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78 Cards in this Set

  • Front
  • Back
List seven ACE inhibitors
Ramipril
Lisinopril
Fosinopril
Enalapril
Perindopril
Captopril
Trandolopril
When are ACE inhibitors indicated?
1) CHF with low ejection fraction (prevents LV remodeling)
2) Hypertension (particularly DM)
3) Proteinuria, including microalbuminuria
4) Acute MI (prevents worsening LV function)
5) Hypertensive crisis
How do ACE inhibitors work?
ACE inhibors block the production of angiotensin II in the lung. AT II is a potent vasoconstrictor. It also stimulates the release of aldosterone from the zona glomerulosa of the adrenal gland
What are the most common adverse effects of ACE inhibitors?
Most common adverse effect is a dry cough.
Angioedema and hyperkalemia may also occur
Ace inhibitors transiently decrease the GFR but are renal protective in the long term
A 63yo female with a history of hypertension comes to the emergency department with palpitations. She is found to have Afib and a pulse rate of 125/minute.
What is the best initial therapy for this patient?
Afib and Aflutter with rapid ventricular rate are best treated with either a CCB, such as verapamil or diltiazem, a beta blocker, such as metoprolol or digoxin.
Target rate is <100BPM
A 63yo female with a history of hypertension comes to the emergency department with palpitations. She is found to have Afib and a pulse rate of 125/minute.
What are the adverse effects of the best initial therapy?
1) CCB: hypotension, constipation, peripheral edema, and heart block
2) Beta Blockers: hypotension, bronchospasm, depression, erectile dysfunction, and worsening of dyslipidemia
3) Digoxin: dysarrhythmia, hyperkalemia, confusion, diarrhea, and visual changes
A 63yo female with a history of hypertension comes to the emergency department with palpitations. She is found to have Afib and a pulse rate of 125/minute.
What is the best long-term therapy?
Chronic atrial arrhythmias should be treated with coumadin with an INR of 2-3 to avoid embolic stroke.
A 63yo female with a history of hypertension comes to the emergency department with palpitations. She is found to have Afib and a pulse rate of 125/minute.
What is the indication for cardioversion?
Electrial cardioversion is indicated when the patient is hemodynamically unstable, exhibiting such symptoms as hypotension, hemodynamically related confusion, shortness of breath, or chest pain.
For which question is spironolactone or eplerenone the correct answer?
1) CHF; as one of the medications that will lower mortality
2) Ascites; best initial diuretic therapy
3) Acne: especially for women
4) Hypertension: rarely
5) Amenorrhea
6) Adrenal hyperplasia or aldosterone-producing adenomas
How do spironolactone and eplerenone work?
Spironolactone is an aldosterone antagonist. It also has anti-adrogenic effects, which is why it helps with hirsuitism, acne, and amenorrhea.
What are the most common adverse effects of spironolactone and eplerenone?
Spironolactone can cause gynecomastia and hyperkalemia
Eplerenone is used for CHF and hypertension as well, but does not inhibit the testosterone receptor. This means that eplerenone can cause hyperkalemia, but NOT gynecomastia
List nine Calcium Channel Blockers
Diltiazem
Verapamil
Nifedipine
Felodipine
Nicardipine
Amlodipine
Nitrendipine
Nisoldipine
Isradipine
When are CCBs the correct answer?
1) Hypertension (in patients with diabetes or high-risk coronary disease)
2) Atrial arrhythmias
3) Pulmonary hypertension
4) Hypertrophic cardiomyopathy
5) Raynaud's phenomena
6) Subarrachnoid hemorrhage
How do CCBs work?
1) Cause potent vasodilation by relaxing smooth muscle in the vascular lining.
2) Inhibit conduction in the AV node of the heart.
What are the most common adverse effects of CCBs?
1) All cause postural hypotension, flushing, constipation, and edema
2) Diltiazem and verapamil can cause AV block.
3) The others, particularly nifedipine, can cause tachycardia
When do you answer a question with propranolol?
1) Cluster and migraine headache prophylaxis; it must be taken for several weeks to prevent headaches.
