Cardiology

ACE inhibitors vs. ARBs.

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ACE INHIBITORS
ACE INH2
ACE INH3
ACE INH4

                                                               What’s the difference?⁠
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💊Angiotensin converting enzymes (ACE) inhibitors and angiotensin receptor blockers (ARBs) are antihypertensive medications used to treat high blood pressure and other comorbid conditions.⁠
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💊While the enzyme inhibitors work by reducing the level of angiotensin II in the body, the receptor blockers inhibit the function of angiotensin II by directly blocking the specific receptor. ⁠
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⭐️Key Takeaways⭐️⁠
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-ACE inhibitors and ARBs have similar benefits, and both work equally well in the body though ARBs are thought to have less side effects. ⁠
-ACE inhibitors and ARBs are both considered first line for the treatment of hypertension. ⁠
-ACE inhibitors remain first line for HFrEF with ARBs as an alternative. ⁠
-For those who cannot tolerate an ACE inhibitor, ARBs are reasonable substitutes (ex: dry cough)⁠
-It is NOT recommended to treat hypertension patients with both ACE inhibitor and ARB as it can increase adverse effects. ⁠

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Dual Antiplatelets

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Dual_Antiplatelets
DA-1

Let’s talk DUAL ANTIPLATELETS 👏🏻

🌟WHEN do you use dual antiplatelet therapy (DAPT)?

1️⃣ Patients who have had acute coronary syndrome event (ACS) such as a heart attack

2️⃣ Patients who have stable ischemic heart disease and receive a stent placement (in other words, non-ACS setting)

🤫 pssst – if you don’t know what an ACS is – it is ANY condition brought on by a sudden reduction or blockage of blood flow to the heart. This is often caused by plaque rupture or clot formation in the heart’s arteries leading to sx of chest pain.

🌟 Okay great, we know when but WHY?

ACS is considered a medical emergency; treatment is needed to reopen the arteries and restore blood flow to the heart so it can work properly. This is usually done with a combination of medications + procedures such as a PCI (percutaneous coronary intervention) where a small structure called a stent is placed to open up the blocked blood vessel.

Afterward, the patient is at higher risk of future thrombotic events since they just had an occurrence and increased risk of stent thrombosis. This is where DAPT is recommended to prevent recurrent ischemic events.

🌟 Cool – but WHAT are dual antiplatelets?

Dual antiplatelet therapy recommendations include:

Aspirin PLUS ticagrelor, prasugrel, or clopidogrel

🌟 P2Y12 inhibitor considerations:

-Prasugrel is the most potent followed by ticagrelor, then clopidogrel (🧠TIP: Prasugrel is the most Potent ‘P’ for potent – but with increased potency comes increased bleeding risks. Avoid prasugrel in pt. age >75, hx of TIA/stroke, and hepatic dysfunction

-All of them are dosed once daily except ticagrelor which is dosed twice daily (🧠TIP: Ticagrelor is dosed ‘T’ for Twice daily) – can your patient be compliant?

-Clopidogrel and prasugrel are affordable and available in generic versions while ticagrelor is not. Can your patient afford it?

 

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Diabetes

Leave a Comment / Cardiology, Endocrinology /
DM
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Let’s 👏🏻 talk 👏🏻 diabetes👏🏻!⁠
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🌟American Diabetes Association (ADA) and the European Society of Cardiology (ESC) released new 2023 guidelines recently and I just had to do a doodle note on it. 🤓⁠
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🌟There has been lots of debates regarding whether metformin should still be first-line for all patients with type 2 diabetes. ⁠
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🌟 It still is a great first-line option for most patients due to it’s proven efficacy, safety, and low cost. There are also some speculation that it m-a-y have cardiovascular benefits as well considering many patients in the clinical trials were also on metformin. ⁠
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💗🫘However, in patients with ASCVD or high ASCVD risks, heart failure, and chronic kidney disease, the ADA/ESC guidelines recommend starting a SGLT-2 inhibitor or GLP-1 agonists with cardiovascular and renal benefits regardless if they have type 2 diabetes. ⁠
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🌟 It is still important to look at patient specific factors (cost, comorbidities, side effects) when deciding which agent to start first or to add on. ⁠
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👉🏻GLP-1 agonists commonly have GI side effects and carry warnings for rare pancreatitis and gallbladder disease. It can cost patients $1000/month. Most of the agents are injectables and supply is not consistent.⁠
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👉🏻SLGT-2 inhibitors are linked to genital yeast infections, and volume depletion. Cost is about $600/month but they do come in oral formulations.⁠
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Reference: Diabetes Care. 2023 Jan 1;46 (suppl 1):S140-S157⁠

