Block 5 Lecture

An epidemiologic study of eating habits is performed. Dietary patterns of adult patients are recorded and compared to risk for cardiovascular diseases. It is observed that persons who eat bacon for breakfast are more likely to have cardiovascular disease than persons who eat oat bran cereal. Which of the following conditions is the 'bacon' group most likely to have? A Mitral annulus calcification B Ventricular aneurysm C Left atrial dilation D Thoracic aortic aneurysm E Aortic valve stenosis

(B) CORRECT. The ventricular aneurysm is a complication of myocardial infarction. The incidence of MI is increased with an atherogenic diet.

CONTRAINDICATIONS For BETA BLOCKERS

-Congestive Heart Failure -Marked bradycardia (HR<55 bpm) -Advanced AV block (1st, 2nd or 3rd Degree) -Severe Peripheral Vascular Disease -Insulin-Dependent Diabetes Mellitus - when take insulin, stim epinephrine, b receptors, increase BP, no effective, so prolonged reduction of Blood sugar. -Sexual Impotence -Bronchospasm

-Nifedipine vs Nicardipine vs Amlodipine

-Nifedipine (tachycardia) - Nicardipine (longer t1/2, coronary selective, no decrease in cardiac contractility) - Amlodipine (can be used in systolic HF unlike other CCBs)

Other non-hypolipidemic indications for Bile Acid-binding resins Cholestyramine and Colestipol

-Prevention of pruritus as a consequence of liver failure -prevent diarrhea for chron's -Treatment of C. difficile infections -Treatment of drug overdose: digoxin, leflunomide & levothyroxine

. --- is strongly associated with an increased risk of STATIN-induced myopathy and Rhabodmyolysis.

. Gemfibrozil (a fibrate drug) is strongly associated with an increased risk of STATIN-induced myopathy and Rhabodmyolysis.

Inhibitors of Cholesterol Absorption Ezetimibe (Zeita®)

. Reduces LDL-C in patients with primary familial hypercholesterolemia (LDLR null mutations)

--- reduces the level of Lp(a) lipoprotein

6. Niacin reduces the level of Lp(a) lipoprotein

RANOLAZINE

A new class of drug used for angina includes ranolazine. It acts by inhibiting a specific sodium channel in the cardiac myocyte that contributes to calcium influx. This reduces contractility and helps reduce oxygen demand.

A 35-year-old man was found down, was delirious, and talking incoherently. On examination in the emergency department his temperature is 39.3°C, pulse 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable spleen tip, and splinter hemorrhages of fingernails. Which of the following laboratory findings is most likely to be present in this man? A Positive urine screen for opiates B Elevated anti-streptolysin O (ASO) C Increased urinary free catecholamines D Elevated Coxsackie B viral titer E Rising creatine kinase (CK) in serum

A. Positive urine screen for opiates This history points to an infective endocarditis. A common risk factor for infective endocarditis, particularly with more severe and acute disease, is intravenous drug use.

CK is a 53 yo woman with a history of chronic pulmonary obstructive disease & heart disease who presents with chest palpitations & dizziness of sudden onset. She has been on theophylline therapy for COPD, along with an quinopril, spironolactone, dihydrochlorothiazide and carvedilol for HF. A12 lead ECG reveals the presence of a tachycardia with narrow QRS complexes & inverted P waves buried at the end of the QRS complex. A tentative diagnosis of PSVT, most likely caused by AV node reentry is made. The best drug for acute conversion of CJ's arrhythmia would be: ? adenosine ? amiodarone ? lidocaine ? procainamide

Adenosine Adenosine has a short half life of ~10 seconds and is highly effective in terminating AV node reentry when given i.v.

when is ccb a good first choice for htn?

African Am with uncomplicated HT Pts with electrolyte, carb or lipid metabolism probs. Ischemic Heart Dx (e.g., CAD) COPD Diabetes Pts w/ atrial fibrillation (non-dihydropyridines)

Preferred treatment for ventricular arrhythmia

Amiodarone

A 6 month old newborn who is in the ICU following cardiac surgery for a congenital defect develops atrial flutter with an atrial rate of 300 beats/min and a 2nd degree AV conduction block with 2:1 atrial to ventricular conduction. An intern inadvertently administers quinidine instead of propranolol, and the patients ventricular rate sky rockets to 300 beats / min. The patient faints. This most likely occured because quinidine is: ? a partial beta agonist ? a potassium channel blocker ? a sodium channel blocker ? antimuscarinic

Anitmuscarinic Although quinidine is very rarely used anymore because of concern about "proarrhythmia" (Torsade), this is a good teaching point. All of the Class IA drugs are effective against atrial tachyarrhythmias, but share the abililty to reduce the effect of the vagus on the AV node, either by being "atropine like" antimuscarinics, or by being weak ganglionic blockers (procainamide). Either mechanism can reduce the AV node ERP, and permit an increase in ventricular rate in the setting of an atrial tachyarrhythmia. You ALWAYS need to pre-treat a patient with another drug that increases the AVN ERP (such as digoxin or a beta blocker) before using a Class IA drug to treat a supraventricular tachycardia. DC cardioversion may be a safer option, but its effects may be temporary.

Available Drugs for lowering Triglyceride levels:

Available Drugs for lowering Triglyceride levels: •Niacin •Fibrates: Gemfibrozil & Fenofibrate •Omega-3 Fatty Acids: Eicosapentaenoic acid/Docosahexaenoic acid *NOTE" STATINs also modestly reduce triglycerides ~10-20%

A clinical study is performed to document complications in persons with glomerulonephritis and with laboratory studies showing an elevated antinuclear antibody and anti-ds-DNA titer. Which of the following cardiac abnormalities is most likely to be present? A Pancarditis B Libman-Sacks endocarditis C Hemorrhagic pericarditis D Lipofuscin deposition E Coronary artery vasculitis

B Libman-Sacks endocarditis Libman-Sacks endocarditis is most often seen in patients with autoimmune diseases such as systemic lupus erythematosus, and SLE often has renal complications with glomerulonephritis.

