Pharmacology
drugs acting on the
cardiovascular system
(CVS)
For Nursing Students
I- Diuretics
Are drugs that
increase
Sodium*
excretion
The rate of*
urine flow
Diuretics
Loop diuretics.
Thiazide diuretics
.Potassium sparing diuretics
.Osmotic diuretics
Diuretics
1- High efficacy:
e.g Loop diuretics … they are the most powerful diuretics
:Moderate efficacy -2
e.g thiazide …. Have moderate diuretic activity
3- Low efficacy:
e.g Potassium sparing diuretics and osmotic diuresis…
have low diuretic activity
Diuretics
Diuretics
2- Thiazide diuretics
1- Loop diuretics
Chlorothiazide
A) Furosemide.
Examples: Hydrochlorothiazide
B) Ethacrynic acid
Chlorthalidone
Inhibition of sodium-potassium- Inhibition of sodium-
chloride co transport mechanism chloride cotransport
Mechanism of
in thick ascending limb of loop mechanism in distal
action:
of henel leading to sodium loss renal tubules increase
and water loss. sodium, chloride and
) cute
Rapid pu &o short
onset a y ede a.
duration. water excretion.
2) Essential hypertension.
1) Edema.
Therapeutic 3) In patient with drug overdose
2) Hypertension
uses: to induce forced diuresis and
rapidpdrug
li i i
Hyperglycemia. 1) Hypokalemia.
Side effects:
3) Hyperuricemia. 4) 2) Hyperuricemia.
Hyponatremia (excess sodium 3) Hyperglycemia
)
Diuretics
Diuretics
3- Potassium sparing diuretics 4- Osmotic diuretics
(aldosterone receptor
antagonist). Mannitol
Examples: B) Triametrine which
(inhibitor of renal epithelial
sodium channels in collecting
Hypertension.
1- Acute renal failure.
Heart failure.
2- Cerebral edema and
Therapeuti
c uses: elevation of intracranial
Adverse effects:
pressure.
Hyperkalemia,
3- Increase IOP in glaucoma
Nausea and vomiting
II- Angina pectoris
Chest pain due to transient myocardial ischemia
imbalance between cardiac work (O2 demand) and coronary flow (O2
supply)
II- Angina pectoris
Types
1- Effort, stable, classic, exertional angina: Occur in exertion
Aetiology: atherosclerosis
2- Prinzmetal (variant, vasospastic. Atypical) angina: Occur at rest
Aetiology: coronary Vasoconstriction
3- Unstable: occur at rest or mild exertion Aetiology: coronary
occlusion
Treatment:
Nitrates
Calcium channel-blocking drugs
Beta-blocking drugs
A. Nitrates
Mechanism of
action
increases
cGMP
Organic
nitrates Activates vasodilatation
release guanylate
cyclase
enzyme
nitric oxide
(NO)
Therapeutic uses (nitrates)
1- All types of
↓
Exertional Angina ( cardiac work and O2 ↓
consumption)
angina:
↓
*Variant angina: coronary vasodilatation
*Mixed-unstable: work, coronary
vasodilatation
2- Prevention They are used before any activity which may
of attacks precipitate anginal attack. Sublingual
nitroglycerin or isosorbide dinitrate is used.
(prophylaxis):
3- Congestive associated with acute myocardial infarction.
heart failure
4- Hypertensive
emergency.
Adverse effects
(nitrates)
Pulsating
Postural
headache,
hypotension
flushing.
Met-haemoglobinemia Reflex tachycardia
Tolerance
repeated or continuous administration of high doses of organic nitrates
leads to decrease in nitrates pharmacological effects
To avoid tolerance, stop therapy for 8-12 hours each day allows the return
of efficacy of the drug.
g
(propranolol, nadolol, atenolol,
t l l )
Mechanism of
action
Lead to
decrease
myocardial
oxygen
demand
Decrease heart at rest and
contractility during
.exercise
Decrease heart rate
Indications of beta-
blockers
Exertional angina
Notes
1- Beta-Blocking drugs are not used in vasospastic
angina (unopposed effects of catecholamines acting on
alpha receptors→↑ coronary resistance).
2- They are contraindicated in bronchospasm –
bradyarrhythmias- H.F
C. Calcium channel blockers
Classification
Dihydropyridine (nifedipine, nicardipine, nimodipine)
Non- dihydropyridines (verapamil, diltiazem)
Mechanism of
action
Blocking the voltage-gated calcium channel (L-type which is the
dominant type in cardiac and smooth muscle).
III- Congestive heart failure
.Heart is unable to pump sufficient blood to meet the needs of the body
1. Dyspnea
Main clinical picture 2. Rapid fatigability
3. Odema of lower limb
1. Rest in bed
Treatment 2. Salt restriction
3. Drug treatment
a. Vasodilator: Captopril, Enalapril,
Sodium nitroprusside
Drug Treatment b. Diuretics: Frosemide,
Hydrochlorothiazide
c. Inotropics: Digitalis, Digoxin
Cardiac glycosides
(digoxin)
Specific and powerful stimulant action on myocardium:
1. Positive inotropic effect (increase force of contraction )
2. Increase cardiac output
3. Negative chronotropic effect (slowing heart rate)
4. Diuretic action
1. Congestive heart failure
- Decrease cardiac size
Therapeutic uses of cardiac - Decrease cardiac rate
glycoside - Decrease venous pressure – congestio
- Decrease dyspnea
- Relief edema
2.Atrial fibrillation and atrial flutter
Clinical manifestations and treatment of
digoxin toxicity
Toxicity Treatment
GIT: anorexia, nausea & 1. Stop digitalis
vomiting (first to appear) 2. KCl orally or i.v When serum K
CNS: Yellow vision, Delirium is normal decrease binding of
, Headache digitalis to heart
3. Phenytoin: Decrease atrial +
Cardiac: Arrhythmia
ventricular arrhythmia
(ventricular or atrial) 4. Specific binding Ab (digibind)
1. Ventricular tachycardia
Contraindications 2. Partial heart block
of cardiac glycoside 3. Recent myocardial infarction
IV- Hypertension
Hypertension is defined as a sustained increase in blood
≥
pressure 140/90 mm Hg.
