Mechanisms Regulating

Arterial Pressure
N203
ATI (Unit 6)
Cardiovascular System -

 ANS helps control pressure by adjusting cardiac output (HR x SV) and peripheral
resistance.
The renin-angiotensin-aldosterone system helps control arterial pressure by:

Releasing angiotensin II potent vasoconstrictor of arterioles and veins

Releasing aldosterone promotes Na+ and H2O retention by kidneys

Vasopressin (ADH) is a potent vasoconstrictor and water reabsorption.
Atrial natriuretic peptide (ANP) is a vasodilator and causes excretion of Na+
and H2O by kidneys. It also inhibits renin secretion.
Decreasing blood volume and dilating arterioles and veins help control BP

Epinephrine

N203
ATI (Unit 6)
Cardiovascular System -

Epinephrine (Adrenaline) Catecholamine

Adrenergic Agonist

Binds to: 1 vasoconstriction / 1 HR, contractility, & AV conduction

2 Bronchodilation

absorption of local anesthetics or extravasated meds

Therapeutic Uses:

congestion of nasal mucosa

BP
Manage superficial bleeding

Treatment of AV block and cardiac arrest

Asthma

Hypertensive crisis
Necrosis from extravasation
Adverse Effects:

Dysrhythmias / myocardial O2 demand angina

Pregnancy (C)
Contraindications/Precautions:

MAOIs effect and duration

TCAs block uptake of epi.
Interactions:

General anesthetics lead heart to be hypersensitive to epi dysrhythmias

-adrenergic blockers (phentolamine)

-adrenergic blockers (propanolol)
Expected Action:

Education:

Stop infusion with evidence of extravasation; treat with -blocker (phentolamine)

Dopamine

N203
ATI (Unit 6)
Cardiovascular System -

Expected Action:

Dopamine (Intropin) Catecholamine

Adrenergic Agonist

Low Dose (Dopamine receptors) Renal vasodilation

Mod Dose (Dopamine, 1) Above + HR, contractility, AV conduction

High Dose (Dopamine, 1, 1) Above + vasoconstriction

Shock
Heart failure
Therapeutic Uses:

Necrosis can occur from extravasation of high doses

Adverse Effects:

Dysrhythmias / myocardial O2 demand angina

Pregnancy (C)
Contraindications/Precautions:

CI: Pheochromocytoma

Interactions:

Education:

Stop infusion with evidence of extravasation; treat with -blocker (phentolamine)

Adrenergic Receptors

N203
ATI (Unit 6)
Cardiovascular System -

Vasoconstriction of arterioles in skin, viscera, and

mucous membranes, and veins

HR, contractility, AV conduction
Release of renin in kidneys
Vasodilation of arterioles in heart, lungs, and

skeletal muscle

Bronchodilation
Relaxation of uterine smooth muscle
Glycogenolysis in liver
Skeletal muscle contraction

Dopamine

Vasodilation of renal blood vessels

Dobutamine

N203
ATI (Unit 6)
Cardiovascular System -

Dobutamine (Dobutrex) -- Catecholamine

Expected Action:

Binds to: 1 vasoconstriction / 1 HR, contractility, & AV conduction

2 Bronchodilation

Therapeutic Uses:

Heart failure

Adverse Effects:

heart rate

Contraindications/Precautions:

Pregnancy (B)

Interactions:

Education:

Stop infusion evidence of extravasation; treat with -blocker (phentolamine)

-Adrenergic Blockers

N203
ATI (Unit 6)
Cardiovascular System -

Proto: Prazosin (Minipress) Others: doxazosin mesylate (Cardura),

Expected
Action:

Phentolamine (Regitine), ergotamine tartrate

Selective 1 blockade resulting in venous and arterial dilation

Hypertension
Therapeutic Uses:

Phentolamine: Extravasation of adrenergic agonists

Doxazosin mesylate: symptoms of benign prostatic hypertrophy

Adverse Effects:

First-dose orthostatic hypotension (monitor BP for 2 hrs post-treatment)

Pregnancy (C)
Contraindications/Precautions:

Interactions:

Antihypertensives additive hypotensive effect

NSAIDs / clonidine antihypertensive effects of prazosin

Education:

Centrally Acting 2 Agonists

N203
ATI (Unit 6)
Cardiovascular System -

Expected Action:

Proto: clonidine (Catapres)

Others: guanfacine (Tenex), methyldopa (Aldomet)

sympathetic outflow in CNS bradycardia, CO, vasodilation, BP

Hypertension Severe cancer pain (epidural)

Investigational: Migraine, flushing from menopause, withdrawal management

Dry mouth (usually resolves in 2-4 weeks)

Adverse Effects:

Drowsiness & sedation

Rebound hypertension

Pregnancy (C)
Contraindications/Precautions:
Therapeutic Uses:

Antihypertensives: Additive hypotensive effect

Prazosin, MAOIs, TCAs: Counteract effects of clonidine.

CNS Depressants: Additive CNS depressant effect

Apply patch to hairless skin on torso or upper arm

Education:
Interactions:

-Adrenergic Blockers

N203
ATI (Unit 6)
Cardiovascular System -

Proto: Cardioselective: metoprolol (Lopressor), Nonselective: propanolol

(Inderal) - Others: Cardioselective: atenolol, Nonselective: nadolol (Corgard)

1-adrenergic blockade HR, contractility, AV conduction

Hypertension
Dysrhythmias (block SA/AV cond.)
Therapeutic Uses:

Angina/MI ( O2 demand - diastole time perfusion - BPO2)

Heart failure (mechanism unknown, probably related to above)

Hyperthyroidism, migraines, stage fright, pheochromocytoma, glaucoma

Expected
Action:

Adverse Effects:

1: Bradycardia CO AV block Orthostatic hypotension

Rebound myocardium excitation (d/c over 1-2 weeks)

2: Bronchoconstriction Glycogenolysis inhibited

CI: AV block, sinus bradycardia

Contraindications/Precautions:

Nonselectives are CI asthma, bronchospasms, heart failure

Interactions:

1: calcium-channel blockers verapamil (Calan) and diltiazem (Cardizem)

intensify effects of -blockers.
2: Insulin prevents glycogenolysis

Angiotensin-Converting
Enzyme (ACE) Inhibitors
N203
ATI (Unit 6)
Cardiovascular System -

Expected
Action:

Proto: captopril (Capoten) Others: enalapril (Vasotec), fosinopril

(Monopril), lisinopril (Prinivil), ramipril (Altace)

Block production of angiotensin II arteriole vasodilation, excretion of Na+ and
H2O, retention of K+, and possible pathological changes to vessels and heart

Heart failure
Hypertension
Therapeutic Uses:

MI ( risk of HF and mortality)

Peripheral neuropathy

Ramipril can prevent MI, stroke, or death in high-risk patients

Hyperkalemia Cough
Neutropenia
Adverse Effects:

Angioedema (swelling in tongue/oropharynx) treat with epinephrine

First-dose orthostatic hypotension

Rash & dysgeusia

Pregnancy (D)
Contraindications/Precautions:

CI: bilateral renal stenosis, history of angioedema

Diuretics1st-dose hypotension
Lithium [Lithium]
Interactions:

AntihypertensivesAdditive effects
NSAIDs antihypertensive eff.

K+ supplements/K+ sparing diuretics hyperkalemia

Captopril 1 hr ac / others or food

Education:

Should see renal function evidenced by proteinuria

Angiotensin Receptor Blockers

(ARBs)
N203
ATI (Unit 6)
Cardiovascular System -

Proto: Losartan (Cozaar) Others: valsartan (Diovan), irbesartan

Expected
Action:

(Avapro), candesartan (Atacand), olmesartan (Benicar)

Blocks action of angiotensin arteriole vasodilation, excretion of Na+ & H2O,
retention of K+

ACE and ARB is that cough and hyperkalemia are not side effects of ARB.

hypertension (all) Stroke prevention (losartan)

Therapeutic Uses:

Mgt of heart failure / mortality prevention after MI (valsartan)

Delay progression of diabetic neuropathy (irbesartan, losartan)

Angioedema
Fetal injury
Adverse Effects:

Pregnancy (D) CI: Renal stenosis

Contraindications/Precautions:

Caution Hx of angioedema

Antihypertensives Additive effect ARBs

Interactions:

ARBs can be taken with or without food

Should see renal function evidenced by proteinuria

Education:

Calcium Channel Blockers

N203
ATI (Unit 6)
Cardiovascular System -

Proto: nifedipine (Adalat) Others: amlodipine (Norvasc), felodipine

(Plendil), nicardipine (Cardene), verapamil (Calan), diltiazem (Cardizem)

Nifedipine: vascular Ca2+channelsvasodilation peripheral & arterioles

Verapamil, Diltiazem: Above + contractility, HR, AV conduction

All: Hypertension
All but Felodipine: Angina
Therapeutic Uses:

Verapamil, Diltiazem: Hypertension, Angina, Dysrhythmias

Nifedipine: Tachycardia, peripheral edema, acute toxicity

Adverse Effects:

Verapamil, Diltiazem: Orthostatic hypotension, peripheral edema, constipation,

cardiac suppression, dysrhythmias, acute toxicity
Expected
Action:

Contraindications/Precautions:

CI: heart block, hypotension, bradycardia, aortic stenosis, severe heart failure

Verapamil, Diltiazem: Grapefruittoxicity

Digoxin[digoxin]

-blockers: HF, AV block, bradycardia

-blockers: Used to reflex tachycardia

Nifedipine: Grapefruittoxicity
Interactions:

Education:

Administer IV over 2-3 minutes

Meds for Hypertensive Crisis

N203
ATI (Unit 6)
Cardiovascular System -

Proto: nitroprusside Others: labetalol (Trandate), diazoxide

Expected
Action:

(Hyperstat), fenoldopam (Corlopam), trimethaphan (Arfonad)

Direct vasodilation of veins and arteries causing rapid BP (preload/afterload)

Hypertensive emergencies
bleeding during surgery by producing controlled hypotension

Therapeutic Uses:

Excessive hypotension
Cyanide poisoning: risk liver dysfunction; Give slowly (5 mcg/kg/min)
along with thiosulfate to deactivate cyanide.

Thiocyanate poisoning: Can manifest as altered mental state/psychosis. Avoid

prolonged use (>3 d). Plasma thiocyanate should be <0.1 mg/mL

Pregnancy (C)
Contraindications/Precautions:

Adverse Effects:

Discard solutions that are blue, red, or green

Protect solutions from light Do not mix other meds nitroprusside.

Education:

Organic Nitrates

N203
ATI (Unit 6)
Cardiovascular System -

Proto: nitroglycerine Others: isosorbide dinitrate (Imdur)

cardiac O2 demand by dilating veins and decreasing venous return (preload)

Relaxes or prevents spasms in coronary arteries thus O2 supply

Treatment of angina (acute, variant, and prophylaxis)

Therapeutic Uses:

IV perioperative BP control, HF d/t acute MI

Headache Tolerance
Orthostatic hypotension
Adverse Effects:

Reflex tachycardia - give metoprolol (Lopressor)

CI: traumatic head injury ICP

Contraindications/Precautions:

Sildenafil (Viagra)Acute or fatal hypotension

Interactions:

EtOH, -blockers, Ca-blockers, diuretics additive hypotensive effects

Sublingual tab/translingual spray: R onset, S duration

Education:

Transmucosal: R onset, L duration

SR caps: S onset, L duration

Transdermal: S onset, L duration (hairless area, min 8 hr/day without med to

lower risk of developing tolerance.

Topical: S onset, L duration

IV: Use glass bottle & mfrs tubing; Start at slow rate (5 mcg/min)
Expected Action:

Cardiac Glycosides

N203
ATI (Unit 6)
Cardiovascular System -

Proto: digoxin

Expected Action:

(+) inotropicSV, CO

Therapeutic Uses:

CI: v-fib, v-tach, 2/3 blocks

Quinidine dig toxicity

Verapamil [digoxin]
Sympathomimetics add to inotropic effect
Loop & thiazide diuretics K+ risk of digoxin dysrhythmia
ACE inhibitors / ARBs risk K+ therapeutic digoxin effects

Check apical pulse: hold < 60 (adults), < 70 (kids), < 90 (infants)
Therapeutic levels = 0.5-2 ng/mL Treat bradycardia atropine
Treat dysrhythmias phenytoin or lidocaine
Activated charcoal or cholestyramine can bind digoxin to prevent absorption.

