It is a anti- hypertensive drug. It is non-selective beta blocker drug. Hence it is beta blocker drug so it has many side effect.Not only Propranolol but also Timolol,Atenolol are beta blocker drugs.
It is a anti- hypertensive drug. It is non-selective beta blocker drug. Hence it is beta blocker drug so it has many side effect.Not only Propranolol but also Timolol,Atenolol are beta blocker drugs.
ANTI HYPERTENSIVE AGENTS [MEDICINAL CHEMISTRY] BY P.RAVISANKAR, HYPERTENSION,...Dr. Ravi Sankar
ANTI HYPERTENSIVE AGENTS [MEDICINAL CHEMISTRY] BY P.RAVISANKAR, HYPERTENSION,TYPES,CAUSES OF HYPERTENSION, CLASSIFICATION, MECHANISM OF ACTION, SAR, ACE INHIBITORS, ARB , DIURETICS(WATER PILLS), TIPS TO STOP SILENT KILLER.
BY P. RAVISANKAR, VIGNAN PHARMACY COLLEGE, VADLAMUDI, GUNTUR,A.P, INDIA.
This presentation deals with the most common antihypertensive drugs used in our day-to-day practice. The common 4 ABCDs (Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, diuretics)
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Introduction
Hypertension is a very common disorder
particularly past middle age.
Hypertension is defined as a BP more than
140mm Hg systolic and 90mm Hg diastolic.
(JNC 7 guidelines).
4. Introduction
Outcomes of Hypertension :-
Atherosclerosis
Ischemic heart disease & cerebrovascular
accidents (CVA)
Nephropathy
Congestive heart failure
“Hence early detection &treatment of htn with
antihypertensive drugs is very important”
5. Normal Blood Pressure Regulation
1. Blood Pressure = Cardiac output (CO) X TPR.
Physiologically CO and PVR is maintained by arterioles ,
postcapillary venules & Heart .
2. Baroreflex : Baroreceptors regulate BP. Central sympathetic neurones
in vasomotor area are tonically active. When there is stretch in the
vessel wall brought about by rise in pressure, baroreceptor stimulation
occurs and inhibits sympathetic discharge. When there is fall in BP,
there is reduction in stretch leading to increased baroreceptor activity
leading to increase in TPR and CO thereby restoring normal blood
pressure.
3. Renin-angiotensin- aldosterone system (RAAS)(role of kidney)
4. Local agents like Nitric oxide
All antihypertensives act via interfering with one or more of the
normal mechanisms
6. Expected Questions
Classification of antihypertensives. Write
the Mechanism of antihypertensive action,
desirable properties and drawbacks of use of
Diuretics/ ACEI/ARBs/CCB/Beta blockers in
HTN.
Drugs for HTN in pregnancy
Drugs for Hypertensive emergencies
Selection of first line antihypertensives
9. Classification of Antihypertensive Drugs
10. Vasodilators:
Arteriolar : Hydralazine, Minoxidil, Diazoxide
Arteriolar + venous: Sodium Nitroprusside
Pnemonic : ABCD
A (ACEI, ARBs, alpha blockers) B(beta blockers)C (CCB,
centrally acting) D (Diuretics, direct renin inhibitors,
dilators)
10. Each group of drugs will be discussed
under the following headings
Examples of drugs under each group
Mechanism of antihypertensive action
Desirable properties as antihypertensives
Drawbacks as antihypertensives
Current status in treatment of hypertension
12. Diuretics
Mechanism of antihypertensive action: (Thiazides)
Act on Kidneys to increase excretion of Na and H2O
decrease in blood volume decrease in COP & hence
decrease in BP.
After 4 - 6 weeks, compensatory mechanisms operate to regain
Na+ balance, plasma volume and Cardiac output but BP
remains low. Why?
Answer: Even after the compensatory mechanisms, there
exists a small deficit of Na+ in the vessel wall. This Na deficit
reduces stiffness of vessel wall leading to vasodilation . This
leads to decrease in TPR and fall in BP.
So, the initial fall in BP due to thiazides is due to fall in COP
but fall in BP is sustained due to fall in TPR.
