Perfusion and clotting: pharm exam 4

•refers to the flow of blood through arteries and capillaries delivering nutrients and oxygen to cell

•physiological process in which blood is converted from a liquid to a semisolid gel

¨increase force of myocardial contraction (treat failing heart muscle)

•When clotting factors are not available, patients experience excessive bleeding.

•If blood clots form when not indicated, then a thrombus (blood clot) may obstruct blood vessels and interfere with blood flow.

decrease force of contraction

¨increased heart rate

decrease heart rate

accelerate conduction

decrease conduction

¨The human heart is an organ that pumps blood throughout the body à supplies oxygen and nutrients  to all tissues and removes carbon dioxide and other wastes. If it fails to do this function, the tissues die.¨

ACE Inhibitors

ARB’s

Beta Blockers

Aldosterone antagonists

Phosphodiesterase inhibitors

Cardiac glycosides

Anticoagulants

Antiplatelets

Thrombolytics

Antifibrinolytics

Loop

Osmotic

Potassium Sparing

Thiazide & Thiazide like

Carbonic anhydrase inhibitors

systolic blood pressure (SBP) of greater than 150 mm Hg or diastolic blood pressure (DBP) greater than 90 mm Hg

systolic blood pressure greater than 140 and DBP greater than 90 (remember… OVER 140…OH LORDY!)

Thiazide-type diuretics for most: May consider ACE 1, ARB,  CCB, or combination

Two drug combination (usually thiazide-type diuretics and ACE 1, or  ARB, BB, CCB, or combination

•Bradycardia with reflex tachycardia

•Dry mouth 

•Drowsiness, sedation 

•Constipation

•Depression

•Edema

•Sexual dysfunction

¨Inhibit Angiotensin Converting Enzyme which prevents the formation of angiotensin II à which prevents the breakdown of the vasodilating substance bradykinin which à Results in decreased Systolic vascular   resistance (afterload), which leads to   vasodilation, and therefore decreased BP

edema and decreased urinary output

ACE Inhibitors

They reduce glomerular filtration pressure and reduce proteinuria and are Standard therapy for diabetics

¨Fatigue 

¨Dizziness 

¨Headache 

¨Mood changes

¨Impaired taste 

¨Possible hyperkalemia 

¨Dry, nonproductive cough, which reverses when therapy is stopped

¨Angioedema: rare but potentially fatal

Drug Allergy, pregnancy – category C first trimester; 2^nd and 3^rd trimester Category D

NSAIDs – decrease antihypertensive effects can lead to acute renal failure

5 mEq/L or higher

Hypotension, renal impairment, or renal failure

ACE inhibitors

“Sartan”

¨losartan

¨eprosartan

¨valsartan

¨irbesartan

¨candesartan

¨olmesartan

¨telmisartan

¨azilsartan

¨Block Angiotensin II from binding with the type I Angiotensin II receptors in tissuesà this blocks vasoconstriction and the secretion of aldosterone in the adrenal gland.

vascular smooth muscle and the adrenal gland

• Hypertension

• Adjunctive drugs for the treatment of Heart failure

• May be used alone or with other drugs such as diuretics

• Drug Allergy

• Pregnancy

• Lactation

• Elderly and patients with renal dysfunction

• Chest pain

• Fatigue

• Hypoglycemia

• Diarrhea

• Urinary tract infection

• Anemia

• Weakness

• Hyperkalemia and cough are less likely to occur than with the ACE inhibitors.

Hypotension and Tachycardia

•Reduce the influx of calcium into the cell

•Results in relaxation of smooth muscle & decreased BP

•Depresses automaticity and conduction velocity in smooth and/or cardiac muscle

IV, po, SL

treatment of hypertension, angina and Tachy dysrhythmias (known as supraventricular tachycardia)

• verapamil

• diltiazem

• amlodipine

• nicardipine

• nefedipine

• nimodipine

“dipine” other than verapamil or diltiazem

• angina

• hypertension: amlodipine

• dysrhythmias

• migraine headaches

• raynaud’s disease

• •Prevent the cerebral artery spasms after subarachnoid hemorrhage: nimodipine

nimodipine

• Hypotension

• Palpitations

• Tachycardia or bradycardia

• Constipation

• Nausea

• Dyspnea

• Rash

• Flushing

• Peripheral edema

• Drug allergy

• Acute myocardial infarction (MI)

