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Cardiovascular disorders are classified as:
- hypertension
- angina pectoris
- congestive heart failure
- arrhythmias
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What are the three natural controls of blood pressure
- 1. ADH (antidiuretic hormone) – hormonal regulation works by altering volume of fluid in system through kidney function. ADH from the pituitary gland leads to vasoconstriction, less urine output due to reabsorption of water.
- 2. Adrenergic effects – Increase cardiac output (beta 1 stimulation), vasoconstriction in skin (alpha 1 stimulation) to divert blood to vessels in skeletal muscle (beta 2 effect), and decrease flow to kidney (reduce urine formation).
- 3. Renin /Angiotensin /Aldosterone system
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What is hypertension?
an increase in arterial pressure due to the fact that the amount of blood in the vessel is greater than the space available in the blood vessel
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What are some major risk factors for hypertension
- Sedentary lifestyle
- Obesity
- Smoking
- Alcohol
- Stress
- Male
- Family Hx of cardiovascular disease
- Postmenopausal woman
- Sodium intake
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What is Primary/essential hypertension
- -Has no identifiable cause
- -90% of all cases
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What is Secondary hypertension
- –Has a known cause
- –Only small amount of the population with hypertension have an underlying disease known to raise blood pressure
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Systolic pressure occurs when
the left ventricle contracts or pumps, forcing the blood out
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Diastolic pressure is when
the left ventricle relaxes, allowing the blood vessels to refill with blood
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What is the cardiac output and how is it determined?
the amount (volume) of blood pumped out per minute by the ventricle of the heart
stroke volume and heart rate. (SV x HR)
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What is Peripheral resistance or ______ and what is it determined by
- afterload
- refers to the resistance offered by the systemic blood vessels to the flow of blood
- –a. size of lumen - smooth muscle contraction
- – b. viscosity of blood (dehydration / polycythemia*)
- – c. length of vessel (add 7 miles of vessels for 1lb. fat)
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Total amount of blood in body is about __ liters. Maintained by the _____
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Stroke volume is the ________.
amount of blood pumped by a ventricle in one contraction
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Preload is the
volume of blood returned to the heart before it beats
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Contractility is the
forcefulness with which the heart contracts
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Treatment of hypertension is aimed at achieving a balance between ______ and ______
cardiac output and total peripheral vascular resistance
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Prehypertension which is _______ is managed with _______ like _______
- 120-139/80-89
- lifestyle modifications
- Reduce weight
- Limit alcohol consumption
- Increase aerobic physical activity
- Restrict sodium intake
- Stop smoking
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Treatment of hypertension in higher ranges should involve major lifestyle modifications and pharmacotherapy like what 6 medications
- ACE inhibitors - lower blood volume
- Alpha 1 blockers, Alpha 2 agonists
- Angiotensin-II Receptor Blockers – (ARBs)
- Beta blockers
- Calcium channel blockers (CCB’s)
- Diuretics
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Stage 1 uncomplicated (no other diseases present) hypertension: systolic = _____ or diastolic = _____ and treatment should start with a ________
- 140-159
- 90-99
- thiazide diuretic
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Stage 2 uncomplicated hypertension systolic = _______ or diastolic = ______ and treatment should start with ______
- 160 or higher
- 110 or higher
- two or more drugs
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Diuretics are _______ and the _______ of antihypertensive drugs in 1950s Still used as ______ drug because they have _______ and are very effective for _______ hypertension
- So-called water pills
- First class
- first-line
- fewer adverse side effects
- mild to moderate
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Diuretics work on different parts of the ______ to promote _______ loss to reduce _______
- kidney
- water and sodium
- blood volume and thereby lower BP
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The kidneys works through
filtration, reabsorption, and secretion
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Diuretics act by increasing the _________ by excretion of _______
- volume of urine production
- excretion of excess fluids in the body
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Increased loss of fluids and electrolytes of diuretics results in ________
dehydration, orthostatic hypotension, xerostomia, and hypokalemia
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What are the three classes of diuretics
- –Thiazides
- –Loop diuretics
- –Potassium-sparing diuretics
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The prototype of Thiazide diuretics is _________ and works in the _________
- hydrochlorothiazide (HCTZ)
- distal tubules of the kidney by inhibiting sodium reabsorption back into the blood, resulting in increased urination
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The antihypertensive effects of Thiazide Diuretics can last for _______ and also result in ______ because ______
- 24 hours
- Hypokalemia
- Potassium is also lost in the urine
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Thiazide Diuretics can cause an increase in
- serum lipids – (increase in total cholesterol)
- Hyperglycemia (increased blood glucose) so contraindicated in diabetics.
