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62 Cards in this Set

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Factors affecting blood pressure
BP = [LVEDV - LVESV] * HR * SVR
How full is the heart at the end of diastole?
How empty is the heart after systole?
How fast is the heart beating?
How much peripheral resistance is there?
Types of receptors affecting blood pressure
Alpha 1
Alpha 2
Beta 1
Beta 2
Dopamine
Vasopressin
Alpha 1 receptors: Locations and effects
Locations: peripheral and splanchnic vasculature.
Action: causes vasoconstriction
Alpha 2 receptors: Locations and effects
Location: Peripheral and splanchnic vasculature, CNS.
Action: causes vascular constriction, roles in pain and sedation.
*Pre-synaptic receptors cause negative feedback: next stimulation will not be as strong.
Beta 1 receptors: Locations and effects
Location: cardiac tissue, peripheral vasculature.
Action: Inotropic, chronotropic, lusitropic effects on cardiac tissue.
Vasodilation in peripheral vasculature.
*presynaptic receptors cause positive feedback.
Beta 2 receptors: Locations and effects
Location: Cardiac tissue, peripheral vasculature, bronchial smooth muscle.
Effects: Inotropic, chronotropic, lusitropic effects in cardiac tissue (same as B1). Vasodilation in peripheral vasculature. Relaxation/dilation in bronchial smooth muscle.
B1/B2 receptor ratio in the heart (normal and in chronic CHF)
Normally B1:B2 is 4-6:1.
In chronic CHF, receptors are downregulated by epi stimulation.
CHF ratio is 1-1.5:1
Dopamine receptors: Locations and effects
Locations: cardiac tissue (2 types), peripheral vasculature, splanchnic vasculature, renal, CNS.
Actions: Inotropic and chronotropic effects in the heart. Vasodilation in splanchnic vasculature (improves renal blood flow). Growing use in neurology, fading in CV.
Vasopressin receptors: Locations and effects
Locations: peripheral vasculature, splanchnic vasculature.
Action: MARKED vasoconstriction.
Stereotypic effects of receptors: alpha, beta, DA, Vasopressin
Alpha receptors: cause vasoconstriction (increase afterload)
Beta receptors: increase inotropy, chronotropy, vasodilation, bronchodilation.
DA receptors: Splanchnic/renal vasodilation.
Vasopressin receptors: vasoconstriction.
Beta adrenergic receptor complex: basic mechanism.
Epi or adrenaline stimulates the receptor (usually a G-protein receptor). The receptor is coupled with adenylyl cyclase, which converts ATP into cAMP. cAMP is the biggest intracellular mediator (signal). cAMP causes phosphorylation of calcium channel. Next time a stimulation comes, Ca enters and interacts with SR - causes Ca release that interacts with actin and myosin (muscle contraction).
Affecting LVEDV
LVEDV: preload, or how full the heart gets before it contracts.
Treatment: Fluids (major), alpha agonists (minor).
Affecting LVESV
LVESV: Afterload (how empty the heart gets after systole) and contractility (ability of the heart to pump against pressure).
Treatment: Affect afterload with vasodilators, ACE inhibitors, nitroprusside, PDE inhibitors. Affect contractility with inotropes, B adrenergic agents, PDE inhibitors.
Affecting HR
Heart rate = chronotropy = pulse.
Treatment: chronotropes (b adrenergic agents, atropine, pacemaker)
Affecting SVR
SVR: systemic vascular resistance.
Treatment: vasoconstrictors (alpha adrenergic agents)
Cardiovascular drugs
Epinephrine
Dobutamine
Norepinephrine
Phenylephrine
Dopamine
Vasopressin
Phosphodiesterase inhibitors
Epinephrine
Adrenaline: "God's inotrope"
B effects at low doses.
A effects at high doses.
Inotopic and chronotropic.
Indications: sepsis, cardiogenic shock, post-CABG (coronary artery bypass graft).
Dobutamine
Inotrope, chronotrope, vasodilating effects. Increases contractility and heart rate. Vasodilates, reduces afterload.
B effects.
Indications: acute MI, mild cardiogenic shock.
