Updated: 12/9/2019

Cardiovascular Medications

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  • Cardiovascular Drug Introduction
    • Cardiovascular medications can be broken down into the following categories:
      • antiarrhythmics
      • antihypertensives
      • inotropes
      • vasodilators
      • diuretics
      • antihyperlipidemics
      • anticoagulants
      • thrombolytics
  • Cardiovascular Drug Table
    • Antiarrhythmics
        • Class I (Na+ Channel Block)
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Lidocaine
        • Na+ channel blockage
        • preferentially binds to Na+ channels in the deactivated state
        • Acute ventricular arrhythmia secondary to:
        • myocardial infarction
        • digitalis toxicity
        • cardiac manipulation (i.e., catherization, surgery)
        • Cardiotoxicity:
        • arrhythmia
        • bradycardia
        •  Neurotoxicity:
        • excitation/depression
        • Procainamide
        • Na+ channel blockage
        • preferentially binds to Na+ channels in the deactivated state
        • Ventricular arrhythmia
        •  Supraventricular arrhythmia
        • SLE-like syndrome:
        • increased incidence in slow acetylators
        • Quinidine
        • Na+ channel blockage
        • preferentially binds to Na+ channels in the activated state
        • Ventricular arrhythmia/tachycardia
        • Atrial fibrillation/flutter
        • Cinchonism
        • ↑ QT interval
      • Class II (β-Block)
        • See antihypertensives below
        • Class III (K+ Channel Block)
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Amiodarone
        • K+, Ca2+, and Na+ channel blocker:
        • broad-spectrum anti-arrhythmic
        • Most types of arrhythmias:
        • secondary due to broad mechanism of action
        • Pulmonary fibrosis
        • Hyper- or hypothyroidism
        • Blue pigment of the skin
        • "smurf skin"
        • Corneal deposits
        • Hepatotoxic
        • Photophobia
        • Bretylium
        • Unknown
        • Ventricular arrhythmia resistant to typical antiarrhythmic therapy:
        • considered last-resort
        • Orthostatic hypotension
        • Nausea
        • Vomiting
        • Sotalol
        • β-blocker
        • K+ channel blocker
        • Ventricular arrhythmia
        • Atrial fibrillation/flutter
        • Torsades de pointes
        • β-blockade
        • Class IV (Ca2+ Channel Blockers)
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Amlodipine
        • Nicardipine
        •  Nifedipine
        • Ca2+ channel blocker
        • preferentially in vasculature
        • Angina
        • Hypertension
        • Peripheral edema
        • Pulmonary edema
        • Flushing/dizziness
        • Reflex tachycardia
        • Remember, they act on vascular smooth muscle
        • Gingival hyperplasia
        • Dilitiazem
        •  Verapamil
        • Ca2+ channel blocker
        • preferentially in vasculature
        • Supraventricular tachycardia
        • Angina
        • Hypertension
        • Cardiac depression
        • Constipation
        • Other Antiarrythmics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Adenosine
        • Adenosine receptor agonist:
        • ↓ cAMP via Gi
        • AV nodal arrhythmia
        • Paroxysmal supraventricular tachycardias
        • Impending doom
        • Vasodilation
        • Dyspnea
        • secondary to bronchoconstriction
        • Atropine
        • Muscarinic antagonist
        • Inhibit secretions
        •  Sinus bradycardia
        •  AV block
        •  Adjuvant with anticholinesterase
        • Antimuscarinic/cholinergic effects
        • Digoxin
        • Cardiac Na+/K+ ATPase inhibitor
        • Heart failure
        •  Atrial fibrillation
        • Arrhythmia
        •  Nausea
        •  Vomiting
        •  Diarrhea
        •  Blurry yellow vision
        • Epinephrine
        • β- and α-agonist:
        • β > α
        • Anaphylactic reactions
        • Hypotension
        • Secondary to β- and α-adrenergic receptor effects
        • β > α
        • Ibutilide
        • K+ channel blocker
        • Atrial fibrillation/flutter
        • Torsades de pointes
        • Isoproterenol
        •  β-agonist
        • Heart block
        •  Bradyarrhythmias
        •  Bronchospasm
        • Arrhythmias
        •  Angina
        • Flushing
        • Magnesium sulfate
        • Effect on Ca2+ and K+ fluxes
        • Torsades de pointes
        •  Digitalis-induced arrhythmia
        • Cardiac arrest
        • ↓ Deep tendon reflexes
    • Antihypertensives
        • β-Blockers
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Atenolol
        • β-blocker
        • β1 > β2
        • Hypertension
        •  Angina
        •  Post-MI secondary prevention
        • Bradycardia
        •  Heart failure
        •  AV block
        • Esmolol
        • β-blocker
        • β1 > β2
        • Supraventricular tachycardia
        • Cardiac arrest
        •  Bradycardia
        •  Hypotension
        • Metoprolol
        • β-blocker
        • β1 > β2
        • Hypertension
        •  Angina
        •  Acute myocardial infarction in hemodynamically stable patients
        •  ↓ Morbidity and mortality in heart failure
        • Hypotension
        •  Bradycardia
        •  AV block
        •  Dyslipidemia
        • Carteolol
        • β-blocker
        • Open-angle glaucoma
