Mechanisms Regulating Arterial Pressure

N203 ATI (Unit 6) Cardio ascular !"stem #

 ANS helps control pressure by adjusting cardiac output (HR x SV) and peripheral resistance. The renin-angiotensin-aldosterone system helps control arterial pressure by: Releasing angiotensin II potent !asoconstrictor o" arterioles and !eins Releasing aldosterone pro#otes Na$ and H%& retention by 'idneys Vasopressin (ADH) is a potent !asoconstrictor and (ater reabsorption. Atrial natriuretic peptide (ANP) is a !asodilator and causes excretion o" Na$ and H%& by 'idneys. )t also inhibits renin secretion. *ecreasing blood !olu#e and dilating arterioles and !eins help control +,

$%ine%hrine

N203 ATI (Unit 6) Cardio ascular !"stem #

-pinephrine (Adrenaline) .atechola#ine Adrenergic Agonist +inds to: /0 !asoconstriction 1 20 HR3 contractility3 4 AV conduction 2% +ronchodilation absorption o" local anesthetics or extra!asated #eds Therapeutic Uses: 5anage super"icial bleeding congestion o" nasal #ucosa +, Treat#ent o" AV bloc' and cardiac arrest Asth#a Hypertensi!e crisis Necrosis "ro# extra!asation Adverse Effects: *ysrhyth#ias 1 #yocardial &% de#and angina ,regnancy (.) Contraindications/Precautions: TCAs bloc' upta'e o" epi. MAOIs e""ect and duration Interactions: 6eneral anesthetics lead heart to be hypersensiti!e to epi dysrhyth#ias -adrenergic !loc"ers (p#entolamine) $-adrenergic !loc"ers (propanolol) Education: Stop in"usion (ith e!idence o" extra!asation7 treat (ith -!loc"er (p#entolamine)
Expected Action:

&o%amine

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

*opa#ine ()ntropin) .atechola#ine Adrenergic Agonist

8o( *ose (*opa#ine receptors) Renal !asodilation 5od *ose (*opa#ine3 21) Abo!e $ HR3 contractility3 AV conduction High *ose (*opa#ine3 21, /1) Abo!e $ !asoconstriction Shoc' Heart "ailure Therapeutic Uses: Necrosis can occur "ro# extra!asation o" high doses Adverse Effects: *ysrhyth#ias 1 #yocardial &% de#and angina ,regnancy (.) Contraindications/Precautions: .): ,heochro#ocyto#a Interactions: Education: Stop in"usion (ith e!idence o" extra!asation7 treat (ith -!loc"er (p#entolamine)

Adrenergic Rece%tors

N203 ATI (Unit 6) Cardio ascular !"stem #

/1 21

Vasoconstriction o" arterioles in s'in3 !iscera3 and

#ucous #e#branes3 and !eins

HR3 contractility3 AV conduction Release o" renin in 'idneys Vasodilation o" arterioles in heart3 lungs3 and

s'eletal #uscle

22

+ronchodilation Relaxation o" uterine s#ooth #uscle 6lycogenolysis in li!er S'eletal #uscle contraction

*opa#ine

Vasodilation o" renal blood !essels

&o'utamine

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

*obuta#ine (*obutrex) 99 .atechola#ine

+inds to: /0 !asoconstriction 1 20 HR3 contractility3 4 AV conduction 2% +ronchodilation Therapeutic Uses: Heart "ailure
Adverse Effects:

,regnancy (+)

heart rate
Contraindications/Precautions:

Interactions:

Education:

Stop in"usion : e!idence o" extra!asation7 treat (ith -!loc"er (p#entolamine)

(#Adrenergic )loc*ers

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: ,ra;osin (5inipress)

Others: doxa;osin #esylate (.ardura)3 ,hentola#ine (Regitine)3 ergota#ine tartrate

Selecti!e /1 bloc'ade resulting in !enous and arterial dilation Hypertension Therapeutic Uses: P#entolamine: -xtra!asation o" adrenergic agonists Do%a&osin mesylate: sy#pto#s o" benign prostatic hypertrophy Adverse Effects: <irst9dose orthostatic hypotension (#onitor +, "or % hrs post9treat#ent) ,regnancy (.) Contraindications/Precautions: Interactions: Antihypertensi!es additi!e hypotensi!e e""ect NSA)*s 1 clonidine antihypertensi!e e""ects o" pra&osin Education:

