Drugs for the Treatment of Cardiovascular Diseases

The term cardiovascular disease refers to a variety of diseases of the heart and blood vessels. Examples of these diseases include _____

Hypertension (HBP), Angina Pectoris (Chest pain), Coronary Heart Disease (Arteriosclerosis), Arrhythmias (electrical conductivity), Heart Failure (CHF), Hyperlipidemia (High Cholesterol)

Patients with cardiovascular disease are now living longer and more productive because of

Comprehensive Drug Therapy, Cardiac Care Units, Intensive Screening, Common for multiple cardiac conditions

The DH first identifies the pt with cardiovascular disease while taking the medical or drug hx. It is common for such a pt to have several cardiovascular conditions, such as _____

HR(heart failure), hypertension, and hypercholesterolemia (excessive cholesterol in your blood)

Patients who have suffered a myocardial infarction (MI) should wait _____ before receiving any type of oral health care to give the heart a chance to heal. If oral health care is needed before _____ have elapsed, consult with the pts cardiologist or general practitioner to determine whether or not the pts heart has healed enough

6 months

Certain medical situations are absolute contraindications to dental tx until a consultation with the pt's provider has identified any special tx alterations that might be warranted. These absolute contraindications apply only to ______

uncontrolled or severe cardiovascular diseases

Very high blood pressure and uncontrolled arrhythmias are examples of _____

absolute contraindications to elective dental tx

Unstable or the recent onset of angina pectoris, uncontrolled heart failure, uncontrolled arrhythmias, significant uncontrolled hypertension are all _____

cardiovascular contraindications to Dental tx

Most cardiovascular pts should benefit from the use of _____ in the local anesthetic agent

epinephrine

The amount and effect of the epinephrine administered must be weighed against the fact that poor pain management can produce the release of _____ which is released by the patient’s body when they feel pain, stress and anxiety

endogenous epinephrine

Using a slow rate of injection and appropriate aspiration techniques to avoid intravascular injection reduces the chance of ______.

vasoconstrictor adverse reaction

______ the most common cardiovascular disease, affecting some 108 million Americans (45%) and more than 1.3 billion individuals worldwide. Also known as the ______

Hypertension, the silent killer

Approximately 90% to 95% of pts diagnosed with hypertension have ______ hypertension which is due to unidentifiable causes. It tends to be familial and may be the result of the interaction between environmental (poor diet, lack if exercise, and obesity) and genetic factors. If untreated it can lead to serious complications such as _____

essential idiopathic or primary, HF and MI

In approximately 10% of hypertensive pts, the cause can be identified and associated with a specific disease process involving the endocrine or renal system or a result of sleep apnea. ____ hypertension can be tx by removing the cause by surgically correcting the renal artery narrowing or discontinuing the offending drug

Secondary

_____ is an office blood pressure of > 130/80 and home measure of <130/80 after three months of diet and lifestyle modifications. _____ hypertension refers to a discrepancy between home and office blood pressure measurements (>130/80 vs. <130/80). This is a “hidden” hypertension → looks normal in office but actually high at home

White coat hypertension, masked hypertension

The most current recommendation by the AHA is a BP goal of less than ____ for all people regardless of age or presence of absence of chronic kidney disease or diabetes

130/80

______ persons experiencing a hypertensive emergency have blood pressures that are very high or rapidly rising and there is usually evidence of retinal and renal damage. The small number of pts in this group must be treated aggressively with antihypertensive agents. _____ can develop in about 5% of pts with primary or secondary hypertension

Hypertensive Emergency (malignant hypertension)

No symptoms are associated with hypertension, which is why it is called the “______”

silent killer

Complications of hypertension affect organs such as _______. After some damage has occurred, symptoms of malfunction become noticeable

the heart, kidney, and brain as well as the retina

Eventually, a sustained elevated blood pressure damages the body’s organs, so untreated hypertensive pts are more likely to have ______. Likelihood of these complications is greatly increased with concomitant smoking

kidney and heart disease and cardiovascular problems (MI, cerebrovascular accident)

When are antihypertensive medications required?

When BP ≥140/90 mm Hg

When are TWO antihypertensive drugs recommended?

When BP is ≥20/10 mm Hg above goal (≈150/90)

How is Stage 1 hypertension (130–139/80–89) treated?

≥10% risk or comorbidities → 1 drug + lifestyle, <10% risk → lifestyle only

What is the mainstay of hypertension management?

Lifestyle modifications

What are first-line antihypertensive drugs?

Diuretics, ACE inhibitors, ARBs, Calcium channel blockers

A rise in BP higher than baseline after abrupt discontinuation of meds

rebound hypertension

Why is hypertension management critical for overall health?

