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CVRN CARDIOVASCULAR PHARMACOLOGY
EXAM QUESTIONS WITH COMPLETE ANSWERS
"Afterload - CORRECT ANSWER - Resistance or pressure in the systemic system that the left
ventricle needs to overcome by increasing force and contraction to the point which opens the aortic valve and blood is propelled into the circulation
- Clinically measured by Systemic Vascular Resistance (SVR)"
"What factors affect afterload? - CORRECT ANSWER - Arterial resistance (hypertension)
- Aortic valve problems
- Blood viscosity
- Use of vasoconstrictor or vasodilator drugs"
"Pathological factors effect reduced contractility - CORRECT ANSWER Acute MI, open heart
surgery, ventricular dysfunction seen in cardiomyopathy and heart failure"
"Pathological factors effect increased contractility - CORRECT ANSWER Early ventricular
hypertrophy"
"Positive inotropic drugs - CORRECT ANSWER increase contractility of the heart"
"Negative inotropic drugs - CORRECT ANSWER decrease contractility of the heart"
"Positive chronotropes - CORRECT ANSWER increase heart rate"
"Negative chronotropes - CORRECT ANSWER decrease heart rate"
"How do "alpha receptors" (α) effect cardiac function? - CORRECT ANSWER Simulation of α
receptors causes vasoconstriction of vascular beds throughout the body"
"Sympathomimetic drugs - CORRECT ANSWER Act at alpha, βeta 1 & 2, and dopaminergic
receptor sites
- Low cardiac output states due to MI, cardiac surgery, trauma
- Acute decompensated heart failure
- Shock states, including cardiogenic shock and
septic shock"
"Sympathomimetic drugs action - CORRECT ANSWER - Mimic the action of norepinephrine or
epinephrine stimulating α and β receptors either directly or indirectly by causing the release of natural neurohormones at storage sites
- Result in peripheral vasoconstriction, increased cardiac contraction, increase HR, and bronchodilation"
"Inotropin (Dopamine®) - CORRECT ANSWER - Results in increased contraction, CO and SV as
well as increased renal blood flow and sodium excretion
- Uses: Cardiogenic shock Septic shock Heart failure Other shock states with low BP Symptomatic bradycardias"
"Epinephrine - CORRECT ANSWER - Marked stimulation of alpha, β1 and β2 receptors,
resulting in increased contractility, heart rate, stroke volume, cardiac output, and coronary blood flow and bronchodilation (positive inotropic and positive chronotropic effects)
- Produces profound vasoconstriction of the periphery, especially of renal and splanchnic beds
- Uses: Hypotension resistant to conventional measures Anaphylactic shock Symptomatic bradycardia unresponsive to atropine Cardiac arrest"
"Norepinephrine (Levophed®) - CORRECT ANSWER - Predominantly an α agonist but also
stimulates β1 receptors at low doses
- Produces vasoconstriction in all vascular beds
- Uses: Hypotension caused by sepsis, MI, or other hypotensive crisis refractory to fluids Dopamine infusion"
"Phenylephrine (Neosynephrine®) - CORRECT ANSWER - Pure α agonist producing
pronounced vasoconstriction, increasing both systolic and diastolic BP, and a reflex decrease in HR
- First line vasopressor if tachyarrythmias preclude
"What vasodilator would be the drug of choice to treat pulmonary hypertension? - CORRECT
ANSWER Milrinone due to its primary effects on increasing contractility, SV and CO and
pulmonary vasodilation"
