What type Ashtma is this?

s/s <2x per week

Nighttime s/s <2 x per month

asymptomatic b/t exacerbations

short acting bronchodilators is first line drug

FEV 1 > 80%

What type of Asthma?

s/s > 2 x per week but less than once a day

Nighttime s/s > 2 x month

exacerbations may affect activity

FEV 1 about 80 %

Inhaled corticosteroid (low dose) can be used

also cromolyn or theophylline

What type of asthma is this?

Daily symptoms and use of rescue inhaler

Exacerbations may last for days

Nighttime s/s > once per week

FEV 1 60-80% predicted

Medium dose corticosteroids or low dose with long active B2, theophylline for nighttime symptoms

What type of asthma is this?

continuous s/s

frequent exacerbations and nighttime symptoms

limited physical activity

FEV1 60% or less

High dose inhaled and oral steroids

Long active bronchodilators

For asthma- what is the treatment of choice for mild asthma?

Chronic asthma?

short acting B2

Inhaled corticosteroids

antiarrhythmic classes:

How do class I work? 

Examples?

Block sodium channels (depression of phase 0 depolarization) 

Ex: Lidocaine, procainamide, quinidine

antiarrhythmic classes:

How do class II work? 

Examples?

Beta Blockers

Beta adrenergic blocking effects

antiarrhythmic classes:

How do class III work? 

Examples?

Blocks K+ channels (prolongs repolarization)

Ex: amiodarone,

antiarrhythmic classes:

How do class IV work? 

Examples?

Calcium Channel Blockers

Ex: Verapamil, diltiazem

B- Blockers

(probably esmolol first line)

What is:

1) Normal BP?

2) Pre-HTN

3) Stage 1 HTN

4) Stage 2 HTN

1) 120/80

2) 120-139/80-89

3) 140-159/90-99

4) > 160/100

B Blockers

diuretics

hydralazine.

How do ACE inhibitors work?

What is a bad effect of ACE inhibitors?

inhibit angiotensin converting enzyme (which converts angiotensin 1 to angiotensin II)

Bad effect:  Also blocks bradykinin (which can build up and cause coughing)

What is the difference b/t  Labetolol and esmolol? 

Why is esmolol short acting?

Labetolol is a vasocodilator

esmolol is a vasoconstrictor and is short acting d/t breakdown by red blood cell esterases

1) CNS depression of sympathetic activity

2) Direct cardiac depression

3) Blocks renin release in the kidneys

1) Bronchoconstriction

2) Hypoglycemia

3) Vasoconstriction

Asthmatics

DM

and Vessel Disease

Tell me about Beta Blockers with Intrinsic sympthomimetic activity (ISA) 

When might they be preffered? 

Have less cardio depression and may be preferred in pts that develop symptomatic bradycardia or postural hypotension with other B-blockers

ex: acebutolol

Beta blockers without ISA are preferred in pts with angina or hx of MI

1) Cardiac Depression

2) Vasodilation

**Both are d/t reduced Calcium in smooth muscle**

How does hydralazine work primarily? 

How does Nitroglycerin work primarily?

1) Hydralazine is an arterial vasodilator (decreases afterload)

2) Nitroglycerin is primarily a venous vasodilator (decreases preload) --also causes transient uterine relaxation.

What is niprides mechanism of action?

How is it broken down?  What can happen that is bad?

Nipride is primarily an arterial and venous vasodilator (does not cause uterine relaxation)

Nipride breaks down into cyanide which combines with thiosulfate in the presence of rhodenase to produce thiocyanate which is peed out.

