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1、NPLEX Combination ReviewCardiovascular Part 1Paul S. Anderson, NDMedical Board Review ServicesCopyright MBRSNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习SGOT / AST “A sick heart can beat f-AST”Identify and monitor HEART! , Kidney,hepatocellular damageIncreased in early MI (peak at 24-36 hrs.)SGPT /
2、 ALT “L is for Liver”Identify and monitor hepatocellular damage.ALTAST Mainly = Liver Dz.GGT / GGTPUseful in detecting space-occupying lesions, biliary dysfunction and ETOH abuse Chemical toxicity.CPKMost often performed to document an acute MI; should be performed upon admission to hospital (after
3、12 hours but before 24 hours).CPK-MB elevation also may be associated with pulmonary embolism.NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习LDH (118.0 273IU/ml)Principle measurement to diagnose conditions in which there is tissue damage.Isoenzymes:LDH-1 Normally Lower than LDH-2In MI: LDH-1LDH-2!Liv
4、er Dz: LDHLDH-2!12-48 hours postNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Plasma Lipid ProfileUsed to determine cardiac risk and to aid in the diagnosis of lipoprotein metabolism disorders:Total cholesterol ( 200mg/dL)HDL ( 100mg/dL associated with increased myocardial risk) Triglycerides ( 140m
5、g/dL) Lipoprotein portion of HDL.(Higher = better) may be more useful than HDL cholesterol to identify patients with CADApolipoprotein B (70 110 mg/dL) major apoprotein of LDL and VLDL; elevated levels indicate increased myocardial risk Lipoprotein (a) ( 30mg/dL correlate 2X greater risk of developi
6、ng CAD. ( 200HDL = Low / LDL = HighTG Chol.II Second Most CommonChol. 200TG NormalNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Homocysteine Increased levels in serum may confer increased myocardial risk.Ammonia (NH3) (5-50mmol/l)Severe liver disease is the most common cause of elevated levels.Vitam
7、in B12 ( 200pg/ml)Decreased values in pernicious anemia and alcoholism.Folate (200 640ng/ml)DECREASED in megaloblastic anemia and alcoholism.INCREASED in acute renal failure and liver disease. TIBC (% Transferrin saturation) 255 450mcg/dL Usually performed in conjunction with serum iron in the evalu
8、ation and diagnosis of iron-deficiency anemia, chronic disease anemia and thalassemias.INCREASED: Fe deficiency anemia, PG and OBC.DECREASED: Anemia chronic disease, sideroblastic anemia and hemochromatosis.Serum Iron:VERY labile! Changes quickly.Ferritin (20 300ng/ml)Detection of iron deficiency an
9、d anemia by reflecting storage of iron.Calculating % Fe. SaturationSerum Iron (mcg/dL) / TIBC (mcg/dL)NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Vascular StudiesARTERIAL AORTA: Performed when working-up probable aneurysms CAROTID: Performed to ensure normal vascular anatomy of common carotid arte
10、ry, internal and external carotids; ruling out stenos is or occlusionLEA: Examining extremity arterial anatomy, normal triphasic blood flow, plaques or other pathological lesions and normal segmental blood pressure.VENOUSLEV: Normal venous anatomy with spontaneous, phasic blood flow pattern, normal
11、venous augmentation with no pathological valves present.Advantages Noninvasive without radiation risk.May obviate need for costly hospitalization.Structural image therefore useful for patients with organ function dysfunction.Does not require ingestion of contrast dyes.DisadvantagesRequires skilled t
12、echnician to operate transducer.Air-filled structures cannot be studied with this procedure.Obese & restless patients cannot be adequately studied.Interfering factorsBowel gas (air) complicates procedure.No open wound or dressing can be used to visualize deep structures.NPLEXCombinationReviewChapter
13、11章结合自然疗法医师注册考试复习ElectrocardiogramResting ECGPerformed to establish baseline ECG.Stress / exercise ECGGraded exercise tolerance test. Systolic values usually increase. Diastolic usually remains unchanged.Test measures the efficiency of the heart during a dynamic exercise stress period.Valuable for d