2) Portal hypertension: Propranolol decreases the frequency of bleeding from esophageal varices
3) Thyroid storm: Propranolol decreases symptoms acutely.
4) Essential tremor
5) Pheochromocytoma
How does propranolol work?
Nonspecific blocker of both Beta-1 and Beta-2 receptors
What are the most common adverse effects of propranolol?
1) Associated with worse adverse effects than Beta-1 specific medications, such as atenolol or metoprolol.
2) Propranolol can cause bronchospasm, depression, bradycardia, hypotension, and ED.
3) It can also cause hyperkalemia by inhibiting the Na/K ATPase.
4) It can have adverse effects on glucose and peripheral arterial disease, which rarely occur with selective beta blockers
34 yo female comes to the emergency department with palpitations. An EKG shows SVT at a rate of 160/min. There is no response to vagal maneuvers, such as carotid sinus massage. What is the most appropriate therapy for this patient?
Adenosine is the drug of choice for SVT that is not responsive to the increased vagal tone of carotid sinus massage. There are no other therapeutic uses for adenosine except to treat SVT.
34 yo female comes to the emergency department with palpitations. An EKG shows SVT at a rate of 160/min. there is no response to vagal maneuvers, such as carotid sinus massage. How does the most appropriate therapy for this patient work?
1) Adenosine reduces calcium currents and is antiarrhythmic by increasing AV nodal refractoriness.
2) It transiently slows the sinus rate and the AV nodal conduction velocity.
3) It is thought to open potassium channels, hyperpolarizing nodal tissue and making it less likely to fire.
34 yo female comes to the emergency department with palpitations. An EKG shows SVT at a rate of 160/min. there is no response to vagal maneuvers, such as carotid sinus massage. What are the most common adverse effects of the most appropriate therapy?
Adenosine causes transient asystole, but this usually lasts less than five seconds. A bolus can precipitate bronchospasm
When is aspirin the best initial therapy?
1) Acute coronary syndromes (MI and unstable angina as well as post-stent and post-surgical bypass patients)
2) Stroke and TIA
3) Peripheral arterial disease
4) Fever reduction (antipyretic)
5) Rheumatoid arthritis
6) Essential thrombocythemia
7) Kawasaki's disease
8) Arthritis, gout, and in general as an analgesic
How does aspirin work?
Aspirin irreversibly inhibits platelets by inhibiting cyclooxygenase
What is aspirin's most common adverse effect?
1) Most common adverse effect is bleeding.
2) Also cause peptic ulcers, asthma, renal insufficiency, and rash
3) In toxic amounts, aspirin leads to metabolic acidosis, tinnitus, encephalopathy, renal insufficiency, and an increased ion gap.
For what condition is dipyridamole the best initial therapy?
NEVER used as a first-line monotherapy for ANYTHING
1) Stroke in combination with aspirin
2) Preventing heart valve embolic complications
3) Peripheral arterial disease with aspirin
4) As diagnostic testing in myocardial perfusion studies with thallium
How does dipyridamole work?
Inhibits adenosine deaminase and phosphodiesterase, which increase levels of cyclic adenosine monophosphate (cAMP).
Cyclic AMP inhibits platelets
What are the most common adverse effects of dipyridamole?
Adverse effects can include the following:
1) Dizziness and headache
2) GI bleeding
For what conditions are clopidogrel and ticlopidine the best initial therapy
Most common adverse effects for both is bleeding.
Ticlopidine is ALWAYS the wrong answer therapeutically.
Ticlopidine is most often associated with neutropenia and thrombotic thrombocytopenic purpura (TTP)
What is cilostazol?
Cilostazole is a phosphodiesterase inhibitor that is use for peripheral arterial disease.
How does cilostazol work?
1) Cilostazole increased levels of cyclic adenosine monophosphate (cAMP)
2) It reversibly inhibits platelet aggregation by inhibiting thrombin, ADP, collagen and epinephrine.
3) It is also a vasodilator that is greatest in the femoral bed and less in the vertebral, carotid, and mesenteric arteries
When is cilostazol the answer?
