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Angiotensin II (active)
Powerful vasoconstrictor
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ACE
- Enzyme which converts Angiotensin I to Angiotensin II
- Found in all blood vessels. There is a lot of ACE present in the capillary rich lungs
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ACE Inhibitors: Uses
- Blocks conversion of Angiotensin I to Angiotensin II
- Mild to moderate HTN
- Treatment for heart disease (vasodilator)
- May be used with a diuretic
- Diabetic prophylatic against renal failure
- Reverse damage in coronary vessel and kidney
- Prevent coronary remodeling
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lisonopril
- Prinivil
- Zestril
- ACE inhibitor
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ACE inhibitors: ADRs
- Dry hacking cough (chief reason for discontinuation)
- First dose effect: significant drop in BP
- Hyperkalemia if also taking K+ products
- Severe renal insufficiency if only 1 kidney or bilateral renal stenosis
- Fetal harm
- Angioedema: discontinue if large wheals on tongue, pharynx, or glottis
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Angiotensin II Antagonists (ARBs)
- Angiotensin II Receptor blockers
- Block action (vasoconstriction and aldosterone production) of Angiotensin II
- Block binding of Angiotensin II to angiotensin receptors
- Uses: HTN, HF, Diabetic nephropathy, MI,and stroke prevention
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losartan
- Cozaar
- Angiotensin II Antagonist
- Newer than ACE inhibitor
- No cough
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Angiotensin II Antagonist: ADRs
- angioedema
- renal failure
- teratogenic
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Direct Renin Inhibitor
- Prevents conversion of angiotensinogen to angiotensin I: blocks the entire RAAS system
- Low absorption especially with a fatty meal
- Works in top of renal system (proximal tubules?)
- Affected by CYP3A4 enzyme system
- ADR: tetrogenic, diarrhea, less cough, and less angioedema
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aliskiren
- Tekturna
- Direct Renin Inhibitor
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Aldosterone antagonist
- Blocks aldosterone receptors in kidneys
- Results in excretion of Na+ and water and retention of K+
- Effective for HTN and HF
- Caution: hyperkalemia
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Eplerenone
- Inspra
- Aldosterone antagonist
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Calcium channel blockers (action)
- Block slow Ca channels which prevents Ca from entering cell - decrease smooth muscle contractions resulting in vasodilation and decreased PVR
- Do not act on veins
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Diltiazem
- Ca channel blocker
- Acts on heart and vascular smooth muscle
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Ca channel blockers (uses)
- HTN
- Cardiac arrhythmias (slows ventricular HR)
- Angina pectoris (causes vasodilation)
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Ca channel blockers: ADRs
- Constipation (blocks smooth muscle in intestines)
- Dizziness, facial flushing, headache, edema in ankles and feet
- cardiac: bradycardia in susceptible pts.
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nifedipine
- Procardia
- Ca channel blocker
- Acts on vascular smooth muscle only
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verapamil
- Calan, Isoptin
- Ca channel blocker
- Acts on heart and vascular smooth muscle
- opposes reflexive tachycardia
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Beta-adrenergic blockers: Actions
- Compete with epinephrine for beta receptors
- Block beta1 receptors (heart): decreased HR, decreased contractility, decreased CO
- Block beta2 receptors (lungs): bronchospasms
- uses: HF, post MI, HTN
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Atenolol
- Tenormin
- Selective beta blocker (blocks only beta1 sites)
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Metoprolol
- Lopressor
- Selective beta blocker (blocks only beta1 sites)
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carvedilol
- Coreg
- Nonselective beta blocker
- Do not give to asmatics or people with respiratory distress
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propranolol
- Inderal
- Nonselective beta blocker
- Do not give to asmatics or people with respiratory distress
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Beta blockers: Properties
- relief of anxiety
- little volume retention
- antianginal
- post MI protection
- reverse left ventricular hypertrophy
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Beta blockers: ADRs
- Bronchospasm (don't give to asmatics)
- mask hypoglycemia (caution with DM)
- Fld retention to HF
- impotence
- cold extremities
- increased triglycerides
- decreased HDL
- exercise intolerance
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hydralazine
- Apresoline
- vasodilator: arterioles
- decreases peripheral resistance
- uses: HTN, HTN crisis (parenterally), HF