14、iagnosing IHD, underlying pathophysiological functioning.Holter monitor Method of continuously recording the ECG; often for 24 hours.Provides documentation of suspected cardiac rhythm disturbances.NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习ECG FindingsInfarctionPathologic Q-Waves.04 sec or & 1/3
15、as deep as R-Wave is high (all but AVR)S-T Segment changesTall Ts, (S-T elevations)Age of infarctHyperacute: Normal Q, ST Elevation, upright TAcute: Q MB Pathologic, ST Less Elevated, T invertedRecent: Q-Change, Isoelectric S-T, Symmetrical T inv.Old: Significant Q- changes, Isoelectric T wavesDrug
16、/ Electrolyte changesDigitalis: Scooped S-TsHyperkalemia: Wide P & QRS, Peaked THypokalemia: Flat T wave, U wave presentHypercalcemia: Short Q-THypocalcemia: Long Q-TPericarditis: P-R Depression, S-T elevationNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Clinical Considerations: ECGInterfering facto
17、rs: Race: ST elevation with T-wave inversion more common in people of African decent.Food Intake: High CHO may shift electrolytes and induce ST depression and T-wave inversion.Anxiety: May induce ST depression and/ or T-wave inversion.Pre-testing activity may alter results.Procedural preparation and
18、 aftercareProper lead placementInstruct patient regarding procedureRecognize limitations of ECGNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Stress EKGIndicationsDefinite indications Atypical symptoms in men or menopausal women Assess prognosis in patient with known CAD Assess patient with Exercise-
19、induced dysrhythmia Possible indications: Typical or atypical symptoms in menopausal women Assess response to therapies Evaluate variant Angina Serial testing in patient with known CAD Family Practice NotebookNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Stress EKGContraindications Aortic Dissection
20、 Critical Aortic Stenosis Critical Left Ventricular outflow-tract obstruction Idiopathic Hypertrophic Subaortic Stenosis (IHSS) Inability to Exercise to adequate level of exertion Uninterpretable Electrocardiogram Left Bundle Branch Block (Adenosine Nuclear needed) Electronically paced rhythm (Pacem
21、aker) WPW Syndrome Abnormal ST segments (1 mm ST abnormality) Recent or active cerebral ischemia Severe uncontrolled Hypertension Uncompensated Congestive Heart Failure Unstable Angina Digoxin Use (Class IIB Recommendation) Cardiac revascularization within last 5 years Family Practice NotebookNPLEXC
22、ombinationReviewChapter11章结合自然疗法医师注册考试复习Ankle Brachial IndexTechnique Measure highest systolic reading in both arms Record first doppler sound as cuff is deflated Record at the radial pulse Use highest of the two arm pressures Measure systolic readings in both legs Cuff applied to calf Record first
23、doppler sound as cuff is deflated Use doppler ultrasound device Record dorsalis pedis pressure Record posterior tibial pressure Use highest ankle pressure (DP or PT) for each leg Calculate ratio of each ankle to brachial pressure Divide each ankle by highest brachial pressure Family Practice Noteboo
24、kNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Ankle Brachial IndexInterpretation Ankle-Brachial ratio 0.95: Normal Ankle-Brachial ratio 0.95: Peripheral Vascular Disease Ankle-Brachial ratio 0.6: Intermittent Claudication Ankle-Brachial ratio 0.5: Multi-level disease Ankle-Brachial ratio 0.26: Rest
25、ing ischemic pain Ankle-Brachial ratio 0.2: Gangrenous extremityFamily Practice NotebookNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Carotid Evaluation / UltrasoundInterpretation of carotid bruit Degree of stenosis by atherosclerotic Plaque Minimum stenosis causing bruit: 50% (75% (1.5 mm lumen) Lo
26、cation Plaque involves posterior wall of common carotid Affects bifurcation and flow into internal carotid Risk of distal thrombus formation in internal carotid Carotid bruit associated risk of stroke at 1 year Asymptomatic carotid bruit: 1% risk at 1 year Transient Ischemic Attack history: 1.7% ris
