1
Q
What is normal blood pressure?
A
120/80 mm Hg
2
Q
What is stage I hypertension?
A
140-159/ 90 - 99
3
Q
What is stage II hypertension?
A
160-179/100-109
4
Q
What is stage III hypertension?
A
180-209/110-119
5
Q
What is pre-hypertension?
A
120-139/80-89
6
Q
What is isolated systolic hypertension?
A
> 140/80
7
Q
What are the 7 risk factors for hypertension?
A
- Blood relatives with hypertension
- Men over the age of 55
- Post-menopausal women
- Obesity
- Smoking
- Diabetes
- High blood cholesterol
8
Q
What are 6 complications of hypertension?
A
- Cerebrovascular hemorrhage
- Stroke
- Renal failure
- Heart failure
- Myocardial infarction
- Retinal damage
9
Q
What % of hyper tension is primary? What % is secondary?
A
95 % primary
5 % secondary
10
Q
What is meant by primary hypertension?
A
- Idiopathic
11
Q
What are 3 possible contributors to primary hypertension?
A
- High sodium in diet/ sodium retention
- Enhanced sympathetic nerve activity
- Pertubations in renin-angiotensin-aldosterone system
12
Q
What are the 4 common precipitating events of secondary hypertension?
A
- Chronic renal disease/ Diabetic neuropathy
- Pheochromocytoma
- Stress
- Aortic coarctation
13
Q
What type of heart failure is left-sided heart failure?
A
Congestive heart failure
14
Q
What type of loading will occur on the right side in CHF?
A
Volume loading
15
Q
What 3 main factors affect blood pressure?
A
- Vascular resistance
- Blood volume
- Cardiac output
16
Q
*** See slide 7… maybe… **
A
** See slide 7… maybe… **
17
Q
What are 2 examples of loop diuretics?
A
- Furosemide/ Lasix
- Bumetanide/ Bumex
18
Q
What is the mechanism of action of loop diuretics?
A
- Inhibition of Na+, K+, and Cl- reabsorption in the loop of henle resulting in electrolyte and fluid excretion
19
Q
What are the 2 indications for loop diuretics?
A
- Acute pulmonary edema
- Congestive heart failure
20
Q
What type of adverse effects typically result from loop diuretics?
A
Electrolyte imbalances such as:
- Hyponatremia
- Hypokalemia
- Reactive increase in renin levels
- Alkalosis
- Hyperuricemia
21
Q
How much sodium chloride resorption is the loop of henle responsible for?
A
50 - 75 %
22
Q
What are 3 thiazide/ thiazide-like diuretics?
A
- Chlorothiazide/ Diuril
- Hydrochlorothiazide/ Hyodrodiuril
- Metolazone/ Zaroxolyn
23
Q
What is the mechanism of action of thiazide and thiazide-like diuretics?
A
Inhibition of Na+, Cl-, and resorption in distal convoluted tubulue
24
Q
What are the 2 indications for thiazide and thiazide-like diuretics?
A
- Hypertension
- CHF
25
What is the advantage of a thiazide/ thiazide-like diuretic over lasix?
- Do not develop tolerance
26
What type of adverse effects result from thiazide and thiazide-like diuretics?
- Electrolyte imbalances
27
What class of drug is a K+ sparing diuretic?
Mineralocorticoid receptor antagonist
28
What is the chemical/ brand name of the most common K+ sparing diuretic?
Spironolactone/ Aldactone
29
From what is aldosterone secreted?
The adrenal cortex
30
What structure does aldosterone work on? What the effect?
- The collecting ducts
| - Enhance exchange of Na+ and K+
31
What is Spironolactone/ Aldactone's mechanism of action?
- Competitive blocker of aldosterone receptors in collecting duct
- Decreases exchange of Na+ and K+
32
What is the indication for use of K+ sparing diuretics?
- In conjunction with thiazides or loop diuretics in treatment of hypertension and CHF
33
What are 6 adverse effects of K+ sparing diuretics?
- Life-threatening hyperkalemia
- Gynecomastia
- Impotence
- Decreased libido
- Acidosis
34
Retention of what electrolyte is promoted by the aldosterone? Which is lost?
