\documentclass[10pt,a4paper]{article}

% Packages
\usepackage{fancyhdr}           % For header and footer
\usepackage{multicol}           % Allows multicols in tables
\usepackage{tabularx}           % Intelligent column widths
\usepackage{tabulary}           % Used in header and footer
\usepackage{hhline}             % Border under tables
\usepackage{graphicx}           % For images
\usepackage{xcolor}             % For hex colours
%\usepackage[utf8x]{inputenc}    % For unicode character support
\usepackage[T1]{fontenc}        % Without this we get weird character replacements
\usepackage{colortbl}           % For coloured tables
\usepackage{setspace}           % For line height
\usepackage{lastpage}           % Needed for total page number
\usepackage{seqsplit}           % Splits long words.
%\usepackage{opensans}          % Can't make this work so far. Shame. Would be lovely.
\usepackage[normalem]{ulem}     % For underlining links
% Most of the following are not required for the majority
% of cheat sheets but are needed for some symbol support.
\usepackage{amsmath}            % Symbols
\usepackage{MnSymbol}           % Symbols
\usepackage{wasysym}            % Symbols
%\usepackage[english,german,french,spanish,italian]{babel}              % Languages

% Document Info
\author{kjaniskevich}
\pdfinfo{
  /Title (pharm250-cardiovascular-and-respiratory.pdf)
  /Creator (Cheatography)
  /Author (kjaniskevich)
  /Subject (PHARM250 Cardiovascular \& Respiratory Cheat Sheet)
}

% Lengths and widths
\addtolength{\textwidth}{6cm}
\addtolength{\textheight}{-1cm}
\addtolength{\hoffset}{-3cm}
\addtolength{\voffset}{-2cm}
\setlength{\tabcolsep}{0.2cm} % Space between columns
\setlength{\headsep}{-12pt} % Reduce space between header and content
\setlength{\headheight}{85pt} % If less, LaTeX automatically increases it
\renewcommand{\footrulewidth}{0pt} % Remove footer line
\renewcommand{\headrulewidth}{0pt} % Remove header line
\renewcommand{\seqinsert}{\ifmmode\allowbreak\else\-\fi} % Hyphens in seqsplit
% This two commands together give roughly
% the right line height in the tables
\renewcommand{\arraystretch}{1.3}
\onehalfspacing

% Commands
\newcommand{\SetRowColor}[1]{\noalign{\gdef\RowColorName{#1}}\rowcolor{\RowColorName}} % Shortcut for row colour
\newcommand{\mymulticolumn}[3]{\multicolumn{#1}{>{\columncolor{\RowColorName}}#2}{#3}} % For coloured multi-cols
\newcolumntype{x}[1]{>{\raggedright}p{#1}} % New column types for ragged-right paragraph columns
\newcommand{\tn}{\tabularnewline} % Required as custom column type in use

% Font and Colours
\definecolor{HeadBackground}{HTML}{333333}
\definecolor{FootBackground}{HTML}{666666}
\definecolor{TextColor}{HTML}{333333}
\definecolor{DarkBackground}{HTML}{B8141A}
\definecolor{LightBackground}{HTML}{FAF0F0}
\renewcommand{\familydefault}{\sfdefault}
\color{TextColor}

% Header and Footer
\pagestyle{fancy}
\fancyhead{} % Set header to blank
\fancyfoot{} % Set footer to blank
\fancyhead[L]{
\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{C}
    \SetRowColor{DarkBackground}
    \vspace{-7pt}
    {\parbox{\dimexpr\textwidth-2\fboxsep\relax}{\noindent
        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
    }
\end{tabulary}
\columnbreak
\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{PHARM250 Cardiovascular \& Respiratory Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{kjaniskevich} via \textcolor{DarkBackground}{\uline{cheatography.com/132444/cs/26837/}}}
\end{tabulary}
\end{multicols}}

\fancyfoot[L]{ \footnotesize
\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{LL}
  \SetRowColor{FootBackground}
  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}kjaniskevich \\
  \uline{cheatography.com/kjaniskevich} \\
  \end{tabulary}
\vfill
\columnbreak
\begin{tabulary}{5.8cm}{L}
  \SetRowColor{FootBackground}
  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 1st March, 2021.\\
   Updated 1st March, 2021.\\
   Page {\thepage} of \pageref{LastPage}.
\end{tabulary}
\vfill
\columnbreak
\begin{tabulary}{5.8cm}{L}
  \SetRowColor{FootBackground}
  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Sponsor}}  \\
  \SetRowColor{white}
  \vspace{-5pt}
  %\includegraphics[width=48px,height=48px]{dave.jpeg}
  Measure your website readability!\\
  www.readability-score.com
\end{tabulary}
\end{multicols}}




\begin{document}
\raggedright
\raggedcolumns

% Set font size to small. Switch to any value
% from this page to resize cheat sheet text:
% www.emerson.emory.edu/services/latex/latex_169.html
\footnotesize % Small font.

\begin{multicols*}{2}

\begin{tabularx}{8.4cm}{p{0.8 cm} p{0.8 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Cardiovascular diseases}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Hypertension} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Heart Failure} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Dysrhythmias} \tn 
% Row Count 3 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Angina \& Myocardial Infarction} \tn 
% Row Count 4 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Lipids} \tn 
% Row Count 5 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Coagulation} \tn 
% Row Count 6 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Anemia} \tn 
% Row Count 7 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{1. Diuretics}} & Diuretics make you pee\{\{nl\}\}Reduce blood volume through urinary excretion of water and electrolytes (Na+, Ca++, Cl-, K+)\{\{nl\}\} Specific mechanism of action varies within the class (thiazide, loop, potassium-sparing)\{\{nl\}\} Depends on where (i.e. which part of the nephron) it works\{\{nl\}\} Effective, Well tolerated\{\{nl\}\} First line treatment for hypertension\{\{nl\}\} Due to manipulation of electrolytes, monitoring is important! \tn 
% Row Count 22 (+ 22)
% Row 1
\SetRowColor{white}
a.Thiazide diuretics\{\{nl\}\}{\emph{Hydrochlorothiazide (HCTZ)}} & Largest, most commonly prescribed class of diuretics \{\{nl\}\}('gentler' than loop diuretics)\{\{nl\}\} Decrease the reabsorption of sodium in the early distal tubule, which increases the production and excretion of urine\{\{nl\}\}  More sodium (and therefore water) is excreted\{\{nl\}\} Treat mild to moderate hypertension and edema that is associated with heart, hepatic, and renal failure \tn 
% Row Count 42 (+ 20)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
b.Loop diuretics\{\{nl\}\}{\emph{Furosemide}} & Are the most effective diuretics\{\{nl\}\} Prevents reabsorption of sodium and chloride in the loop of Henle\{\{nl\}\} Reduce edema associated with heart, hepatic, or renal failure\{\{nl\}\} Cause large amounts of fluid to be quickly excreted – along with potassium (K+)\{\{nl\}\} Used to provide short-term hypotension, not so much for blood pressure maintenance \tn 
% Row Count 18 (+ 18)
% Row 3
\SetRowColor{white}
c.Potassium sparing diuretics \{\{nl\}\}{\emph{Spironolactone}} & Block either sodium pump (leaving more sodium in tubule) or aldosterone further along in the nephron (late distal tubule and collecting duct)\{\{nl\}\} Achieve diuresis without affecting blood potassium levels \{\{nl\}\} Preferred in patients at high risk of developing hypokalemia \{\{nl\}\} Sometimes combined with other diuretics (as an add-on) to minimize potassium loss \tn 
% Row Count 37 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
{\bf{2.Calcium channel blockers \{\{nl\}\} (CCB)}} & Muscle contraction is controlled by calcium moving in and out of channels across cell membranes (Ca++ influx causes contraction)\{\{nl\}\} Blocking the channels limits muscular contraction, relaxing muscle in both the periphery and heart\{\{nl\}\} Reduce blood pressure by lowering peripheral resistance and cardiac output \tn 
% Row Count 16 (+ 16)
% Row 5
\SetRowColor{white}
{\emph{Nifedipine}} & Mechanism of action: blocks calcium channels in myocardial and vascular smooth muscle (blood vessels \textgreater{} heart) – long-acting dihydropyridine (LA-DHP) \tn 
