CVS disorder Flashcards
CVS disorder
Hypertension
Ischemic Heart Disease
Cognitive Heart Failure
Hypertension
Any sustained BP systolic/diastolic above 140/90
At least 3 measurement
Asymptomatic
Hypertension Stage
Prehypertensive 120/80 40-60 years
Stage 1 140/90
Stage 2 160/100
Hypertension Complication
Heart attack Coronary heart disease Stroke Renal failure Blindness
Mean Arterial Pressure(MAP)= CO x Total Peripheral Resistance(TPR)
CO= Heart rate, Stroke volume(Contractility, Filling pressure(Venous tone, Blood volume)) TPR= Blood volume Arteriolar diameter
Major mechanism control BP
Neural = Ans(PSNS,SymNS)
Hormonal
Local Factor = Alter blood vessel
Catecholamine
Adrenal Hormonal control BP mechanism
Phaeochromacytoma(tumor)
Increase sec
Aldosterone
Adrenal Hormonal control BP mechanism
Na, H20 retention
Inc BP
Angiotensin II
Renal renin(SymNS) Hormonal control
Stimulate sympa NS
Affect aldosterone release
Inc BV, hypertension
Antihypertension Drug Target
CNS, ANS - Decrease sympatetic tone Heart- Decrease cardiac output Veins - Dilate - Decrease preload Arterioles - Dilate- Decrease afterload Kidney- Increase diuresis- Inhibit RAA system
Type of hypertension
White Coat
Essential
Secondary
White Coat
Stress associated with office/environment
Need 3-6 independent measurement
Essential
No known cause(95%)
Pharmacological theraphy
Secondary
Increase BP secondary to pathology
Renal Artery Stenosis
Secondary Hypertension
Isocheimal result increase AR(Angiotensinogen Renin)
Phaeochromocytoma
Secondary Hypertension
Tumor in chromafin cell of adrenal gland
Hypersecretion of adrenal catecholamine
Aortic Coarctation
Secondary Hypertension Severe congestion at arch & increase upper body pressure to maintain lower body perfusion Back BV are very dilated
Adrenal Tumor
Secondary Hypertension
Hypersecretion of glycocorticoid(aldosterone)
Hyperthyroidism
Secondary Hypertension
Increase CO with palpitation
General Hypertension treatment strategy
Diagnosis- At least 3 independent measurement
Determination of primary vs secondary hypertension
If secondary treat underlying pathology
If primary initiate lifestyle change
next Pharmacological treatment essential hypertension
lifestyle change include
Weight reduction Salt reduction Withdrawal of drug Tobacco Alcohol Stress reduction
Class of Anti-Hypertensive Drug
Diuretic(de BV) Peripheral a1 adrenergic antagonist Central Sympatholytic a2 agonist B-adrenergic antagonist Anti-angiotensin II Ca++ channel blocker Vasodilator
Type of Diuretics
Thiazides
Loop Diuretic
K+ Sparing
Osmotic(HTN emergency)
Hydrochlorothiazide
Thiazides Mild to moderate HTN Direct vasodilator action Start with low potency diuretic Used with low na, high k
Furosemide
Loop Diuretic
Severe HTN, with CHF
Spironolactone
K+ Sparing
Combination with other drug
Week, prevent K loss
Diuretic Site of Action
Renal nephron
Different segment of nephron
Diuretic MOA
Inc urinary Na & H2O excretion,
dec extracellular fluid, plasma vol
All decrease Na reabsorption
Act on renal system, transporter, hormones, ion channel
Diuretic Effect on cardiovascular
Acute decrease in CO
Chronic decrease TPR, CO return normal
Compensate Na+ retaining reflex
Diuretic ADR
Hypokalemia Hyperglycemia(Thiazides) Hyperuricemia(gout) Dizziness Electrolyte imbalance Hyperlipidemia
Diuretic Contraindication
Hypersensitivity Compromised kidney function Cardiac glycosides Hypovolemia Hyponatremia
MOA antagonist a1
Competitive antagonist a1 receptor on sm
Site of action a1 antagonist
Peripheral arterioles, sm
Block a1= vasodilator
Major mech sym con of BP
Adr a1 antagonist
Postural Hypotension
Tachycardia
Nausea, drowsiness
Postural Hypotension
Adr a1 antagonist
1st dose syncope
Take smaller dose
Take when sitting
Type a1 antagonist
Prazosin(Miniores)
Terazosin(Hytrin)
a1 antagonist Fx to CVS
Vasodilation, reduce peripheral resistance
a1 antagonist Contraindication
Hypersensitivity
a1 antagonist Uses
Diabetes, asthma, hypercholesterolemia
Mild to moderate HTN
Often used with diuretic, B-antagonist
Clonidine
Central Sympatholytic a2 agonist
Direct agonist
Rebound increase in BP
Prolong used Salt, water retension Add diuretic
Methyldopa
