Angina, Heart Failure, and Related Drugs PDF

Angina ‡ characterized by chest pain or discomfort due to coronary heart disease. ‡ Problem is *ischemia ʹ inadequate amount of oxygenated blood ‡ increase oxygen demand decrease oxygen supply (It affects the blood vessel) Two parts affected by ischemia ‡ Myocardial ischemia ʹ inadequate supp...

Angina ‡ characterized by chest pain or discomfort due to coronary heart disease. ‡ Problem is *ischemia ʹ inadequate amount of oxygenated blood ‡ increase oxygen demand decrease oxygen supply (It affects the blood vessel) Two parts affected by ischemia ‡ Myocardial ischemia ʹ inadequate supply of oxygenated blood in the heart. ‡ Cerebral ischemia ʹ inadequate supply of oxygenated blood in the brain. ‡ most fatal because it can result to stroke ‡ Æ paralysis which can result to comatose 3 TYPES OF ANGINA Stable Angina - aka effort angina, classic angina - most common type of angina - commonly present to smoker and hypertensive patient - main cause is atherosclerosis - chest pain is predictable or expected, when there is physical exertion or activity. Unstable Angina - aka angina at rest/crescendo angina - chest pain is unexpected, experienced during at rest - common at night - main causes are atherosclerosis and thrombosis WƌŝŶnjŵĞƚĂů͛Ɛ Angina - vasospastic or variant angina - severe form of angina - chest pain occurs at night up to early morning , takes place during at rest and during physical exertion ANTIANGINAL DRUGS ‡ Organic nitrates ‡ Calcium Channel blockers ‡ Beta blockers ‡ Ivabradine & Nicorandil hypertensive patients - monotherapy with slow release or long acting CCB or Refractory cases- CCBs Beta blockers - refractory to organic nitrates normotensive patients - with angina & normal BP Acute treatment of Vasospastic - DOC: Nitroglycerin angina - alternative: Propranolol with nifedipine DOC: verapamil/diltiazem Unstable Angina Pectoris *aspirin ʹ inhibits thromboxane formation *cilostazol ʹ antiplatelet with vasodilating effect, inhibit PDE3 *clopidogrel ʹ inhibit adenosine diphosphate pathway Sildenafil - vasodilator which is used to manage erectile dysfunction - also used to manage angina pectoris Æ MOA: phosphodiesterase isoform-5 inhibitor (PDE5), as an inhibitor it increases CGMP which result to vasodilation men ʹ sildenafil increases the blood flow in corpus cavernosa Æ erection ‡ Arrhythmia ÆDefined as the abnormal firing rate, regularity or site of origin of cardiac impulse, involve irregular and abnormal heart rhythm. ‡ Normal heart rhythm: 60-90 beats per minute ‡ * heart rhythm is regulated by the SA Node (phase maker of heart) ANTIARRHYTHMIC DRUGS Type I ʹ NA Type II ʹ Beta Type III ʹ K Type IV ʹ Ca IA ʹ Quinidine, -͟K>K>͟ĞdžĐĞƉƚ Bretylium Verapamil Procainamide, Sotalol Amiodarone Diltiazem Dysopiramide Dronaderone CI: Nifedipine IB ʹ Lidocaine, Sotalol Mexiletine, Phenytoin IC ʹ Moricizine, Flecainide, Propafenone Heart Failure HEART FAILURE - medical condition characterized by impairment of left ventricle - there is no ability to pump sufficient oxygenated blood - inadequate supply of oxygenated blood coming from ventricle Æ can result to hospitalization Symptoms of heart failure based on exertion Class1 - asymptomatic - no limitation on physical activity Class 2 - mild to moderate moderation on - physical activity - can be relieved during at rest Class 3 - marked limitation on physical activity - can happen even during at rest Class 4 - any physical activity can trigger heart failure symptoms 2 Forms of heart failure 1. Low output ‡ most common Æ no metabolic demand/requirement, but the heart cannot compensate with the requirements for oxygenated blood 2. High output ‡ characterized by metabolic disorder ‡ Ex. Hyperthyroidism - increases demand for oxygenated blood because patient suffers from palpitation or tachycardia. ‡ Anemia - hematopoietic disorder characterized by low levels of haemoglobin (oxygenated blood) 1. Inotropic agent (increases the force of contraction) * cardiac glycoside - digitalis - Most important ion affected by digitalis is K channel, therefore it can cause hypokalemia - Alternative for hypokalemia is KCl or MgSO4 Deslanoside - alternative for rapid digitalization 2.. Diuretics -to reduce fluid overload in patient suffering from fluid retention *Thiazide / loop diuretics - commonly used - same cardiac effect with cardiac glycosides (hypokalemia- can cause digitalis toxicity, must be given separately with cardiac glycosides) 3. Vasodilator - main goal is to reduce pulmonary congestion Use: left sided heart failure - it can increase cardiac output Ex. Organic nitrates, sodium nitroprusside Ex. Minoxidil, hydralazine, prazosin Angiotensin Converting Enzyme Inhibitor - first line agent for heart failure - beneficial to prevent cardiac hypertrophy Captopril - most widely used Ramipril, quinapril can also be used except enalapril Enalapril - only use for hypertensive emergency Prob with vasodilator such as ACEI can promote fluid retention therefore must be given with beta blocker or diuretics Beta blockers - prophylaxis for px with chronic heart failure Carvedilol - first beta blocker approved for heart failure - mixed acting alpha and beta blocker Cardioselective : bisoprolol and metoprolol Other inotropic agents Inamrinone - also known in the market as amrinone ‡ toxic effect : hepatotoxic & aplastic anemia ‡ can cause bone marrow suppression and liver damage Milrinone - associated with thrombocytopenia ‡ can cause hemorrhage or bleeding Agents used in dyslipidemia ‡ abnormalities of lipoproteins ( important carrier transporter of lipids/fats in the body) ‡ problem is either a decrease or increase level of lipoproteins ‡ LDL / bad cholesterol- lipoproteins that increase ‡ HDL/good cholesterol - lipoproteins that decrease HMG-COa reductase inhibitor ‡ 3-hydroxy-3-methylglutaryl coenzymeA ‡ enzyme necessary for formation of mevalonic acid ‡ Main goal: prevent the synthesis of the immediate metabolic precursor of cholesterol (No mevalonic acid no cholesterol) ‡ ends with statin ‡ most effective drug in reducing LDL secretion Drugs Atorvastatin Fluorinated congeners -prototype drug Fluvastatin Lactone prodrug - Lovastatin - Simvastatin Rosuvastatin Indication: most Active lactone ring effective drug in severe - Pravastatin hypercholesterolemia Common schedule of administration: ‡ given at night (because at night synthesis of cholesterol is higher) ‡ Except atorvastatin & rosuvastatin (can be given either in the morning or at night ) ADR ‡ increase hepatic enzyme (serum aminotrasferases) Æ hepatotoxicity ‡ Increase creatinine kinase (for muscle metabolism) Æ rhabdomyolysis ‡ Cardiomyopathy Bile acid binding resin Bile acid - byproduct of cholesterol synthesis - important in the absorption of fats - (function: emulsifying agent) Common bile acid binding resin - cholestyramine, cholestipol * bile acid is synthesized in the liver and stores in the gall bladder Niacin - vit B3 - water soluble vitamin - effective in reducing LDL &VLDL secretion in endothelial cells - associated with vasodilating effect Adr : warm sensation or flushing Remedy to reduce flushing it must be taken with aspirin  THYROID AND ANTITHYROID DRUGS HYPOTHYROIDISM HYPERTHYROIDISM ‡ Myexedema ‡ Cretenism ‡ Thyrotoxicosis ‡ ,ĂƐŚŝŵŽƚŽ͛ƐĚŝƐŽƌĚĞƌ ‡ 'ƌĂǀĞ͛ƐĚŝƐĞĂƐĞ ‡ Endemic goiter ‡ Exopthalmos ‡ Sporadic goiter Drugs: Drugs: 1. Thioamides ʹ Methimazole & 1. Levothyroxine ʹ DOC PTU 2. Liotrix 