- Na+ maintained
| - K+ lost
35
What are 2 common adverse effects of potassium sparing diuretics?
- Hyperkalemia
| - Acidosis
36
What are 2 combination therapies that include K+ sparing diuretics?
- Amiloride and Hydrocholorothiazide (Moduretic)
| - Spironolactone and isobutylhydrocholorthiazide (Aldazide)
37
What are 2 methods of controlling hyperkalemia?
- IV injection of insulin and dextrose
| - Echange resin (Sodium polystyrene, Kayexalate)
38
Describe the renin-angiotensin II-aldosterone system.
- Renin secreted by renal cells
- Rening convers angiotensin to angiotensin I
- Angiotensin I converted to Angiotensin II by Angiotensin converting enzyme (ACE)
- Angiotensin II increases levels of aldosterone, and constricts vascular smooth muscle
39
What 3 effects does aldosterone have?
- Increase blood volume
- Increase sodium levels
- Decrease potassium levels
40
What is the counter-therapeutic effect of loop and thiazide diuretics?
- When blood volume is lost, the kidneys increase renin production to compensate
41
What type of drug can prevent the counter-therapeutic effects of loop and thiazide diuretics?
ACE inhibitors
42
What are 4 ACE-inhibitors?
- Captopril/ Capoten
- Enlapril/ Vasotec
- Lisinopril/ Prinivil
- Quinapril/ Accupril
43
What is the mechanism of action of ACE-inhibitors?
- Inhibition of angiotensin converting enzyme
- Reduces levels of vasoconstriction by Angiotensin II
- Reduces level of aldosterone by inhibiting angiotensin II
- Increases levels of vasodilator bradykinin
44
What are 2 indications for ACE-inhibitors?
- Diabetic hypertensive populations (slow development of diabetic neuropathy)
- Hypertensive populations with left ventricular hypertrophy (reverses/ slows down hypertrophy)
45
What are 5 adverse effects of ACE-inhibitors?
- Cough
- Dizziness
- Angioedema due to bradykinin
- Hyperkalemia
- Renal insufficiency
46
What are 3 angiotensin-receptor blockers?
- Losatran/ Cozaar
- Valsartan/ Diovan
- Candesartan/ Atacand
47
What is the mechanism of action of ARBs?
- Competitive inhibition of AT-1 receptor in vascular smooth muscle
- Relaxation of smooth muscle and decreased vascular resistance
48
What are 2 indications for ARBs?
- Diabetic hypertensive populations
| - Hypertensive populations with left ventricular hypertrophy
49
What is 1 adverse effect of angiotensin-receptor blockers?
- Hypotension
50
When should ARBs be discontinued? Why?
In 2nd and 3rd trimesters. Fetal circulation is affected
51
What are 3 beta-1 blockers used for the treatment of hypertension?
- Metropolol/ Lopressor
- Atenolol/ Tenormin
- Esmolol/ Breibloc
52
What is a non-selective beta blocker used to treat hypertension?
- Propranolol/ Inderal
53
What is the mechanism of action of beta-blockers?
- Blocks renin production in kidneys
| - Decrease in myocardial contractility
54
What is the indication for beta-blockers in cardiac patients?
- Hypetensive patients with angina following heart attack
55
In whom should beta-blockers be avoided? Why?
- Should be avoided in diabetics
| - Masks hypoglycemic tachycardia
56
What are 3 alpha-1 blockers used to treat hypertension?
- Prazocin/ Minipress
- Doxazocin/ Cardura
- Terazocin/ Hytrin
57
What is the mechanism of action of an alpha-1 blocker?
- Blocks effect of NE (at sympathetic neurons) or epinephrine to active alpha receptors on vascular smooth muscle, decreasing vasoconstriction and growth-promoting actions
58
What is the indication for alpha-1 blocker?
- Combination therapy with diuretics, and beta-1 blockers for hypertension
59
Why shouldn't alpha blockers be used alone?
- Increased risk of CHF
60
What is the adverse effect of alpha-1 blockers?
