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Notes Cardiology 53 COMMONLY USED CARDIAC THERAPEUTICS . . CONT. Notes Table 15. Beta-Blocker Actions Clinical Effects Propranolol Atenolol Acebutolol Labetalol ß-Activity non-selective ß1 ß1 non-selective ␣-Activity N N N α1 ISA N N +++ + +++ + + ++ – – – +++ lipid adverse effects ++ ++ – + CNS adverse effects +++ + ++ ++ brochoconstriction orthostatic hypotension Carvedilol (α1-and non-selective ß-blockade) ❏ useful in functional class II-III CHF (65% reduction in mortality) ❏ antioxidant CALCIUM CHANNEL BLOCKERS ❏ major subtypes are represented by diltiazem (benzothaizepine), verapamil (phenylalkylamine) and nifedipine (dihydropyridine) ❏ diltiazem and verapamil are strong cardiodepressants, whereas the dihydropyridines are strong vasodilators Table 16.

CONT. Signs ❏ x-descent only, absent y-descent ❏ hepatic congestion Clinical Pearl ❏ Classic quartet: hypotension, increased JVP, tachycardia, pulsus paradoxus ❏ Beck’s triad: hypotension, increased JVP, muffled heart sounds Investigations ❏ 12 lead ECG: electrical alternans (pathognomonic) ❏ echocardiography: pericardial effusion, diastolic compression of cardiac chambers (RA and RV) ❏ cardiac catheterization: mean RA, LA, LV and RV diastolic pressures all high and equal Management ❏ pericardiocentesis – ECHO-, fluoroscopic- or ECG-guided ❏ pericardiotomy ❏ avoid diuretics and vasodilators (these 9 venous return to already under-filled RV ––> 9 LV preload ––> 9 CO) ❏ fluid administration may temporarily 8 CO ❏ treat underlying cause CONSTRICTIVE PERICARDITIS Etiology ❏ any cause of acute pericarditis may result in chronic pericarditis Symptoms ❏ dyspnea, fatigue, palpitations ❏ abdominal pain Signs ❏ general examination - mimics CHF (especially right-sided HF) • ascites, hepatosplenomegaly, edema ❏ pulses: 8 JVP, Kussmaul's sign (paradoxical 8 in JVP with inspiration), Friedrich's sign (prominent “y” descent > “x” descent) ❏ pressures: BP normal to decreased, +/– pulsus paradoxus ❏ precordial examination: +/– pericardial knock (early diastolic sound) Investigations ❏ 12 lead ECG: low voltage, flat T wave, +/– AF ❏ chest x-ray: pericardial calcification, effusions ❏ CT or MRI: pericardial thickening ❏ cardiac catheterization: equalization of RV and LV diastolic pressures, RVEDP > 1/3 of RV systolic pressure Management ❏ medical: diuretics, salt restriction ❏ surgical: pericardiectomy Table 12.

Beta-Blocker Actions Clinical Effects Propranolol Atenolol Acebutolol Labetalol ß-Activity non-selective ß1 ß1 non-selective ␣-Activity N N N α1 ISA N N +++ + +++ + + ++ – – – +++ lipid adverse effects ++ ++ – + CNS adverse effects +++ + ++ ++ brochoconstriction orthostatic hypotension Carvedilol (α1-and non-selective ß-blockade) ❏ useful in functional class II-III CHF (65% reduction in mortality) ❏ antioxidant CALCIUM CHANNEL BLOCKERS ❏ major subtypes are represented by diltiazem (benzothaizepine), verapamil (phenylalkylamine) and nifedipine (dihydropyridine) ❏ diltiazem and verapamil are strong cardiodepressants, whereas the dihydropyridines are strong vasodilators Table 16.

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Cardiology by Ross H.


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