Pharmacology Chapter 12 Quiz

Questions and Answers

How should secondary hypertension be treated?

By dealing with the underlying issue.

How do you treat primary (essential) hypertension?

With multiple drugs.

What are the first line treatments for primary hypertension?

Usually thiazide-type diuretics, but also ACE inhibitors, ARBs, and CCBs.

How do you choose which first line treatment to use first?

By considering race, side effect profiles, and patient preference. Signup and view all the answers

Which drugs are not often used as first line treatment in black patients?

ACE inhibitors and ARBs. Signup and view all the answers

Which first line treatment is not given to patients with constipation?

CCBs. Signup and view all the answers

What should you do if one drug is not effective to reach the target blood pressure?

Add a second first line treatment. Signup and view all the answers

What other drugs will patients with heart failure be on?

Beta blocker, diuretic, and other antihypertensive drugs. Signup and view all the answers

What other drugs will patients with angina be on?

Beta blocker and maybe nitrates. Signup and view all the answers

In cases of malignant hypertension or hypertensive crisis, which drugs are typically used?

Sodium nitroprusside or fenoldopam in combination with beta blockers and diuretics. Signup and view all the answers

When are drugs first line for gestational hypertension?

Methyldopa, labetalol, and nifedipine. Signup and view all the answers

Why are digoxin and other positive inotropic agents no longer used as first line treatment for heart failure?

Evidence has shown they do not reduce mortality and are only helpful to treat symptoms. Signup and view all the answers

When are digoxin and other positive inotropic agents used?

To control symptoms in patients already on optimized therapy. Signup and view all the answers

What does the current treatment of heart failure focus on?

Reducing fluid volume, blood pressure, and cardiac remodeling. Signup and view all the answers

What is the first step in pharmacological treatment of heart failure?

Reduction of fluid volume; diuretics, usually loop diuretics, are used along with an aldosterone receptor blocker (spironolactone and eplerenone). Signup and view all the answers

What are the agents of choice for heart failure?

Diuretics (usually a loop + aldosterone receptor blocker), ACE inhibitor or ARB, beta blocker (carvedilol, metoprolol, bisoprolol). Signup and view all the answers

What does adding an aldosterone receptor blocker along with a diuretic do?

Helps prevent hypokalemia and reduces digoxin toxicity. Signup and view all the answers

How do ACE inhibitors or ARBs help patients in heart failure?

Reduce blood pressure, reduce cardiac remodeling, reduce sensitivity of sympathetics, prolong survival. Signup and view all the answers

How do beta blockers help patients with heart failure?

Reduce heart contractility; the long-term use of beta blockers is cardioprotective and prolongs survival. Signup and view all the answers

When should beta blockers not be given to patients with heart failure?

When the patient is in decompensating failure. Signup and view all the answers

What is next for patients on optimized background therapy complaining of dyspnea and fatigue, particularly in black patients?

Vasodilator; drug of choice dependent upon symptom; venous dilator such as isosorbide dinitrate, arteriole dilator such as hydralazine or DHP-CCB, BiDil (hydralazine/isosorbide dinitrate). Signup and view all the answers

What is the mechanism of action of ivabradine?

If (funny channel) inhibitor in SA node. Signup and view all the answers

What is the use of ivabradine?

Reduce heart rate in patients on maximally tolerated beta-blocker dose. Signup and view all the answers

What is nesiritide?

Synthetic brain-derived natriuretic factor (BNDF). Signup and view all the answers

What is nesiritide used for and how is it administered?

Decompensating heart failure; IV administration in hospital. Signup and view all the answers

What are the effects of nesiritide?

Natriuresis, vasodilation, reduces RAAS. Signup and view all the answers

What is bosentan?

Endothelin receptor antagonist. Signup and view all the answers

What is the use of bosentan?

Right-sided heart failure secondary to pulmonary hypertension. Signup and view all the answers

What do the positive inotropic agents do?

