cardiovascular drugs

name cardiovascular diseases

hypertension

angina pectoris (chest pain)

cornonary heart disease (ateriosclerosis)

arrythmias (electrical conductivity)

heart failire (CHF)

hyperlipidemia (high cholesterol)

List Cardiac Contradictions (meaning we dont treat)

unstable/recent onset of angina

uncontrolled HF

uncontrolled arrythmias

significant HBP/uncontrolled HBP

List Dental implications with cardiovascular disease

Tx may be delayed

Dr consult needed

type, stress, elective procedures

LA can be used on cardio pts and even benefit from it however there is a ________ because the severity fo disease, poor pain managment can ingrease endogenous epi and too much of it can stress the heart. The safe dose of epi for cardiac pts is _____. Drug interactions must also be considered.

vasoconstrictor limit, 0.04mg

These drugs interact with Epi. _____ by increasing BP (ex. welbutrin). _______ by increasing BP and reflex bradycardia. _______ by increasing blood glucose lvls.

Tricyclic antidepressants, Beta-blockers-nonselective, antidiabetics

What are some contraindications with use of LA

hx of allergy (amides, esters, sulfa, sulfities sensitivity)

choice of LA (pregnancy, disease, ex. pivocaine vs lidocaine)

vasoconstrictor limit (cardio, hyperthyroidism, tricyclics antidepressants, nonselective beta blockers)

Lidocaine (Xylocaine), Mepivacaine (Carbocaine, Polocaine, Isocaine), Prilocaine (Citanest), Bupivacaine (Marcaine), and Articaine (Septocaine are all types of __________.

local anesthesia

Lidocaine (Xylocaine), Benzocaine (Hurricane, Anbesol, Benzodent, Orabase), Tetracaine (Pontocaine), Dyclonine (Dyclone) are all types of __________.

topical anesthetic

__________ in LA pprolongs the duration of action, increases the depth of anesthersia, delays systemic absorption, and reduces the toxic effect.

Vasoconstrictor use

________ is when a heart cannot pump efficiently enough to meet the bodies demand for 02 or circulation.

Heart failure

Whats the symptoms/process of HF?

heart enlarges (due to excess blood that it cant pump out)

patient becomes tachycardiac

right or left sided HF occurs (left is usually 1st)

If the left side of the heart fails, the blood backs up into the lungs and is known as __________, producing dyspnea (shortness of breath/difficulty breathing) and orthopnea (samething but while lying flat).

pulmondary edema

If the right side of the heart fails, the right ventricle is unable to remove all the blood from that side of the heart. This causes systemic congestion aka ________ with fluid acculmulation and presenting with pitting in the skin.

peripheral edema

Name as many HF medications as you can

diuretics

ACEI (angiotension converting enzyme inhibitors)

ARB (antiotensin receptor blocker)

beta blockers

aldosterone antagonists

vasodilators

angiotensin II receptor inhibitors

I (f) channel inhibtors

cardiac glycoside

______ aka “water pill” reduces BP, increase urine. Types of these Thiazide, Thiazide-like, Loop, and Potassium Sparing)

Diuretics

__________ block angiotensin I to II pathway and therefore blocks the formation of angiotensin II. Causing vasodilation and blocks aldosterone secretion, decreasing fluid volume.

ACE inhibitors (ACEIs)

___________ prevents angiotensin II by blocking angiotensin II receptors, causing vasodilation.

Angiotensin receptor blockers (ARBs)

_______ decrease the HR and myocardial contractility and redcuing cardiac output by blocking receptor stimulation.

beta blockers

__________ blocks aldosterone. _______ arterially allows the heart to pump woth less resistance, venously there is less blood retruns and reduces work load on heart.

aldosterone antagonists, vasodilators

____________ inhibits Neprilysin, lowers BP, also blocks angiotensin II receptors.

angiotensin II receptor Neprilysin inhibitors

_______ inhibtis the If ion channel in the SA node, reducing pacemaker activity and reduces HR.

I(f) channel inhibitor

_________ increases the force of the contraction of the heart aka a positive inotropic effect but reduces the heart rate. Also called a ________ an example of this is Digoxin.

Cardiac glycoside, digitalis glycoside

________ is a cardiac (digitalis) glycoside that is used for HR and tachycardia arrythmias. The pharm effect of this drug is to reduce the HR by increasing the strenfth of the heart contraction without increased oxygen demanded, therefore reduces heart size, edema and HR.

