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198 Cards in this Set

  • Front
  • Back
Evolution of atherosclerotic plaques
accumulation of lipoproteins-->oxidative stress-->cytokines-->monocytes come in -->foam cells--> sm mm cells proliferate--> elab ECM = fibrofatty lesion --> calcification
Anticoagulation in vascular endothelial cells
Prostacyclin
Thrombomodulin
Heparin sulfate
Endogenous thromboplastin (t-PA)
Procoagulation in vascular endothelial cells
Plasminogen activating factor
Tissue factor
Von Willebrand factor
Typical vs Graft atherosclerosis
typical = eccentric, lipids, focal

graft = concentric, no lipid core, diffuse
Effects of statins
regression of atherosclerosis
reduce sudden death
plaque stablization
reduce fibrosis
reduce AF
Statins MOA to improve coronary flow
reduce ACh's vasoconstriction on diseased coronary aa's

(ACh vasodilates healthy ones)
Statins tox
elevated liver enzymes
myopathy
rhabdomyolysis
MI- ST elevation vs depression
elevation = transmural ischemia
depression = subendocardial ischemia
Acute Plaque rupture therapy
thrombolytics
angioplasty/stent
inc coronary flow (nitro)
beta blockers
prevent platelet thrombosis
ASA, clopidogrel
heparin
prevent thrombosis
6 statins in order of potency
Fluvastatin
Lovastatin

Pravastatin
Simvastatin

Atorvastatin
Rosuvastatin
6 classes of diuretics and their prototype
Carbonic anhydrase inhib-- acetazolamide

Osmotic agents - mannitol

Loop - furosemide

Thiazides - HCTZ

Aldosterone antag (K sparing)- spironolactone

ADH antagonist - conivaptan
Acetazolamide -- type, site, clinical use
CA inhib, PCT

mountain sickness, urine alkalinization, glaucoma
Acetazolamide tox (4)
CA inhib

hyperchloremic metabolic acidosis, dec diuretic action, renal stone, hepatic encephalopathy
Mannitol -type, site, clinical use
osmotic, PCT and descending limb

kidney protection, reduce intracranial and intraocular P
Mannitol tox (3)
exacerbate CHF edema
acute hyponatremia (dilutional)
later hypernatremia (lose water>Na)
Furosemide-type, site, clinical use
Loop, thick ascending limb (block Na/K/Cl)

get fluid off lungs in CHF!
treat edema in hep and kid failure
treat hyperkalemia
treat anion overdose
treat hypercalcemia
Furosemide tox (6)
hypokalemic met acidosis
ototox
hyperuricemia
hypomagnesemia
sulfur allergy
dehydration
Other loop diuretics
ethacryinic acid (ototox)
bumetanide
HCTZ-type, site, clinical use
thiazide, block Na/Cl transport in DCT

treat htn and CHF
prevent Ca kidney stones
HCTZ tox
hypokalemia
hypokalemic metabolic acidosis
hyperuricemia
hyperglycemia
inc LDL
sulfonamide allergy
Other Thiazide diuretics
Indapamide
Chlorthalidone
Metolazone--- super potent w/ loop!
Sprinolactone MOA
K sparing
antagonism of mineralcorticoid receptors
Amiloride MOA
K sparing
inhibition of Na+ influx in luminal membrane
Primary and 2ary hyperaldosteronism
Primary = Conn's syndrome - ectopic secretion, hypokalemia
2ary = CHF

treat w/ K sparing (Aldost antag) diuretics
K sparing diuretics tox
hyperkalemia (balance w/thiazide)
interact w/ ACE inhib, NSAIDs
hyperchloremic met acidosis
gynecomastia
Conivaptan (V1a and V2) and Tolvaptan (V2) -type, site, clinical use
ADH receptor antag, medullary CD

treat SIADH, treat hyponatremia
ADH antag tox
hypernatremia (+dehydration)
nephrogenic diabetes insipidus
classification of htn
pre= up to 135/80s
mild = 140/90
Stage 1 mod = 140-159/90-99
Stage 2 severe= 160/100 and up
2ary htn
pheochromocytoma
Cushing's (inc cortisol, Na retention)
Primary aldosteronism - Lo K, inc Na
coarctation of aorta
renal aa constriction (renin)
Local regulation of BP
endothelin 1 constricts
NO dilates

