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94 Cards in this Set
- Front
- Back
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Why do we use Nitrates?
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They are useful in treating all forms of angina.
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what is one of the most commonly used anti-anginal agents?
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Nitrates
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What might you prescribe to a patient that experiences exertional anginal in order to improve excercise tolerance and time to onset of angina?
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Nitrates
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When should your patient take a nitrate if they have exertional angina?
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Immediately before exercise or stress to prevent ischemic episodes
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Although nitrates work on the blood vessels, where will you see the effects?
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The heart
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What is the MOA of nitrates?
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Dilation of the large veins which leads to the pooling of blood in the veins, ultimately reducing the preload.
(decreases the venous return to the heart) |
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Is there any evidence that suggest that nitrates decrease mortality or rate of AMI?
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NO--they reduce the symptoms of angina
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Why are nitrates more effective when administered sublingually or transdermally?
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Because all nitrates are broken down by 1st pass effect
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When does sublingual nitrates peak and how long do the effects last?
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peaks in 1-2 mins and lasts for 30-60 mins
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When nitrates are transdermal, when is the peak level reached and how long are the effects?
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peaks in 30-60 mins and lasts the whole day
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Which route of administration of nitrates peaks with in 2mins and only lasts 3-5 mins?
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IV
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When is the peak reached and how long are the effects of topical paste nitrates?
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peaks within an hour and effects last 2-12 hours
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Can a patient taking nitrates experience tolerance?
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YES
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How do help our patients not build a tolerance to nitrates?
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By having our patients have a "nitrate-free" period
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How long should the "nitrate free" period last?
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This helps prevents tolerance and this period should be 10-12 hours daily and usually at night when the demand on the heart is less
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How do advise patients that wear a nitrate patch in order to prevent nitrate tolerance?
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Wear the patch for 12 hours then remove the patch for 12 hours...nitrate free interval typically in the afternoon to avoid angina symptoms
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What is the most common adverse effect associated with nitrates?
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Cerebral ischemia (aka headache)
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What is a common adverse effect with patients that use transdermal nitrates?
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contact dermatitis
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What are some adverse effects of taking nitrates?
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1. hypotension
2. facial flushing 3. rebound tachycardia 4. cerebral ischemia--headache 5. contact dermatitis--transdermal 6. aggravation of peripheral edema |
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Before administering nitrates to any man, what should you ask them???
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Are you taking any erectile dysfunction medication (Viagra)??
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Nitrates have drug interactions with the following:
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1. alcohol
2. antihypertensives 3. vasodilators (PDE5-inhibitors--viagra) |
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Why should patients on nitrates avoid vasodilators?
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increased risk of orthostatic hypotension
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Timolol, propranolol and metoprolol are all examples of what type of medication?
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Beta-blockers
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Why might you give beta-blockers for a patient suffering with angina?
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prophylactically--> reduces ischemic burden by decreasing heart rate and blood pressure
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What drug can reduce the risk of MI by 10-20%?
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beta blockers
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Why would you choose beta-blockers rather than calcium channel blockers for management of angina?
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studies show better outcomes with beta blockers
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What side effects are associated with beta-blockers?
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depression
dizziness bradycardia impaired exercise tolerance insomnia erectile dysfunction :( |
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Amlodipine (Norvasc)
Isradipine (DynaCirc) Nicardipine (Cardene) These are all examples of what class of drug used in the management of angina? |
Calcium Channel Blockers
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Can you use dihydropyrine, Nifedipine, as anginal management?
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NO! this is hazardous in angina
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What drugs are indicated in hypertension and various forms of angina?
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Calcium channel blockers:
Amlodipine (Norvasc) Isradipine (DynaCirc) Nicardipine (Cardene) |
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Peripheral edema is a major side effect of which medications?
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Calcium channel blockers:
Amlodipine (Norvasc) Isradipine (DynaCirc) Nicardipine (Cardene) |
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What are some of the side effects associated with calcium channel blockers?
Amlodipine (Norvasc) Isradipine (DynaCirc) Nicardipine (Cardene) |
headache
peripheral edema palpitations flushing |
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Do beta- blockers or calcium channel blockers enhance myocardial contractility and output?
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calcium channel blockers enhance contractility and output
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How does the non-dihydropyridine CCB, Verapamil, work?
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1. It dilates peripheral arterioles thereby reducing afterload
2. slows the AV node |
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Which non-dyhdropyridine CCB reduces frequency of angina and need for nitrates?