A 22-year-old man has had increasing malaise over the past 3 weeks. On physical examination his vital signs show T 39.2°C, P 105/minute, RR 30/minute, and BP 80/40 mm Hg. On auscultation of his chest a loud systolic cardiac murmur is heard, and his lungs have bibasilar crackles. Needle tracks are seen in his left antecubital fossa. He has splinter hemorrhages noted on fingernails, as well as painful erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A chest radiograph shows pronounced pulmonary edema. Which of the following laboratory test findings is most likely to be present in this patient's peripheral blood? A Creatine kinase-MB of 8% with a total CK 389 U/L B Positive blood culture for Pseudomonas aeruginosa C Total serum cholesterol of 374 mg/dL D Blood urea nitrogen of 118 mg/dL E Antinuclear antibody titer of 1:512

B Positive blood culture for Pseudomonas aeruginosa The history points to infectious endocarditis and acute congestive heart failure. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely organisms to be found with a history of injection drug use.

Patients with posterior transmural infarcts are at greatest risk for which of the following? A. Aneurysm B. Conduction blocks C. Free wall rupture D. Infarct expansion E. Mural thrombi

B. Conduction Blocks

what new hld drug has No muscle Adv effect, as ACSVL1 not expressed in muscle

Bempedoic Acid

A 64 yo man with a history of systolic HF develops pulmonary edema with difficulty breathing. Which drug is the best choice to acutely increase cardiac output in this patient within the next 30 mins? A. captopril B. digoxin C. dobutamine D. epinephrine E. norepinephrine

C. Dobutamine Dobutamine is a beta-1 selective agonist that will increase myocardial contractility & heart rate

Which of the following microscopic features is most indicative of reperfusion of irreversibly damaged ischemic myocardium? A. Endothelial swelling B. Hypereosinophilic cytoplasm C. Necrosis with contraction bands D. Neutrophilic infiltrate E. Wavy fibers

C. Necrosis with contraction bands

A 55-year-old woman without known chronic medical problems presents for annual health maintenance exam. On cardiac auscultation, there is midsystolic click. Within 5 years she has increasing dyspnea. Echocardiography now shows mitral regurgitation from prolapse of a leaflet. Which of the following pathologic changes is most likely present in this valve? A.Dystrophic calcification B.Large, destructive vegetations C.Myxomatous degeneration- the presence of a midsystolic click suggests the presence of mitral valve prolapse. The pathologic finding in mitral valve prolapse if myxomatous degeneration of the mitral valve leaflets. A small proportion of patients with mitral valve prolapse go on to develop mitral regurgitation. D.Rheumatic fibrosis E.Two leaflets

C.Myxomatous degeneration- the presence of a midsystolic click suggests the presence of mitral valve prolapse. The pathologic finding in mitral valve prolapse if myxomatous degeneration of the mitral valve leaflets. A small proportion of patients with mitral valve prolapse go on to develop mitral regurgitation.

what's DORZOLAMIDE

CA inhibitor: topical preparation for ocular use—avoids systemic effects

first line drug for angina

CCB, BB esp if have HTN too, nitrate

Captopril vs Enalapril vs lisinopril

Captopril - short half life, requires multiple daily doses, active metabolites Enalapril - converted to active metabolite enalaprilat, longer onset of action, longer half-life, can dose 1-2x per day Lisinopril - water soluble, excreted unchanged by kidney, longer half-life, allows 1x daily dosing, more predictable onset and duration of action

ACE INHIBITORS IMPROVE SURVIVAL IN CHRONIC LV DYSFUNCTION AND CHF: name 3

Captopril, Enalapril, Lisinopril

What's the clinical name for narrowing of the aorta past the ductus arteriosus

Coarctation of Aorta

A 27 year-old patient with a history of familial hypercholesterolemia that has been well controlled for the past 3 years arrives in the Emergency Department with severe muscle pain. Blood tests confirm a lovastatin plasma level 10 times higher than normal. If taken concomitantly, which of the following could account for the development of these symptoms? ? concentrated grapefruit juice ? ethanol ? rifampin ? St John's wort

Concentrated grapefruit juice (equivalent to 6 whole grapefruits per day) can significantly increase the bioavailability of some statins (e.g. atorvastatin, lovastatin & simvastatin) by degrading intestinal CYP3A4, resulting in potentially large increases in drug plasma levels, and increasing the likelihood for statin related toxicity. In contrast, clinical data indicate the increase in risk of side effects when consuming "typical amounts" of grapefruit (e.g. one 8 oz glass of unconcentrated juice, or 1 grapefruit per day) is minimal (e.g. an increase of 1-2 per 100,000 patient years)(Am J Med 129:26-29; 2016) .