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Heart Failure Drugs

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Heart Failure
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Heart Failure3
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💔 Let’s talk about HF medications 👏🏻⁠
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🧠 Understanding heart failure (HF) medications can be difficult if you don’t understand the underlying pathophysiology of the condition. ⁠
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🤓 Check out the slides to learn more about the pathophysiology of heart failure that leads to the common symptoms seen. ⁠
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✨ Goals of therapy are to manage structural heart disease, reduce morbidity and mortality, decrease Na+ and water retention, and eliminate or minimize HF symptoms. ⁠
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✨ The cornerstones of HF treatment are medications targeted towards decreasing the activity of compensatory mechanisms and improving cardiac workload, controlling excess fluid, and enhancing cardiac contractility. ⁠
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⭐️ Loop diuretics: control symptoms of fluid overload (e.g., shortness of breath, edema)⁠
⭐️ ACE/ARBs/ARNIs: shown to decrease mortality; recommended in ALL pt. with HFrEF ⁠
⭐️ Beta-blockers: shown to decrease mortality when added to an ACE inhibitor; recommended in ALL patients with HFrEF⁠
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👉🏻 Check out the full review of HF medications in our F-R-E-E Heart Failure Guide which includes a mind map coloring page and heart failure drug table!

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Calcium Channel Blockers⁠

Leave a Comment / Cardiology, Top 200 Drugs /
CCB1
CCB2
CCB3
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💊 Calcium channel blockers (CCBs) are used in the treatment of many cardiovascular conditions including hypertension and angina so needless to say they easily make the top 200 drugs prescribed.⁠⠀
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👉🏻 They are divided into subclasses, non-dihydropyridines, and dihydropyridines and differ by their pharmacokinetic properties, clinical uses, response, and selectivity. ⁠⠀
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👉🏻 Dihydropyridine CCBs end in the suffix ‘-ine’: ⁠⠀
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-AmlodipINE⁠⠀
-NicardipINE⁠⠀
-NifedipINE⁠⠀
-NimodipINE⁠⠀
-FelodipINE⁠⠀
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👉🏻 Non-dihydropyridine CCBs don’t end in the suffix ‘-ine’ hinted by the name of the subclass, NOn-dihydropyridINE:⁠⠀
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-Verapamil⁠⠀
-Diltiazem⁠⠀
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Warfarin INR Goals

Leave a Comment / Cardiology, Hematology /
Warfarin
Warfarin2

⭐Test your knowledge and check your answers on the second slide!

Let’s talk warfarin INR goals 🤓⁠
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💊 Warfarin is a vitamin K antagonist that requires INR (international normalized ratio) monitoring due to its narrow therapeutic index. Dosing is affected by many factors including diet, drug interactions, genetics, and close INR monitoring is required to decrease the risks of bleeding and/or clotting.⁠
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🤔 Overall, direct oral anticoagulants (DOACs) are now recommended over warfarin in the majority of clinical situations unless there is a compelling reason for them to on warfarin such as valvular atrial fibrillation, severe renal dysfunction, patient costs, or close therapeutic anticoagulation monitoring required.⁠
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🔑 Key points about INR monitoring:⁠
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-Baseline INRs are recommended prior to initiating warfarin therapy⁠
-Warfarin requires overlap or ‘bridging’ with heparin or LMWH for 5 days and until INR is within goal for 24 hours (TIP: warFARin takes a long time to achieve full anticoagulation so think FAR into the future compared to other anticoagulants)⁠
-Changes in the INR is typically seen 2-3 days after administration of the dose (TIP: a physician I use to work with always said Jesus rose on the 3rd day and so will your INR 😅)⁠
-Prior to making a dose adjustment, assess for any missed doses, drug interactions, dietary intake or supplements, documentation of bleeding, or other changes that can affect the INR⁠
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How many of the INR goals did you get correct? TIP is to memorize the outlier – the majority of the time, the INR goal is 2-3 except in high-risk patients such as those with mechanical valve replacements in the MITRAL position (goal is higher 2.5-3.5)⁠
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Beta-Blockers⁠⠀