"What is the most common drug combination seen in acute heart failure to treat hypotension? -
CORRECT ANSWER - Dopamine or norepinephrine
- Dobutamine at doses to support cardiac output" "What factor needs to be taken into account when using vasopressors or inotropes in severe
coronary atherosclerosis? - CORRECT ANSWER Severe atherosclerosis results in low coronary
blood flow; the addition of a sympathomimetic increases the myocardial oxygen demand; the coronary arteries may not be able to deliver the needed blood flow; ischemia, angina, or MI may result" "What is the antagonist used when catecholamines (epinephrine, norepinephrine) are infiltrated
into the tissues? - CORRECT ANSWER If extravasation occurs, infiltrate area with
phentolamine (Regitine®) to counter act the vasoconstriction effects"
"Beta Blockers actions - CORRECT ANSWER - Binds with beta adrenergic receptors to block
the response to sympathetic impulses, circulating catecholamines, or adrenergic drugs
- β1 blocking specific drugs result in decreased HR, slower AV conduction, decreased contractility and CO leading to lower BP
- β2 blocking specific drugs increase airway resistance and inhibits peripheral vasodilating effects of catecholamines
- There are combined or specificβ1 and β2 blocking agents"
"Beta Blockers uses - CORRECT ANSWER - Hypertension
"Calcium Channel Blockers uses - CORRECT ANSWER Prinzmetal's (Variant)angina, chronic
stable angina, paroxysmal supraventricular tachycardia, hypertension, atrial fibrillation/flutter"
"ACE Inhibitors actions - CORRECT ANSWER - Suppresses the renin-angiotensin-aldosterone
system by inhibiting the conversion of angiotensin I to angiotensin II resulting in a decrease in peripheral resistance and lower aldosterone secretion (leading to less fluid and sodium reabsorption)
- End result is lower BP, and possible increase in CO due to the lower SVR"
"ACE Inhibitors uses - CORRECT ANSWER - Heart failure(except in acute decompensated
heart failure with hypotension)
- Hypertension
- CHF post MI
- Left ventricular dysfunction"
"ACE Inhibitors side effects - CORRECT ANSWER - Cough
- Hyperkalemia (especially with underlying kidney disease)
- Bronchospasm in patients with underlying reactive airway disease"
"Angiotensin II Receptor Blockers uses - CORRECT ANSWER - MI
- Hypertension
- Heart failure
- investigational: CHF in combination with ACE or ARB (not both) reduces morbidity and mortality"
"Alpha-1-Adrenergic Blocking Agents - CORRECT ANSWER - Blocks alpha-1 adrenergic
receptors resulting in dilation of arterioles and veins which decreases BP
"Nitrate Vasodilators actions - CORRECT ANSWER - Relax vascular smooth muscle which
dilates peripheral veins and arteries
- Decrease venous return to the heart results from increased venous capacitance
- Preload, afterload and BP are reduced as is myocardial oxygen consumption and workload
- Reflex tachycardia may result
- Venous response higher at lower doses, with arterial response greater at higher does"
"Nitrate Vasodilators uses - CORRECT ANSWER - First line for unstable angina and prophylaxis
in chronic stable angina
- Hypertension and CHF
- MI and pulmonary edema"
"Nitroprusside (Nipride) actions - CORRECT ANSWER - Direct acting on smooth muscles
leading to peripheral vasodilation of both arteries and veins
"How quickly after an MI should an ACE inhibitor be started on a hemodynamically stable patient?