        •  Intraocular hypertension
        • Conjunctival hyperemia
        • Propranolol
        • β-blocker
        • β1 = β2
        • Hypertension
        •  Angina
        •  Essential tremor
        •  Migraine prophylaxis
        •  Thyrotoxicosis
        •  Supraventricular arrhythmias:
        • also ventricular tachycardias
        • Bradycardia
        •  AV block
        •  COPD and asthma exacerbation
        •  Vasospasm exacerbation in Prinzmetal angina
        • Sotalol
        • β-blocker
        • K+ channel blocker
        • Ventricular arrhythmia
        •  Atrial fibrillation/flutter
        • Torsades de pointes
        •  β-blockade
        • Carvedilol
        • α- and β-blocker
        • Congestive heart failure
        •  Hypertension
        •  Antiarrhythmic
        • Hypotension
        •  Cardiovascular effects: bradycardia, etc.
        • Labetolol
        • α- and β-blocker
        • Hypertension
        •  Hypertensive emergencies:
        • such as in pregnancy
        • (i.e., gestational HTN, preeclampsia, eclampsia, etc.)
        •   Orthostatic hypotension
        • ACE Inhibitors
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Benazepril
        •  Captopril
        •  Enalapril
        •  Lisinopril
        • Angiotensin-converting enzyme (ACE) inhibitor
        • Hypertension
        •  Heart failure
        •  Diabetic kidney disease
        • Cough
        •  Hyperkalemia
        •  Teratogen
        •  Angioedema
        •  ↓ Glomerular filtration rate (GFR)
        •  Hypotensio
        • Angiotensin II Antagonists
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Losartan
        •   Candesartan
        •   Valsartan
        • Angiotensin receptor blockers (ARBs)
        • Hypertension
        • Heart failure
        • Diabetic kidney disease
        • Hyperkalemia
        •   Teratogen
        •   ↓ Glomerular filtration rate (GFR)
        •   Hypotension
        • Antiadrenergics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Clonidine
        • α2-agonist
        • Hypertension
        •  Attention deficit hyperactive disorder (ADHD)
        •  Tourette syndrome
        •  Opioid withdrawal
        • Depression of the CNS
        •  Respiratory depression
        •  Bradycardia
        •  Hypotension
        •  Miosis
        • Doxazosin
        •  Terazosin
        • α1-blocker
        • Hypertension
        •  Benign prostatic hyperplasia symptoms
        • Orthostatic hypotension
        •  Urinary incontinence
    • Inotropes
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Amrinone
        •  Milrinone
        • Phosphodiesterase (PDE) inhibitor
        •   Heart failure
        • Arrhythmia
        • Dobutamine
        • β- and α-agonist
        • β1 > β2, α
        •   Heart failure
        • Tachyarrhythmia
        •  Hypertension
        • Dopamine
        • Dopamine, β- and α-agonist
        • D1 = D2 > β > α
        • Low cardiac output/poor perfusion
        •  Hypotension
        •  At low doses, increases renal perfusion
        • Arrhythmia
        •  Angina
        • Epinephrine
        • β- and α-agonist
        • β > α
        • Type I hypersensitivity reactions
        •  Hypotension secondary to septic shock
        •  Cardiac arrest
        • Angina
        •  Arrhythmia
        •  Anxiety
        •  Respiratory difficulties
        • Norepinephrine
        • β- and α-agonist
        • α > β
        • Hypotension
        •  Cardiac arrest
        •  Septic shock
        • Hypertension
        •  Bradycardia
        •  Arrhythmia
        •  Anxiety
        •  Dyspnea
        • Phenylephrine
        • α-agonist
        • α1 > α2
        • Hypotension
        •  Decongestant
        • Hypertension
        •  Reflex bradycardia
        •  Anxiety
        •  Pulmonary edema
    • Vasodilators
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Hydralazine
        • ↑ cGMP, leading to smooth muscle relaxation
        •  Severe hypertension
        •  Heart failure
        • Tachycardia
        •  SLE
        • Nitroprusside
        • ↑ cGMP
        • Severe hypertension
        •  Decompensated heart failure
        • Hypotension
        •  Cyanide toxicity (potential)
        • Minoxidil
        • Arteriolar vasodilator
        •  Opens K+ channels
        • Severe hypertension
        •  Androgenetic alopecia
        • Tachycardia
        •  Salt and water retention
        •  Hirsutism
        • Diazoxide
        • Opens K+ channels in smooth muscle
        • Severe hypertension
        •  Hypoglycemia in the setting of insulin-secreting tumors
        • Hypotension
        •  Hyperglycemia
    • Diuretics
        • Carbonic Anhydrase Inhibitors
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Acetazolamide
        • Carbonic anhydrase inhibitor
        • Edema
        • Mountain sickness
        • Glaucoma
        • Idiopathic intracranial
        • hypertension (pseudotumor cerebri)
        • Metabolic acidosis
        •  Hyperammonemia
        •  Paresthesias
        •  Sulfa allergy
        • Loop Diuretics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Bumetanide
        • Furosemide
        • Torsemide
        • Inhibit Na+/K+/2Cl− transporter of thick ascending limb of loop of Henle
        • Hypertension
        •  Edema:
        • due to heart failure, liver failure, nephrotic syndrome
        •  Hypercalcemia
        • Ototoxicity
        •  Metabolic hypokalemic alkalosis
