Pharm Test 3 - Angina Pectoris & Anti-Htns

Front 1

Describe the etiology and tx of Classic "Angina of effort"

Back 1

Obstruction, esp with exercise

Drugs or surgery

Front 2

Describe the etiology and tx of Variable/Prinzmetal's Angina

Back 2

Spasm or VC

Reversed by nitrates or CCBs

Front 3

O2 demand depends on (3):

Wall tension changed by (2):

Back 3

Cardiac workload = HR, contractility, and wall tension

Pressure and volume

Front 4

Coronary blood flow is proportional to (2):

Back 4

Perfusion pressure and duration of diastole

Front 5

How do antianginal drugs work (2)?

Why is increasing 02 supply inefficient for tx of angina?

Back 5

Increase 02 supply

Decrease 02 demand

"Coronary steal" phenomenon

Front 6

Which drug classes improve the regional flow distribution to the heart (02 supply)? {3 classes}

Back 6

Nitrates, CCBs, BBs

Front 7

Which drug classes improve coronary blood flow (02 supply)? {2 classes}

Back 7

Nitrates, CCBs

Front 8

Which drug classes decrease HR & contractility (02 demand)? {2 classes}

Back 8

Some CCBs, BBs

Front 9

Which drug classes decrease preload (02 demand)? {1 class}

Back 9

Nitrates

Front 10

Which drug classes decrease afterload (02 demand)? {1 class}

Back 10

CCBs

Front 11

Which are the 3 fastest acting nitrates?

Back 11

Inhaled amyl nitrite
IV nitroprusside (risk of cyanide poisoning)
Sublingual nitroglycerin (bypasses first pass metab)

Front 12

Nitroglycerin & Isosorbide dinitrate

Biochem Mech

Back 12

Causes VD by releasing nitrite ion, which is metab to NO, which activates GC, which increases cGMP

Front 13

VD by nitrates is uneven. Describe how.

Back 13

Large veins are markedly dilated and decrease preload.

Small arterioles are less dilated and decrease afterload.

Either way, you still get decreased 02 demand.

Front 14

What are the two general relief mechanisms of nitro tx?

Does total coronary blood flow change?

Back 14

Predominant relief mech: decrease 02 demand

Secondary relief mech: redistribution of coronary bloff flow

No

Front 15

What other parts of the body will nitro affect (3)?

Back 15

Any smooth mm: bronchi, GI, GU.

Front 16

What does sodium nitrite have to do with cyanide?

Back 16

Sodium nitrite is used to induce methemoglobin formation for tx of cyanide poisoning.

Front 17

Nitro drugs

Adverse Effects (3)

Back 17

Acute toxicity = marked hypotension, HA, tachycardia

Can result in tolerance

Can result in Monday disease.

Front 18

What is Monday Disease?

Back 18

Refers to workers who are chronically exposed to high nitrate levels. Their tolerance drops over the weekend, and they experience toxicity sxs on Monday back at work.

Front 19

Name the 6 important CCBs for angina tx.

Back 19

Verapamil
Diltiazem
"- dipines"/dihydropyridines
- Nifedipine
- Nimodipine
- Isradipine
- Amlodipine/Norvasc

Front 20

What is the mech of CCBs?

What are the two effects relating to the tx of angina?

Back 20

Bind L-type CCs on sm mm.

Decreases cardiac contractility, automaticity, conduction and also causes long-term vasc VD.

Front 21

What two roles does IC Ca play?

Back 21

Triggers muscle contraction in myocardium & vasc sm mm

Required for pacemaker activity (SA & AV node)

Will also relax other sm mm to lesser extent.

Front 22

In heart and vasc sm mm, what opens Ca channels?

Then, what drug closes them?

Back 22

Beta rec stim opens them.

CCBs (duh)

Front 23

Which blood vessels are most sensitive to CCB VD?

Which drug has the greatest impact on arteriolar VD?

Which drug has the greatest impact on venous VD?

Back 23

Arterioles

CCBs

Nitrites

Front 24

Which drugs don't affect venous dilation at all, but have some effect on arteriolar VD?

Back 24

Hydralazine and Minoxidil

Front 25

What are the three prototypes for CCBs? Compare them.

