m1 (for long quiz) (quiz2 not included)

Antheroma

also known as plaques

blood pressure

the outward pressure of blood against blood vessel walls, is the product of blood flow from the heart and inward resistance of blood vessel walls

• baroreceptor reflex

• renin-angiotensin-aldosterone system

2 ways of regulation of blood pressure

baroreceptor reflex

responsible for short-term regulation of blood pressure (moment to moment regulation of blood pressure)

renin-angiotensin-aldosterone system

all medicine target what pathway

1. carotid sinus

2. aortic arch

two main locations of baroreceptor

HYPERTENSION

◼ Persistent diastolic BP greater than 90 mm Hg and systolic BP greater than 140 mm Hg

◼ American Heart Association : > 140/90

◼ WHO : > 160/95

Primary or Essential Hypertension

hypertension caused by genes (no specific identifiable causes)

hypertension due to specific disease/identifiable cause

Secondary Hypertension

hypertension caused by comorbidities

secondary hypertension

pheochromocytoma

dusty color tumor

○ Pheochromocytoma

○ Renal Artery Constriction

○ Cushing’s Syndrome

○ Primary Aldosteronism

○ Thyroid/Parathyroid Disease

secondary hypertension is due to specific disease/identifiable causes:

Joint National Committee

JNC

<120/<80

normal hypertension BP

120-139/80-89

Prehypertension BP

140-159/90-99

Stage 1 Hypertension BP

≥160/≥100

Stage 2 hypertension BP

 CHF

 CAD

 Renal Disease

 Ischemic Stroke

 Atherosclerosis

 Retinal Disease

 Aneurysm

 Cardiomyopathy

What are the Complications of Hypertension?

pheochromocytoma

causes excessive production of catecholamines

• increased Cardiac Output

• Systemic Vascular Resistance

two main mechanisms that lead to hypertension

• hypertension

• stress

• pheochromocytoma

causes of increaed cardiac output that leads to hypertension (??)

• stress

• atherosclerosis

• renal artery disease

• pheochromocytoma

• thyroid dysfunction

• cerebral ischemia

causes of increaed vascular resistance that leads to hypertension (??)

diuretic

drugs to decrease blood volume

beta blockers

drugs to decrease cardiac output

vasodilators

drugs to decrease vascular resistance

1. DIURETICS

2. SYMPATHOPLEGICS

3. DIRECT VASODILATORS

4. AGENTS THAT BLOCK PRODUCTION OR ACTION OF ANGIOTENSIN (ANGIOTENSIN ANTAGONISTS)

ANTIHYPERTENSIVE AGENTS

DIURETIC AGENTS

AGENTS TO LOWER BLOOD PRESSURE BY DEPLETING THE BODY OF SODIUM AND REDUCING BLOOD VOLUME

• CAIs - PCT

• Loop Diuretics - TAL

• Thiazides - DCT

• K sparing - CD

• Osmotic diuretics

drugs that modify salt excretion

• ADH antagonist

• ADH antagonist

• Osmotic diuretics

drugs that modify water excretion

thiazide-like diuretic

Indapamide

furosemide

most famous diuretic

1. spironolactone

2. eplerenone

K sparing diuretics - aldosterone antagonist

• Triamterene

• Amiloride

K sparing diuretics - ENac inhibitors

Carbonic anhydrase Inhibitor

weakest diuretic

decrease

Inhibition of Carbonic Anhydrase: __ bicarbonate concentration in the blood

Block the Na+/K+/2Cl- symporter (cotransporter) in thick ascending loop of Henle

MOA of loop diuretics

Amiloride and Triamterene

inhibit the Na+ influx through ion channel (ENaC)

Spironolactone, Eplerenone

antagonize the effect of aldosterone (mineralocorticoid)

-

syndrome of antidiuretic hormone

SIADH

MINOXIDIL

Orally active vasodilator

Minoxidil (Rogaine)

Used topically as a stimulant to hair growth for correction of baldness

Edema due to sodium and water retention

 Reflex tachycardia

 Flushing

 Headache

 Hirsutism/Hypertrichosis

Adverse Effects of Minoxidil

MINOXIDIL and HYDRALAZINE

Dilates arterioles but not veins

severe hypertension

hydralazine is effective in __ hypertension

nitrates

hydralazine when combined with __, it is effective in heart failure

systemic Lupus Erythrematosus

SLE

 Lupus-like syndrome

 Cardiovascular effects (Hypotension, Reflex tachycardia, Palpitation, Angina)

 CNS effects (Headache, Nausea, Anorexia)

Adverse Effects of Hydralazine

SODIUM NITROPRUSSIDE

Parenterally administered vasodilator

SODIUM NITROPRUSSIDE

Dilates both arterial and venous vessels

SODIUM NITROPRUSSIDE

Used in treating hypertensive emergencies as well as severe heart failure

 Hypotension

 Metabolic acidosis

 Arrhythmias

 Methemoglobinemia may also develop during infusion

 Accumulation of Cyanide

Adverse Effects of SODIUM NITROPRUSSIDE

Accumulation of Cyanide

Adverse Effects of SODIUM NITROPRUSSIDE

methylene blue

DOC for methemoglobinemia

Vit. B12

cyanide antidote kit

IV

Cyanide = inhibits complex __ = cellular hypoxia

DIAZOXIDE

Effective and relatively longacting parenterally administered arteriolar dilator

DIAZOXIDE

used to treat hypoglycemia secondary to insulinoma

 Hypotension

 Reflex tachycardia

 Hyperglycemia (inhibit insulin release)