Centrall" Acting (2 Agonists

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: clonidine (.atapres) Others: guan"acine (Tenex)3 #ethyldopa (Aldo#et)

sy#pathetic out"lo( in .NS bradycardia3 .&3 !asodilation3 +, Hypertension Se!ere cancer pain (epidural) )n!estigational: 5igraine3 "lushing "ro# #enopause3 (ithdra(al #anage#ent *ry #outh (usually resol!es in %9= (ee's) Adverse Effects: *ro(siness 4 sedation Rebound hypertension ,regnancy (.) Contraindications/Precautions: Antihypertensi!es: Additi!e hypotensi!e e""ect Interactions: Pra&osin' 5A&)s3 T.As: .ounteract e""ects o" clonidine. .NS *epressants: Additi!e .NS depressant e""ect Apply patch to hairless s'in on torso or upper ar# Education:
Therapeutic Uses:

+#Adrenergic )loc*ers

N203 ATI (Unit 6) Cardio ascular !"stem #

Proto: Cardioselecti e, #etoprolol (8opressor)3 Nonselecti e: propanolol ()nderal) 9 Others: Cardioselecti e, atenolol3 Nonselecti e, nadolol (.orgard) 219adrenergic bloc'ade HR3 contractility3 AV conduction Hypertension *ysrhyth#ias (bloc' SA1AV cond.) Therapeutic Uses: Angina15) ( &% de#and 9 diastole ti#e per"usion 9 +,&%) Heart "ailure (#echanis# un'no(n3 probably related to abo!e) Hyperthyroidis#3 #igraines3 stage "right3 pheochro#ocyto#a3 glauco#a Adverse Effects: 1: +radycardia .& AV bloc' &rthostatic hypotension Rebound #yocardiu# excitation (d1c o!er 09% (ee's) 2: +ronchoconstriction 6lycogenolysis inhibited .): AV bloc'3 sinus bradycardia Contraindications/Precautions: Nonselecti!es are .) : asth#a3 bronchospas#s3 heart "ailure Interactions: 1: calciu#9channel bloc'ers (erapamil (Calan) and diltia&em (Cardi&em) intensi"y e""ects o" 29bloc'ers. 2: )nsulin pre!ents glycogenolysis Expected Action:

Angiotensin#Con erting $n-"me (AC$) Inhi'itors

N203 ATI (Unit 6) Cardio ascular !"stem #

(5onopril)3 lisinopril (,rini!il)3 ra#ipril (Altace) +loc' production o" angiotensin II arteriole !asodilation3 excretion o" Na$ and H%&3 retention o" ?$3 and possible pathological changes to !essels and heart Heart "ailure Hypertension Therapeutic Uses: ,eripheral neuropathy 5) ( ris' o" H< and #ortality) )amipril can pre!ent 5)3 stro'e3 or death in high9ris' patients Hyper'ale#ia .ough Neutropenia Adverse Effects: Angioede#a (s(elling in tongue1oropharynx) treat (ith epinephrine <irst9dose orthostatic hypotension Rash 4 dysgeusia ,regnancy (*) Contraindications/Precautions: .): bilateral renal stenosis3 history o" angioede#a *iuretics0st9dose hypotension 8ithiu# @8ithiu#A Interactions: Antihypertensi!esAdditi!e e""ects NSA)*s antihypertensi!e e"". ?$ supple#ents1?$ sparing diuretics hyper'ale#ia Captopril 0 hr ac 1 others : or B "ood Education: Should see renal "unction e!idenced by proteinuria

Expected Action:

Proto: captopril (.apoten) > Others: enalapril (Vasotec)3 "osinopril

Angiotensin Rece%tor )loc*ers (AR)s)

N203 ATI (Unit 6) Cardio ascular !"stem #

(A!apro)3 candesartan (Atacand)3 ol#esartan (+enicar) +loc's action o" angiotensin arteriole !asodilation3 excretion o" Na$ 4 H%&3 retention o" ?$ C A.- and AR+ is that cough and hyper'ale#ia are not side e""ects o" AR+. hypertension (all) Stro'e pre!ention (losartan) Therapeutic Uses: 5gt o" heart "ailure 1 #ortality pre!ention a"ter 5) ( (alsartan) *elay progression o" diabetic neuropathy (ir!esartan' losartan) Angioede#a <etal injury Adverse Effects: ,regnancy (*) .): Renal stenosis Contraindications/Precautions: .aution : Hx o" angioede#a Antihypertensi!es Additi!e e""ect : AR+s Interactions: AR+s can be ta'en (ith or (ithout "ood Education: Should see renal "unction e!idenced by proteinuria