27、k Other studies question bruit significance Family Practice NotebookNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Carotid Evaluation / UltrasoundEvaluation Carotid Artery Duplex Ultrasonography Standard diagnostic tool for carotid stenosis Less expensive than MRA Accuracy for diagnosing severe carot
28、id stenosis Test Sensitivity: 86% Test Specificity: 87% Carotid Magnetic Resonance Angiography (MRA) Better than ultrasound at defining carotid anatomy Accuracy for diagnosing severe carotid stenosis Test Sensitivity: 95% Test Specificity: 90% Family Practice NotebookNPLEXCombinationReviewChapter11章
29、结合自然疗法医师注册考试复习EchocardiogramIndication Every patient with Congestive Heart Failure! Distinguishes Systolic Dysfunction Diastolic Dysfunction Identify underlying valve disease Identify underlying ischemic heart damage Quantify Congestive Heart Failure severity NPLEXCombinationReviewChapter11章结合自然疗法医师
30、注册考试复习EchocardiogramAssessment Chamber size (diastolic and end-systolic dimensions) Left Ventricular Hypertrophy Left Atrial Enlargement Ejection Fraction (EF) Systolic Dysfunction: EF 50% Echocardiogram accuracy is +/- 5% at best Heart Valve Function and dysfunction Wall thickness and wall motion a
31、bnormalities Family Practice NotebookNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习ThrombolysisNeeded when the intrinsic clotting mechanisms are activatedArrhythmiasFibrillationProsthetic valvesHyper-coaguable (thick) bloodHigh FibrinogenDehydrationMultiple sites in the clotting cascade can be affec
32、tedNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Anti-thromboticsOutpatientMOAUsesAdverse EffectsOtherWarfarinCoumadinVitamin K antagonist(Extrinsic) Factors 2,7,9,10Thrombosis, rheumatic heart disease, embolism, ischemic heart diseaseProlonged bleeding, hemorrhage, diarrhea, fever,rashMonitor pro-t
33、hrombin timeNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习AntithromboticsMainly IV / inpatientMOAUsesAdverse EffectsOtherHeparinInhibits clotting factors by binding to antithrombin III (AT3) and ENHANCING the thrombin blockade of AT3.Prevention of deep vein thrombosis, embolism, DICHemorrhage, cutan
34、eous necrosis, chills, pruritus, feverAdminister cautiously in men-struating women, patients with liver disease or blood diseaseNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习CLOTTING PATHWAYSMeasured by: PTTDrugs: HeparinMeasured by PT/INRDrugs: Warfarin, ASA, Vitamin-E, EFAsFactors 2-7-9-10PROTHROM
35、BIN ACTIVATOR made up of V&X: Started by X alone and V becomes active with + feedbackExtrinsic Pathway: Damage outside of blood vessels.Intrinsic Pathway:Blood trauma (turbulence and viscosity) or collagen and blood contact.Antithrombin III keeps Thrombin INACTIVENPLEXCombinationReviewChapter11章结合自然
36、疗法医师注册考试复习AntithromboticsMOAUsesAdverse EffectsClopidogrelPlavixAspirin (ASA)Prevent formation of platelet aggregating substance: thromboxane A2 (TxA2) The pro-inflammatory cytokine produced by COX activity along with PG2 in the arachadonate cascade.Reduce risk of MI, StrokeSalicylism (ASA), GI dist
37、ress, bleeding, tinnitus, rash, occult bloodTTP(Plavix)NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习ASA for PreventionMost patients use 75-162mg / day “low dose ASA”Average is one 81mg ASA (baby aspirin)Am J Cardiol 2008;102:396-400 compared the effects of aspirin 300 mg/day and combined therapy wi
38、th aspirin 100 mg/day and clopidogrel 75 mg/day on platelet function Both strategies significantly decreased ADP- and collagen-induced platelet aggregation, the authors report: 18 of 30 patients treated with aspirin 300 mg/day and 25 of 30 treated with aspirin 100 mg/day and clopidogrel 75 mg/day ha
39、d adequate platelet inhibition.Increasing the aspirin dose to 300 mg/day or adding clopidogrel to aspirin can provide adequate platelet inhibition in a significant number of those patients with impaired responses to low-dose aspirin, the investigators conclude.NPLEXCombinationReviewChapter11章结合自然疗法医
40、师注册考试复习Clopidogrel (Plavix) Rx:75 mg TabletsPreventive: 75mg qdAcute (STMI): 300mg loading dose then 75mg qdLiterature lists continuing ASA Rx as wellNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events.N Engl J Med.