- CORRECT ANSWER Within 24 hours has the best result in decreasing mortality rates" "Which organ is adversely effected by the use
of ACE-inhibitors? - CORRECT ANSWER Kidneys
Caution should be used in renal insufficiency or renal stenosis
- Monitor creatinine levels closely
- Can use in end stage renal failure as the kidneys are already gone"
"Which drug is used to treat Prinzmetal's (Variant) angina? - CORRECT ANSWER Calcium
channel blockers are used due to their relaxing effects on the smooth muscle cells, decreasing the vasospasms associated with Prinzmetal's angina"
"When are calcium channel blockers used in the post MI? - CORRECT ANSWER - They are not
recommended post MI
- Used successfully in angina with patients who cannot take beta blockers and in patients post MI with preserved EF" "When beginning new angiotensin II receptor blocker therapy, what is the most common side
effect? - CORRECT ANSWER Hypotension"
"What is the most common combination of drugs given post MI? - CORRECT ANSWER -
Aspirin
- Beta blocker
- ACE inhibitor
- Statin
- Platelet inhibitor"
"What are the major effects of nitroglycerin in CHF patients? - CORRECT ANSWER Decrease
preload by increased venous blood pooling which relieves over worked heart muscle and decreases oxygen consumption"
"Nitroglycerin post MI helps in what hemodynamic changes? - CORRECT ANSWER -
Decreased preload, afterload, and BP
- Increased myocardial oxygen delivery from coronary dilation
- Decreased myocardial oxygen consumption"
"Which vasodilator is associated with cyanide toxicity? - CORRECT ANSWER - Nitroprusside
- Use with caution in the renal impaired patient"
"What are the major hemodynamic effects of nitroprusside? - CORRECT ANSWER - Decrease
SVR
- Decreased afterload and preload"
"What is the major electrolyte imbalance associated with loop diuretics? - CORRECT ANSWER
Hypokalemia"
"What are the major side effects to using diuretics? - CORRECT ANSWER - Dehydration
"If a patient is sensitive to sulfonamides, which diuretic class should they use with caution? -
CORRECT ANSWER Thiazide diuretics"
"What are the most common side effects patients complain about while on statins? - CORRECT
ANSWER Body aches, joint pain, fatigue"
"Anticoagulant drugs classes and types - CORRECT ANSWER Additional classifications of
anticoagulants
- ASA
- P2Y12 platelet inhibitors
- Indirect Factor Xa inhibitors
- GP Iib/IIIa Platelet inhibitors Types
- Unfractionated heparin (is the old standard)
- Low molecular weight heparins (are newer)
- Oral anticoagulants
- Direct thrombin inhibitor anticoagulants"
"Unfractionated Heparin actions - CORRECT ANSWER - Activates antithrombin III which is
needed to inactivate thrombin and factor Xa activity
- This Inhibits thrombin which is needed for the conversion of fibrinogen to fibrin
- Inhibits the activation of fibrin stabilizing factor preventing the formation of a stable clot"
"Unfractionated Heparin uses - CORRECT ANSWER - Angina
- NSTEMI & STEMI
"Platelet Glycoprotein GPIIb/IIIa Antagonists - CORRECT ANSWER Action
- Interrupt the action between fibrinogen and Von illebrand's factor with the platelet complex GPIIb/IIIa esulting in the interruption of platelet aggregation Uses
- UA/NSTEMI/STEMI patients undergoing PCI Common medications
- Abciximab
- Eptifibatide
- Tirofiban"
"In what bleeding disorder would you see heparin ordered as the treatment of choice? -
CORRECT ANSWER DIC: disseminated intravascular coagulation"
"What is the major action of anticoagulants? - CORRECT ANSWER Inhibit the development
and enlargement of clots by actions in the coagulation cascade by blocking the actions of clotting factors or platelets"
"What is the most major and common side effect of anticoagulants? - CORRECT ANSWER -
Bleeding
- Can lead to hypovolemic shock" "If a patient has heparin induced thrombocytopenia with thrombosis , what is the anticoagulant
class of choice? - CORRECT ANSWER Direct thrombin inhibitor anticoagulants like argatroban
or bivalirudin" "Which patient population is at greater risk for bleeding complications from antiplatelet therapy?
