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152 Cards in this Set
- Front
- Back
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angina is due to
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insufficient coronary blood flow to myocardium
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angina =
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myocardial O2 demand exceeds coronary O2 supply
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stable angina is caused by
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some degree of atherosclerotic occlusion in coronary vessels, so at some intensity of exercise, O2 demand exceeds O2 supply, causing pain
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how do you treat stable angina?
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rest and nitroglycerin
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Prinzmetal (aka variant or vasospastic) angina is cause by
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temporary vasospasm of coronaries; more common in women than men
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tx of Prinzmetal angina
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nitroglycerin
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unstable angina is caused by (2 things)
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1. acute plaque change --> partial trhombus
2. atherosclerotic occlusion severe enough that moment-to-moment sedentary changes in heart activity cause O2 demand to exceed O2 supply |
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can unstable angina be tx with NTG?
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no
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4 general treatments of angina
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1. dilate coronary arteries
2. dilate coronaries and systemic veins 3. dilate coronaries and systemic arterioles 4. decrease cardiac contractility |
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to dilate coronary arteries for prompt relief of stable or Prinzmetal anginal attack
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NTG
nitrolingual spray or nitrostat sublingual tabs |
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how does NTG relieve angina?
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systemic veins dilate --> decrease in VR --> decrease in preload --> decrease in cardiac work
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to dilate coronaries and systemic veins long-term to prevent anginal attacks
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NTG
Nitrodur - patch NitroBID - ointment Isosorbide mononitrate or dinitrate - long-acting tabs |
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to dilate coronaries and systemic arterioles to prevent anginal attacks
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dihydropyridine class of Ca-channel blocker like nifedipine (Procardia XL)
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to decrease cardiac contractility to prevent anginal attacks
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BB - propranolol or metoprolol
or non-dihydropyridine class of Ca-channel blocker - Verapamil (decreases HR and contractility) - Diltiazem (decreases HR, contractility, dilates coronaries and arterioles - used for Prinzmetal's) |
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2 side effects of NTG
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headache
postural hypotension |
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tolerance to long-acting nitrates develops rapidly -- how can you prevent this?
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take the NTG patch or ointment off at night
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major side effect of Ca-channel blockers
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constipation
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which class of drug is the only one to be used to decrease HR and contractility in a patient with a damaged heart from MI or CHF?
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BBs
verapamil and diltiazem do not have the same beneficial effects as BBs should never use Ca-channel blockers in these pts |
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these two things have been found to decrease risk of newly forming plaque as well as decreasing existing plaque
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lifestyle changes and medication
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CAD is positively correlated with
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high TC, but more so with high LDL
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High HDL is...
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correlated with decreased risk of CAD
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total cholesterol =
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VLDL + LDL + HDL, where VLDL is TG/5
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primary goal in cholesterol-lowering therapy is to reduce
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LDL
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target levels of cardiac lipids in normal person:
TC LDL HDL ratio of TC to HDL |
TC <200
LDL <130 HDL >60 TC:HDL ratio as low as possible |
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statins (HMG CoA reductase inhibitors) are used mainly to...
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decrease LDL
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2 statins that decrease LDL by 50%
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atorvastatin (Lipitor) and rosuvastatin (Crestor)
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how do statins lower LDL?
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by inhibiting the rate limiting step in cholesterol synthesis
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statins decrease intracellular/hepatic synthesis of cholesterol. this causes...
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increased number of extracellular LDL receptors --> increased cellular uptake of LDL --> decreased plasma LDL
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2 major side effects of statins
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1. myopathy/muscle pain - pretty common, so need to test CPK-MM regularly
2. elevated liver enzymes, so need to test AST and ALT regularly |
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this drug decreases risk of CV events just as much as statins, and is cheaper
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aspirin
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which class of drugs is used to treat high TGs
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fibrates
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which fibrate can decrease TG by 50%?
another common fibrate? |
fenofibrate (Lofibra)
gemfirozil (Lopid) |
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high TGs (>500) can cause...