A patient with intermittent claudication from vascular disease should be treated with cilostazol. It is the single best therapy for PAD.
It should be used in addition to aspirin, dipyridamole, and exercise
What are the most common adverse effects associated with cilostazol?
Cilostazole causes edema dizziness, and vertigo.
The most serious adverse effects are atrial fibrillation, ventricular tachycardia, and CHF.
72 yo male with CHF has recently been started on ramipril, metoprolol, spironolactone, and furosemide. He had developed a chronic dry cough that makes it difficult for him to sleep. Which medication should you stop?
ACE inhibitors are the most likely medications to be causing a chronic cough. This symptom is secondary to their effect on bradykinin levels.
72 yo male with CHF has recently been started on ramipril, metoprolol, spironolactone, and furosemide. He had developed a chronic dry cough that makes it difficult for him to sleep. Which medication should you add as an alternative?
Angiotensin receptor blockers (ARBs) should be started in patients who are intolerant of ACE inhibitors. ARBs have the same indications as ACE inhibitors, such as CHF, hypertension, and acute myocardial infarction. They seem to have an equivalent mortality benefit as well. ARBs include losartan, olmesartan, valsartan, irbesartan, candesartan, telmisartan, and eprosartan
72 yo male with CHF has recently been started on ramipril, metoprolol, spironolactone, and furosemide. He had developed a chronic dry cough that makes it difficult for him to sleep. What are the most common adverse effects of the alternative medication?
The most common adverse effects of ARBs are hypotension and hyperkalemia.
List five Glycoprotein IIb/IIIa inhibitors.
Abciximab
Tirofiban
Eptifibitide
Lamifiban
Orbofiban
What are GPIIb/IIIa inhibitors?
Platelet aggregation inhibitors that are useful in keeping the coronary artery open in acute settings.
How do GPIIIb/IIIa inhibitors work?
They work by reversibly antagonizing the IIb/IIIa receptor on the platelet.
This prevents fibrinogen and von Willebrand's factor from binding to the receptor on the platelet which prevents the platelets from binding to the endothelial lining and each other.
When are GPIIb/IIIa inhibitors the answer?
An adjunctive therapy for angioplasty and other percutaneous coronary interventions. They are also useful for other percutaneous coronary interventions. They are also useful for non-ST segment elevation MIs when thrombolytics are not indicated.
What are the most common adverse effects of GPIIb/IIIa inhibitors?
Bleeding
Thrombocytopenia
Coronary artery dissection
List five thrombolytics.
tPA
Anistreplase
Streptokinase
Alteplase
Tenecteplase
What are thrombolytics?
Recombinant versions of tissue plasminogen activator that are used to reopen acutely thrombosed coronary arteries.
How do thrombolytics work?
tPA cleaves plasminogen to plasmin. Plasmin will dissolve fibrin that has been freshly deposited. After several hours, fibrin is cross-linked by factor XIII or "clot stabilizing factor". This makes the fibrin refractory to dissolution by plasmin.
When are thrombolytics contraindicated?
Thrombolytics are contraindicated when there is a major bleed occurring, such as melena or intracranial bleeding. It is also contraindicated with aortic dissection, head trauma, or BP>180/110
When are thrombolytics the answer?
tPA is the answer when the question describes chest pain within 12 hours and 1mm of ST elevation or a new left bundle branch block.
tPA has less efficacy than primary angioplasty for an acute infarction
tPA is also indicated for ischemic stroke within three hours as well as pulmonary emboli with hemodynamic instability, such as hypotension
When is digoxin most useful?
Digoxin has two main indications: rate control of atrial fibrillation and symptomatic control in congestive failure.
What is the most likely question for which digoxin is the answer?
If a question about CHF asks, "Which of the following is most likely to lower mortality?" digoxin would be the WRONG answer. Digoxin does NOT lower mortality in CHF, but it does decrease the severity of symptoms and the frequency of hospitalization. Digoxin will NOT convert atrial fibrillation to sinus rhythm, but it will slow the rate.
How does digoxin work?
Digoxin inhibits the Na/K ATPase. This increases cytosolic calcium levels and increases the force of contraction of cardiac muscle.