V1a and V2 vasopressin receptor antagonist

Conivaptan (combined)

Compelling indications for HTN with PMHx of DM

Diabetes mellitus - ACEIs, a-adrenergic antagonists, CCBs limited effects on carb metabolism ACEIs delay loss of renal function in diabetics

A 69 yo woman presents to the Tulane ED with signs of ankle edema, shortness of breath & other symptoms consistent with CHF. Her echocardiogram indicates that she has a relatively normal EF of 54%. A drug that would be contraindicated in treating this patient is: ? digoxin ? hydrochlorothiazide ? metoprolol ? quniapril ? spironolactone ? verapamil

Digoxin Yes "dig" would be contraindicated. This patient has symptoms of diastolic HF, in which digoxin is contraindicated. Patients with diastolic dysfunction require drugs that help reverse remodeling & improve diastolic filling. Making the heart "contract more forcefully" is the wrong approach, and might cause more harm than good.

hich of the following is true regarding HOCM? A. Etiology includes genetic and non-genetic causes B. In women, it is most common in late pregnancy C. Mutations in cytoskeletal proteins are seen in about 50% of cases D. Patients receiving doxorubicin are at increased risk E. The ejection murmur is due to ventricular outflow obstruction

E. The ejection murmur is due to ventricular outflow obstruction

A 26-year-old previously healthy woman has had worsening fatigue with dyspnea, palpitations, and fever over the past week. On physical examination her vital signs show T 38.9°C, P 104/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is slightly irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Laboratory studies show a troponin I of 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events? A Anti-streptolysin O titer of 1:512 B Total serum cholesterol of 537 mg/dL C Echovirus serologic titer of 1:160 D Blood culture positive for Streptococcus, viridans group E ANCA titer of 1:80

Echovirus serologic titer of 1:160 She has a febrile illness with findings that suggest myocarditis, which can have features of cardiomyopathy because of the diffuse myocardial involvement. The most likely organisms are enteroviruses (coxsackie B virus, echovirus) as well as adenoviruses.

--- increase the risk of myopathy when combined with statins.

Fibrates increase the risk of myopathy when combined with statins.

Statins that are affected by CYP2C9 inhibitors:

Fluvastatin & Rosuvastatin(+/-)

For uncomplicated hypertension, ---should be used in drug treatment for most, either alone or combined with drugs from other classes.

For uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes.

Compelling indications for HTN with PMHx of HF

Heart Failure - ACEIs or ARBs reduce mortality ACEI or ARB can be combined with diuretics for congestion, BBs + spironolactone to reduce remodeling

PJ, a 64 yo man with a history of diastolic dysfunction comes to your clinic for an annual checkup. In reviewing his current list of daily medications (he brought his pill containers with him in a paper bag), which of the following would be considered contraindicated, and warrent further discussion with PJ? atenolol diltiazem hydrochlorothiazide ibuprofen spironolactone

Ibuprofen is a NSAID, and these drugs promote Na retenion, and can make CHF worse. In addition they tend to reduce the efficacy of diuretics, ACE inhibitors & ARBs - drugs that most patients with CHF will be taking. Combining an NSAID with both a diuretic or either an ACE-inhibitor or ARB may also produce renal failure (known as the "triple whammy effect").

A 65 year old patient admitted to the Tulane Emergency Department for severe chest pain is diagnosed with severe hypertension and a dissecting aorta. What i.v. medication would you choose to manage his condition? ? atenolol ? furosemide ? phenyephrine ? sodium nitroprusside

Intravenous sodium nitroprusside one of the drugs of choice for rapid lowering of systolic BP to <120 mm Hg (within 20 minutes) in the setting of a dissecting aorta. Most other hypertensive emergencies do not call for such rapid changes in BP, due to the overriding concern about reductions in cerebral blood flow associated with rapid drops in blood pressure.

--(which statins)-- undergo metabolism by CYP3A4 in the intestine

Lovastatin, Simvastatin, Atorvastatin

Minoxidil

Minoxidil - drug resistant hypertension - give with loop diuretic and bb

Af Am with HTN

Monotherapy with diuretics, CCBs most efficacious Monotherapy with BBs and ACEIs not as effective though good control obtained when combined with diuretics.

Compelling indications for HTN with PMHx of MI

Myocardial Infarction - ACEIs reduce remodeling, ACEIs reduce incidence of subsequent MI BBs (non-ISA) reduce arrhythmia and remodeling

___ are the NUMBER ONE CHOICE for ACUTE TREATMENT of ANGINA!

NITRATES are the NUMBER ONE CHOICE for ACUTE TREATMENT of ANGINA!

A 50-year-old man who recently began combination therapy for dyslipidemia (high LDL, low HDL, high triglycerides) arrives in your clinic suffering from flushing, diarrhea, itchiness, dry skin, and a rapid pulse. Which of the following agents is most likely responsible for these side effects? ? cholestyramine ? ezetimibe ? gemfibrozil ? lovastatin ? niacin

Niacin Correct! These are well known side effects of niacin. These side effects can be reduced by using extended release formulations, and by pre-treatment with aspirin or ibuprofen. Niacin produces most of its side effects by direct activation of a G-protein coupled receptor that stimulates PLA2, resulting in the COX-1 mediated conversion of arachidonic acid to prostaglandins (an effect blocked by NSAIDs). The other hypolipidemics do not share the same combination of side effects.

Nitroprusside

Nitroprusside - emergencies (only 24 hrs), immediate onset, brief duration, promotes art and venous dilation

what are the pcks9 drugs about?

PCKS9: Proprotein convertase subtilisin/kexin type 9 •PCSK9 is a secreted protein produced by the liver & other cell types • •Binds to the LDLR at the cell surface and is internalized with the receptor and LDLs •Prevents LDLR recycling back to the plasma membrane and instead targets the receptor to degradation in the lysosome

--(2 things plz)-- are the typical causes for a hemorrhagic pericarditis.

Pericardial tumor and tuberculosis are the typical causes for a hemorrhagic pericarditis.