Adverse Effects of Diazoxide

• esmelol (htn - tachycardia)

• fenoldepam

• diazoxide (occasionally)

drugs used for hypertensive emergencies

Dopamine D1 receptor

agonist

MOA of fenoldopam

 Reflex tachycardia

 Headache and flushing

 Increases IOP

toxicities of fenoldopam

• PERIPHERAL EDEMA

• Reflex tachcardia

vasodilator monotherapy s/e

Lercanidipine

Amlodipine

Lacidipine

vasodilators that can be used as monotherapy

-

nifedine cannot be used as mnotherapy

however, (ADALAT CC) = /

Nifedipine

1st gen dihydropyridine (CCB)

• Isradipine

• Nicardipine

• Felodipine

• Nimodipine

2nd gen dihydropyridine (CCB)

Amlodipin

3rd gen dihydropyridine (CCB)

Clevidipine

4th gen dihydropyridine (CCB)

Verapamil (Phenilalkylamine)

Diltiazem (Benzothiazepines)

NON-DIHYDROPYRIDINES CCBs

Verapamil

NON-DIHYDROPYRIDINES

greatest depressant effect on the heart

Diltiazem

NON-DIHYDROPYRIDINES

intermediate action

NON-DIHYDROPYRIDINES

: Cardioselective; Intermediary effects in the heart and blood vessels

Nifedipine

ultra short acting used in emergency management of severe hypertension

Calcium Channel Blockers

Prophylactic therapy in both effort and vasospastic angina

nifedipine

(drug) Abort acute anginal attack

Calcium Channel Blockers in combination with nitrates

Atheroslerotic angina (CCB with what)

verapamil, diltiazem (not approved for this purpose)

drugs for supraventricular tachycardia

 Migraine

 Preterm labor

 Stroke

 Hemorrhagic stroke associated with subarachnoid hemorrhage – nimodipine

 Raynaud’s syndrome

Clinical Uses of Calcium Channel Blocker

Raynaud’s syndrome

spasm of small arteries

ANGIOTENSIN ANTAGONISTS

Reduce peripheral vascular resistance and blood volume

I. Angiotensin-converting Enzyme Inhibitors

II. Angiotensin II-Receptor Blockers

III. Renin Inhibitor - Aliskiren

Angiotensin Antagonists

• Captopril

• Lisinopril

ACE inhibitors that are not prodrug

○ Saralasin

○ Losartan

○ Valsartan

○ Telmisartan

○ Olmesartan

○ Irbesartan

○ Candesartan

○ Eprosartan

○ Azilsartan

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)

 Mild to moderate hypertension

 CHF

 Diabetes mellitus

 In patients with heart failure and chronic kidney disease

Clinical uses of ACE INHIBITORS

ACE INHIBITORS

Can be used safely in ischemic heart disease patients for hypertension

ACE INHIBITORS

Most effective in conditions associated with high renin activity for hypertension

renoprotective

 ACEIs exert a __ effect

ACE INHIBITORS

Useful in treating patients with chronic kidney disease for hypertension

 Hemophilia

 Headache

 Fever

 Hyperkalemia

 Allergy

 Orthostatic hypotension

 Angioedema

 Cough

 Less common with ARBs

 Renal damage in nondiabetic renal vascular disease

 Teratogenic

Adverse effects of Angiotensin Antagonists

Cough

Adverse effect of Angiotensin Antagonists

less common with ARBs

 Fetal hypotension, anuria, and renal failure (renal dysgenesis)

 Contraindicated during the 2nd and 3rd trimester of pregnancy

Adverse effects of Angiotensin Antagonists

 angiotensin antagonists to delay diabetic nephropathy

 ACEIs

Choice of Antihypertensive Drugs Based on Patient Characteristics

Diabetic patients and those with chronic kidney disease

 beta-blockers

 calcium antagonists

 avoid hydralazine

Choice of Antihypertensive Drugs Based on Patient Characteristics

CAD patients

CHF

Choice of Antihypertensive Drugs Based on Patient Characteristics

 ACE inhibitors and/or diuretics

 avoid beta-blockers and calcium antagonists

avoid beta-blockers and diuretics

Choice of Antihypertensive Drugs Based on Patient Characteristics

Athletes

 calcium antagonists

 avoid beta-blockers

Choice of Antihypertensive Drugs Based on Patient Characteristics

Broncho-pulmonary disease patients

avoid beta-blockers and thiazide diuretics

Choice of Antihypertensive Drugs Based on Patient Characteristics

Dyslipidemic patients

 calcium antagonist (nifedipine)

 Vasodilators or ACE-inhibitors

 avoid beta-blockers

Choice of Antihypertensive Drugs Based on Patient Characteristics

Peripheral vascular disease patients