What are the most common adverse effects of digoxin?
Digoxin at toxic levels can cause nausea, vomiting, arrhythmias, confusion, hyperkalemia, and visual disturbances.
A patient with CHF maintained on only a diuretic and digoxin is admitted because of confusion, hypotension, nausea, bradycardia, and visual disturbance. His digoxin level is markedly elevated. What is the best therapy for this patient?
Severe digoxin toxicity should be treated wiht digoxin-binding antibodies (Digibind). The indications for digoxin-specific Fab fragments (d-Fab) are: hyperkalemia, arrhythmias, encephalopathy, or hypotension
A patient with CHF maintained on only a diuretic and digoxin is admitted because of confusion, hypotension, nausea, bradycardia, and visual disturbance. His digoxin level is markedly elevated. What is the most common arrhythmia associated with digoxin toxicity?
The most common electrocardiographic abnormalitiy is ectopy. However, the most common serious rhythm disturbance is atrial tachycardia with variable block. Sinus bradycardia is common as well. Any form of rhythm disturbance may occur.
A patient with CHF maintained on only a diuretic and digoxin is admitted because of confusion, hypotension, nausea, bradycardia, and visual disturbance. His digoxin level is markedly elevated. What do you expect the patient's potassium level to be?
Digoxin toxicity leads to hyperkalemia, because digoxin inhibits the Na/Ka ATPase.
What is amiodarone?
It is a potent antiarrhythmic medication with excellent efficacy but multiple side effects from long-term use. It is the drug of choice for ventricular fibrillation in an acute resuscitation.
How does amiodarone work?
Amiodarone is structurally similar to thyroid hormone. It blocks inactivated Na+ and Ca2+ channels and has a beta-blocking effect. It potently inhibits abnormal automaticity.
What are the most common adverse effects of amiodarone?
Hyperthyroidism
Hypothyroidism
Pulmonary fibrosis
Non-sight-threatening corneal deposits.
When is amiodarone the answer?
When the question involves:
1) Qs seeking a high-efficacy treatment of Vfib and Vtach
2) Qs seeking a treatment for conversion of Afib with systolic dysfunction
3) Qs asking about amiodarone's adverse effects
A 68 yo female is being evaluated in your office for worsening shortness of breath with minimal exertion. Her echocardiogram shows an ejection fraction of 32 percent. What medications will most likely lower her mortality?
Medications that have a clear mortality benefit in CHF are:
1) Beta blockers: metoprolol and carvediolol
2) ACE inhibitors: All are effective
3) ARBs: Candesartan and Valsartan
4) Spironolactone
A 68 yo female is being evaluated in your office for worsening shortness of breath with minimal exertion. Her echocardiogram shows an ejection fraction of 32 percent. What procedure can lower her mortality?
An implantable cardioverter defibrillator has benefit for reducing mortality with ischemic cardiomyopathy and an ejection fraction <35 percent.
A 27 yo female from Ecuador is evaluated because of increasing SOB. She shows rales on exam. She has an early diastolic extra heart sound and a diastolic decrescendo murmur. The symptoms have become worse because of pregnancy. What is the diagnosis?
Pt. has mitral stenosis.
A 27 yo female from Ecuador is evaluated because of increasing SOB. She shows rales on exam. She has an early diastolic extra heart sound and a diastolic decrescendo murmur. The symptoms have become worse because of pregnancy. How did she get this disease?
Mitral stenosis is most often from rheumatic fever in the past.
A 27 yo female from Ecuador is evaluated because of increasing SOB. She shows rales on exam. She has an early diastolic extra heart sound and a diastolic decrescendo murmur. The symptoms have become worse because of pregnancy. What is the best initial therapy?
The best initial therapy for mitral stenosis is preload reduction with sodium restriction and a diuretic. This is problematic because of her pregnancy. Diuretics can potentially cause intrauterine growth retardation.
A 27 yo female from Ecuador is evaluated because of increasing SOB. She shows rales on exam. She has an early diastolic extra heart sound and a diastolic decrescendo murmur. The symptoms have become worse because of pregnancy. What is the most effective long-term treatment?