13. Diuretics
Mechanism of antihypertensive action (high ceiling
diuretics)
Fall in BP is dependent only on reduction in plasma volume
& Cardiac output (similar to the initial fall in BP due to
thiazides) but unlike thiazides the Na deficit is not persistent
due to short action of high ceiling diuretics . Hence no fall in
t.p.r and no sustenance of BP fall.
14. Diuretics
Desirable properties of Diuretics as antihypertensives
- Once a day dosing
- No fluid retention
- No tolerance development to antihypertensive action
- Low incidence of postural hypotension
- Effective in isolated systemic hypertension
- Less risk of fractures in elderly (hypocalciuric action of
thiazides)
- Low cost
15. Diuretics
Drawbacks of Diuretics as antihypertensives
Hypokalaemia – muscle pain and fatigue
Hyperglycemia
Hyperlipidemia
Hyperuricaemia
Sudden cardiac death – tosades de pointes due to
hypokalemia
All the above adverse effects occurr at higher doses of
thiazides (50 – 100 mg per day). These adverse effects
are minimal with low doses (12.5 to 25 mg). So, low
doses of Thiazides are used as antihypertensives now.
16. Diuretics
Current status
Thiazides are mild antihypertensives, cause fall of
abt 10mm Hg in BP. Alone they are used only in
mild HTN (stage 1 HTN). Low dose of thiazide
therapy is used preferably with a potassium sparing
diuretic as first choice in elderly.
They prevent tolerance to other antihypertensives.
Can be used as combination in any grade of HTN.
Indapamide : modified thiazide with minimal side effects
It has very mild diuretic action and is used mainly as
antihypertensive and not as diuretic.
17. Diuretics
Loop diuretics
Cause more fluid & electrolyte imbalance. They are
indicated in HTN only if it is complicated by:-
- Chronic renal failure
- Refractory CHF
- Resistance to thiazides
- Marked fluid retention.
K+ sparing diuretics
Used only in conjunction with Thiazides to prevent K+
loss & to supplement their antihypertensive action.
18. Angiotensin Converting Enzyme (ACE)
Inhibitors
Examples :-
Captopril, Lisinopril., Enalapril, Ramipril , Fosinopril
Mechanism of antihypertensive action
Inhibit the Renin Angiotensin Aldosterone system (RAAS).
WHAT IS RAAS???
Next slide
19. RAAS
Renin is produced by JG cells of kidney in response to
Fall in BP or blood volume
Decrease Na+ in macula densa
Renin acts on a plasma protein Angiotensinogen to convert it
to Angiotensin-I
Angiotensin-I is rapidly converted to Angiotensin-II by ACE
(present in luminal surface of vascular endothelium)
Angiotensin-II is degraded by peptidases to produce
Angiotensin-III
Angiotensin II causes vasoconstriction (increased TPR) leading
to rise in diastolic BP.
Both Angiotensin-II and Angiotensin-III stimulates Aldosterone
secretion from Adrenal Cortex . Aldosterone promotes Na+ &
water reabsorption by the kidneys leading to increased blood
volume & increased COP & systolic BP.
21. ACE inhibitors
MOA : Inhibit synthesis of Angiotensin II by
inhibiting ACE –> decrease in (tpr) and blood
volumefall in diastolic and systolic BP.
22. ACE inhibitors
Desirable properties of ACEI as antihypertensives
No postural hypotension
Not much electrolyte imbalance
Renal perfusion well maintained
Reverses the ventricular hypertrophy
No hyperuricemia
No deleterious effect on plasma lipid profile
No rebound hypertension
Only minimal worsening of quality of life like general
wellbeing, sleep and work performance.
23. ACE inhibitors
Drawbacks/ adverse effects
Cough – persistent brassy cough due to inhibition of bradykinin
breakdown in lungs
Hyperkalemia (in renal failure patients, those with K+ sparing
diuretics, NSAID and beta blockers (routine check of K+ level))
First dose Hypotension – sharp fall may occur
Angioedema: swelling of lips, mouth, nose etc.
