1. Week 5 Cardiovascular and Respiratory Systems Chapters 26 and 27: HS140 – Pharmacology

2. Cardiovascular Disorders Functions of Circulatory System Composed of heart (pump) and blood vessels Delivers oxygen, nutrients, hormones etc to various cells throughout the body Removal of waste products Pulmonary Circulation  filter blood through lungs to drop off CO 2 and pick up O 2 Systemic Circulation  delivers fresh (oxygenated) blood to all tissues except heart/lungs Coronary Circulation  provides fresh blood to myocardium

3. Diseases of the Heart & Vessels Coronary Artery Disease (CAD)  decreased blood flow through coronary arteries from … Atherosclerosis  hardening/narrowing of blood vessels Statins are especially useful Angina  spasms of the cardiac muscle as a result of ischemia (oxygen deprivation) Nitrates are pivotal in treatment Myocardial Infarction (MI, heart attack)  heart is deprived of blood supply and tissues become necrotic Hypertension (increased blood pressure)  >140/90; >120/80 = pre-hypertension Dangerous: increased blood flow damages the artery walls and more likely for plaque formation to occur

4. CHF Congestive Heart Failure  heart muscle is weak and cannot pump sufficient volume of blood – ‘pooling’ Drug combination most often used is: Digoxin and Lasix (furosemide) Digoxin is a positive ionotrope-increasing strength of contraction of heart Lasix is a diuretic that causes ‘elimination’ of excess body fluid, reducing edema(swelling)

5. Drugs in treatment of CV diseases Diuretics for HTN Inhibit sodium chloride reabsorption to excrete more H 2 O May lead to decreased K+ levels (hypokalemia) Lasix®-furosemide  loop diuretic-most potent Hydrodiuril®-hydrochlorothiazide (hctz)  commonly used Aldactone®-spironolactone  potassium sparing Many combinations with HCTZ, ex:Hyzaar®= Losartan/HCTZ Patient counseling points: take diuretics in morning (otherwise pee all night long), sip water or chew gum to relieve dry mouth, avoid sunlight with loops or thiazides

6. Nitrates for Angina Oldest, most used for angina attack to relieve intense pain via Sublingual route (SL)= under tongue Dilate systemic blood vessels to reduce cardiac work and oxygen consumption Work by relaxing smoothe blood vessel walls Isosorbide mononitrate/dinitrate-differ in duration of action, and are swallowed (PO) SE’s: headache, tachycardia, lightheadedness, dizziness, hypotension

7. Nitroglycerin (NTG) Sublingual NTG: acute anginal attacks (dosing) 1 tab SL at onset of pain; may repeat 1 tab every 5 minutes for 2 doses. If pain persists, pt to seek medical attention NTG unstable, should be kept original bottle (dark, tightly closed vial); expiration date is 6 months from bottle opening Transdermal NTG: available as a patch that slowly releases NTG through the skin Applied to hairless area of skin; rotated daily Do not keep on longer than 12 hours !! NTG spray-good for those with poor dexterity

8. Beta blockers for HTN, angina Block sympathetic output and decrease oxygen use Decrease heart rate, force of contraction, and blood pressure Examples: (olol’s) Inderal®-propranolol Tenormin®-atenolol Toprol XL®-metoprolol succinate Lopressor®-metoprolol tartrate SE’s: tachycardia, dizziness, bronchospasm, beware hide symptoms of hypoglycemia in DM pts

9. ACE Inhibitors & ARB’s for HTN, CHF Inhibit the renin-angiotensin-aldosterone system from causing vasoconstriction Treat CHF, severe HTN  result in renal and systemic vasodilation ARB (angiotensin-2 receptor blockers)  “sartans” ie. Cozaar®=losartan ACE I’s (angiotensin-converting-enzyme inhib)  “prils” ie. Zestril®=prinivil; Altace®=ramipril SE’s: “ace” cough,hyperkalemia, angio-edema

10. Calcium Channel Blockers for HTN, angina Interfere with influx of calcium in vascular and smooth muscle Reduce ability of vessels to constrict – result is decreased blood pressure Calan®=verapamil Cardizem®=diltiazem Plendil®=felodipine SE’s: edema, headache, reflex tachycardia

11. Hyperlipidemia We all need cholesterol and triglycerides (fats) to form cell membrane and nervous tissue! Excessive lipids in circulation leads to hyperlipidemia and potential for artherosclerosis (plaques which accumulate and harden the artery walls) HDL(‘good cholesterol’) - high density lipoproteins carry cholesterol out of blood stream and into liver for storage; GOAL >35 LDL(‘bad’ cholesterol) - low density lipoproteins carry cholesterol from the liver to the blood stream GOAL <130

12. HMG-CoA reductase inhibitors aka “STATIN’s” ex: Lipitor (atorvastatin) Zocor (simvastatin) Crestor (resuvastatin) Most effective agents to lower TOTAL cholesterol and LDL levels Must be continued for life to reduce the progression of Coronary Artery Disease (CAD) Major side effect: rhabdomyolysis (muscle breakdown, symptom is muscle-aches) Other SE’s: Headache, cramping