Back 25

Verapamil - strongest cardiac effects (Depress automaticity)

Nifedipine - strongest VD & reflex tachycardia inducer. Also, diff type: dihydropyridine.

diltiazem - inbetween.

Front 26

nifedipine

Drug Class:

How can it cause MI?

General Adverse Effect of CCBs:

Back 26

CCB

Causes rapid hypotension, reflex tachycardia.

Hyperglycemia & decreased platelet aggregation

Front 27

Verapamil, Diltiazem

Drug Class:

Main Adverse Effect:

General Adverse Effect of CCBs:

Contraindications:

Back 27

CCB

Might cause serious cardiac depression through SA/AV node effects

Hyperglycemia & decreased platelet aggregation

GF inhibits P450 = verapamil toxicity

Front 28

What do Beta Blockers do for angina (2)?

What do Beta Blockers NOT do, ever?

Back 28

Decrease SNS = less 02 demand.

Resulting bradycardia increases coronary perfusion time

They never produce coronary VD!

Front 29

Beta Blockers

Adverse Effects (4):

Which angina do you NOT use Beta Blockers for?

Back 29

Bronchoconstriction
Hyperlipidemia
Mask hypoglycemia
CNS effects

Do NOT use them for Variant/Prinzmetal's angina: slows HR, prolongs ejection time, increases LV end-diastolic volume = increased O2 demand.

Front 30

List the 3 PDE5 inhibitors

Back 30

sildenafil
vardenefil
taladaifil

Front 31

What were PDE5I's first developed for?

What else do they treat, besides ED?

Back 31

Tx of angina

Tx of pulmonary HTN

Front 32

Sildenafil

Drug Class:

Mech:

Why might someone have vision troubles using sildenafil?

Back 32

PDE5I

Selective inhibition of cGMP specific PDE, increasing NO release.

Somewhat selective for retina-specific PDE6

Front 33

Sildenafil

PHKs:

Interactions:

Contraindications:

Back 33

Oral: well abs, rapid action
t1/2: 4 hrs
P450 3A4 metab

Do NOT use with nitro tx, alpha blockers, or 3A4 inhibitors = severe
hypotension.

NOT for use in children or pregnant women.

Front 34

Vardenifil

Drug Class:

How is it different from sildenafil (2)?

Back 34

PDE5I

More selective for PDE5, so less visual side effects.

Also achieves maximum plasma concentration sooner. Gets the pt into the action faster.

Front 35

Tadalafil (Hey, honey! Ta-da!!!)

Drug Class:

How is it different from sildenafil (3)?

Back 35

PDE5I

Longer duration: 24-36 hrs
Allows for more sexual sponteneity
Zero visual disturbances

Front 36

Ranolazine

Drug Class:

Mechs (3):

Use:

Back 36

None mentioned

PFox inhibitor
Inhibits late inward Na current
Decreases LV stiffness

Tx of chronic, stable angina as a last resort

Front 37

Ranolazine

PHKs (3):

May cause:

Back 37

Oral: 73% bioavail
RExc
P450 metab - so lots of interactions expected

TdP

Front 38

Bosentan

Drug Class:

Mech:

Use:

Adverse Effects:

Back 38

Endothelin rec antagonist

Competitive antagonist for both Type A & B recs

Orally, and only for severe pulm HTN

P450 rxns, teratogenic

Front 39

What are the two tx goals for angina?

Back 39

Increase exercise tolerance

Decrease frequency of attacks

Front 40

List three common drug combos for the tx of angina

Back 40

BBs & CCBs

2 CCBs

Nitrates & BB or CCBs to decrease reflex tachycardia.

Front 41

What are endothelins?

So, then, what is an example of an endothelin rec inhibitor?

Back 41

Peptides that counter NO = VC

Bosentan = VD

Front 42

If your patient has X, tx with ?:

Asthma:
DM:
HF:
HTN:
Ulcer:

Back 42

Asthma: CCB, NO
DM: CCB, NO
HF: NO
HTN: BB, CCB
Ulcer: BB, NO

Front 43

Which anti-HTNs work at the VMC (2)?

Back 43

Clonodine
Methyldopa

Front 44

Which anti-HTNs work at the SNS nerves (2)?

Back 44

Reserpine
guanethidine

Front 45

Which anti-HTNs work at the a-recs in blood vessels (1)?