Norepinephrine
Levophed: "God's pressor."
POTENT VASOCONSTRICTOR
A effects predominate.
B effects are present (maintain contractility against more afterload)
Vasoconstriction and increased SVR.
Indications: sepsis, distributive shock with good CO.
Phenylephrine (Neosynephrine)
Pure alpha agonist.
Vasoconstriction and increased SVR.
Indications: Mild sepsis, hypotension with good CO.
Dopamine (Intropin)
Dose dependent:
B effects at low doses
A effects at high doses
Not used much.
Vasopressin (Pitressin)
Intense vasocontriction though vasopressin receptors.
Non-adrenergic, no direct cardiac effects. Beware: splanchnic vasoconstriction and ischemia.
Indications: raise MAP during cardiac arrest, ACLS, severe shock, CABG (on ACEI)
Phosphodiesterase inhibitors (PDEI)
Milrinone & amrinone
Vasodilators and inotropes
Augments B adrenergic stimulation, causes smooth muscle relaxation (hypotension).
Indications: CABG, vasoconstricted with low CO.
Drugs that act on alpha receptors
NE, phenylephrine, epi, DA
Drugs that act on beta receptors
Isoprotenerol, Epi, Dobutamine, Norepi, DA, Dopexamine
Drugs that act on PDE
Milrinone,amrinone: PDE inhibitors
General drug classes for the treatment of hypertension
Diuretics
Beta blockers
ACE inhibitors
Calcium channel blockers
Vasodilators
Centrally acting agents
Diuretics: 3 types and mechanism of action
Thiazide diuretics: inhibit Na+ absorption at distal tubule
Loop diuretics: Inhibit Na/Cl absorption at ascending loop of Henle
Potassium sparing diuretics: K+ exchange at distant renal tubule (inhibit aldosterone)
Thiazide diuretics: drugs
Hydrochlorothiazide (HCTZ)
Chlorthalidone (Hygroton)
Metolazone (Zaroxolyn)
Indapamide (Lozol)
Thiazide diuretics: dosing and indications
Oral agents, taken 1/day, good for long term management of HTN. Takes 1-2 hours before effects are seen (urine output increases).
Thiazide diuretics: Side effects.
Electrolyte wasting
(ESPECIALLY potassium, magnesium), sodium. Hyperglycemia
Gout
Dehydration
RASH (due to sulfur)
HCTZ overdose: electrolyte wasting without any more blood volume reduction (>25mg).
Hydrochlorothiazide
HCTZ
Most commonly used Thiazide diuretic
Loop diuretics: drugs
Furosemide (Lasix)
Bumetanide (Bumex)
Torsemide (Demadex)
Ethacrynic acid (Edecrin)
Loop diuretics: dosing and indications
Taken 3x/day - for patients with decompensated heart failure, compromised renal function (works higher in the nephron). Duration: 4-6 hours. Onset: 30 minutes - use these when you want to get fluid off in a hurry.
Loop diuretics: side effects
Electrolyte wasting (ESPECIALLY potassium, magnesium), sodium
Hyperglycemia
Gout
Dehydration
Rash
***ALL GIVE RASH EXCEPT ETHACRYNIC ACID (no sulfur moiety)
Furosemide
Lasix
Gold Standard of Loop Diuretics
Potassium sparing diuretics: drugs
Spirinolactone (Aldactone)
Eplerenon (Inspra)
Triamterene
Amiloride
Potassium sparing diuretics: usage and indications
Dosing: given 1x/day. Slow onset of action (hours-days) because you're inhibiting a hormone (aldosterone). Duration is about 1 day.
Potassium sparing diuretics: Side effects
Hyperkalemia
***Spirinolactone causes gynecomastia
ACE inhibitors and ARB's: mechanism of action
Hypertension drugs
ACE inhibitors block angiotensin-converting enzyme (which converts aI to aII).
ARB's block angiotensin II receptors.
ACE inhibitors and ARB's: side effects
Both ACEI and ARB's cause hyperkalemia, increased serum creatinine, acute renal failure, angioedema. CONTRAINDICATED FOR PREGNANCY.