Digoxin

Adverse effects associated with ________ are GI distress, ____ salivation and gag reflex, and cranial nerve V like pain.

digoxin, increased

What are the considerations for a pt taking digoxins?

watch for OD signs (low TI)

use epi with caution (arrythmias)

monitor pulse for bradycardia

pts taking tetracycline/erythromycin (increase toxicity of digoxin)

Drug interactions associated with ______ are adrenergic agents (^ risk of abnormal HR), and erythromycin/tetracycline (^ the lvls of this drug)

digoxin

_________ may result from abnormal impulse generation or conduction. This can be caused by cardiac diseases such as myocardial anoxia, atherosclerosis, and heart block.

Arrythmias

The two types of arrythmia are _______ which is less dangerous and is an abnormal rhythm above the heart and __________ is an abnormal rhythm from the bottom of the heart, usually more life threatening.

atrial (supraventricular), ventricular

_________ agents all depress the heart area that beats abnormally, the specific actions of these drugs are complicated, and the long term effects need to be studied.

antiarrythmic

What are the 4 groups of antiarrhythmic agents?

Na channel blockers

beta blockers

K+ blockers

Ca channel blockers

Implications and managment of pts taking ____ antiarrhythmic agents should be checking BP and pulse, record type, and drug therapy.

any/all

Implications and managment of pts taking ____ (antiarrhythmic agents) should include CHECKING INR when taking Warfarin (Coumadin) and check bleeding and bruising w/ Direct Thrombin Inhibitors (blood thinner) and Factor Xa Inhibitors (blood thinner)

drugs to treat AFIB

Implications and managment of pts taking ____ (antiarrhythmic agents) include liver toxicity, blue skin coloring, and XEROSTOMIA.

amiodarone

Implications and managment of pts taking ____ (antiarrhythmic agents) include gingival enlargement, verapamil is most associated with this.

Ca channel blockers

Implications and managment of pts taking ____ (antiarrhythmic agents) include xerostomia, as an anticholinergic side effect because its blocking parasympathetic activity.

disopyramide

Implications and managment of pts taking ____ (antiarrhythmic agents) include SLE (systemic lupus erythematosus) -like syndrome, CNS depression, and xerostomia.

procainamide

Implications and managment of pts taking ____ (antiarrhythmic agents) including GI effects, xerostomia, and chinconism (cluster of side effects associated with this drug).

Quinidine

Implications and managment of pts taking ____ (antiarrhythmic agents) include gingival enlargement. Although this drug can be used as an antiarrythmic its primarily used as an anticonvulsant.

phenytoin

Implications and managment of pts taking ____ (antiarrhythmic agents) include its drug interactions with epi and to limit to cardiac dose if the patient’s conditon warrants it.

nonspecific beta blocker

________ is not listed under antiarrythmias even though its used to tx some arrythmias. It shortens the refractory period of atrial and ventricular tissues. Toxic doses of this drug can result in ventricular arrhythmias.

digoxin

__________ is a common cardio disease that is charcaterized by pain or discomfrt in the chest radiating to the left arm and shoulder. Its caused when the coronary arties do not supply a sufficient amount of oxygen to the myocardium for its current work.

angina pectoris

what are the symptoms of angina pectoris?

pain

chest discomfort

radiates to left arm, shoulder, jaw, neck, back

can be precipitaed by stress, anxiety, apprehension, physical exercise

The pharm effect of __________ is to reduce the work load on the heart by reducing cardiac output, peripheral resistance or both. These drugs are not a cure though.

antianginal agents

what are the two nitroglycerin classifications?

short acting (NGT, Nitrostat, Nitrolingual)

long acting (Nitrobid)

Adverse reactions associated with ________ are syncope, flushing, localized burning and tingling (under tongue). ________ are a class of drug used to treat erectile dysfunction and when these drugs interact can cause a significant interaction chacterized by severe drop in BP that can be FATAL and tolerance is developed.

antianginal agents, Phosphodiesterase inhibitor (PDE5)

________ is degraded by heat, light and moisture. It should be stored:

-in OG glass brown container

-tightly sealed

-dont refridgerate

-check expiration (meds are active until exp unless opened)

-after bottle is opened meds are good for 3months

nitroglycerin

Different types of antianginal preparations include _______ (vasodilator, reduces workload/o2 demand which reduces pain),

_______ (blocks beta receptor, reduces BP),

______(vasodilator, reduce BP, HR, etc),

_______ (doesnt alter BP or HR alone, usully used in combo and in chronic angina),

_______ (improves myocardial oxygen supply demand balance),

and ________ (used for chronic angina and those that cant tolerate ACEIs)

nitroglycerin, beta blockers, Ca channel blockers, ranolazine, ACEIs, ARBs

What are the considerations for a pt taking nitroglycerin?

