Arrhythmias
What medication classes cause torsade de pointes?
How do you treat torsade de pointes?
Class 1a and Class 3 anti arrhythmics
IV magnesium sulfate or isoproterenol
What medications do we use in the acute phase of every type of angina?
Which nitrate has bioavailability of 100%?
Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate
Isosorbide mononitrate
Name the potassium sparing diuretics and how they work.
Aldosterone receptor antagonists block aldosterone at the distal convoluted tubule: spironolactone and eplerenone
eNac receptor antagonists in the distal nephron that block the reabsorption of sodium and water from urine: amiloride and triamterene
Name some CCBS, their types, and their specificity.
DHPs: amlodipine, nimodipine, nifedipine -pines (vessels)
NonDHPs: verapamil (cardiac) and diltiazem (cardiac and vessels)
"cut the PINES down and put ZEM in the MIL"
Which meds decrease cardiac remodelling?
Beta blockers, ACEi, ARBs, renin inhibitors, aldosterone receptors antagonists, ARNi (sacubitril and valsartan)
Quinidine, procainamide, and disopyramide all belong to this class of antiarrhythmics.
Match each medication with its corresponding ADR: strong anticholinergic properties, cinchonism, and lupus-like syndrome.
Class 1a
Strong anticholinergic: disopyramide
cinchonism: quinidine
Lupus-like syndrome: procainamide
What is an absolute contraindication of nitrates and why?
Do not use within 24 hrs of sildenafil use due to severe hypotension and reflex tachycardia that can precipitate an MI
Name some loop diuretics and how they work.
These meds are considered "high ceiling diuretics" making them extremely efficacious. Because of this, what are some adverse reactions of these meds?
Frusemide, furosemide, bumetanide, torsemide, and ethacrynic acid. Work at the ascending loop of henle to block sodium/chloride channels.
Severe electrolyte imbalances: hypokalemia, hypocalcemia, hypomagnesemia, hyponatremia.
This medication is specifically used in the management of subarachnoid hemorrhage?
Nimodipine
Dogixin, bypridines/PDE3 inhibitors (inamrinone, milrinone), beta agonists (dobutamine)
These class 1B medications can be used to treat ventricular arrhythmias such as premature ventricular contractions (PVCs) and ventricular fibrilation (Vfib).
Mexiletine and lidocaine
Which loop diuretics cause interstitial nephritis and rash? Which loop diuretic is safe in pts with sulfa allergy?
furosemide, frusemide, bumetanide, torsemide
ethacrynic acid
Which CCB should never be given in HF?
Which CCB is unsafe in pts with CAD due to its reflex tachycardia - (MI)
Verapamil- exacerbates HF bc it slows conductivity and FoC in an already weakened heart.
Nifedipine
This cardiac glycoside decreases HR and increases contractility. It is used mostly in Afib.
Digoxin
These sodium channel blockers are used in both supraventricular tachyarrhythmias and ventricular tachyarrhythmias. (class and name)
They are used 3rd line in afib*
Class 1c: flecainide, propafenone
Which diuretics are first line for pts with essential hypertension with no other comorbidities (diabetes, kidney disease, etc)?
Thiazides: hydrochlorothiazide, clothalidone, metolazone, indapamide
ACEi -pril
ARBs -sartan
Describe the MOA of Digoxin
Competitively binds to Na+/K+ pump, increasing intracellular Na+, inhibiting Ca+/Na+ pump, increasing intracellular calcium which increases contractility (FoC).
Which sodium channel blockers are given to post MI pts because they have the most pronunced effect on ischemic tissue?
Class 1B : lidocaine, mexiletine
What is the mechanism of action for thiazides?
List some common adverse effects.
Why don't we give thiazides to pts with diabetes?
Work on distal convolute tubule by blocking sodium/chloride cotransporter. Lower blood volume initially, long term use lowers TPR due to unknown mechanism.
Hypokalemia, hypomagnesemia, hyponatremia, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia.
Can can hyperinsulinemia due to elevated blood glucose, making DM and BP worse.