Statin of choice when drug interactions are a concern

Pravastatin is not metabolized by P450 enzymes - drug of choice when drug interactions are a concern

Fish Oils: Omega-3 long chain polyunsaturated fatty acids

Primary Clinical Effect: • Lowers serum TG levels by ~30-50% • Minor increase in HDL • Can increase LDL in some individuals

A 56-year-old man has a routine checkup. He is found to have a blood pressure of 175/110 mm Hg. A month later his blood pressure is 170/105 mm Hg. He elects to do nothing about this, because he feels fine. If he remains untreated, this man is at greatest risk for which of the following conditions? A Pleural effusions B Pulmonary congestion C Hyperplastic arteriolosclerosis D Tricuspid insufficiency E Myocardial infarction

Pulm congestion (B) CORRECT. The pressure load on the left ventricle will always lead to left venricular hypertrophy, and if untreated eventually the heart can no longer compensate and there is left heart failure, which leads to pulmonary congestion and edema.

A 63 yo patient with a history of atrial arrhythmias arrives in the ED with complaints of tinnitus, visual disturbances, hearing loss & severe diarrhea. The patient is given oxygen by nasal cannula, and ECG leads, pulse oximeter and an automated blood pressure cuff are applied. The patient crys out and faints immediately. His ECG indicates the presence of a multifocal ventricular tachycardia with a "twisting of the points" (continuous change in QRS electrical axis). Which of the following drugs is most likely responsible for this patient's symptoms? ? amiodarone ? lidocaine ? propranolol ? quinidine ? verapamil

Quinidine has characteristic side effects (cinchonism) and is a well known cause of Torsade de pointes (along with about 40 other drugs). This is why all patients initiated on quinidine (and Class IA drugs in general) are hospitalized for the first 24 hrs - which is when this arrhythmia has a fairly high incidence of occuring. The explanation for this is that at lower doses, quinidine blocks IKr first (which is the cause for EADs & Torsade), and then at higher doses quinidine blocks Na channels & to some extent Ca channels. At that point, Torsade is less likely to occur, since Na & Ca currents are believed to be contributors to the upstroke of EADs.

TREATMENT OBJECTIVES IN ACUTE CHF

Reduce pulmonary congestion - Loop diuretics (Furosemide) - Venodilators (Nitroglycerin) Increase cardiac output - Increase cardiac contractility (Beta adrenergic agonists, phosphodiesterase inhibitors) - Reduce afterload (Nitroprusside)

moa of bile acid resins

Resins are cationic polymers that bind to negatively charged bile acids and prevent their reabsorption in the small intestine.

What is the clinical manifestation of lesions on the eye due to infective endocarditis called?

Roth spots

Reduces mortality by ~30% in patients with heart failure & LV dysfunction that develops after a myocardial infarction. ? amlodipine ? amilioride ? furosemide ? mannitol ? spironolactone

Spironolactone is an aldosterone antagonist that has been shown to significantly reduce mortality & morbidity in this setting of CHF.

A 43 yo man being treated for a recent myocardial infarction develops symptoms of arthralgia, myalgia, fever & pleuritis. Upon exam the patient is found to have a high titer of antinuclear antibodies. Which of the following medications is most likely responsible for these symptoms? ? amiodarone ? propranolol ? procainamide ? quinidine ? verapamil

These symptoms reflect the "lupus-like" syndrome that commonly develops in patients on procainamide. A lupus-like syndrome occurs in 20-25% of patients on procainamde for more than one year.

A drug with modest antihypertensive effects that is often reserved for use in patients that develop hypokalemia in response to taking another more potent diuretic. ? ethacrynic acid ? furosemide ? hydrochlorothiazide ? indapamide ? triamterene

Triamterene blocks epithelial Na channels in the collecting duct, and is K-sparing.

tolvaptan, mozavaptan, and lixivaptan

V2 receptor antagonists ADH antag

A 64 yo woman who is experiencing progressive dyspnea of effort comes to your office for a physical exam. Her pulse is regular at 95 beats/min, and her blood pressure is 126/84 mm Hg. Auscultation of her lungs reveals inspiratory crackles at both bases. There is no peripheral edema, and the cardiac apical pulse is not displaced. An echocardiogram reveals a left ventricular chamber that is not dilated, with an estimated EF of 55%. Based upon your observations, which of the following would be most likely to reduce this patient's symptoms? ? digoxin ? dobutamine ? dopamine ? hydralazine ? verapamil

Verapamil This patient is suffering from diastolic HF (failure with a near normal ejection fraction). That means the defect is related to diastolic filling, and not the fraction of ventricular volume that gets ejected. Verapamil, diltiazem & beta blockers will assist in diastolic filling by helping the ventricle be "less stiff" as well as slowing the heart rate to increase diastolic filling time.

After confirming the absence of a carotid bruit, the cardiologist confirms the diagnosis of PSVT by firmly massaging CJ's right carotid artery for approximately 5 seconds, which produced a conversion to normal sinus rhythm for several minutes. She then inserts an IV line thru a peripheral vein until its tip is relatively close to the heart, and injects a 6 mg bolus of adenosine as fast as possible, followed immediately by a flush of 5 mls of saline. After observing no effect, the dose was increased to 12 mg, and then to 18 mg. Shortly thereafter, the patient became hypoxic, and PSVT persisted. Concluding that the chronic use of theophylline (an adenosine receptor antagonist) may be producing too much antagonism, she considers trying a slower i.v. infusion of a different drug that could also be taken orally for chronic prophylaxis against PSVT. This drug is: ? nifedipine ? nitroglycerin ? ranolazine ? verapamil

Yes! Verapamil (& diltiazem) are reserved as 2nd-line drugs for conversion of PSVT to normal sinus rhythm. They were replaced by adenosine in the ~1980's. This is because adenosine tends to be a bit more effective, and has a much shorter half life - so that any unwanted side effects (e.g. heart block, hypotension) don't last long. Verapamil & diltiazem have the potential for producing bradycardia & profound hypotension in a small percentage of patients. While the percentage may be small, the half-life of both these drugs are several hours, so this type of toxicity is serious when it occurs.

