04 Smooth Muscles

Vasoactive

Nitrates

  • Dynamite: nitrates (e.g. nitroglycerine)

  • Nitric oxide exhaust: nitrates are metabolized and release nitric oxide

  • Grump: nitric oxide causes an increase in cGMP in vascular smooth muscle cells

  • Chains constricting pants/shirts: MLCK usually causes vasoconstriction

  • Cut P lock off chain: increased cGMP causes myosin light chain dephosphorylation, preventing its interaction with actin.

  • Dilated blue pants: nitrates cause venous dilation and increased venous capacitance

  • Modestly dilated red sleeves: nitrates cause some vasodilation of large arteries, but minimal dilation of arterioles

  • preload: Nitrates decrease preload

  • Folded tongue: sublingual administration of nitroglycerine avoids first pass metabolism (for acute symptom relief)

  • Anvil: antianginal therapy

  • Angina anvil:nitrates treat chronic stable angina

  • Discarded oxygen mask: nitrates reduce myocardial oxygen requirements

  • Anvil medal: nitrates treat Prinzmetal angina

  • Broken heart strings: nitrates are useful in acute coronary syndrome (ACS) (unstable angina, NSTEMI, STEMI)

  • Emergency shut-off: IV nitroglycerine can be used in hypertensive emergency

  • Wet lung spots: nitroglycerine is an acute treatment for pulmonary edema

  • Mouth cave: oral nitrate preparations have a longer duration of action

  • Single nitro stick in cave: isosorbide mononitrate (oral)

  • Double nitro stick in cave: isosorbide dinitrate (oral)

  • Big pile of dynamite: oral nitrate preparations require larger dosing

  • Fainting: nitrates can cause orthostatic hypotension (venous blood pool in extremities)

  • Heart reflex hammer: nitrate induced hypotension causes reflex tachycardia

  • muted beta bugle: beta blockers help prevent reflex sympathetic activation

  • Nitrates can cause throbbing headaches and flushing

  • Oxidized iron wheels: nitrates can cause methemoglobinemia

  • No tolerance for 24 hr work day: avoid tolerance with daily nitrate free intervals

  • "Monday disease" - with workplace nitrate exposure, tolerance disappears over weekend (decreased drug exposure at work) causing headache and dizziness recur on monday

  • No right turn: nitrates should be avoided in right sided MI (reduce right ventricular preload, use IV fluid to enhance preload)

  • Fill* station on blocked track: patients on PDE-5 inhibitors (e.g. sildenafil) should avoid nitrate therapy for 24 hrs, avoid severe hypotension

  • Obstructed heart smokestack: nitrates are contraindicated with hypertrophic obstructive cardiomyopathy (HOCM), worsens on decreased preload

Migraine

  • Pounding head shaped bell: migraine therapy

  • Three gems on hat: migraine pain due to activation of trigeminal nerve afferents in the meninges

  • Dilated sleeves: trigeminal afferents release vasoactive peptides (e.g. CGRP, substance P, neurokinin A) onto meningeal vessels -> vasodilation and protein extravasation

  • Sumowrestler: triptans (e.g. sumatriptan) are an acute treatment for migraines

  • "b" and "d" shaped fingers: triptans (e.g. sumatriptan) are 5-HT1b and 5-HT1d receptor agonists

  • Smiley face on headband: 5-HT1b and 5-HT1d receptors are located on the meningeal vessels

  • Tightening red headband: triptans (e.g. sumatriptan) cause vasoconstriction of cerebral and meningeal vessels. Decreases stretch of pain receptors

  • Sumo taking out the 3 gems: triptans also activate 5-HT1b and 5-HT1d receptors on the trigeminal nerve, preventing release of vasoactive peptides

  • Hair stem: triptans also activate 5-HT1b and 5-HT1d receptors in the brain stem, inhibiting pain pathways

  • Constricted coronary crown: triptans can cause coronary vasospasm

  • Anvil in the sumo's shadow: triptans are contraindicated in patients with angina

