Review: Exam II Cardiovascular Anatomy and Physiology PED 205.
Cardiovascular Review II-1
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Transcript of Cardiovascular Review II-1
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Cardiovascular Review II
Ana H. Corona, MSN, FNP-C
Nursing Instructor
October 2007MedlinePlus; Random Outlines 2007; nurseCE.com
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Coronary Artery Disease (CAD) Coronary arteries cannot deliver adequate blood
supply to the heart muscle to meet the tissue
demand.
Characterized by obstruction or narrowing of the
vessel lumen.
Risk factors some cannot be changed while
other risk factors can be modified or eliminated.
Patient education is an important aspect of thenursing care of patients with CAD because the
educated patient can take steps to improve his
condition.
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Risk Factors
Risk factors that cannot be changed (non-modified):
age, sex, race, genetic make-up, and
family history. The major risk factors fall into the category
of modifiable risk factors:
Hypertension, elevated serum cholesterollevels, and cigarette smoking.
Additional modifiable risk factors:
weight, activity level, and stress levels
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Arteriosclerosis
Primary cause of CAD. Arteriosclerosis isdefined as hardening or thickening of the
arteries.
Characterized by thickening and loss of elasticity
of the arterial walls.
Deposits of yellowish plaques (called
atheromas) are formed within the medium and
large sized arteries. These atheromas are made up of cholesterol,
lipoid material, and lipophages (cells that ingest
or absorb fat).
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Diagnostic Tests
Ankle/brachial index (ABI)
Arteriography
Cardiac stress testing CT scan
Doppler study
Intravascular ultrasound (IVUS)
Magnetic resonance arteriography (MRA)
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Medications/Treatment
Low-fat diet
Weight loss
Exercise. Blood thinners
Cholesterol lowering agents
Angioplasty Stents
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Coronary Heart Disease (CHD)
Coronary heart disease (CHD) is a collective
name for a number of ischemic diseases of
the myocardium.
The major diseases of CHD are:
angina pectoris
cardiac dysrhythmias
myocardial infarction
congestive heart failure (CHF)
sudden cardiac death.
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Diagnostic Tests
EKG
Exercise Stress Test
Echocardiogram
Nuclear scan Coronary angiography/arteriography
Electron-beam computed tomography (EBCT) tolook for calcium in the lining of the arteries -- the
more calcium, the higher your chance for CHD Coronary CT angiography
Magnetic resonance angiography
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Medications ACE inhibitors to lower blood pressure Blood thinners (antiplatelet drugs) to reduce
your risk of blood clots
Beta-blockers to lower heart rate, blood
pressure, and oxygen use by the heart Calcium channel blockers to relax arteries,
lowering blood pressure and reducing strain onthe heart
Diuretics to lower blood pressure
Nitrates (such as nitroglycerin) to stop chest painand improve blood supply to the heart
Statins to lower cholesterol
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Angina Pectoris
A clinical syndrome of ischemic heart disease Manifested by paroxysmal chest pain.
An early warning of CV deterioration.
The symptoms occur as a result of myocardial
oxygen demand that exceeds the ability of thecoronary arteries to deliver oxygen.
(The coronary arteries supply the myocardiumwith the oxygenated blood it needs to workeffectively.)
The main cause for this inability to meet oxygendemand is the presence of atherosclerosis thatcauses advanced occlusion or stenosis of one ormore of the three major branches of thecoronary artery tree.
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Angina Pectoris
The pain of angina pectoris occurs whenthe heart is stressed or worked to a pointwhere the oxygen demand is greater thanthe amount of oxygen that can be
delivered. This usually occurs with exertion
Onset of pain will occur with exertion, and
relief will normally occur with rest. Rest will decrease the workload on theheart, thereby decreasing the heart'soxygen demand and relieving the pain.
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Unstable Angina Pectoris
A term used to describe the exacerbation
of the symptoms of angina pectoris.
Characterized by increased severity ofsymptoms, increased ease in provoking
attacks of angina, and less predictability in
controlling angina attacks.
Symptoms may be severe enough to
mimic an acute myocardial infarction.
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Diagnostic Tests
Blood tests to check the levels of creatine
phosphokinase (CPK), myoglobin, and
troponin I and T
Coronary angiography
ECG
Echocardiography Stress tests
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Medication/Treatment
Blood thinners (antiplatelet drugs)
Aspirin and clopidogrel may reduce the
chance of heart attack in certain patients. Heparin and nitroglycerin.
Other treatments may include medicines
to control blood pressure, anxiety.
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Acute Myocardial Infarction (AMI)
Results from an imbalance between oxygendemand and oxygen supply to the myocardium.