• 2^nd and 3^rd degree AV block with out pacemaker

• Hypotension

Avoid grapefruit and grapefruit juice

• Obtain BP and AP prior to administration

• Monitor BP

• Postural (orthostatic) hypotension

• Avoid alcohol and smoking

• Encourage weight loss

• Assess necessary labs

• Compliance with medication regimen

• Na restricted diet

• Change positions slowly

• calf pumping

• TED hose

it can cause severe rebound hypertension, MI

• diet – low fat

• low sodium – See DASH diet – amazing results

• Engage in regular exercise

• reduce stress

• weight loss

• avoid prolonged standing or sitting

  • Avoid heat

• Serum creatinine and potassium – ACE inhibitors

• ACE inhibitors can cause renal impairment, which can be identified with serum creatinine

ACE inhibitors can also cause hyperkalemia

diuretics

• Decreased preload 

• Decreased Cardiac Output   

• Decreased total peripheral resistance

Decreased workload of the heart and decreased BP

thiazide

inhibit Na & Cl reabsorption in early portion of distal tubule

inhibit Na & Cl reabsorption in ascending loop of Henle

Block sodium reabsorption in distal tubule or inhibit action of aldosterone; Inhibit K excretion

increase osmotic concentration of renal tubules – promoting water excretion

inhibit carbonic anhydrase  - Increase excretion of bicarbonate, Na & water

chlorothiazide and hydrochlorothiazide

furosemide and bumetanide

spironolactone and triamterene

Mannitol

acetazolamide

oral

begins 2 hours after oral dose

orally and IV

Po- diuresis begins in 60 minutes; IV - within 5 -10 minutes

Carbonic Anhydrase Inhibitor

edema, fluid volume excess, and hypertension

• hypotension

• dehydration

• electrolyte imbalance - especially hypokalemia

• ECG changes, dysrhythmias

• anorexia, N, V, decrease peristalsis

• skeletal muscle weakness

• metabolic alkalosis - from chloride depletion

• ototoxicity

• hyperglycemia, hyperuricemia

• Vertigo, dizziness

• Aminoglycosides which increase ototoxicity

• antihypertensive which decrease BP

• Monitor I & O, daily weight, BP

• Monitor electrolytes - especially K (can cause dysrhythmias, muscle weakness & cramps)

• Give early in the day to prevent nocturia

• Diet – if potassium losing diuretic ( can cause high potassium, low sodium diet of citrus fruit, bananas, fish, etc.)

Directly relax arteriolar or venous smooth muscle (or both)

which results in:

• Decreased Systolic Vascular Resistance

• Decreased afterload

• Peripheral vasodilation

• diazoxide

• hydralazine

• minoxidil

• nitroprusside (Nitropress)

• Treatment of hypertension

• May be used in combination with other drugs

• Sodium nitroprusside

• and IV diazoxide

• dizziness

• headache

• anxiety

• Tachycardia

• edema

• Dyspnea

• nausea, vomiting, diarrhea,

• hepatitis

• systemic lupus erythematosus

• vitamin B₆ deficiency

• rash

• bradycardia

• decreased platelet aggregation

• rash

• hypothyroidism

• Hypotension

• methemoglobinemia,

• (rarely) cyanide toxicity

• ECG changes

• pericardial effusion or tamponade

• angina

• breast tenderness

• rash

• thrombocytopenia

antianginal

Imbalance of oxygen supply and oxygen demand

ranolazine (given orally)

1. Minimize the frequency of attacks and decrease the duration and intensity of angina pain.

2. Improve the patient’s functional capacity with as few adverse effects as possible.

3. Prevent or delay the worst possible outcome -> myocardial infarction

Dilate blood vessels.

Prophylaxis and treatment of angina and other heart problems

• Nitroglycerine

• Isorbide dinitrate

• Isorbide mononitrate

• Drug allergy

• Severe anemia

• Closed angle glaucoma

• Hypotension

• Severe head injury

• Erectile dysfunction drugs (sildenafil, tadalafil, vardenafil)

• Store tablets in dark, airtight container

• Take 1 every 5 minutes x 3

• Replace supply every 3 months

• spray against oral mucosa

• do not inhale spray

• rotate sites

• apply in thin layer to hairless area, cover with plastic

• must be administered in glass bottle, use special tubing

• Monitor BP, pulse

• Instruct patients to avoid nicotine

• headache

• postural hypotension

• reflex tachycardia

• dizziness

• weakness

• Syncope

• palpitations

occurs in vasodilation (occurs rapidly & overcompensates and increases heart rate)

when using more than 1 nitrate form

¨Onset of action 1 to 2 minutes (fastest of all dosage forms), peak action not applicable, duration of action 3 to 5 minutes