JL is a 59 year old man recently diagnosed with Stage 1 hypertension. His history is unremarkable except that both parents and a grandparent died from systolic heart failure at a relatively early age. Which antihypertensive drug would be best at preventing heart failure if prescribed to JL? ? an ACE inhibitor ? an alpha blocker ? a beta blocker ? a calcium channel blocker ? a diuretic

a diuretic Studies have shown that alpha blockers actually double the risk of heart failure compared with a diuretic, and both calcium channel blockers and ACE inhibitors are also inferior to a diuretic for preventing CHF.

A 56 year-old patient recently initiated on statin therapy reports to your clinic with concerns about recent-onset feelings of discomfort, uneasiness and anorexia. When questioned, he states that he has not noticed any signs of muscle pain or dark colored urine. Which lab test should be performed to assess whether these symptoms may be related to a known drug side effect? ? alanine and aspartate transaminase ? blood urea nitrogen ? creatinine clearance ? plasma Vit B12 & folate levels

alanine and aspartate transaminase Serious cases of statin-induced hepatotoxicity have been reported, although in patients with normal liver function, the incidence is estimated to be only ~2%. When it does occur, hepatotoxicity results in increased plasma levels of liver enzymes. The risk for statin-induced hepatotoxicty is increased in patients with underlying liver disease, and those who drink excessive amounts of alcohol.

Pulsus parvus et tardus is associated with --

aortic valve stenosis.

A 26-year-old woman with hyperlipidemia comes to your clinic to discuss changing her drug therapy since she is planning to have a child in the near future. Which of the following drug therapies is considered by the FDA to have an unacceptably high risk in pregnancy (FDA pregnancy category X) due to animal studies suggesting a potential for causing congenital malformations? ? atorvastatin ? colestipol ? ezetimibe ? gemfibrozil ? omega 3 supplements

atorvastatin

HTN with pregnancy

avoid ACEi or ARBS and BB usually use methyldopa

PT with obstructive airway HTN

avoid BB

which diuretic to avoid with hypercalcemia

avoid thiazide diuretics because they increase the reabsorption of calcium. -USE LOOP INSTEAD

What CHF/antiarrhythmic medication is CONTRAINDICATED for pts with asthma?

beta blockers

drug interactions with thiazides

beta blockers... but sometimes it is used? it lowers bp

A definite contraindication for the use of ACE inhibitors and ARBs includes: ? asthma ? bilateral renal stenosis ? diabetes ? tachycardia ? hypokalemia

bilateral renal stenosis Ang II is necessary for maintaining efferent arteriole resistance in this setting. Reducing Ang II levels, or Ang II effects, can reduce GFR and cause kidney failure in this setting. REMEMBER THIS!

Cholestyramine and Colestipol are examples of

bile acid resins

Reserpine

blocks VMAT vesicular transporter, prevents storage of NE centrally and peripherally. combined with diuretics for mild or moderate htn

A 67 yo man with a history of coronary artery disease presents to the ED with chronic atrial fibrillation, an average ventricular rate of 120-140 beats/min, and an ejection fraction of 35%. The best drug for controlling his ventricular rate would be: ? digoxin ? diltiazem ? nifedipine ? quinidine ? atropine

digoxin This patient has both AFib & systolic HF. Digoxin will produce an increase in vagal tone, which can be used to reduce the ventricular rate <80 beats/min. It also produces a positive inotropic effect that will help increase ejection fraction.

A first-line choice in uncomplicated hypertension

diuretics

splinter hemorrhages associated with

endocarditis

what is Therapy of choice for patients with Familial dysbetalipoproteniemia/Type III Hyperlipoproteinemia: - plasma triglycerides and IDL/VLDL remnants

fibrates

which hld drug uses ppar and when use it?

fibrates and use with high triglyccerides Therapy of choice for patients with Familial dysbetalipoproteniemia/Type III Hyperlipoproteinemia: - plasma triglycerides and IDL/VLDL remnants

NM is a 62 year old woman who is diagnosed with hypercalcemia related to a parathyroid hormone secreting tumor. Other than cancer chemotherapy, a temporary treatment for her hypercalcemia could include administration of: ? acetazolamide ? furosemide ? hydrochlorothiazide ? spironolactone

furosemide Loop diuretics are used to treat: 1 ) severe edema (e.g. associated with CHF), 2) hyperkalemia, 3) acute renal failure (to increase urine flow), and 4) hypercalcemia. Remember that!

DM is a 62 year old African-American man who has had poorly controlled hypertension for the past 10 years, and now presents with signs of ankle edema, a low GFR and a serum creatinine of 2.5 mg/dL. The most effective drug for producing a diuresis and fall in blood pressure in DM is: ? amlodipine ? furosemide ? hydrochlorothiazide ? losartan ? ramipril

furosemide This patient has a low GFR. Because DM is African-American he is most "likely" to be salt sensitive and respond well to a diuretic. Since his GFR is low, a loop diuretic is the drug of choice. Loop diuretics are the most efficacious agents for producing a diuresis.

What combination of medications & patient conditions are contraindicated? losartan & a patient with a BP of 140/90 metoprolol & a patient with HR=70/min diltiazem & a patient with Prinzmetal's angina furosemide & a patient with leg cramps verapamil & a patient with diastolic HF

furosemide & a patient with leg cramps Leg cramps are often a sign of hypokalemia. A highly efficacious loop diuretic will likely increase the degree of hypokalemia, and severe hypokalemia is potentially life-threatening. Check the patient's plasma K level & normalize before giving a patient a loop diuretic.