2. Ipodate and Iopanoic acid 3. Iodine 131 3. Desiccated Thyroid 4. Propranolol 5. Thyroidectomy INSULIN DOC for Type I DM Rapid Acting Insulin lispro Insulin aspart Insulin glulisine Short Acting Regular Soluble insulin Intermediate NPH or Isophane Acting Long Acting Insulin Glargine Insulin Detemir Oral Hypoglycemic Agents Secretagogues Sulfonylurea 1st Gen ʹ Tolbutamide, Chlorpropramide, Tolazamide 2nd Gen ʹ Glibenclamide, Glipizide, Glimepiride Meglitinides Repaglinide, Nateglinide Thiazolidinediones Troglitazone, Pioglitazone, Rosiglitazone Alpha-glucosidase Acarbose, Voglibose, inhibitors Miglitol Dipeptidylpeptidase Sitagliptin inhibitor Euglycemic Agents insulin sensitizer Metformin ADR: laxative effect ʹ diarrhea appetite suppression ʹ anorexia abdominal pain Phenformin Withdrawn due to lactic acidosis Summary of important DOC DRUG INDICATION Epinephrine 1st line cardiac stimulant, anaphylactic shock Norepinephrine 1st line inotropic agent in the Mx of septic shock Dobutamine 1st line drug for cardiogenic shock Salbutamol / albuterol 1st line bronchodilator in acute asthma attacks Loratadine / Fexophenadine Only antihistamine allowed for pilots Methylphenidate DOC for ADHD Amphetamine Alternative for ADHD Phenoxybenzamine DOC for carcinoid syndrome Beta blockers DOC for CSAP (chronic stable angina pectoris) Atropine DOC for cholinergic toxicity Summary of important DOC DRUG INDICATION Pralidoxime, DOC for organoPO4 poisoning Diacetylmonoxide, atropine Ipratropium, Oxytropium, DOC bronchodilator for COPD Tiotropium Dantrolene DOC Malignant hyperthermia Sucralfate DOC for stress-induced ulcer in critically-ill patients Methotrexate 1st line DMARDS in RA Colchicine 1st line Tx in acute gout Allopurinol 1st line hypourcemic agent in chronic gout Aspirin,325 mg/day 1st line in the primary and secondary prevention of acute thrombotic events Summary of important DOC DRUG INDICATION -statins 1st line in Hypercholesterolemia Fibrates 1st line in hypertriglyceridemia Carbonic anhydrase inhibitors 1st line in open angled glaucoma Thiazide diuretics 1st line Tx in HTN (as monotherapy or combination therapy) and in nephrogenic diabetes insipidus Na Nitroprusside 1st line in HTNsive emergencies ACE-inhibitors Base Tx component of CHF, 1st line Mx of HTN in CKD and DM Px and 1st line for albuminuria Amyl nitrite Initial Mx of CN- poisoning Lidocaine 1st line in ventricular tachycardia assoc. With digitalis toxicity and post-MI Amiodarone 1st line in ventricular tachycardia Summary of important DOC DRUG INDICATION Adenosine 1st line in acute supraventricular tachycardia MgSO4 1st line in Torsades de pointes SABA 1st line reliever in BA and alternative reliever in COPD LABA 1st line controller (with inhaled GC) for COPD Locally-acting inhaled GC 1st line controller for BA Systemic GC (parenteral) 1st line in status asthamticus Levo-thyroxine 1st line in hypothyroidism Summary of important DOC DRUG INDICATION Thioamides (PTU, 1st line in hyperthyroidism methimazole) Perchlorate DOC in amiodarone-induced hyperthyroidism Metformin 1st line initial Tx of type 2 DM esp. among obese Px Lithium 1st line Tx and prevention of bipolar disorder Lorazepam DOC for Status epilepticus Isoflurane Preferred anesthetic in neurosurgery Diazepam DOC to prevent and arrest convulsion in anesthetic toxicity Summary of important DOC DRUG INDICATION Pen G (2-4 M units IM) DOC for syphilis Metronidazole Pseudomembranous colitis Streptomycin 2nd line forTB, for MultiDrug Resistant TB Co-trimoxazole DOC for Pneumocystis carinii pneumonia Dapsone, Rifampin, WHO triple Tx for lepromatous type of Clofazimine leprosy Dapsone, Rifampin DOC for tuberculoid type of leprosy Amphotericin B Systemic mycoses