Hey, what's up everyone, Doctor Zishan here.
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So again, thank you all so much and good luck.
All right, so let's talk about cardio farm.
Cardio Farm is arguably the highest yield subject when it
comes to farm because we have so many different topics that
happen with cardio, IE coronary artery disease, hypertension,
we've got beta blockers, we've got ACE inhibitors, we've got
nitrates, we've got statins. We've got so many different
drugs that pop up under cardio farm that I want to address them
in a podcast. And the first one we're going to
start with is we're going to start with ACE inhibitors.
ACE inhibitors end in PRIL, PRIL, so things like captopril,
lisinopril, enalapril. The mnemonic that we want to
know is ACE I. And with PHARM, again,
identifying the drug is very important in this situation.
We identified this drug as an ACE inhibitor knowing that it
ends in PRILPRIL. The second thing we want to know
with PHARM questions is we want to be able to identify the side
effect, which is where that mnemonic I just talked about ACE
I comes in and the mnemonic is A for angioedema, C for cough, E
for excess potassium, and then the I for instead we can use
Arbs. Let me elaborate on each one of
these side effects. The first one is angioedema.
Angioedema actually becomes ask graph.
Angioedema is in fact the swelling of the lips, swelling
of the mouth, swelling of the tongue.
And in this situation we are scared that this is in fact
airway, airway, airway. The second thing is we've got
cough. Now this cough is not airway.
It is a nagging cough, maybe even a night time cough, a dry
cough, a hacking cough, whatever they say it is a side effect,
but it's not airway, but it is something that we want to with
angioedema and with cough. We want to instead the I and
ACE. I instead use an ARB and Arbs
and insartan and we'll get into that here in a little bit.
The E is excess potassium, but why does it have excess
potassium? Well, let's think about this.
It's an ACE inhibitor. So what does that mean?
Well, it's an angiotensin converting enzyme inhibitor.
Angiotensin converting enzyme inhibitor.
Now I'm going to make this really, really boring and
excruciatingly painful because I'm going to talk about the
RAAS, the renin angiotensin aldosterone system.
Well, of the three topics that I just talked about, renin,
angiotensin, aldosterone in the system, the one I'm worried
about is aldosterone. Aldosterone is responsible for
sodium. Sodium goes up, water follows
it. So if I take a step back into
the angiotensin and I inhibit the conversion of it, IE the ACE
and inhibitor, angiotensin converting enzyme inhibitor, I'm
not going to make aldosterone. I don't make or I decrease
making aldosterone. I decrease sodium and I decrease
water following it. So I get rid of sodium, I get
rid of water, which means I decrease blood pressure.
But if sodium goes down, there's an inverse pump.
That sodium, potassium pump means sodium goes down,
potassium goes up. So This is why we have that
excess potassium. And then again, instead for
angioedema and for cough, we use Arbs, Arbs and in Sartan,
valsartan, Losartan, these are angiotensin receptor blockers,
angiotensin receptor blockers or Arbs of again in this situation,
I'm knocking out angiotensin. If I knock out angiotensin, I
knock out or decrease the production of aldosterone.
If I decrease the production of aldosterone, I decrease sodium,
I decrease the water that follows it and I decrease blood
pressure in return since sodium goes down.
Well, guess what? Potassium goes up as potassium
goes up. We can't swap out an ACE
inhibitor for an ARB when both have excess potassium.
So that's why only angioedema and cough are going to be the
reasons why we switch from an ACE inhibitor to an ARB.
But both cause excess potassium. So if we have excess potassium,
we're going to scrap both drugs and we're going to find
something else for blood pressure.
The the other thing about both these drugs is that they're both
teradigens. Both of these are going to be
unsafe in pregnancy, which leads me to your quick tip.
Hypertensive mothers love nifedipine.
This pneumonic is going to help you remember the drugs that are
safe in pregnancy. Hypertensive hydralazine mothers
methyl dopa love labetalol. Nifedipine is nifedipine.
So these are two super high yield drugs.
We've got ACE inhibitors, we've got Arbs.
We talked a little bit about the Raas, the side effects which are
super important, the contraindications with
pregnancy. And we can go to alternatives if
we can't use any of them in excess potassium because both
'cause that if both of them are tradigens, we must switch them
out. So in the next section, we'll
talk about drugs that are safe in pregnancy or that can be used
as alternatives in the case that we have excess potassium.