A patient on statin therapy has achieved their target goal for lowering LDL-C, but has high triglyceride levels. Which class of drug, if added to their therapy, would be the best choice to correct this remaining dyslipidemia? ? colestipol ? ezetimibe ? gemfibrozil ? alirocumab

gemfibrozil

A 56 yo man with a history of exertional angina presents to the Emergency Department with blurred vision, low blood pressure, bradycardia & confusion. During his history taking you learn that he took three tablets of his "heart medicine" (metoprolol) after forgetting to take them for 3 days. Which drug of choice should be given to reverse his cardiovascular symptoms by increasing heart rate & myocardial contractility, and thereby blood pressure as well? ? atropine ? glucagon ? insulin ? isoproterenol ? norepinephrine

glucagon Glucagon has its own cardiac receptors that stimulate adenylate cyclase (as do beta-1 receptors). Hence it can produce similar effects as beta-1 agonists, but via an independent group of receptors that are not effected by beta-blockers. There is also less guesswork involved in picking the right dose needed to correct the patient's condition since there is no competition between the agonist (glucagon) & thge antagonist (metoprolol) involved. Great choice!

HK is a 51 year old woman who has been on antihypertensive drug therapy for the past 3 months. During her most recent visit her fasting blood glucose level was found to be 112 mg/dL (above normal). Which agent in an antihypertensive drug regimen would be most likely to have caused her glucose intolerance? ? diltiazem ? hydrochlorothiazide ? lisinopril ? losartan ? minoxidil

hydrochlorothiazide Thiazides are known to produce mild hyperglycemia. It is typically not of clinical consequence in non-diabetics, and can be minimized by correcting any associated hypokalemia (the two side effects appear to be linked). The effect on plasma glucose is typically very small with the low doses of thiazides typically prescribed for treating hypertension, since low doses have minimal naturetic effects.

TM is a 52 year old caucasian man who has recently been diagnosed with hypertension by his primary care physician. His blood pressure during the past 2 visits has averaged 145/95 mm Hg. He is 240 lbs & 5'11" tall and exercises regularly. His ECG indicates mild LVH. His plasma lipids and fasting glucose are normal. He is a smoker (1 pack/day). He is advised to enter a smoking cessation program to reduce CV risk, moderate his consumption of alcohol, adopt a DASH diet, and maintain his daily routine of 30 min a day of aerobic exercise - with the target of losing at least 22 lbs over the next year. TM's physician then discusses the options for drug therapy, and they select an appropriate drug regimen, which is: ? furosemide + losartan ? hydralazine ? hydrochlorothiazide ? hydrochlorothiazide + ramipril ? metoprolol + amlodipine

hydrochlorothiazide + ramipril This patient will need at least 2 drugs to reduce his SBP from 145 to <130 mm Hg. If he is successful in losing weight, with concomitant reduction of BP, one of the 2 drugs can be reduced in dosage, or discontinued. The 2017 ACC/AHA recommends therapy with 2 drugs consisting of either a thiazide, an ACE-I (or ARB) and a CCB . Note that the side effects of the thiazide (mild hypokalemia) can be countered by either an ACE-I or an ARB (which can produce mild hyperkalemia).

contraindication for thiazide use for htn

hypokalemia

What is advantage of adding a non dihydro CCB?

if pt is tachy, add on reduces pacemaker and conduction currents

JC is a 85 yo man who is brought to the Tulane ED by ambulance after complaining of chest pain for the past 45 minutes. He is given a chewable aspirin, sublingual nitroglycerin, and oxygen by mask, followed by i.v. morphine. His ECG shows ventricular tachycardia. A minute later he faints as his blood pressure falls to below 60/30 mm Hg. The best treatment for JC's condition would be: ? amiodarone i.v. ? epinephrine i.v. ? immediate DC cardioversion ? lidocaine i.v. ? procainamide i.v.

immediate DC cardioversion Yes! Shock him - up to 3 times to try and reestablish a sinus rhythm before doing anything else (200 J --> then 200-300 J --> then 360 J) is the standard of care for "pulseless VT/VF. Drugs can be given afterwards. Try to get his circulation going first by reestablishing the pumping action of the heart before giving meds.

As a 3rd yr medical student in Baton Rouge you are helping with the longitudinal care of a EJ, a 68 yo woman suffering from coronary artery disease. One day you are called to the ED where you find EJ complaining of chest pain that radiates down her left arm which began less than an hour ago. She has been given a chewable aspirin, sublingual nitroglycerin, oxygen by nasal canula, and i.v. morphine. Her ECG indicates ST segment elevation, and her cardiac enzymes (CPK-MB & troponin I) are elevated. She is given clopidegrel & is scheduled for an immediate coronary angioplasty. While talking to EJ, she complains to you of shortness of breath. Auscultation of her lungs reveals inspiratory crackles at both bases. You make a tentative diagnosis of pulmonary edema secondary to an MI that requires drug management. Your resident agrees with you & asks you what effect would amrinone (a phosphodiesterase inhibitor), digoxin or a high dose of dopamine have in common if you administered any of them for her pulmonary edema. Having ace'd the Med Pharm course, you answer that they would produce a(n): ? decrease in cytoplasmic cAMP ? decrease in heart rate ? decrease in venous return ? decrease in total peripheral resistance ? increase in ventricular contractility

increase in ventricular contractility YES! Dr. C is proud of you. In HF following an MI amrinone, digoxin & moderately higher doses of dopamine can improve cardiac function & thereby relieve pulmonary congestion by exerting a positive inotropic effect - they all increase ventricular contractility.Amrinone (which increases cAMP in both heart & vascular smooth muscle) & lower doses of dopamine can cause vasodilation, but this is not an effect of digoxin. Digoxin's ability to increase vagal tone is not shared by amrinone or dopamine. Drugs that increase contractility via stimulation of beta-1 receptors (dobutamine, dopamine) increase cAMP, but digoxin does not.