Expected Action:

Proto: 8osartan (.o;aar) > Others: !alsartan (*io!an)3 irbesartan

Calcium Channel )loc*ers

N203 ATI (Unit 6) Cardio ascular !"stem #

Proto: ni"edipine (Adalat) > Others: a#lodipine (Nor!asc)3 "elodipine (,lendil)3 nicardipine (.ardene)3 !erapa#il (.alan)3 diltia;e# (.ardi;e#) Ni*edipine: !ascular .a%$channels!asodilation peripheral 4 D arterioles Verapamil' Diltia&em: Abo!e $ contractility3 HR3 AV conduction All: Hypertension All but +elodipine, Angina Therapeutic Uses: Verapamil' Diltia&em, Hypertension3 Angina3 *ysrhyth#ias Ni*edipine: Tachycardia3 peripheral ede#a3 acute toxicity Adverse Effects: Verapamil' Diltia&em, &rthostatic hypotension3 peripheral ede#a3 constipation3 cardiac suppression3 dysrhyth#ias3 acute toxicity Contraindications/Precautions: .): heart bloc'3 hypotension3 bradycardia3 aortic stenosis3 se!ere heart "ailure Digo%in@digo%inA Interactions: Verapamil' Diltia&em: 6rape"ruittoxicity 29bloc'ers: H<3 AV bloc'3 bradycardia Ni*edipine: 6rape"ruittoxicity 29bloc'ers: Esed to re"lex tachycardia Education: Ad#inister )V o!er %9F #inutes
Expected Action:

Meds .or /"%ertensi e Crisis

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action: Therapeutic Uses: Adverse Effects:

Proto: nitroprusside > Others: labetalol (Trandate)3 dia;oxide

(Hyperstat)3 "enoldopa# (.orlopa#)3 tri#ethaphan (Ar"onad)

*irect !asodilation o" !eins and arteries causing rapid +, (preload1a"terload) Hypertensi!e e#ergencies bleeding during surgery by producing controlled hypotension

-xcessi!e hypotension .yanide poisoning: ris' : li!er dys"unction7 6i!e slo(ly (G #cg1'g1#in) along (ith thiosul"ate to deacti!ate cyanide. Thiocyanate poisoning: .an #ani"est as altered #ental state1psychosis. A!oid prolonged use (HF d). ,las#a thiocyanate should be IJ.0 #g1#8 ,regnancy (.) Contraindications/Precautions:
Education:

*iscard solutions that are blue3 red3 or green ,rotect solutions "ro# light *o not #ix other #eds : nitroprusside.

0rganic Nitrates

N203 ATI (Unit 6) Cardio ascular !"stem #

Proto: nitroglycerine > Others: isosorbide dinitrate ()#dur) cardiac &% de#and by dilating !eins and decreasing !enous return (preload) Relaxes or pre!ents spas#s in coronary arteries thus &% supply Treat#ent o" angina (acute3 !ariant3 and prophylaxis) Therapeutic Uses: )V perioperati!e +, control3 H< d1t acute 5) Headache Tolerance &rthostatic hypotension Adverse Effects: Re"lex tachycardia 9 gi!e metoprolol (-opressor) .): trau#atic head injury )., Contraindications/Precautions: .ildena*il (Viagra)Acute or "atal hypotension Interactions: -t&H3 29bloc'ers3 .a9bloc'ers3 diuretics additi!e hypotensi!e e""ects .u!lingual tab1translingual spray: R onset3 S duration Education: Transmucosal: R onset3 8 duration .) caps: S onset3 8 duration Transdermal: S onset3 8 duration (hairless area3 #in K hr1day (ithout #ed to lo(er ris' o" de!eloping tolerance. Topical: S onset3 8 duration IV: Ese glass bottle 4 #"rLs tubing7 Start at slo( rate (G #cg1#in) Expected Action:

Cardiac 1l"cosides

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: digoxin

($) inotropicSV3 .&

Therapeutic Uses: Adverse Effects:

(9) chronotropic H "ill ti#e SV3 .& *ysrhyth#ias3 A9<ib

Tx o" H<

6) e""ects .NS e""ects ("atigue3 !ision changes) *ysrhyth#ias3 cardiotoxicity: ris' "ro#?$3 @digo%inA3 D disease .): !9"ib3 !9tach3 %1FM bloc's /uinidine dig toxicity Verapamil @digoxinA Sy#patho#i#etics add to inotropic e""ect 8oop 4 thia;ide diuretics ?$ ris' o" digo%in dysrhyth#ia A.- inhibitors 1 AR+s ris' ?$ therapeutic digoxin e""ects .hec' apical pulse: hold I NJ (adults)3 I OJ ('ids)3 I PJ (in"ants) Therapeutic le!els Q J.G9% ng1#8 Treat bradycardia : atropine Treat dysrhyth#ias : p#enytoin or lidocaine Acti!ated charcoal or c#olestyramine can bind digo%in to pre!ent absorption.