41、 2006; 354(16):1706-17 (ISSN: 1533-4406)CONCLUSIONS: In this trial, there was a suggestion of benefit with clopidogrel treatment in patients with symptomatic atherothrombosis and a suggestion of harm in patients with multiple risk factors. Overall, clopidogrel plus aspirin was not significantly more
42、 effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes. NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac Function - BasicsNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac FunctionElectrical functionCreates the rhythmic pumpi
43、ng of blood via muscular contractionWhen irregular createsArrhythmiasExtra beatsHydraulic functionMass movement of blood through the chambersPushed by muscle contractionControlled by valves in the systemWhen irregular createsMurmursAberrant blood flowNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Car
44、diac Muscle PhysiologyEPIEPIB-1 AdrenergicreceptorBeta blockersCa+CA+ Channels CA+ InfluxAdenylate cyclaseCyclase-aATPcAMPProt. KinaseProt.Kinase-a“Phosphorylation” Tension GenerationCross Bridge FormationCA+ Channel Blockers NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac AP and Ca+ ChannelCa
45、+ Channel OpenNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Carnitine at the Mitochondrial MembraneNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Drugs to correct rhythm disturbances:These drugs are used to “calm” the electrical impulses in the heart.This “calming” creates less aberrant heart beating
46、These drugs come in four classesTwo classes are also anti-hypertensive drugsTwo classes are specifically rhythm agentsNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Class I Anti-arrhythmicsMOAUsesAdverse EffectsOtherDigoxin Cardiac Glycoside(also)LidocaineInhibits the sodium/potassium pump to increas
47、e intracellular calcium.Calcium drives the cardiac AP plateau.CHF, paroxysmal atrial tachycardia,atrial fibrillation, atrial flutter, Fatigue arrhythmias muscular weaknessagitationblurred visionanorexianauseaMonitor blood levels.Toxicity may be life threatening. Yellow halo around vision may develop
48、.Quinidine*NOT Quinine!Decreases automaticity, conduction velocity and prolongs refractory periodHas anticholinergic effectsAtrial flutter atrial fibrillationpremature atrial and ventricular depolarizationArrhythmia, nauseavomiting diarrhea cinchonism fever vertigoheadacheProlongs QRS and QT interva
49、ls on EKGNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cinchonism!Quinine AND Quinidine:Tinnitus / Hearing LossHeadache / NauseaDizziness / VertigoVisual changesNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Digitalis / Quinidine Rx:Digitalis:(Capsules 0.05, 0.1, 0.2mg:Tabs 0.125, 0.25 mg)Dose 0.05 t
50、o 0.35mg bidTherapeutic dose levels in 7-21 daysMeasure trough level; Effective level 0.8-2 ng/mLQuinidine:(Sulfate; 200, 300mg: Gluconate; 324mg ER)Dose 300-400mg sulfate q-6hrsDose 324 ER q-8-12hrsMeasure trough level 30-35 hours after starting or changing therapy; Effective level 2-6 mcg/mLNPLEXC
51、ombinationReviewChapter11章结合自然疗法医师注册考试复习Class IIBeta BlockersClass IIIAmiodaroneClass IVCalcium Channel Blockersdelay in repolarizationprolongation in APslowing of electrical conduction reduction in SA node fct.decreased conduction through accessory pathwaysAbout 7 out of every 10 patients will expe
52、rience some type of reaction, and between 1 in 20 and 1 in 5 will experience side effects that are severe enough to stop the medication. The most severe side effect related to the lungs. These reactions can be fatal. (One in 10 of those that develop lung toxicity will die.) rare, fatal liver toxicit
53、y has occurredAntiarrhythmicsMOAAdverse EffectsOtherNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习DiureticsNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Na+ HANDLING ALONG THE NEPHRONNumbers = % NaArrows = Direction of flowPROXIMAL TUBULEReabsorbs 67% (2/3) Na & H2OReabsorbs all Glucose, HCO3, & Ami