  • Anvil medals in the sumo's shadow: triptans are a known trigger of Prinzmetal angina

  • Lantern cluster: triptans (and inhaled oxygen) are also an acute treatment for cluster headaches

  • Fire extinguisher: NSAIDs are an acute treatment for migraine

  • Calci-Yum icecream nozzles: calcium channel blockers can be used for migraine prophylaxis

  • Muted beta bugle: beta blockers can be used for migraine prophylaxis

  • festiVAL PRO: valproic acid (an antiepileptic) can be used for migraine prophylaxis

  • Toupee: topiramate (an antiepileptic) can be used for migraine prophylaxis

  • Tricycle: tricyclic antidepressants (e.g. amitriptyline) can be used for migraine prophylaxis

Prostaglandins

  • Head and assistant coaches: COX-1 and COX-2 produce prostanoids (e.g. prostaglandins)

  • Pro slugger: prostaglandins

  • "E": PGE1 and PGE2

  • Dill pickle: alprostadil (PGE1)

  • Erect bat: alprostadil treats erectile dysfunction

  • Dilated red sleeves: alprostadil is a vasodilator

  • Opening air duct: alprostadil maintains patent ductus arteriosus

  • Closing air duct: NSAIDs (e.g. indomethacin) promote closure of ductus arteriosus

  • Missed swing: misoprostol (PGE1)

  • Gastric protective equipment: misoprostol promotes protective mucus secretion by gastric mucosa

  • Missed swing hitting fire extinguisher: misoprostol can prevent NSAID-induced peptic ulcer

  • Opening uterus bag: misoprostol promotes uterine contraction to facilitate labor or terminate pregnancy

  • Flooded bathroom: misoprostol can cause diarrhea

  • Dino helmet: dinoprostone (PGE2)

  • Opening uterus bag: dinoprostone promotes uterine contraction and ripens the cervix to facilitate labor or terminate pregnancy

  • "F": PGF2a

  • Cardboard box: carboprost (PGF2a)

  • Opening uterus bag: carboprost promotes uterine contraction to control postpartum hemorrhage or terminate pregnancy

  • LA tan sandals: latanoprost (PGF2a)

  • World traveler boots: travoprost (PGF2a)

  • Leaking eyeballs: latanoprost and travoprost treat glaucoma by increasing aqueous humor outflow (not production)

  • Brown sunglasses: latanoprost and travoprost can produce brown pigmentation in iris

  • High tension pulmonary rackets: pulmonary hypertension

  • Dilated pro-cycler: prostacyclin analogs cause vasodilation (e.g. iloprost, epoprostenol)

  • iLOW - ePRO setting: iloprost and epoprostenol (prostacyclin analogs) treat pulmonary hypertension

  • Fainting: iloprost and epoprostenol may cause flushing, headache, hypotension

  • FILL: -fill suffix of phosphodiesterase isoform 5 (PDE-5) inhibitors (e.g. sildenafil, tadalafil)

  • Don't phoster disinterest: phosphodiesterase isoform 5 (PDE-5) inhibitors (e.g. sildenafil tadalafil

  • Grump: PDE-5 inhibitors increase cGMP

  • Erect bat: PDE-5 inhibitors (e.g. sildenafil, tadalafil) treat pulmonary hypertension and erectile dysfunction

  • Boss man Stan: bosentan treats pulmonary hypertension

  • End o' the line: bosentan is an endothelin inhibitor

  • Dilated red sleeves: bosentan (an endothelin inhibitor) causes vasodilation

  • Liver spot: bosentan is associated with fatal hepatotoxicity

Allergy and Pulmonary

Histamines

  • beehive: histamine sequestered inside the granules of mast cells

  • "Q" dandelion: H1 histamine receptor is coupled to Gq protein (mediates allergic inflammation)

  • Honeypot with 2 "S" handles: H2 histamine receptor is coupled to Gs protein, increased cAMP