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pancreatitis
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side effect of fibrates
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myopathy
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this drug causes the greatest increase in HDL (by 25%)
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niacin
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this drug causes the largest changes in all 3 lipids
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niacin
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2 side effects of niacin
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1. facial flushing - can take aspirin or NSAIDs 30 minutes before taking in order to decrease this
2. gout |
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what can you do to prevent niacin-induced flushing?
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extended release niacin
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what are bile acid binding resins used for?
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to lower LDL (by 30%)
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3 bile acid binding resins
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cholestyramine
colesevelam colestipol |
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5 side effects of bile acid binding resins
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1. bloating
2. flatulence 3. abdominal pain 4. decrease absorption of vitamins ADEK 5. decrease absorption of other drugs |
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this drug directly decreases GI tract cholesterol absorption
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ezetimibe (Zetia)
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do all of the anti-hyperlipidemic drugs affect both HDL and LDL?
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yes
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which anti-hyperlipidemic drug class decreases LDL most?
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statins
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which anti-hyperlipidemic drug class increases HDL most?
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niacin
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which anti-hyperlipidemic drug class decreases TGs most?
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fibrates
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the most important drug combo for cardiac lipids
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fenofibrate + statin
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substance that has significant cardio-protective effects and is under-utilized in practice
what is beneficial about them? |
omega-3 fatty acids (from fish oil or dietary supplements)
they decrease TGs |
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this potentiates the toxicity of digoxin
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hypoK
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how do thiazides tx HTN?
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dump some fluid volume
long-term they cause arteriolar vasodilation* |
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how do thiazides tx diabetes insipidus?
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polydipsia and polyuria paradoxically respond because of the decrease in plasma volume
first, aldosterone causes increased Na and water retention which decreases polydipsia; second, there is less volume being filtered which decreases polyuria |
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ceiling diuretics
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thiazides; ceiling b/c they are no better at higher doses
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2 most commonly used thiazides
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hydrochlorothiazide
Chlorthalidone |
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what do thiazide diuretics decrease? how about loop diuretics?
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thiazides - Na reabsorption in distal convoluted tubule
loops - Na reabsorption in ascending limb of loop of Henle |
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when do thiazides become ineffective?
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GFR <30
Ccr < 50 |
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2 common uses for thiazides
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tx of CHF and HTN
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first choice of drug for mild HTN
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thiazide diuretic
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thiazides do what to Ca and K? so what can they treat?
loops do what to Ca and K? so what can they treat? |
thiazides increase Ca reabsorption and K excretion; tx osteoporosis and prevent Ca stones
loops increase excretion; tx hyperCa and hyperK |
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3 side effects of thiazides
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increase K excretion --> hypoK
increase H+ excretion --> alkalemia decrease uric acid excretion --> gout |
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3 things that can be used to compensate for thiazide-induced hypoK
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1. K-sparing diuretic
2. K supplement 3. bananas |
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3 loop diuretics
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1. furosemide (Lasix)
2. bumetanide 3. ethacrynic acid |
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which kind of diuretic still works in a patient with renal insufficiency? why?
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loops
decrease renal vascular resistance and increase renal blood flow |
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drug of choice for reducing/mobilizing pulmonary edema of heart failure
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loop diuretics
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these diuretics work quickly and so are useful in emergencies
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loops
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2 side effects of loops
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1. ototoxicity (esp. when given with aminoglycoside)
2. shock (b/c of severe rapid reduction in blood volume and hypovolemia) |
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loop most likely to cause ototoxic deafness
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ethacrynic acid
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3 K-sparing drugs
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TAS
triamterene amiloride spironolactone |
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possible side effect of K-sparing drugs
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hyperK
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aldosterone receptor antagonist and therefore not useful in normoaldosteronism; can't treat Addison's
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spironolactone
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2 side effects of spironolactone
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1. gynecomastia
2. menstrual abnormalities b/c it resembles sex steroids |
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most common osmotic diuretic
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mannitol
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how does mannitol work? how must it be given?