% Row Count 24 (+ 8)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Anything that causes vasodilation will also cause reflex tachycardia  Therefore, anything that causes vasodilation requires heart rate monitoring} \tn 
% Row Count 27 (+ 3)
% Row 7
\SetRowColor{white}
{\bf{3.Renin-angiotension-aldosterone system \{\{nl\}\}(RAAS) agents  }} & RAAS is triggered in times of low blood pressure \{\{nl\}\}  End result of uninterrupted RAAS is increased blood pressure\{\{nl\}\}drugs affecting RAAS \{\{nl\}\}Reduce blood pressure by:\{\{nl\}\} Reducing peripheral resistance\{\{nl\}\} Decreasing blood volume \tn 
% Row Count 40 (+ 13)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 8
\SetRowColor{LightBackground}
\seqsplit{a.Angiotensin-converting-enzyme} inhibitors \{\{nl\}\}(ACE Inhibitors)\{\{nl\}\}{\emph{-pril}} & Inhibit \seqsplit{angiotensin-converting-enzyme} (ACE), resulting in less angiotensin II and aldosterone, which reduces blood pressure\{\{nl\}\} Prevents conversion of angiotensin I to angiotensin II, therefore: Prevents aldosterone secretion Prevents the direct vasoconstriction\{\{nl\}\} {\emph{Pregnancy category D}} \tn 
% Row Count 15 (+ 15)
% Row 9
\SetRowColor{white}
b.Angiotensin II receptor blockers \{\{nl\}\} (ARBs)\{\{nl\}\}{\emph{-sartan}} & In the same pathway (RAAS), ARBs block angiotensin II from causing vasoconstriction, and block the release of aldosterone at the adrenal gland \{\{nl\}\} Very similar uses and adverse effects as ACE-I\{\{nl\}\} **Also newer drugs involved in the RAAS: Aliskiren – renin inhibitor \tn 
% Row Count 29 (+ 14)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{4.Adrenergic agents}}} \tn 
% Row Count 30 (+ 1)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 11
\SetRowColor{LightBackground}
a.β-Blockers \{\{nl\}\}{\emph{-olol}} & β-receptors in heart (β1), lungs (β2), blood vessels (β2) + many others \{\{nl\}\} Cardio-selective: reduce heart rate and slow down myocardial conduction and contractility = reduce cardiac output \{\{nl\}\} Non-selective: also produce vasodilation = lower peripheral resistance and reduce cardiac output\{\{nl\}\}Because of their action in the heart, their primary use is for angina, arrhythmias, heart failure, and post-myocardial infarction\{\{nl\}\}  Also used off-label for migraine prevention, or as a performance enhancing drug\{\{nl\}\}  Drug dependence occurs, so upon abrupt discontinuation = reflex tachycardia (Requires tapering ) \tn 
% Row Count 32 (+ 32)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 12
\SetRowColor{LightBackground}
b.α1-Blockers & Block α1–receptors in the periphery – relaxes smooth muscle and reduces peripheral resistance and cardiac output (indirectly)\{\{nl\}\} Vasodilation = ↓ venous return to heart = ↓ cardiac output\{\{nl\}\} Primary continuous use is for urinary incontinence and benign prostatic hyperplasia (BPH) \{\{nl\}\} Work very quickly to reduce blood pressure \tn 
% Row Count 18 (+ 18)
% Row 13
\SetRowColor{white}
{\emph{Doxazosin}} & Blocks vasoconstriction caused by stimulation of α–receptors, therefore reducing peripheral resistance\{\{nl\}\} Used to treat urinary incontinence, BPH, hypertension \tn 
% Row Count 27 (+ 9)
% Row 14
\SetRowColor{LightBackground}
c.α2-Agonists & Stimulate α2-receptors in the CNS, which causes the identical response as the α1-blockers in the periphery  vasodilation  reduces peripheral resistance and cardiac output (indirectly)\{\{nl\}\}  When α2-receptors are stimulated, the outflow of sympathetic nerve impulses from the CNS to the heart and blood vessels is inhibited\{\{nl\}\} α2-agonists and α1-blockers = same clinical result\{\{nl\}\}Rarely used for long-term ({\emph{clonidine, methyldopa}})\{\{nl\}\}  Reserved for patients with hypertension which has been resistant to other therapies \tn 
% Row Count 54 (+ 27)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Hypertension (cont)}}  \tn
% Row 15
\SetRowColor{LightBackground}
d.Miscellaneous & {\emph{Labetalol}}: partial agonist @ β2, blocks @ α1 \& β1\{\{nl\}\} {\emph{Carvedilol}}: blocks β1\&2 and α1 \tn 
% Row Count 5 (+ 5)
% Row 16
\SetRowColor{white}
{\bf{5.Direct-acting vasodilators}}\{\{nl\}\}{\emph{Hydralazine, minoxidil, nitroprusside}} & Directly relax arteriolar smooth muscle in blood vessels  reduce peripheral resistance\{\{nl\}\} Work at cellular level – each differently\{\{nl\}\} Quickly reduce blood pressure\{\{nl\}\}Generally reserved for acute care to dilate quickly under close monitoring \tn 
% Row Count 18 (+ 13)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Normal sinus rhythm}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/kjaniskevich_1614587847_Normal Sinus rythym.PNG}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.96 cm} x{5.04 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{About Action Potentials}}  \tn
% Row 0
\SetRowColor{LightBackground}
Resting State (kind of) & Na+ and Ca++ are outside cell, K+ is inside cell (+ charge higher outside, than inside – POLARIZED) \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
\seqsplit{Depolarization} & Na+ and Ca++ channels open, and both rush into the cell to try and balance out charges (it is mostly the Ca++ increase inside the cell responsible for muscle contraction) \tn 
% Row Count 12 (+ 7)
% Row 2
\SetRowColor{LightBackground}
\seqsplit{Repolarization} & In a further attempt to get back to resting state, the K+ channels open and K+ rushes out \tn 
% Row Count 16 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Remember that calcium also has a role in muscle contraction! \newline If a patient is asymptomatic with an arrhythmia, we don't have to treat it \newline We only treat arrhythmias that affect cardiac output or increase risk of clots \newline Electric shock / defibrillation – like a reset button for the SA node – hoping to return to normal sinus rhythm in an emergency \newline Patients with certain types of dysrhythmias are at an increased risk of a clot – therefore, often also on anticoagulants}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{What are dysrhythmias/arrhythmias ?}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Any abnormality of electrical conduction (in the generation or conduction) that results in a disturbance of the heart rate or rhythm \newline % Row Count 3 (+ 3)
Atrial dysrhythmias are more common and less severe than ventricular dysrhythmias \newline % Row Count 5 (+ 2)
Diagnose using ECG \newline % Row Count 6 (+ 1)
{\bf{Myocardial action potential:}}  \newline % Row Count 7 (+ 1)
Conduction is sent along the pathway using Na+, K+, and Ca++ channels \newline % Row Count 9 (+ 2)
Drugs correct dysrhythmias by either:  \newline % Row Count 10 (+ 1)
Manipulating these channels  \newline % Row Count 11 (+ 1)
Altering autonomic activity (α and β receptors)% Row Count 12 (+ 1)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Arrhythmias}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Sodium channel blockers\{\{nl\}\} (class I)}}\{\{nl\}\}{\emph{Procainamide}} & Slow down depolarization by preventing Na+ from rushing into the cell\{\{nl\}\} Lengthen the duration of the action potential\{\{nl\}\}  Can also suppress ectopic activity (arrhythmias coming from an incorrect source)\{\{nl\}\} Similar in structure to anesthetics, therefore potential for CNS effects \tn 
% Row Count 15 (+ 15)
% Row 1
\SetRowColor{white}
{\bf{ β-blockers \{\{nl\}\}(class II)}} & Slows heart rate\{\{nl\}\} Decreases conduction velocity through the AV node\{\{nl\}\} Altering the adrenergic nervous system\{\{nl\}\} Usually used for dysrhythmias associated with heart failure (choose cardio-selective ones)\{\{nl\}\} Remember: DO NOT STOP ABRUPTLY = reflex tachycardia \{\{nl\}\}Contraindicated in clients with heart block, severe bradycardia, asthma, COPD, elderly, diabetics \tn 
