Pharm 1 - Lipid Lowering And Chf (Nierenberg)

Front 1

Function of chylomicrons, VLDLs, LDLs and HDLs

Back 1

They carry important lipids, TGs and cholesterol.

Front 2

Fasting LDL levels

Back 2

With tons of previous CV issues - <70

Great - <100
Desirable <130
Borderline 130-159
Bad >160

Front 3

Fasting HDL levels

Back 3

Great >60
Desirable >50
Borderline 40-50
Bad <40

Front 4

General cholesterol pathway

Back 4

Cholesterol is brought into hepatocytes by carrying molecules (e.g. LDL) and degraded to bile acids. These bile acids then secreted into gut and stool. But body sees bile acids in lumen of gut and absorbs some back into hepatocytes.

Front 5

Cholestyramine

Back 5

A resin that is a bile acid sequestrant. Binds to them and inhibits enterhepatic reuptake of bile salts.

This increases fecal loss of bile acids, increase bile acid synthesis, increases cholesterol synth, increases LDL receptor expression on cell surf of hepatocytes.

Given as a powder.

Front 6

SE of cholestyramine

Back 6

Very bad gas, diarrhea, abs of fat-sol vitamins.

Front 7

Effectiveness of cholestyramine

Back 7

10-20% reduction of LDL

Front 8

Nicotinic acid

Back 8

This is the same as Vit B3/niacin (which is used to tx pellagra).

Decreased prod of VLDLs and LDLs, increase in LDL receptor in liver. Can reduce TGs and LDLs.

Front 9

SEs of nicotinic acid

Back 9

Facial flushing which can be lessened with aspirin (at high doses).

Some pts also develop hepatitis (at sustained release formulations).

ALMOST NEVER USED AS MONOTHERAPY.

Front 10

Gemfibrozil

Back 10

Fibric acid derivative that probably inhibits lipolysis and decreases FA reuptake. Also inhibits hepatic secretion of VLDLs.

Front 11

SEs of gemfibrozil

Back 11

Elev of LFTs/mild hepatitis, myositis, GI distress.

Don't rx with statins bc of similar SEs.

Front 12

Lovastatin

Back 12

Lactone that inhibits HMG-CoA reductase. This stops prod of cholesterol and up-regulates LDL receptors on hepatocytes. Also results in small increase in HDLs.

Front 13

Lovastatin metabolism

Back 13

CYP3A4.
So be careful of drugs that are metab by CYP3A4 bc this will compete with their metabolism. (e.g. cyclosporine which has a very narrow ther range)

Also be careful with things that inhibit CYP3A4.

Front 14

Lovastatin SEs

Back 14

Liver and muscle. Never combine with fibrate (muscle or liver) or niacin (hepatitis).

Avoid in pregnancy too.

Front 15

Atorvastatin

Back 15

50-60% reduction (Lipitor)

Front 16

Lovastatin effectiveness

Back 16

35-40% reduction and intermediate cost

Front 17

Simvastatin effectiveness

Back 17

35-40% reduction and very low cost.

Front 18

Ezetimibe

Back 18

Blocks intestinal abs of cholesterol and phytosterols. Acts at brush border.

Reduces hepatic chol stores and increases blood clearance of cholesterol.

This is usually in combo with a statin.

Front 19

Ezetimibe SEs

Back 19

Caution in pts with hepatic or renal impairment.
HA and diarrhea can result.

Front 20

JUPITER trial

Back 20

Giving rosuvastatin to pts with high CRP reduced CV events and mortality.

Front 21

Causes of shock

Back 21

Sepsis, hemorrhage, burn, acute MI, anaphylaxis

Front 22

Heart failure

Back 22

Reduction of CO (forward failure)
or increase in venous filling pressure (back failure)

Accompanied with remodeling.

Front 23

Positive inotropic effects...

Back 23

LV contractility usually.

Front 24

Positive chronotropic effects...

Back 24

HR usually at SA node

Front 25

Positive dromotropy effects...

Back 25

Conduction usually through the AV node.

Front 26

Solution to low preload

Back 26

Volume replacement.

Front 27

Solution to bradycardia (either chronotropy or dromotropy)

Back 27

Atropine (but this won't work in a pt who had a heart transplant bc vagus n. is no longer connected to the heart)
Isoproterenol
Pacemaker

Front 28

Tachycardia/arrythmia

Back 28

Cardioversion (paddles)
Antiarrythmics

Front 29

Short-term diminished inotropic state

Back 29

Epinephrine
DA
Dobutamine
Amrinone
calcium
glucagon
digoxin
correct pH
correct hypoxemia.

Front 30

NE

Back 30

mainly effects alpha 1 so you get vasoconstriction. do not give this to ppl with contractility problems.

Front 31

Epinephrine

Back 31

Alpha 1, beta1, beta2. So it is good for anaphylaxis, increasing contractility.

Front 32

Dobutamine

Back 32

Similar to dopamine but more specific for beta1 compared to dopamine.

Increases contractility of the ventricles more than the SA node effects of stimulating tachycardia.

This is good bc in the coronary care unit you don't really need tachycardia.

Front 33

Correcting peripheral vasoconstriction

Back 33

(Captopril)
Enalpril
Lisinopril
Hydralazine
Prazosin
Carvedilol (partly an alpha1 blocker)
Nitroglycerin
Nitroprusside

Front 34

Correcting excessive, abnormal contractility (e.g. idiopathic hypertrophic subaortic stenosis)

Back 34

Propanolol or verapamil

(these drugs relax the big heart muscle)

Front 35

Where are there beta receptors?

Back 35

SA node, AV node, ventricles.

Front 36

Dopamine

Back 36

Low dose - DA receptors in mesentary and kidney to increase blood there.

Medium - Beta1 receptors; increases contractility and HR

High - Stim alpha1 to produce vasoconstriction (bad for CHF)

IV only. MAOIs intensify its effects.

Front 37

Amrinone

Back 37

Inotropic and vasodilator. Mainly at peripheral arterioles.

IV admin.

May cause arrythmias. Do not mix with furosemide.

Good to use during diminished inotropic state.

Front 38

Vasodilators used to improve CHF

Back 38

Lisinopril, hydralazine, prazosin, nitroprusside.

In general, pure vasodilators like hydralazine and nitroprusside don't improve pt survival.

Remember BiDil for black pts. (hydralazine plus isosorbide dinitrate)

Front 39

Preload reducing agents

Back 39

Diuretics.

Front 40

Acute tx of heart failure

Back 40

Inotropic support is ok acutely, but harmful long term.

And beta blockers make things worse short term, but help long term.

Front 41

Things that cause remodeling:

Back 41

Beta stimulation
AT II
Aldosterone.

(want to interrupt these long-term)

Front 42

Tx of CHF long term

Back 42

Carvedilol, sustained release metoprolol. Or ACE inh.

Front 43

Blocking aldosterone can lead to...

Back 43

hyperkalemia.