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it increases water excretion
must be given IV |
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used to maintain tubular fluid after toxic ingestion, prevents ARF due to circulatory shock, lowers increased ICP
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mannitol
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what must be given with mannitol
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PO or IV fluid to prevent dehydration
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most common cause of heart failure
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left systolic dysfunction due to CAD
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3 compensatory mechanisms in HF to increase CO and maintain GF pressure
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1. sympathetic tone - increases HR and contractility, increases renin secretion, and vasoconstriction
2. RAS system to increase volume 3. cardiac hypertrophy (dilated and globular) |
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increased salt intake, increased exertion, illness/fever, emotion, not taking meds, and AMI can cause this in chronic HF patient
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decompensation, exacerbation, or acute HF
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DOC for all stages of heart failure b/c limit cardiac remodeling and decrease M&M
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ACEIs
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2 ACEIs
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Lisinopril, Captopril
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3 side effects of ACEIs
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1. dry cough
2. pharyngeal angioedema and airway closure 3. ARF in pt with RAS b/c it vasoconstricts the dilated efferent arterioles causing no pressure |
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2 ARBs
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Losartan, Candesartan
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why do ACEIs and ARBs decrease cardiac remodeling?
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they decrease aldosterone, so no volume overload and decreased filling pressures
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this drug is used in advanced HF for the same reason ACEIs and ARBs are used
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spironolactone
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negative inotropes that improve systolic function in HF and decrease remodeling b/c they block renin
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beta blockers
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2 beta blockers for heart failure
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Carvedilol
Metoprolol |
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beta blocker that is also an alpha blocker
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Carvedilol
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which class of drugs have no use in HF
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Ca-channel blockers
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positive inotrope reserved for pts not responding to combo therapy of ACEI, BB, and diuretic
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digoxin
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which kind of HF is digoxin used for
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only left-sided systolic HF
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sx of digoxin toxicity
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1. severe dysrhythmias
2. N/V 3. headache and confusion 4. blurred vision, halos, etc. |
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3 electrolyte disturbances that predispose to dig toxicity
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1. hypoK
2. hypoMg 3. hyperCa |
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digoxin Ab
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Digiband
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DOC for mild asthma and also for rescue in all severities of asthma
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short-acting B2 agonists
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2 short-acting B2 agonists
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albuterol
terbutaline |
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salmeterol
formoterol |
2 long-acting B2 agonists
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do short-acting B2 agonists have anti-inflammatory action? how about inhaled glucocorticoids?
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no
yes |
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DOC for moderate or severe asthma
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inhaled glucocorticoids
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fluticasone (Flovent)
triamcinolone (Azmacort) |
inhaled glucocorticoids
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best combination therapy for controlling moderate and severe asthma
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inhaled steroid + long-acting B2 agonist
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tx of status asthmaticus
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sometimes PO steroid like prednisone
or IV steroid like methylprednisolone |
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side effect of inhaled steroids
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oral candidiasis
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po anti-leukotrienes
inhaled anticholinergics po theophylline inhaled cromolyn and nedocromil subq monoclonal Ab to IgE |
alternatives to inhaled steroid + long-acting B2 agonist
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only remaining anti-leukotriene (leukotriene receptor blocker)
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montelukast (Singulair)
anti-inflammatory |
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inhaled anticholinergic that causes bronchodilation and decreased mucus secretion
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ipratropium (Atrovent)
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bronchodilator with slight anti-inflammatory effect
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theophylline
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cromolyn and nedocromil
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mast cell stabilizers used to block allergen and exercise induced asthma
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Xolair
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monoclonal Ab that binds IgE and prevents it from binding to mast cells
expensive and not first-line |
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long-acting anticholinergic for COPD
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tiotropium (Spiriva)
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what drugs other than Spiriva can be used for COPD
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B2 agonists
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combo of long-acting anticholinergic (Spiriva) + long-acting B2 agonist (salmeterol)
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used for COPD
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do inhaled steroids aid in COPD?