% Row Count 34 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Arrhythmias (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
{\bf{Potassium channel blockers\{\{nl\}\} (class III)}} & Delays repolarization and lengthens refractory period\{\{nl\}\} Mostly used for ventricular arrhythmias (repolarization is one of the last steps – in ventricles) \{\{nl\}\}Many have multiple actions at other receptors \{\{nl\}\} ex. {\emph{Sotalol}} – β-blocker and potassium-blocker \tn 
% Row Count 14 (+ 14)
% Row 3
\SetRowColor{white}
{\emph{Amiodarone}} & Amiodarone is a potassium channel blocker and a sodium channel blocker, among other mechanisms of action \{\{nl\}\} Widely distributed and stored in tissues, so toxicity can be difficult to get rid of \{\{nl\}\} Primarily used to treat resistant ventricular tachycardia and atrial dysrhythmias\{\{nl\}\} LOW THERAPEUTIC range \tn 
% Row Count 30 (+ 16)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Arrhythmias (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
{\bf{ Calcium channel blockers \{\{nl\}\}(class IV)  }} & Reduce automaticity, slows conduction through AV node, slows heart rate\{\{nl\}\}  Remember: {\emph{diltiazem and verapamil}} were more selective for heart  AND it is Ca++ \textgreater{} Na+ that influences cardiac muscle contraction \tn 
% Row Count 11 (+ 11)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Miscellaneous}}} \tn 
% Row Count 12 (+ 1)
% Row 6
\SetRowColor{LightBackground}
{\emph{Digoxin}} & Decreases automaticity of SA node and slows conduction through AV node – but not by blocking any ion channels \{\{nl\}\} Requires therapeutic drug monitoring\{\{nl\}\} Remember to teach signs of toxicity\{\{nl\}\} Remember importance of potassium \tn 
% Row Count 24 (+ 12)
% Row 7
\SetRowColor{white}
{\emph{Adenosine}} & An endogenous nucleoside that reduces automaticity of SA node and slows conduction through AV node\{\{nl\}\} Sometimes used in diagnosing patients who cannot complete a stress test\{\{nl\}\} 10 second half-life (bolus IV injection) \tn 
% Row Count 36 (+ 12)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{If it can correct a arrhythmia, it can also cause a arrhythmia \newline By manipulating the action potential OR the nervous system, we are also manipulating factors / variables that affect blood pressure (cardiac output and peripheral resistance) \newline Therefore, monitoring would include for ALL:  \newline ECG \newline Blood pressure \newline Heart rate}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.08 cm} x{5.92 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{About anemia}}  \tn
% Row 0
\SetRowColor{LightBackground}
Anemia & occurs when red blood cells (erythrocytes) or hemoglobin have a diminished capacity to carry oxygen Due to: blood loss, excessive destruction, or diminished synthesis \tn 
% Row Count 6 (+ 6)
% Row 1
\SetRowColor{white}
\seqsplit{Erythropoiesis} & the process of making erythrocytes in bone marrow\{\{nl\}\} If we are lacking a substance for erythropoiesis, we won't have as many RBCs \tn 
% Row Count 11 (+ 5)
% Row 2
\SetRowColor{LightBackground}
\seqsplit{Erythropoietin} & – the hormone released by the kidneys that instructs the bone marrow to make RBCs \tn 
% Row Count 14 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Anemias are classified according to appearance of erythrocyte, which tells pathologists which ingredient is missing \newline General signs and symptoms of anemia  \newline General fatigue \newline Weakness \newline Pale skin \newline Shortness of breath (dyspnea) \newline Dizziness \newline Strange cravings to eat items that aren't food, such as dirt, ice, or clay \newline Tingling or crawling feeling in the legs \newline Tongue swelling or soreness}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.6 cm} x{4.4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Anemia}}  \tn
% Row 0
\SetRowColor{LightBackground}
Vitamin B12\{\{nl\}\}{\emph{Cyanacobalamin}} & Required for erythropoiesis\{\{nl\}\} Does not absorb very well from GI tract – must have intrinsic factor present to absorb (genetic differences)  Often given by IM injection (monthly maintenance)\{\{nl\}\} B12 deficiency presents as memory loss, confusion, unsteadiness, tingling in limbs, delusions, mood disturbances (more CNS effects) \tn 
% Row Count 16 (+ 16)
% Row 1
\SetRowColor{white}
Folic Acid \{\{nl\}\}{\emph{Folate}} & Required for erythropoiesis\{\{nl\}\} Does not require intrinsic factor to absorb from GI (more readily absorbed)\{\{nl\}\} Deficiency results in anemia, but no neurological symptoms\{\{nl\}\} Require folic acid during neural tube formation in pregnancy – suggest supplements in any woman of child-bearing age\{\{nl\}\} Green, leafy vegetables – or supplements (1-5mg) Corrected in 2 weeks  1 month \tn 
% Row Count 34 (+ 18)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.6 cm} x{4.4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Anemia (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
Iron & Involved in the oxygen carrying capacity of the erythrocytes\{\{nl\}\} Different formulations (or salts) have different absorptions and bioavailability \{\{nl\}\} Ferrous sulfate (red), ferrous gluconate (green), ferrous fumarate\{\{nl\}\}Iron interferes with absorption of many other drugs (antibiotics, thyroid meds)\{\{nl\}\} It is an ion that binds to some medications, forming a complex too large to absorb\{\{nl\}\} It is better absorbed (↑ to 10\%) in presence of vitamin C \{\{nl\}\} Antacids decrease absorption of iron (by changing the pH of the gastric contents) and need to be separated by \textasciitilde{} 2 hours\{\{nl\}\} General recommendation: separate iron supplements from other meds by 2 hours if possible \tn 
% Row Count 32 (+ 32)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.6 cm} x{4.4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Anemia (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
Growth Factors & When anemia is a result of a lack of growth factor, we can replace the growth factor with biologics\{\{nl\}\} Erythropoietin alfa or darbepoietin alfa = to replace erythropoietin (EPO)\{\{nl\}\} Hormone secreted by kidneys – low in kidney failure and cancers\{\{nl\}\} EPO = "blood doping"  oxygen carrying capacity is increased, boosting endurance \tn 
% Row Count 16 (+ 16)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Monitoring for Anemia: \newline B12, folate levels \newline CBC (RBC, hemoglobin, hematocrit) \newline Iron, ferritin  \newline Potassium  \newline Neuro status (confusion, etc.) \newline Arrhythmias  \newline Resolving of symptoms (fatigue, pale colour) \newline GI adverse effects with iron}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for lipids}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Statins }}\{\{nl\}\}{\emph{Atorvastatin (Lipitor®)}} & Inhibit HMG-CoA-reductase, which is involved in the synthesis of cholesterol in the liver\{\{nl\}\} Reduces the amount of cholesterol made by our body\{\{nl\}\} Also increases the amount of LDL removed from the blood\{\{nl\}\} First drug of choice; therapy continues for life\{\{nl\}\} Very well tolerated\{\{nl\}\} DO NOT USE IN PREGNANCY\{\{nl\}\} Choice of statin is dependent on lipid profile Some are good at lowering LDL, some better at raising HDL, etc. \tn 
% Row Count 22 (+ 22)
% Row 1
\SetRowColor{white}
{\bf{Fibrates }} \{\{nl\}\}{\emph{Fenofibrate}} & "Lipid metabolism regulator" – changes production levels of lipoproteins, but different pathway than statins\{\{nl\}\} Lower triglyceride levels and raise HDL levels\{\{nl\}\} Some also lower LDL\{\{nl\}\} More gastrointestinal adverse effects than statins\{\{nl\}\} May be used with a statin in some cases \tn 
% Row Count 37 (+ 15)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for lipids (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