Back 45

The "-sins"

Front 46

Which anti-HTNs work at the beta-recs in the heart (1)?

Back 46

The Beta Blockers - "-olols"

Front 47

Which anti-HTNs work at the vasc sm mm and/or cause VD (8)?

Back 47

VDs: hydralazine, minoxidil, diazoxide, nitroprusside (VD both arteries & veins)

CCBs: verapamil, diltiazem, "-dipines"

D1 rec agonist: fenoldopam

Front 48

Which anti-HTNs work at the kidneys (1)?

Back 48

Diuretics

Front 49

What does the poly pill consist of (6 drugs)? [tx of FATBAS-tards]

Back 49

Folic acid, Aspirin, Thiazides, BBs, ACEIs, Statins

Front 50

If your pt is over 65 and has HTN, what do you treat with?

What do you NOT treat with?

Back 50

Diuretics, ACEIs, CCBs

(Central acting a-agonist)

Front 51

If your pt is African American and has HTN, what do you treat with?

What do you NOT treat with?

Back 51

Diuretics, CCBs

(BBs)

Front 52

If your pt is pregnant and has HTN, what do you treat with?

What do you NOT treat with?

Back 52

Methyldopa, labetalol

(ACEI, ARB)

Front 53

If your pt has angina pectoris and has HTN, what do you treat with?

What do you NOT treat with?

Back 53

BBs, CCBs

(Central acting a-agonist)

Front 54

If your pt has had an MI and has HTN, what do you treat with?

Back 54

BB, ACEI, aldosterone antagonist

Front 55

If your pt has CHF and has HTN, what do you treat with?

Back 55

Diuretic, ACEI, ARB, BB

Front 56

If your pt has asthma and has HTN, what do you treat with?

What do you NOT treat with?

Back 56

CCB, ACEI

(Never BB)

Front 57

How do diuretics tx HTN (2)?

Which thiazide is a VD?

Back 57

Acutely, they reduce body Na stores, reducing blood volume.

After 6-8 wks, they activate K channels, causing a decrease in periph resistance.

Indapamide

Front 58

Thiazides are most effective in what population?

Which diuretic is the 1st choice for HTN tx?

Back 58

Old, black men.

Thiazides

Front 59

List the 6 subtypes of sympatholytics used in HTN.

Back 59

Central agonists
Ganglion Blockers
Neuron Blockers
a1 Blockers
BBs
Combined a & Beta Blockers

Front 60

Clonodine & Methyldopa

Drug Class:

Mech (2):

Contraindications (2):

Back 60

Central a-agonists

Act on a2 recs in brain medulla to decrease SNS tone.
Also results in decreased renin.

Do NOT use with TCAs or yohimbine

Front 61

Clonodine and Methyldopa both have a risk of severe side effects. What are they?

Which one is a prodrug?

Back 61

Clonodine: sudden w/d causes severe hypotension

Methyldopa: may cause hemolytic anemia with + Coomb's test. Prodrug.

Front 62

How can clonodine be administered?

Back 62

Orally or transdermally. Don't sit in a hot tub with a clonodine patch on - will pass out.

Front 63

Mecamylamine

Drug Class:

Class action:

Used for:

Back 63

Only Ganglion Blocker we need to know.

Complete blockade of PNS & SNS. Bad juju.

Not used much due to bad side effects, but this one is being used for tx of Tourette's (Fuck! ASS! Get me a beer!)

Front 64

Guanethidine

Drug Class:

Mech:

Adverse Effect with IV admin:

Back 64

Adrenergic Neuron Blocker

Replaces NE in the vesicles, inhibiting NE release.

HTN crisis, esp in pheochromocytoma.

Front 65

What does guanethidine have to do with sex?

Back 65

May cause retrograde ejaculation. (along with postural hypotension, diarrhea, fluid retention)

Front 66

Reserpine/AKA:

Drug Class:

Mech:

Contraindications (1):

Back 66

Reserpine = the "Dirty Drug"

Adrenergic Neuron Blocker

Called "dirty" because it eliminates SNS tone via inhibition of NE transport into vesicle.

Serious rx with MAOIs because released NE needs to be metab by MAO.

