Cardiovascular: Pharmacology - Antihypertensives Flashcards
Outline 6 main classes of antihypertensives and briefly describe what physiological determinants of HTN they target
AABCDN
1. ACEIs: inhibits ACE to decrease angiotensin II -> decreased TPR and preload
2. ARBs: block AT1 receptors -> decreased TPR and preload
3. B-blockers: decreased HR, TPR and preload (via increased venous pooling)
4. CCBs: decreased TPR
5. Diuretics: decrease preload
6. Nitrates: decreased preload (via venodilation) and TPR (via arterial vasodilation)
Outline five classes of anti-anginal drugs
B-blockers
CCBs
Nitrates
Vasodilators (nicorandil)
If inhibitor (ivabradine)
What is the formula for BP? What is the formula for CO?
BP = CO x TPR
CO = HR x SV
Give a brief overview of RAAS
(there is a better diagram in your paper notes)
Describe in detail the mechanism of ACEIs. What is the effect on TPR, CO and HR?
Inhibits ACE to prevent hydrolysis of angiotensin I to angiotensin II and inactivation of bradykinin (ACE called “plasma kinanase” in this latter reaction)
Decreases TPR
CO and HR unchanged
What is the advantage of ACEIs over direct vasodilators?
Do not induce reflex sympathetic activation (can be used safely in IHD)
Why are ACEIs used in CKD and in DM?
Shown to reduce proteinuria and stabilise renal function independent of BP-lowering effect
Name three long-acting ACEIs
Lisinopril
Ramipril
Perindopril
Which ACEIs are prodrugs converted to active metabolites via hydrolysis in the liver?
Enalapril
Lisinopril
Ramipril
Perindopril
Captopril half-life and bioavailability
t1/2 = 2.2hrs
Bioavailability = 65%
Give two examples of ACEIs which are primarily renally excreted and must be dose-reduced in renal impairment
Captopril
Lisinopril
Lisinopril half-life and bioavailability
t1/2 = 12hrs
Bioavailability = 25%
Enalapril half-life
t1/2 = 11hrs
List five adverse effects of ACEIs
- First dose hypotension in hypovolaemic patients
- AKI (especially in setting of bilat renal artery stenosis)
- Hyperkalaemia
- Effects due to increased bradykinin and substance P: dry cough, wheeze, angioedema
- Contraindicated in pregnancy (increased risk stillbirth, prematurity, IUGR)
Identify some specific adverse effects of captopril
Neutropenia
Proteinuria
Allergic skin rash
Drug fever
Give four examples of ARBs
Losartan
Candesartan
Telmisartan
Valsartan
What is the mechanism of action of ARBs?
Block AT1 receptors (decreased TPR, CO and HR unchanged)
No effect on bradykinin
List three adverse effects of ARBs
Similar to ACEIs but without bradykinin/substance P effects:
1. First dose hypotension in hypovolaemic patients
2. AKI (especially in setting of bilat renal artery stenosis)
3. Hyperkalaemia
Outline the pharmacokinetics of losartan. Is dose reduction required in renal impairment?
t1/2 = 1-2hrs
Bioavailability = 36%
No dose reduction required in renal impairment
Which B-blockers have been shown to decrease mortality from HF and post-MI?
Bisoprolol
Metoprolol
Carvedilol
Which B-blockers have a use in hypertensive emergencies?
Labetalol
Esmolol
Is propranolol a selective or non-selective B-blocker?
Non-selective
Give four examples of cardioselective B-blockers
Metoprolol
Atenolol
Bisoprolol
Esmolol
Which B-blocker undergoes high first-pass metabolism?
Metoprolol
Give three examples of B-blockers which additionally have vasodilator activity. Explain how this occurs
Labetalol: a-blocker activity
Carvedilol: a-blocker activity
Nebivolol: increases endothelial NO
Carvedilol half-life
7-10hrs
Nebivolol half-life
10-12hrs
Esmolol half-life and typical clinical application
t1/2 = 9-10mins
Used to treat peri-op HTN
What type of Ca2+ channel do CCBs act on?
L-type
What four common features are shared by all CCBs?
Orally active
High first-pass metabolism
High plasma protein binding
Extensively metabolised
Which two CCBs can be administered IV?
Verapamil
Diltiazem
What is the difference between dihydropyridines and other CCBs?
Dihydropyridines: bind to same site on a1 subunit of L-type Ca2+ channels
Other: bind to different receptors in another region of a1 subunit
Dihydropyridines have higher ratio of vascular:cardiac effects
What is unique about the mechanism of verapamil?
In addition to inhibiting L-type Ca2+ channels, also inhibits K+ channels
This means it is less vasodilatory than other CCBs
Describe in detail the mechanism of action of CCBs
Block L-type Ca2+ channels by binding at inner side of membrane (therefore bind more effectively to open and inactive channels rather than closed channels)
Decreases transmembrane Ca2+ current to induce smooth muscle relaxation (decreased TPR), and negative inotropy, chronotropy and dromotropy
Outline the organ effects of CCBs on smooth, cardiac and skeletal muscle
Smooth muscle: vasodilation, bronchodilation, decreased GI motility, uterine relaxation
Cardiac muscle: negative inotropy, reduced HR (due to decreased SA node pacemaker rate and decreased AV conduction velocity)
Skeletal muscle: no effect
Why are CCBs less likely to cause orthostatic hypotension?
Arteriolar vasodilation > venodilation
Why do CCBs have no effect on skeletal muscle?
Skeletal muscle uses intracellular pools of Ca2+ so does not require as much transmembrane flux to produce contraction
Which CCBs are used to prevent cerebral vasospasm/infarct following SAH?
Nimodipine and nicardipine (have high affinity for cerebral blood vessels)
What are the most important adverse effects of CCBs?
Related to cardiac depression: bradycardia, AV block, cardiac arrest, HF
Amlodipine half-life and bioavailability
t1/2 = 30-50hrs
Bioavailability: 65-90%
Felodipine half-life and bioavailability
t1/2 = 11-16hrs
Bioavailability = 15-20%
Nifedipine half-life and bioavailability
t1/2 = 4hrs
Bioavailability = 45-70%
Verapamil half-life and bioavailability
t1/2 = 6hrs
Bioavailability = 20-35%
Diltiazem half-life and bioavailability
t1/2 = 3-4hrs
Bioavailability = 40-65%
Mechanism of action of diuretics in treatment of HTN
Initial: decreased blood volume to decrease CO (may transiently increase TPR)
After 6-8 weeks: CO back to baseline, decreased TPR
How many mmHg do diuretics lower BP by?
10-15mmHg