Stimulate heart contractility directly, improving the symptoms of heart failure. Signup and view all the answers

What is the prototypic ionotropic agent?

Digoxin. Signup and view all the answers

What other positive ionotropic agents are available for in-hospital treatment?

Phosphodiesterase inhibitors and adrenergic receptor agonists. Signup and view all the answers

What is the mechanism of digoxin and positive inotropic agents?

Inhibition of Na/K ATPase -> Na gradient diminished -> less Ca removed from intracellular fluid, increasing Ca available in SR during each contraction -> increases strength of contraction. Signup and view all the answers

What are common side effects of digoxin?

GI complaints: anorexia, nausea, vomiting, diarrhea; yellow/green halos or change in color perception - pathognomonic; dysrhythmia. Signup and view all the answers

What is pathognomonic of digoxin?

Yellow/green halos in visual field or change in color perception. Signup and view all the answers

What does digoxin toxicity present with?

Severe gastrointestinal complaints, hallucination and delusions, cardiac dysrhythmias. Signup and view all the answers

What can increase the toxicity of digoxin?

Hypercalcemia due to additive ionotropic effects; hypokalemia because in competition with digoxin for same binding site. Signup and view all the answers

If a patient on digoxin is hypokalemic, what do you treat with if hypomagnesemic?

Potassium; magnesium. Signup and view all the answers

What is the treatment for digoxin toxicity?

Anti-digoxin antibodies, DigiFab and Digibind. Signup and view all the answers

What is the mechanism of action of DigiFab and Digibind?

Bind to digoxin and prevent digoxin from binding to the Na/K ATPase. Signup and view all the answers

How do you make the clinical decision to use one of these agents?

Rule of 6; if the patient is known to have ingested more than 6 mg of digoxin, if serum digoxin level is more than 6 ng/mL, if serum potassium is higher than 6 mEq/L. Signup and view all the answers

What are 2 PDE inhibitors commonly used for heart failure?

Inamrinone and milrinone. Signup and view all the answers

What is the mechanism of action of inamrinone and milrinone?

Inhibit PDE-3 -> increases intracellular concentration of cAMP -> activates PKA -> increases Ca-induced Ca release (CICR) -> increasing available Ca for contraction. Signup and view all the answers

When are inamrinone and milrinone used?

By IV injection in acutely ill patients. Signup and view all the answers

What are the side effects of inamrinone and milrinone?

Hepatotoxic, myelosuppressive leading to thrombocytopenia, increase risk of dysrhythmia. Signup and view all the answers

What is dobutamine?

Beta1 selective agonist available to improve cardiac function in acutely ill patients. Signup and view all the answers

What is the use of dobutamine?

Decompensating heart failure with hypotension; stimulates both beta receptors in heart and alpha receptors in vasculature. Signup and view all the answers

How is dopamine used as an inotrope?

Moderate dose improves cardiac contractility; high dose increases blood pressure. Signup and view all the answers

What is theophylline?

PDE inhibitor that is less selective than milrinone or inamrinone. Signup and view all the answers

When is theophylline used?

Asthma or COPD - not first line. Signup and view all the answers

When does angina occur?

When cardiac work outpaces cardiac perfusion. Signup and view all the answers

What are the three forms of angina?

Stable, unstable, and Prinzmetal. Signup and view all the answers

What is stable angina due to?

Coronary artery disease. Signup and view all the answers

What is unstable angina due to?

When a patient with stable angina acutely experiences a change in the quantity or quality of chest pain and fails to obtain relief from usual medications and rest. Signup and view all the answers

What is Prinzmetal's angina?

Due to coronary vasospasm; may not be associated with underlying coronary artery disease. Signup and view all the answers

What is the treatment of Prinzmetal's angina?

CCB for prophylaxis; nitrates for acute relief. Signup and view all the answers

What is the treatment of stable angina?

Nitrates for acute relief; short-acting or long-acting nitrates for prophylaxis; CCBs or beta-blockers for prophylaxis; statins; antiplatelets; lifestyle modification; treatment of aggravating factors. Signup and view all the answers

What are the lifestyle modifications for angina?