Education:

Dysrhythmias, A-Fib

Interactions:

GI effects
CNS effects (fatigue, vision changes)
Dysrhythmias, cardiotoxicity: risk fromK+, [digoxin], disease

Contraindications/Precautions:

(-) chronotropic > fill time SV, CO

Tx of HF

Adverse Effects:

Antidysrhythmics
(Class IA: Na+-Channel Blockers)

N203
ATI (Unit 6)
Cardiovascular System -

Sodium channel blockers: procainamide (Pronestyl),

quinidine, disopyramide, tocainide, propafenone

Expected Action:

conduction / automaticity / repolarization rate

Therapeutic Uses:

Ventricular tachycardia

Adverse Effects:

Supraventricular tachycardia

Blood dyscrasias

Interactions:

Atrial flutter

Atrial fibrillation

Systemic lupus syndrome (resolve with d/c medication)

Cardiotoxicity (QRS, QT)

Contraindications/Precautions:

CI: Sens. to quinidine, complete block, lupus

Antihypertensives additive hypotensive effect

Anticholinergics anticholinergic effects

Antidysrhythmics in therapeutic effects / toxicity potential

Education:

Anticholinergic Effects

N203
ATI (Unit 6)
Cardiovascular System -

Dry Mouth

Urinary retention

Constipation

Tachycardia

Blurred vision

Mydriasis

Antidysrhythmics
(Class IB: Na+-Channel Blockers)

N203
ATI (Unit 6)
Cardiovascular System -

Sodium channel blockers: lidocaine (Xylocaine)

Expected Action:

conduction / automaticity / repolarization rate

Therapeutic Uses:
Adverse Effects:

Short-term use only for ventricular dysrhythmias

Respiratory arrest

CNS effects (fatigue, paresthesias, seizures)Tx seizures phenytoin (Dilantin)

Contraindications/Precautions:

CI: Stokes-Adams, Complete block

Pregnancy (B)

Interactions:

Cimetidine, phenytoin, -Blockers effects of lidocaine.

Education:

Never administer lidocaine that has epinephrine in it.

Loading dose followed by maintenance dose of 1-4 mg/min.

Antidysrhythmics
(Class IV: Ca2+-Channel Blockers)

N203
ATI (Unit 6)
Cardiovascular System -

Calcium-channel blockers: verapamil (Calan),

diltiazem (Cardizem)

Expected Action:

force / HR / AV node conduction

Therapeutic Uses:
Adverse Effects:

Atrial fibrillation

Atrial flutter

Digoxin[digoxin]

Grapefruittoxicity

-blockers: HF, AV block, bradycardia

Education:

CI: heart block, hypotension, bradycardia, aortic stenosis, severe heart failure

Interactions:

SVT

Orthostatic hypotension, peripheral edema, constipation, cardiac suppression,

dysrhythmias, acute toxicity

Contraindications/Precautions:

Antidysrhythmics
(Class III: K+-Channel Blockers)

N203
ATI (Unit 6)
Cardiovascular System -

Potassium channel blockers: amiodarone (Cordarone),

bretylium, sotalol, dofetilide

Expected Action:

conduction / automaticity / repolarization rate / contractility

Therapeutic Uses:

Recurrent V-fib

Pulmonary toxicity Visual disturbances (can blind)

Cardiac effects sinus bradycardia & AV block / may cause HF / Hypotension

Liver/thyroid dysfunction
CNS effects
GI effects
Phlebitis: Central venous line is indicated

Adverse Effects:

Conversion of A-fib (oral)

Recurrent V-tach

Highly
Toxic

Grapefruit toxicity
Cholestyramine [amiodarone]
Quinidine, procainamide, digoxin, diltiazem, warfarin levels of these
-blockers, verapamil, diltiazem bradycardia
Diuretics, antidysrhythmics, macrolide antibiotics risk dysrhythmias