Central Sympatholytic a2 agonist Converted to methylnorepinephrin False neurotrans DOC in pregnancy Prolong used Salt, water retension Add diuretic
Site of action a2 agonist
CNS Medullary Cardiovascular Center
MOA a2 agonist
activate CENTRAL a2 receptor
Peripheral sym inhibition
Decrease norepinephrine release
Decreased vasoconstriction Decrease TPR
Type of B antagonist
Propanolol(Inderal) Atenolol(Tenormin) Metoprolol(Lopressor) Nadolol(Corgard) Pindolol(Visken)
Site of action B antagonist
Selective b1 heart
Non selective b1&2 heart kidney
MOA B antagonist
Competitive antagonist with b adrenergic receptor
B antagonist Fx on CVS
Heart- Dec contractility, reduce BP
Kidney - Antagonize catecholamine
Antagonize catecholamine
Dec renin release
Dec angiotensin 2, Dec TPR
Dec aldosterone release, No na retention CO reduce, BP reduce
Adr B antagonist
Bradycardia
Exercise intolerance
B antagonist Contraindication
Asthma
Diabetes
Bradycardia
Hypersensitivity
B antagonist Uses
Selectively Nadolol nonselective 20h t1/2 Metoprolol selective b1 3-4h t1/2 Risky in pulmonary disease Mixed a/b blocker- Labetalol Post MI- protective With diuretic- Prevent reflex tachycardia
Anti-angiotensin II drug type
ACE inhibitor(-pril)
Angiotensin 2 receptor antagonist
Direct renin inhibition (Aliskiren)
ACE inhibitor example
Enalopril (Commonly used IV hypertensive emergency) Captopril(prototype) Quinapril(Accupril) Fosinopril(Monopril) Moexipril(Univasc) Lisinopril(Zestril,Prinivil) Benazepril(Lotensin)
ACE inhibitor function
Angiotensinogen»_space;renin»_space;angiotensin
1»ACE»angiotensin 2
In present of ACE Inhibitor, no angiotensin 2 act on sympathetic system, no aldosterone
Associated with persistent cough due to accumulation of
bradykinin(breakdown)
Angiotensin 2 receptor antagonist
Block receptor where angiotensin supposed to bind
Act on type 1 receptor
Angiotensin 2 antagonist example
Valsartan(Diovan)
Losartan(Cozaar)
Candesartan(Atacand)
Adr antiangiotensin 2
Hyperkalemia
Angiogenic edema, cough (ACE Inhibitor)
Rash
Itching
CVS fx antiangiotensin 2
Dec CO
Dec constriction, Dec TPR
antiangiotensin 2 Contraindication
Pregnancy
Bilateral renal stenosis
Hypersensitiviy
antiangiotensin 2 Uses
Diabetes, renal insufficient
Adjunctive theraphy with heart failure
Often used with diuretic
Verapamil(Calan)
Ca++ channel blocker
Cardiac muscle, rec in force of contraction
Nifedipine(Procardia)
Ca++ channel blocker Inc SymNS Tachycardia Mainly arterioles of vascular sm CI - CAD or Heart failure
Diltiazem(Cardizem)
Ca++ channel blocker
Between cardiac & vascular
MOA of Ca++ blocker
Block Ca++, Decrease contraction, Rec TPR
Ca++ blocker adr
Headache
Dizziness
Peripheral edema
Ca++ blocker Contraindication
Congestive heart failure
Pregnancy & Lactation
Post-myocardial infection
Vasodilator
Rarely used unless emergency Dilate BV, BP fall, reflex tachycardia occur Accompony with B-blocker - Reduce heart rate Diuretic - Prevent Na, H2O retention
Hydralazine(Apresoline)
Vasodilator
Act on NO, Ca++
Lupus
Safe for pregnancy
Nitroprusside(Nipride)
Vasodilator Used in emergency hypertension Act on NO Cyanide toxicity Iv only
Diazoxide(Hyperstat IV)
Vasodilator
Severe hypertension
Minoxidil(loniten)
Vasodilator
Act on blood vessel
Hypertrichosis
Fenoldopam(Corlopam)
Vasodilator
Act in dopamine receptor
Vasodilator Site of action
Vascular sm
Vasodilator CVS fx
Vasodilation
Decrease TPR
Vasodilator Adr
Reflex tachycardia
Inc SymNS Hydralazine, Minoxidil, Diazoxide
Summary MOA site HTN
Brain a2 agonist Heart b blocker Receptor angiotensin: a1 anta, Ang 2 anta Vasodilator, Ca++ anta Kidney : Diuretic, B- bocker Lung, VSM, Kidney, CNS ACE inhibitor
HTN TT common condition
Heart failure- ACE inhibitor, Diuretic MI - B-blocker, ACE inhibitor Diabetes- ACE inhibitor, Avoid B-blocker Isolated systolic hypertension -Diuretic, Ca++ anta Renal insufficiency- ACE inhibitor Angina- B-blocker, Ca++ anta Asthma- Ca++ blocker, Avoid B-blocker
ischemic heart disease
Angina pectoris
Angina pectoris
Sudden, severe subternal pain , pressure
Imbalance between oxygen demand & supply
Angina pectoris Type
Stable
Unstable
Vasospastic