- First-dose phenomenon
| - Orthostatic hypotension in 50 % of patients
61
What are 4 common calcium channel blockers?
- Verpamil/ Isoptin
- Nifedpine/ Adalat
- Dilitiazem/ Cardiazem
- Amlodipine/ Norvasc
62
What is the mechanism of action of calcium channel blockers?
- Block Ca++ channels in arteriolar smooth muscles
- Flow Ca++ in cell blocked
- Prevents/ decreases contraction
- Decreases peripheral resistance
63
What is the indication for Ca++ channel blocker?
- Elderly populations with low circulating renin levels
64
What are 2 direct-acting vasodilators used to treat outpatients?
- Hydralazine/ Apresoline
| - Minoxidil/ Loniten
65
What are 2 vasodilator used in an emergency situation?
- Sodium nitroprusside
| - Diazoxide/ Hyperstat IV
66
What is the mechanism of action of a direct-acting vasodilator?
- Direct relaxation of vascular smooth muscles
| - Decreased peripheral resistance
67
What are 4 adverse effects of direct-acting vasodilators?
- Reflex tachycardia- Hypotension
- Fluid retention
- Hypertrichosis (Minoxidil)
- Methemoglobinemia (Sodium nitroprusside_
68
What are the 2 major centrally acting sympatholytic agents for the treatment of hypertension?
- Clonidine/ Catapress
| - Reserpine
69
What is the mechanism of action of Clonidine?
- Agonist of alpha-2 receptor in brainstem
| - Reduces sympathetic outflow
70
What is the mechanism of action of Reserpine?
- Inhibit vascular storage of norepinephrine and dopamine in central adrenergic neurons
71
What is the major adverse effect of Reserpine?
- Depression
72
What is congestive heart failure?
Inability of the heart to maintain adequate blood flow to meet the demands of peripheral tissues and itself
73
What is the most common form of CHF?
- Systolic failure because of decreased pressure and volume loads on right and left ventricles
74
What are 3 causes of CHF?
- Uncontrolled hypertension
- Coronary artery diseases
- Idiopathic cardiomyopathy
75
What are 7 symptoms of CHF?
- Orthopnea
- Paroxymal Nocturnal Dyspnea
- Tachypnea
- Peripheral edema
- Ankle swelling
- Weight gain
- Hepatomegaly
76
Describe the pathogenesis of CHF as it relates to sympathetic nerve activity and kidney perfusion.
Increased sympathetic activity:
- Tachycardia
- Vasoconstriction
- Increased vascular resistance
Decreased kidney perfusion:
- Increased renin release
- Increased angiotensin II release (which increases vascular resistance)
- Decreased urine output (which leads to edema)
77
What are the 3 therapy objectives for a patient with CHF?
- Increase CO
- Decrease ventricular filling volume
- Slow pathological remodeling of ventricles
78
What 3 drugs are used in CHF, and what is the basic function of each?
- Diuretics (gets rid of fluid)
- Vasodilatorys (decrease resistance problems due to sympathetic activation)
- Inotropic agents (heart stimulation)
79
What loop diuretics are typically used in CHF?
- Furosemide
| - Bumetanide
80
What problem may occur when using loop diuretics for CHF?
- Resistance to the actions of the loop diuretic when the drug is used chronically
81
How can the problems with resistance to loop diuretics be overcome?
Paired with a thiazide diuretic
82
What type of diuretic may be used in mild CHF?
- Thiazides
83
What type of diuretic has beneficial effects in advanced CHF, and can be used in combination therapy?
- Spironolactone
84
What vasodilators are used in the treatment of CHF?
- ACE-inhibitors
| - ARBs
85
Which type of vasodilator is a first line therapy in the treatment of CHF?
- ACE-inhibitors
86
What is are the 2 types of nitrovasodilators used in CHF?
- Sodium nitroprusside
| - Organic nitrates (isosorbide, dinitrate, nitroglycerin)
87
What is the mechanism of action of nitrovasodilators?
- Release of nitric oxide --> potent vasodilator
88
What is a second-line option for vasodilation in treatment of CHF?
