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Pharm 2 > Vasodilators and Antihypertensives - Week 1 > Flashcards

Vasodilators and Antihypertensives - Week 1 Flashcards

1
Q

Idiopathic HTN is related to:

A

overactivity of ANS and interaction w the renin-angiotensin system along w factors r/t Na homeostasis and intravasc vol

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2
Q

How does idiopathic HTN develop?

A
  • initially, SVR normal
  • BP is increased d/t increased CO
  • SVR increases to prevent the increased BP from being transmitted to the capillary bed where it would affect cell homeostasis
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3
Q

pre-existing disease states that cause peri-op HTN

A 
Pheochromocytoma
Hyperthyroid
Autonomic hyperreflexia
Renal disease
MH
Poorly controlled HTN
Intercranial HTN
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4
Q

Iatrogenic causes of peri-op HTN

A 
Type of procedure
Hypercarbia
Hypervolemia
Hypothermia
Hypoxia
Airway manipulation 
Aortic cross clamp
Pain
Inadeq anes
Meds
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5
Q

Primary cause of perioperative HTN

A

increased symp discharge w systemic vasoconstriction

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6
Q

Complications of peri-op HTN

A 
CVA
MI
LV dysfx
Ischemia
Increased suture tension
Cognitive dysfunction (post-op delirium) 
Hemorrhage 
Arrhythmias
Pulm edema
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7
Q

What are the 4 mechanisms of action of vasodilators, and give 2 examples of each)

A

Direct smooth muscle dilation
- production of intracellular NO (SNP and nitrates)
- CCBs
Alpha 1 antagonists (prozosin and labetalol)
Alpha 2 agonists (clinidine and alpha-methyldopa)
ACE inhibitors (catapril and elanapril)

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8
Q

3 classifications of vasodilators according to their sites of action

A

Arterial dilators (reduce after load)
Venodilators (reduce preload)
Balanced vasodilators

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9
Q

How do vasodilators cause a reflex increase in HR?

A

Baroreceptors

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10
Q

2 possible outcomes of redistribution of coronary blood flow using a vasodilator

A
  • improved collateral circulation

- coronary steal

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11
Q

___ - ___% of the coronary artery perfusion to the LV occurs during diastole.

A

70-90%

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12
Q

What governs myocardial perfusion?

A

Aortic diastolic pressure

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13
Q

In the presence of ischemic heart disease, the collateral arteries are maximally dilated and coronary perfusion is largely ________ (vol or press) dependent.

A

Pressure

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14
Q

Explain the concept of coronary steal.

A

Narrowed coronary arteries are always maximally dilated to compensate for the decreased blood supply. Dilating the other arterioles causes blood to be shunted away from the coronary vessels.

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15
Q

Which drug assists in blood supply to ischemic zones of the heart, NTG or SNP?

A

NTG

NTG preferentially dilates conductance vessels and directs more blood toward ischemic zones

SNP dilates both epicardial conductance and intramyocardial resistance vessels and in the presence of CAD, shunts blood away from ischemic zones

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16
Q

What type of drug is hydralazine?

indirect vs direct acting, arterial vs venous

A

direct acting arterial vasodilator

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17
Q

What reflex activity may be seen w hydralazine?

A

increased:

  • HR
  • contractility
  • renin activity
  • fluid retention
  • CO
  • SV
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18
Q

What decreases more as a result of the decrease in SVR caused by hydralazine, SBP or DBP?

A

DBP decreases more

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19
Q

Why might hydralazine cause increased chest pain?

A

it increases myocardial O2 demand leading to ischemia

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20
Q

In what 3 pt populations should hydralazine be avoided?

A
  • CAD (b/c of coronary steal)
  • increased ICP
  • lupus (hydrazine can cause positive ANA titers, which shows up as lupus)
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21
Q

CNS hydralazine side effects

A

Headache, dizziness, tremor

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22
Q

CV Hydralazine side effects

A

palpitations
angina
tachycardia
flushing

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23
Q

GI Hydralazine side effects

A

anorexia
N/V
abd pain
paralytic ileus

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24
Q

Other Hydralazine side effects

A 
Anemia
Agranulocytosis
Muscle cramps
Edema
Nasal congestion
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25
Q

Name some advantages to hydralazine

A
  • maintains/increases cerebral blood flow

- increases CO and SV

26
Q

Name some disadvantages to hydralazine

A
  • reflex tachycardia
  • na and water retention
  • longer duration of action
  • tachyphylaxis w monotherapy
27
Q

How does nitro work?

A

causes a release of NO for nonspecific relaxation of the vasc smooth muscle

28
Q

What does nitro dilate more, the veins or the arteries?

A

veins

29
Q

Nitor decreases what 3 things?

A
  • PVR
  • Venous return
  • Myocardial O2 consumption
30
Q

name 2 other functions of nitro that are beneficial during a cardiac event

A

relaxes coronary vessels

relieves spasms

31
Q

Why should nitro be used w caution in a pt with increased ICP?

