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PANCE/PANRE Review
“If you can't
explain it simply,
you don't
Understand it
well enough”
Einstein
John Bielinski, Jr. MS, PAC 1
3:30
1. A&P Review
2. Cardiomyopathies
3. Valvular Heart Disease
4. Conduction Disorders
5. ACLS
6. Heart Blocks
7. CHF
8. HTN
9. ACS
10. EKG 2
Cardiac BRC
Sympathetic vs.
Parasympathetic
S P
3
Venous – Arterial
Clotting –
Platelets
Sympathetic vs.
Parasympathetic
4
ANS
Sympathetic NS Parasympathetic NS
Stress
“Adrenergic”
Sympathomimetic
S= “Staying Alive”
Response
Catecholamine
5
Increased:
Heart Rate
Contraction
Lungs Bronchodilate
Pupils Dilate
Increased BP
6
ANS
Sympathetic NS Para
Sympathetic NS
ALPHA
7
Alpha = Vasoconstriction
Alpha Receptor
Alpha antagonists for BPH
8
Adrenal
Hormones
10
•Aldosterone
•Cortisol
• STRESS HORMONE
•Epinephrine
Adrenal Hormones
11
• Mineral-corticoids
•  Aldosterone
• Electrolyte & H2O balance
• Gluc-o-corticoids = STRESS
HORMONE
•  Cortisol = “steroids”
• Androgens
•  Epi
CO = (EF x SV) X HR
Epi drives diastole
ALDO
Na Na Na Na…
Na Na Na
Na….
K
Terminology
• Chronotrope
–Time
• Inotrope
–Force of
contractio
n
Positive chronotrope = atropine, epi, dopamine
Negative chronotrope = “funnel drugs”
Positive inotrope = Dig, dopamine
Negative inotrope = BB, CCB
Sympathetic NS
Para
Sympathetic NS
ALPHA
BETA
Vaso-
Constriction
Beta
One
Beta
Two 15
α
“ISA”
α
Acebutolol (Sectral®)
Atenolol (Tenormin®)
Betaxolol (Kerlone®, Betoptic®)
Bisoprolol (Zebeta®)
Esmolol (Brevibloc®)
Nebivolol (Bystolic®)
Metoprolol (Lopressor®, Toprol-XL®).
“ISA”
Acebutolol (Sectral®)
Carteolol (Ocupress®)
Penbutolol (Levatol®)
Pindolol (Visken®)
Intrinsic Sympath
-O-
Mimetic Activity
BB make you
pupil like a
BB!
α
Carvedilol
(Coreg®, Coreg CR®)
Labetalol
(Trandate®)
Beta Blocker with
Alpha Blockade
Alpha and Beta Blocker
• Levobunolol (Betagan®)
• Metipranolol (OptiPranolol®)
• Nadolol (Corgard®)
• Propranolol
– (Inderal®, Inderal LA, InnoPran XL®))
• Sotalol (Betapace®, Sorine®)
• Timolol (Betimol®, Blocadren®, Istalol®,
Timoptic®).
Avoid Beta Blocker:
Cocaine
OD
(Causes HTN)
Acute Withdrawal
(Causes
HTN/Tachycardia)
Beta
Two
22
• Albuterol
– Proventil, Ventolin
• Xopenex
Beta
Two
Beta “Crossover”
Beta I Receptor Beta 2 Receptor
Increased:
Heart Rate
Contraction Dilates Lungs
24
Critically Important Question:
When are beta blockers acutely contraindicated?
BAD
25
Beta blockers are
to CHF what
ACEIs are to
Diabetic 26
AV Node
“Funnel Drugs”
AV
Node
Beta Blockers
Calcium Blockers
Digoxin 28
Calcium Channel
Blockers
•Di-hydros
• Vaso-Di
• “DIE”
Non-Di-hydros
Diltiazem (Cardizem)
Verapamil
CCB (Non-Di-
Hydros)Diltiazem (Cardizem)
Verapamil  Bad in CHF!
• Covera-HS
• Verelan PM
• Verelan Brain  Headache, dizziness
Dilation  Flushing, peripheral edem
Constipation w/ verapamil = 25%
Non-
N N
Non-
dihydropyridines
are funnel drugs
Vaso-Di-lators
(CCB)
• Amlodipine (Norvasc)
• Felodipine (Plendil)
• Isradipine (DynaCirc)
• Nicardipine (Cardene)
• Nifedipine (Procardia/Adalt)
• Nimodipine SAH
• Nitrendipine
Pine box =
dead!
…pine
Dig
CHF
A. Fib
34Negative chronotrope/ Positive inotrope
35
Name the Monkey
What is the action of
Digoxin?
A. + Inotrope + chronotrope
B. + Inotrope - chronotrope
C. - Inotrope + chronotrope
D. - Inotrope -
chronotrope
36
Sympathetic NS Parasympathetic NS
ALPHA
BETA
Vaso-
Constriction
Beta
One
Beta
Two
P “After Sex”
Effect
37
AV Node
The
job of the
Vagus Nerve is
to relax
the heart
38
Sympathetic vs.
Parasympathetic
39
Stimulating the
Vagus Nerve = “Whoooooo”
40
AV Node
The
job of the
Vagus Nerve is
to relax
the heart
41
Mad as a
…
Dry as a …
Blind as a …
Red as a …
Hot as …
Mad as a
Hatter
Atropine = Anticholinergic
Glauco
ma
43
Urine
Retenti
on
44
What Meds Are
Anti-
cholenergic?