-pt takes nitro before appt or premed w/ nitro or anxiolytic

-make sure pt is seated (hypotensice effects)

-headache results, give analgesic

-watch chair position when raising pt watch for syncope

-ensure proper storage

-be prepared for anginal attack (have pt put on counter)

-ensure pt has not used PDE5’s wwithin 24 hrs of administering nitro

________ is the most common cardiovascular disease.

hypertension

Normal BP is defined as less than ______. Hypertension is defined as BP greater than ______, although this BP is a goal for those pts diagnosed with BP regardless of age or presence/absence of chronic kidney disease or diabetes.

120/80, 130/80

Most commonly no symptoms are associated with hypertension which is why its called ________. _________ can lead to organ damage to the heart, kidney, brain and retina. Treatment includes healthy lifestyle chnages and drug therapy.

silent killer, Untreated HBP

__________ is a category of hypertension that is due to unidentifiable causes (idiopathic), may be due to familial Hx, genetics, or environmental (poor diet, lack of exercise, and obesity). This type is most commonly seen in dental offices. Occurs in 90 to 95% of pts diagnosed.

primary/essential hypertension

__________ is a category of hypertension that can be identified and associated with a specific disease process involving the renal or endocrine system or a result of sleep apnea. Can also be caused due to _________ with (steroids, NSAIDS, BCP, decongestants, tricyclic antidepressants). Can be treated by removing the cause including. Occurs in approx 10% of pts diagnosed.

secondary hypertension, drug therapy

___________ is a category of hypertension where a person experiences a hypertensive emergency having BP very high or rapidly rising, There is usually evidence of renal and retinal damage. Can develop in about 5% of pts with primary or secondary hypertension.

malignant hypertension/hypertensive emergency

What are the big four antihypertensive agents?

diuretics

ACEI’s

ARB’s

Ca Channel Blockers

Try to name as many antihypertensive agents listed as possible

diuretics

potassium salts

ACE inhibitors

ARB

direct renin inhibitors

Ca channel blockers

beta blockers

alpha 1 blockers

central alpha agonists

direct vasolators

peripheral adrenergic neuron antagonists

List the general adverse reactions associated with Antihypertensive agents

xerostomia

dysgeusia (distorted sense of taste)

gingival enlargement

orthostatic hypotension

constipation

CNS depression (additive w/ other drugs such as opiods/benzos)

Diuretics are a class of antihypertensive agents that consist of 3 types (thiazides, loop, and K+ sparing). These agents are among the most used for HBP Tx.

_______ is the most commonly used thiazide and many patients are treated solely with this.

_______ can be considered “strong cousins” of thiazides, most commonly used loop diuretic, is the prototype drug. Acts on the ascending limb of the loop of Henle.

_______ combined with _____ thiazide (Dyazide and Maxide) is one of the most often used preparations which reduced the loss of potassium and preventing hypokalemia.

Hydrochlorothiazide (HCTZ)

Furosemide (Lasix)

Triamterene (Dyrenium)

__________ are a class of antihypertensive agents that are not cardiac drugs, however lack of potassium caused by diuretics must be managed and is often done with this drug.

Potassium salts

__________ are a class of antihypertensive agents that typically end in -pril (Catopril(Capoten), Linsinopril (Zestril)). These agents lowers BP and cardiac output without lowering the HR.

Pts may present with altered taste and lichenoid pemphigoid lesions.

Effectiveness is reduced by _______.

These drugs are less effective in black patients.

Angiotensin Converting Enzyme Inhibitors (ACEIs), NSAIDS

__________ are a class of antihypertensive agents that typically end in -artan (Losartan (Cozaar)). Like ACEIs, these drugs are less effective in black patients due to low renin activity unless combined with a thiazide diuretic or CCB. These drugs are just as effective for management of BP w/ equal renoprotective and cardioprotective effects.

Angiotensin Receptor Blockers

__________ are a class of antihypertensive agents that is the 1st in a new class of drugs for Tx of hypertension. It can be used alone or in combo w/ antihypertensive agents. Aliskiren (Tekturna) works by inhibiting renin thereby reducing levels of angiotensin I and II, and aldosterone.