Prevents serious outcomes like myocardial infarction (MI)

The three major types of diuretics are:

Thiazides (thiazide-like), loop, and potassium (K) sparing

______ diuretics are among agents most commonly used for the tx pf hypertension. Hydrochlorothiazide (HCTZ) is the most commonly used ____

Thiazide (“water pill”)

_____ a thiazide-like agent, however it is 1.5 to 2 times more potent than HCTZ and has a longer duration of action; it continues through the night (these drugs are taken in the morning bc they cause diuresis (increased production of urine)

chlorthalidone

Many pts with stage 1 hypertension are treated solely with HCTZ. When other antihypertensive drugs are used, they are often combined with _____.

thiazides

The thiazides initially inhibit the reabsorption of _____ from the distal convoluted tubule and part of the ascending loop of Henle in the ____. Water and chloride ions passively accompany the sodium, producing diuresis.

sodium, kidney

What is the mechanism of thiazide diuretics?

Decrease sodium reabsorption → increase urine → lower BP

What condition can thiazides worsen due to ↑ uric acid?

Gout

The most important dental drug interaction with the thiazides is with the ______. They can reduce the antihypertensive effect of the thiazide diuretics. However, they can increase the risk of cardiovascular adverse events, especially in those with cardiovascular disease

nonsteroidal antiinflammatiry drugs (NSAIDs)

What is the most common oral side effect of thiazides?

Xerostomia

_____ can be considered the “strong cousins” (Lasix) of the thiazides. It is the most commonly used ____ diuretic, is the prototype drug

Loop

Potassium-Sparing Diuretics are “punny” diuretics with _____ ability.

Potassium-catching

Although the potassium salts are NOT _______, lack of potassium caused by the diuretics must be managed, often with potassium supplementation

cardiac drugs

______ are indicated in the tx of hypokalemia produced by diuretics. It is relatively contraindicated in pts with _________

Potassium Salts, severe renal impairment or those receiving potassium-sparing diuretics

_____ should not be given to patients taking potassium supplements because hyperkalemia occurs with ____

ACEIs

Micro-K, K-Lyte, K-Lor, and Klor-Con are

examples of potassium supplements

_____ prevent the conversion of angiotensin I to angiotensin II (Angiotensin is a hormone in your body that helps control blood pressure and fluid balance). They are commonly used to treat hypertension.

ACEIs

This drug has been found to prolong survival in pts with HF and low left ventricular ejection fraction (LVEF) after a MI, to reduce mortality in pts with HF without low LVEF who are at high risk for adverse cardiovascular events, and to decrease proteinuria in patients with either diabetic or nondiabetic nephropathy

ACEIs

____ meds end in -pril, and examples of this drug include:

Angiotensin-Converting Enzyme Inhibitors (ACEIs), Catopril (Capoten) and Linsinopril (Zestril)

Cardiac output and heart rate are relatively unaffected with this drug

ACEIs

Dysgeusia, an altered sense of taste, is most commonly reported in patients taking captopril an ______ drug. Autoimmune oral lesions such as lichenoid or pemphigoid reactions may have oral manifestations.

ACEIs

The antihypertensive effectiveness of ACEIs is reduced by administration of the ______.

NSAIDs

The _____ act by attaching to the angiotensin II receptor and blocking the effect of angiotensin II.

ARBs

____ end with the suffix -artan

ARBs

Losartan (Cozaar) is the prototype of ____

ARBs

LIKE ACEIs, ARBs are less effective in ______ and ______ unless combined with a diuretic or calcium channel blocker

black patients, other patients with low renin activity

Aliskiren (Tekturna) is the first of a new class of drugs approved by the FDA for the tx of hypertension. What is this new class of drug?

Direct Renin Inhibitors

_____ is indicated for oral use either as a monotherapy or in combination with other antihypertensive drugs.

Aliskiren (Tekturna) a direct renin inhibitor

verapamil (Calan), nifedipine (Procardia XL), and diltiazem (Cardizem) are the common ______

Calcium Channel Blocking Agents (CCBs)

Many Calcium Channel Blocking Agents (CCBs) end in the suffix ____

-dipine

These agents are used to treat hypertension and other cardiac conditions, such as arrhythmias and angina, vasodilation, SM relaxation, lowers BP, HR

Calcium Channel Blocking agents

Today only long-acting ____ are used. The short-acting ____ were associated with a higher risk of MIs and fatalities when taken at higher doses

Calcium Channel Blockers (CCB)

The adrenergic blockers include the ______

alpha blokers and beta blockers

Two alpha receptor subtypes _____ have been identified for alpha 1 blockers

alpha 1 & alpha 2

To avoid orthostatic hypotension dizziness, lightheadedness, or syncope: Raise patient from chair slowly.

To avoid drowsiness or nervousness: use caution if other sedating drugs are necessary.