“Anti-”
• Anti-depressants
Amitriptyline (Elavil), doxepin (Sinequan),
imipramine (Tofranil), nortriptyline (Pamelor)
• Anti-nausea & Anti-dizziness Promethazine
(Phenergan), prochlorperazine (Compazine),
trimethobenzamide (Tigan)
What Meds Are Anti-
cholenergic?
Anti-tone meds (aka muscle relaxants)
Metaxalone (Skelaxin), cyclobenzaprine (Flexeril), orphenadrine
(Norflex), methocarbamol (Robaxin), carisoprodol (Soma)
Anti-spasmodics - Urinary
Oxybutynin (Ditropan), flavoxate (Urispas), tolteradine (Detrol)
Anti-spasmodics - GI
Dicyclomine (Bentyl)
Anti-histamines
Meclizine (Antivert), scopolamine (TransDerm Scop)
What Meds Are
Anticholenergic?
Anti-arrhythmics
Disopyramide (Norpace), procainamide (Pronestyl), quinidine
Anti-psychotics
chlorpromazine (Thorazine), thioridazine (Mellaril), clozapine (Clozaril),
thiothixene (Navane), fluphenazine (Stelazine)
Antidepressants (Tricyclic)
Amitriptyline (Elavil), Nortriptyline (Pamelor)
Anti-diarrhea
Atropine-diphenoxylate (Lomotil)
Anti-Parkinson
Benztropine (Cogentin)
What Meds Are
Anticholenergic?
Heart Blocks
SA
Wenckebach
1st Degree HB
It’s the job of the
Vagus nerve to slow
the heart 49
Stimulating the Vagus
Nerve
• Stimulate with Medications
• Stimulate with Vagal Maneuvers
50
Vagus NerveBlock/Cut Stimulate
Atropine
Adenosine/
Vagal Maneuvers
Speeds Slow 51
Key ACLS
Meds
•ATropine  Tachycardia
•ADenosine  Down
•AMiodarone  Mellows
Sympathetic
ALPHA
BETA
Vaso-
Constriction
Pumps
Heart
Opens
Lungs
Slows/Relaxes
Heart
In Summary:
Autonomic Nervous System
Parasympathetic
53
Narcotic Officers
COPS
ATF
Killers
Narcotic
Officers
Cops
ATF
KILLERS
55
N
C
ATF
0 = N  In
K
1 = N Stops
2 = C  In
3 = K Out
ATF
56
Na+
Ca+
ATF
0 = Na+  In
K+
1 = Na+ Stops
2 = Ca+  In
3 = K+ Out
57
Cardiac
Action
Potential
58
Hyperkalemi
a
&
Vunerable
to shock!
T Wave
Vaughan Williams
Antiarrhythmic Drugs
• Class I: ___ Channel Blocker
• Quinidine, procainamide, disopyramide
–Ia: Procainamide/Quinidine
– Ib: Lidocaine, phenytoin
– Ic: Flecainide, propafenone
• Class II: ß-Blockers
• Class III: _____ Blocker ( Amiodarone )
• Class IV: Ca+ Channel Blocker 60
Drugs that Cause
SLE• Methyldopa  HTN, Gestational hypertension & pre-
eclampsia
• Quinidine  1A Antiarrhythmic (wide QRS)
• Chlorpromazine  Typical Antipsychotic
• Hydralazine  HTN
• Isoniazid  TB. Use w/ Vitamin B6
• Procainamide 1A Antiarrhythmic (wide QRS)
“M & Q put a CHIP in the Agent” 61
Vaughan Williams
Antiarrhythmic Drugs
• Class I: ___ Channel Blocker
• Quinidine, procainamide, disopyramide
–Ia: Procainamide/Quinidine 
LUPUS! ALSO Tricyclic Antidepressants
– Ib: Lidocaine, phenytoin, mexiletine
– Ic: Flecainide, propafenone, moricizine
• Class II: ß-Blockers
• Class III: _____ Blocker ( Amiodarone )
• Class IV: Ca+ Channel Blocker 62
AV Node
“Funnel Drugs”
AV Node
Beta Blockers
Calcium Blockers*
Digoxin
Vaughan Williams
Antiarrhythmic Drugs
• Class I: ___ Channel Blocker
• Quinidine, procainamide, disopyramide
–Ia: Procainamide/Quinidine 
LUPUS! ALSO Tricyclic Antidepressants
– Ib: Lidocaine, phenytoin, mexiletine
– Ic: Flecainide, propafenone, moricizine
• Class II: ß-Blockers
• Class III: _____ Blocker ( Amiodarone/Sotalol)
• Class IV: Ca+ Channel Blocker 64
Am-EYE-o-darone
Vaughan Williams
Antiarrhythmic Drugs
• Class I: ___ Channel Blocker
• Quinidine, procainamide, disopyramide
–Ia: Procainamide/Quinidine 
LUPUS! ALSO Tricyclic Antidepressants
– Ib: Lidocaine, phenytoin, mexiletine
– Ic: Flecainide, propafenone, moricizine
• Class II: ß-Blockers
• Class III: _____ Blocker ( Amiodarone/Sotalol)
• Class IV: Ca+ Channel Blocker 66
AV Node
“Funnel Drugs”
AV Node
Beta Blockers
Calcium Blockers*
Digoxin

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