The most effective therapy for mitral stenosis is a balloon valvuloplasty. The procedure is ideal for a pregnant woman. Pregnancy increases plasma volume by 50 percent and worsens symptoms. Balloon valvuloplasty is safe in pregnancy and is by far preferable to open heart surgery.
Your patient has recently been diagnosed with coronary artery disease by stress test. He is a nonsmoker. He does not have diabetes or hypertension. His LDL is 145 after three months of lifestyle modifications, including diet, exercise, and attempts at weight loss. What is the best initial therapy for this patient?
Statin (HMG-CoA reductase inhibitor)
All experts agree that an LDL level above 130 definitely needs drug therapy. Persistent elevations above 100 probably need therapy as well.
Your patient has recently been diagnosed with coronary artery disease by stress test. He is a nonsmoker. He does not have diabetes or hypertension. His LDL is 145 after three months of lifestyle modifications, including diet, exercise, and attempts at weight loss. What are the most common adverse effects of therapy?
Most common adverse effect of statin therapy is hepatotoxicity. LFTs should be checked after several weeks of therapy.
Rhabdomyolysis or myositis is not as common as liver toxicity. Routine monitoring of creatine phosphokinase level is NOT essential.
Your patient has recently been diagnosed with coronary artery disease by stress test. He is a nonsmoker. He does not have diabetes or hypertension. His LDL is 145 after three months of lifestyle modifications, including diet, exercise, and attempts at weight loss. What is the goal of therapy?
The goal of therapy for coronary artery disease is an LDL <100. The goal is the same for the equivalents of coronary disease as well such as diabetes, carotid artery disease, peripheral artery disease, or aortic disease
Case 1: A diabetic, hypertensive, obese smoker is found on angiography to have coronary disease. Her LDL is 110.
Case 2: A diabetic is found to have an LDL of 122.
Case 3: A man with coronary disease has an LDL of 170 despite treatment with a statin and lifestyle modifications for the last six months. His triglycerides are elevated, and his HDL is low. What is the best treatment for each case?
Case 1: Best therapy is always initially with a statin.
Case 2: Statins are the best therapy
Case 3: When the goal cannot be met with a statin, a second medication should be added. Cholestyramine binds cholesterol in the bowel but leads to bloating, abdominal pain, and flatus. The best therapy specifically for triglycerides is a fibric acid derivative, such as gemfibrazol. Niacin is the best medication to raise the HDL. Niacin causes flushing and elevations of glucose and uric acid. Ezetamib lowers lipid levels but has NO proven mortality benefit.
Case 1: A diabetic, hypertensive, obese smoker is found on angiography to have coronary disease. Her LDL is 110.
Case 2: A diabetic is found to have an LDL of 122.
Case 3: A man with coronary disease has an LDL of 170 despite treatment with a statin and lifestyle modifications for the last six months. His triglycerides are elevated, and his HDL is low. What is the goal of therapy for each case?
Case 1: The goal of therapy in a person with coronary disease and diabetes, or coronary disease with multiple risk factors, is ideally an LDL <70. Established risks are diabetes, smoking, HTN, and an age >45 in men and >55 in women.
Case 2: The goal in a diabetic is LDL <100.
Case 3: The goal is an LDL <100 and triglycerides <150.
A 53 yo experiences syncope while at the opera. She loses her pulse. She is found to have ventricular tachycardia. Electrical cardioversion restores her to sinus rhythm. What is the best therapy for this patient?
Implantable cardioverter/defibrillator is the best therapy to prevent sudden death from either ventricular tachycardia or ventricular fibrillation. Electrophysiologic studies are not necessary. She has already shown she has sustained Vtach with loss of pulse. Inducing an arrhythmia is not necessary. Beta blockers may be useful to prevent the arrhythmia from developing, but the life-threatening nature of her rhythm disturbance makes the defibrillator essential.
Case 1: A man with metastatic cancer develops a DVT.
Case 2: A woman with metallic heart valve presents for routine care.
What is the best initial form of anticoagulation in each case?