In 90 percent of the cases this imbalance is
preceded by atherosclerosis and decreased
blood flow in the coronary arteries. The inadequate blood flow results in decreased
oxygen delivery to the heart muscle, which
causes ischemia, injury, and death of a portion
of the myocardium (infarction).
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Myocardial Infarctions
Myocardial infarctions are described as beinganterior, inferior, or posterior, depending uponthe location of the infarcted area of the heartmuscle.
Infarcts can be further classified as beingtransmural or non-transmural.
A transmural infarct (Non Q-Wave MI) is onethat involves damage to the full thickness of the
myocardium. A non-transmural MI involves only a partialthickness of the muscle.
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Signs & Symptoms AMI
Chest Pain is the major presenting symptom. Pain is usually substernal and may radiate to the
neck, shoulders, arms, or epigastric area.
Pain is described as heaviness, constriction,burning, or similar to indigestion.
There may be little or no pain present at all.
May be difficult to distinguish from angina.
Shortness of breath, diaphoresis, weakness,fatigue, anxiety, nausea, vomiting, abnormal
blood pressure, and abnormal heart rate. Pain, anxiety, and arrhythmias occur in the early
stages of MI.
Ventricular fibrillation is the greatest threat to life
in the first hours after MI.
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Diagnostic Tests
Coronary angiography CT scan
Echocardiography
Electrocardiogram (ECG) -- once or repeated
over several hours
MRI
Nuclear ventriculography
Troponin I and troponin T CPK and CPK-MB
Serum myoglobin
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Management of AMI ECG monitoring
Bedrest to reduce the workload of the heart
Intravenous therapy
Morphine to reduce pain and relieve anxiety
Oxygen
Nitroglycerin to relieve pain
Thrombolytic Therapy
Aspirin: Antiplatelet medications to help preventclots
Heparin or lovenox vasodilators, beta blocker, calcium channel
blockers and lidocaine as antiarrhythmictherapy.
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Nursing Care & Management
Three major considerations: observationand prevention of further myocardial
damage and complications, promotion of
an environment that allows for maximumcomfort and rest, and patient education to
fully prepare the patient for discharge.
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Nursing Care & Management: Continue
Observation and prevention include thefollowing nursing considerations:
(a) Frequent monitoring of the vital signsand ECG.
(b) Observation for signs of impendingheart failure by close monitoring of intakeand output, daily weight, breathe sounds,and serum enzymes.
(c) Careful assessment anddocumentation of each episode of chestpain to include severity, duration,
medication given, and relief obtained.
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Nursing Care & Management: continue
Promotion of a restful and comfortableenvironment:
(a) Provide emotional support to reduceanxiety and stress.
(b) Orient patient to the (CCU) routine andenvironment.
(c) Schedule patient care activities carefully to
avoid interrupting the patient's sleep.
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Patient Education
(a) Promote compliance with prescribed
meds, diet, and other tx measures by
explaining the need for each and the possible
consequences of noncompliance.
(b) Review all activity limitations and
restrictions.
(c) Counsel the patient on the action thatshould be taken when he is confronted with
chest pain or other symptoms.
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Heart Failure (CHF) Inadequate cardiac output,
resulting in poor perfusion of all organ systems.
Left heart failure: The pumping action ofthe left ventricle is compromised, but theright ventricle continues to function
normally. There is an imbalance between the out-put
of each ventricle.
The right heart continues to pump bloodinto the lungs to be oxygenated.
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CHF: left sided heart failure
The failing left heart is unable to return thatsame volume of blood to the systemiccirculation.
Results in accumulation of blood in thepulmonary blood vessels.
Increased pressure in the pulmonaryvessels causes fluid to leak into the
interstitial lung tissue, compromising gasexchange.
This condition is called pulmonary edema.
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Right Sided Heart Failure
Right sided heart failure usually follows leftsided failure.
The increased pressure in the pulmonaryvessels causes "back pressure" to the right
side of the heart. This interferes with venous return, and
consequently, the organs of the bodybecome congested.
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CHF: right sided heart failure
This condition, known as congestive heartfailure (CHF), is manifested by neck veindistention and body edema.
Right sided failure may occur without leftsided failure.
This condition, called corpulmonale, may
be caused by pulmonary hypertensionsecondary to lung disease or by thepresence of pulmonary emboli.
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CHF Diagnostic Tests
Echocardiogram Heart catheterization
Chest x-ray
Chest CT scan
Cardiac MRI
Nuclear heart scans(MUGA, RNV)
ECG, which may alsoshow arrhythmias
CBC
Blood chemistry Serum sodium
BUN
Creatinine Liver function tests
Serum uric acid
Atrial natriuretic peptide(ANP) and brainnatriuretic peptide (BNP)
Urinalysis
Urinary sodium
Creatinine clearance
Swan-Ganzmeasurements (rightheart catheterization)
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Medications/Treatment Low Sodium Diet
ACE inhibitors such as captopril and enalapril -- thesemedications open up blood vessels and decrease thework load of the heart.
