Slide 1Review of Cardiac SystemRememberCardiac outputArterial pressureRegulation of arterial pressureRAASCardiac conductionCoronary VasculatureAtherosclerosisHypertensionJNC VII Classification of HTNJNC 7 Hypertension Treatment AlgorithmSlide 15Classes of drugs to treat HTNHTN EmergencyAlpha1 antagonists (not a first-line choice)Beta Blockers (antagonist)Uses of Beta BlockersBeta Blocker ADRBeta-Blockers (-lol) - examplesDirect vasodilatorsHydralazine (Apreseline)Sodium Nitroprusside (Nipride)Calcium Channel Blockers2 types of CCBSE CCBDrugs that effect the RAASSlide 30ACE (prils)ACE (end in PRIL)ARB (sartans)Aldosterone AntagonistsDiureticsLoop diureticsThiazidesPotassium sparing diureticsNSG 325 Cardiac 9/23/20131Review of Cardiac System•Circulatory system•Heart- pumps blood•Arterial system-distributes oxygenated blood to body. Arteries include muscles in vessels. HIGH pressure system•Venous system- Low pressure system-returns blood to the heart. •Capillaries- where exchange of gas and nutrients occur•Pulmonary system- blood from RV to LA. LOW pressure2Remember•The circulation system is a closed system. The output of the right and left heart must be equal over time for effective functioning3Most of the blood in the circulatory system is located in the venous system4Cardiac output•HR x SV= CO•Average 4-6 L/minute•HR controlled by ANS•SV •Myocardial contractility•Cardiac preload•Cardiac afterload•Pre-load •End diastolic volume or end diastolic pressure•Afterload•Arterial pressure that left ventricle must overcome to eject blood5Arterial pressure•Arterial pressure is influenced by: peripheral resistance X CO•Arterial pressure is regulated by:•ANS•Renin-Angiotensin system•Kidneys6Regulation of arterial pressure•Steady state control by ANS•Rapid control by ANS via baro-receptor reflex•Constriction of arterioles and veins•Increase in HR7RAAS•Renin-angiotensin-aldosterone system•Constriction of arterioles and veins (Angiotensin II)•Retention of water by kidneys (Aldosterone)8Cardiac conductionSA nodeAV nodeBundle of HISPurkinje fibers9Coronary Vasculature Exit from Aorta MainstemRCALADLeft circ10Atherosclerosis 11Hypertension•1 in 3 adults in US have HTN (Primary and Secondary)•Contributing factors•Older age•Obesity•For those < 45: M>F; after 65 M=F•Family history•OSA, CKD, Thyroid disease12JNC VII Classification of HTN13JNC 7 Hypertension Treatment Algorithm14Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)Initial Drug ChoicesDrug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling IndicationsLifestyle ModificationsStage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB).Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.Without Compelling IndicationsNot at Goal Blood PressureOptimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.15Classes of drugs to treat HTN•Diuretics- Thiazide diuretic (HCTZ)•Anti-adrenergic medications•Beta blockers•Direct acting vasodilators•Hydralazine•Calcium Channel blockers •Verapamil (Calan)•Drugs that suppress RAAS•ACE•ARB16HTN EmergencyDBP > 120Nitroprusside (Nipride IV)17Alpha1 antagonists(not a first-line choice)•Terazosin (Hytrin) Doxazosin (Cardura)•Use: HTN, BPH•Action: vasodilation from blocking alpha1 receptors on arterioles and veins•ADE: orthostatic hypotension, reflex tachycardia, inhibit ejaculation, nasal congestion •Caution: Do NOT combine with PDE-5 inhibitors (Viagra)18Beta Blockers (antagonist)Prevents the binding of Epi and NE, to beta receptors. Which results in:HRBP Contractility, Automaticity and AV node conductionDecrease oxygen demand Decreased renin production19Uses of Beta BlockersAngina pectorisHypertension Cardiac dysrhythmias (tachycardia)Myocardial infarction and post-MIHeart failure •Hyperthyroidism*•Migraine•Stage fright*•Pheochromocytoma•Glaucoma20Beta Blocker ADR•Too much of a good think is a bad thing•Bradycardia•Reduced CO•AV heart block•Bronchoconstriction (B2)Symptoms include: Fatigue, lower exercise tolerance, ED, depression21Beta-Blockers (-lol) - examples•Nonselective•propranolol (Inderal)•timolol (Blocadren)•sotalol (Betapace)•nadolol (Corgard)•Cardioselective•atenolol (Tenormin)•metoprolol (Toprol, Lopressor)•esmolol (Brevibloc)•Beta1&2+Alpha1•carvedilol (Coreg)•labetalol 22Direct vasodilators•Relax vascular smooth muscle•Calcium Channel Blocker (CCB)•Hydralazine•Nitroprusside23Hydralazine (Apreseline)•Direct vasodilator of arterioles•Indication-mod to sever HTN•ADR: rebound tachycardia, sodium retention•Metabolized: Liver and Kidney•PO, IV•Short actingRoute Onset Peak DurationPO 45 min 2 hours 2-4 hourIV 5-20 min 15-30 min 2-6 hours24Sodium Nitroprusside (Nipride)Action: peripheral vasodilation by a direct action on the venous and arteriolar smooth muscles.HIGH ALERT MEDICATIONRapid lowering of BPMetabolized in RBC’s and tissues to cyanide and by the liver to thiocyanate.½ life 2 minutesUsed to treat HTN crisis.25Calcium Channel Blockers•Prevents calcium ions from entering cells therefore effects contraction•Relaxation of arterioles•Used to treat HTN, angina, cardiac dysrhythmias (atrial).262 types of CCBDihydropyridines•nifedipine(Procardia)•Amlodipine (Norvasc)•Feldipine (Plendil)Have less cardiac suppression effects than nondihydropyridinesNon-dihydropyridines•Verapamil (Calan)•Diltiazem (Cardizem)27SE CCB•Reflex tachycardia, flushing, dizziness, edema, headache•Monitor B/P, pulse•Caution in geriatric patients and those with hepatic impairment28Drugs that effect the RAAS•ACE•ARB•Direct Renin inhibitor (not in this country)•Aldosterone Antagonist2930ACE (prils)•Lower BP by preventing the formation of angiotensin II (no vasoconstriction and volume expansion)Results in vasodilatation and reduced blood volumeADR-cough, angioedema, first-dose hypotension, hyperkalemiaCONTRAINDICATED in PREGNANCY31ACE (end in PRIL)Captopril (Capoten), lisinopril (Prinivil/Zestril)Enalapril (Vasotec) (can be given IV)Benazepril (Lotensin)Caution: monitor renal