Transcript Anatomy, Physiology, Pathophysiology and

PHARMACOLOGY AND
PATHOPHYSIOLOGY
Anatomy, Physiology, Pathophysiology and Pharmacology of
the Cardiovascular System
BASIC ANATOMY
AND PHYSIOLOGY
BASIC ANATOMY
AND PHYSIOLOGY
THE CARDIAC CYCLE
BASIC ANATOMY
AND PHYSIOLOGY
PRELIMINARY ELECTROCARDIOGRAPHY
• Will be reviewed in
detail in
cardiovascular system
in Med - Surg
CARDIOVASCULAR PATHOPHYSIOLOGY OVERVIEW
•
Hyperlipidemia
•
Hypertension
•
Hypotension
•
CHF
–
•
http://www.youtube.com/watch?v=3YddwXPWVSc&safe=acti
ve
CAD
–
http://www.youtube.com/watch?v=NZ14XjOQoFY
•
Cardiomegaly
•
STEMI / NSTEMI
–
http://www.youtube.com/watch?v=H_VsHmoRQKk
•
Dysrhythmias
•
Angina
–
http://www.youtube.com/watch?v=RXuPBaKzmfM
HYPERLIPIDEMIA
• High Cholesterol
• LDL vs HDL
– Bad Cholesterol and Good Cholesterol
– Build up of plaque in arteries
– Blocks Blood flow; may lead to 100%
occlusion
– Blood Clots can form
– Leads to STEMI, CVA
– To Correct:
Medications, Stents, Surgery (CABG)
THE DIFFERENCE BETWEEN HDL AND LDL
•
LDL
•
Delivers cholesterol to cells
•
Used for membranes and synthesis of steroid
hormones
•
HDL
•
Liver removes LDL and other lipoproteins from
circulation
•
Excess cholesterol from cells is brought back to
liver
•
Reverse cholesterol Transport
•
HDL precursor is produced in liver
•
Circulates in bloodstream, gathers cholesterol
forms HDL and returns to liver
•
Protects against Heart Disease
•
http://www.youtube.com/watch?v=6_pT_uL2b3E
HMG-COA REDUCTASE:
• An enzyme that is a catalyst during the manufacturing of
cholesterol
• Inhibits the manufacture of cholesterol or promotes the
breakdown of cholesterol
• Lowers the blood levels of cholesterol and serum triglycerides
• Increases blood levels of HDLs
HMG-COA REDUCTASE INHIBITORS
STATINS
• Atorvastatin
– Lipitor
• Lovastatin
– Mevacor
• Pravastatin
– Pravachol
• Simvastatin
– Zocor
HMG-COA REDUCTASE INHIBITORS
• Adjunct to Diet Treatment
• Primary Prevention of Coronary Events
• Secondary Prevention of Cardiovascular Events
HMG-COA REDUCTASE INHIBITORS
• Adverse Reactions
– Headache, Blurred Vision, Dizziness, Insomnia
– Abd. Pain, cramping, constipation, nausea
– Elevated CPK level, rhabdomyolysis
• Contraindications
– Known allergies
– Pregnant / Breastfeeding
– ETOH abuse, Acute infection, hypotension, trauma, endocrine disorders
HMG-COA REDUCTASE INHIBITORS
• Interactions
• Macrolides, erythromycin, clarithromycin
– Increased risk of severe myopathy or rhabdomyolysis
• Amiodarone
– Increased risk for myopathy and for severe myopathy or rhabdomyolysis
• Niacin
– Increased risk for severe myopathy or rhabdomyolysis
HMG-COA REDUCTASE INHIBITORS
• Interactions
• Protease inhibitors
– Elevated plasma levels of HMG-CoA Reductase inhibitors
• Verapamil
– Increased risk for myopathy
• Warfarin
– Increased anticoagulant effect
BILE ACID
• Manufactured by liver
• Stored in gallbladder
• Emulsifies lipid aggregates
– Breaks it down