- Ca++ Channel Blockers
89
What is the major benefit of beta blockers in the treatment of CHF?
Retards pathological remodelling of ventricles by neutralizing NE abd epinephrinr
90
What are 2 cardiac glycosides (inotropic drugs used in CHF?
- Digoxin/ Lanoxin
| - Digitoxin/ Crystodigin
91
What is the mechanism of action of Cardiac Glycosides?
- Inhibition of Na+/K+ ATPase pump in ventricular myocytes leading to elevation of intracellular Ca++ and increased myocardial contractility
- Potentiation of vagal nerve effects on heart
92
Why does it take a long time for cardiac glycosides to be eliminated from the body?
- Long half-lives
93
What is a problem with cardiac glycoside use?
Narrow therapeutic index
- Cardiac arrhythmia due to inhibition of Na+/K+ pump
- Atrial arrhythmia (A-fib, sinus brachycardia)
- Ventricular arrhythmia (angina, MI)
94
The level of what electrolyte is specifically related to digoxin toxicity?
- Potassium
95
What are the negative and positive effects of cardiac glycosides?
```
Negative:
- Decreases heart rate
Positive:
- Increased CO
- Increased Kidney perfusion
- Increased urine output
```
96
What 2 drugs are indicated for short-term support of circulation in advanced CHF?
- Dopamine
| - Dobutamine/ Dobutrex
97
What is the mechanism of action of dopamine and dobutamine?
- Positive inotropic effects
| - Vasodilation
98
What is the mechanism of action of inamirnone/ inocor and milirnone/ primacor?
- Inhibit phosphodiesterase enzyme
- Stimulates myocardial contractility
- Accelerates myocardial relaxation
- Decreases vascular resistance
99
What stages of HF put patients at risk for development of HF?
A and B
100
What stages of HF are symptomatic?
C and D
101
In what stage of HF is structural heart disease present, but there are no symptoms?
B
102
What stage of HF is end-stage?
D
103
What stage of HF puts a patient at high risk for HF, but patients show no structural heart disease?
A
104
What stage of HF would a patient that demonstrates past or current symptoms of be classified as?
C
105
Can a patient revert back to an earlier stage of HF?
No
106
What are 4 non-pharamacological management techniques of HF?
- Daily weight monitoring
- Exercise as tolerated
- Sodium restriction
- Fluid restriction
107
What should a patient with HF's sodium intake be limited to?
< 2 gm/ day
108
What should a patient with HF's fluid intake be limited to?
< 1.5 L/ day
109
What are the 3 aspects of pharamcologic management of HF?
- Appropriately manage and treat co-morbid illness
- D/C drugs that may contribute to HF
- Recommend treatment options based on ACC/AHA staging
110
What is the purpose of drugs in stage A HF, and what are they?
- Slow disease progression
- ACE-I
- ARB
111
What is the most common adverse effect of ACE inhibitors?
- Dry cough in 7 - 15 % of patients
112
What is the contraindication for ACE inhibitors?
- Angioedema
113
What 2 parameters should be monitored in patients taking ACE inhibitors?
- Renal function (SCr)
| - K+
114
What is the most common adverse effect of ARBs?
- Dry cough, but less common than in ACE-I
115
What are the 2 contraindications for ARBs?
- Bilateral renal artery stenosis
| - Pregnancy in 2nd and 3rd trimesters
116
What 2 parameters should be monitored in patients taking ARBs?
- Renal function (SCr)
| - K+
117
What is the drug therapy for stage B HF?
- ACE-I or ARB
PLUS
- Beta blocker
118
What is the mechanism of action of bisoprolol?
Beta-1 blocker
119
What is the mechanism of action of Carvedilol?
Non-selective beta and alpha receptor blocker
120
What is the mechanism of action of metoprolol succinate?
Beta-1 receptor blocker
121
What are 4 common adverse effects of beta-blockers?
- Hypotension
- Bradycardia
- Fluid retention
- Fatigue
122
What are 2 relative contraindications for beta-blockers?
- HR < 60 bpm
| - SBP <100 mmHg
123
What are 2 co-morbidities that are precautions for beta-blockers?
