HYPERTENSION MEDICATIONS

Pharm treatments
o Diuretics
Na and fluid in body
SE = dehydration, orthro hypo, electrolyte imbal, glucose
o Beta blockers
Negative chronotrope (beat slower) and negative inotrope (less
force)
SE = brady, fatigue, ED, blunted SS response for hypoglycemia
in diabetics
AVOID = in acute heart failure
o ACE inhibitors
preload and afterload
SE = renal failure, K+, Cough, Angioedema, Teratogenic
AVOID = bilateral RAS
o Angiotensin II receptor blockers (ARBs)
May replace ACEi in pts w/ dry cough
SE = renal, K, angioedema, teratogenic
AVOID = bilateral RAS
o Calcium channel blockers
Keeps Ca from entering muscle cells of heart and blood vessels
and allows vessels to relax
DHP = amlodipine, nefedipine
Non-DHP = verapamil, diltiazem (negative inotropes)
SE = brady, edema
AVOID = acute heart failure
o Alpha adrenergic blockers
nerve impulse that constrict blood vessels
SE = ortho hypo, dizzy, fatigue
o Central acting adrenergic blockers
Act in brain to SS
SE = orthohypo, dizzy, fatigue, dry mouth, brady
Rebound HTN w/ acute withdrawal
o Aldosterone receptor antagonists
Blocks receptor in DCT
Na and water absorption and K retention
arterial compliance
SE = hyperkalemia, gynecomastia (spironolactone)
Indications on when to use which drug class
o Heart Failure = Diuretics, BB, ACEI, ARBS, Aldo ant
o Post MI = BB, ACEI
o High coronary disease risk = BB, ACEI
o Diabetes = ACEI, ARB
o Chronic kidney disease = ACEI, ARB
Resistant HTN
o Elevated BP despite 3 meds
o Due to med non compliance, not at max dose, using other agents,
volume overload
o Tx max dose, add meds, renal artery denervation
Points from practice questions
o High BP on right arm and normal on left possible coarctation
(stenosis) Do a CT angiography of aorta
o Pt w/ DM use ACEI
o Pt post MI use Betablocker

ACUTE CORONARY SYNDROME MEDICATIONS

Anti-ischemic therapy
o Oxygen
o Nitrates for coronary artery vasodilation
Sublingual first, then IV if pain after 3 tablets, hypertension or
HF
Reduce resistance (afterload) and preload
MOA = metab NO stims GC cGMP dephosph MLC
SMC relaxation and vasodilation
CONTRA
if hypotension is likely otherwise it could result in RV infarct
or severe aortic stenosis
if pt has taken PDI (Viagra) in last 24 hours
o Beta blockers
Short acting = Metoprolol or Atenolol
CONTRA
Bronchospasm
Severe brady
Heart block higher than first degree unless pt has permananet
pacemaker
Pulm edema
MI due to cocaine abuse b/c may result in coronary artery
spasm
o Non-DHPs if Pt cant take beta blockers
DHP should not be given regardless if beta blockers are
contraindicated
o ACEi for HF
ARBs if you cant take ACEI
o Statins
Atorvastatin or rosuvastatin
Anti ischemic therapy contraindications
o Nitrates if BP <90 or RV infarction
o Nitrates w/in 24 hours of sildenafil or tadalafil
o Immediate release DHP CCB in absence of beta blocker therapy
o IV betablockers in pts w/ acute HF, low output state, 2nd or 3rd
degree block or cardiogenic shock, asthma, or reactive airway
disease
o NSAIDS and COX-2 inhibitors
Antiplatelet therapy
o Aspirin non enteric coated
Inhibition of TxA2 and PGI2
o Platelet P2Y12 receptor blockers
Clopideogrel, ticlopidine, prasugrel, ticagrelor
Block adenosine phosphate receptor P2Y12 on platelets
Use w/ asprin
Prasugrel has a more rapid onset
Dont use prasugrel if prior TIA/stroke
Ticagrelor binds reversibly (clopidegrol and prasugrel bind
irreversibly)
Recommendation = Clopidegrol or ticagrelor
o GI prophylaxis if hx of GI bleeding
o GIIbIIIa inhibtors
For all diabetics and all all pts in early invasive arm
For pts before angiography
Eptifibatide more than abciximab or tirofiban
For pts after angiography
Abciximab or eptifibatide over tirofiban