• Decreased bile acids = increased use of cholesterol to
manufacture bile
– Approx. 50mg of cholesterol is converted to bile acids and eliminated
in bile
BILE ACID SEQUESTRANTS
• Questran
– cholestyramine
• Welchol
– colesevelam
• Prevalite
– Cholestyramine
BILE ACID SEQUESTRANTS
Used for
Hyperlipidemia
Pruritus associated with partial biliary obstruction
BILE ACID SEQUESTRANTS
• Adverse Reactions
– Constipation
– Aggravation of hemorrhoids
– Abd. cramps
– Nausea
– Vitamin K malabsorption
• Increased bleeding risk
– Vitamin A and D deficiencies
– Iron
BILE ACID SEQUESTRANTS
• Contraindications / Precautions
• Known allergy
• Complete Biliary Obstruction
• Liver and Kidney Disease
• Pregnancy and Breastfeeding
BILE ACID SEQUESTRANTS
• Interactions
• Anticoagulants
– Decreased effect of the anticoagulant (particularly cholestyramine)
• Thyroid hormone
– Loss of efficacy of thyroid; also hypothyroidism (particularly with
cholestyramine)
• Ursodiol
– Reduced absorption of ursodiol (particularly cholestyramine and
colestipol)
BILE ACID SEQUESTRANTS
• Interactions
• Aspirin, clindamycin, penicillin G, tetracycline, clofibrate, niacin,
digitalis glycosides,
– Decreased serum level or decreased GI absorption
• Furosemide, thiazide diuretics, hydrocortisone, methyldopa
propranolol, phenytoin
– Decreased serum level or decreased GI absorption
FIBRIC ACID
• Raise HDL
• Lower LDL
• Increase in activity of hepatic lipase and lipoprotein lipase
• Reduction in VLDL as well as reduction in liver synthesis of VLDL
FIBRIC ACID DERIVATIVES
• fibs (within the name)
• Lipofen, Tricor, Trilipix
– fenofibrate
• Lopid
– gemfibrozil
FIBRIC ACID DERIVATIVES
• Adverse Reactions
– N/ V / D
– GI Upset
– Cholelithiasis
– Cholecycstitis
FIBRIC ACID DERIVATIVES
• Contraindications / Caution
• Known Allergy
• Significant hepatic or renal dysfunction
• Primary Biliary Cirrhosis
• PUD
• DM
• Pregnancy / Breastfeeding
FIBRIC ACID DERIVATIVES
• Interactions
• Anticoagulants
– Enhanced effects of the anticoagulants (particularly with gemfibrozil and
fenofibrate)
• Cyclosporine
– Decreased effects of cyclosporine (particularly with gemfibrozil)
FIBRIC ACID DERIVATIVES
• Interactions
• HMG-CoA
– Increased risk for rhabdomyolysis (particularly with gemfibrozil and
fenofibrate)
• Sulfonylureas
– Increased hypoglycemic effects (particularly with gemfibrozil)
HYPERTENSION
FACTORS INFLUENCING BLOOD PRESSURE
• Ejection Fraction
– Blood ejected from LV :: Amount of Blood in LV Prior to Contraction
• Stroke Volume
– Volume of Blood Ejected by the heart per contraction
– Influenced by Preload, Contractility and Afterload
• Cardiac Output
– Amount of blood pumped in one minute
FACTORS INFLUENCING BLOOD PRESSURE
• Contractility
– Contractile strength of heart
• Preload
– Amount of blood that fills the ventricles during diastole
• Afterload
– Resistance the ventricle pump against
http://www.youtube.com/watch?v=diG519d
FVNs
ANGIOTENSIN CONVERTING ENZYME
• Converts angiotensin I to angiotensin II