Diuretics -- there are several types including thiazide, loopdiuretics, and potassium-sparing diuretics; they help rid
your body of fluid and sodium. Digitalis glycosides -- increase the ability of the heart
muscle to contract properly; prevent heart rhythmdisturbances
Angiotensin receptor blockers (ARBs) such as losartan
and candesartan which, like ACE inhibitors, reduce theworkload of the heart; this class of drug is especiallyimportant for those who cannot tolerate ACE inhibitors
Beta-blockers -- this is particularly useful for those with ahistory of coronary artery disease
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Nursing Care & Management CHF
During the acute phase, nursing considerationsinclude the following:
Monitoring fluid retention by weighing the patientdaily.
Monitoring intake and output. Frequent assessment of vital signs.
Frequent monitoring of electrolytes.
Promoting mental and physical rest to reduce theworkload of the heart.
Administration of prescribed medications toimprove the heart's effectiveness as a pump.
Administration of prescribed dietary restrictions(sodium and fluids).
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Nursing Care & Management CHF
Patient education should include the following
nursing considerations:
Instruction on effective coping mechanisms
that will reduce stress in daily living.
Compliance in taking prescribed
medications.
Compliance in following the prescribeddietary and fluid restrictions.
The importance of regular check-ups.
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Q1
Cyanosis and potential cyanide poisoning
are possible with
a. nitroglycerinb. nitroprusside (Nipride)
c. nitrofurantoin (Macrodantin)
d. nitrous oxide
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A1
b. nitroprusside (Nipride)
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Q2
Identify the beta blocker(s)
a. guanabenz (Wytensin)
b. prazocin (Minipres)c. acetbutolol (Sectral)
d. enalapril (Vasotec)
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A2
c. acetbutolol (Sectral) -- hint -- look for
the "olol" suffix!
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Q3
Identify the ACE inhibitor(s)
a. atenolol (Tenormin)
b. captopril (Capoten)c. propranolol (Inderal)
d. ranitidine (Zantac)
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A3
b.captopril (Capoten) -- hint-- look for
the "pril" suffix!
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Q4
Digoxin (Lanoxin) causes
a. negative inotropic, positive chronotropicaction
b. negative inotropic, negative chronotropicaction
c. positive inotropic, positive chronotropic
actiond. positive inotropic, negative chronotropic
action
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A4
d. positive inotropic, negative
chronotropic action
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Q5
Your patient is lethargic, nauseated, and has apulse of 52. You see that he is taking digoxin(Lanoxin) 0.25mg daily, and also has
hydrochlorothiazide (HydroDiuril) 50mg twicedaily. He is also playing with the color knobs onthe television. You would check for a
a. drop in sodium levels
b. drop in potassium levelsc. drop in digoxin (Lanoxin) levels
d. drop in calcium levels
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A5
b. drop in potassium levels
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Q6
Asthmatic patients could experience
bronchoconstriction problems with which
of the following agents?
a. isoproterinol (Isuprel)
b. digoxin (Lanoxin)
c. pindolol (Visken)
d. dextromethorphan
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A6
c. pindolol (Visken) -- a beta blocker
can cause B-2 blocking which can
result in bronchospasm
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Q7
Hypertensive therapy available as a 7-day
patch
a. atenolol (Tenormin)b. methyldopa (Aldomet)
c. minoxidil (Loniten)
d. clonidine (Catapres)
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A7
d.clonidine (Catapres)
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Q8
Regarding nitroglycerin
a. tingling on the tongue is a sign of toxicity with
the sublingual tablets
b. special tubing is always used for IV infusion
c. oral nitrates such as Isordil and Sorbitrate are
just as effective as topical patches
d. care should be taken to avoid absorption of thepaste or injection solution onto the skin of the
caregiver
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A8
d.care should be taken to avoid
absorption of the paste or injection
solution onto the skin of the caregiver
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Q9
Nonpharmacologic therapy ofhypertension includes
a. dynamic exercise at least 3 times a week
b. magnesium and calcium supplementation
c. moderation in alcohol consumption
d. weight loss
e. all of the above
f. a, c, d only
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A9
e. all of the above
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Q10
Angiotensin II
a. is increased in the presence of enalapril
(Vasotec)b. causes drops in aldosterone levels
c. can result in water retention
d. increases sodium excretion
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A10
c.can result in water retention
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Q11
The antihypertensive agent also used for
hair regrowth is
a. nitroglycerinb. nitroprusside (Nipride)
c. minoxidil (Loniten) -- the topical hair
regrowth product is also known as
Rogaine
d. verapamil (Calan)
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A11
c. minoxidil (Loniten) -- the topical hair
regrowth product is also known as
Rogaine
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Q12
High fiber diets can have what effect on
the blood levels of digoxin (Lanoxin)?