{\bf{ Niacin   }}\{\{nl\}\}{\emph{Nicotinic acid / nicotinamide / niacinamide / vitamin B3}} & Available without a prescription (OTC)\{\{nl\}\} Exact mechanism is unknown, but reduces synthesis of LDL, VLDL, and increases HDL\{\{nl\}\} Also causes peripheral vasodilation  flushing\{\{nl\}\} More gastrointestinal effects than statins \tn 
% Row Count 12 (+ 12)
% Row 3
\SetRowColor{white}
{\bf{Bile Acid Resins }} & Bind to bile acid made by the liver to enhance excretion of cholesterol\{\{nl\}\} Bile acid then does not absorb through intestinal wall (forms a complex, too big to pass through plasma membrane), so once bile acid is bound, it is excreted with feces\{\{nl\}\} The liver responds by getting rid of even more cholesterol\{\{nl\}\}  Drug of choice in pregnancy (no absorption occurs!) \tn 
% Row Count 31 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for lipids (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{ Miscellaneous  }}} \tn 
% Row Count 1 (+ 1)
% Row 5
\SetRowColor{white}
{\emph{Ezetimibe}} & inhibits intestinal cholesterol absorption – used along with a statin \tn 
% Row Count 5 (+ 4)
% Row 6
\SetRowColor{LightBackground}
{\emph{Orlistat }} & doesn't allow fats to be absorbed from intestine  – {\emph{anal discharge}} (anti-obesity drug) \tn 
% Row Count 10 (+ 5)
% Row 7
\SetRowColor{white}
{\emph{Omega-3}} & insufficient evidence for cholesterol, but likely no harm \tn 
% Row Count 13 (+ 3)
% Row 8
\SetRowColor{LightBackground}
{\emph{Psyllium (Metamucil®)}} & similar mechanism to bile acid resin \tn 
% Row Count 15 (+ 2)
% Row 9
\SetRowColor{white}
{\bf{PCSK9 Inhibitors}} \{\{nl\}\}{\emph{Alirocumab, evolocumab}} & Class of biologics for very high-risk patients (of a cardiovascular event) who have not reached targets with statins\{\{nl\}\} Monoclonal antibodies for PCSK9, which promotes LDL degradation – reduce LDL substantially\{\{nl\}\} Administered SC every 2 weeks (q2w), monitor within 4-8 weeks \tn 
% Row Count 30 (+ 15)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication}}  \tn
% Row 0
\SetRowColor{LightBackground}
Thiazide Diuretics\{\{nl\}\}{\emph{Hydrochlorothiazide (HCTZ)}} & Electrolyte imbalances (especially loss of potassium - hypokalemia) – monitor all electrolytes\{\{nl\}\} Hyperglycemia – monitor blood glucose\{\{nl\}\} Dizziness – monitor upon standing\{\{nl\}\} Hypotension – monitor blood pressure/vitals\{\{nl\}\} Some drug interactions – most mild and require ↑ monitoring; sulfa drug \{\{nl\}\}  Important to warn patient about ↑ peeing! AM dosing! \tn 
% Row Count 20 (+ 20)
% Row 1
\SetRowColor{white}
Calcium Channel Blockers\{\{nl\}\}{\emph{Nifedipine}} & Dizziness, hypotension, headache, flushing, reflex tachycardia*, constipation, peripheral edema \tn 
% Row Count 25 (+ 5)
% Row 2
\SetRowColor{LightBackground}
ACE Inhibitors & electrolyte imbalances (esp. potassium) \{\{nl\}\} first-dose syncope\{\{nl\}\} orthostatic hypotension\{\{nl\}\} unexplained persistent dry cough Theory: due to high levels of bradykinin usually broken down by ACE\{\{nl\}\} angioedema (rare) \tn 
% Row Count 37 (+ 12)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
Angiotensin II Receptor Blockers \{\{nl\}\}(ARBs) & Same adverse effects as ACE-I \tn 
% Row Count 3 (+ 3)
% Row 4
\SetRowColor{white}
α1-Blockers\{\{nl\}\}{\emph{Doxazosin}} & orthostatic hypotension (first-dose syncope), dizziness, headache \tn 
% Row Count 7 (+ 4)
% Row 5
\SetRowColor{LightBackground}
α2-Agonists & more CNS adverse effects than α1-blockers:\{\{nl\}\} Sedation, depression, fatigue, + orthostatic hypotension, dizziness, headache, etc \tn 
% Row Count 14 (+ 7)
% Row 6
\SetRowColor{white}
Direct Vasodilators\{\{nl\}\}{\emph{Hydralazine, minoxidil, nitroprusside}} & Multiple dangerous side effects limit use to emergencies and acute care:\{\{nl\}\} Reflex tachycardia, lupus-like syndrome (hydralazine), pericardial effusions (minoxidil), sodium and fluid retention\{\{nl\}\}* arthralgia, arthritis, fever, myalgia, pleural effusions; resolves upon discontinuation \tn 
% Row Count 29 (+ 15)
% Row 7
\SetRowColor{LightBackground}
β-Blockers & IF a β–blocker is stopped abruptly = REBOUND TACHYCARDIA  + Tachycardia, headache, tremor, chest pain, arrhythmia or  myocardial infarction\{\{nl\}\}  IF a β–blocker needs to be discontinued, it should be tapered slowly over 1-2 weeks\{\{nl\}\}Hypotension, Bradycardia, Hyper/hypoglycemia (depends on individual agent), Hyperlipidemia, Nausea, Shortness of breath, fatigue, diminished libido, Dizziness\{\{nl\}\}Depending on the selectivity of the individual agent, β-blockers can cause both hypoglycemia AND hyperglycemia\{\{nl\}\} In addition, they can also MASK symptoms of hypoglycemia (things like tachycardia, tremor, and anxiety)(see Module 6) The only symptom that remains unopposed is SWEATING \tn 
% Row Count 64 (+ 35)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 8
\SetRowColor{LightBackground}
Cardiac Glycosides \{\{nl\}\}{\emph{Digoxin}} & dysrhythmias, nausea, vomiting, anorexia, visual disturbances Narrow therapeutic range = toxicity \tn 
% Row Count 5 (+ 5)
% Row 9
\SetRowColor{white}
Digoxin Toxicity & Acute Toxicity: anorexia, nausea, vomiting, lethargy, confusion, weakness, hyperkalemia, dysrhythmias \{\{nl\}\}  Chronic Toxicity: abdominal pain, anorexia, dysrhythmias, confusion, delirium, disorientation, headache, hypokalemia, hypomagnesemia, nausea, vomiting, ocular disturbances \tn 
% Row Count 20 (+ 15)
% Row 10
\SetRowColor{LightBackground}
Loop Diuretics\{\{nl\}\}{\emph{Furosemide}} & hypokalemia, dysrhythmias (related to K+), dehydration, hypotension \tn 
% Row Count 24 (+ 4)
% Row 11
\SetRowColor{white}
Sodium Channel Blockers\{\{nl\}\}{\emph{Procainamide}} & nausea, anorexia, diarrhea, vomiting, abdominal pain, headache, dysrhythmias, hypotension\{\{nl\}\} High doses may result in confusion or psychosis\{\{nl\}\} Lupus effect – agranulocytosis, bone marrow depression, anemias – 30-50\%  of patients using \textgreater{} 1 year \tn 
% Row Count 37 (+ 13)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 12
\SetRowColor{LightBackground}
Potassium Channel Blockers\{\{nl\}\}{\emph{Amiodarone}} & pneumonia-like syndrome, blurred vision, photosensitivity, nausea, vomiting, anorexia, fatigue, dizziness, and hypotension \{\{nl\}\}Corneal microdeposits = blurred vision = permanent blindness \{\{nl\}\} Neurological abnormalities in 20-40\% patients  (Delirium, confusion, tremors, sleep disturbances)\{\{nl\}\} Pulmonary abnormalities in 10-15\%\{\{nl\}\} GI – 25\%\{\{nl\}\} Further dysrhythmias\{\{nl\}\} Elevated liver enzymes = Cirrhosis\{\{nl\}\} Blue/grey skin abnormality; photosensitivity; alopecia (hair loss)\{\{nl\}\} Hypo- or hyperthyroidism \tn 
% Row Count 27 (+ 27)
% Row 13
\SetRowColor{white}
Calcium Channel Blockers \{\{nl\}\}(CCBs) \{\{nl\}\}{\emph{Verapamil or diltiazem}} (cardioselective) & headache, constipation, hypotension, peripheral edema, dizziness  \{\{nl\}\}Less peripheral effects than nifedipine (vessels \textgreater{} heart)\{\{nl\}\} Avoid grapefruit juice (possible toxicity due to CYP3A4 inhibition) \tn 
% Row Count 38 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 14
\SetRowColor{LightBackground}
Warfarin & Hemorrhage – of any type Upper and lower GI tract (gums -{}-\textgreater{} rectum) Respiratory Genitourinary tract Skin\{\{nl\}\} All other adverse effects are rare \tn 
% Row Count 8 (+ 8)
% Row 15
\SetRowColor{white}
Antiplatelets\{\{nl\}\}{\emph{ASA (acetylsalicylic acid)}} & Can cause GI upset because they also inhibit prostaglandin synthesis in the stomach, which ↓ mucosal lining\{\{nl\}\}nausea, dyspepsia, increased risk of bleeding \{\{nl\}\} 81mg = "Baby Aspirin"- often recommended to prevent cardiac event in high risk patients\{\{nl\}\} We do not give Aspirin to babies \tn 
% Row Count 23 (+ 15)
% Row 16
\SetRowColor{LightBackground}
Thrombolytics & high bleeding risk, watch for cognitive change which could be a sign of cerebral hemorrhage \tn 