- –May decrease the effectiveness of antidiabetic drugs
- uric acid levels resulting in gout
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Success of diuretic treatment relies on __________ through the kidneys that is driven by _________ therefore _______ drugs can decrease the effects of diuretics
- increased blood flow (increasing filtration and increasing output)
- prostaglandins
- NSAID
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The prototype of loop diuretics is ________ and works by _______. It is the ______ effective diuretic and has an onset of ______
- furosemide (Lasix)
- Inhibit reabsorption of NaCl in the Loop of Henle (in the kidney) and in the distal tubules
- most effective
- one hour (rapid)
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The prototypes for Potassium Sparing Diuretics are ________ and work in the ________
- Spironolactone (Aldactone) and Triamterene (Dyrenium)
- distal tubule of the kidney where inhibition of sodium reabsorption results in a corresponding reduction in K excretion
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Spironolactone + hydrochlorothiazide =
Aldactazide
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Triamterene +HCTZ =
Maxide or Dyazide
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Adrenergic Blockers and Agonists are selected to
- 1.Block α1-receptors, which inhibits vasoconstriction
- 2.Stimulate α2-receptors which inhibit the release of catecholamines that cause vasoconstriction, eg.,EPI and NE
- 3.Block beta 1-adrenergic postsynaptic receptors, preventing stimulation of the heart
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What are the three prototypes of Alpha 1 blockers
- –prazosin (Minipress);
- –doxazosin (Cardura)
- –terazosin (Hytrin) - also useful in treatment of BPH (benign prostatic hypertrophy) thru relaxation of smooth muscle
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What are the centrally and peripherally Alpha 2 agonist
–CENTRALLY – work in the CNS to reduce NE. clonidine (Catapres) - not routinely used due to many side effects
–PERIPHERALLY - deplete neurons of adrenergic neurotransmitters and prevent NE release from nerves that terminate on the heart, stopping sympathetic outflow. reserpine (Serpelan) – fewer problems than the centrally acting alpha 2 agonists.
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What drug is a Nonspecific beta blocker
propranolol - (Inderal): Could cause problems with epinephrine. Limit epinephrine to cardiac dose
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Name two specific Beta 1 blockers
- atenolol (Tenormin)
- metaprolol (Lopressor, Toprol)
Selective β1-receptor blockers act directly on the heart and not on the bronchioles or pancreas (OK in diabetics and asthmatics).
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Drop in BP results in decreased renal blood flow which stimulates the kidney to secrete the enzyme _____. which converts angiotensinogen (produced in the _____) into _________. ___________, made in the _____, cleaves angiotensin I into Angiotensin II
- renin
- liver
- angiotensin I
- Angiotensin Converting Enzyme (ACE)
- lung
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Angiotensin II is a __________ and causes:
potent vasoconstrictor
- increased blood pressure
- decreased urine production
- increased reabsorption of H2O
- adrenal cortex to release Aldosterone
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Aldosterone is a mineralocorticoid that acts on _______ to increase reabsorption of _________ in exchange for the excretion of ________. Therefore causing an increase in ______.