ACE inhibitors also cause a buildup of bradykinins in the lungs (due to ACE inhibition) and cause irritation and cough.
ACE inhibitors: Drugs
Captopril (Capoten)
Enalapril (Vasotec)
Lisinopril (Zestril, Privinil)
Ramipril (Altace)
Benazepril (Lotensin)
Enalapril
Lisinopril
Hypertension drugs, ACEI's. Most commonly used, tested, trusted.
ACEI's: dosage and indications
Captopril is given 3 times per day, onset 15 minutes, duration 6 hours. Best for inpatients.
Enalapril, Lisonopril, Ramipril, Benazepril are given 1x/day, onset 1 hour, duration 24 hours, best for otupatients.
ARB's: Drugs
Losartan (Cozaar)
Valsartan (Diovan)
Irbesartan (Avapro)
Candesartan (Atacand)
Olmesartan (Benicar)
Telmisartan (Micardis)
ARB's: dosage and indications
Given 1x/day. Onset 1-2 hours, duration 24 hours.
Beta blockers: drugs
Atenolol (Tenormin)
Metaprolol (Lopressor, Toprol XL)
Propanolol (Inderal, Inderal LA)
Labetalol (Trandate, Normodyne)
Carvedilol (Coreg)
Side effects of beta blockers
CNS: Drowsiness, lethargy, confusion (Higher lipid solubility = more CNS side effects)
Bronchoreactive events (those that also work on B2 receptors)
AV nodal blockade
Atenolol
Beta blocker
Low lipid solubility
B1 selective
Beta blockers: B1 selective vs non-selective drugs
B1 receptors are located on the heart. B2 receptors are located peripherally in vessels and lungs. Selective B1 blockers are cardioselective and do not have pulmonary effects (such as bronchospasm).
Beta blockers: mechanism of action
By blocking beta receptors, they cause decreased HR, contractility, and CO. They also block renin release from the kidney and indirectly lower BP.
Metaprolol
Beta blocker
Moderate lipid solubility
B1 selective
Propanolol
Beta blocker
High lipid solubility (so CNS side effects are higher)
NOT B1 selective - DO NOT GIVE TO A PERSON WITH ASTHMA.
Labetalol, Carvedilol
Beta blockers.
Moderate lipid solubility
Block A1, B1, and B2 receptors.
So they decrease CO and also inhibit vasoconstriction.
Calcium channel blockers: drugs
Verapamil
Diltiazem
Nifedipine
Nicardipine
Isradipine
Nisoldipine
Calcium channel blockers: mechanism of action
For control of HTN.
These drugs decrease Cardiac contractility, heart rate, and peripheral vascular resistance.
Calcium channel blockers: Tissue specificity
Vasodilators: block dihydropyridine channels (all end in -pine), cause reflex tachycardia.
Nifedipine
Nicardipine
Isradipine
Nisoldipine
Felodipine
Amlodipine
Negative inotropes and chronotropes: verapamil, diltiazem.
**Diltazem works on both.
Best calcium channel blocker drugs
Amlodipine - due to long duration of action
Diltiazem - both vasodilator and negative inotrope/chronotrope
HTN drugs: Peripheral A1 receptor blockers
Terazosin, Doxazosin, Prazosin. Cause inhbition of vasoconstriction. Reserved for males with benign prostatic hypertrophy. INCREASE in cardiac events when used as the only therapy.
HTN drugs: Peripheral A2 receptor agonists
Clonidine, methyldopa. Cause increased vasodilation. Use as add-on therapy with a diuretic.
HTN drugs: Vasodilators
Hydralazine, Minoxidil. Cause major blood pressure decreases. Bad side effect profiles. Use with diuretic and beta blocker to counteract compensatory changes.
Drugs that cause refractory hypertension
NSAIDs, COX 2 inhibitors
OTC items: decongestants, appetite suppressants
Herbal products: ephedra, ma huang, bitter orange, licorice.
Licorice: used to treat ulcers, promotes retention of Na, K, water.
Bitter orange/guarana: either or both found in top 5 weight loss products.