Cardio Pharm Mega Reviewer

Blocks Na/Cl.

Distal convoluted tubules

First line HTN

Adjunct for edema

Metolazone is added for synergy

Do not use with:

Sulfa allergy

CrClearance < 30

Gout

Watch out for:

Low Na, K, Mg

High Glucose, lipids, uric acid, calcium

Photosensitivity

THIAZIDES

HCTZ

Chlorothiazide

Chlorthalidone

Metaolazone

Blocks Na/K/2Cl in THICK ASCENDING LOOP OF HENLE

Strongest diuretics

Indication:

Heart failure

Pulm edema

Acute decompensated HF

HTN when kidneys are poor

Do not use:

Anuria

Sulfa allergy

Watch for:

Ototoxicity

High uric acid

LOOP DIURETICS:

Furosemide

Bumetanide

Torsemide

NON-SULFONAMIDE Loop Diuretic

Edema in patient with sulfa allergy

DO not use:

Severe watery diarrhea with prior use

Watch for:

Ototoxicity

GI bleed

Diarrhea

Livery toxicity

LOOP DIURETIC:

Ethacrynic Acid

Blocks aldosterone to keep K and lose Na

Used for:

HFrEF

Resistant HTN

Hyperaldosteronism

Cirrhosis

Edema

Low K

Do not use:

K>5.5

Addison Disease

SCr>2.5

Watch for:

Hyperkalemia

Gynecomastia

ED and menstrual changes

"Potassium Sparing Diuretics"

Spironolactone

Eplerenone (Aldosterone antagonists)

Blocks Na channels (ENAC) in the Collecting Tubule

NO EFFECT ON ALDOSTERONE

Use:

Paired with a thiazide in combo pills to spare K

HTN, Edema

Watch for:

Hyperkalemia

Megaloblastic anemia, reduced platelets

"Potassium Sparing Diuretics" without effect on Aldosterone

Amiloride

Triamterene

Raises GLUC (Glucose, Lipids, Uric Acid, Calcium)

Thiazides

Loses calcium

Loop Diuretics

Keeps Calcium (helps in osteoporosis)

Thiazides

Loop Side Effects

O-totoxicity

H-ypokalemia

D-ehydration

A-llergy (SULFA)

N-ephritis

G-out

Central a2 agonist turns down sympathetic outflow from brain

Use:

Refractory HTN

Do not use:

Never stop suddenly

Watch for:

Rebound hypertensive crisis

Dry mouth

Patch rash

Clonidine

Converted to alpha-methylnorepinephrine, a central a2 agonist

Use:

HTN in pregnancy (1st choice is Labetalol)

Do not use:

Active MAOI therapy

Liver disease

Watch for:

Sedation

Depression/nightmare

lactation

drug fever

Methyldopa

Blocks a1 receptors on vessels->relax

Use:

Add on for HTN

BPH

Watch for:

First dose orthostatic hypotension/fainting (give first dose at bedtime for this reason)

Nasal congestion

Prazosin

Terazosin

Doxazosin

"zosin"-Selective a1 blockers

Non Selective alpha antagonist (Reversible):

Blocks alpha 1 and alpha 2

Use:

Pheochromocytoma diagnosis

Vasopressor extravasation

Do not use:

Active MI

Coronary Insufficiency

Watch for:

Reflex tachycardia

Phentolamine

Nonselective alpha antagonist (irreversible):

Long lasting and irreversible

Use:

Pheochromocytoma before surgery

Do not use:

Any condition where BP drop is dangerous

Watch for:

Nasal congestion

Myosis

Hypotension

Tachycardia

Phenoxybenzamine

Cardioselective (Beta 1 only)

Safe choice in asthma and COPD

Metoprolol

Atenolol

Esmolol (IV and short acting)

Betaxolol

Bisoprolol

IV Cardioselective (Beta 1) Beta Blocker that is given IV and is ultra-short acting

Esmolol

Non Selective (Beta 1 and Beta 2)

Can cause bronchospasms

Avoid in severe asthma and COPD

Propanolol

Nadolol

Mixed alpha 1 and Beta Blockers

Also causes vasodilation

Labetalol

Carvedilol

Drug of choice for HTN in pregnancy

Labetalol

Mixed Beta Blocker used in Heart Failure

Carvedilol

Class of medications which can be given with:

Post MI

Angina

AFib rate control

Thyrotoxicosis

HTN

Beta Blockers

Beta Blockers used in Heart Failure with Reduced Ejection Fraction

Metoprolol

Succinate

Carvedilol

Bisoprolol

Class of medications which should be not given if with:

2nd/3rd degree heart block

Sick sinus syndrome

Cardiogenic shock

Prinzmetal (vasospastic angina)

Decompensated HF

WPW

Nonselective agents in severe asthma/COPD

Beta blockers

Class of medications which should never be stopped abruptly for risk of rebound angina/MI

Beta Blockers

B1 selective Beta Blockers

Atenolol

Betaxolol

Bisoprolol

Esmolol

Metoprolol

Non Selective Beta Blockers

Nadolol

Propanolol

Mixed alpha and beta blocking

Labetalol

Carvedilol

Never stop these cold turkey

Clonidine

Betablockers

Blocks ACE-->less angiotensin

Bradykinin build up

Used in Diabetes (Nephro protective, reduces proteinuria)

Do not use in:

Pregnancy, bilateral renal artery stenosis

Never combined with ARB or aliskiren

Watch for:

Dry cough

angioedema

Hyperkalemia

ACE Inhibitors:

Lisinopril

Captopril

Enalapril

Benazepril

Fosinopril

Ramipril

The "-pril's"

ACE Inhibitor

Blocks AT1 receptors for Angiotensin II

Use:

When an ACE causes cough

Can be used with Diabetics

Do not use:

Pregnancy

Bilateral renal artery stenosis

Never with an ACEi

Watch for:

Less cough than ACEi

Angioedema

Hyperkalemia

ARBS

Losartan

Valsartan

Zilsartan

Clandesartan

Irbesartan

Olmesartan

Blocks renin at the top of the cascade

Use:

HTN

Diabetic neph

CKD

Do not use:

Pregnancy

with an ACEi or ARB

Children

DIRECT RENIN INHIBITOR

Aliskiren

Causes:

Angioedema

Cough

Elevated K

ACE Inibitors

HTN meds never given in pregnancy

Prils and Sartan's

Pregnancy Safe Hypertensive Medications

Labs Need Moms:

Labetalol

Nifedepine

Methyldopa

This class of drugs requires checking K and Serum Creatinine a week after starting

RAAS Drugs:

ACE

ARBs

Aliskiren

Blocks L-type Ca2+ channels in Blood Vessels-->Arteriolar dilation

Use:

HTN

Stable angina

Prinzmetal angina

Hypertensive Emergency (The "IV one")

Watch for:

Peripheral edema

Headache

Flushing

Reflex tachycardia

Dihydropyridines:

Amlodipine

Felodipine

Nifedipine

Nicardipine (IV)

CCB which causes increased cardiac events

Nifedpine

CCB which are indicated in Heart Failure

Amlodipine

Felodipine

Blocks CA2+ channels in the HEART

(SA/AV node, muscle) and vessels

Use:

AFIB rate control

PSVT

Stable Angina

HTN

Do not use:

WPW

HFrEF/Severe LV Dysfunction

2nd/3rd degree block

Sick sinus

Cardiogenic Shock

hypotension

Acute MI

Non-Dihydropyridines:

Verapamil

Diltiazem

CCBs which dilates vessels

Dihydropyridines

"-dipines"

CCBs which slows the heart

Non-Dihydropyridines:

Verapamil/Diltiazem

In combination, these hypertensive medications can cause severe bradycardia

Beta blocker plus:

Verapamil/Diltiazem

Dilates arterioles

Use:

HTN

HFrEF combined with isosorbide dinitrate

Do not use:

Aortic Dissection

CAD

Rheumatic Mitral Valve Disease

Watch for:

Drug induced lupus

Reflex tachycardia

Headache

Hydralazine

Opens K Channels (arterioles dilate)

Use:

Refractory HTN

Do not use:

Pheochromocytoma

Watch for:

Hair growth (Hypertrichosis)

Fluid retention, hypotension

Minoxidil

Releases nitric oxide (NO)

Raises cGMP-->Arteries and Veins dilate

IV form acts in seconds

Use:

HTN Emergency

Severe acute HF

Do not use:

PDE-5 inhibitors (Sildenafil)