BP= COxPVR
Which diuretic vasodilates?
furosemide
How much do diuretics lower BP?
10-15mmHg
What is the favored class of diuretic to treat htn?
When contraindicated?
Thiazides
unless kidney disease
How do sympatholytics dec BP?
dec PVR
dec HR and contractility
Methyldopa MOA
sympatholytic
alpha-methyl NE
central alpha agonist
Methyldopa tox
sedation, CNS, Coombs +, hemolytic anemia, hepatitis
Clonidine MOA
sympatholytic
central alpha agonist
alpha 2 --reduce NE release
Clonidine tox
(central alpha agonist, antihtn)
dry mouth, sedation, depression, w/drawal, htn crises
Ganglionic blockers
list and MOA
hexamethonium, trimethaphan, mecamylamine

block nicotinic cholinoreceptors on postganglionic neurons (block PANS and SANS and effects on BP)
Adrenergic neuronal blocking agents
list and MOA
guanethidine
guanadrel
reserpine - block uptake of biogenic amines DONT USE
block NE release
Contraindications for Beta antagonists
DM1, asthma/ COPD, PVD, acute cardiac decompensation, heart block, raynauds
Hydralazine MOA and toxicity
nonspecific vasodilator
NO mechanism
slow acetylators= lupus-like syndrome
tolerance
inc HR = worse angina
peripheral neuropathy and drug fever
Minoxidil MOA and toxicity
nonspecific vasodilator
hyperpolarization of sm mm-- opening K channels
depolarization is more difficult
inc HR
inc fluid and salt retention
hypertrichosis
Sodium nitroprusside MOA
nonspecific vasodilator
activate guanylyl cyclase
dilate aa and vv
Nonspecific vasodilators
hydralazine, minoxidil, sodium nitroprusside, diazoxide, fendolopam
Sodium nitroprusside tox
-w/ rhodanese enzyme def= cyanide poisoning
-thiocyanate poison = diosriented, psychosis, mm spasm, convulsion
-thyroid dysfun (thiocyanate mess w/ iodine)
-methemoglobinemia
Diazoxide
nonspecific vasodilator
hyperpolarizing agent
like thiazide minus diuretic
hypotension and hyperglycemia
Fendolopam
nonspecific vasodilator
D1 agonist
dilate aa's
natriuresis
inc intraocular pressure!
ACE inhibitor toxicities
hyperkalemia
azotemia
hypotension
cough
teratogen (2nd and 3rd trimester) cranial facial abnormalities
drug fever
angioedema -- esp lips
Clinical use for sympathomimetics
septic shock
hemorrhagic shock
hypovolemic shock
cardiogenic shock
severe HF
Epinephrine effects and uses
alpha 1 = constriction
beta 2 = dilation
beta 1 = inotropic/chronotropic

asystole!
anaphylaxis
NE effects and uses
alpha = inc bp
beta 1 = inotropic and chronotropic (but baroreflex blunts HR response)

use to inc sys and diastolic pressure
DA effects and uses
dilate renal afferent arterioles
natriuretic
(high dose = alpha agonist, inc BP and inotropy)
use in hypotension w/ oliguria...
Direct acting sympathominetics
phenylephrine (alpha ag)
methoxamine (alpha ag)
isoproterenol (beta ag w/ lil alpha)
dobutamine (b1 ag)
ephedrine (beta ag)
midodrine (a1 ag)
htn treatment in pt w/ hyperlipidemia
ACE inhib and Ca channel blockers dont raise lipids or HR :)

Niacin lowers LDL and raises HDL

diuretics raise HDL + reactive tachy
beta blockers = inc lipids
alpha blockers = reactive tachy
CHF pt w/ htn and fluid on lungs
How treat and what risks?
Furosemide (cuz potent diuretic+ vasodilation)
tox =
hypokalemic metabolic acidosis
hyperuricemia
hypomagnesia
dehydration
What diuretic class would you give for hypercalcemia?
Loop!
(furosemide, bumetanide, torsemide)