Contraindications/Precautions: Interactions:

Education:

Antid"srh"thmics
(Class IA, Na2#Channel )loc*ers)

N203 ATI (Unit 6) Cardio ascular !"stem #

odiu! channe" #"oc$ers: procaina#ide (,ronestyl)3 Expected Action:

Ruinidine3 disopyra#ide3 tocainide3 propa"enone Supra!entricular tachycardia Atrial "lutter

conduction 1 auto#aticity 1 repolari;ation rate

Therapeutic Uses:

Ventricular tachycardia
Adverse Effects:

Atrial "ibrillation

Syste#ic lupus syndro#e (resol!e (ith d1c #edication) .ardiotoxicity (SRS3 ST) .): Sens. to 0uinidine3 co#plete D bloc'3 lupus

+lood dyscrasias
Interactions:

Contraindications/Precautions:

Antihypertensi!es additi!e hypotensi!e e""ect

Anticholinergics anticholinergic e""ects Antidysrhyth#ics in therapeutic e""ects 1 toxicity potential

Education:

Anticholinergic $..ects

N203 ATI (Unit 6) Cardio ascular !"stem #

*ry 5outh Erinary retention .onstipation Tachycardia +lurred !ision 5ydriasis

Antid"srh"thmics
(Class I), Na2#Channel )loc*ers)

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

odiu! channe" #"oc$ers: lidocaine (Tylocaine)

conduction 1 auto#aticity 1 repolari;ation rate

Therapeutic Uses: Adverse Effects:

Short9ter# use only "or !entricular dysrhyth#ias Respiratory arrest .): Sto'es9Ada#s3 .o#plete D bloc' ,regnancy (+)

.NS e""ects ("atigue3 paresthesias3 sei;ures) Tx sei;ures : p#enytoin (Dilantin)

Contraindications/Precautions: Interactions:

Cimetidine' p#enytoin' 29+loc'ers e""ects o" lidocaine.

Education:

Ne!er ad#inister lidocaine that has epinep#rine in it.

8oading dose "ollo(ed by #aintenance dose o" 09= #g1#in.

Antid"srh"thmics
(Class I3, Ca22#Channel )loc*ers)

N203 ATI (Unit 6) Cardio ascular !"stem #

Ca"ciu!%channe" #"oc$ers: !erapa#il (.alan)3 Expected Action:

diltia;e# (.ardi;e#)

"orce 1 HR 1 AV node conduction

Therapeutic Uses: Adverse Effects:

Atrial "ibrillation

SVT

Atrial "lutter

&rthostatic hypotension3 peripheral ede#a3 constipation3 cardiac suppression3 dysrhyth#ias3 acute toxicity
Contraindications/Precautions:

6rape"ruittoxicity

.): heart bloc'3 hypotension3 bradycardia3 aortic stenosis3 se!ere heart "ailure
Interactions:

Digo%in@digo%inA

29bloc'ers: H<3 AV bloc'3 bradycardia

Education:

Antid"srh"thmics
(Class III, 42#Channel )loc*ers)

N203 ATI (Unit 6) Cardio ascular !"stem #

Potassiu! channe" #"oc$ers: a#iodarone (.ordarone)3 Expected Action:

bretyliu#3 sotalol3 do"etilide .on!ersion o" A9"ib (oral) Recurrent V9tach

conduction 1 auto#aticity 1 repolari;ation rate 1 contractility

Therapeutic Uses:

Recurrent V9"ib
Adverse Effects:

,ul#onary toxicity Visual disturbances (can blind) .ardiac e""ects sinus bradycardia 4 AV bloc' 1 #ay cause H< 1 Hypotension 8i!er1thyroid dys"unction .NS e""ects 6) e""ects ,hlebitis: .entral !enous line is indicated Pre&nanc' (D) CI: AV bloc'3 bradycardia3 ne(borns3 in"ants

Contraindications/Precautions: Interactions:

(i&h"' Toxic

6rape"ruit toxicity .holestyra#ine @a#iodaroneA /uinidine' procainamide' digo%in' diltia&em' 1ar*arin le!els o" these 29bloc'ers3 (erapamil' diltia&em bradycardia *iuretics3 antidysrhyth#ics3 #acrolide antibiotics ris' dysrhyth#ias

Antid"srh"thmics
($ndogenous 1lucoside)

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Endo&enous )"ucoside: adenosine (Adenocard)3 ibutilide (.or!ert)

conduction through AV node

Therapeutic Uses: Adverse Effects:

,aroxys#al SVT

Uol""9,ar'inson Syndro#e

Sinus bradycardia3 dyspnea3 "lushed "ace (usually I 0 #in) ,regnancy (.)