% Row Count 28 (+ 5)
% Row 17
\SetRowColor{white}
Anti-fibrinolytics & Most common adverse effect = infusion site reactions\{\{nl\}\}They also slow down blood flow = bradycardia, hypotension \tn 
% Row Count 34 (+ 6)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 18
\SetRowColor{LightBackground}
Vitamin B12 & Rare adverse effect: low potassium \tn 
% Row Count 2 (+ 2)
% Row 19
\SetRowColor{white}
Iron & All oral supplements can cause nausea, dyspepsia, GI bleeding, constipation, black stool (Take with food) \tn 
% Row Count 8 (+ 6)
% Row 20
\SetRowColor{LightBackground}
Statins\{\{nl\}\}{\emph{Atorvastatin (Lipitor®)}} & intestinal cramping, diarrhea, constipation and rarely liver damage, rhabdomyolysis\{\{nl\}\} All adverse effects (even nausea and vomiting) are rare \tn 
% Row Count 16 (+ 8)
% Row 21
\SetRowColor{white}
Fibrates\{\{nl\}\}{\emph{Fenofibrate}} & heartburn, abdominal pain, diarrhea, nausea, flatulence, skin reactions (itchiness, redness, rash), rhabdomyolysis, liver damage\{\{nl\}\} Not as well tolerated as statins \tn 
% Row Count 25 (+ 9)
% Row 22
\SetRowColor{LightBackground}
Niacin & : flushing, nausea, abdominal pain, hyperglycemia, gout, flatulence, rhabdomyolysis \tn 
% Row Count 30 (+ 5)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Cardiovascular medication (cont)}}  \tn
% Row 23
\SetRowColor{LightBackground}
Bile Acid Resins\{\{nl\}\}{\emph{Cholestyramine}} & Adverse effects limited to gastrointestinal reactions:\{\{nl\}\} constipation (ensure sufficient water intake), bloating, gas, nausea, steatorrhea\{\{nl\}\}  Drug interactions: May potentially alter absorption of any drug, vitamin, or mineral Separate by 2 hours (you will see variations of this) \tn 
% Row Count 15 (+ 15)
% Row 24
\SetRowColor{white}
PCSK9 Inhibitors\{\{nl\}\}{\emph{Alirocumab, evolocumab}} & local injection site reactions, upper respiratory tract infections, itch \tn 
% Row Count 19 (+ 4)
% Row 25
\SetRowColor{LightBackground}
{\emph{Nitroglycerin}} & headache, reflex tachycardia, flushing, hypotension \{\{nl\}\}ANYTHING THAT CAUSES VASODILATION WILL CAUSE REFLEX TACHYCARDIA \tn 
% Row Count 26 (+ 7)
% Row 26
\SetRowColor{white}
β-Blockers & hypotension, bradycardia, hypoglycemia, hyperglycemia, etc. \tn 
% Row Count 29 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.8 cm} x{5.2 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{The 3 Variables of Blood Pressure}}  \tn
% Row 0
\SetRowColor{LightBackground}
Blood Volume & Blood volume is regulated by the kidneys. \{\{nl\}\}Blood volume measurement may be used in people with congestive heart failure, chronic hypertension, kidney failure and critical care. \tn 
% Row Count 7 (+ 7)
% Row 1
\SetRowColor{white}
Peripheral resistances & the resistance of the arteries to blood flow. \{\{nl\}\}As the arteries constrict, the resistance increases and as they dilate, resistance decreases.\{\{nl\}\} Peripheral resistance is determined by three factors: \{\{nl\}\}1.Autonomic activity: sympathetic activity constricts peripheral arteries.\{\{nl\}\}2.Pharmacologic agents: vasoconstrictor drugs increase resistance while vasodilator drugs decrease it. \{\{nl\}\}3.Blood viscosity: increased viscosity increases resistance. \tn 
% Row Count 25 (+ 18)
% Row 2
\SetRowColor{LightBackground}
Cardiac output & the amount of blood pumped by each ventricle per minute. \{\{nl\}\}To calculate this value, multiply stroke volume (SV), the amount of blood pumped by each ventricle, by the heart rate (HR) in beats per minute. \{\{nl\}\}Use following equation: CO = HR × SV. \tn 
% Row Count 35 (+ 10)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{These are the different things that we can manipulate (with drugs), in order to affect blood pressure}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.44 cm} x{4.56 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Hormones and Neurotransmitter involved in BP}}  \tn
% Row 0
\SetRowColor{LightBackground}
Antidiuretic hormone (ADH) & released by hypothalamus and pituitary that:\{\{nl\}\} Keeps fluid in the body Constricts blood vessels \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
Epinephrine and norepinephrine & both constrict blood vessels via adrenergic receptors \tn 
% Row Count 8 (+ 3)
% Row 2
\SetRowColor{LightBackground}
Aldosterone & released by adrenal glands that tells kidney to keep sodium (and therefore water) in the body \tn 
% Row Count 13 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Remember Wherever sodium goes, water follows}}}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.28 cm} x{4.72 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Homeostasis}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Detected by:} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\seqsplit{1.chemoreceptors} \{\{nobreak\}\} & measure CHEMICALS levels like pH, levels of oxygen, carbon dioxide \tn 
% Row Count 4 (+ 3)
% Row 2
\SetRowColor{LightBackground}
2. baroreceptors \{\{nobreak\}\} & measure PRESSURE levels \tn 
% Row Count 6 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Controlled by:} \tn 
% Row Count 7 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{1.Autonomic nervous system} \tn 
% Row Count 8 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{\seqsplit{2.Renin-angiotensin-aldosterone} system (RAAS)} \tn 
% Row Count 9 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.04 cm} x{4.96 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Kidneys and Diuretics}}  \tn
% Row 0
\SetRowColor{LightBackground}
Filtration & when urine is first created, substances are filtered from blood -{}-\textgreater{} urine \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
Reabsorption \{\{nobreak\}\} & substances move back from urine -{}-\textgreater{}blood through tubules \tn 
% Row Count 7 (+ 3)
% Row 2
\SetRowColor{LightBackground}
Secretion & – substances move from blood -{}-\textgreater{} urine through tubules \tn 
% Row Count 10 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Urine = Filtration- Reabsorption +Secretions}}} \tn 
% Row Count 11 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{What is heart Failure ?}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/kjaniskevich_1614587464_Blood flow review.PNG}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{The inability of the heart to pump enough blood to meet the body's metabolic demands \newline A weakened heart \newline Pre-load ǂ Afterload \newline  \newline Classic Presentation = FED \newline Fatigue, Edema, Dyspnea \newline  \newline If Heart Failure is in the left, it will back up into the lungs (congestion and pulmonary edema) \newline If Heart Failure is in the right, it will back up into periphery (peripheral edema, leg edema)}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Heart Failure}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{ACE inhibitors (ACE-I) }} & Reduce afterload = improve cardiac output\{\{nl\}\} Dilate vessels = decreasing preload\{\{nl\}\} Interrupts the RAAS, which enhances excretion of sodium and water\{\{nl\}\} Lowers peripheral resistance and reduces blood volume\{\{nl\}\} Drug of choice for heart failure because it interrupts both compensatory mechanisms \tn 
% Row Count 16 (+ 16)
% Row 1
\SetRowColor{white}
{\bf{Angiotensin II receptor blockers (ARBs)}} & Reduce afterload = improve cardiac output\{\{nl\}\} Indirectly dilate vessels = decreasing preload\{\{nl\}\} Block angiotensin II from causing vasoconstriction and block adrenal glands from releasing aldosterone\{\{nl\}\} Same pathway as ACE-I, different place in the pathway \{\{nl\}\} Like ACE-Is, interrupt both compensatory mechanisms\{\{nl\}\} used in clients who have not responded to ACE-I \tn 
% Row Count 35 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Heart Failure (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