Front 67

Prazosin (terazosin, doxazosin)

Drug Class:

Mech:

Huge benefit:

Back 67

a1 Blockers

a1 block reduces NE - causes VD of BOTH arteries & veins

a1 selection means less reflex tachycardia

Front 68

Prazosin

Adverse Effects (2):

Lack of adverse effect (1):

Back 68

First-dose phenomenon: hypotension, syncope

Increased renin (& Na & H2O retention)

NO hyperlipidemia, though.

Front 69

BBS and HTN

Mechs (3):

BBs are more effective for tx of HTN in:

Back 69

Heart: reduce CO
Kidney: reduce renin
CNS: reduce SNS tone

Young white people.

Front 70

Why would you add other HTN drugs to BB tx (2)?

Back 70

Reduce reflex tachycardia from extreme VD
Counteract increase in renin

Front 71

Nebivolol

Drug Class:

Other Mech:

Back 71

BB

Increases prod of NO = periph VD

Front 72

BB

Adverse Effects (3)

Back 72

Hyperlipidemia + low HDL = atherosclerosis

Mask hypoglycemia

Increase exercise tol for angina pts but decrease for CHF pts

Front 73

BB

Contraindicated conditions (4)

Preferred for (3)

Back 73

DM
CHF
Cardiac Blocks
Asthma

angina, p MI, migraines

Front 74

Labetalol & Carvedilol

Drug Class:

Other details (3):

Back 74

Combined a & Beta Blockers = lowered BP

Labetolol is OK in pregnancy but is usually only used in emergencies.
They can be hepatotoxic.
May cause bronchospasm.

Front 75

Hydralazine

Drug Class:

Administration:

Mechs (2):

Adverse Effects (2):

Back 75

VD

Oral

Selectively dilates arteries
Also increases NO prod

SLE in slow acetylators
May cause angina due to reflex tachycardia

Front 76

Minoxidil

Drug Class:

Administration:

Mech:

Adverse Effects:

Is also a:

Back 76

VD

Oral

Selectively dilates arteries

Hypertrichosis
May cause angina due to reflex tachycardia

K channel blocker

Front 77

Name two HTN drugs that also act through NO

Back 77

Hydralazine
Sodium Nitroprusside

Front 78

What combo HTN tx is incredibly effective in the African American population?

Back 78

Hydralazine & isosorbide dinitrate

Front 79

Sodium nitroprusside

Drug Class:

Administration:

Adverse Effects (2):

Mech:

Back 79

VD

IV

Like NO, rapid.

Cyanide accum. & metab acidosis

Front 80

Diazoxide

Drug Class:

Administration:

Mech:

Is also a:

Also causes:

Back 80

VD

IV

Activates ATP K channels

Non-diuretic thiazide with long duration of action 24-36 hrs

Excessive hair growth

Front 81

Fenoldopam

Drug Classes:

Administration:

Mech:

Back 81

VD, D1 rec agonist

IV

Stims relax of sm smm. t1/2 = 5 mins

Front 82

What drugs cause gingival hyperplasia (3)?

Back 82

"-dipines" (CCBs)
phenytoin
cyclosporine

Front 83

What is the most common adverse effect of verapamil?

Back 83

Constipation

Front 84

How do you tx long term HTN with VDs?

Acute?

Back 84

Oral VDs

IV VDs

Front 85

Captopril & Enalapril

Drug Class:

Mech:

Back 85

ACEI

ACE converts AngI to AngII. When blocked = VD. Also destroys bradykinin, so inhibit = enough bradykinin.

Front 86

Why would you use ACEIs for HTN?

Most effective for who?

Back 86

Fewer side effects: no cardiac, CNS, or renal compromise.

Young white people.

Front 87

ACEIs

More benefits (2):

Adverse Effects (3):

Back 87

Well abs/excreted.
Enhances anti-HTN efficacy of other drugs.

Severe hypotension in hypovolemic pts
Acute renal failure in stenosis
Bad for 2nd & 3rd trimester of preg
May cause coughing & angioedema

Front 88

Losartan

Drug Class:

Selective for:

Better because (2):

Back 88

Angiotensin rec Blocker

AT1 recs

Reduce mortality better than atenolol
No coughing or angioedema like ACEIs

Front 89

Aliskren

Drug Class:

Blocks:

Contraindicated in:

Back 89

Renin inhibitor

Formation of AngI

Pregnancy