- ADR: reflexive tachycardia, salt and H20 retention, heart failure, drug-induced lupus
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minoxidil
- Loniten or Rogaine
- Similar to hydralazine but more intense
- ADRs more intense too
- uses: severe HTN, unresponsive to other drugs
- ADR: hypertrichosis (Rogaine)
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sodium nitroprusside
- Nipride
- Acts directly on both arteries and veins
- Quick reduction of BP of pt in HTN crisis
- metabolized to cyanide; measure thiocyanate levels
- caution: prolonged use
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clonidine
- Catapres
- centrally acting sympathetic nervous system inhibitors
- block sympathetic nervous system
- PO and transdermal
- Other uses: migraine, pain, opioid withdrawal
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Centrally acting sympathetic nervous system inhibitors
- action: decreases sympathetic tone = peripheral vasodilation
- uses: mild to moderate HTN (not first line, better drugs available)
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prazosin
- Minipress
- Sympatholytic
- Action: decrease PVR and CO
- Uses: mild to moderate HTN
- ADRs: orthostatic hypotension (give at bedtime), resistance/tolerance, Na+ & fluid retention
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Drugs for HF
- beta blockers (decrease LV fx, decrease HR, survival)
- diuretics (esp thiazide and loop: decrease fld vol excess, edema, workload)
- Renin inhibitors (ACE and ARBs): increase renal flow, decrease HTN, decrease cardiac remodeling
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digoxin
- Lanoxin
- cardiac glycoside
- increase contraction, decrease HR
- rapid onset, short duration
- digitalis - foxglove (native plant in N. America)
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digoxin: uses
- congestive HF: systolic (inability to pump)
- dysrhythmias (atrial fib, atrial flutter, surpraventricular tachycardia)
- slows conduction through AV node (dromotropic)
- inotropic: increase contraction
- chronotropic: decrease HR
- does not prolong life (2nd line drug)
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digoxin assessment
- apical pulse: ADR = decr HR (<60 adult, <70 child, <90 infant)
- monitor serum electrolytes: hypokalemia can cause digoxin toxicity
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dopamine
- Intropin
- Positive inotropic
- Given for shock: increase BP, increase CO, increase urine output
- low dose: increase urine output
- med dose: increase urine output, increases CO
- high dose: renal vasoconstriction = decrease urine output and increase BP (DO NOT WANT THIS)
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inamrinone
- Inocor
- inotropic agent
- increases contraction, promotes vasodilation
- Use: if not responding to other drugs; usually short term in hospital
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Class Ia antiarrythmics
- Blocks Na+ channels: slows
- Slows conduction velocity in atria, ventricles
- Delays time for heart to repolarize for another impulse
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quinidine
- sulfate, gluconate
- Class Ia antiarrhythmics
- uses: AF (atrial fibrillation), PVC (premature ventricular contraction), VT (ventricular tachycardia)
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procainamide
- Pronestyl
- Class Ia antiarrhythmics
- uses: AF (atrial fibrillation), PVC (premature ventricular contraction), VT (ventricular tachycardia)
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quinidine: ADRs
- diarrhea (may become severe)
- cinchonism- tinnitus, vertigo, visual disturbances, hearing loss, confusion
- cardiac toxicity
- used in sustained VT, atrial fib, and atrial flutter
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procainamide
- measure CBC with 1st therapy as leukocytes, neutrophils, and platelets may drop
- if antinuclear antibody elevated for prolong use may lead to lupus
- useful for terminating VT and VF
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Class 1b antiarrhythmics
- Blocks sodium influx: slows conduction
- accelerate the repolarization phase
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lidocaine
- Xylocaine
- Uses: ventricular dysrhythmias (PVC, VT)
- treats both acute and chronic conditions
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lidocaine
- loading dose - IV push (50 mg/min)
- continuous infusion: 1-4 mg/min
- ADRs: (parasthesia, numbness, agitation, disorientation)
- Do NOT give lidocaine with preservative
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Class Ic antiarrhythmics
- Action: blocks sodium channels: slows
- depresses sinus node automaticity
- prolonged conduction in the atria,, AV node, ventricle,
- uses: life-threatening arrhythmias refractory to other antiarrhythmics
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propofanone
- Rythmol
- Class Ic antiarrhythmic
- may make VT worse
- May decrease myocardial contractility, exacerbating HF
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