A buildup of cyanide can cause histoxic hypoxia (blocks mitochondrial respiration)

1) B Blockers- for chronic prophylaxis (depresses heart)

2) Nitrates- for acute attacks, reduce O2 demand by reducing preload

3) Ca Channel Blockers- good for variant angina, reduce preload/afterload and increase coronary flow

4) ASA- reduces coronary thrombosis

5) Statins

Classify this angina:

Marked Limitation of ordinary activity (angina may occur with climbing one flight of stairs, walking one or two blocks)

Classify this angina:

Does not occur with ordinary physical activity (may occur with strenuous activity)

Classify this angina:

Inability to perform physical activity without angina (angina may be at rest)

Classify this angina:

Slight limitation of physical activity (may occur with mild activity, cold weather, emotional stress)

Hypotension

headache

dizziness

palpitations

B blockers

Calcium Channel Blockers

Short acting nitrates

Classify CHF:

Marked Limitation in activity, light activity causes symptoms

Classify this CHF:

Unable to do any activity without symptoms, symptoms at rest.

Classify this CHF:

Slight limitation in physical activity.  Ordinary activity results in dyspnea, fatigue, and/or palpitations

Classify this CHF:

No limitation, ordinary activity dow not cause dyspnea, fatigue or palpitations

1) ACE inhibitors

2) B- Blockers

3) Diuretics

**Additionally people with severe LV failure may be on digoxin***

1) Bronchoconstriction (watch in asthmatics)

2) Hypoglycemia (and block hypoglycemic response of tachycardia- watch in diabetics)

3) Vasoconstriction (watch out for pts with vascular disease)

1) Beta 1 agonsists (eg dopamine, dobutamine)

2) Na/K atpase inhibition (eg digitalis)

• When the Na/K ATPase pump is inhibited the Ca/Na antiporter takes over increasing Calcium and therefore inc. contractility

3) Increase Calcium (only in hypocalcemia)

4) PDE-III inhibition (eg milrinone, amrinone)

5) Glucagon (stimulates Adenylate Cyclase--> increased cAMP--> inc contractility

1) Atrial arrhythmia (Dig slows AV conduction)

2) Heart failure

K+ level is inversely proportional to digoxin receptor bindinng regardless of digoxin level. 

The lower the K+ level the more digoxin binds and the more toxic it can be;  the higher the K+ level the less binding and less toxic

Tell me about digoxin Half life?

Therapeutic index?

1) 36 hours- therefore duration of action is 3-6 days

2) Digoxin has a narrow therapuetic index.  The effective dose is the same as the toxic dose.

1) GI: N/V, Anorexia, Cramps

2) Visual: Green/Yellow Halo vision, flickering lights, white borders

3) Cardiac: all arrhythmias

Subtypes of B-blockers:

What type are these?

Propranolol, atenolol, metoprolol

Subtypes of B-blockers:

What type

Esmolol

Subtypes of B-blockers:

What type are these?

acebutolol, penbutolol, pindolol

Subtypes of B-blockers:

What type are these?

Labetolol, carvedilol

Subtypes of B-blockers:

What type are these?

nebivolol-bystolic

Calcium Channel Blockers-

Recall: Beta blockers cause vasoconstriction and make vasospasm worse

What cardiac risk stratification do the following fall under?

Emergency Operations

major vascular

Peripheral Vascular

Prolonged Procedures (large fluid shifts and blood loss)

What cardiac risk stratification do the following fall under?

Carotic endarterectomy

Head and neck surgery

Intraperitoneal and intrathoracic

Orthopedic

Prostate

Intermediate risk procedures (cardiac risk < 5%)

What cardiac risk stratification do the following fall under?

Endoscopy

Superficial procedures

Cataracts

Breast surgery

1) MI within 3 months of surgery

2) Angina (CCS classes of 3 or 4)

3) Decompensated CHF

4) Significant arrhythmias with large fluid shifts

5) Severe Valvular dx

1) Angina (Class 1 or 2)

2) Pervious MI (> 3 months from surgery)

3) Prior or compensated Heart failure

4) DM

1) Age > 70

2) Abnormal EKG

3) Rhythm other than NSR

4) Hx of CVA

5) Uncontrolled HTN

6) Low functional capacity