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Verapamil
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What sides effects might your patient taking Verapamil experience?
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constipation
hypotension bradycardia edema CHF AV node block |
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Which calcium channel blocker might you suggest for a patient that experiences exercise induced angina?
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Diltiazem
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What is the difference between Diltiazem and Verapamil?
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Diltiazem does not reduce the heart rate as much as Verapamil
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What are some side effects associated with Diltiazem?
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diarrhea
edema headache dizziness |
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How does diltiazem affect oxygen supply to the heart?
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Diltiazem increases O2 supply to the heart
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What condition occurs due to the cardiac output being inadequate to provide O2 needed by the body?
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Congestive Heart Failure (CHF)
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What happens during systolic failure?
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the mechanical pumping action (contractility) and the ejection fraction of the heart are decreased
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What happens during diastolic failure?
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Stiffening and loss of adequate relaxation which leads to a decrease in cardiac output and decrease in ejection fraction
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Congestive heart failure (CHF) is a condition that involves...
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many processes and organs such as, the sympathetic nervous system, kidneys, angiotensin II, aldosterone, etc.
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What drug is a potent, selective inhibitor of the active transport of Na+ and K+ across cell membranes?
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Digoxin (Lanoxin)
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What happens when digoxin (lanoxin) bind to a specific site on the Na+, K+ ATPase pump?
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there is an increase force of contraction (inotropic effect)
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What does inotropic mean?
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Affecting the contraction of muscle, especially heart muscle. (http://medical-dictionary.thefreedictionary.com/inotropic)
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How does Digoxin (Lanoxin) affect:
tissue perfusion edema ventricular rate parasympathetic tone chronotropic effect |
increases tissue perfusion
decreases edema decreases ventricular rate decreases parasympathetic tone (-)chronotropic effect (Affecting the rate of rhythmic movements, such as the heartbeat.) |
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What does chronotropic mean?
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Affecting the rate of rhythmic movements, such as the heartbeat.
(http://medical-dictionary.thefreedictionary.com/inotropic) |
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When you put your patient on Digoxin (lanoxin) can they switch brands once they start?
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NO
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Within how many hours will Digoxin (Lanoxin) peak in the body?
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9-12 hours
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How much of the Digoxin (lanoxin) is absorbed?
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45-85% and is distributed to many tissues in the body
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What is Eubacterium lentum? and why might this be an issue when administering Digoxin?
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Eubacterium lentum is a gram-positive, asaccharolytic, obligately anaerobic bacillus, that lives in the GI tract.
E. lentum will "eat up" Digoxin (lanoxin) therefore you need to dose appropriately |
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What is the relationship between Digoxin (lanoxin) and GFR?
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Digoxin (lanoxin) is excreted in the urine with a clearance that almost matches GFR (if they have renal insufficiency you need to lower dose)
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Does Digoxin (lanoxin) have a wide or narrow therapeutic index?
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NARROW
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What adverse CV effects might be caused by Digoxin (Lanoxin)?
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arrhythmia (atrial or ventricular)
AV block |
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What adverse CNS effects might be due to Digoxin (Lanoxin)?
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vision changes
fatigue stupor |
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What adverse GI effects might be induced by Digoxin (Lanoxin)?
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Nausea
vomiting anorexia |
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What visual disturbances might be caused by Digoxin toxicity?
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blurred or yellow vision
halos *visual disturbances might be the 1st sign of dig tox* |
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Describe some psychological effects of digoxin toxicity.
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delirium
fatigue malaise confusion dizziness abnormal dreams |
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The following are CV effects caused by dig toxicity:
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atrial and ventricular ectopic arrhythmias
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What types of drugs should your patient avoid when on Digoxin (lanoxin)?
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1. drugs that cause hypokalemia (diuretics) because they predispose the pt to dig tox
2. quinidine, verapamil, amiodarone because they displace digoxin from tissue binding sites (increase dig levels in the plasma) |
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What medications are used as add on therapy with digoxin (lanoxin) when CHF persists?
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Bipyridine Derivatives:
-amrinone (Inocor) -milrinone (Primacor) *these are inpatient IV medications only (heart transplant pts)* |
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How do bipyridine derivatives (amrinone and milrinone) affect stroke volume, contractility, vascular resistance, ejection fraction, and sinus rate?
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increases stroke volume, contractility, ejection fraction and sinus rate
BUT decreases vascular resistance |
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Which of the Bipyridine derivatives, amrionone (Inocor) or milrinone (Primacor) is used more often?