Normal blood pressure up to 120/80------Increase blood
pressure above 140/90
Types:
1- Primary: idiopathic
2- Secondary: due to known cause: Renal disease, Toxemia of
pregnancy, Use of certain drugs
Antihypertensive drugs
Are drugs used to normalize blood pressure
Classification
I- Diuretics
II- Sympatholytics:
A. Stimulation of α2 receptor centrally: Methyldopa and Clonidine
B. Blocking action of transmitter of receptor site:
1- Beta-adrenergic blockers: Non selective: propranolol (B2-B1),
Selective: atenolol (B1)
2- Selective α1 adrenergic blockers: prazosin
3- α and B blockers: labetalol
III- Direct vasodilators:
1- Arteriodilators: Hydralazine and Diazoxide
2- Arterio and venodilator: Sodium nitroprusside
IV- Angiotensin converting enzyme inhibitors: Captopril
V- Calcium channel blockers: Verapamil , Nifedipine, Diltiazem
III - Direct vasodilators:
A- Arterial vasodilators
B- Arterial and venous vasodilators
III - Direct vasodilators: A- Arterial vasodilators
1- Hydralazine 2- Minoxidil:- 3- Diazoxide:
Used by rapid I.V
1- Used orally in
injection in: -
severe
Hypertensive
Indications: Moderate to hypertension
emergency
severe hypertension 2- Topical use to
-Treatment of
stimulate hair
hypoglycemia due
growth
to hyper-
insulinoma
1- Headache Side effects:
Side effects:
2- Salt and water 1- Reflex
1- Severe
retention tachycardia
hypotension
3- Reflex tachycardia 2- Salt and water
2- Reflex
4- Lupus – retention
tachycardia
Erythromatosus like 3-Hypertrichosis
3-Hyperglycemia
syndrome
III - Direct vasodilators:
B- Arterial and venous vasodilators
Sodium nitroprusside
Indications:
- Hypertensive emergency
Provide controlled hypotension during anesthesia
used by I.V infusion, kept in dark bottles
Side effects:
1- Severe hypotension
2- Cardiac dysrhythmia
3- Acidosis
4- Tubular necrosis.
IV- Calcium channel blockers
Verapamail , Diltiazem , Nifedipine used orally
Indications
1- Treatment of hypertension
2- Cardiac arrhythmia
3- Angina pectoris
Side effects:
1- Dizziness hypotension flushing.
2- Pedal edema.
3- Bradycardia after I.V use
Contraindications
1- A.V block.
2- Heart failure
V- Angiotensin converting enzyme inhibitors
(ACEIs), Angiotensin II Receptor antagonists
Angiotensin converting enzyme Angiotensim II Receptor
inhibitors (ACEIs) antagonists
1- Orally effective.
Losartan
2- Refractory hypertension
Side effects:
1- Dry cough, edema
2- Severe hypotension advantage: not cause dry
3- Hyperkalemia. cough or edema.
4- Skin rash
5- Renal insufficiency
Anti-coagulants
For Nursing
Anti-coagulants
Anti-coagulants are drug that prevent blood coagulation
Types:
1. Parenteral: heparin 2. Oral: warfarin
Point of
comparison Heparin Warfarin
1- Administration Parenteral I.V. S.C. Oral
2- Onset of action Rapid within minutes Delayed after 3 days
3- Side effects Bleeding, Bleeding, drug
Thrombocytopenia, interactions
4- Neutralization
Hypersensitivity Vitamin k, fresh
( Antidote )
frozen plasma
5- Cross placental Protamine sulphate Cross (teratogenic)
barrier Don’t cross (not
teratogenic)
6- Therapeutic uses Deep venous thrombosis, Pulmonary embolism
Prevention of post-operative thrombosis, Acute
myocardial infarction, Dialysis machine.
g py
anemias
Anemia
It is usually defined as: low hemoglobin, low RBC count
and low RBC mass.
Usually presents with pallor, fatigability, weakness and
pale conjunctiva
Types of anemia
A) Iron deficiency anemia (microcytic hypochromic)
B) Megaloblastic anemia
A) Iron deficiency anemia
Requirements of iron : 5-10 mg in food
Prepration
Oral Parenteral
gluconate, Ferrous fumarate
acid complex
should be given after meals and - Skin discoloration
- Abdominal colic
- Local inflammation
Treatment of Iron Overdose
In case of iron toxicity: Treatment is carried out by:
1. Gastric lavage by NaHCO3 to ppt iron
2. I.V. fluids to treat collapse and dehydration after blood
loss
3. Sodium bicarbonate for acidosis
4. Barbiturates: to treat convulsion
5. Iron cleating agent (desferoxamine) binds iron and
enhance its renal elimination.
B) Megaloblastic anemia
Failure of stomach to secrete the intrinsic factor which is
required for the absorption of cyanocobalamine (vit B12).
Characters
1. macrocytic hyperchromic anemia 2. glossitis
3. diarrhea 4. peripheral neuritis 5. ataxia
Preparation and adminstration
1. cyanocobalamine injection
2. vit B12 with intrinsic factor oral preparation
3. hydroxocobalamine
C. Folic acid deficiency anemia
Treated with folic acid 10-20 mg / day
orally
