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Anti-Hypertensive Flashcards

1
Q

Cardiovascular mortality risk doubles with each what BP increment?

A

20/10mmHG

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2
Q

What is hypertension?

A

> 130/>80

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3
Q

CO=

A

SV X HR

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4
Q

SV=

A

EDV-ESV

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5
Q

BP=

A

CO X SVR

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6
Q

Rationale for reducing CO?

A

Reduce blood volume
Reduce HR
Reduce SV

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7
Q

Rationale for reducing SVR?

A

Dilate systemic vasculature

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8
Q

5 anatomical site of BP control:

A
  1. Resistance arterioles
  2. Capacitance venules
  3. Pump output heart
  4. Volume kidneys
  5. CNS- sympathetic nerves
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9
Q

4 Renin angiotensin aldosterone system (RAAS) antagonists

A
  1. Angiotensin-converting enzyme (ACE) inhibitors
  2. Angiotensin II receptor blocker (ARBs)
  3. Neprilysin inhibitor plus ARBs
  4. Aldosterone antagonists (Potassium sparing diuretics)
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10
Q

Pathway for renin angiotensin aldosterone system (RAAS)

A 
Angiotensinogen (liver)
Angiotensin I from renin (kidney)
Angiotensin II from ACE (lungs)
Arteriole vasoconstriction and adrenal cortex 
Aldosterone 
Sodium retention
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11
Q

What does ACE inhibit

A

Angiotensin I and bradykinin

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12
Q

5 common clinical uses for ACE inhibitors

A
  1. Heart failure
  2. CAD
  3. HTN
  4. Chronic renal disease with proteinuria
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13
Q

5 adverse effects from ACE inhibitors

A
  1. Increase serum potassium
  2. Acute renal failure
  3. Pregnancy
  4. Dry cough and angioedema (rare)
  5. Hypotension in patients with volume and/or salt depletion
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14
Q

What does ACE inhibitors drug name end with?

A

“pril”

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15
Q

What does ARBs inhibit?

A

Angiotensin II attaching to the receptors to allow for vasoconstriction and aldosterone secretion

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16
Q

4 common clinical uses for ARBs

A
  1. Heart failure
  2. CAD
  3. HTN
  4. Chronic kidney disease with proteinuria
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17
Q

When is ARBs most common used?

A

As an alternative to ACE inhibitors when patients develop dry cough

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18
Q

4 adverse effects for ARBs

A
  1. Increase serum potassium
  2. Acute renal failure
  3. Pregnancy
  4. Hypotension in patients with volume and/or salt depletion
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19
Q

What does ARBs dug name end in?

A

“sartan”

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20
Q

What does neprilysin inhibitor plus ARBs inhibit?

A

Block break down of peptides (valsartan and LBQ675)

Block angiotensin II connecting to it’s receptors

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21
Q

Common clinical uses for neprilysin inhibitor plus ARB

A

Heart failure

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22
Q

5 Adverse effects of neprilysin inhibitor plus ARB

A 
Hyperkalemia 
Cough 
Angioedema 
Renal function deterioration 
Hypotension
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23
Q

3 Contraindications for neprilysin inhibitor plus ARB

A

36 hours of ACE inhibitors (angioedema)
Pregnancy
Bilateral renal artery stenosis

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24
Q

What does direct renin inhibitor (DRI) inhibit?