Direct renin inhibitors

__________ are a class of antihypertensive agents that typically end in -dipine (Verapimil (Isootin), Nifedipine (Procardia), Diltiazem (Cardizem)). These drugs are used for HBP, arrhythmias, angina. Causes vasodilationn by SM relaxation and lowers BP and HR by its effect on heart. Only ______ version of this drug is used today.

Ca Channel Blockers, long-acting

__________ are a class of antihypertensive agents that typically end in -olol (Propranolol, Metoprolol, Pindolol, Acebutolol). This drug reduces BP and cardiac output. This drugs have a nonspecific reaction w/ Epi and the caution required depends on pts cardiac disease, provider should follow _______. Unlike ACEI’s this drug BP lowering effect is not reduced by NSAIDS.

beta blockers, cardiac dose

__________ are a class of antihypertensive agents such as Doxazosin (Cardura) and Terazosin (Hytrin). Both subtypes 1 and 2 treat hypertension, also known for treat benign prostatic hyphertrophy, taking this agent is known as “killing two birds w/ one stone”. _____ can interfere with the antihypertensive effects of this drug. Use of _____ w this drug can result in severe vasodilation and relflex tachycardia.

alpha 1 blockers, NSAIDS, Epi

__________ are a class of antihypertensive agents such as Clonidine (Catapres) and Methyldopa (Aldomet) not used as commonly bc they generally have more adverse reactions. They are CNS mediated and used when other drugs are ineffective.

Central Alpha Antagonists

__________ are a class of antihypertensive agents such as Hydralazine (Apresoline) which acts directly on the arterioles to reduce peripheral resistance. At the same time a ^HR and ^cardiac output occurs. A serious toxic reaction with this drug produces lupus-like symptoms.

Direct Vasodilators

__________ are a class of antihypertensive agents such as Reserpine, was once used as a tranquilizer. Low doses can be used as an antihypertensive but side effects can include bad dreams and thoughts of suicide.

Peripheral Adrenergic Neuron antagonist

Considerations for pts taking antihypertensives

xerostomia

gingival enlargement (drug induced)

check BP every appointment

avoid additive drug effects (CNS depression)

look for hypokalemia (^risk of arrhythmias w/ epi)

low neutrophils w/ ACEI (^risk of infection)

__________ and _________ are elevations of plasma lipid concentrations above normal accepted values. _____ is bad cholesterol, _____ is good cholesterol, and ____ is very bad low cholesterol.

hyperlipidemia, hyperlipoproteinemia, LDL (low-density lipoproteins), HDL (high-density lipoproteins), VLDLs (very low density lipoproteins)

Risk factors for patients with cholesterol issues mainly used the ________ and no longer focuses on whether or not has a cholesterol count >200. __________ include heart healthy diet, regular excercise, weight reduction, and no smoking.

10yr atherosclerotic risk assessment, Lifestyle modifications

The ___________ are the first choice of therapy for most patients with athersclerotic heart disease and elevated cholesterol values, they are referred to as statins because their generic names end in that. They lower cholesterol levels by inhibiting _______ reductase, the rate limiting enzyme in cholesterol synthesis.

HMG CoA (3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors)

_________ are approved to treat elevated cholesterol values and low cholesterol values. This drug works by inhibiting intestinal absorption of cholesterol and making less available to liver cells. ex Ezetimibe (Zetia)

Inhibitor of Intestinal Absorption of Cholesterol

________ is a B vitamin, but in larger doses it has a therapeutic effect. It lowers cholesterol levels by inhibiting the secretion of VLDL-Cs without accumulation of triglycerdies in the liver, this reduces LDL (bad) synthesis and increase plasma HDL (good) activity. ex Niacin extended release (Niaspan)

Niacin

_________, lower cholesterol levels by binding resins with the bile acids which produces an insoluble product that is lost in the GI tract. The bile acids must be replaced and the formation of new one use up cholesterol. ex colesevelam (Welchol)

Cholestyramine

___________, these agents are used to treat hyperlipedmias and works by increasing lipolysis (fat metabolsim for energy) of triglycerides, decreasing lipolysis in adipose tissue, and inhibiting secretion from VLDL-Cs from the liver ex. fenofibrate (TriCor), Fenofibric acid (Trilipix)

Fibric acid derivatives

____________ is a newer drug. This is a protein in the liver that binds to and degrades the LDL receptors, therefore there are fewer receptiors and more LDL are metabolized by the liver. ex. alirocumab (Praluent), evolocumab (Repatha)

Proprotein Convertase Subtilisin/ Kexin Type 9 Inhibitors (PCSK9)

________ are long chain omega-3 polyunsaturated fatty acids present in cold water fish, they are commericially available in capsules to treat elevated cholesterol levels. However thesse can worsen glycemic control in diabetic pts.