        •  Hypovolemia
        •  Sulfa allergy
        •  Insterstitial nephritis
        •  Gout
        •  Efficacy is decreased when used with NSAIDs
        • Thiazide Diuretics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Chlorothiazide
        • Hydrochlorothiazide (HCTZ)
        • NaCl reabsorption inhibitor in distal convoluted tubule
        • Heart failure
        • Edema
        • Nephrogenic diabetes insipidous
        • Calcium nephrolithiasis
        • Sulfa allergy
        • Hypokalemia
        • Hyper-uricemia, glycemia, calcemia, lipidemia
        • Metabolic alkalosis
        • K+ Sparing Diuretics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Amiloride
        • ENaC epithelial channel blocker in cortical collecting ducts
        • Heart failure
        •  Hyperaldosteronism
        •  Nephrogenic diabetes insipidus
        •  States of K+ depletion (i.e., use of thiazides)
        • Hyperkalemia
        • Spirolactone
        • Aldosterone receptor blocker in cortical collecting ducts (in their cytoplasm)
        • Heart failure
        •  Hyperaldosteronism
        •  Hepatic ascites
        • Hyperkalemia
        •  Gynecomastia
    • Antihyperlipidemics
        • HMG-CoA Reductase Inhibitors
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Atorvastatin
        • Cerivastatin
        • Fluvastatin
        • Lovastatin
        • Pravastatin
        • Simvastatin
        • HMG-CoA reducase inhibitor
        • Vascular disease secondary to atherosclerosis
        • Myopathy
        •  Hepatotoxicity
        •  Potential for teratogenicity
        • contraindicated in pregnancy
        • Other Antihyperlipidemics
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Fenofibrate
        • Gemfibrozil
        • PPAR-α agonists
        •  Upregulates lipoprotein lipase
        • Hypertriglyceridemia, low HDL
        • cholesterol
        •  Can ↑ HDL in most patients
        • Myopathy
        •  Gallstones (cholesterol)
        • Niacin
        • ↑ HDL and ↓ LDL and triglycerides
        • Dyslipidemia
        • Flushing, pruritis
        • NSAIDs can help
        •  Hepatotoxicity
        •  Hyperuricemia
        •  Hyperglycemia
    • Anticoagulants
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Abciximab
        • Tirofiban
        • GpIIb/IIIa inhibitor
        • Unstable angina
        •  Prevention of cardiac ischemia in 
        • percutaneous coronary intervention
        • Bleeding
        •  Thrombocytopenia
        • Anagrelide
        • Phosphodiesterase III inhibitor
        • Thrombocythemia
        • can be seen in myeloproliferative disorders
        • Palpitations
        •  Headache
        •  Thrombocytopenia
        •  Bleeding
        • Cilostazol
        • Phosphodiesterase III inhibitor
        • Secondary ischemic stroke prevention
        •  Intermittent claudication
        •  Thromboembolic complication prevention
        • i.e., cardiac valve replacement, percutaneous coronary intervention
        • Headache
        • Flushing
        • Hypotension
        • Aspirin
        • Irreversible COX inhibitor
        • Impairs TXA2 synthesis
        • Treatment and prevention of arterial thrombosis
        • Tinnitus
        •  Gastrointestinal toxicity
        •  Renal toxicity
        •  Reye syndrome:
        • children with viral infection
        •  Metabolic acidosis-respiratory alkalosis:
        • respiratory alkalosis early
        • Platelet Aggregation Antagonists
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Ticlopidine
        • Clopidogrel
        • ADP-receptor antagonist
        • thus impairs expression of GpIIb/IIIa receptors
        • Acute coronary syndrome
        •  Prevention of cardiac ischemia in percutaneous coronary intervention
        •  Treatment and prevention of arterial thrombosis
        • Leukopenia (ticlopidine)
        •  Thrombotic thrombocytopenic purpura
    • Thrombolytics
        • Thrombin Inhibitor
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Alteplase
        • Streptokinase
        • Urokinase
        • Aids in conversion of plasminogen to plasmin
        • Early myocardial infarction and ischemic stroke
        •  Pulmonary embolism
        • Bleeding
    • Other
        • Name
        • Mechanism of Action
        •  Key Indication
        •  Key Toxicity
        • Digoxin-Immune Fab
        • Binds excess digoxin or digitoxin
        • Digoxin toxicity
        • Heart failure exacerbation
        • Albumin
        • Blood volume expander:
        • acts as an oncotic agent
        •  Antihyperbilirubinemic:
        • Binds to various substances in the bloods (i.e., bilirubin, drugs, etc.)
        • Hypovolemia
        •  Subacute bacterial peritonitis
        •  Cirrhosis
        • Heart failure
        •  Edema
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(M2.PH.17.4754) A 70-year-old obese male presents to the emergency department with shortness of breath and cough of sudden onset. The patient states that his symptoms came on while he was sleeping. The patient has a past medical history of type II diabetes and is currently taking lisinopril, metformin, insulin, and fish oil. On physical exam, you note bipedal edema and jugular venous distention (JVD). An EKG and chest radiographs are obtained (Figures A and B). The patient is started on BIPAP and medical therapy and his symptoms improve rapidly. Lab values are as follows.