- kidney cells
- water and sodium
- potassium
- BP
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Name three ACE inhibitors
Drug names that end in –pril
- captopril (Capoten)
- enalapril (Vasotec)
- lisinopril (Zestril)
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ACE inhibitors are the preferred drug for patients with
diabetes and hypertension
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What are the adverse effects and the drug interactions with ACE Inhibitors
- Persistent cough which can develop immediately or after months of therapy
- Also, dizziness, headache, xerostomia, orthostatic hypotension, angioedema
Drug interaction: occurs when an NSAID such as naproxen sodium or ibuprofen is taken with an ACE inhibitor
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What are the side effects and drug interactions with Angiotensin-II Receptor Blockers (ARB)
Fewer side effects – lower incidence of cough and fewer side effects than ACE inhibitors
NSAIDs drug interaction
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What are the prototype of Angiotensin-II Receptor Blockers (ARB)
- losartan (Cozar)
- valsartan (Diovan)
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valsartan + HCTZ =
Diovan HCT
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Calcium Channel Blockers (CCB’s) inhibit calcium entry by blocking calcium channels into _______. Calcium is responsible for ________ . So CCB's cause ________
- vascular smooth muscle cells
- vascular smooth muscle contraction
- vasodilation
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What are the two classifications of CCB's and which one is the most effective
Dihydropyridines:
Nondihydropyridines: most effective
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Name the three Dihydropyridines CCBs
- Nifedipine (Procardia)
- amlodipine (Norvasc)
- felodipine (Plendil)
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Name the two Nondihydropyridines CCBs
- verapamil (Calan, Isoptin)
- diltiazem (Cardizem)
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Adverse effects of CCBs are : ____________ especially with ________
orthostatic hypotension, reflex tachycardia, hypotension, and gingival enlargement
nifedipine
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The majority of myocardia ischemia or ________ represents a manifestation of __________
- reduced blood flow
- artherosclerosis
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Angina pectoris is a _______ and occurs when the ________
- temporary chest pain, pressure or discomfort
- metabolic demands of the heart exceed the ability of the coronary arteries to supply adequate blood flow and oxygen to the heart
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Classical symptoms of angina are
squeezing chest pain that radiates to the left, both or right arms, and the jaw
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What are the three types of angina
- Stable
- Unstable
- Variant (Prinzmetal’s angina)
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Describe stable angina
–Chest pain (angina) is intermittent on exertion but relieved by rest
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Describe Unstable Angina
–Oxygen demand exceeds oxygen supply at rest, and the frequency and severity of attacks increases. Platelet clumping. Most will progresses to MI
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Describe Variant (Prinzmetal’s angina)
–Due to a heart vasospasm, often while sleeping
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What are some Drugs/Treatment for Angina
- Nitrates
- β1-blockers
- Calcium channel blockers
- Aspirin: Platelet inhibition
- Lifestyle modifications
- Cholesterol reduction
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Patients with unstable angina are at high risk for __________ and require _________
- heart attack
- antiplatelet drugs
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What is the mechanism of action of Nitrates and what are the prototypes
- Nitrates relax vascular smooth muscle and cause vasodilation
- Nitroglycerin (NTG)-most common, used sublingually as tablet or spray (Nitrostat and Nitrolingual); or transdermally on patch (Transderm Nitro)
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Acute Angina attacks are treated with ________. One tab q __ minutes for __ doses
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Preventative measures of Acute Angina Attacks include
anxiolytics pre-op. medication, eg., benzodiazepine (Valium), nitrous oxide with dental teatment,
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Viagra (“the little blue pill”), is _________ and when taken with nitrates can result in _________
- hypotensive (causes the smooth muscles of blood vessels to relax)
- a great drop in blood pressure
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What is the mechanism of action of beta blockers with patients with angina and what patients are they used with
Decrease myocardial oxygen demand by decreasing the heart rate, contractility and tension
- –Stable angina who require long-term treatment
- –Angina who also have hypertension
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Cardioselective β1-blockers used in the treatment of angina are:
- –atenolol (Tenormin)
- –metoprolol (Lopressor)
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Nonselective β1-blockers used in the treatment of angina are
- –propranolol (Inderal)
- –nadolol (Corgard)
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What is the mechanism of action of CCB with patients with angina and what patients are they used for
Reduce anginal symptoms but do not reduce mortality
- Drug of choice in variant angina (Prinzmetal’s)
- Used in hypertension and arrhythmias
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What CCBs are used in the treatment of angina
- verapamil (Calan, Isoptin)
- diltiazem (Cardizem)
- amlodipine (Norvasc)
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What angina medication reduce mortality and which do not
- Beta blockers and aspirin reduce mortality
- CCB do not reduce mortality
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Dipyridamole - (Persantine)
- Nonnitrate used for prophylaxis treatment of angina and not for an acute attack
- –May decrease platelet aggregation
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What is the mechanism of action aspirin with angina
antiplatelet effect, reduces mortality in patients with unstable angina and helps prevent stroke
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