A

Renin

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25
Clinical uses for DRI
HTN
26
What is DRI available to be in combo with?
Amlodipine + HCTZ
27
What is the is the drug name for DRI?
Aliskiren (tekturna)
28
5 Adverse effects for DRI
``` Hyperkalemia Angioedema Renal function deterioration Diarrhea Hypotension in patients with volume and/or salt depletion ```
29
2 Contraindications for DRI
Aliskiren with ARBs or ACEIs in patients with DM | Pregnancy
30
Risk of hyperkalemia and renal impairment elevates when DRI is used with what in DM patients?
ARBs and ACEIs
31
Aldosterone antagonists inhibit what?
Sodium and water retention
32
What 2 drugs are aldosterone antagonists
Spironolactone | Eplerenone
33
How does aldosterone antagonists increase BP?
Induce sodium and water retention
34
4 clinical uses for aldosterone antagonists
Hyperaldosteronism Resistant HTN Heart failure MI with LV dysfunction
35
3 Adverse effects for aldosterone antagonists
Renal dysfunction Hyperkalemia Endocrine abnormalities
36
What can aldosterone antagonists cause?
Myocardial, renal, and vascular fibrosis
37
Contraindication for aldosterone antagonists
1. SCr >2.5 (men) >2 (women) | 2. Potassium >5
38
2 mechanism of actions for diuretics (decrease BP)
1. Depleting body of sodium and H2O | 2. Reducing blood volume (decrease SV)
39
6 types of diuretics
1. Loop diuretics 2. Thiazide diuretics 3. Potassium sparing diuretics 4. Osmotic diuretics 5. Carbonic anhydrase inhibitors 6. Vasopressin (ADH) antagonists
40
3 uses for loop diuretics
1. Edematous 2. Hyperkalemia 3. HTN (2nd line)
41
7 Adverse effects for loop diuretics
1. Na/volume depletion 2. Hypokalemia 3. Hypocalcemia 4. Hypomagnesemia 5. Metabolic alkalosis 6. Hyperuricemia 7. Ototoxicity
42
4 thiazides
Hydrochlorothiazide Chlorthalidone Indapamide Metolazone
43
Is thiazide 1st or 2nd line to treat HTN?
First line
44
Is thiazide more or less potent than loops?
Less potent
45
8 adverse effects of thiazide
1. Hypovolemia 2. Hypokalemia 3. Hypoatremia 4. Hypochloremia 5. Hypomagnesemia 6. Hyperkalemia 7. Hyperuricemia 8. Metabolic alkalosis
46
2 different potassium sparing diuretics
Sodium channel blockers | Aldosterone receptor antagonists
47
Are potassium sparing diuretics weak or strong diuretics
Weak
48
What is the adverse effect for potassium sparing diuretics?
Hyperkalemia
49
What do central anti-adrenergics target?
Adrenergic neurons in CNS
50
What does central anti-adrenergics prevent?
Releasing of catecholamines
51
How is central anti-adrenergics controlled?
Negative feedback inhibition (alpha 2= inhibit NE release)
52
Where on the brain is the inhibitory effect on NE located at?
Prefrontal cortex
53
What drug is a central anti-adrenergic (alpha2 agonists)
Clonidine
54
What 4 things specifically lower BP in central anti-adrenergics?
1. Lower venous return 2. Lower TPR 3. Lower HR 4. Lower SV
55
What does methyldopa get converted into?
Methylnorepinephrine
56
What does methylnorepinephrine do when released?
NOT activate adrenergic receptors | CAN act on the alpha2 receptors (further inhibit NE release)
57
What is a big adverse effect of central anti-adrenergic?
Rebound HTN with withdrawal
58
4 clinical uses of central anti-adrenergic
1. HTN (NOT 1st line and resistant HTN) 2. ADHD 3. HTN in pregnancy 4. Treatment of withdrawal
59
2 non-selective alpha antagonists
Phenoxybenzamine | Phentolamine
60
What is phenoxybenzamine?
Irreversible, non-competitive antagonist
61
What is phentolamine?
Reversible, competitive antagonist
62
How are phenoxybenzamine and phentolamine treated?
Pheochromocytoma
63
When is phentolamine used?
HTN crisis
64
4 adverse effects of nonselective alpha antagonists
1. Reflex tachycardia 2. Postural hypotension 3. Cardiac arrhythmias 4. Ischemic cardiac events
65
Adverse effect of phentolamine?
Stimulates GI SM and enhance gastric acid secretion
66
Adverse effects of phenoxybenzamine?
Mutagenic
67
What does alpha1 antagonists do?
Inhibit binding of NE to Postsynaptic alpha1 receptors