Low output acute hF

Leber optic atrophy

Watch for:

Cyanide Toxicity (Metabolic Acidosis, Arrhythmia)

Hypotension

Sodium Nitroprusside

Dopamine-1 agonist-->arteries dilate

Use:

HTN Emergency

Post-Op HTN

Do Not Use:

Increased ICP

Glaucoma

Sulfite allergy

Watch for:

Headache

Flushing

Reflex Tachycardia

Fenoldopam

Opens K channels

Looks like thiazide without the Diuretic Effect

Use:

Severe HTN

Do not use:

Functional hypoglycemia

Watch for:

Hyperglycemia (blocks insulin release)

Profound Hypotension

Diazoxide

Drugs which Induce Lupus

SHIPP:

Sulfonamides

Hydralazines

Isononiazid

Procainamide

Phenytoin

Rogaine, hairgrowth drug

Minoxidil

Prussian blue-->Cyanide Compound-->Cyanide Toxicity

Nitroprusside

Dilates arterioles

Can cause reflex tachycardia and fluid retention, THUS must be paired with a beta blocker and diuretic

Hydralazine

Minoxidil

*Remember that NO dilates both arteries and veins. These just dilate Arterioles.

First Line HTN

Thiazide, ACEi/ARB or CCB

HTN meds for Diabetes or CKD

ACEi or ARB

CAD/POST MI drugs

ACEi/ARB + Beta Blocker

BPH

alpha 1 blockers ("zosin) as add on

If with Gout, avoid these HTN meds:

Avoid Thiazides and Loops

If with Asthma/COPD, avoid:

Nonselective Beta Blockers

BP uncontrolled on full doses of 3 drugs (including a diuretic).

Resistant HTN

Add:

Aldosterone Antagonist

Loop diuretic

Beta Blocker

Alpha Blocker

Vasodilator or Clonidine

BP >180/120 with organ damage

Hypertensive Emergency

Use IV Drugs:

Nicardipine

Labetalol

Esmolol

Nitroprusside

Fenoldopam

Worsens the tear of aortic dissection

Hydralazine

Releases NO, raises cGMP and relaxes smooth muscles

VEINS > ARTERIES

Preload and O2 demand drop

Use:

Sublingual NTG for every angina patient (acute attacks)

Chronic angina prevention

Do not use for:

PDE-5 Inhibitors (Sildenafil, tadalafil) or riociguat

Inferior Wall/Right Ventricular MI

Hypotension

Nitrates:

Nitroglycerin

(NTG: SL, spray, patch, IV)

Isosorbide Dinitrate (ISDN)

Isosorbide mononitrate

Blocks the late Na+ current in ischemic heart cells

Lowers wall tension and oxygen use

Use:

Chronic angina when other drugs fail

Do not use:

Liver dysfunction

Strong CPY3A4 inhibitor or inducer

Watch for:

QT prolongation

Dizziness, constipation, headache, nausea

Ranolazine

mu-upioid agonist

Pain relief plus some venous/arterial dilation

Use:

ACS pain not relieved by NTG

Dyspnea from pulmonary edema

Do not use:

Respiratory depression

Asthma attack

GI obstruction

Other CNS depressants

Watch for:

Can cause slow aspirin absorption

Respiratory depression

Hypotension

Sedation/Constipation

Morphine

Used when Beta blockers can't be used for ACS

Can be used for Prinzmetal Angina

Dihydropyridine CCB's

Use within 24 hours of ACS

Beta blockers

If used with PDE-5 inhibitors (Viagra) can cause BP crash

Nitrates

Since these drop preload, avoid in inferior MI (Right ventricle is preload dependent

Nitrates

Blocks Cox-1 to decrease thromboxane A2

Aspirin

Blocks P2Y12 so ADP cannot bind

Clopidogrel

Prasugrel

Ticagrelor

Blocks GPIIb/IIIa from binding with fibrinogen to link platelets (final step)

Eptifibatide

Tirofiban

Irreversibly blocks COX-1-->Less Thromboxane A2

Use:

Every ACS (Chewed)

Primary/secondary prevention of MI

Stroke

PAD

81mg for life after ACS

Do not use:

Active bleeding

Asthma + Rhinitis + Nasal polyp

Watch for:

GI ulcer

Bleeding

Angioedema

Aspirin

Blocks ADP at the P2Y12 receptor

Use:

Dual antiplatelet therapy (including aspirin) for 12 months

ACS, stroke, PAD, PCI

Do not use:

Active bleeding (ulcer, intracranial)

Hold before planned CABG

Watch for: Bleeding

P2Y12 Inhibitors:

Clopidogrel

Prasugrel

Ticagrelor

Irreversible P2Y12 Prodrug

Clopidogrel

Prasugrel

Reversible P2Y12 (non-prodrug)

Ticagrelor

What is P2Y12 combined with for dual antiplatelet therapy?