Def not a thiazide cuz holds on to Ca2+!
Active young guy with htn
How do you protect his heart?
ACE inhib or Ca channel blocker
both cardioprotective and no effect on inotropy and chronotropy like B blocker

could give pindolol cuz partial B agonist
Htn lady w/ 2+ proteinuria
how treat and protect kidneys?
ACE inhibitors are nephroprotective!!
Dialysis worsens lipid profile
that sucks...
Accelerated htn signs, workup, treatment
eg: 190/120, pitting edema, disoriented, lil SOB, 3+ proteinuria

do workup for rheumatic fever
dont lower BP too fast = CNS probs, lower ~25%

give esmolol bc short action
Cushings w/ hypokalemia
Gotta get rid of the tumor!

Don't give thiazide or loop diuretics bc worsen the hypokalemia
hypovolemic shock!
give fluids if not overloaded

Dont give dobutamine!-- dilate = more hypotensive

dont wana inc contracility if not HF

Could give NE, but gotta get blood to renal so give DOPAMINE
Orthostatic hypotension treatment
Drug of Choice = midodrine (a1 ag)
also can use ephedrine, yohimbine
prazosin makes it worse! (alpha blocker)
What drug for htn used in pregnant ladies?
methyldopa most widely used

verapamil and other Ca blockers not gonna hurt baby if u need to used those
Htn pt on furosemide and amiodarone....what else can I give?
methyldopa and clonidine centrally acting alpha agonist
ganglionic blocking agent (side effects)
cardiac resting potential
-80 to -95mV
Ventricle cells permeable to...
K+
Less to Na+ or Ca++
Phases of action potential
0- upstroke, Na channels open --> +25 to 35mV
1- early fast repolarization, Na close, K open
2- plateau, Ca++ open (K out = Ca in)
3- repolarization K open, Ca close
4- diastole, reestab concentrations
Threshold potential of SA node
-40mV
ACh vs NE in the SA node
ACh inc K conductance = K out, makes depol harder
NE dec K conductance = K stays in, cell more positive= depolarization

influence automaticity
altered automaticity
1. increased Phase 4 slope= tachy – NE, amphetamines, hyperthyroid, atropine, hypokalemia, digoxin at purkinje.
2. Decreased slope of phase 4 bradycardia – BB, CCB.
3. Hyperpolarized diastolic potential, suppressed depol – Vagal/PANS activity, muscarinic, antiACHE, digoxin at SA/AV.
4. Elevated threshold bradycardia – sodium channel blocker, injury.
trigger arrhythmias
Early afterdepolarizations-- phase 2 or 3 = Vtach and Torsades de Pointes

Delayed afterdepolarizations- phase 4- from inc intracellular Ca (too much digitalis, PDEinhib), hypoxia
effective refractory period
0,1,2, most of 3

0 and1 = absolute
2 and 3 need super strong stimulus
pacemaker determined by
whoever has fastest rise of phase 4 slope
Automaticity increased by...
SANS
hypokalemia
Hypokalemia and arrhythmia
dec K+ conductance, dec the hyperpolarization effect of the ion during phase 4
potential remains "partly depolarized" it promotes automaticity.