- Asthma/ COPD
| - Peripheral vascular disease
124
What 2 paraemeters should be monitored in patients using beta-blockers?
- HR
| - Blood pressure
125
What is the drug therapy for all patients in stage C HF?
- Diuretics
- ACE-I or ARB
- Beta blockers
126
What are 3 drug therapies for selected patients in stage C HF?
- Aldosterone antagonist
- Digitalis
- Hydralazine/ nitrates
127
What are 2 devices for selected patients in stage C HF?
- Biventricular pacing (BivP)
| - Implantable cardioverter difibrillator (ICD)
128
Are loop or thiazide diuretics more potent?
Loop
129
Are loop or thiazide diuretics longer acting?
Thiazides
130
Are loops an adjunct to thiazides, or are thiazides an adjunct to loops?
Thiazides adjunct to loops
131
Are loops or thiazides more appropriate for treatment of renal dysfunction?
Loop
132
What thiazide is the only one appropriate for renal dysfunction?
Metolazone
133
What is the half-life of furosemide?
4 - 6 hours
134
What type of diuretic is most appropriate for CHF?
Loop
135
Where do loop diuretics prevent reabsorption of sodium and chloride?
Ascending loop of henle AND distal renal tubule
136
Where do thiazide diuretics prevent reabsorption of sodium?
Distal renal tunule only
137
What is 1 common adverse effect of diuretics?
Urinary frequency
138
What are 2 contraindications for diuretics?
- Anuria
| - Renal decompensation
139
What 3 parameters should be monitored in patients taking diuretics?
- Electrolytes
- Renal function
- Weight
140
What are 2 common aldosterone antagonists?
- Spironolactone
| - Eplerenone
141
What is a common adverse effect of an aldosterone antagonist?
Gynomastia (benign enlargement of breast tissue in males)
142
What is the contraindication for the use of aldosterone antagonists?
- Hyperkalemia
143
What 3 parameters should be monitored in patients taking aldosterone antagonists?
- Renal fxn (ScR)
- K+
- BP
144
What is the half-life of digitalis?
40 hours
145
What is the usualy dose of digitalis?
0.125 to 0.25 mg
146
What should the serum levels of digitalis be?
0.5 - 0.8 ng/mL
147
How is digitalis expelled from the body?
The kidneys
148
Above what serum level will arrythmia result in digitalis?
< 1.2 ng/mL
149
What 5 drugs is toxicity enhanced by?
- Quinidine
- Amiodarone
- Low K+
- Low Mg
- High Ca+
150
What is the mechanism of action of Digoxin?
- Inhibits the Na/ K+ ATPase
- Increases Na/Ca exchange
- Increases in intracellular calcium
- Increased myocardial contractility (arrythmias)
151
What are 6 side effects of Digoxin?
- Visual disturbance
- Myocardial Infarction
- Vomiting
- Nausea
- Vomiting
- Dizziness
152
What should be always kept in mind when administering Digoxin?
Narrow TI
153
What parameters should be monitored in a patient taking Digoxin?
- Serum concentrations
154
What is the mechanism of action of Hydralazine? What load is affected by Hydralazine?
- Direct vasodilation of arterial smooth muscle
| - Reduced afterload
155
What is the mechanism of action of long-acting nitrates?
- Vasodilation
| - Decreased cardiac oxygen consumption by increase of intracellular cyclic-GMP
156
What are 4 side effects of Hydralazine?
- Reflex tachycardia
- Lupus
- Headache
- Flushing
157
What is the side effect of nitrates?
- Headache
158
What are 3 contraindications for Nitrates?
- PDE-5 inhibitors
- Head trauma
- Cerebral hemorrhage
159
What parameter should be monitored in patients taking Hydralazine/ Nitrates?
- Orthostasis
160
What are 2 treatments for stage D HF?
- Hospice care
| - Heart transplant
161
What is a self-care strategy for medication adherence?
Pill organizer
162
What is a self-care strategy for dietary adherence?
- Fluid restriction
| - Sodium restriction
163
What is a self-care strategy for monitoring of daily weight?