Nonsteroidal antiinflammatory drugs (NSAIDs) interfere with the antihypertensive effect of alpha 1 blockers

Epinephrine (sympathomimetics) should not be used to treat hypotension

Management of Dental pts taking alpha1-blocking agents

_______ are examples of selective alpha1-adrenergic blocking drugs

Doxazosin (Cardura) and terazosin

Labetalol (Trandate) is a ____ that also has a alpha-receptor blocking activity

Beta-adrenergic receptor blocking drug

Nonselective or nonspecific Beta-adrenergic receptor blocking drugs, such as _____, the prototype, block both Beta1 and Beta 2 receptors. In usual doses, the selective, or specific B-adrenergic receptor blocking drugs, such as _____, block the B1-receptors more than the B2-receptors (B1>B2). At larger doses, receptor selectivity disappears.

propranolol, metoprolol

Pindolol and acebutolol have ______ activity and cause some B-stimulation while blocking catecholamine action

partial agonist

_____ lower blood pressure by primarily decreasing cardiac output. Other effects that may contribute to their antihypertensive effect include a lowering of plasma renin levels, reduction in plasma volume and venous return, a decrease in sympathetic outflow from the CNS, and a reduction in peripheral resistance. These drugs are often used as either single drugs or in combination with other

B-blockers, antihypertensive drugs

Large cardiovascular outcome trials have found that _____ are less effective than ACEIs, ARBs, and CCBs in preventing cardiovascular events such as stroke. They are also less effective in ______

B-blockers, black patients

Nonselective B-blockers can have drug interactions with _____

Epinephrine

Patients pretreated with a nonspecific _______, such as propranolol, and given ______ may have a twofold to fourfold increase in vasopressor response (blood pressure goes up more in pts pretreated with this blockers than in untreated pts), resulting in _____. Via the ______ nerve, the increase in blood pressure triggers a reflex bradycardia

B-blocker, epinephrine, hypertension, vagus

In patients with cardiovascular disease or higher blood pressure, the amount of epinephrine given to patients taking nonspecific B-blockers should be limited to the _______ unless careful blood pressure monitoring accompanies the use of larger doses

cardiac dose,

Propranolol, Metoprolol, Pindolol, and Acebutolol are all

Beta blockers

These antihypertensive agents are used less because they generally have more or less tolerated adverse reactions. It is used in some pts in whom the previously discussed antihypertensives are ineffective

Clonidine

_____ is a CNS-mediated (centrally acting) antihypertensive drug. It reduces heart rate, cardiac output, and total peripheral resistance

Clonidine

The other centrally acting antihypertensive drug is _____. The centrally acting antihypertensive drugs may be combined with diuretics in essential hypertesion management

Methyldopa

_______ exerts its antihypertensive effect by acting directly on the arterioles to reduce peripheral resistance (vasodilation). It also rises heart rate and output

Hydralazine

A serious toxic reaction of Hydralazine produces symptoms like those of _______

systemic lupus erythematosus (lupus-like reaction)

_____ is bad cholesterol and _____ is good cholesterol, and very-low-density-lipoproteins is _____

LDL, HDL, VLDL

_____ are referred to as “bad cholesterol” because they deposit excess cholesterol in artery walls and are considered the most dangerous.

LDL-Cs

______ are referred to as “good cholesterol” because they have the lowest cholesterol content and are considered beneficial (they carry cholesterol away from the blood vessels

High-density lipoproteins (HDL-Cs)

The newest guidelines from the ACC/AHA no longer recommend using specific cholesterol targets to determine tx for patients with elevated cholesterol values. The focus is on patient's estimated _______

10-year atherosclerotic cardiovascular disease risk

Lifestyle modifications, including adhering to a heart healthy diet, getting regular exercise, avoiding tobacco products, and maintaining a healthy weight remain a critical component of lowering lipid levels and should be used in conjunction with ______

cholesterol-lowering drugs

3-Hydroxy-3-Methylglutaryl Coenzyme are _____

Reductase Inhibitors Statins

Inhibitor of Intestinal Absorption of Cholesterol, reduces intestinal absorption of cholesterol ______

Zetia

A B vitamin that lowers cholesterol by inhibiting the secretion of VLDL-Cs

Niacin

Cholestyramine (Welchol) is a bile acid sequestrant that causes bile acids to be ____ with the drug and ______. This leads the liver to make more ______ receptors and pull ______ out of the blood.

bound, excreted, LDL, LDL

The fibric acid derivatives, __________, are used to treat hyperlipidemias, especially when triglycerides are elevated.

gemfibrozil (Lopid), fenofibrate(TriCor), fenofibric (Trilipix)

fenofibrate(TriCor) and fenofibric (Trilipix) agents work by increasing ______, decreasing lipolysis in adipose tissue, and inhibiting secretion of VLDL-Cs from the liver

lypolysis (fat metabolism for energy) of triglycerides

____ a protein in the liver that binds to LDL receptor and degrades it once the LDL particulates are taken from extracellular fluids into cells. As a result, there are fewer LDL receptors to go the cell surface and pick up more LDL particulates that are taken to the liver for metabolism. PCSK9 inhibitors are the newest in the class of drugs that have been shown to decrease LDL cholesterol by as much as 60%.

Proprotein convertase subtilisin/kexin type 9 inhibitos