may be caused by chronic use of thiazide-diuretics
Automaticity decreased by...
PANS
Blocks in conduction
Sinus exit block
AV block
Bundle branch block
His- purkinje block
re-entry requisites
Bidirectional block exists
Anatomical substrate
Unidirectional block
Critically timed excitation (2 in a row)
Rate of atrial tachy, atrial fib, atrial flutter
a tachy--150-250
a fib--250-350
a flutter--350-600
reentrant arrhythmias
atach, aflutter, afib, vtach
Torsades de pointes
form of polymorphic ventricular tachycardia (VT)
gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line
Class 1a sodium channel blockers
Quinidine
Procainamide
Disopyramide
Class 1b sodium channel blockers
Lidocaine
Mexiletine
Tocainide
Class 1c sodium channel blockers
Flecainide
Propafenone
Class II antiarrhythmics
(Beta blockers)
Propanolol
Atenolol
Metoprolol
Class III antiarrhythmics
(K+ channel blockers)
Amiodarone
Dronedarone
Sotalol
Ibutilide
Class IV antiarrhthymics (Ca2+ blockers)
Dilitiazem
Verapamil
What antiarrhythmics Torsades as a side effect?
Quinidine, Sotalol
What sodium channel blocker causes a lupus-like syndrome and hypotension as side effects?
Procainamide
What anti-arrhthymics cause CNS side effects?
-1b sodium channel blockers (lidocaine, mexiletine, tocainide)
-amiodarone (Kchannel blocker)
-Propanolol
What K+ channel blocker affects the thyroid?
Amiodarone
What sodium channel blocker causes agranulocytosis?
Tocainide
Which antiarrhythmics can be proarrythmic?
Quinidine (1a... cause Torsade)
Sotalol (3 -- torsade)
Propafenone (1c)
Ibutilide (K blocker)
Which antiarrhythmics cause dec LV function?
Verapamil
Atenolol
Sotalol (K blocker)
Kinetics of 1a, 1b, 1c
1a intermediate
1b rapid
1c very slow
Which antiarrhythmics cause hypotension?
Procainamide
Diltiazem
Verapamil
What does procainamide break down into and what is that metabolite's effect?
NAPA --- class III (K+channel blocker)
Which sodium channel blockers have class III action?
Quinidine and Procainamide

(prolong QT)
What drug treats HOCM, A and V arrhythmias, and causes atropine like side effects (urinary retention, dry mouth, warmth, blurry vision)?
Disopyramide
What inactivates lidocaine?
Alpha 1 acid glyocprotein (acute phase reactant)
Which antiarrhythmic only acts on ventricle?
Lidocaine
Relationship b/w lidocaine and mexiletine?
Mexiletine = orally active form of lidocaine
(1b sodium channel blockers)
Which drug is fluorinated procainamide?
Flecainide (1a --> 1c)
^treat atrial arrhythmias
Propafenone
weak beta blocker and Ca channel blocker

treat supraventricular arrhythmias

negatively inotropic
Which beta blocker is polar and which is nonpolar?
polar = atenolol
nonpolar = metoprolol
Propanolol has some ___ action
1a sodium channel blocker
Which is the most effective anti-arrhythmic and only one that reduces sudden death?
Amiodarone

K channel blocker
but also weak Na and Ca channel blocker

increases effective refractory period
Amiodarone toxicity
thyroid (cuz 2 iodine molecules)
liver
blood
skin
optic
neuropathy
pulm fibrosis
Dronedarone
amiodarone minus iodine
treat sinus vtach
Vernakalant use and toxicity
convert afib
tox = dysgeusia (taste), sneezing, parasthesias
What K channel blocker do you have to adjust the dosing for kidney disease?
Dofetilide (cleared renally)
What class 3 drug is also a strong beta blocker?
Sotalol
What Ca channel blocker suppresses automaticity (treat EADs and DADs)?
Verapamil
Adenosine effects
activate inward K current
inhibit Ca outward current
= hyperpolarization
stop SA and AV node conduction (inc refractory period)
What blocks adenosine?
theophylline
caffeine
dipyridamole
Magnesium
deficiency = Torsades de pointes

treats digitialis arrhythmia
Block Ca and K channels
Bretylium
anti adrenergic (block release and uptake of NE)

hyperpolarizes cell
high output heart failure
shunts
PE
Beriberi
severe anemia
septicemia
hyperthyroidism
Paget's disease
valve disease
Levosimendan
Ca sensitizer
Ryanodine
plant alkaloid that blocks Ca release
2 problems you need to address to treat heart failure
decrease in stroke work and increase in pressure
neurohormones that make HF worse
NE, angII, endothelin, aldosterone, ADH
INOTROPES
digitalis (digoxin)
inamrinone
milrinone
dobutamine
DIURETICS used in HF
acute - furosemide

chronic = other loop ones (furos, torsemide, bumetanide)