ACEi and ARBs
What are some common GI and CNS effects of Digoxin?
GI: n/v/d, anorexia
CNS: yellow/green discoloration of vision. disorientation, hallucination
gynecomastia
A 30 year old female comes into the ER with concerns of palpitations. Upon further evaluation, you learn the pt has a history of sudden onset palpitations and chest tightness with accompanying anxiety. She sometimes feels faint and feels her heart beating quickly. These episodes seem to come on randomly and terminate abruptly. What is the most likely diagnosis and treatment?
Paroxysmal supraventricular tachycardia treated with adenosine
Which receptors makes propranolol effective in long term blood pressure control?
Why wouldn't we give propranalol to pts with Asthma, COPD, or Raynauds?
Propranolol blocks beta 1 receptors in JG cells, blocking the release of renin, making it an effective long term bp med.
Propranolol is a non-selective beta blocker and has action on beta 2 receptors in the bronchus promoting vasoconstriction, as well as alpha 1 receptor in the peripheral vasculature promoting vasoconstriction.
These medications are good for diabetic patients bc they protect their kidneys from obliteration and proteinuria, but are contraindicated in renal artery stenosis.
ACEs and ARBs
What are the electrical effects of digoxin?
What electrical change can be seen in an EKG in digoxin toxicity?
Prolonged PR interval due to slowing of the AV node and a flattened T wave (slower repolarization of the ventricles)
Bigeminy
This medication belongs to has mixed class antiarrhythmic activity and is used as first line therapy for converting Afib into normal sinus rhythm. This medication is considered the medicant of choice for pts with HF.
Once converted, you switch the pt over to this other medication in the same class.
Amiodorone, sotalol
What beta blockers are given to pts that are sensitive to BBs and why?
Beta blockers w/ ISA - acebutolol, labetalol, penbutalol, pindolol, prevents severe hypotension and bradycardia.
Which ARB causes diarrhea, malabsorption, and bloating "sprue like syndrome"
Olmesartan
An excess of these two ions can decrease the effects of Digoxin.
Why do loop diuretics increase digoxin effects?
Digitalis induced vomiting may cause hypo____, which can facilitate toxicity.
K, Mg
Loop diuretics lower potassium which increases the effects of digoxin.
magnesium
What medications control heart rate in Afib? Name the classes and drug names. Of these classes, which is known to be the most effective?
Class 2 beta blockers: esmolol, propranolol, metoprolol, class 4 NDHP CCBs: verapamil, diltiazem, and Digoxin.
Beta-blockers are most effective.
Prazosin, terazosin, doxazosin are what kind of medications? How do they work?
Alpha receptor blockers: inhibit vasoconstriction, lower TPR, lowers afterload, lowers CO and BP.
This medication works on RAAS by inactivating Renin
Aliskiren
An excess of this ion increases digoxin effects.
Calcium
Which class of antiarrhythmics is contraindicated in pts with heart failure and pts with wolf-parkinson=white syndrome? Why?
They have a negtive inotropic effect making a HF heart reduce FoC even more. They can also accelerate pts with WPW into vtach which can be deadly.
What are some major adverse effects of prazosin?
Floppy iris syndrome, "first dose" hypotension, dizziness, drowsiness, headaches, weakness, postural hypotension, palpitations, nervousness.
Which diuretics are used in chronic HF?
Spironolactone and eplerenone
Quinidine and verapamil both _______ Digoxin effects. How do they do this?
Verapamil- inhibits p-glycoprotein efflux pump, increases serum digoxin concentration.
Quinidine- displacement rxn with digoxin, increasing serum levels.
Which antiarrhythmics are used to treat PVCs?
Class 2 beta blockers: esmolol, propranolol, metoprolol, Class 1B sodium channel blockers lidocaine and mexiletine, amiodarone (mixed class 3)
Name some central sympatholytics.
if stopped abruptly, which one can cause rebound hypertension?
Which one is safe in pregnancy, but can cause hepatitis and hemolytic anemia?