So as we talked about ACE inhibitors and Arbs both being
tradigens, I wanted to actually touch on the drugs or at least
the most popular drugs that you're going to see potentially
on your board exams that are in fact teratogens.
The pneumonic is Teratowa TERATOWA Teratowa.
The first T stands for thalidomide.
Thalidomide was an anti cancer drug that was approved back in
the late 90s and had a direct effect on the fetus and was in
fact labeled as a tradigen because of the impact that it
had on the fetus. But ultimately this is not a
popular drug that we see in real life but for the sake of the
boards it is something that we should be able to identify as a
tradigen. The E in Tradua is epileptic
drugs, things like valproic acid, things like phenytoin,
which we'll get into in another section when we do a little
neurodrugs. The R in Tritowa is retinoid,
Retinoid meaning vitamin A, vitamin A being used for acne.
So things like retina, retina, a retinoid with retinoid or
vitamin A. We're concerned about this being
a Tritogen and I think this is one of those ones that we have
to pay attention to because I say this all the time.
If in your answer choices during your exam, you see when was the
last menstrual cycle, do a urine pregnancy test, do an HCG.
If you see any of these in your answer choices or are they
sexually active, take a step back on that question and ask
yourself why did they put this into the answer choice?
Because chances are it's there for a reason.
Now, it's not always going to be the right answer, but at least
it makes you think, hey, why did they put that in there?
Because that's not a common answer choice.
So again, if you think about a young female patient or a
sexually active female patient, we're concerned about them being
on potentially retinoid or vitamin A derivative, which
helps with acne, but is in fact a tradigen.
The A is what we just talked about.
We talked about ACE inhibitors and Arbs.
So that's what brought me to Tyrata Wah.
The second T in Tyrata Wah is third element.
So if you think about the that shocker that's in the middle of
your head, you think about the third element and the 3rd
element being a mood stabilizer like lithium.
So a little bit of a stretch there with this pneumonic.
But if you think about third element, you think about the
shocker in the middle of your head, you think about your mood,
you think about mood stabilizer, and hopefully it brings you to
lithium. The O is oral contraceptives.
So again, we're concerned about any type of Ocps being a
triadogen, the West being warfarin and the A in triadua
being alcohol. So again, Triadua is a great
mnemonic to help you remember the more commonly tested
triadogens that may show up on your boards.
So moving on to other types of antihypertensive drugs.
So we talked about our ACE inhibitors, we talked about our
Arbs. Now let's talk about an
alternative that we can use in fact for hypertension, which is
our calcium channel blockers. For calcium channel blockers,
there are two different classes. I'm going to focus on one for
hypertension and that is what it's called our
dihydropyridines. And I don't really need you to
know that term, but these are the ones that end in dipene.
So again, that's suffix or identification of farm drugs
with calcium channel blockers. Look for the drugs that end in
Dipene, things like amlodipine, nicartipine, nifedipine,
nimotipine. These all end in that DIPINE,
and these are our dihydropyridine calcium channel
blockers. They're a great alternative for
hypertension. Not only can we use these drugs
for hypertension, but as we go through some of the lectures
that I've taught, we can in fact use this drug for angina because
of the fact that this can vasodilate, meaning it makes our
vessels dilated, It opens up those vessels in the coronary
arteries. So as we use calcium channel
blockers to open up those vessels in the coronaries, as we
use calcium channel blockers to vasodilate, especially in the
coronary arteries, because we have that atherosclerosis
leading to angina or that chest pain, we now are allowing that
blood flow to get to that portion of the heart that is not
getting it causing that chest pain.
So the purpose of calcium channel blockers is to
vasodilate. But wait a minute, calcium
channel blockers are not going to just work on one vessel.
They're not going to work just on the coronary arteries.
They're going to work systemically, which means I'm
vasodilating throughout the entire body.
If I vasodilate throughout the entire body, just think about
the room I'm making in different vessels in the periphery, which
means I've now created the ability for blood to flow with
gravity into that space I've created in my periphery.
Which means if I stand up, can I potentially get a syncopal
episode or have orthostatic hypotension?