• Powerful vasoconstrictor
ACE INHIBITORS
• Suppression of renin-angiotensin – aldosterone system
• Prevents or Inhibits ACE
• Sodium and Water are not contained
– Decrease in BP
ACE INHIBITORS
• PRILS
• benazepril
– Lotensin
• captopril
• lisinopril
– Prinivil, Zestril
• enalapril
– Vasotec
ACE INHIBITORS
• Adverse Reactions
– N/V/D
– Gastric Irritation
– Anorexia
– Constipation
– Rash
– Dry Cough
– Tachycardia
– Hypotension
– Proteinuria
– Neutropenia
ACE INHIBITORS
• Contraindications
– Known Allergy
– Impaired renal function
– CHF
– Sodium depletion
– Volume Depletion
– Angioedema
– Pregnancy / Breastfeeding
• Fetal and neonatal death
ACE INHIBITORS
• Precautions
– Electrolyte imbalances
– Coronary insufficiency
– Cerebrovascular insufficiency
– Diuretic Use
ACE INHIBITORS
• Interactions
• Diuretics
– Decrease effectiveness of ACEI
• NSAIDs
– Decrease effectiveness of ACEI
• Digoxin
– Increase or decrease in serum levels of digoxin
• Lithium
– Increase in serum levels
– Lithium Toxicity
ANGIOTENSIN II RECEPTOR
ANGIOTENSIN II RECEPTOR BLOCKERS
• SARTANS
• valsartan
– Diovan
• losartan
– Cozaar
• olmesartan
– Benicar
• losartan and hydrochlorothyazide
– Combined ARB with diuretic = Hyzaar
ANGIOTENSIN II RECEPTOR BLOCKERS
• Used for
– CAD
– HF
– Those who cannot tolerate ACEI
– Those with Renal Disease secondary to DM
– Those with DM
ANGIOTENSIN II RECEPTOR BLOCKERS
• block the binding of angiotensin II at the receptor sites found in
smooth muscle and adrenal gland, this stops renin angiotensin
system and lowers blood pressure
ANGIOTENSIN II RECEPTOR BLOCKERS
• Adverse Reactions
– Fatigue
– Depression
– Dizziness
– HA
– Syncope
– Abd. Pain
– N/V/D
– Constipation
– Hypotension
– Sx. Similar to URI
ANGIOTENSIN II RECEPTOR BLOCKERS
• Contraindications
– Pregnancy and Breastfeeding
• Fetal or Neonatal death / injury
BETA BLOCKERS
• OLOLs
• acebutolol
– Sectral
• atenolol
– Tenormin
• Metoprolol
• nadolol
• Propranolol
– Inderal
BETA BLOCKERS
• Uses
– Hypertension
– Dysrhythmias
– HF
– Angina
– MI
– Glaucoma
– Generalized Anxiety Disorder
– Hyperthyroidism
BETA BLOCKERS
• Adverse Reactions
– Fatigue
– Cold Hands
– HA
– GI Upset
– N/V/D
– Dizziness
– Constipation
– Decreased Libido
– Depression
– Increased cholesterol / triglycerides
BETA BLOCKERS
• Contraindications / Cautions
– Asthmatics
• Trigger severe attacks
– DM
• Mask signs of Low FSBS
CALCIUM CHANNEL
CALCIUM CHANNEL BLOCKERS
• PINEs
• Amlodopine
– Norvasc
• Nicardipine
– Cardene SR
• nifedipine
– Procardia
• diltiazem
– Cardizem
• Verapamil
– Calan
CALCIUM CHANNEL BLOCKERS
• Uses
– HTN
– Migraines
– Raynaud’s
– Dysrythmias
– Pulmonary HTN
– Angina
– Brain Aneurysm Complications
CALCIUM CHANNEL BLOCKERS
• Adverse Effects
– Constipation
– Nausea
– Tachycardia
– Dizziness
– Rash
– Drowsiness
– Flushing
– Peripheral Edema
CALCIUM CHANNEL BLOCKERS
• Contraindicated
– Known Hypersensitivity
– Sick Sinus Syndrome
– Second and Third Degree AV Block