- CORRECT ANSWER Female geriatric patients with low body weight and renal insufficiency have a much higher incidence of bleeding with antiplatelet therapy" "What diagnosis are low molecular weight
heparins most commonly used in? - CORRECT ANSWER Prevention or treatment of DVT"
"What drug classification would you not see combined with heparin in the cardiac
patient? - CORRECT ANSWER - Direct thrombin inhibitors
- Direct thrombin inhibitors are used in patients who
cannot take heparin (if they have heparin induced thrombocytopenia)"
"What is the usual concurrent therapy seen with thrombolytic therapy? - CORRECT ANSWER -
Heparin
- Aspirin and/or other antiplatelet drug
- The goal is to prevent reocclusion or reclotting after the thrombolytic has caused lysis of the clot"
"When is thrombolytic therapy the first choice in treatment of an acute MI? - CORRECT
ANSWER When a skilled practitioner who can perform a PCI is not available or the facility does
not have a cardiac catheterization lab to perform a PCI"
“Frank Starling's curve - CORRECT ANSWER ↑ preload = ↑ SV = ↑ CO in normal
circumstances with a compliant ventricle In a non-compliant ventricle, a large increase in preload actually decreases CO"
"Cardiac compliance - CORRECT ANSWER - The ability of the ventricles to distend when
preload enters the ventricles during diastole
- In normal ventricles, increased preload (volume) results in increased distention and increased CO
- If myocardial oxygenation is low (MI), fibrosis or hypertrophy has occurred, the ventricles are less compliant and CO decreases with increased preload"
"Cardiac contractility - CORRECT ANSWER - Heart's intrinsic contractile strength that is
independent of the other determinants of CO
- There is no non-invasive way to measure contractility
- Ejection fraction is a surrogate for contractility
- Physiological determinants of contractility are oxygenation, pH, electrolyte balance, and temperature"
"How do "βeta 1 receptors" effect cardiac function? - CORRECT ANSWER - Simulation of βeta
1 receptors (β1) with β1 adrenergic medications causes a positive chronotropic effect, positive inotropic effect
- If blocked, all of the above decrease"
"How do "βeta 2 receptors" effect cardiac function? - CORRECT ANSWER Simulation of βeta 2
receptors (β2) with β2 adrenergic medications causes a vasodilation of the coronary arteries as well as relaxation of bronchial smooth muscle and dilation of major blood vessels"
"Inotropin (Dopamine®) doses - CORRECT ANSWER Low dose: 0.5-2 mcg/kg/min
"Severe hypotension caused by cardiogenic shock which has been nonresponsive to dopamine
and dobutamine, what is another drug choice? - CORRECT ANSWER Norepinephrine"
"Dopamine at 15 mcg/kg/min has what hemodynamic effect? - CORRECT ANSWER At 15
mcg/kg/min the effect is mostly α with resulting vasoconstriction of the periphery and renal blood flow is impaired" "When infusing epinephrine, what should you monitor closely besides the patients
hemodynamics? - CORRECT ANSWER - Blood glucose levels should be monitored very closely
as epinephrine stimulates glucose release from the liver
- IV insulin infusions maybe necessary
- Also monitor for acidosis" "In a combined drug therapy of dopamine at 2mcg/kg/min and dobutamine at 7mcg/kg/ min,
what are the expected hemodynamic changes? - CORRECT ANSWER - Increased CO from
increased contractility resulting in increased SV; possible decreased preload
- Decreased SVR
- Improved renal blood flow, with improved renal output and decreased preload" "When titrating down vasopressors or inotropes, what factors influence how quickly
you titrate? - CORRECT ANSWER - Drug half-life
- Hemodynamic stability
- How many the patient is on; titrate one at a time taking into consideration the drug actions" "Which sympathomimetic would not be a drug of choice to treat hypotension resulting from an
acute MI? - CORRECT ANSWER - Phenylephrine
- As a pure α drug, the resulting vasoconstriction and increase in SVR would increase myocardial oxygen demand"
"When infusing vasopressors, what parameters need to be monitored? - CORRECT ANSWER -