Serum:
Na+: 137 mEq/L
K+: 3.2 mEq/L
Cl-: 100 mEq/L
HCO3-: 31 mEq/L
BUN: 20 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.9 mg/dL

Which of the following is the best explanation of this patient's current presentation?

QID: 108981
FIGURES:

Furosemide

18%

(18/100)

Hydrochlorothiazide

42%

(42/100)

Renal tubular acidosis type I

19%

(19/100)

Renal tubular acidosis type II

9%

(9/100)

Renal tubular acidosis type IV

9%

(9/100)

M 6 D

Select Answer to see Preferred Response

(M2.PH.17.4725) A 66-year-old female with congestive heart failure, diabetes mellitus, depression, and osteoarthritis presents to the emergency department with fatigue, blurry vision, and diarrhea. Her home medications include furosemide, lisinopril, carvedilol, digoxin, metformin, glyburide, amitriptyline, and occasional ibuprofen for knee pain. She endorses recent knee pain and an increase in her glyburide dose.

Her labs include the following:

Serum:
Na+: 137 mEq/L
K+: 3.3 mEq/L
Cl-: 99 mEq/L
HCO3-: 24 mEq/L
BUN: 17 mg/dL
Cr: 1.62 mg/dL
Glucose: 160 mg/dL

An EKG can be seen in Figure A.

What is the most likely inciting event for this patient's presentation?

QID: 108568
FIGURES:

Increase in glyburide dose as amitriptyline is hepatically cleared

11%

(3/27)

Recent NSAID use as amitriptyline is renally cleared

4%

(1/27)

Increase in glyburide dose as digoxin is hepatically cleared

7%

(2/27)

Increase in glyburide dose as digoxin is renally cleared

19%

(5/27)

Recent NSAID use as digoxin is renally cleared

59%

(16/27)

M 6 C

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