Aspirin

P2Y12 which is Given for prior stroke/TIA or Age > 75

Prasugrel

Reversibly blocks GP IIb/IIIa so fibrinogen can't link platelets

Use:

ACS/PCI (Iv loading dose then infusion)

Do not use:

Low paltelts

Active or recent bleeding

Surgery/trauma within 4-6 weeks

Severe uncontrolled HTN

Increased PT

Watch for:

Thrombocytopenia

Bleeding

Hypotension

GP IIb/IIIa Inhibiors:

Eptifibatide

Tirofiban

Binds antithrombin which then inactivates thrombin (IIa), Xa, and other factors

Use:

ACS (UA/NSTEMI/STEMI)

VTE Treatment/Prevention

AFib

DO Not use:

Active bleeding

Severe thrombocytopenia

History of HIT

Watch for:

Bleeding

Heparin induced thrombocytopenia (HIT)

Increased LFTs

Monitor aPTT

Unfractionated Heparin (UFH)

Antithrombin mediated

Mainly Xa > Thrombin

Use:

STEMI

VTE

Do not use:

Actively bleeding

History of HIT

CrCl

Enoxaparin

Causes Gynecomastia and Hyperkalemia

Spironolactone

Can cause yeast infections, volume depletion

SGLT2 inhibitors

First line for heart failure

ARNI

Beta Blockers we can use in Heart Failure

Carvedilol, metoprolol succinate, bisoprolol

Adverse effects of loops

Ototox

Lowers K Mg Ca

Dehydration

Low BP

High uric acid

Increases glucose

Sulfa Allergy

Used for Acute Heart Failure with gross dyspnea, 2+ edema, pleural effusion etc.

Loop diuretics (Furosemide, Bumetanide, Torsemide)

Must Know Beta Blockers

Used in VTAC

Amiodaraone

Activates peroxisome (PPAR) receptor

Fibrates:

Gemfibrozil

Fenofibrate

Low Molecular Weight Heparin

Antithrombin mediated

Xa only (synthetic)

use:

DVT/PE treatment and prevention

Do not use:

Active bleeding

Low body weight

Severe kidney impairment

Watch for:

Bleeding

Anemia

Fondaparinux

Bind DIRECTLY to Thrombin (no antithrombin needed)

Bivalirudin:

PCI (esp with HIT or HIT risk), >75

Agatroban: HIT

Dabigatran: AFib stroke prevention, DVT/PE

Do not use:

Active bleed

Adjust for kidney function

Dabigatran: mechanical heart valves

Watch for:

Bleeding

Monitor aPTT

Direct Thrombin Inhibitors:

Bivalirudin (IV)

Argatroban (IV)

Dabigatran (Oral)

Converts plasminogen to plasmin-->Dissolves fibrin in the clot

Use:

STEMI only when PCI can't happen within 120minutes

Give within 30 minutes of arrival

Treats ischemic stroke and massive PE

Do not use:

Prior Intrcranial Bleed

Ischemic stroke within 3 months

Brain tumor/AVM

Active bleeding

Suspected aortic dissection

Recent major head/face trauma

Severe uncontrolled HTN

Watch for:

Intracranial Bleed

Angioedema

Alteplase (tPA)

Reteplase

Tenecteplase

Fibrinolytic which can cause angioedema

Alteplase

Fibrinolytic which also treats ischemic stroke and massive PE

Alteplase

-grel

P2Y12 Blocker

-fiban

-tide

GP IIb/IIa

-parin

Heparin family

-rudin

-gatran

-troban

Direct Thrombin Inhibitor

-teplase

Plasminogen activator

"Clot buster"

What does ACS need both of?

Antiplatelets (stops platelet plug)

Anticoagulant (stops fibrin mesh)