- Purchase scale
| - Log book
164
What is myocardial ischemia?
- Insufficient blood flow through coronary arteries leadings to imbalance between O2 supply and demand
165
What is angina pectoris?
Choking, squeezing pain in chest produced by ischemia
166
What is myocardial infarction?
Extreme ischemia, leading to cardiac tissue damage and cell death
167
What is stable angina?
- Exertional angina
- Blockage of coronary arteries by artherosclerotic lesions
- Pain and discomfort following exercise or stress
168
What is unstable angina?
- Caused by artherosclerotic lesion and/or clot that can occlude smaller coronary vesels
- Most common cause of MI
169
What is prinzmetal angina?
- Variant/ vasospastic
| - Spasmso f coronary arteries that are sudden and unpredictable
170
What 2 factors contribute to myocardial oxygen demand?
- Heart rate
| - Preload/ Afterload
171
What 2 factors contribute to coronary blood flow?
- Coronary vascular resistance
| - Aortic pressure
172
What does coronary blood flow affect?
Myocardial oxygen supply
173
What is an example of an organic nitrate (that will be on the exam)?
Isosorbide dinitrate
174
What effect greatly decreases organic nitrates efficacy when taken PO?
- First-pass effect
175
What other effect decreases organic nitrate therapy over time?
- Tolerance
176
What side effect should be monitored when using organic nitrates?
- Severe drops in BP
177
What is the half life of nitrogylcerin?
3 minutes
178
What is the half life of isosorbide dinitrate?
45 minutes
179
What formulation of organic nitrates provide immediate relief of angina symptoms within 1 - 2 minutes?
- Sublingual tablets
| - Inhalation spray
180
What formulation of organic nitrates is used for prophylaxis in patients having more than one angina attack?
Oral nitrate
181
What formulation of organic nitrates is used for short-term prophylaxis in anticipation of an angina attack?
- Transmucosal
| - Buccal
182
What type of nitrate is used in acute management of unstable angina?
Nitroglycerin
183
Describe the process of a nerve signal conducting through the heart including relevant nodes and structures.
- Signal generated form SA node (pacemaker) under control of sympathetic and parsympathetic systems
- Signal travels to AV node contracting atria
- Signel enters ventrivles through bundle of His and Purkinje fibers causing ventricular contraction
184
What is the P wave?
Atrial depolarization
185
What is the QRS complex?
Ventricular depolarization
186
What is the T wave?
Ventricular repolarization
187
What are 2 examples of abnormal heart rhythms?
- Atrial fibrillation
| - Ventricular tachycardia
188
What is a class 1 antiarrhythmic drug?
Na+ channel blockers
189
What is a class 2 antiarrhythmic drug?
Beta blocker
190
What is a class 3 antiarrhythmic drug?
K + channel blocker
191
What is a class 4 antiarrhythmic drug?
Ca++ channel blocker
192
What are 3 examples of class 1 antiarrhythmic drugs?
- Quindine
- Lidocaine
- Procainamide
193
What are 2 examples of class 2 antiarrhythmic drugs?
- Metoprolol
| - Propanolol
194
What is 1 example of class 3 antiarrhythmic drugs?
- Amiodarone
195
What are 2 examples of class 2 antiarrhythmic drugs?
- Verapamil
| - Diltiazem
196
What class of drugs antagonize sympathetic nerve activity, decreasing SA automaticity and causing a negative iontropic effect?
- Class II (Beta-blockers)
197
What class of drugs extend the duration of action potentials through the heart?
Class III/ K+ channel blockers
198
What class of drugs decrease conduction velocity through the heart?
Class I/ Na+ channel blockers
199
What class of drugs antagonize sympathetic nerve activity on the SA and AV nodes?
Class IV/ Ca++ channel blockers
200
What are 2 common cardiac glycosides?
- Digoxin
| - Digitoxin
201
What is the mechanism of action of cardiac glycosides?
- Enhance effects of vagus nerve on heart
- Slows SA node
- Slows conduction through AV node
202
What type of arrythnmias are cardiac glycosides used to treat?
Artrial arrhythmia associated with tachycardia