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no, except in exacerbation
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propranolol or verapamil
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A-flutter
SVTs (AV nodal re-entry) |
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propranolol or amiodarone + Coumadin
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A-fib
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lidocaine or amiodarone
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acute V-tach (in AMI)
V-fib not responding to defibrillation |
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3 classes of antiplatelets and examples of each
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1. COX-1 inhibitor (aspirin)
2. ADP receptor blocker (Plavix) 3. GP IIb/IIIa receptor blocker (ReoPro and Aggrastat) |
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Disalcid
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non-acetylated salicyclic acid, so has no anti-platelet effect
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Celebrex, APAP, Vioxx
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COX-2 inhibitors (no anti-platelet effect)
when taken alone, believed to cause CV events b/c of increased production of thromboxane A2 |
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claudication, visible arterial insufficiency, ankle-brachial index <0.9
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PAD - should be taking ASA
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side effects of ASA
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prolonged bleeding time --> increased risk of hemorrhagic stroke, GI bleed
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what is used if ASA cannot be tolerated
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Plavix
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side effect of Plavix and other ADP blockers
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neutropenia
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inhibits action of thrombin by binding anti-thrombin and activating it to inhibit thrombin
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heparin and lepirudin
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inhibits synthesis of thrombin
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warfarin
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anticoag of choice in pregnancy b/c doesn't cross placenta
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LMWH
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aPPT used to monitor effect of...
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IV heparin
1.5-2.5x NL |
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enoxaparin (Lovenox)
dalteparin (Fragmin) |
LMWH - given subq and don't need aTTP (replacing IV heparins)
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antidote for heparin-induced hemorrhage
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lower dose, D/C, or Protamine sulfate (doesn't work as well for antidote to LMWH)
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4 side effects of heparin
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hemorrhage
hypersensitivity thrombocytopenia DIC |
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tx of DIC
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stop heparin, may use lepirudin
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direct thrombin antagonist
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lepirudin
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vitamin K antagonist
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coumadin
b/c during synthesis of clotting factors, vit K is deactivated and coumadin doesn't allow reactivation |
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monitored by PT
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coumadin
1.5-2.5x normal |
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antidote for coumadin-induced bleeding
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vitamin K oral
if very severe, IV or FFP |
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teratogenic anti-coag
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warfarin
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alteplase and streptokinase
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thrombolytics
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convert plasminogen to plasmin
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thrombolytics
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"fibrin-selective" thrombolytic b/c it has greater affinity for plasminogen already bound to fibrin
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alteplase
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induces a systemic fibrinolytic state b/c it binds to free plasminogen in the plasma
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streptokinase
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side effect of streptokinase
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increases risk of hemorrhage
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antidote for fibrinolytic state of streptokinase
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aminocaproic acid (Amicar)
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pts with healing wounds, pregnancy, recent CVA, or metz CA should no take these
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thrombolytics
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what is the window for use of thrombolytics?
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2-6 hours (acute)
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most successful delivery of thrombolytics for AMI
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intra-coronary (cardiac cath) but usually have to give IV b/c of the window
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tx for Fe-deficiency anemia
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oral ferrous sulfate
Fe supplements 3-6 months |
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side effects include constipation and black stools
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Fe supplements
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in pt who can't take or absorb oral Fe, such as inflammatory bowel disease, what should they take?
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parenteral Fe therapy - Iron Dextran
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3 causes of folate-deficiency anemia
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pregnancy
alcoholism folate-antagonistic drugs like trimethoprim |
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tx of folate-deficiency anemia
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folic acid
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2 causes of B12-deficiency anemia
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lack of intrinsic factor: pernicious anemia or gastric resection
dietary deficiency |
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tx of dietary B12 deficiency anemia
tx of pernicious anemia or B12 malabsorption |
oral B12
IM B12 to normalize and Nascobal nasal gel to maintain |
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neurologic sx of B12 deficiency
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1. parasthesias
2. tinnitus 3. decreased vibration sense 4. decreased proprioception and balance problems |
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tx of severe anemia from ESRD, HIV, CA
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erythropoietin and Fe supplement
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