Case 1: Pts with DVT can receive either low molecular weight heparin or IV-unfractionated heparin. Their efficacy is identical. This treatment is followed by warfarin to an INR of 2-3.
Case 2: Metal heart valves maintain lifelong anticoagulation with warfarin. Pts with metal heart valves are the only patients in which you routinely maintain the target INR above 2-3. Their target is at least 2.5-3.5.
Case 1: A man with metastatic cancer develops a DVT.
Case 2: A woman with metallic heart valve presents for routine care.
What is the mechanism of action of the initial form of anticoagulation in each case?
Case 1: Heparin potentiates the effect of antithrombin on the clotting cascade.
Case 2: Warfarin inhibits the vitamin K-dependent clotting factors (II, VII, IX, and X).
Case 1: A man with metastatic cancer develops a DVT.
Case 2: A woman with metallic heart valve presents for routine care.
What is the duration of therapy?
Case 1: First DVT should be maintained on warfarin for at lease six months.
Case 2: Metal heart valves receive lifelong anticoagulation.
Case 1: A man with metastatic cancer develops a DVT.
Case 2: A woman with metallic heart valve presents for routine care.
What are the most common adverse effects of each initial therapy?
The most common adverse effect of both therapies is bleeding. Heparin can result in thrombocytopenia (HIT).
Case 1: A 32 yo female in her third trimester of pregnancy is admitted with HTN, edema, and proteinuria. She is being prepared for delivery.
Case 2: A 67 yo male develops torsade de pointes post-infarction. He is hemodynamically stable.
What is the best medical therapy for these patients.
Magnesium sulfate is the best medical therapy for preeclampsia and eclampsia as well as torsade de pointes. Magnesium prevents seizure in eclampsia.
Case 1: A 32 yo female in her third trimester of pregnancy is admitted with HTN, edema, and proteinuria. She is being prepared for delivery.
Case 2: A 67 yo male develops torsade de pointes post-infarction. He is hemodynamically stable.
How does the best medical therapy work for both cases?
Magnesium works by decreasing acetylcholine in motor nerve terminals and acting on the myocardium by slowing the rate of SA node impulse formation and prolonging conduction time. Magnesium appears to inhibit calcium uptake into smooth muscle cells, reducing uterine contractility. In general, Mg++ relaxes excitable neuronal and muscular tissue.
Case 1: A 32 yo female in her third trimester of pregnancy is admitted with HTN, edema, and proteinuria. She is being prepared for delivery.
Case 2: A 67 yo male develops torsade de pointes post-infarction. He is hemodynamically stable.
What are the most common adverse effects for the best medical therapy for each patient?
Magnesium sulfate can lead to muscular weakness and loss of reflexes. It causes diarrhea by promoting bowel evacuation through osmotic retention of fluid, which distends the colon. Severe magnesium toxicity can lead to respiratory paralysis.
A 31 yo female comes to the emergency department with palpitations. The EKG reveals a short PR interval. Supraventricular tachycardia develops. When diltiazem is administered, the patient develops Vtach. The patient remains hemodynamically stable.
What is the best initial medical therapy?
WPW syndrome is best treated with procainamide or amiodarone, if an acute arrhythmia such as SVT or VT develops. These agents are effective against both atrial and ventricular arrhythmias, making them the drugs of choice.
A 31 yo female comes to the emergency department with palpitations. The EKG reveals a short PR interval. Supraventricular tachycardia develops. When diltiazem is administered, the patient develops Vtach. The patient remains hemodynamically stable.
What are the indications for cardioversion?
Cardioversion is indicated if the patient becomes hemodynamically unstable. Hemodynamic instability is defined as chest pain, SOB from congestive failure, confusion, or hypotension (systolic BP <90)
A 31 yo female comes to the emergency department with palpitations. The EKG reveals a short PR interval. Supraventricular tachycardia develops. When diltiazem is administered, the patient develops Vtach. The patient remains hemodynamically stable.
What is the best long-term curative therapy?
Radioferquency catheter ablation after electrophysiologic studies is curative. The accessory conduction pathway is destroyed in an electrophysiology laboratory.