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betablocker
betablocker2
betablocker3
betablocker
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🔝 Beta-blockers are one of the top 200 drugs prescribed as they are indicated for many different cardiovascular diseases such as hypertension, angina, atrial fibrillation/flutter, and heart failure with reduced ejection fraction. ⁠⠀
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⭐Generally, there are two types of beta-adrenergic receptors, beta-1 and beta-2 receptors.⁠⠀
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-Non-selective beta-blockers block both beta-1 (β1) and beta-2 (β2) adrenoceptors. ⁠⠀
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-Cardioselective beta-blockers are relatively selective for β1 adrenoceptors (remember you have 1 heart) and tend to be favored in patients with diabetes or COPD/asthma. ⁠⠀
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-Some beta-blockers also cause vasodilation through blockade of vascular alpha receptors making them great for use in hypertension.⁠⠀
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🧠 Use the mnemonic – Be (β1) selective about your MAN BABE to help you remember the beta-blockers that are cardioselective. ⁠⠀

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ACE-inhibitors ⁠

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ACE-inhibitors
ACE-Inhibitors
ACE3
ACE4

 Let’s talk about ACE-inhibitors ⁠⠀
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💊 Angiotensin-converting enzyme (ACE) inhibitors are a class of drugs mainly used in the treatment of hypertension and heart failure with reduced ejection fraction (HFrEF). They are one of the top 200 drugs prescribed and because of that, they are an important class to know. ⁠⠀
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⭐ Drugs in this class end in the suffix ‘-pril’ such as: ⁠⠀
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-LisinoPRIL⁠⠀
-FosinoPRIL⁠⠀
-EnalaPRIL⁠⠀
-RamiPRIL⁠⠀
-QuinaPRIL⁠⠀
-BenazePRIL⁠⠀
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❗Do not use this medication in patients who: ⁠⠀
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-Have a hypersensitivity to ACE inhibitors or any of their components⁠⠀
-Pregnant or breastfeeding: box warning for patients who are or may become pregnant as it can cause fetal toxicity⁠⠀
-History of angioedema, bilateral renal stenosis, and concurrent use with aliskiren in patients with diabetes⁠⠀
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Diuretic Classes

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There are 5 main types of diuretic classes with different mechanisms of action, site of action, and side effect profiles. ⁠ ⁠ 1) Loop diuretics work on the loop of Henle (as the name implies)⁠ 2) Osmotic diuretic work on the glomerulus⁠ 3) Thiazides work on distal convoluted tubule⁠ 4) Carbonic anhydrase work on the proximal tubule⁠ 5) Potassium-sparing diuretics (aldosterone antagonists and sodium channel blockers) work on the distal convoluted tubule⁠ and collecting ducts

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Beta-1 Cardioselective Beta-Blockers

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❤️ Cardioselective beta-blockers work on the beta-1 receptors. Beta-1 receptors primarily are found in cardiac tissues whereas beta-2 receptors are located in the lungs (remember: 1 heart, two lungs). ⁠ ⁠ ❤️ Cardioselective beta-blockers exert their effect by binding to the beta-1 receptor sites selectively and inhibiting the action of epinephrine and norepinephrine on these sites. They are often preferred in patients with respiratory disease as they are less likely to cause constriction of airways or peripheral vasculature.⁠

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Calcium Channel Blockers

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Calcium channel blockers (CCBs) are used in the treatment of many cardiovascular conditions including hypertension and angina. They are divided into subclasses, non-dihydropyridines and dihydropyridines and differ by their pharmacokinetic properties, clinical uses, response, and selectivity.

 

Key Points

The non-dihydropyridine CCBs do not end in the suffix ‘-ine’ hinted by the name of the subclass, non-dihydropyridines. They cause more cardiac depression and less vasodilation than dihydropyridine CCBs resulting in a reduction in heart rate and cardiac contractility.

  • Verapamil
  • Diltiazem

 

Dihydropyridine CCBs end in the suffix ‘-ine’ and have more vascular selectivity and fewer cardiac effects. They act primarily as peripheral vasodilators and are used in the treatment of hypertension and angina. They do not suppress AV node conduction or SA node automaticity.

  • Amlodipine
  • Nicardipine
  • Nifedipine
  • Nimodipine
  • Felodipine

 

Mechanism of Action:

The name of this class, calcium channel blockers, hints at its mechanism of action – inhibits the entry of calcium into cells of the cardiac and peripheral vascular smooth muscles. 

  • Calcium entry into L-type channels of cardiac and peripheral vascular cells is needed for them to contract or constrict more strongly. 
  • By blocking calcium entry, calcium channel blockers cause 
    • peripheral vascular smooth muscle relaxation (decreases blood pressure)
    • decreased myocardial contractility (decrease myocardial demand making them effective in angina)
    • decrease heart rate and conduction velocity (useful in arrhythmias). 