{\bf{ β-blockers}} & Slow heart rate and reduce blood pressure = reduce cardiac workload and provides rest \{\{nl\}\} Negative inotropic effect Decreased heart contractility\{\{nl\}\} Blocks the over-stimulation of sympathetic nervous system (fight-or-flight) that occurs in patients with heart failure \{\{nl\}\} Must be introduced slowly and NEVER abruptly stopped\{\{nl\}\}Generally, we avoid β–blockers in patients with Diabetes (Type 1 \& 2) and patients who are at a high risk of hypoglycemia (ex. elderly) \tn 
% Row Count 24 (+ 24)
% Row 3
\SetRowColor{white}
{\bf{Cardiac glycosides}} \{\{nl\}\}{\emph{Digoxin}} & Slows heart rate by acting on SA and AV nodes  = improves cardiac output\{\{nl\}\} Requires steady levels of potassium for action\{\{nl\}\} Positive inotropic effect Increases heart contractility\{\{nl\}\} Second-line treatment for heart failure (primary treatment for arrhythmias)\{\{nl\}\} NARROW THERAPEUTIC RANGE DRUG Requires drug monitoring to ensure proper loading dose, digitalization, and doses to maintain steady state\{\{nl\}\} Mechanism of action: increases the contractility of myocardial contraction (+ inotropic) – requires steady levels of potassium for action \{\{nl\}\} Used for dysrhythmias and heart failure IF other drugs fail \tn 
% Row Count 56 (+ 32)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for Heart Failure (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
{\bf{ Diuretics }} & Work in different places in the nephron of kidney\{\{nl\}\} Reduce blood volume and cardiac workload\{\{nl\}\} ALSO reduce edema and pulmonary congestion Mostly for symptom relief of excess fluid \{\{nl\}\} Used in addition to other heart failure drugs\{\{nl\}\} As heart failure progresses, we see the stronger loop diuretics (furosemide) used more often, at higher doses\{\{nl\}\} Mechanism of action: prevents reabsorption of sodium and chloride, primarily in the Loop of Henle to increase urine flow, reduce blood volume and cardiac workload\{\{nl\}\} For symptomatic relief of excess fluid \tn 
% Row Count 29 (+ 29)
% Row 5
\SetRowColor{white}
{\bf{Vasodilators}} & Relax blood vessels = lowers blood pressure = reduces afterload and preload\{\{nl\}\} Minor role in heart-failure treatment\{\{nl\}\} {\emph{Hydralazine:}} arteries \textgreater{} veins (afterload)\{\{nl\}\} {\emph{Isosorbide:}} veins \textgreater{} arteries (preload) For heart failure, sometimes are used together for highest effect \tn 
% Row Count 44 (+ 15)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.12 cm} x{4.88 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Bleeding disorders}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Can be due to disease of bone marrow (where we make blood cells), or genetics} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
Hemophilia's & there are lots of types, depending on which factor they lack \tn 
% Row Count 5 (+ 3)
% Row 2
\SetRowColor{LightBackground}
Von Willebrand's Disease & lack von Willebrand factor \tn 
% Row Count 7 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{We focus treatment on trying to get the blood to clot, or stopping bleeding} \tn 
% Row Count 9 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{VIP clotting factors}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Factors involved in forming a blood clot:}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Platelets} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
Prothrombin & -{}-\textgreater{} (prothrombin activator) -{}-\textgreater{} thrombin-{}-\textgreater{} fibrinogen -{}-\textgreater{} fibrin strands \tn 
% Row Count 6 (+ 4)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Vitamin K} \tn 
% Row Count 7 (+ 1)
% Row 4
\SetRowColor{LightBackground}
{\bf{Factors involved in dissolving a blood clot (fibrinolysis):}} & Plasminogen -{}-\textgreater{} (tissue plasminogen activator) -{}-\textgreater{} plasmin \tn 
% Row Count 11 (+ 4)
% Row 5
\SetRowColor{white}
Thrombus & =a stationary clot \tn 
% Row Count 12 (+ 1)
% Row 6
\SetRowColor{LightBackground}
Embolus & =a travelling clot \tn 
% Row Count 13 (+ 1)
% Row 7
\SetRowColor{white}
Deep Vein Thrombosis \{\{nl\}\}(DVT) & = clot in veins of leg (calf) \tn 
% Row Count 15 (+ 2)
% Row 8
\SetRowColor{LightBackground}
Pulmonary Embolism \{\{nl\}\}(PE) & = clot that has travelled to the lung \tn 
% Row Count 17 (+ 2)
% Row 9
\SetRowColor{white}
Cerebrovascular Accident \{\{nl\}\}(CVA) (Stroke) & = clot that has travelled to the brain{\emph{ }} a stroke can also be caused by a bleed in the brain \tn 
% Row Count 22 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Clinical presentation of Clot  \newline Swift neurological status change \newline Swollen, red, sore calf (DVT) \newline Signs of myocardial infarction (chest pain) \newline Signs of stroke (one-sided weakness or numbness, sudden confusion, trouble speaking, difficulty understanding speech, vision loss, loss of balance and coordination) \newline Dyspnea, chest pain, coughing up blood (pulmonary embolism) \newline Colour changes in skin}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for bleeding disorders}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Anticoagulants}} \{\{nobreak\}\} & Prevent a clot from forming, either by inhibiting a specific clotting factor or by inhibiting platelet action\{\{nl\}\}NOT = BLOOD THINNERS \tn 
% Row Count 7 (+ 7)
% Row 1
\SetRowColor{white}
a.Unfractionated heparin & Does not dissolve a clot, but prevents them from getting bigger and new ones from forming\{\{nl\}\} Binds to multiple clotting factors \{\{nl\}\} SC or IV only - no oral or IM \{\{nl\}\} Do not massage injection site (bleeding \& bruising)\{\{nl\}\} Short half-life (1.5h) – used in situations where we need it to work quickly, or have the ability to stop it quickly (like pre-surgery)\{\{nl\}\} Antidote = protamine – works within 5 minutes\{\{nl\}\} Dose is dependent on condition \tn 
% Row Count 31 (+ 24)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for bleeding disorders (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
b.Low molecular weight heparins \{\{nl\}\} (LMWH)\{\{nl\}\}{\emph{Tinzaparin, enoxaparin, dalteparin\{\{nl\}\} -parin}} & Longer duration of action and more predictable response, so often a choice for discharge (can teach patient to do SC injection)\{\{nl\}\} Doses are decided according to patient weight and what we're treating (post-surgery, treat DVT, prevent clot for dialysis) – so, DOUBLE OR TRIPLE CHECK CORRECT DOSAGE\{\{nl\}\} SC injection or directly in hemodialysis catheter; no IM\{\{nl\}\} Still use protamine as antidote, but not as effective \tn 
% Row Count 22 (+ 22)
% Row 3
\SetRowColor{white}
c.Warfarin & Inhibits the synthesis of multiple clotting factors\{\{nl\}\} Oral therapy for people with a long-term need for anticoagulation (atrial fibrillation, valve replacement, treatment of DVT or PE)\{\{nl\}\} Warfarin takes \textasciitilde{} 3 days to reach a therapeutic level, so when transitioning from heparin/LMWH to warfarin, there must be an overlap of therapies \{\{nl\}\} Even higher risk of bleeding during overlap\{\{nl\}\} Antidote = vitamin K – works in a few hours \{\{nl\}\}This is why we caution foods high in vitamin K, because we want stability of anticoagulation \{\{nl\}\}Important to take at same time each day (most institutions will give all warfarin at the same time – like supper)\{\{nl\}\} MUST GIVE CORRECT DOSE\{\{nl\}\} Patient must be consistent with checking for drug interactions and signs of bleeding \tn 
% Row Count 62 (+ 40)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for bleeding disorders (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
d.New Oral anticoagulants \{\{nl\}\}(NOACs) & Inhibit more specific clotting factors {\emph{Rivaroxaban (Xarelto®), apixaban (Eliquis®) }}= inhibit Factor Xa\{\{nl\}\} {\emph{Dabigatran (Pradaxa®)}} = thrombin inhibitor\{\{nl\}\}  Pros: No INRs, predictable response, one dose  less chance of error\{\{nl\}\} Cons: No antidote, need dosage adjustment in kidney failure, \$\$, more dyspepsia than warfarin, more difficult to individualize therapy with restricted doses\{\{nl\}\} All still cause bleeding, many drug interactions \tn 