a. lower
b. raise
c. no change
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A12
a. lower
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Q13
Your patient has a heart rate of 79. After
being stabilized on propranolol (Inderal),
what is a likely heart rate?
a. 84
b. 65
c. propranolol (Inderal) has no effect on
heart rate
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A13
b. 65
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Q14
For atrial fibrillation and atrial flutter, you
turn to
a. lidocaine (Xylocaine)
b. quinidine (Qunidex)
c. amantadine (Symmetrel)
d. pilocarpine (Isopto Carpine)
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A14
b. quinidine (Qunidex)
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Q15
The equation MAP = CO x TPR
a. is used to determine the flow rate of TPNs
b. describes the relationship of cardiac output and
total peripheral resistance to the average blood(or mean arterial) pressure
c. shows that a decrease in CO can cause an
increase in TPR
d. shows that an increase in MAP always means
an increase in CO
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A15
b. describes the relationship ofcardiac
output and total peripheral resistance
to the average blood (or mean
arterial) pressure
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Q16
Antidote for warfarin overdose
a. protamine zinc insulin
b. protamine sulfatec. vitamin K
d. warfarin
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A16
c. vitamin K
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Q17
Antidote for heparin overdose
a. protamine sulfate
b. vitamin Kc. vitamin E
d. cyanocobolamine
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A17
a. protamine sulfate
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Q18
Antiplatelet agents include all of the
following except
a. acetylsalicylic acid
b. acetaminophen
c. ticlopidine (Ticlid)
d. dipyridamole (Persantine)
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A18
b. acetaminophen
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Q19
Regarding cholesterol therapy, the goal is
to
a. reduce LDL and raise triglycerides
b. reduce LDL and raise HDL
c. raise LDL and raise HDL
d. raise LDL and reduce triglycerides
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A19
b. reduce LDL and raise HDL
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Q20
Which organ requires extra monitoring
when the patient is undergoing lipid-
lowering therapy?
a. kidney
b. brain
c. liver
d. pancreas
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A20
c. liver
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Q21
A classic drug interaction, greatly involving
an increased bleeding time, involves
warfarin and
a. vitamin B-6
b. acetaminophen
c. acetylsalicylic acid
d. all of the above
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A21
c. acetylsalicylic acid
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Q22
Which vitamin is involved in the coagulant
process?
a. vitamin C
b. vitamin B-6c. vitamin D
e. vitamin K
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A22
e. vitamin K
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Antihypertensive Drugs
Beta Blockers
Atenolol (Tenormin)
Penbutolol (Levatol)
Metoprolol (Lopressor)
Carteolol (Cartrol)
Esmolol (Brevibloc)
Betaxolol (Kerlone) Acebutolol (Sectral)
Nadolol (Corgard)
Pindolol (Visken)
Timolol (Blocadren)
Propranolol (Inderal)
Labetalol(Trandate/Normodyne)
For hypertensive emergencies
Nitroprusside (Nipride)
Others Methyldopa (Aldomet)
Clonidine (Catapres)
Guanfacine (Tenex)
Guanabenz (Wytensin)
Reserpine (Serpasil)
Guanethidine (Ismelin) Prazocin (Minipres)
Hydralazine (Apresoline)
Minoxidil (Loniten)
Ace Inhibitors:
Captopril (Capoten) Enalapril (Vasotec)
Lisinopril (Zestril/Prinivil)
Benazepril
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Diuretics "Water pills"
Hydrochlorothiazide (HydroDiuril) Chlorothiazide (Diuril)
Methchlothiazide (Enduron)
Chlorthalidone (Hygroton)
Indapamide (Lozol) Furosemide (Lasix)
Bumetanide (Bumex)
Ethacrynic acid (Edecrin)
Spironolactone (Aldactone)
Triamterene with hydrochlorothiazide(Dyazide/Maxide)
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Anti-anginal drugs
Nitroglycerin (Nitrostat)
Amyl nitrate Isosorbide Dinitrate (Isordil)
PETN (Peritrate)
Dipyridamole (Persantine)
D f di h th i
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Drugs for cardiac arrhythmia
Quinidine (Quinidex) Digoxin (Lanoxin)
Procainamide
(Procan/Pronestyl)
Disopyramide (Norpace) Lidocaine (Xylocaine)
Tocainide (Tonocard)
Mexiletine (Mexetil)
Encainide (Enkaid)
Bretylium (Bretylol) Nifedipine (Procardia)
Bepridil (Vascor)
Isradipine (DynaCirc)
Nimodipine (Nimotop) Diltiazem (Cardizem)
Nicardipine (Cardene)
Verapamil
(Calan/Isoptin)