A

it dilates the meningeal vessels

32
Q

Does nitro affect renal or pulm blood flow?

A

Yes. it decreases RBF with the decrease in BP, and it dilates pulm vessels

33
Q

Why should nitro be titrated slowly?

A

Titrating too quickly can create chest pain

34
Q

Where and by what is nitro metabolized?

A

in the liver by glutathione nitrate reductase

35
Q

What causes nitro to eventually fail?

A

Nitrite ion oxidizes Hgb to metHgb (the effects of nitro are reduced b/c it is all bound up)

36
Q

T/F: With chronic administration, tolerance to nitro can occur in arterial vessels but not in the venous vessels.

A

True

37
Q

CNS s/e of nitro

A 
HA
apprehension
blurred vision
vertigo
dizziness
faintness
(these can lead to emergence delirium)
38
Q

CV s/e of nitro

A

Syncope
Increased HR
Postural HoTN
Palpitations (from reflex changes)

39
Q

GI s/e of nitro

A

Dry mouth
Abd pain
N/V

40
Q

Other s/e of nitro

A 
methemoglobinemia (via metabolism)
flushing 
rash
anaphylaxis
oral and conjunctival edema
41
Q

Warnings/contraindications for nitro

A
  • PDE5 inhibitors (Viagra and Cialis)
  • Narrow angle glaucoma
  • head trauma
  • cerebral hemorrhage
  • severe anemia
  • HoTN
  • (tx beyond 3 days will probably fail)
42
Q

Advantages to Nitro

A
  • Rapid onset
  • Short duration
  • coronary vasodilator
  • decreased myocardial O2 consumption
  • no major toxicities
  • no coronary steal
  • reduced PVR
43
Q

Disadvantages to Nitro

A
  • Decreased DBP
  • reflex tachycardia
  • Possible HoTN
  • variable efficacy
  • Tachyphylaxis
  • methemoglobinemia
  • intrapulm shunting
  • prolonged bleeding time
44
Q

Does SNP directly or indirectly vasodilator arteries and veins?

A

Directly

45
Q

How does SNP affect BP and HR

A

decreases BP, slightly increases HR

46
Q

How does SNP affect cerebral blood flow and ICP?

A

increases CBF and ICP

47
Q

How does SNP affect renal blood flow?

A

maintains or slightly reduces it

48
Q

Does SNP increase or decrease myocardial O2 demand?

A

overall, it reduces the demand (nitro is better, but SNP still works)

49
Q

What happens if SNP is abruptly discontinued?

A

reflex tachycardia and HTN. taper it off slowly

50
Q

Onset, Peak, Duration, and Halflife of SNP

A

Onset: <1 min
Peak: 2-3 min
Duration: 5-10 min
Half-life: 2.7-7 days

51
Q

CNS side effects of SNP

A 
Restlessness
Apprehension
Musc twitching
HA
Dizziness
52
Q

CV side effects of SNP

A

Profound HoTN
Palpitations
Fluctuations in HR
Retrosternal discomfort

53
Q

GI and other s/e of SNP

A 
N/V
Abd pain
Nasal stuffiness
Increased serum cr
Thiocyanate/cyanide toxicity
54
Q

Warnings/contraindications of SNP

A

Congenital optic atrophy
Hypovolemia
Compensatory HTN (AV shunting, aortic coarctation)
Inc ICP
Severe renal/hepatic impairment (doesn’t worsen them; just may cause SNP metabolites to build up)

55
Q

Presentation of Thiocyanate \ Cyanide toxicity with SNP

A 
Hypotension
Blurred vision
Fatigue
Metab acidosis
Pink skin
No reflexes
Faint heart sounds
56
Q

Risk of thiocyanate/cyanide toxicity increases with doses over _______ for > ____ days of SNP therapy

A

4 mcg/kg/min

2 days

57
Q

SNP will result in thiocyanate in the blood. what is a safe range for the Thiocyanate levels? What range is toxic? Fatal?

A

Safe: 6-29 mcg/mL
Toxic: 35-100 mcg/mL
Fatal: >200 mcg/mL

58
Q

What is the normal cyanide level in the blood for nonsmokers? For smokers?
What cyanide level is toxic? Fatal?

A

Nonsmokers: <0.2 mcg/mL
Smokers: <0.4 mcg/mL

Toxic: >2 mcg/mL
Fatal: >3 mcg/mL

59
Q

tx for cyanide toxicity

A
  • Stop infusion
  • 100% O2
  • Correct metab acidosis
  • 3% nitrite 4-6 mg/kg slowly IV
  • Sodium thiosulfate 150-200 mg/kg IV over 15 min
  • Vit B12 25 mg/hr
60
Q

Advantages to SNP

A

Fast on
Fast off
Dec myocardial O2 demand

61
Q

Disadvantages to SNP

A 
Reflex tachycardia
Cyanide toxicity
Intrapulm shunting
Precipitous drop in BP is possible
Photodegradation
Methemoglobinemia
Coronary steal
Enhanced bleeding
Cerebral vasodilator

Pharm 2 (7 decks)

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