Clonidine, methyldopa, guanabenz, guanafacine
Clonidine, methyldopa
Loop diuretics such as furosemide is used in what condition?
Acute HF or HF exacerbation to quickly pull off fluid.
What are the steps in managing digoxin toxicity?
1. correct potassium levels
2. omit several doses to reduce serum levels
3. Lidocaine and phenytoin can correct bigeminy
4. Severe toxicity is treated with Digibend
What medications are used to treat Vfib?
IV amiodarone or lidocaine after dfib.
These medications are strong arterial dilators that are contraindicated in pts with HF due to their ability to trigger RAAS.
What are common side effects of these medications.
Hydralazine- Lupus like Syndrome and minoxidil- hirsutism
Which beta blockers reduce mortality in pts with HF?
Carvedilol (alpha and beta)
metoprolol (b1 specific)
Bypyridines, also called ___________, are only used in acute HF or severe HF exacerbation. Name these meds and and give their adverse effects. Which med is safest?
PDE inhibitors
amrinone, milrinone
ADRs: bone marrow suppression, liver toxicity, GI upset, arrhythmias
milrinone (less BMS and LT)
Sodium channel blockers that reduce AV node conduction and increase refractory time- Name the classes and meds within each class.
Class 1a: quinidine, procainamide, disopyramide
Class 1b: lidocaine, mexiletine
Class 1c: Flecainide, propafenone
Reserpine and guanadrel are both peripheral sympathetic inhibitors that reduce the effects of NTs. How do they work? Which one causes depression/suicidal ideation? Which one is known to cause orthostatic hypotension?
Reserpine- inhbiits VMAT, doesn't package NTs into vesicles to release into synapse. (depression/suicidal ideation)
Guanadrel- "false NT" gets packaged and released into cleft, but don't work like NTs. (orthostatic hypotension)
How do bipyridines work?
Inhibit the degradation of cAMP that activates Protein Kinase- A, responsible for allowing calcium into myocytes and increasing contractility of the heart.
What class of antiarrhythmics are beta blockers? What meds are in this category?
Class 2: esmolol, propranolol, metoprolol
Pheochromocytoma is treated with these meds
Nicardipine or phenoxybenzamine
How do beta agonists help in the treatment of acute HF or stage 4 HF exacerbations?
What is the name of this medication?
They increase the intracellular level of cAMP which increases calcium levels and contractility. This is helpful because it promotes contractility and increases FoC, allowing for more ejection fraction and organ perfusion.
Dobutamine
Potassium channel blockers, such as ibutilide and dofetilide are what class?
What are some mixed class 3 drugs?
Class 3
Amiodarone (class 1-4 action, mostly 3*) and sotalol (class 2 and 3)
What is used in the treatment of hypertensive emergency?
How does this medication work?
This med can cause cyanide poisoning, how do we treat this?
Sodium nitroprusside- enzyme independent NO donor that promotes vasodilation via guanylyl cyclase that converts GTP into cGMP which dephosphorylates MLK-phosphate to MLK
Sodium thiosulfate or hydroxocobalamin
Reduces cardiac remodeling (angiotensin 2/aldosterone) while reducing preload and afterload, decreases fluid retention, promotes vasodilation.
Verapamil and diltiazem belong to what class? What is their action?
Are these drugs specific to a certain tissue type?
Class 4, calcium channel blockers.
Verapamil is specific to heart tissue
Diltiazem has both heart and vessel targets, mostly heart
Med used in insulinomas and reducing BP. How doe sit work?
Diazoxide- directly inhibits potassium ATPase in the beta cells which inhibits insulin release.
What does Nesiritide do? What other medication works in the same pathway, but in a different way?
Nesiritide is a synthetic BNP that decreases afterload by producting potent venous and arteriolar vasodilation, effectivley reducing afterload. It also promotes sodium and water loss via the kidneys. This is used in acute or decompensated HF.
Sacubitril is a neprilysin inhibitor that blocks neprilysin from degrading BNP, keeping more BNP around to work.