% Row Count 23 (+ 23)
% Row 5
\SetRowColor{white}
Antiplatelets \{\{nl\}\}{\emph{ASA, dipyridamole, clopidogrel, ticlopidine}} & Can be given along with anticoagulants, because affect different places in clotting cascade \{\{nl\}\} +++ bleeding risk if combined\{\{nl\}\} Can cause GI upset because they also inhibit prostaglandin synthesis in the stomach, which ↓ mucosal lining \tn 
% Row Count 36 (+ 13)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for bleeding disorders (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
{\emph{ASA}} & Irreversibly binds to cyclo-oxygenase in platelets, which prevents it from aggregating \{\{nl\}\} Effects of one dose lasts 7-10 days (irreversible binding) \tn 
% Row Count 8 (+ 8)
% Row 7
\SetRowColor{white}
Thrombolytics & TPA = tissue plasminogen activator OR other drugs that do same thing (alteplase)\{\{nl\}\} Convert plasminogen -{}-\textgreater{} plasmin, which breaks down many clotting factors  \{\{nl\}\}  Destroy a clot that's already formed -{}-\textgreater{} used in emergency situations (like stroke, MI, DVT, PE)\{\{nl\}\}If the patient is actively bleeding DO NOT GIVE\{\{nl\}\} Dosed according to weight\{\{nl\}\} Only administered by RN with special training and in facility with appropriate equipment to monitor for hemorrhage \tn 
% Row Count 32 (+ 24)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of medication for bleeding disorders (cont)}}  \tn
% Row 8
\SetRowColor{LightBackground}
Antifibrinolytics & Promote clotting, to prevent bleeding during surgery or emergency\{\{nl\}\} They also slow down blood flow -{}-\textgreater{} bradycardia, hypotension\{\{nl\}\} Tranexamic acid most common (can give orally)\{\{nl\}\} All are rarely prescribed compared to anticoagulants\{\{nl\}\}Many biologics developed for genetic conditions that lack a clotting factor (products very specific to type of hemophilia)\{\{nl\}\} Used to both prevent and treat bleeding – treatment would continue for life (most intervals every 3-4 days, longer intervals with newer products) but dosages change\{\{nl\}\} Most developed using recombinant DNA to replace missing factor \tn 
% Row Count 31 (+ 31)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{About coronary artery disease}}  \tn
% Row 0
\SetRowColor{LightBackground}
Atherosclerosis & = narrowing or occlusion of an artery due to plaque \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
Plaque & = a fatty, fibrous material that accumulates gradually due to high cholesterol – attracts WBCs, platelets, remnants of dead cells, fibrin that narrows and then eventually occludes the artery\{\{nl\}\} Also makes the vasculature less elastic, which means it can't respond to dilation \tn 
% Row Count 17 (+ 14)
% Row 2
\SetRowColor{LightBackground}
Coronary Artery Disease\{\{nl\}\} (CAD) & = narrowing or occlusion of the coronary arteries \tn 
% Row Count 20 (+ 3)
% Row 3
\SetRowColor{white}
Angina Pectoris & = chest pain caused by insufficient oxygen to a portion of the myocardium \tn 
% Row Count 24 (+ 4)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Types of Angina}}} \tn 
% Row Count 25 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{1.Stable Angina – when symptoms are predictable as to frequency, intensity and duration} \tn 
% Row Count 27 (+ 2)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{2. Variant Angina – when the chest pain is caused by spasms of the smooth muscle of coronary arteries rather than atherosclerosis} \tn 
% Row Count 30 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{About coronary artery disease (cont)}}  \tn
% Row 7
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{3. Unstable Angina – when symptoms are more intense and occur during periods of rest; unpredictable} \tn 
% Row Count 3 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.84 cm} x{4.16 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Angina}}  \tn
% Row 0
\SetRowColor{LightBackground}
Nitrates \{\{nl\}\}{\emph{Nitroglycerin}} & Potent vasodilator\{\{nl\}\} Relaxes arterial and venous smooth muscle – opens up everything\{\{nl\}\} Decreases workload of the heart and myocardial oxygen demand -{}-\textgreater{} chest pain alleviated\{\{nl\}\} Short acting formulations: nitroglycerin sublingual spray or tablets – for emergencies\{\{nl\}\} Long acting formulations: isosorbide – for prevention of frequent angina episodes; nitroglycerin patch\{\{nl\}\}Can be given sublingual (SL), orally, IV, transdermally, topically; SL = relief in 4 minutes \tn 
% Row Count 25 (+ 25)
% Row 1
\SetRowColor{white}
β-Blockers & Reduces cardiac workload\{\{nl\}\} Slows heart rate and reduces contractility\{\{nl\}\} Used for prevention of chronic angina (if occurring often or unstable)\{\{nl\}\} Cardio-selective preferred \tn 
% Row Count 35 (+ 10)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.84 cm} x{4.16 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Angina (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
Calcium Channel Blockers \{\{nl\}\} (CCB) & Reduce cardiac workload and dilate coronary arteries, and reduce peripheral resistance (depends on selectivity)\{\{nl\}\} Bring more oxygen to myocardium\{\{nl\}\} Both types (cardio-selective and non) work\{\{nl\}\} First choice for prevention of variant angina because they help prevent the cardiac muscle spasm\{\{nl\}\} For those \seqsplit{intolerant/contraindicated} for β-blockers (elderly, diabetic, asthma/COPD) \tn 
% Row Count 20 (+ 20)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Respiratory diseases}}  \tn
% Row 0
\SetRowColor{LightBackground}
Asthma & Chronic inflammatory disease of the airway with 2 components\{\{nl\}\} Inflammation treat w/ anti-inflammatories \{\{nl\}\} Bronchoconstriction treat w/ bronchodilators\{\{nl\}\}  Often have triggers that cause exacerbations Environmental (pets, foods, pollens), NSAIDs, cold weather \tn 
% Row Count 14 (+ 14)
% Row 1
\SetRowColor{white}
Chronic Obstructive Pulmonary Disease \{\{nl\}\} COPD & Lung disease that includes chronic bronchitis and emphysema\{\{nl\}\} Chronic bronchitis: airways are swollen and filled with mucous\{\{nl\}\} Emphysema: air sacs are damaged, leaving less surface area for oxygen to enter blood stream\{\{nl\}\}  COPD patients have frequent lung infections and exacerbations – frequent hospitalizations \tn 
% Row Count 31 (+ 17)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Respiratory diseases (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
Common Cold & Viral infection of upper respiratory tract (URTI)\{\{nl\}\} Antibiotics not indicated or appropriate\{\{nl\}\}  Treat symptoms only – resolves by itself Cough Congestion Fever Body aches, mild headache \tn 
% Row Count 10 (+ 10)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Inhalers}}  \tn
% Row 0
\SetRowColor{LightBackground}
Advantages & Large surface area for absorption, Direct to site of action, resulting in fast onset, Reduces systemic side effects (does not eliminate) \tn 
% Row Count 7 (+ 7)
% Row 1
\SetRowColor{white}
Disadvantages & Precise doses dependent on patient condition/abilities, Correct use of devices critical, Some oral absorption due to inadvertent swallowing \tn 
% Row Count 14 (+ 7)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Types of Inhalation Devices}}} \tn 
% Row Count 15 (+ 1)
% Row 3
\SetRowColor{white}
1. Metered Dose Inhaler \{\{nl\}\} (MDI) & Deliver drugs via a propellant (drug is in a solution)\{\{nl\}\} Requires hand-eye co-ordination\{\{nl\}\} Spacers and aerochambers improve distribution \tn 
% Row Count 22 (+ 7)
% Row 4
\SetRowColor{LightBackground}