Contraindications/Precautions:

.): %1FM bloc'3 AV bloc'3 atrial "lutter3 atrial "ibrillation

Interactions:

5ethylxanthines (t#eop#ylline' ca**eine) Adenosine receptors are bloc'ed Dipyridamole (Persantine) Epta'e is bloc'ed leading to e""ects
Education:

Very short li"e (I 0 #in)

Ad#inister by )V bolus3 "lushed (ith NS

Antili%emics
/M1 CoA Reductase Inhi'itors
(!tatins)
N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: ator!astatin (8ipitor) > Others: si#!astatin (Vocor)3 lo!astatin

(5e!acor)3 pra!astatin (,ra!achol)3 rosu!astatin (.restor)

8*8 by 8*8 receptors in li!er V8*8 H*8 ,ro#ote !asodilation 1 plaRue9site in"la##ation 1 thro#boe#bolis# ris'
Therapeutic Uses: Adverse Effects:

0M hypercholesterole#ia ,re!ention o" stro'e and coronary e!ents.

H*8

5yopathy (#onitor .?) ,eripheral neuropathy Hepatotoxicity e!idenced by seru# transa#inase Pre&nanc' *+, rosu(astatin in Asians .): ,regnant 1 !iral or -t&H hepatitis .aution : "etocona&ole <ibrates ris' o" #yopathy 5ed that suppress .W,FA= ("etocona&ole' eryt#romycin) statin le!els 6rape"ruit juice and (lo(astatin or sim(astatin) Toxicity -o(astatin : e!ening #eal (others &? B "ood) Ator(astatin or *lu(astatin should be used (ith renal insu""iciency

Contraindications/Precautions: Interactions:

Education:

Antili%emics 5 6i'rates

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: ge#"ibro;il (8opid) > Others: "eno"ibrate (Tricor)

T6 by V8*8 excretion
Therapeutic Uses: Adverse Effects:

,ro#ote H*8 precursor production

plas#a V8*83 plas#a H*8 6all stones Hepatotoxicity ,regnancy (.) 5yopathy .aution : statins

Contraindications/Precautions:

.): li!er disorders 1 se!ere renal dys"unction 1 gallbladder disease

Interactions:

Statins #yopathy

C#olestyramine absorption

2ar*arin ris' o" bleeding (#onitor ,T and )NR)

Antili%emics 5 Cholesterol A'sor%tion Inhi'itor

N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: e;eti#ibe (Vetia)

)nhibit absorption o" cholesterol secreted in the bile and "ro# "ood.
Therapeutic Uses: Adverse Effects:

Adjunct to #odi"ied diet to help 8*8 (alone or : statin) Uell9tolerated no ad!erse e""ects Pregnancy (X) .aution : breast"eeding

Contraindications/Precautions:

.): Renal dys"unction

Interactions:

+ile acid seRuestrants (c#olestyramine) absorption

Ese (ith "ibrates (gem*i!ro&il) ris' o" gall stones and #yopathy Cyclosporine le!els o" e&etimi!e
Education:

Ta'en once per day (ithout regard to "ood

Antili%emics
)ile#Acid !e7uestrants
N203 ATI (Unit 6) Cardio ascular !"stem #

Expected Action:

Proto: cholestyra#ine (Suestran) > Others: colestipol (.olestid)

8*8 receptors in li!er pro#otes upta'e o" seru# cholesterol 8*8

Therapeutic Uses:

Adjunct (ith H56 .oA reductase inhibitor (eg ator(astatin) 4 diet 8*8
Adverse Effects:

No syste#ic e""ects (not absorbed in 6) tract)

Contraindications/Precautions: Interactions:

.onstipation

.): biliary disease or V8*8

Digo%in' 1ar*arin' t#ia&ides' tetracyclines "or# co#plexes absorption

Education:

*issol!e in (ater or applesauce to pre!ent esophageal irritation or i#paction.