– Hypotension
– Ventricular Dysfunction
– Cardiogenic Shock
CALCIUM CHANNEL BLOCKERS
• Precautions
– CHF
Renal Impairment
– Hepatic Impairment
– Pregnancy and Breast Feeding
• Interactions
– Cimetidine and Ranitidine
• Increase effect of CCB
– Theophylline
• Increased serum levels of theophylline
– Digoxin
• Increased Risk of Digitalis Toxicity
NITRATES
• Relax Smooth Muscle layer of blood vessels
• Increased arterial lumen
NITRATES
• Uses
– Angina
– Perioperative HTN
• Nitroglycerine
– SL Tablets
– Glass IV Bottles (Drip)
– TD Patch
NITRATES
• Adverse Reactions
– HA
– Dizziness
– Weakness
– Hypotension
– Rash
– Flushing
– Nausea
NITRATES
• Contraindications
– Known Hypersensitivity
– Severe Anemia
– Closed Angle Glaucoma
– Postural HTN
– Head Trauma
– Cerebral Hemorrhage
– Adhesive Allergy (TD Patches)
– Constrictive Pericarditis
NITRATES
• Precautions
– Severe Hepatic or Renal Disease
– Head Trauma
– Acute MI
Hypothyroidism
– Pregnancy and Breastfeeding
NITRATES
• Interactions
– ETOH
• Severe hypotension
• Cardiovascular Collapse
– ASA
• Increase in nitrate plasma concentrations
– CCB
• Increased symptomatic orthostatic hypotension
• Heparin
– Increased effect of heparin
– Sexual Enhancement Medications
• Increased Hypotension
TREATMENT OF HYPOTENSION (NOT IN TEXT)
• Causes of Hypotension
– Hyponatremia
– Dehydration
– Medications
– Shock
TREATMENT OF HYPOTENSION
• Fluid Bolus
• Trendelendurg
• Discontinue the Medication
TREATMENT OF HYPOTENSION
• Pharmacology
– Sympathomimetic Agents
• Shock Medications
• Alpha Adrenoceptor Agonists
– Methoxamine
– Phenylephrine
• Beta Adrenoceptor Agonists
• Norepinephrine
• Epinephrine
• These drugs mimic the sympathetic
adrenergic stimulation
TREATMENT OF HYPOTENSION
• Pharmacology
– Vasopressors
– Levophed
• Norepinepherine
– Dobutamine
– Dopamine
– Pitressin
• Vasopressin (V2)
– Stimate
• Desmopressin (V2)
ANTICOAGULANTS
• Coumadin
– warfarin
• Lovenox
– enoxaparin
• Heparin
• Xarelto
– rivaroxaban
• Pradaxa
– Dabigatran
• Tissue Plasminogen Activator
– tPA
• Tenecteplase
– TNKase
– http://www.youtube.com/watch?v=A6gyWtvrYG8&
safe=active
ANTICOAGULANTS
• Coumadin
– Depletes Prothrombin
• Heparin
– Inhibits formation of fibrin
– Inhibits Conversion of Fibrinogen to Fibrin
– Inactivates Clotting Factors
• Lovenox
– Inhibits reaction by binding to Antithrombin III
• TNKase
– Fibrin Selectivity disrupts plasminogen activation
ANTICOAGULANTS
• Uses
– DVT
– Atrial Fibrillation
– Pulmonary Embolism
– MI
– CVA
– Disseminated Intravascular Coagulation
– Central Line Catheter Patency (Heparin)
ANTICOAGULANTS
• Adverse Reactions
– Bleeding
– N/V/D
– Abdominal Cramping
– Alopecia
– Rash
– Hepatitis
– Jaundice
– Thrombocytopenia
– Blood Dyscrasias
ANTICOAGULANTS
• Contraindications
– Known Sensivity
– Active Bleeding
– Leukemia
– Tuberculosis
– Uncontrolled HTN
– GI Ulcers
– Recent Surgery
• Particularly of the eye or CNS
– Aneurysms
– Breast Feeding
ANTICOAGULANTS