13. Bile Acid Sequestrants Non-absorbable drugs bind bile acids in the GIT to form insoluble complexes that are excreted in feces Not commonly used since Statins arrived Can decrease LDL and total cholesterol Beware using in pts with gallstones, hemorrhoids, and vitamin A, D, E, K Ex: cholestyramine, colestipol SE’s: constipation, n/v, dizziness

14. Important Facts about Hypolipemics Diet modification is the PRIMARY method for reducing LDL & cholesterol levels Statins are the most effective drugs for lowering LDL & total cholesterol Bile-acid-binding resins prevent reabsorption of bile acids in the intestines Cholestyramine powder must be mixed with 8ox of water prior to administering

15. Coagulation Blood clot formation is necessary to prevent excessive blood loss (wounds, surgery) Platelet plugs followed by coagulation results in hemostasis (stoppage of blood flow) Thromboembolism occurs if blood clot or undissolved matter forms in blood vessel, blocking blood flow

16. Common Anticoagulants Heparin – immediate action, short duration Administered parenterally Warfarin (Coumadin) – delayed onset Administered orally Used prophylactically to prevent deep vein thrombosis or thrombus formation in Atrial Fib BEWARE! monitor pt for bruising, bloody stools, bleeding gums Coumadin has lots of drug-interactions... PT/INR levels must be monitored closely!

17. Other drugs Antiplatelet drugs: suppress clumping of platelets in arteries Ex: aspirin, Plavix® Thrombolytics: dissolve clots already formed Activase(alteplase), Streptase(streptokinase) Topical hemostatics: gelatin or cellulose sponges that absorb excess blood and fluids

18. Coagulation - Key Points Hemostasis occurs with the formation of the platelet plug, followed by coagulation. Anticoagulants help prevent venous thrombi; antiplatelet drugs help prevent arterial thrombi Heparin is adminstered intramuscularly or deep subcutaneously Warfarin is the prototype for oral anticoagulants

19. Respiratory System/Disorders Respiratory Tract – Upper/Middle/Lower - carries Oxygen to, and … - removes Carbon Dioxide from, the lungs Any change in the Resp.System will affect all body systems, therefore … before treating other problems, this oxygen-carbon dioxide exchange system must be corrected! See diagrams on page-525 of your textbook

20. Upper Resp Tract Conditions Allergic Rhinitis – caused by histamine release Symptoms include: *sneezing,*runny nose, *itching, and *congestion Histamine protects us from environment! Greatest concentration of Histamine found in *skin,*GI tract, and the *lungs – those organs most exposed to potenially damaging elements around us

21. Drugs for Nasal Congestion(1) Antihistamines – notice … ‘anti-Histamine’ these block the H1 receptor sites, preventing histamine’s action 1 st Generation: -- sedating, short acting examples -chlorpheniramine (ChlorTrimeton) -diphenhydramine (Benadryl) 2 nd Generation: -less, or NON-sedating, and much longer duration of action (Claritin, Zyrtec)

22. Drugs for Nasal Congestion(2) Decongestants: reduce congestion by shrinking swollen mucous membranes of the nasal passage Often combined with AntiHistamines Oral and Nasal preparations are both available Phenylephrine – most widely used, less elevation of blood pressure, no METH link! Pseudoephedrine(e.g.,Sudafed) – stimulates the CNS causing elevated BP, insomnia, agitation … used in Crystal-Meth production!

23. Drugs for Nasal Congestion(3) Nasal Decongestant Sprays/Drops (topical) examples: Afrin, NeoSynephrine Important Patient Warning and Info: Use exactly as directed on package (usually q12h), DO NOT USE more than 3-5 consecutive days … why? “Rebound Congestion”, makes these habit-forming! Tolerance occurs rapidly, resulting in patients using larger and larger doses to get the same level of symptom-relief Topical Decongestants act much faster than Oral Decongestants, but Oral agents do not cause Rebound Congestion!

24. Glucocorticoids (steroids) Nasal Glucocorticoids (Flonase, Nasacort) Most effective meds for prolonged seasonal or year-round allergic rhinitis Excellent relief of symptoms such as: *congestion, *runny nose, *sneezing, *itching Interesting Drug! –NOT a STEROID- CromolynSodium (Nasalcrom) – actually prevents the release of Histamine – unique!

25. Drugs for Cough (antitussives) Productive Cough – should not be suppressed! –the act of coughing serves important function … the clearing of mucous from the airway Dry, Hacking, ‘Tickling’ Cough – o.k. to suppress –usually deprives patient of sleep, can cause discomfort if not treated OPIOID(syrups): elevate the cough ‘threshold’ –may be habit-forming (codeine,hydrocodone) nonOPIOID’s: less GI side-effects, NOT habit forming

26. Other Agents for cough … Cough suppressant Tessalon(benzonatate) -a local anesthetic, relieves cough by numbing the cough receptors (gag reflex) AntiHistamines(again!) – reduces the drainage of nasal secretions, which many times is the cause of the ‘Tickly’ cough!

27. Lower Respiratory Tract The Bronchial Tree and the Lungs Pneumonia Thick Mucous Secretion(sputum) COPD (Chronic Obstructive Pulmonary Disease) … Asthma Emphysema Chronic Bronchitis EXPECTORANTS required to thin and mobilize sputum