Smoking cessation, diet, exercise, stress reduction. Signup and view all the answers

What are the aggravating factors of angina?

Hypertension, diabetes mellitus, dyslipidemia, depression. Signup and view all the answers

What is the mechanism of action of ranolazine?

Alters Na-dependent Ca channel conductance during ischemia; inhibits fatty-acid oxidation in cardiomyocytes. Signup and view all the answers

What is the use of ranolazine?

Angina prophylaxis. Signup and view all the answers

Study Notes

Hypertension Treatment

Secondary hypertension is treated by addressing the underlying cause.
Primary (essential) hypertension management typically involves multiple medications.
First-line treatments for primary hypertension:
- Thiazide-type diuretics
- ACE inhibitors
- ARBs (Angiotensin II Receptor Blockers)
- CCBs (Calcium Channel Blockers)
Factors influencing the choice of first-line treatment:
- Patient's race
- Side effect profiles of drugs
- Patient preferences
ACE inhibitors and ARBs are less commonly used as first-line treatments in Black patients.
CCBs are not suitable for patients suffering from constipation.
If one drug fails to achieve target blood pressure, a second first-line treatment should be added.

Heart Failure Management

Patients with heart failure often require additional medications, including beta blockers, diuretics, and other antihypertensives.
In cases of decompensated heart failure, beta blockers should not be administered.
First pharmacological step for heart failure treatment aims at reducing fluid volume, typically using loop diuretics and an aldosterone receptor blocker like spironolactone.
Key agents in heart failure treatment include diuretics, ACE inhibitors or ARBs, and beta blockers (carvedilol, metoprolol, bisoprolol).
Adding an aldosterone receptor blocker helps prevent hypokalemia and decreases digoxin toxicity.

Digoxin and Ionotropic Agents

Digoxin is no longer first-line due to lacking evidence for mortality reduction; it is reserved for controlling symptoms in patients on optimized therapy.
Positive ionotropic agents increase heart contractility but may have side effects such as gastrointestinal issues and dysrhythmias.
Pathognomonic symptoms of digoxin toxicity include yellow/green halos in vision.
Treat digoxin toxicity with anti-digoxin antibodies like DigiFab and Digibind, which prevent digoxin from binding to Na/K ATPase.

Additional Heart Failure Treatments

PDE inhibitors like inamrinone and milrinone are utilized for acutely ill patients but have side effects including hepatotoxicity and thromobocytopenia.
Dobutamine is a beta-1 selective agonist useful in decompensated heart failure with hypotension.
Theophylline, a less selective PDE inhibitor, is used in asthma or COPD but is not first-line therapy.

Angina Types and Management

Angina arises when cardiac workload surpasses perfusion capabilities.
Three forms of angina: stable, unstable, and Prinzmetal's angina.
Stable angina is a result of coronary artery disease, while unstable angina involves acute episodes of chest pain unrelieved by usual measures.
Prinzmetal's angina is caused by coronary vasospasm, potentially independent of coronary artery disease.
Treatment for Prinzmetal's angina includes CCBs for prophylaxis and nitrates for acute relief.

Stable Angina Treatment

Management of stable angina includes acute relief with nitrates, alongside prophylactic measures like long-acting nitrates, CCBs, beta-blockers, statins, and antiplatelet therapy.
Lifestyle modifications critical for patients include smoking cessation, diet improvements, regular exercise, and stress management.
Aggravating factors for angina include hypertension, diabetes, dyslipidemia, and depression.

Ranolazine

Acts by modifying Na-dependent calcium channel conductance during ischemia and inhibiting fatty-acid oxidation in heart cells.
Prescribed for angina prophylaxis to manage symptoms.

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Test your knowledge on hypertension treatment from Pharmacology Chapter 12. This quiz covers both primary and secondary hypertension management, including first-line treatments and drug options. Perfect for students looking to reinforce their learning on this critical topic.