68
What does alpha1 antagonists cause?
Relax SM | Decrease PVR and venous return
69
Clinical use of selective alpha1 antagonists
HTN (not 1st line)
70
5 adverse effects of selective alpha1 antagonists
1. Postural hypotension 2. Syncope 3. Fluid retention 4. Nasal congestion 5. Drowsiness
71
What is 1st does phenomenon
Faintness and/or syncope within 30min-6hrs after initial dose Use low initial dose at bedtime Titrate slowly
72
What 3 locations at beta1 receptors?
Heart SA and AV node Kidneys
73
What 3 locations are beta2 receptor
Lungs Vascular SM Liver/pancreas
74
Beta1 blockade cause?
Decrease HR Decrease contractility Decrease renin release
75
Beta2 blockade cause?
Bronchoconstriction Decrease insulin secretion Vasoconstriction
76
Theorized effect on beta-blockers
Inhibit release of NT and decrease sympathetic activity
77
Beta1 selectivity for heart
Bradycardia Negative inotropy Decrease BP
78
Beta1 selective on lungs
Less bronchospasm
79
Beta1 selectivity with peripheral effects
Metabolic effects | Circulatory
80
2 effects on non-selective beta1 and beta2
1. Similar cardiac and antiHTN effects | 2. More pulmonary and peripheral effects
81
What does beta blocker drugs name end in?
“olol”
82
5 beta blocking effects
1. Negative chronotropic 2. Negative dromotropic 3. Anti-arrhythmic 4. Negative inotropic 5. Anti-ischemic
83
3 non-vasodilation BB hemodynamics:
1. Acute decrease in CO ~20% with compensatory reflex rise in SVR 2. SVR returns to baseline 3. BP lowers chronically from decreased HR and CO
84
Are BB first line antiHTN?
NO
85
Why aren’t BB 1st line antiHTN? (3)
1. Other drugs have better CV protection 2. Lowers brachial BP but not central BP 3. Mortality may be higher with atenolol
86
What does vasodilation BB BP reduction come from?
Decreased HR and SVR
87
4 BB contraindications
1. Bradycardia 2. Severe asthma or bronchospasm 3. Severe depression 4. Cardiogenic shock or hypotension
88
6 BB adverse effects
1. Smooth muscle spasm 2. Exaggeration of the cardiac therapeutic actions 3. CNS penetration 4. Worsened quality of life 5. Adverse metabolic side effects 6. Withdrawal phenomenon
89
3 main clinical uses for BB
1. Ischemic heart disease (chronic stable angina and acute coronary syndrome) 2. Heart failure with reduced EF (metoprolol succinct, carvedilol, bisoprolol) 3. Tachyarrhythmias
90
2 different types of Ca++ channels:
1. T(transient) type | 2. L type
91
What is t-type Ca channel?
- opens at more negative potentials | - dominant in SA node
92
What is L-type Ca channel?
- located on vascular SM, cardiac myocytes, cardiac nodal tissue - dominant in AV node - required for initiation of contraction via Ca++
93
2 types of Ca channel blockers?
1. Non-dihydropyridines (NON-DHPs) | 2. Dihydropyridines (DHPs)
94
What do NON-DHPs effect?
SA AV Contractility
95
What do DHP effect?
Contractility | Vasodilation
96
NON-DHPs effect on: | SA, AV, inotropic, myocardial blood flow, peripheral arterioles
``` Normal/decrease Decrease Decrease Increase Increase ```
97
DHPs effect on: | SA, AV, inotropic, myocardial blood flow, peripheral arterioles
``` Normal Normal Normal Increase Increase ```
98
BB effects on: | SA, AV, inotropic, myocardial blood flow, peripheral arterioles
Decrease all
99
2 NON-DHPs medications
Verapamil | Diltiazem
100
Verapamil
More cardio selective More potent HR lowering effect Stronger suppression of contractility
101
Diltiazem
More effective vasodilator Better antiHTN Moderate suppression of contractility
102
Clinical uses for NON-DHPs (4)
HTN Supreventricular tachyarrhythmias Chronic stable angina Coronary spasm
103
3 contraindications of NON-DHPs
Severe hypotension or cardiogenic shock LV dysfunction (<40%) Bradycardia
104
Is nifedipine DHPs long or short acting?
Short
105
How does DHPs work?
Rapid vasodilation Rapid drop BP Rapid reflex adrenergic activation with tachycardia Increase demand
106
Unusual side effects of DHPs (4)
Muscle cramps Myalgia Hypokalemia Gingival swelling