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Milronone (Primacor) is used more often and is 20x more potent than amrinone (Inocor)
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what are the adverse effects associated with the Bipyridine derivatives, amrionone (Inocor) and milrinone (primacor)?
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GI
hepatotoxicity fever thrombocytopenia headaches (possibly less ADR's with milrinone) |
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Should you give beta blockers to a patient with unstable heart failure?
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NO
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Describe the MOA with the beta blockers:
bisoprolol (zebeta) carvedilol (coreg) metoprolol (lopressor/toprol XL) |
attenuation (dilution) of the high catecholamine (sympathomimetic) concentrations thereby decreasing heart rate and decreasing remodeling
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Are the effects of beta blockers immediate?
bisoprolol (zebeta) carvediol (coreg) metoprolol (lopressor/toprol XL) |
NO... it may require several months of treatment before benefits are seen
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What medication will you use as the 1st line of treatment in patients with left ventricular dysfunction but no edema?
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ACE inhibitors/ARBs
benazepril (lotensin) captopril (capoten) enalapril (vasotec) fosinopril (monopril) lisinopril (prinivil/zestril) quinapril (accupril) ramipril (altace) candesartan (atacand) irbesartan (avapro) losartan (cozaar) telmisartan (micardis) valsartan (diovan) |
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What happens when you try to discontinue digoxin (lanoxin)?
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they decompensate
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How do ACE-i and ARBs work?
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they decrease preload and afterload therefore slow the progression of ventricular dilation
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When will you most likely switch a patient from an ACE-inhibitor to an ARB?
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If they cannot tolerate the ACEi induced cough
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Why would you use a diuretic in a patient with CHF?
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to relieve pulmonary congestion and peripheral edema
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When would you use a loop diuretic, such as furosemide?
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if your patient had a more severe case of edema
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What is the diuretic of choice when treating mild heart failure?
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Thiazide such as HCTZ
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What electrolyte must you watch with a patient on a diuretic and/or digoxin?
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K+
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If you are concerned about your hypokalemia, what diuretic might you choose?
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K+ sparring, such as, spironolactone
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Spironolactone is a K+ sparring diuretic that is an aldosterone antagonist, what does that mean?
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It means that Spironolactone prevents salt retention
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If your patient has advanced heart failure and an elevated aldosterone levels due to angiotensin II stimulation, what medication might you suggest to help?
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Spironolacton which is a K+ sparring drug as well as an aldosterone antagonist
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Why would you use dobutamine (dobutrex)?
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in order to increase cardiac output in CHF patients
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How does dobutamine (dobutrex) work?
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it is a beta 1-receptor adrenergic agonist that increases contractility
BUT does NOT increase heart rate or blood pressure and has minimal effects on the blood vessels |
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What is the half life of dobutamine (dobutrex)?
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t1/2= 2.4mins
*this is an IV inpatient drug* |
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What adverse effects might be caused by dobutamine (dobutrex)?
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tachycardia
hypotension nausea headache palpitations anginal symptoms dyspnea ventricular arrhythmias |
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What happens to cardiac preload if you dilate venous blood vessels?
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it is decreased
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How do you decrease systemic resistance and afterload?
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by dilating arterioles (hydralazine)
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If your patient is intolerant to ACEi, or beta blocker, what combo is used?
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hydralazine and isosorbide dinitrate
(2nd line therapy) hydralazine= arteriole dilator |
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What are the steps in treating chronic CHF?
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1. reduce heart workload
2. restrict Na+ intake 3. restrict H2O?? 4. give diuretics 5. ACEi or ARB 6. Digoxin (if systolic dysfunction w/ 3rd heart sound or a-fib present) 7. beta blocker (if stable Class II-IV CHF) 8. vasodilators |
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When will you give digoxin to a patient with chronic CHF?
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if systolic dysfunction with a 3rd heart sound or a-fib is present
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How can you decrease the workload of the heart?
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limit activity
reduce weight control hypertension |
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what type of drug is Diliazem?
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Calcium Channel Blocker
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What class of drug is Verapamil?
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Calcium Channel Blocker
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Amlodipine (Norvasc)
Isradipine (DynsCirc) Nicardipine (Cardene) What class do these drugs belong to? |
Calcium Channel Blockers
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What adverse effect is most commonly associated with Calcium Channel Blockers?
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peripheral edema
Amlodipine (Norvasc) Isradipine (DynsCirc) Nicardipine (Cardene) Verapamil Diliazem |