metolazone (if resistant to loop)

spironolactone and eplerenone
ACE INHIBITORS
captopril
enalapril
lisinopril
ramipril (lipophilic)
Name the lipophilic ACE inhibitor
Ramipril
ARB prototype
Losartan
acts on AT1 receptor

don't use w/ ACE inhibitors!
Aliskiren
Renin inhibitor
VASODILATORS
Hydralazine/ ISDN
Nitroprusside
Bosentan (pulm htn only)
Carvediol + metoprolol (reduce afterload)
Systolic dysfunction treatment
remove sodium -- diuretic + diet
antagonize RAAS-- ACE, ARB, renin inhibitor
^inotropy -- low dose digoxin
Beta blockers - carvediol+metaprolol
vasodilate-- ISDN/hydralazine
cardiac resynchronization
LVAD
transplant
antagonize aldosterone (eplerenone)
Diastolic dysfunction treatment
Beta blockers
ACE inhibitors
Aldosterone antagonist (Epelerenone)
Nesiritide
synthetic brain natriuretic peptide
natriuresis and diuresis
treat acute HF
Bosentan
inhibit endothelin
vasodilator
treat pulmonary htn -- NOT HF
Acute HF treatment
IV furosemide (or metolazone)
Vasodilators/ intotropes
ACE or ARB
intra-aortic balloon counterpulsation
LVADN
Digoxin in acute HF
NOT RECOMMENDED
ineffective + arrhythmogenic
Hyponatremic pt in acute HF...
can use Conivaptan
V1a antagonist
effective against dilutional hyponatremia
Nitroprusside vs Nitroglycerine
Nitroprusside = afterload
Nitroglycerine= preload
Dobutamine vs Dopamine
Dobutamine = afterload + inotropic
Dopamine= natriuretic at low dose
Digitalis MOA
inhibit Na/K pump
slows Na/Ca exchanger
Ca builds = stronger contraction
Digitalis electrical effects
shortens APD
inc DADs

increase vagal tone = decrease HR
Digitalis toxicity
nausea, arrhythmias (VT) and coronary constriction (sympathetic outflow), visual disturbances (blue scotoma)
Digitalis PK
cleared renally
Very low TI! 1ng/mL therpeutic vs 2ng/mL toxic!
Reverse digitalis toxicity
Mg ++ or Digibind

Ca++ inc digitalis toxicity!
Inamrinone
PDE inhibitor = inc Ca
treat acute decompensation

myelosuppression and liver tox
Milrinone
PDE inhibitor = inc Ca
treat acute decompensation

vasodilator+ inotrope
Dobutamine
B1 stimulator
vasodilate + inotropic
Dopamine
B1 stimulator
D1 inc renal perfusion, natriuresis @ low dose
Spironolactone and eplerenone role in HF
reduce aldosterone = reduce preload
also antifibrotic
ACE inhibitors' role in HF
dec afterload (stop angII's vasoconstriction)
inc bradykinin (vasodilator)
prevent remodeling post MI
What drug produces thiocynate and cyanide toxicity?
Nitroprusside
Effort angina treatment
nitrates
dihydropyridines w/ beta blockers
nondihydropyridines
beta blockers
Vasospastic/variant angina treatment
nitrates
dihydropyridines

beta blockers make it worse!!! give w/nitrates
Unstable angina treatment
nitrates

beta blockers make it worse!!! give w/nitrates
therapeutic effects of nitrates
coronary dilation
arterial dilator
venodilator
dec platelet aggregation
adverse effects of nitrates
tolerance
reflex tachycardia (block w/betablockers)
methemoglobinemia
Oral and inhaled nitrates
oral= isosorbide dinitrate

inhaled= amyl nitrate
Nicroandil
anti-anginal
NO release
K channel opener
Dihydropyridines
treat variant and effort agina and htn
nifedipine (short acting)
amlodipine (long acting)
isradipine (long acting)
nimodipine (cerebral bv's)
Non-dihydropyridine
MOA
Verapamil/Diltiazem

bind alpha1 subunit on Ca channel on smooth mm, SA and AV nodes, and myocardial cells