54、no AcidsReabsorbs Na via Cotransport with Glucose, AAs, PO4; And via Countertransport in the Na+ / H+ Exchange.Site of Carbonic Anhydrase Inhibitor activity (Blocks HCO3 reabsorption)THICK ASC. LOOP of HENLEReabsorbs 25% of NaNa-K-Cl cotransporterSite of Loop Diuretic actionDISTAL TUBULE / COLL. DUC
55、TReabsorbs 8% Na via. Na-Cl cotransporterSite of thiazide diuretic actionNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Na+ HANDLING ALONG THE NEPHRONPROXIMAL TUBULEReabsorbs 67% (2/3) Na & H2OSite of Carbonic Anhydrase Inhibitor activity (Blocks HCO3 reabsorption)THICK ASC. LOOP of HENLEReabsorbs 25
56、% of NaSite of Loop Diuretic actionDISTAL TUBULE / COLL. DUCTReabsorbs 8% Na via. Na-Cl cotransporterSite of thiazide diuretic actionNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Antihypertensive/DiureticsMOAUsesAdverse EffectsOtherChlorothiazide(Hydrochloro-thiazide HCTZ)Inhibits sodium and chlorid
57、e re-absorption in distal tubule resulting in a decrease in the glomerular filtration rateHTNEdemaHypokalemia, oliguria, anuria, GI disturbance, hypercalcemia, hyperglycemia, hyperuricemia, renal failureC.I. in patients with hypersensitiv-ity to thiazide or sulfonamide drugsFurosemideLasixLoop diure
58、tic, inhibits sodium and chloride re-absorption in the Loop of HenleEdema, HTNHypokalemia, oliguria, anuria, GI disturbance, hypercalcemia, hyperglycemia, hyperuricemia, ototoxic, hypovolemiaNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Triamterene(Often in combination with HCTZ as “Maxzide”Spironol
59、actonePotassium sparing diuretic acts on distal tubulesAldosterone antagonistEdema, HTNEdemaHTNSome endocrine uses (PCOS)*Hyperkalemia, nausea, vomiting, diarrheaSame, plus breast deformity and tendernessMay turn urine blueFolic Acid BaseMultiple toxicitiesAntihypertensive/DiureticsMOAUsesAdverse Ef
60、fectsOtherNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习ALDOSTERONESpironolactoneBLOCKS!Leads to Na EXCRETION (in urine) and K retention (in blood)NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习DiureticsHCTZ12.5mg capsules; 25, 50, and 100mg tabletsEdema: 50-100mg qd until edema resolvedShort term on
61、lyMax Dose 200 mg acutelyHTN:12.5 50mg qdHCTZ / Triamterene25mg / 37.5mg - Maxzide; 50mg / 75mg Maxzide-25Furosemide 20, 40, and 80mg TabletsEdema: 80 mg qd (may increase as required up to 600mg total daily)HTN: 40mg bidNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Antihypertensive Drugs:Beta Blocke
62、rsEND IN “-OLOL”ACE InhibitorsEND IN “-PRIL”ARBs (Angiotensin Receptor Blockers)END IN -SARTANCatecholamine AgentONLY ONE: ReserpineCalcium Channel BlockersAll the rest!NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Beta-BlockersNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac Muscle PhysiologyE
63、PIEPIB-1 AdrenergicreceptorBeta blockersCa+CA+ Channels CA+ InfluxAdenylate cyclaseCyclase-aATPcAMPProt. KinaseProt.Kinase-a“Phosphorylation” Tension GenerationCross Bridge FormationCA+ Channel Blockers NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习AntihypertensivesBeta BlockersMOAUsesAdverse Effect
64、sOtherAtenololAcebutololBetaxololBisoprololEsmololMetoprolol 1 adrenergic receptor blocker, decreases cardiac output and renin releaseHypertension, anginaFatigue, drowsiness, vertigo, dizziness, bradycardia, hypotension, bronchospasm, CHFEnhance effects of digitalisPropranololCarteololNadololPindolo
65、lSotalolTimololBlocks both 1 and 2 adrenergic receptorsHypertension, angina, arrhythmias, migraines, essential tremorsFatigue, bradycardia, hypotension, lethargy, nausea, vomiting, diarrhea, CHFAbrupt discontinuation may cause tachycardia and rebound hypertensionNPLEXCombinationReviewChapter11章结合自然疗
66、法医师注册考试复习Beta BlockersAtenolol (Tenormin)25, 50 or 100mg tabletsHTN: 50 mg qdIncreases to 100 mg qd maximunMigraine Prophylaxis100mg qdNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Calcium Channel BlockersNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac Muscle PhysiologyEPIEPIB-1 Adrenergicrece