Rashes, urticaria
Dysgeusia: loss or alteration of taste
Foetopathic: hypoplasia of organs, growth retardation etc
Neutropenia
Proteinuria
Acute renal failure ( occurs in patients with bilateral renal artery
stenosis)
24. ACE inhibitors
Current status
1st line antihypertensive Drug
Used in relatively young patients
Most appropriate antihypertensives in patients with:-
Diabetes,
Chronic kidney disease,
CHF
Left ventricular hypertrophy,
Angina, post MI, stroke
Dyslipidemia,
Gout
Avoid in : Pregnancy, bilateral renal artery stenosis,
hypersensitivity , hyperkalaemia , Preexisting dry
cough
25. ACE inhibitors (2 important ones)
Captopril
Sulfhydryl containing dipeptide.
Not a prodrug. Has drawbacks mentioned earlier
Half life: 2 Hrs, multiple doses
Enalapril
Prodrug – converted to enalaprilate
Advantages over captopril:
More potent
Longer duration of action-once daily dose
Absorption not affected by food
Rash and loss of taste are less frequent
Slower onset of action, hence first dose hypotension
26. ACE inhibitors – other uses
(to be discussed under ACE inhibitors chapter)
Congestive Heart Failure
Myocardial Infarction
Prophylaxis of high CVS risk subjects
Diabetic Nephropathy
Schleroderma crisis
27. Angiotensin Receptor Blockers (ARBs)
Examples
Losartan, Candesartan, Valsartan,Telmisartan
Mechanism of antihypertensive action
Angiotensin Receptors (AT1 & AT2) are present on
target cells. Most of the physiological actions of
angiotensin are mediated via AT1 receptor.
ARBs are competitive antagonists and inverse
agonist of AT1 receptor. Blocks all the actions of A-II
mediated by AT1 like vasoconstriction, aldosterone
release and renal actions of salt & water
reabsorption.
28. ARBs
Current status of ARBs
Similar to ACEI BUT theoretical superiority over ACEIs is
claimed due to following reasons:
Cough is rare – no interference with bradykinin
degradation.
Complete inhibition of AT1 & action of angiotensin II is
fully blocked– (In case of ACEI, Angiotensin II formed
by other mechanisms not involving ACE can act on
AT1 reeptor & produce the effects)
AT1 blockade results in indirect activation of AT2 –
vasodilatation (additional benefit)
Rare 1st dose hypotension
Low dysgeusia & angioedema
Fetopathic like ACEI & hence should not be used in
pregnancy.
29. Direct renin inhibitor-Aliskiren
Inhibits production of Angiotensin I & II.
Equally effective as ACEI & ARBs.
Since experience with it is limited, so it is used only
as a second line antihypertensive when more
established ACEI & ARBs cannot be used.
30. Beta blockers
Examples
- Non selective: Propranolol
- Cardioselective: Metoprolol ,Atenolol
Mechanism of antihypertensive action
- Decreases heart rate, contractility, conduction velocity,
cardiac output (inverse agonist on β1 ). Total peripheral
resistance increases initially.
- Initial phase : COP decreases (systolic BP decreases), t.p.r
increases (diastolic BP increases) overall little BP
change.
- With prolonged use resistance vessels adapt to decreased
COP so that t.p.r decreases both systolic & diastolic BP
decrease
31. Beta blockers
Desirable properties as antihypertensives
No postural hypotension
No salt and water retention
Low incidence of side effects
Low cost
Once a day regime
Drawbacks of non selective beta blockers:-
Fatigue, lethargy (low CO?)– decreased work capacity
Bradycardia
Loss of libido – impotence
Cognitive defects – forgetfulness
Worsening of carbohydrate tolerance, lipid profile, PVD,
asthma.
Sudden withdrawal—chance of rebound HTN,
precipitation of MI or angina
32. Beta blockers
Advantages of cardio-selective beta blockers over non-
selective beta blockers:
Safer in asthmatics (no bronchoconstriction)
Safer in diabetes (no interference with hypoglycemia
induced glycogenolysis)
Less worsening of PVD
Lipid profile-less deterioration
33. Beta blockers
Current status:
As first line drugs cardioselective beta blockers alone
in mild/moderate HTN
- Action maintained over 24hrs
Preferred in:-
- Young non-obese hypertensives those with coexisting
anxiety, migraine, tachycardia & those with IHD
- For preventing sudden cardiac death in Post MI
patients
- In stable heart failure along with ACEI
Not preferred in old
34. Αlpha blockers
Examples
Non selective alpha blockers (Phenoxybenzamine,
Phentolamine) not used in chronic essential
hypertension but used in Pheochromocytoma.