Stable(exertional, typical, classic, angina of effort,atherosclerotic angina)
Atherosclerosis
Can percipitate by Exercise, Cold, Stress
Emotion, Eating
Therapeutic goal
Dilate c.artery- Increase o2 delivery
Decrease cardiac load-Preload & afterload
Unstable(Preinfarction, Crescendo, Angina at rest)
Change in character, frequency, duration of stable angina & episode of angina at rest
Caused by recurrent episode of small platelet clot site of ruptured atherosclerotic plaque, can precipitate local vasospasm
Unstable Therapeutic rationale
Inhibit platelet agg & thrombus formation
Decrease cardiac load
Vasodilate coronary arteries
Vasospastic(Variant, Prinzmetal)
Caused by transient vasospasm of coronary vessel
Associated with atheromas
Chest pain may develop at rest
Therapeutic rationale- Decrease vasospasm of c.vessel, Ca++ blocker effective >70%, Increase o2 delivery
Type AP drug
Organic nitrate (DOC)(nitrovasodilator) Calcium channel blocker Beta adrenergic blocker
Production of nitric oxide
Taken sublingual
Short lived
SM relaxant
Organic nitrate fx
Vasodilate coronary artery
Reduce preload & afterload
Increase blood flow
Isosorbidemononitrate(5-ISMN)
oral Organic nitrate
Not affected by first pass
Isosorbidedinitrate(ISDN) (first pass)(oral ON)
Glyceralnitrate(GNT)(sublingual)
Hepatic blood flow & disease can affect pharmacokinetic
Rapid onset given sublingually(1-3min) last for (20-30 min), not suitable for maintainance theraphy
Nitroglycerine
Tolerance problem, Use transdermal patches, Avoid first pass
Apply when doing work, remove before sleeping
IV- treat severe recurrent unstable angina
Slowly absorbed preparation AP
Oral, buccal, transdermal
prolong prophylaxis against angina(3-10hour)
Can lead to tolerance(tachyphylaxis)
Amyl Nitrate
Inhalation ON AP
Rapid onset, short duration(3-5min)
Adr excessive ON
Orthostatic hypotension Tachycardia Severe throbbing headache Dizziness Flushing Syncope
Contraindicated ON
Elevated intracranial pressure
Drug interaction ON
Sildenafil(Viagra) other PDE-5 inhibitor
Erectile dysfunction
Can potentiate action of nitrovasodilator
Inhibit breakdown of cGMP
Should not be taken within 6 hour taking nitrovasodilator
Calcium channel blocker AP
Vasodilate coronary artery
Reduce after load
Nondihydropyridines also decrease heart rate & contractility
Verapamil, Diltiazem
Beta adrenergic blocker AP
Dec h.rate & contractility
Dec afterload , dec in CO
Improve myocardial perfusion due to decrease in heart rate
For post MI
Congestive Heart Failure
Progressive inability of heart to supply adequate blood flow
to vital organs
Accomponiedby significant fluid retention (Leg edema, Pulmonary congestion, Ascites)
Leading cause of mortality & morbidity
CHF Symptom
Shortness of breath
Edema
Fatigue
CHF cause
Hypertension Coronary artery disease(CAD) Diabetes Mitral Valve Disease Chronic Alcohol Intake
CHF drug
Increase contraction force(c.inotropes)
Reduce venous return(Diuretic, Vasodilator)
Reduce renin & angiotensin(ACE Inhibitor, B-blocker, Ang 2 blocker)
Dobutamine
Beta 1 agonist, inc contractility & CO
Acute heart failure Taken IV
Cardiac inotropes
Digoxin
Cardiac inotropes
Inhibit Na/K ATPase Pump, More ca, more contraction
Restore vagal tone, Counteract sym stimulation
Increase refractoriness of AV node, dec ventricular response to atrial rate
First line or patient with atrial fibrilation
T1/2 30-36 hour
Digoxin ADR
Narrow TI
Nausea, vomiting, gynecomastia, visual disturbance, psychosis
Ventricular bigeminy, AV block, Bradycardia
Not combined with Amiodarone, Verapamil, beta blocker,
Increase plasma con of digoxin by inhibit its excretion
Digoxin Toxicity(Hypokalemia)
Tt with higher dose of Potassium Heart Failure need diuretic, Potassium sparing diuretic Digitoxin antibody(digibind) used in life-treatening digoxin overdose(antidote)
Milrinone
Inodilator
Phosphodiesterase 3 inhibitor
CHF Condition
CO dec, Less renal perfusion pressure, Neurohormonal activation, Sym stimulation, Tachycardia, aldosterone(na n h20 retention), Lung congestion, Shortness of breath
CHF Stage
Class 1- Mild, no symptom
Class 2- Mild, gradually
Class 3- same
Class 4- Unable to do any physical activities, Heart symptom appearing