A 76 yo man being treated with digoxin, captopril & furosemide for systolic HF & hypertension presents to the ED with complaints of dizziness & fatigue. His lab values indicate a plasma K level of 2.5 mM. While waiting for his X-ray results the patient faints and his current ECG indicates the presence of sinus bradycardia & 3rd degree AV conduction block. The most likely explanation for this patient's rhythm disturbance is: ? a direct effect of hypokalemia on SA node automaticity & AV conduction ? captopril overdose ? furosemide interacting with captopril ? increased vagal tone caused by digoxin

increased vagal tone caused by digoxin Hypokalemia (most likely caused by the loop diuretic) is known to increase the intensity of effect of digoxin due to reducing the activity of Na/K ATPase, which digoxin also inhibits. Digoxin increases vagal tone, and this can produce sinus bradycardia & AV conduction block. The patient might also be exhibiting other signs of digoxin toxicity, such as....? (that's an open ended question for you to answer).

when you should not use ccb for angina

it should never be used in a patient with unstable angina or in patients with acute myocardial infarction as the reflex tachycardia can further increase demand and exacerbate ischemia.

Preferred treatment for ventricular arrhythmia caused by digoxin toxicity

lidocaine

A 59 yo man with a history of systolic HF arrives in the ED with complaints of chest palpitations, nausea and visual (color) disturbances. His chart indicates that he is currently taking digoxin, captopril, metoprolol & furosemide. An ECG reveals the presence of frequent runs of ventricular bigeminy. His echocardiogram indicates an ejection fraction of 40%. His lab results show cardiac enzymes to be within normal limits, a serum potassium of 4.0 mM, and an elevated digoxin level of 2.2 ng/ml. The most appropriate drug for treating this patient's arrhythmia would be: ? amiodarone ? atropine ? lidocaine ? propranolol ? verapamil

lidocaine Lidocaine is indicated for ventricular arrhythmias caused by digoxin. It has the least negative inotropic side effects compared to Class Ia drugs, and does not have a drug-drug interaction with digoxin like several other drugs including amiodarone, verapamil & quinidine.

JD is a 62 year old overweight man recently diagnosed with hypertension (143/92 mm Hg) and type 2 diabetes. Which of the following would be the best drug of first choice to manage his hypertension? ? atenolol ? hydrochlorothiazide ? lisinopril ? metoprolol ? nifedipine

lisinopril Patients with a history of either diabetes or kidney disease should be given an ACE-I or an ARB to prevent the development of, or further progression of kidney disease. REMEMBER THIS!

ETHACRYNIC ACID

loop dieuretic (only non-sulfonamide but most toxic) •Last resort; used only when others exhibit hypersensitivity •No CA inhibition Nephrotoxic and ototoxic

TORSEMIDE

loop diuretic •Longer half-life than furosemide: ~ 3 hrs •Longer duration of action, too: ~ 5-6 hrs •Better oral absorption than furosemide •80% metabolized by the liver

what's BUMETANIDE

loop diuretic that is 40x more potent than furosemide, 1 hr half life and 50% metab by liver

Pt with both HTN and HLD Tx

low dose diuretics have little effect on cholesterol and triglycerides BBs can raise triglycerides, alpha blockers decrease LDL/HDL ratio. CCBs, ACEIs, ARBs have little effect on lipid profile.

Julie H is a 32 year old woman with a history of mild hypertension who is planning to begin a family with her husband in the immediate future. She is currently being treated with Hyzaar (a combination of hydrochlorothiazide and losartan). Which agent could she be switched to that has a well established track record for saftey in the treatment of essential hypertension during pregnacy? ? aliskiren ? candesartan ? captopril ? methyldopa ? propranolol

methyldopa

A 60 yo woman with a history of smoking presents with the chief complaint of chest pain that occurs at night while at rest. A treadmill test is negative. A 24 hr holter recording reveals transient ST elevation and AV block (suggestive of occlusion of her right coronary artery) that are temporaly associated with anginal attacks. A coronary angiography with provocative testing with acetylcholine injection reproduces her chest pain & ECG changes. Which drug will be contraindicated in her treatment? ? diltiazem ? isosorbide dinitrate ? metoprolol ? nitroglycerin sublingually ? verapamil

metroprolol Correct choice. Beta blockers (both beta-1 selective and nonselective types) are contraindicated in vasospastic angina because of the concern about blocking beta-2 receptors in coronary arteries, and leaving "alpha receptors unopposed"...resulting in enhanced likelihood of vasospasm. Beta-1 selective blockers are only selective, and are not specific for only blocking beta-1 vs beta-2 receptors.