Specific alpha-1 blockers like prazosin, terazosin and
doxazosine are used in HTN treatment
Mechanism of antihypertensive action
Blockade of vasoconstrictor α receptors
- pooling of blood in capacitance vesselsdecreased
venous return & decreased COP fall in BP
35. Αlpha blockers
Adverse effects:
postural hypotension
salt and water retention
Nasal stuffiness
Miosis
failure of ejaculation in males
Current status:
But not used as first line agent,
May be added to diuretics + beta blockers if target
bp is not achieved with their use alone.
36. Alpha + beta blockers
Labetalol used IV for rapid BP reduction. Orally used
for severe HTN.
Carvedilol used as antihypertensive as well as in
CHF.
38. Calcium Channel Blockers
Mechanism of antihypertensive action
Three types of Ca+ channels in smooth muscles – Voltage
sensitive, receptor operated and leak channel
Voltage sensitive are again 3 types – L-Type, T-Type and N-
Type
Normally, L-Type of channels admit Ca+ and causes
depolarization – excitation-contraction coupling through
phosphorylation of myosin light chain – contraction of vascular
smooth muscle –vasoconstriction-- elevation of BP
CCBs block L-Type channel resulting in :-
- Smooth Muscle relaxation
- Negative chronotropic, ionotropic effects on heart.
DHPs have highest smooth muscle relaxation and vasodilator
action followed by verapamil and diltiazem. Hence DHPs are the
CCBs used in HTN.
39. Calcium Channel Blockers
Desirable properties
Do not compromise haemodynamics – no
impairment of work capacity
No deleterious effect on lipid profile, uric acid or
electrolyte balance.
Can be given to asthma, angina and PVD patients
No renal and male sexual function impairment
No adverse fetal effects and can be given in
pregnancy
Minimal effect on quality of life
41. Calcium Channel Blockers
Current status
Used as 1st line by many because of excellent
tolerability and high efficacy.
Preferred in elderly/asthma/COPD/PVD/
stroke/DM/pregnant/isolated systolic HTN
To be avoided in:-
Myocardial inadequacy, CHF
Conduction defects
Receiving beta blockers
IHD, post MI cases.
Enlarged prostate
GERD
43. Vasodilators
Hydralazine
Directly acting vasodilator
MOA: hydralazine causes NO release – relaxation of
vascular smooth muscle – fall in BP.
Uses: 1) Moderate hypertension when 1st line fails
2) Hypertension in Pregnancy
Minoxidil
Relaxes smooth muscle & relaxes arterioles.
Used only in life threatening HTN & topically in alopecia
44. Sodium Nitroprusside
Rapidly acting vasodilator (both arteriolar & venous)
MOA: RBCs convert nitroprusside to NO (enzymatically)
& non enzymatically by glutathione to NO & CN- –..>NO
causes vasodilation of both resistance (arterioles) and
capacitance vessels (veins) and reduces t.p.r and CO
(decrease in venous return)
Uses: Hypertensive Emergencies
Adverse effects: Palpitation, pain abdomen,
disorientation, psychosis, weakness and lactic acidosis.
Psychosis is due to CN- formation
45. Centrally acting Drugs
Alpha-Methyl dopa: (Alpha methyl analogue of DOPA) - a
prodrug
MOA:Gets converted to alpha methyl Noradrenaline.
which acts on alpha-2 receptors in brain and causes
inhibition of adrenergic discharge – fall in BP
Only used therapeutically now in Hypertension
during pregnancy.
Clonidine: Agonist of central alpha-2 receptor
Not frequently used now because of tolerance and
withdrawal hypertension
46. Some important points
Antihypertensives preferred in a patient with coexisting DM:-
- ACEI, ARBs, CCBs, Diuretics(less prefererred as
compared to other 3 due to hyperglycemia)
Antihypertensives preferred in a patient with coexisting
asthma/copd – CCBs, ARBs
Antihypertensives preferred in a patient with coexisting
CAD:- Diuretics, ACEI, ARBs, cardioselective beta
blockers
Antihypertensives preferred in a patient with coexisting
stroke – diuretics, ACEI, ARBs, CCBs
47. Drugs for Hypertension in pregnancy
Drugs found safe for treating HTN in pregnancy
- Alpha methyl Dopa
- CCBs like Nifedipine (BUT they should be stopped before
labour as they weaken uterine contractions)
- Cardioselective beta blockers & those with ISA (atenolol,
Metoprolol) used only if no other choice available
- Prazosin, Clonidine
- Hydralazine
48. Drugs for Hypertension in pregnancy
Drugs to be avoided
- ACEI : fetopathic
- Diuretics : reduce uteroplacental circulation
increased risk of fetal death
- Non selective beta blockers : causes low birth
weight, neonatal bradycardia and hypoglycemia.