Interactions:

Pregnancy (D)
CI: AV block, bradycardia, newborns, infants

Contraindications/Precautions:

Antidysrhythmics
(Endogenous Glucoside)

N203
ATI (Unit 6)
Cardiovascular System -

Expected Action:

Endogenous Glucoside: adenosine (Adenocard), ibutilide (Corvert)

conduction through AV node

Therapeutic Uses:
Adverse Effects:

Paroxysmal SVT

Wolff-Parkinson Syndrome

Sinus bradycardia, dyspnea, flushed face (usually < 1 min)

Contraindications/Precautions:

Pregnancy (C)

CI: 2/3 block, AV block, atrial flutter, atrial fibrillation

Interactions:

Methylxanthines (theophylline, caffeine) Adenosine receptors are blocked

Dipyridamole (Persantine) Uptake is blocked leading to effects

Education:

Very short life (< 1 min)

Administer by IV bolus, flushed with NS

Antilipemics
HMG CoA Reductase Inhibitors
(Statins)
N203
ATI (Unit 6)
Cardiovascular System -

Expected
Action:

Proto: atorvastatin (Lipitor) Others: simvastatin (Zocor), lovastatin

(Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor)

LDL by LDL receptors in liver VLDL

HDL
Promote vasodilation / plaque-site inflammation / thromboembolism risk

1 hypercholesterolemia
Prevention of stroke and coronary events.

Therapeutic Uses:

HDL

Myopathy (monitor CK)

Peripheral neuropathy

Hepatotoxicity evidenced by serum transaminase

Pregnancy (X) rosuvastatin in Asians

Contraindications/Precautions:

Adverse Effects:

CI: Pregnant / viral or EtOH hepatitis

Lovastatin evening meal (others OK food)

Atorvastatin or fluvastatin should be used with renal insufficiency

Education:

Caution ketoconazole

Fibrates risk of myopathy

Med that suppress CYP3A4 (ketoconazole, erythromycin) statin levels
Grapefruit juice and (lovastatin or simvastatin) Toxicity

Interactions:

Antilipemics Fibrates

N203
ATI (Unit 6)
Cardiovascular System -

Proto: gemfibrozil (Lopid) Others: fenofibrate (Tricor)

Expected Action:

Therapeutic Uses:

Adverse Effects:

Gall stones

Hepatotoxicity

Pregnancy (C)

Myopathy

Caution statins

CI: liver disorders / severe renal dysfunction / gallbladder disease

Interactions:

Promote HDL precursor production

plasma VLDL, plasma HDL

Contraindications/Precautions:

TG by VLDL excretion

Statins myopathy

Cholestyramine absorption

Warfarin risk of bleeding (monitor PT and INR)

Antilipemics Cholesterol
Absorption Inhibitor
N203
ATI (Unit 6)
Cardiovascular System -

Proto: ezetimibe (Zetia)

Expected Action:

Inhibit absorption of cholesterol secreted in the bile and from food.

Therapeutic Uses:

Adverse Effects:

Adjunct to modified diet to help LDL (alone or statin)

Well-tolerated no adverse effects

Contraindications/Precautions:

Pregnancy (X)

Caution breastfeeding

CI: Renal dysfunction

Interactions:

Bile acid sequestrants (cholestyramine) absorption

Use with fibrates (gemfibrozil) risk of gall stones and myopathy

Cyclosporine levels of ezetimibe

Education:

Taken once per day without regard to food

Antilipemics
Bile-Acid Sequestrants
N203
ATI (Unit 6)
Cardiovascular System -

Expected Action:

LDL receptors in liver promotes uptake of serum cholesterol LDL

Therapeutic Uses:

Proto: cholestyramine (Questran) Others: colestipol (Colestid)

Adjunct with HMG CoA reductase inhibitor (eg atorvastatin) & diet LDL

Adverse Effects:

No systemic effects (not absorbed in GI tract)

Contraindications/Precautions:

CI: biliary disease or VLDL

Digoxin, warfarin, thiazides, tetracyclines form complexes absorption

Education:

Constipation

Interactions:

Dissolve in water or applesauce to prevent esophageal irritation or impaction.