destruction of skeletal muscle)
-Patients complain of muscle pain.
Liver Failure