- Sodium nitroprusside
49. Drugs for Hypertensive Emergencies
Hypertensive emergencies : Systolic BP > 220 or diastolic
BP > 120 mm Hg with evidence of active end organ damage.
Hypertensive urgency : Systolic BP > 220 or diastolic BP >
120 mm Hg without overt signs of endorgan damage.
Controlled reduction of BP is required to prevent :-
1. Cerebrovascular accident (haemorrhage)
2. Hypertensive encephalopathy
3. Hypertensive acute LVF and pulmonary edema.
4. Unstable angina or MI with raised BP.
5. Dissecting aortic aneurysm.
6. Acute renal failure with raised BP.
50. Drugs for Hypertensive Emergencies
Oral therapy (not recommended due to problems)
- Nifedipine (causes abrupt fall in BP and precipitates
MI or stroke, or may be fatal).
- Captopril (response is variable and it carries risk of
excessive hypotension).
- Clonidine (produces sedation and rebound rise in BP
on stopping the drug).
51. Drugs for Hypertensive Emergencies
Parenteral therapy
- Sodium nitroprusside : DOC for emergencies due to its
instantaneous, balanced arteriovenous vasodilatory
action & lack of development of tolerance.
- GTN : Acts in 2–5 min and has brief titratable action, but is
a less potent hypotensive. Its predominant venodilator
action makes it particularly suitable for lowering BP in
acute LVF, MI, unstable angina.
- Hydralazine : is less predictable, and not a first line drug.
Used in eclampsia.
- Esmolol : Useful when cardiac contractility and work is to
be reduced, such as in aortic dissection.
52. Drugs for Hypertensive Emergencies
- Phentolamine : Drug of choice for hyperadrenergic
states, e.g. hypertensive episodes in
pheochromocytoma, cheese reaction or clonidine
withdrawal.
- Labetalol : Can be an alternative in pheochromocytoma,
etc. Also used to lower BP in MI, unstable angina,
eclampsia.
- Furosemide : as an adjunct with any of the above drugs
if there is volume overload (acute LVF, pulmonary
edema, CHF)
53. Principles of HTN treatment
NON PHARMACOLOGICAL MEASURES
Diet
Salt restriction in diet
Aerobic activity or exercise
Weight reduction
Reduce alcohol intake
Mental relaxation
54. Principles of HTN treatment
Stage I HTN treatment
- Start with a single appropriate drug. A B C D rule (A—ACE
inhibitor/ARB; B—β blocker; C—CCB, D—diuretic). A & B
are preferred in younger patients (<55 years), C & D are
preferred in the older (> 55 years) for step 1 treatment.
- Initiate therapy at low dose; if needed increase dose
moderately.
- If only partial response is obtained, add a drug from another
complimentary class.(step 2).
55. Principles of HTN treatment
Stage II HTN treatment
Started on a 2 drug combination; one of which usually is a
thiazide diuretic.(directly step 2)
Rationale for combination therapy : Since BP is regulated
by several interrelated factors, an attempt to block one of
them tends to increase compensatory activity of the others.
Hence drugs with different mechanisms of action are
combined.
Eg: Drugs which increase plasma renin activity— diuretics,
vasodilators, CCBs, ACE inhibitors may be combined with
drugs which lower plasma renin activity—β blockers,
clonidine, methyldopa.
56. Steps of therapy
In step 2 when two drugs are to be used, combine
one out of A or B with one out of C or D.
When 2 drugs are inadequate in achieving target BP
lowering, 3 drug regimen is prescribed. Both C and D
are combined with A or B
Patients who fail to reach the goal BP with 3 drugs
are labelled as ‘resistant hypertension’. In them even
4 drug therapy (step 4 )may have to be given to
achieve the target BP.