Fish oils (omega 3 fatty acids)

List the dental implications/considerations of high cholesterol

^risk of CAD, MI, cardiac arrest

check BP and HR

be aware of how to handle these emergencies

baseline vitals are needed in case of emergency

GI and liver abnormalities lab test may be needed

__________ are drugs that in some way interfere with coagulation. These are used for tx after MI, for stroke prevention, and thrombophlebitis.

anticoagulants

__________ is one of the most commonly use anticoagulant agent in hospitalized patients, this is because it must be given by injection and cannot be used orally, its outpatient use is essentially nonexistent.

Parenteral Anticoagulants (Heparin)

__________ is an anticoagulant that is administered subcutaneously, this drug inhibits factor Xa more than it inhibits thrombin as compared to unfractionated Heparin which inhibits thrombin more than factor Xa. Has longer half life and permits fewer doses each day, greater bioavailability.

Low molecular weight heparain (LMWH)

_________ is an oral anticoagulant that has a narrow TI, its effect is monitored with INR. Common adverse reactions with this drug include bleeding and hemorrhage which is a risk when taking Aspirin w/ this drug. _________ increase the toxicity of this drug by increasing INR, antibiotics can also potentiate the effect of this drug.

Warfarin (Coumadin), Acetaminophen

_________ is the most commonly used oral anticoagulant and its MOA is interference w/ clotthing factirs. THis drug has _______ by accumulating and plateaus (half life of clotting factors have to deplete), this is why the effect of the drug persists after therapy ends. ________ can include hemorrhage so monitoring pt is necessary.

warfarin (coumadin), delayed onset, adverse reactions

Drug interactions with Warfarin (Coumadin)

______ can cause hemorrhage

______ can increase INR, close monitoring of INR required

_______ can increase effect of warfarin

aspirin, acetaminophen, antibiotics

___________ are inhibitors that prevent coagulation by selectively blocking the active site of factor Xa and do not require a cofactor (antithrombin III) for actvity. These drugs reduce stroke risk. Most common side effects are with the GI and increased bleeding risk that can be fatal. This drug doesnt have a widely available antidote like warfarin does to combat the anticoagulation (vitamin K)

Factor Xa

____________ are anticoagulants that directly prevent clotting and are indicated for prevention of stroke prevention and systemic embolism

Direct thrombin inhibitors

___________ is a theinopyridine and is an inhibitor of ADP-induced platelet aggregation which results in increased bleeding time, but it doesnt alter INR or PT time. Excessive bleeding could result with use of this drug. Use of this drug should be stopped ___ day prior to dental tx and their doctor should be consulted with. Avoids NSAIDS and Asprin.

Clopidogrel (Plavix), 5

___________ is a thienopyridine an is an inhibitor of ADP-induced platelet aggregation which results in increased bleeding time. It is used for stroke prevention and also doesnt alter PT and INR time. Avoid ______.

Ticlopidine (Ticlid), NSAIDS

_________ is a thienopyridine used in conjunction with to prevent MI and stent thrombosis. Its contrainidcated in people with history of stroke or transient ischemic attacj.

Prasugrel (Effient)

__________ is a thienopyridine that is a platelet aggregation inhibitor that is used in conjunction with Aspirin for prevention of MI and stroke in persons with acute coronary syndrome, common side effects include shortness of breath and increased bleeding.

Ticagrelor (Brilinta)

________ and ______ are enzymes called clot busters belonging to the thienopyridine class, they are thrombolytic drugs that naturally dissolve clots and they are delivered directly to the site of the clot.

Streptokinase (Streptaste) and Alteplase (Activase)

__________ is a thienopyridine that is used to prolong the life of platelets in pts with prosthetic heart valves as adjunct to warfarin therapy, this drug does not offer any additional anticlotting benefit over the use of aspirin or warfarin.

Dipyridamole (Persantine)

__________ is a dimethylxanthine in the thienopyridine class and works by improving blood flow by lowering/thinning blood viscosity instead of through clotting.

Pentoxifylline (Trental)