  • Golden gastric honey looks like stomach: H2 histamine receptor mediates gastric acid secretion

  • Dripping nose sap: histamine increases nasal and bronchial mucus production (H1 receptor activation)

  • Dripping vascular sap: histamine increases vascular permeability (H1 receptor activation) (urticaria/hives)

  • Constricted lung branch: histamine causes constriction of bronchial smooth muscle (H1 receptor activation)

  • Brain tree: histamine functions as a neurotransmitter (H1 receptor regulates sleep and arousal)

  • fairy rubbing nose: allergic rhinitis

  • Bee swatter: H1 receptor blocker (antihistamine) treats allergy

  • Dragonfly fairy: diphenhydramine and dimenhydrinate (1st-generation H1 receptor blockers)

  • Color fairy: chlorpheniramine (1st-generation H1 receptor blocker)

  • Fairy cuiSINE: hydroxyZINE, mecliZINE, promethaZINE (1st-generation H1 receptor blockers)

  • Fairy dust and dander: histamine mediates type-1 allergic reaction -> hives, allergic rhinitis (H1 receptor blockers are first line therapy)

  • Seasick fairy sailors: 1st-generation H1-blockers treat vestibular nausea or motion sickness (lipophilic -> enter CNS -> act on vestibular system and brainstem)

  • Falling "extra parking" cone: 1st-generation H1-blockers treat extrapyramidal side effects caused by antipsychotics, e.g. acute dystonia (antimuscarinic effects re-establish dopaminergic-cholinergic balance)

  • Sleeping under brain tree: 1st-generation H1-blockers cause drowsiness (lipophilic -> cross BBB -> central effects)

  • Antimuscarinic tea party: 1st-generation H1-blockers antagonize peripheral and central muscarinic receptors (e.g. pupillary dilation, dry mouth, urinary retention, constipation, exacerbation of glaucoma, and delirium)

  • Cut smiley face cake: 1st-generation H1-blockers antagonize serotonin receptors in the CNS

  • Stuffed fairy: 1st-generation H1-blockers stimulate appetite and weight gain (anti- serotonergic effects)

  • Extinguished single alpha candle, fainted fairy: 1st-generation H1-blockers antagonize alpha-1 receptors -> dizziness and hypotension

  • Delirious elderly man: 1st-generation H1-blockers cause cognitive impairment in the elderly (central antihistamine and antimuscarinic effects)

  • Fox, satyr, and rat: 2nd-generation H1-blockers: fexofenadine, cetirizine, loratidine

  • Fox, satyr, and rat stand outside of brain tree: 2nd-generation H1-blockers are less lipophilic -> do not cross BBB -> less sedating (also less antimuscarinic, antiserotonergic, or anti-alpha adrenergic properties)

Asthma Drugs

  • Dilated beta 2 tuba: selective beta-2 agonists (e.g. albuterol) treat bronchoconstriction in asthma

  • ROL call: "-rol" suffix of the selective beta-2 agonists (e.g. albuterol, pirbuterol)

  • "Do not disturb": terbutaline (a selective beta-2 agonist) treats bronchoconstriction in asthma

  • Inhaler: selective beta-2 agonists (e.g. albuterol) are available as metered dose inhalers for acute symptom relief

  • Moon face: inhaled corticosteroids (e.g. beclomethasone, budesonide, fluticasone) can be added as daily maintenance therapy for persistent symptoms

  • Moon eclipsing inflammatory sun: corticosteroids treat asthma by blocking later inflammation and cellular infiltration

  • Canadian snow: Candida albicans

  • Snow cone tongue: inhaled corticosteroids (e.g. beclomethasone, budesonide, fluticasone) can cause oropharyngeal candidiasis

  • AA league: arachidonic acid (AA) is the precursor of leukotrienes (and prostanoid) synthesis