Indications:

Non-dihydropyridines 

  • Hypertension
  • Arrhythmias

Dihydropyridines

  • Hypertension
  • Angina
  • Migraines

 

Side Effects: 

The main side effects of calcium channel blockers are hypotension and dizziness which is related to their effects on vasodilation so it is easier for you to memorize. 

In addition, they can also cause the following side effects by subclass:

  • Non-dihydropyridines
    • Constipation, gingival hyperplasia, worsening cardiac output, and bradycardia.
  • Dihydropyridines
    • Peripheral edema, headache, flushing

Clinical Pearls/Education:

  • Non-dihydropyridines are contraindicated in patients with decompensated heart failure, second or third-degree AV blockade, and sick sinus syndrome due to their inhibitory effects on the SA and AV node, slowing cardiac conduction and contractility. 
  • Monitor patients for hypotension, edema, and bradycardia. 
  • Peripheral edema is dose-dependent and may occur within 2 to 3 weeks of initiating calcium channel blocker therapy, particularly dihydropyridines. Peripheral edema due to the redistribution of fluid from the intravascular space to the interstitium. 
  • Diphydroyridines can cause reflex tachycardia and acute hypotension due to their potent vasodilating effects. This effect is more common with first-generation short-acting dihydropyridines (e.g. immediate-release nifedipine) and less with newer agents that are longer acting (e.g. amlodipine). The effect may be lessened by using sustained-release formulations.
  • Diltiazem decreases AV node conduction and heart rate to a lesser extent than verapamil but these drugs should be monitored closely for bradycardia especially with patients on beta-blockers. 
  • Verapamil and diltiazem are considered moderate cytochrome P450 3A4 enzyme inhibitors and should be monitored for drug interactions. 
  • Constipation is a more common side effect with verapamil and occurs to a lesser extent with diltiazem. 

References:

  • McKeever RG, Hamilton RJ. Calcium Channel Blockers. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482473/
  • Maclaughlin EJ, Saseen JJ. Hypertension. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill.

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Calcium Channel Blockers (Mechanism of Action)

Leave a Comment / Cardiology, Top 200 Drugs /
💊 Calcium channel blockers (CCBs) are used in the treatment of many cardiovascular conditions including hypertension and angina. They are divided into subclasses, non-dihydropyridines, and dihydropyridines and differ by their pharmacokinetic properties, clinical uses, response, and selectivity. ⁠ ⁠ 💊 The name of this class, calcium channel blockers, hints at its mechanism of action – inhibits the entry of calcium into cells of the cardiac and peripheral vascular smooth muscles. ⁠ ⁠ 🗒️ Calcium entry into L-type channels of cardiac and peripheral vascular cells is needed for them to contract or constrict more strongly. ⁠ ⁠ 🗒️ By blocking calcium entry, calcium channel blockers cause:⁠ 👉🏻 peripheral vascular smooth muscle relaxation (decreases blood pressure)⁠ 👉🏻 decreased myocardial contractility (decrease myocardial demand making them effective in angina)⁠ 👉🏻 decrease heart rate and conduction velocity (useful in arrhythmias). ⁠

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Entresto® (Sacubitril/Valsartan)

Leave a Comment / Cardiology /

📖 Angiotensin receptor-neprilysin inhibitors (ARNI) is a new class of heart failure medications. ⁠
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☝🏻 The first drug in this class is Entresto® (sacubitril/valsartan). It is a combination medication comprised of a neprilysin inhibitor (sacubitril) and an angiotensin II receptor blocker (valsartan). ⁠
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💊 Sacubitril is a prodrug that inhibits neprilysin thus preventing it from breaking down natriuretic peptides. This mechanism leads to an increase in vasodilation and diuresis as levels of natriuretic peptides rise. ⁠
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💊 Valsartan directly blocks angiotensin II receptors inhibiting angiotensin II from binding onto the receptors and causing vasoconstriction and aldosterone release.⁠
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Calcium Channel Blockers

Leave a Comment / Cardiology, Top 200 Drugs /
Calcium channel blockers (CCBs) are used in the treatment of many cardiovascular conditions. They are divided into subclasses, non-dihydropyridines and dihydropyridines. The non-dihydropyridine CCBs cause less vasodilation and more cardiac depression than dihydropyridine CCBs (hence why they are not recommended in decompensated heart failure). They cause reductions in heart rate and contractility. Dihydropyridine CCBs have more vascular selectivity and fewer cardiac effects. They are indicated in the treatment of hypertension and angina. They do not suppress AV conduction or the SA node automaticity.

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