can worsen HF (but still used in acute HF to treat AF decompensating mitral stenosis)
Verapamil
nondihydropyridine

strong effect on SA and AV node
negatively inotropic
treat SVT (AV block)-- slows ventricular response
Diltiazem
nondihydropyridine

more vasodilator
strong SA and AV node block
Nebivolol
treat htn
vasodilate, NO release
Ranolazine
anti anginal
late Na channel blocker
dec Ca++ = reduce contractility
also dec FA oxidation (change metabolsm of myocardium)
Ivabradine
Na channel blocker
inhibit hyperpolarization-activated Na channel in the SA node
slows HR
non pharamacological treatment of angina
angioplasty + stent
surgical revascularization
intra-aortic balloon counterpulsation for unstable
Why give beta blockers and nitrates together?
Bblockers may worsen vasospasm and dec coronary flow, but reduce O2 demand

betablockers stop the reflex tachy from nitrates
Peripheral aa disease and claudication treatment
pentoxifylline
cilostazol
venoplasty
Pentoxifylline
treat PAD and claudication
xanthine derivative
makes RBCs more pliable, venodilation
Cilostazol
treat PAD and claudication
PDE3 inhibitor= venodilation
Why be careful w/ ED treatment and angina treatment?
PDE-5 inhibitors (inc cGMP) potentiate nitrates = hypotension --- need 6hr nitrate free interval
Alprostadil
PGE1 analog
inject into cavernosa or urethral suppository
worked if PDE5 inhibitors don't
treatment for ACS
nitro
beta blocker
heparin
anti-platelet
treatment for nonSTEMI
ASA
clopidogrel
heparin

(thrombolytics don't work)
treatment for STEMI
nitro
beta blockers
nondihydro Ca channel blockers
ACE inhibits
Antiplatelet
Heparin
Bivalirudin
Heparin action and adverse effects
action- potentiates antithrombin III

adverse- thrombocytopenia
How reverse heparin?
protamine
Low-molecular heparin
Enoxaparin

(less bleeding, easier dosing)
Rivaroxiban
oral factor 10 inhibitor

prevent emboli in AF pt's
Direct thrombin inhibitors
Hirudin
Bivalirudin
Argatroban
Dabigatran
Primary action of warfarin
inhibits factors 7,9,10
genetic polymorphisms that determines how warfarin affects pt
VKORC1 - determine degree of effect

CYP2C9*2 or CYP2C9*3
*2 = 17% lower dose
*3 = 37% lower dose
What should INR be in a pt on warfarin?
2-3.5
MOA of fibrinolytic agents
lyse thrombi by catalyzing formation of plasmin from plasminogen
when to use fibrinolytic agents
MI
PE
DVT
ascending thrombophlebitis
stroke
Fibrinolytic agents
Streptokinase-- faciliates plasmin formation
Urokinase-- faciliates plasmin formation
Alteplase--human tPA
Reteplase--recombinant tPA
Tenecteplase-- mutant tPA
Antiplatelet drugs
ASA
Clopidogrel
Ticlopidine
Prasugrel
Ticagrelor
Abciximab
Dipyridamole
Cilostazol
Antidotes for warfarin and heparin
Vitamin K1
antagonizes warfarin's effects on 7,9,10

Protamine
combines w/ heparin
1mg/100units heparin
Clopidogrel
antiplatelet
inhibits ADP (adenosine diphosphate)
Ticlopidine
like clopidogrel (inhibit ADP)

leukopenia and blood dyscrasias :(
Prasugrel
like clopidogrel (inhibit ADP)

activated faster
less drug interaction
more bleeding
Ticagrelor
Newest clopidogrel-like agent

structure like adenosine
Abiciximab
ab against IIb/IIa receptor on platelet
Dipyridamole MOA
inhibits adenosine uptake by platelet
inhibits cGMP PDE activity
use w/ ASA in pt's w/ prosthetic heart valves
Cilostazol MOA
PDE inhibitor
promotes vasodilation
inhibits platelet aggregation

treat claudication
(for pts who fail ASA and clopidogrel)