Additional drugs for the treatment of Severe Homozygous Familial Hypercholesterolemia - Lomitapide (Juxtapid®) -Mipomersen (Kynamro®)

mipo: •Reduces expression of apoB48 & apoB100 resulting in reduced production of both chylomicrons and VLDLs and hence leading to lower levels of LDLs (~25-30%) •BLACK BOX WARNING- HEPATOTOXICITY lomitapide: Lomitapide •Inhibitor of microsomal triglyceride transfer protein (MTP) •MTP is required for the assembly of both chylomicrons & VLDLs •Since chylomicrons and VLDLs give rise to LDLs LOMITAPIDE can reduce LDL levels in FH patients (~50%) •BLACK BOX WARNING- HEPATOTOXICITY

what's the most important adverse effect of statins?

muscle probs (rhabdo, etc)

What is first line CCB for htn?

nifedipine

A 57 yo man with a history of atrial fibrillation is diagnosed with classic angina. Which of the following would be contraindicated in this patient? ? diltiazem ? metoprolol ? nifedipine ? verapamil ? warfarin

nifedipine Nifedipine is a "dihydropyridine" type L-type calcium channel blocker. These drugs are vascular-selective, and will produce a fall in mean arterial blood pressure. This effect will reduce the AVN ERP by baroreceptor reflex. This is not an effect you want to produce in a patient with both AFib & angina of effort, because it will increase ventricular rate - and increase the likelihood of both an anginal attack, or a myocardial infarction.

A 60-year-old Caucasian woman experiences progressive dyspnea while traveling from New Orleans to Washington, DC by airplane (nonstop). You are asked to examine her, and you make the diagnosis of acute pulmonary edema. The flight attendant brings an oxygen tank and a nasal cannula to provide supportive therapy, and you take off your tie and summon other passengers to do the same to apply rotating tourniquets to the patient's extremities. You then ask the other passengers if they carry which of the following drugs with them, with hope of inducing peripheral venous pooling and reducing cardiac preload in this patient? ? digoxin ? hydralazine ? nitroglycerin ? propranolol ? verapamil

nitroglycerin

A class of antianginal medications with multiple mechanisms of action that include: decreased preload, decreased oxygen demand, decreased afterload (at high doses), and increased myocardial oxygen delivery by dilating large epicardial arteries. ? beta blockers ? dihydropyridine calcium channel blockers ? nitrates ? non-dihydropyridine calcium channel blockers

nitrtrates (beta blockers and non-dihyro don't decrease preload, dihydro increase o2 demand and have reflex tachy)

contraindications to statins

preganncy and liver dx

TREATMENT OBJECTIVES IN CHRONIC CHF

prevent vent remodeling with ace inhib, bb, arbs, aldo antag decrease sx with diuretic or venodilator increase co with digitalis, ace inhib, arbs, hydralazine

A drug prescribed for prophylaxis for the exertional (classical) form of angina, but NOT for variant (vasospastic) angina is: ? clopidogrel ? nifedipine ? nitroglycerin ? propranolol ? verapamil

propranolol Yes Yes Yes!! Beta blockers can block beta-2 receptors and result in "unopposed" alpha mediated vasoconstriction in patients with vasospastic angina.

IVABRADINE

reduces heart rate by inhibiting the funny current that regulates that rate at which the sinus node cells of the heart spontaneously depolarize. Reducing HR without Bblocker so treat angina without same side effects of bblocker

Ivrabradine side effects

reserved for use with bb in HF with reduced EF, luminous phenomena/brady/av block

Aschoff bodies - diagnosis?

rheumatic fever

A 59 yo man with a history of angina is given a prescription for an oral nitrate formulation (isosorbide dinitrate) 20 mg bid. A second agent that this patient should be warned "NOT" to take while on this oral nitrate formulation is: ? aspirin (low dose) ? grapefruit juice ? metoprolol ? sildenafil ? St. John's wort

sildenafil

2 most common side effects of niacin

skin flushing and itching makes uric acid -> gout

HTN for elderly

smaller doses with small increments simple regimens monitor side effects closely

Angina first line

sublingual ntg, beta blocker and then if sx persist ccb, long acting ntirate or ranalzine

METOLAZONE

thiazide diuretic (most efficacious) renal insufficiency use •10X more potent than Hydrochlorothiazide •Half-life of 4-5 hrs

K+ sparing diruetics that is 10X less potent than AMILORIDE with same MOA

traimterene

Lidocaine's use as an antiarrhythmic is limited to in-hospital use for ---. Amiodarone is currently prefered over lidocaine for treatment of most ventricular arrhythmias, except for those caused by digoxin toxicity.

ventricular arrhythmias

PG is a 67 year old man with HTN, asthma and atrial fibrillation. He is able to walk 6 blocks before stopping to rest, and his echo shows an EF of 57%. His rhythm is irregularly irregular, with a ventricular response between 110-160/min. Which of the following agents would be the safest in treating his HTN and controlling his ventricular response? ? atenolol ? benzepril ? hydrochlorothiazide ? losartan ? verapamil

verapamil This is the best choice. It would increase the AV node Effective Refractory Period and slow his ventricular rate, while also reducing arterial BP. This is an example of treating a patient with a comorbid condition (AFib).

A 62 yo man with diastolic dysfunction develops pulmonary edema caused by the sudden onset of atrial fibrillation with a rapid ventricular response. To prevent the deterioration of the heart's ability to maintain circulation, which of the following should be given? ? lidocaine ? digoxin ? dobutamine ? nifedipine ? verapamil

verapamil Verapamil is the best choice. It will increase the AV node ERP and thereby reduce the ventricular rate in the setting of AFib. It may also improve diastolic dysfunction by slowing the rate (more diastolic filling time) and helping the heart "relax" during diastole. (Digoxin is contraindicated in diastolic HF, and its effect to increase vagal tone takes ~6 hrs to reach steady state)

•Bempedoic Acid- whats it

•Bempedoic Acid is a PRODRUG that is converted to its active form by the liver enzyme Very Long Chain Acyl-CoA Synthetase 1 (ACSVL1) ---> this is a little before hmg coa reductase in the pathway reduces ldl-c no muscle side effetct

--- are therefore useful in some patients with calcium oxalate stones.

•Thiazides are therefore useful in some patients with calcium oxalate stones.