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60 Cards in this Set
- Front
- Back
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Which is the "energy requiring process"?
Ventricular pumping Ventricular filling |
Ventricular filling
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The _______ pressures of the heart increase with ischemia.
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The FILLING pressures of the heart increase with ischemia.
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What are two general principles for treating myocardial ischemia?
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- Increase myocardial oxygen supply
- Decrease cardiac work (reduce HR, reduce BP (wall tension)) |
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What is the list of major classes of agents used to treat myocardial ischemia?
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- Beta blockers
- Calcium channel blockers - Nitrates - Morphine - Platelet inhibitors (aspirin, clopidogrel) - ACE inhibitors - ARBs - HMG-CoA reductase inhibitors |
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Prototypical beta-1 receptor antagonist
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Metropolol
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What is responsible for the neural control of the release of renin?
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Beta adrenergic input to the kidney is responsible for renin secretion.
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Beta blockers: Secretion of renin
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Reduces the release of renin.
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Beta blockers: AE
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Lipid soluble so has CNS penetration. Can cause depression.
Also bradycardia, bronchospasm (beta 2) |
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What are five commonly used beta blockers?
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Metoprolol
Atenolol Propranolol Labetolol Esmolol |
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Beta blockers: What is the main M of A?
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They reduce myocardial oxygen demand by reducing BP, wall tension, and HR.
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Why should you never stop a beta blocker abruptly?
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Can lead to a hyper-adrenergic state!
In the presence of a sustained beta blockade, there is: - Upregulation of beta receptors. - Increased sensitivity of individual receptors to beta stimulation - Increased output of catecholamines from sympathetic nerve terminals. |
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What are three classes of calcium channel blockers?
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1. Dihydropyridine Class (e.g. Amlodipine)
2. Phenylalkylamine Class (e.g. Verapamil) 3. Benzothiazipine Class (e.g. Diltiazem) |
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What are the central/heart effects of CCBs?
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SA node inhibition
AV node inhibition Myocardial depression |
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What are the peripheral effects of CCBs?
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Vasodilation
Smooth muscle relaxation |
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CCBs: M of A
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Varies according to the tissue type, but basically they block the inward flow of Ca.
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Which has the most peripheral vasodilatory action
Amlodipine Verapamil Diltiazem |
Amlodipine > diltiazem > verapamil
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Which of has the most affect on the AV node and on myocyte contraction?
Amlodipine Diltiazem Verapamil |
Verapamil > Diltiazem > Amlodipine
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List the CCBs in order of decreasing half-life
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Amlodipine > Verapamil > Diltiazem
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CCBs: route of elimination?
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Hepatic
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CCBs: uses?
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Amlodipine - HTN, Angina
Verapamil - HTN, Angina, SVT Diltiazem - HTN, Angina, SVT |
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c/c beta blockers and CCBs: mortality reduction
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No proof of mortality reduction with CCBs
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What is the formula for coronary perfusion pressure?
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CPP = MAP - LVEDP. The more the LVEDP goes up, the less the perfusion pressure.
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What are two commonly used agents that reduce LVEDP?
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Morphine
Nitrovasodilators (Nitrates) |
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Short-acting nitrate
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Nitroglycerin
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Intermediate-acting nitrate
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Isosorbide dinitrate
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Long-acting nitrate
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Isosorbide mononitrate
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Nitrates: M of A
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Nitrates metabolized to release NO-like compound --> NO binds to guanylyl cyclase --> cGMP up --> intracellular Ca down --> SMC contractility down
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Nitrates: AE
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Headache
Postural hypotension Reflex tachycardia Flushing |
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How does morphine lower LVEDP?
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Via opiod receptors. Causes pooling in veins. Does not lower BP much. Reduces adrenergic tone.
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What clinical symptom are nitrates the most useful for treating?
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Angina
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Nitrates + what medication = bad?
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Viagra
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Aspirin: M of A
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Aspirin prevents platelet aggregation by irreversibly acetylating COX and by reducing the production of thromboxane A2 (the body's most potent vasoconstrictor).
Note that platelets don't have a nucleus, so they can't make more COX-1. Other tissues can. |
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Aspirin: antidote
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IV platelets
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Aspirin: dosing ranges
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81 to 325 mg PO
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Clopidogrel: M of A
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Clopidogrel inhibits the ADP induced exposure of the fibrinogen binding site (glycoprotein IIb/IIIa receptor complex) on activated platelets.
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Clopidogrel: dosing
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75-600 mg
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Clopidogrel: antidote
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IV platelets
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Name three ACE inhibitors
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Lisinopril
Captopril Enalapril |
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ACE inhibitors: AE
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Cough
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Name two Angiotensin receptor blockers
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Losartan
Ibesartan |
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What is the limiting step enzyme involved in cholesterol biosynthesis?
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HMG-CoA Reductase
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What happens if you inhibit HMG-CoA Reductase? What does the body think is going on?
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Decreased de novo synthesis of cholesterol --> body thinks that it is starved of cholesterol --> more hepatic LDL receptors --> plasma is cleared of LDL
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Can statins reverse an arteriosclerotic plaque?
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No
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? |
H&P, PE, nitro sublingual, aspirin, statin (even if LDL is normal), maybe a beta blocker
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Why do people have angina on cold days?
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Cold days = vasoconstriction --> preload up
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Why do people have angina upon exertion?
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exertion up --> BP up --> wall stress up --> O2 demand up
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of athsma? |
No beta blockers (not first line)
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of fainting spells? |
No beta blockers
No Verapamil |
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What is the limiting step enzyme involved in cholesterol biosynthesis?
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HMG-CoA Reductase
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What happens if you inhibit HMG-CoA Reductase? What does the body think is going on?
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Decreased de novo synthesis of cholesterol --> body thinks that it is starved of cholesterol --> more hepatic LDL receptors --> plasma is cleared of LDL
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Can statins reverse an arteriosclerotic plaque?
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No
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? |
H&P, PE, nitro sublingual, aspirin, statin (even if LDL is normal), maybe a beta blocker
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Why do people have angina on cold days?
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Cold days = vasoconstriction --> preload up
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Why do people have angina upon exertion?
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exertion up --> BP up --> wall stress up --> O2 demand up
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of athsma? |
No beta blockers (not first line)
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of fainting spells? |
No beta blockers
No Verapamil |
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of aspirin allergy? |
Treat with clopidogrel
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of depression? |
Maybe stay away from beta blockers or only use non-lipid soluble beta blockers.
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A 53 y.o. woman presents to your office with breathlessness upon climbing staires. She tells you that all the members of her family have had heart disease.
What are your thoughts about further evaluation? What is the single most useful test in this situation? |
***
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A 71 y.o. man presents to your office with a dull aching sensation in the left shoulder with walking. It occurs only going up hills on cool days. It does not interfere with normal household activitties, but he does like to go for walks and he is no longer able to. You do an evaluation and find that he has a normal ejection fraction.
What do you do next? Any recommendations for medications? What are the consequences when you find out his PMH includes: - A history of fainting spells? |
No nitro, maybe no beta blockers. Not the CCBs that lean towards heart rate slowing (Verapamil, Diltiazem)
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