Infusion site: Monitor for signs of extravasation which can cause tissue necrosis; use central line if possible
- Hemodynamic profile if patient has a PA catheter
- Volume status
- Vital signs including I/O, temperature, limb circulation, pulse strength through out the body
- Electrolyte balance
- Oxygenation"
"Calcium Channel Blockers actions - CORRECT ANSWER - Inhibit the influx of calcium through
the cell membrane, resulting in depressed automaticity and conduction velocity in smooth and cardiac muscle leading to depressed contraction
- In coronary vessels, dilation occurs in both normal and ischemic tissues and inhibits coronary spasms
- Decreases SVR, thus lowering cardiac oxygen demand
- Slows AV conduction and atria conduction"
"ACE Inhibitors cautions - CORRECT ANSWER - Patients with bilateral renal artery stenosis,
hyperkalemia, increased creatinine
- Use for all MI patients within 24 hrs unless there is hypotension or other contraindications"
"Angiotensin II Receptor Blockers actions - CORRECT ANSWER - Block angiotensin II receptors
in vascular smooth muscle and the adrenal gland
- This blocks the vasoconstriction and aldosterone secreting effects of angiotensin II
- BP is lowered with minimal orthostatic hypotension
- Does not effect the enzyme that converts angiotensin I to angiotensin II (ACE)"
"Antihyperlipidemia Agents actions - CORRECT ANSWER - Inhibit HMG-CoA reductase which
results in the interruption of the early steps in the synthesis of cholesterol
- Increase HDL cholesterol and decrease LDL cholesterol , total cholesterol, VLDL cholesterol, and plasma triglycerides
- Maximum effect seem in 4-6 weeks
- Avoid grapefruit juice to avoid potential increase in drug serum concentrations"
"Antihyperlipidemia Agents uses - CORRECT ANSWER - Primary hypercholesterolemia; mixed
dyslipidemia; hypertriglyceridemia
- Prevention of coronary artery disease and MI
- Significantly reduces CV events
- Common drug group name: "statins"" "Which are the most common cardio-selective beta blockers that can be used in patients with
obstructive pulmonary diseases? - CORRECT ANSWER Atenolol, esmolol, metoprolol are all
β1 selective and less likely to cause bronchospasms (β1 selectivity is not absolute)"
"What effect do beta blockers have on diabetics? - CORRECT ANSWER They may mask signs
(tachycardia, tremors) of hypoglycemia in diabetic patients on insulin or oral hypoglycemic agents"
"Why are ACE inhibitors used in post MI patients? - CORRECT ANSWER - Studies have shown
that they prevent and retard LV dysfunction and remodeling that occurs post MI
- Use also decreases risk of CHF post MI as well as recurrent infarction
- DVT
- Arterial thrombus
- Acute ischemic stroke
- Acute MI"
"Thrombolytics side effects - CORRECT ANSWER - Bleeding at procedure sites as well as any
other area
- Major hemorrhage with the side effects of major leeding at any site"
"Thrombolytics special considerations - CORRECT ANSWER Reocclusion may occur quickly
after lysis of clot. Therefore concurrent treatment is recommended with heparin, aspirin, and/or other antiplatelet drugs to reduce the risk of major reocclusion with life threatening consequences"
"Common Thrombolytics - CORRECT ANSWER - t-PA
"What laboratory level is monitored closely when a patient is on warfarin? - CORRECT
ANSWER - INR is monitored daily during loading of the drug until it is in therapeutic range
- INR is monitored frequently in patients on an outpatient basis"
"What is the antidote for an overdose of heparin? - CORRECT ANSWER - Protamine sulfate
- May also give fresh frozen plasma to aid in clotting" "Post percutaneous coronary intervention (PCI) with stent placement, what class of drug would
you ordered for the patient? - CORRECT ANSWER - Antiplatelets
Clopidogrel (Plavix®) Aspirin"
"What are the major contraindications for thrombolytic therapy? - CORRECT ANSWER -
Intracranial hemorrhage
- Active bleeding
- Recent CPR (relative contraindication if > 10 minutes)
- Malignant intracranial neoplasm
- Ischemic stroke within last 3 months
- Suspected aortic dissection
- Closed Head or facial trauma within last 3 months
- Recent major surgery"