Anticoagulatn terapy = for unstable angina and NSTEMI (given only

at hospital)
o *Unfractioned heparin
o *Enoxaparin
o Bivalarudin
o Fondaparinux
o If angiography w/in 48 hours (early invasive strategy)
Bivalirudin or UFH
o When fondaparinux is chosen, UFH or bivalirudin should be given
before PCI
o For pts using conservative strategy (non invasive)
Fondaparinux or enoxaparin
Secondary/long term prevention meds
o Aspirin
o Beta blcokers
o ACEI
o Aldosterone blockade
o Statins
o Risk factor management

ANTI-ARRHYTHMIC MANAGEMENT AND PHARMACOLOGY

Class 1a = Na channel blockade
o AF rhythm control
o SE = All prolong QTc
o Disopyramide
Not for HF
CYP3A4 substate
o Quinidine
Inhibit CYP2D6
Diarrhea
o Procainamide
SLE symptoms
Agranulocytosis
Monitor CBC
Class 1b = Na channel blockade
o VF or pulseless VT rhythm control
o Not a maintancence med, used in acute cases
o Lidocaine
Given as a continuous IV infusion
Metabolite causes seizures
Class 1c = Na channel blockade
o AF rhythm control
o All prolong QTc
o Avoid in FRrEF due to neg inotropy and worsening EF
o Flecainide
o Propafenone
Class 2 = beta blockade
o Purely rate control
o Cardioselective = BEAM (b1 only)
Bisoprolol, esmolol, atenolol, metoprolol
o Nonselective = (B1 and 2)
Propanolol
o Mixed
Carvedilol
o Target HR in asymptomatic AF < 110 (young)
o Target HR in symptomatic AF <80 (old)
o Caution in HFrEF
o Increase dose of this med to max tolerated dose first
o Avoid duplicate beta blockade w/ nDHP CCB
o Dont use in diabetics
Class 3 = Potassium channel
o AF Rhythm control
o All prolong QTc
o Amiodarone
Has activity of all 4 classes but effect based on K channel
blockade
Prolong phase 3
Most effective anti-arrhymic for maintaining sinus in AF
Inhibits conversion of T4 to T3 = monitor thyroid fxn
Many drug interactions
o Sotalol
o Dofetilide
o Dronedarone

Shorter half life than amiodarone (lacks iodine)

Dont use in HFrEF
Class 4 - Calcium channel - NDHPs
o AF rate control only
o Dont use in HFrEF due to neg inotropy
o conduction through SA and AV node via L type calcium channels
o Dilitazem
o Verapamil
Class 5 Misc
o Digoxin
o For rate control
o No negative effect on inotropy so can be used in HFrEF and Afib
o MOA = cell contractility by inhibiting Na/L ATPase
Also a vagal mimetic and electrical threshold in purkinje
fibers
o Tox = yellow green halos
Clinical Trials
o CAST Trial
Purpose = use of rhythm control post MI would decrease
incidence of morality
Result
Flecainide and all 1c drugs used w/ caution in pts w/
structural heart disease
o Andromeda
Purpose = test whether dronedarone reduces rate of
hospitalization due to HF and recue mortality
Do not use Drenedarone in symptomatic HF w/ recent
decompensation
o AFFIRM trial
Compare effect of long term tx w/ rate vs rhythm control in pts
w/ Afib
Result
Rate control has an advantage of lower risk of Side effects

HEART FAILURE, INOTROPES, PRESSORS

ACEIs and ARBS
o Improvement in HF symptoms
o SE = cough
o Vasodilation on both arterial and venous sides
Diuretics
o Thiazides
o K sparing
o Loop diuretics
o volume and preload = congestive symptoms
o SE = Hypokalemia
Spironolactone

o Antag of Aldo receptor

o SE = hyperkalemia, gynecomastia
Digoxin
o LV EF, CO and exercise capacity
Beta receptor antag
Hydrazaline + Nitrate
o Hydrazaline = direct acting vasodilator = afterload
o Use in pts who cant use ACEIs
Sacubtirl+Valsartan
o Inhibit neprilysin less breakdown of ANP, BNP, CNP
vasodilation and imporved renal Na elimination
Acute management of decompensated HF
o Dobutamine
Beta receptor agonist
o Milrinone
PDE inhibitor
Psotive inotrope and chronotrope
o Nitroprusside = preload and afterload
Drugs that may hurt HF pts
o Diltizem and verapamil = in systolic failure harmful
Used to tx diastolic failure
o Flecainide, Moricizine = Class 1c antiarrhymics that killed ppl w/
structural heart disease