67、ptorBeta blockersCa+CA+ Channels CA+ InfluxAdenylate cyclaseCyclase-aATPcAMPProt. KinaseProt.Kinase-a“Phosphorylation” Tension GenerationCross Bridge FormationCA+ Channel Blockers NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiac AP and Ca+ ChannelCa+ Channel OpenNPLEXCombinationReviewChapter11章
68、结合自然疗法医师注册考试复习Antihyper-tensivesCa+ Channel BlockersMOAUsesAdverse EffectsOtherBepridilMibefradilVerapamilIsoptenCalcium channel blockerAngina, hypertensionConstipation, hypotension, dizziness, edema, nausea, CHF Increased levels with cimetidineDiltiazemCardizemCalcium channel blockerAngina, hyperte
69、nsion, atrial fibrillation or flutterHeadache, edema, dizziness, arrhythmias, CHF, nausea, constipation, rashIncreased levels with cimetidineAmlodipineFelodipineNicardepineNefidipineNifedipineProcardiaCalcium channel blockerAngina, hypertensionDizziness, CHF, MI edema, headache, weakness, nausea, Ca
70、psule passed in stool, medicine released in gutNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Calcium Channel BlockersAmlodipine (Norvasc)2.5, 5 and 10mg tabletsAngina5 to 10 mg qdHTN2.5 to 5 mg qdMaximum dose is 10 mg qdNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Angiotensin AgentsNPLEXCombination
71、ReviewChapter11章结合自然疗法医师注册考试复习ALDOSTERONE RENIN ANGIOTENSIN SYSTEMACE-I - BLOCKARB BLOCKNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习AntihypertensivesMOAUsesAdverse EffectsOtherACE InhibitorsCaptoprilBenazeprilEnalaprilLisinoprilFosinaprilInhibits ACE angio-tensin converting enzyme in the lungs.Hyp
72、er-tension, heart failureDry persistent cough Tachycardia, hypotension, urticaria, rash, Renal dysfunction headache HyperkalemiaContra-indicated in preg-nancyNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习AntihypertensivesMOAUsesAdverse EffectsARBsCandi-/ Irbe-Epro- / Lo-Telme- / Val- (sartan)Blockad
73、e of ANG-2 ReceptorsHyper-tension in those with ACE intolerance due to CoughHypotensionRenal DysfunctionHyperkalemiaNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Angiotensin AgentsACE InhibitorsQuinapril (Accupril)5, 10, 20 and 40mg tabletsDose for HTN 10-20 mg to startMaximum dose 80 mg qdARBsCande
74、sartan (Atacand)4, 8, 16 and 32 mg tablets16 mg qd starting doseOften used 8 16 mg bidNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习No clinically meaningful difference in hypertensionWith the exception of rates of cough, the available evidence does not strongly support the hypothesis that ACE inhibi
75、tors and ARBs have clinically meaningful differences in benefits or harms for individuals with essential hypertension, according to the reports authors, led by Dr David B Matchar (Duke Center for Clinical Health Policy Research, Durham, NC).He and his colleagues analyzed 69 reports based on 61 rando
76、mized and observational studies that lasted at least three months and directly compared an ACE inhibitor and an ARB in adults with essential hypertension and evaluated meaningful end points like blood pressure control, treatment compliance, and adverse events.NPLEXCombinationReviewChapter11章结合自然疗法医师
77、注册考试复习Peripheral Anti-AdrenergicNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Peripheral anti-adrenergicMOAUsesAdverse EffectsOtherReserpineDepletes catecholamine stores in PNS and maybe CNSEssential hypertensionDrowsiness, sedation, nervousness, depression, Decr. HR, nasal congestion, nausea / diar
78、rhea Parasympathetic PredominanceDo NOT administer MAO inhibitors and Reserpine within two weeks of each otherRx of Reserpine:Available in 0.1 and 0.25mg tabletsCommon Rxs:- 0.1 qd to bid- 0.25 qd to bidDo not use in catecholamine responsive depressives.Overdose symptoms include hyper-parasympatheti
79、c activity.NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习But doesnt Rauwolfia and Reserpine use make people kill themselves?Lets go through this now:NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Peripheral anti-adrenergicMOAUsesAdverse EffectsOtherReserpineDepletes catecholamine stores in PNS and ma