107
How long or short acting DHPs preferred?
Long
108
Is DHPs first or second line HTN?
First
109
4 clinical uses for DHPs
HTN Chronic stable angina Coronary spasm Raynaud’s phenomenon
110
Chief side effect of DHPs?
Ankle edema
111
2 HTN emergency meds
Nicardipine IV | Clevidipine IV
112
Tunica intima
Endothelial cells
113
Tunica medica
SM cells | Sheets of elastin
114
Tunica externa
Loosely woven fibers of collagen
115
How do nitroglycerin (glyceryl trinitratel, NTG) work?
NTG produce NO NO goes to SM cells Stimulate guanylyl cyclase Increase cGMP (vasodilates veins and arteries)
116
What do organic nitrates do to preload and afterload?
Decrease because of the vasodilation
117
What does organic nitrates do to myocardial oxygen consumption and oxygen delivery to heart tissue?
Decrease myocardial oxygen consumption | Increase oxygen delivery to heart tissue
118
3 most common ways to receive NTG?
Sublingual/spray IV Transdermal patch
119
2 nitrate preparations:
``` Isosorbid dinitrate (ISDN) Isosorbid mononitrate (ISMN) ```
120
What is isosorbid dinitrate?
Low bioavailability, high first pass metabolism | Converted to active mononitrate metabolite (via liver)
121
What is isosorbide mononitrate?
High bioavailability, no first pass metabolism
122
How does nitrate preparations produce vasodilation?
ISDN -> ISMN -> NO -> cGMP -> vasodilation
123
5 clinical uses of organic nitrates
1. Chronic stable angina 2. Unstable angina and ACS 3. Acute HR and pulmonary edema 4. Chronic heart failure 5. HTN
124
Contraindication of nitrate?
Right ventricular infarction
125
4 Adverse effects of nitrate?
Headache Hypotension, dizzy, syncope Reflex tachycardia Halitosis (bad breath)
126
Serious nitrate interaction
Decrease BP Syncope Erection
127
Nitrate tolerance (tachyphylaxis) (3)
- loss of nitrate-induced vasodilation - reduced nitrate-induced BP lowering effect - attenuation of nitrate-induced anti-ischemic effect
128
What is Monday disease at explosive factory?
Nitrate tolerance
129
How long does nitrate tolerance occur?
2-3days
130
What are 2 parenteral vasodilators?
Sodium nitroprusside | Fenoldopam
131
What 3 things are nitroprusside?
Complex of iron Cyanide groups Nitro so moiety
132
Does sodium nitroprusside cause tolerance?
No
133
How does sodium nitroprusside cause vasodilation?
Rapid uptake by RBCs NO and cyanide NO activates GC -> cGMP and causes vasodilation
134
What does sodium nitroprusside cause in preload and afterload?
Decreases in both
135
What does normal LV function do with sodium nitroprusside?
Decrease BP
136
What does severely impaired LV function do with sodium nitroprusside?
Decrease afterload leads to rise in SV and CO
137
What is sodium nitroprusside toxicity?
Cyanide toxicity
138
What is treatment for cyanide toxicity with sodium nitroprusside?
Hydroxocobalamin, sodium thiosulfate
139
3 additional toxicity problems with sodium nitroprusside?
Hypotension Coronary steal Increase ICP
140
3 Sodium nitroprusside clinical uses?
HTN emergencies Acute decompensated HF Perioperative HTN in cardiac surgery
141
In HF, a reduced afterload can do what to SV and CO?
Enhance them
142
2 therapeutic uses for hydralazine (oral direct vasodilator)?
HTN | HF with reduced EF
143
Therapeutic uses of minoxidil (oral direct vasodilator)?
Severe HTN poorly responsive to other HTN drugs | LAST RESORT
144
3 adverse effects of oral direct vasodilators
Headaches, flushing Baroreceptor (mediated reflex tachycardia) Salt and water retention (edema)
145
What is fenoldopam?
Selective agonist of D1-like dopamine receptor
146
Is fenoldopam rapid or slow acting?
Rapid acting arteriolar vasodilator
147
When is fenoldopam used?
HTN emergencies and postop HTN
148
What are the 2 major toxicities with fenoldopam?
Reflex tachycardia | Hypokalemia
149
What should be done when BB are used with fenoldopam?
With caution: substantial hypotension because BB inhibit sympathetic reflex

Pharmacology (14 decks)

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