• Precautions
–
–
–
–
–
–
–
–
–
–
–
Fever
CHF
Diarrhea
DM
Cancer
HTN
Renal or Hepatic Disease
Psychoses
Depression
Potential sites of bleeding or hemorrhage
Recommended use of Contraceptives in Women
ANTICOAGULANTS
• Increased Risk of Bleeding with:
–
–
–
–
–
–
–
–
ASA
NSAIDS
PCN
Aminoglycosides
Tetracyclines
Cephalosporins
Beta Blockers
Loop Diuretics
• Decreased Effectiveness of Anticoagulant
–
–
–
–
Barbituates
Diuretics
Vitamin K*
Oral Contraceptives
ANTIPLATELET DRUGS
• ASA
– Prohibits Aggregation
• ADP Blockers
– Alter cell membrane to prevent aggregation
– Plavix
• Clopidogrel
• Glycoprotein Receptor Blockers
– Inhibits platelet aggregation via enzyme production
– COX Inhibitors
ANTIPLATELET THERAPY
• Uses
– ACS
– MI
– CVA
– Intermittent Claudication
ANTIPLATELET DRUGS
• Adverse Reactions
– Heart Palpitations
– Bleeding
– Dizziness
– HA
– N/V/D
– Constipation
ANTIPLATELET DRUGS
• Contraindicated
– Known Hypersensitivity
– CHF
– Active Bleeding
– Thrombotic Thrombocytopenia Purpura
– Pregnancy and Breastfeeding
ANTIPLATELET DRUGS
• ASA and NSAIDs
– Increased Risk of Bleeding
• Macrolide Antibioitics
– Increased Effectiveness of Anti-infective
• Digoxin
– Decreased Digoxin Serum Levels
• Phenytoin
– Increased Phenytoin Serum Levels
CARDIOTONICS
• Two Groups
– Cardiac Glycosides
– Phosphodisterase
CARDIOTONICS
• Cardiac Glycosides
– Digoxin
• Lanoxin
– Uses
•
•
•
•
CHF
A – flutter
A – fib
Paroxysmal Atrial Tachycardia
DIGOXIN
• Increase Cardiac Output
– Slows the conduction velocity through the AV node
– Decreases Heart Rate
DIGOXIN
• Contraindications
–
–
–
–
–
V – tach
V – Fib
Sick Sinus Syndrome
Renal Impairment
AV Block
• Precautions
–
–
–
–
–
Electrolyte Imbalance
Carditis
MI
Heart Block
Renal or Hepatic Impairment
DIGOXIN
• Interactions
– Increased plasma dig levels leading
to toxicity
•
•
•
•
•
•
•
•
•
Amiodarone
Benzodiazepines
Indomethacin
Itraconazole
Macrolide
Quinidine
Spironolactone
Tetracyclines
Verapamil
• Interactions
– Decreased plasma dig levels leading
to toxicity
•
•
•
•
•
•
Aminoglycoside
Antineoplastics
Activated Charcoal
Neomycin
Rifampin
St. John’s Wort
ANTIARRHYTHMIC DRUGS
• Uses
– PVC
– Vtach
– PAT
– A fib
– A flutter
– Tachycardia
ANTIARRHYTHMIC DRUGS
• Tambocor
– Flecainide
• Procanbid
– Procainamide
• Cordarone
– Amiodarone
• Betapace
– Sotalol
• Beta Blockers and CCBs also used
ANTIARRHYTHMIC DRUGS
• Adverse Reactions
– Light Headedness
– Weakness
– Hypotension
– Bradycardia
– Arrhythmias
– Urinary Retention
ANTIARRHYTHMIC DRUGS
• Precautions
– Renal or Hepatic Disease
– Electrolyte Disturbances
– CHF
ADDITIONAL MEDICATIONS AND TREATMENTS
• Pacemakers
• Implantable Cardioverter – Defibrillator
• Coronary Artery Bypass Surgery
• Cardiac Catheterization
ADMINISTRATION OF MEDICATIONS
• Always Obtain Vitals
• Withhold if HR less than 60
• Withhold if SBP less than 100 or 90
• Observe for Adverse Reactions and Toxicity
• Cardiac Monitoring
• Lab Values
– PT / INR
– Serum Levels