80、ybe CNSEssential hypertensionThese are RARE in hyper-catecholamine patients.Drowsiness, sedation, nervousness, depression, Decr. HR, nasal congestion, nausea / diarrhea Parasympathetic PredominanceDo NOT administer MAO inhibitors and Reserpine within two weeks of each otherNPLEXCombinationReviewChap
81、ter11章结合自然疗法医师注册考试复习NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Rauwolfia and ReserpineReserpine Tablets:0.1 and 0.25mg availableDose is 0.1 0.25 qd bidRauwolfia:Watch tincture concentrationAverage dose 1-3 mL qd - bidNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Anti-Anginal DrugsNPLEXCombination
82、ReviewChapter11章结合自然疗法医师注册考试复习Anti-anginal drugsMOAUsesAdverse EffectsOtherNitroglycerin Increases blood supply to heart; decreases preload and afterloadAngina Headache, dizziness, hypotension, tachycardia, bradycardia, rashAmyl NitrateUnknown, thought to be dilation of arterial and venous systemAng
83、inaThrobbing headache, dizziness, hypotension, tachycardia, bradycardia, Antidote for cyanide poisoningPapaverine HCl“Cardiac vessel dilation”AnginaSimilar to Nitro.No longer usedCalcium Channel BlockersSee aboveAnginaNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Nitrate Rx:NTG SL-Tablets 0.3, 0.4 o
84、r 0.6mgAcute angina:Dose 1 SL tablet up to 1 tablet every 5 minutes for 3 dosesOther dose forms available:Spray, Cream, Long Acting CapsulesNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习L-Arginine PO dose1000 2000mg bidMagnesium Glycinate PO dose100-300mg bidZinc PO dose20-50mg bid (taken in the mid
85、dle of a meal to decrease nausea!)Angina Rx:NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Lipid ManagementNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Basics:HDL:“Good” although there are better and worse forms.Acts more like a hormone than a lipid moleculeLDL:“Bad” although there are better (large
86、r) and worse (smaller) forms.Carry OXIDANTS!Generally LOWERING these makes one less inflammatoryTriglycerides:Stimulated in production by CHO intakeElevations often indicate Pro-Inflammatory status and disorders of Insulin Sugar biochemistryNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习LDL Oxidation
87、: The LDL has the potential to carry an incredible load of free radical.Anti-Oxidant effects of Vitamins E, C, GSH and the RBC - Lipid Plasma InteractionReduced GlutathioneOxidized GlutathionePlasmaASCASC RDHALDLRBCTocoToco RLDL + R = “oxidized LDL”NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Chole
88、sterol TransportNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cellular Cholesterol BalanceNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习High Cholesterol TypesLipoprotein Electrophoresis5 Sub categories of hyperlipidemiaFredricksons GenotypesTypes 2 & 4 are most commonType 4 is 1-2 X more common than
89、 Type 2Generally High TC, TGs (higher than TC), and LDLResponds to carbohydrate restrictionPoor response to low fat dietsType 2generally High TC, LDL, and NORMAL TGsResponds better to reduced fat dietsNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Sugar / Insulin and TG SynthesisBLOODCYTOSOLMITOCHOND
90、RIA CHO AcetylCoA AcetylCoA Carboxylase Insulin(+) Malonyl CoAPalmitateCPT-1(-)Acyl UnitsBeta OxidationEnergyAcyl Units Esterify to TGsTGs to BloodNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Lipid Lowering AgentsMOAUsesAdverse EffectsOtherLovastatinMev
91、acorSimvastatinZocorAtorvastatin LipitorFulvistatin LescolPravistatin PravacolHMG CoA reductase inhibitorHyperlipidemiaGI distress, headache, dizziness, abdominal cramps, rash, liver toxic, rhabdo-myaloysisMonitor liver functionCheck AST and ALT prior to Rx, and at 6 weeks post-Rx.Rx along with 75-1
92、00 mg Co-Q10 minimum.Discontinue if patient has muscle pain concomitant to Rx EVEN if LFTs are normal.NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Statin Rx:Atorvastatin (Lipitor)10, 20, 40 and 80mg tabletsDose 10 to 20mg qdStart at 40mg qd if LDL reduction need is greater than 45%Maximum dose 80mg