2. Dry Powder Inhalers \{\{nl\}\}(DPI) & Delivers medication in a powder form, using patient's own inhalation (no propellant)\{\{nl\}\} Requires ability to inhale quickly and deeply\{\{nl\}\} Leaves slight residue in mouth\{\{nl\}\} Cannot use spacers with these devices \tn 
% Row Count 33 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Inhalers (cont)}}  \tn
% Row 5
\SetRowColor{LightBackground}
3. Nebulizers & Vaporize a liquid into a fine mist\{\{nl\}\}  Requires a machine\{\{nl\}\} Takes a long time to deliver one dose (time-consuming)\{\{nl\}\} Inconvenience of being near machine for every dose \tn 
% Row Count 9 (+ 9)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Respiratory diseases}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Bronchodilators }} & Target the bronchoconstriction component\{\{nl\}\} Used in both asthma and COPD (or any time bronchodilation is needed)\{\{nl\}\} Literally open up the airway to let air in (make airways bigger) \tn 
% Row Count 10 (+ 10)
% Row 1
\SetRowColor{white}
1. β-Agonists & Open up the airway very quickly\{\{nl\}\} Relax bronchial smooth muscle – selective for β2 (stimulating sympathetic)\{\{nl\}\} We don't give orally because 1) would not act as fast, and 2) tachycardia\{\{nl\}\} Short acting are "rescue" agents – {\emph{salbutamol}}\{\{nl\}\} Long acting are used more as disease progresses for maintenance therapy – {\emph{salmeterol, formoterol, indacaterol, vilanterol}} \tn 
% Row Count 30 (+ 20)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Respiratory diseases (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
2. Anticholinergics & Bronchoconstriction that occurs in both asthma and COPD is largely caused by stimulation of muscarinic receptors – so blocking this pathway makes sense\{\{nl\}\} Don't work as fast as β-agonists \{\{nl\}\} Does NOT make any clinical difference in secretions Could either provide a benefit OR an adverse effect\{\{nl\}\} Acute and maintenance therapy – Newer agents better for long term \tn 
% Row Count 19 (+ 19)
% Row 3
\SetRowColor{white}
{\emph{Ipratropium (Atrovent®)}} & Used mostly in COPD\{\{nl\}\} Must be dosed quite often due to short duration of action (\textasciitilde{}q4h – approximately every 4 hours) \tn 
% Row Count 26 (+ 7)
% Row 4
\SetRowColor{LightBackground}
3. Methylxanthines \{\{nl\}\}{\emph{Theophylline, aminophylline, oxtriphylline}} & Induces Fight-or-flight response \{\{nl\}\}Stimulants, similar in structure to caffeine  stimulate the CNS  relax bronchial smooth muscle \{\{nl\}\} Narrow therapeutic range (requires monitoring), adverse effects (stimulant!), and numerous drug interactions limit its use to severe asthma that has not responded to other treatments\{\{nl\}\}  Oral or IV route \tn 
% Row Count 44 (+ 18)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Respiratory diseases (cont)}}  \tn
% Row 5
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{  Anti-inflammatories}}} \tn 
% Row Count 1 (+ 1)
% Row 6
\SetRowColor{white}
1. Corticosteroids & Anti-inflammatory and immuno-suppressive\{\{nl\}\} Used to prevent exacerbations and progression of disease\{\{nl\}\} Suppress airway inflammation and secretions\{\{nl\}\} Must be used daily to work; won't provide "rescue" if used as needed (PRN) by patient\{\{nl\}\} Dose is increased OR switched to oral during exacerbation\{\{nl\}\} Inhaled route minimizes numerous systemic steroid side effects \tn 
% Row Count 21 (+ 20)
% Row 7
\SetRowColor{LightBackground}
{\emph{Fluticasone (Flovent®)}} & Produces anti-inflammatory and immunosuppressive effects  reduces inflammation and secretion\{\{nl\}\} Used in both asthma and COPD \tn 
% Row Count 28 (+ 7)
% Row 8
\SetRowColor{white}
2. Leukotriene Receptor Antagonists & Reduce inflammation by blocking leukotrienes in inflammation cascade; also useful in allergies\{\{nl\}\} Preventative – not "rescue"\{\{nl\}\} Not as effective as corticosteroids\{\{nl\}\} Must be taken daily to work\{\{nl\}\} Oral \tn 
% Row Count 40 (+ 12)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Respiratory diseases (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Miscellaneous}}} \tn 
% Row Count 1 (+ 1)
% Row 10
\SetRowColor{white}
Omalizumab & a monoclonal antibody (biologic) that attaches to IgE to prevent inflammation from triggers \tn 
% Row Count 6 (+ 5)
% Row 11
\SetRowColor{LightBackground}
Roflumilast & oral phosphodiesterase-4 inhibitor (PDE4); taken daily to prevent inflammation associated with COPD \tn 
% Row Count 11 (+ 5)
% Row 12
\SetRowColor{white}
Acetylcysteine & a mucolytic: dissolves or breaks up mucous in lungs, making easier to get out (less viscous) \tn 
% Row Count 16 (+ 5)
% Row 13
\SetRowColor{LightBackground}
Pulmonary vasodilators & specific for receptors in lungs; use potent vasodilators such as nitric oxide; will still have systemic effects (hypotension -{}-\textgreater{} reflex tachycardia) \tn 
% Row Count 24 (+ 8)
% Row 14
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Cold symptom relief Medication}}} \tn 
% Row Count 25 (+ 1)
% Row 15
\SetRowColor{LightBackground}
Antitussives  \{\{nl\}\} {\emph{dextromethorphan (DM), codeine}} & suppress cough by stimulating opioid (sigma) receptors \tn 
% Row Count 28 (+ 3)
% Row 16
\SetRowColor{white}
Decongestants \{\{nl\}\}{\emph{pseudoephedrine, phenylephrine}} & stimulants that cause vasoconstriction and shrinks swollen mucous membranes \tn 
% Row Count 32 (+ 4)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Classes of Medication for Respiratory diseases (cont)}}  \tn
% Row 17
\SetRowColor{LightBackground}
Expectorants\{\{nl\}\}{\emph{guafenesin}} & increases mucous flow/movement so it can be expelled by coughing \tn 
% Row Count 4 (+ 4)
% Row 18
\SetRowColor{white}
Anti-histamines  \{\{nl\}\}{\emph{diphenhydramine, chlorpheniramine}} & antagonize histamine receptors (involved in allergic response); better for allergy symptoms than common cold; may help sneezing \tn 
% Row Count 11 (+ 7)
% Row 19
\SetRowColor{LightBackground}
{\emph{Acetaminophen}} & fever or aches/pains, included if product says "…\& Flu"; an extra ingredient in most combo products \tn 
% Row Count 17 (+ 6)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Respiratory Medication}}  \tn
% Row 0
\SetRowColor{LightBackground}
β-Agonists\{\{nl\}\}{\emph{Salbutamol (Ventolin®)}} & tachycardia, anxiety, arrhythmias, nervousness, restlessness, tremor, vertigo, headache, hypokalemia\{\{nl\}\} Typical dose: 1-2 puffs up to QID PRN\{\{nl\}\} Caution if arrhythmias or on β-blockers \tn 
% Row Count 10 (+ 10)
% Row 1
\SetRowColor{white}
Anticholinergics\{\{nl\}\}{\emph{Ipratropium (Atrovent®)}} & hoarseness, dry mouth, cough, bitter taste (rinse mouth after use)\{\{nl\}\} Caution in conditions contraindicated to anticholinergic use (elderly, incontinence, glaucoma, kidney disease) – may still be used due to little systemic absorption but will still monitor \tn 
% Row Count 24 (+ 14)
% Row 2
\SetRowColor{LightBackground}
Methylxanthines\{\{nl\}\} {\emph{Theophylline, aminophylline, oxtriphylline}} & Narrow therapeutic range (requires monitoring),\{\{nl\}\} adverse effects (stimulant!), \{\{nl\}\}and numerous drug interactions limit its use to severe asthma that has not responded to other treatments \tn 
% Row Count 34 (+ 10)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Adverse effects of Respiratory Medication (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
Corticosteroids\{\{nl\}\}{\emph{Fluticasone (Flovent®)}} & hoarseness, change in voice, thrush, watch for systemic steroid effects (hypertension, hyperglycemia, osteoporosis)\{\{nl\}\}  MUST RINSE MOUTH AFTER USE TO PREVENT THRUSH (ORAL CANDIDIASIS – FUNGAL INFECTION) DUE TO IMMUNO-SUPPRESSIVE QUALITIES \tn 
% Row Count 13 (+ 13)
% Row 4
\SetRowColor{white}
Leukotriene Receptor Antagonists & Few adverse effects/well tolerated: headache, cough, GI upset \tn 
% Row Count 17 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}