So we must educate our patients to change positions slowly
because the last thing we want is for them to stand up, fall
down, hit the head, and now they're dead.
So educate them to change positions slowly because again,
we are vasodilating, creating blood or creating room for blood
to pool into our lower extremities.
Which means if over the course of time, I've got a patient
that's on amlodipine or nicardipine or nifedipine and
they're taking it for a long period of time, they're
chronically taking this medication and I've created room
in the periphery for blood to pool, have I not just created
peripheral edema? I have.
So educate them on the peripheral edema.
Make sure that they're wearing compression stockings, make sure
they're elevating their legs, not allowing that blood to pool.
So some takeaways with calcium channel blockers.
Again, we're talking about the dihydropyridines.
They end in dipene. They are potent vasodilators.
They're going to work systemically, so they'll help
with that hypertension, but not only that, they're going to help
with angina. More importantly, they'll create
room in the coronary arteries for that blood to flow.
But in the periphery they do the same thing.
They create room for blood to flow, which means that we can
get that orthostatic hypertension, we can get that
peripheral edema. So those are our
dihydropyridine, calcium channel blockers.
All right. Another super high yield cardio
drug is amiodarone. So before I get into amiodarone,
I do want to point out that the boards love confusing three
different drugs that all start with a that are all cardio
drugs. The first one being amiodarone,
which is what we're going to get into.
The next one is adenosine and atropine.
So amiodarone we're about to get into and then adenosine and
atropine. They're going to try to confuse
you about South with amiodarone. We've got to worry about what we
use it for. So identifying amiodarone first
and foremost, what do we use it for?
Well, we use it for atrial fibrillation, atrial flutter and
for ventricular tachycardia. So these dysrhythmias that we
talked about in EKG lecture ultimately may have the use for
amiodarone. If we're using amiodarone, we
must know the side effects because the side effects for
amiodarone are nasty and the way to remember them is simple.
PFTSTFTS and LFTS. What does that mean?
PFTS, pulmonary function test. This drug can cause pulmonary
fibrosis. Now let's think about this.
I talk about fibrosis in general.
Fibrosis, the scarring of tissue, the fibrosing of tissue
is irreversible. Think about any scar that you've
ever gotten or you've ever witnessed or you've ever seen.
Does it ever go backwards? It doesn't.
So anytime we have a drug that can do that can cause pulmonary
fibrosis in the lungs, is going to lead to an irreversible
restrictive lung disease. I'm fibrosing the lung because
of this drug, and I'm on this drug for long periods of time.
I'm going to end up causing irreversible damage to my lungs.
So how is this going to present? Well, how about a patient that
presents with shortness of breath that has been on
amiodarone? Yeah, how about that patient
that was recently started on Amiodarone that can't walk from
the bedroom to the kitchen without getting short of breath
or their O2 sets are now 90%. That's not normal.
This becomes ask Graf. It becomes airway, airway,
airway. So what do we do?
We stop the offending agent because ultimately we do not
want to cause pulmonary fibrosis because it is irreversible.
The TFTS is the thyroid function test.
This drug is not going to. This drug is also going to mess
with the thyroid, which means that if I'm started on
amiodarone and it's going to mess with the thyroid, then I'm
looking at the first sign and symptom of hypothyroidism, which
is what it's not weight gain, it's it's not cold intolerance.
It's in fact fatigue. They're going to say I'm tired.
So now we're going to do a work up.
We're going to look at their thyroid function test, get a
free T3A, free T4 and a TSH. Then we're also concerned about
their LFTS, their liver function test.
This drug is severely hepatotoxic.
So again, we don't want to take a drug that's going to lead to
hepatotoxicity because again, we can lead to fibrosing or
scarring of the liver. And if we're on it for a long
time, that is in fact cirrhosis. And we get into depth with the
problems of cirrhosis with the AB CS of cirrhosis when we have
scarring or fibrosing of the liver.
So now we're going to check their ALT and their AST.
So amiodarone being a nasty drug that the boards would love to
test because the side effects are so significant.
Used again in atrial flutter, atrial fibrillation, ventricular
tachycardia. Remember your PFTS, your LFTS
and your TFTS, your pulmonary function test, your liver
function test, and your thyroid function test.