93、 qdDraw Lipids and LFTs 4 weeks after therapy initiation or does adjustmentNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习A Multicenter Placebo Controlled Dose Ranging Study of AtorvastatinJournal of Cardiovascular Pharmacology and Therapeutics, Vol. 3, No. 2, 119-123 (1998)Patients received placebo
94、or atorvastatin 10, 20, 40, 60, or 80 mg once daily. Adjusted mean decreases in LDL cholesterol for patients receiving atorvastatin 10, 20, 40, 60, and 80 mg were 37%, 42%, 50%, 52%, and 59%, respectively, compared with a mean increase of 0.3% for patients receiving placebo NPLEXCombinationReviewCha
95、pter11章结合自然疗法医师注册考试复习CholestyramineQuestranCombines with bile acid to form an insoluble compound that is excretedHyper-lipidemiaConstipation, fecal impaction, abdominal pain, nauseaReduces absorp-tion of fat soluble vitaminsLipid Lowering AgentsMOAUsesAdverse EffectsOtherNPLEXCombinationReviewChapte
96、r11章结合自然疗法医师注册考试复习NiacinStimulates hepatic lipid metabolismHyper-lipid-emia Niacin flush, rash, GI distressGive with B-Complex and Vitamin C to avoid Hepatic Effect.Lipid Lowering AgentsMOAUsesAdverse EffectsOtherMay be Rxd alone or in a combination of Niacin and a low dose statin.Rx a high potency
97、B-Complex AND Vitamin C (gram per gram of Niacin).Rx takes at least 1500 2000 mg daily to have any significant effect on lipids.SLOW release is generally better tolerated.Slow release is NOT more dangerous than immediate release if Rxd properly.LOWERS: TC, LDL AND TGRAISES: HDLNPLEXCombinationReview
98、Chapter11章结合自然疗法医师注册考试复习Niacin Rx:Niacin Extended Release (Niaspan)250, 500, 750 or 1000mg tabletsStart with 1000 mg hs, work up to 1500 2000mg hsAvoid spices, tannins etc with medication81mg ASA taken with the Niacin reduces flushingNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Advicor Rx:Lovastati
99、n / Niacin combination:20/500, 20/750, 20/1000 or 40/1000mgDose is 1 po qhsNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习FibratesFenofibrate (TriCor)Multiple dose formatsTo lower Triglycerides48 145 mg qd Maximum dose 145mgNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习LovazaOmega-3-acid ethyl esters
100、 (1 gram capsules)Normal Sig is 2 capsules bidIndicated alone or with Statins in patients with high (200-499) or very high (500) triglycerides.Alone in very high TGWith 40 mg Statin in high TGNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Cardiovascular (CV) causes of chest painAngina: Covered laterN
101、PLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习PERICARDITISUsually more localized, sternal or over cardiac apex sharp, stabbing, knife-like painlasts hours to days aggravated by deep breathing or lying supine and relieved by sitting up and leaning forward may auscultate friction rubNPLEXCombinationRev
102、iewChapter11章结合自然疗法医师注册考试复习DISSECTING AORTIC ANEURYSManterior chest pain, may radiate to backexcruciating, tearing pain; sudden onset, lasts hours to dayspain unrelated to anything BP lower in left armNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Noncardiac causes of chest painGI disorders: peptic u
103、lcer, esophageal reflux, hiatal hernia, cholecystitis; pain usu burning, cramping, aching; worse supine; may be meal relatedMusculoskeletal disorders: variable location; aching pain, made worse with movement or palpation; touching surface of chest aggravates the pain.Spontaneous Pneumothorax: unilat
104、eral location; sharp, localized; sudden onset lasting many hrs; dyspnea, SOB, painful breathingNPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习Noncardiac causes of chest painPulmonary Embolism: pleurisy type pain, dyspnea, pleural rub, pain over area of infarction; hemoptysis with lg infarctionPulmonary Hypertension: substernal pain, pressure, dyspnea, accentuated pulmonary second heart soundAnxiety States: localized pain, sharp, burning; moves from place to place, brief duration, with emotional situations; frequent sighing NPLEXCombinationReviewChapter11章结合自然疗法医师注册考试复习