  • Lacrosse Coach Lox: lipoxygenase (LOX) converts AA into leukotrienes

  • Lacrosse players: leukotrienes LTB4, C4, D4, and E4 are important regulators of inflammation

  • B4 attracting first-responders: LTB4 is a chemoattractant for inflammatory cells (e.g. neutrophils

  • First responders: neutrophils

  • Hand clamping lacrosse stick bronchi: LTC4, D4, E4 increase airway vascular permeability, mucus production, and bronchoconstriction

  • Lacrosse goal CysLT1: receptor for LTD4 (most potent bronchoconstrictor)

  • Monte the broadcaster: "-kast" suffix of LTD4-receptor antagonists (e.g. montelukast, zafirlukast)

  • Blocked D4 shot: LTD4-receptor antagonists (e.g. montelukast, zafirlukast) are an alternative therapy for mild persistent asthma

  • Dilated scarf: LTD4-receptor antagonists cause bronchodilation

  • Open mouth: LTD4-receptor antagonists are administered orally

  • Godzilla falling on Coach Lox: zileuton (a direct lipoxygenase inhibitor) is an alternative therapy for mild persistent asthma

  • Liver spot: zileuton has a risk of hepatotoxicity

  • ASA umpire grabbing Coach Cox: inhibition of COX shifts the AA metabolism to the LOX leukotriene pathway (exaggerated in aspirin-induced asthma)

  • Salute formation: salmeterol and formoterol (long acting beta-2 agonists) treat moderate or severe persistent asthma

  • Long tapering flag: salmeterol and formoterol (beta-2 agonists) have a long duration of action

  • Inhaler: long acting beta-2 agonists (salmeterol, formoterol) are administered as a daily controller inhaler

  • Higher moon face: an increased dose of inhaled corticosteroids treats moderate or severe persistent asthma

  • Xanthine energy drink: methylxanthines (e.g. theophylline) are an alternative therapy for mild to severe persistent asthma

  • Xanthine energy drink: methylxanthines (e.g. theophylline) are an alternative therapy for mild to severe persistent asthma

  • "flyin'": theophylline (a methylxanthine)

  • Caffeine: methylxanthines are related to caffeine

  • "Don't phoster disinterest": methylxanthines (e.g. theophylline) are phosphodiesterase inhibitors

  • "Camping'": methylxanthines increase cAMP, bronchodilation

  • Open mouth: theophylline is administered orally

  • Shaking kid: methylxanthines (e.g. theophylline) have CNS side effects including nervousness and tremor

  • Holding up heart watch: methylxanthines (e.g. theophylline) can cause tachycardia

  • Chrome bumper hitting energy drinks: methylxanthines (e.g. theophylline) are metabolized by the cytochrome P-450 system

  • Treat overdose with activated charcoal

  • Bee hive: mast cell degranulation is important to the pathogenesis of asthma

  • IgE gun shooting hive: antigen binding to IgE on mast cells causes degranulation and release of inflammatory mediators (e.g. histamine)

  • Limousine: omalizumab (an anti-IgE monoclonal antibody) is an adjunctive therapy for moderate or severe persistent asthma

  • Grabbing end of IgE gun: omalizumab is a monoclonal antibody directed against the Fc portion of IgE, preventing mast cell sensitization

  • chrome Lynn's bee control dispenser: cromolyn sodium

  • Bee sedating smoke: cromolyn sulfate inhibits mast cell degranulation (preventing release of histamine)

  • Beta-2 tuba: inhaled short-short acting beta-2 agonists (e.g. albuterol) treat an acute severe asthma exacerbation

  • Moon face: systemic corticosteroids treat acute severe asthma exacerbation

  • Ivy: corticosteroids are administered IV or orally during an acute severe asthma exacerbation

  • Cat-ipra-pillar: nebulized ipratropium bromide (anticholinergic) can be added to treat an acute severe asthma exacerbation

  • Epic: subcutaneous or intramuscular epinephrine can be used to treat an acute severe asthma exacerbation

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