Basc

Pharmacoogy
Cardovascuar Drugs
Case Study 1
35 YO mae, a poce omcer, 511,
weght=258 bs (BMI=??____)
Hx: hypertenson (BP 140/80), anxety.
Has taken testosterone suppements n
past, now uses "body budng" shakes.
Famy Hx: Father, paterna grandfather-
DM
Labs: FBS=79, TSH norma
Case Study 1
Visit 1
TC= 167
TG= 539
HDL= 18
LDL= 243
Dagnoss?
What drug/s w you prescrbe?
Dscuss the avaabe preparaton, dosng,
MOA, drug nteracton, adverse ehect,
excreton of the chosen drug/s.
Case Study 2
39 YO mae wth frequent urnaton
causng sexua actvty dsturbance,
wth excessve thrst, burred vson.
Hx: Obesty, BMI= 33
Famy Hx: Mother has DM
Meds: None
Non-fastng Accucheck (Tota cho)=
297
Case Study 2
TC
TC
305
305
252
252
Trig
Trig
540
540
149
149
HDL
HDL
170
170
33
33
LDL
LDL
295
295
190
190
HgbA1C
HgbA1C
11.9
11.9
5.6
5.6
Diagnosis?
What drug/s will you prescribe?
Discuss the available preparation, dosing, M!,
drug interaction, e"cretion, adverse e#ect o$ the
chosen drug/s%
Case Study &
62 YO Femae wth CHD s/p CABG wanted me
to manage pds. She aso has Hypertenson.
Meds: Copdogre, Atenoo, Lsnopr,
Atorvastatn (stopped by Pt due tomyagas)
Current abs:
TC= 248
Trg= 178
HDL= 22
LDL= 156
Case Study 3

Dagnoss?

What drug/s w you prescrbe?

Dscuss the avaabe preparaton,

dosng, MOA, drug nteracton,
excreton, adverse ehect of the
chosen drug/s.
Case Study 4
58 Year od mae, smoker
Famy Hx: Mother wth DM, sster ded age 35 from MI
BP= 160/90 Puse 78
Labs: TC= 310, TG= 250, HDL=29, LDL=156, FBS=88

Based on score, what s LDL goa?

Dagnoss?

What drug/s w you prescrbe?

Dscuss the avaabe preparaton, dosng, MOA, drug

nteracton, excreton, adverse ehect of the chosen
drug/s.
Case study 5
74 Year od Mae (smoker), experencng angna on and
oh, had MI ast year, advsed angopasty
Fam. Hx: Mother wth NIDDM, sster ded age 70 from
MI
BP= 120/70 Puse 82
Labs: TC= 210, TG= 132, HDL=35, LDL=236, FBS 139

Dagnoss?

What drug/s w you prescrbe?

Dscuss the avaabe preparaton, dosng, MOA, drug

nteracton, adverse ehect, excreton of the chosen
drug/s.
Case Study 6
48 Year od mae, smoker, dabetc
Famy Hx: Mother wthHPN, father had stroke
BP= 130/90 Puse 69
Labs: TC= 210, TG= 370, HDL=46, LDL=216, FBS=149

Based on score, what s LDL goa?

Dagnoss?

What drug/s w you prescrbe?

Dscuss the avaabe preparaton, dosng, MOA, drug

nteracton, excreton, adverse ehect of the chosen
drug/s.
Thank You

'uestions?
JOSEPHINE S. JIMENEZ, MD
INTERNAL MEDICINE
UPCM 2006
Thank you!!
!()*+SC,*+S
-S
The Heart
(he $unction o$ the heart
--crcuate bood throughout the body by:

Pumping blood through the lungs removes carbon dioxide

and refreshes the blood with oxygen

The oxygenated blood is pumped to the body to provide

oxygen and nutrients and to remove waste products.

The coronary arteries are the blood vessels that supply blood
and oxygen to the heart muscle.
Coronary Artery Dsease
Coronary artery dsease s one of the most common
and serous ehects of agng.
Fatty deposts bud up n bood vesse was and
narrow the passageway for the movement of bood.
The resutng condton, caed atherosclerosis often
eads to eventua bockage of the coronary arteres and
a "heart attack".
Signs and Sy.pto.s
/one0 (his is re$erred to as silent
ische.ia% 1lood to your heart .ay
be restricted due to C!D, but you
don2t $eel any e#ects%
Chest pain0 -$ your coronary
arteries can2t supply enough
blood to .eet the o"ygen
de.ands o$ your heart, the result
.ay be chest pain called angina%
Shortness o$ breath0 So.e people
.ay not be aware they have C!D
until they develop sy.pto.s o$
congestive heart $ailure3 e"tre.e
$atigue with e"ertion, shortness
o$ breath and swelling in their
$eet and an4les%
)eart attac40 +esults when an
artery to your heart .uscle
beco.es co.pletely bloc4ed and
the part o$ your heart .uscles $ed
by that artery dies%
Signs &
Symptoms
None
Chest
Pain
Shortness
Of Breath
Heart
Attack

Hgh bood choestero

Hgh bood pressure

Smokng

Obesty

Lack of physca actvty

+is4 5actors
Nonmodabe

Sex

Heredtary

Race

Age
Modabe

Hgh bood
pressure

Hgh bood
choestero

Smokng

Physca actvty

Obesty

Dabetes

Stress and anger

Manage.ent

Many peope are abe to manage

coronary artery dsease wth
festye changes and medcatons.

Other peope wth severe coronary

artery dsease may need
angopasty or surgery.

Stenting

a stent is introduced into a blood vessel on a balloon

catheter and advanced into the blocked area of the artery

the balloon is then inflated and causes the stent to expand

until it fits the inner wall of the vessel, conforming to
contours as needed

the balloon is then deflated and drawn back

The stent stays in place permanently, holding the vessel

open and improving the flow of blood.
!ngioplasty

a balloon catheter is passed through the guiding catheter to the

area near the narrowing. A guide wire inside the balloon catheter is
then advanced through the artery until the tip is beyond the
narrowing.

the angioplasty catheter is moved over the guide wire until the
balloon is within the narrowed segment.

balloon is inflated, compressing the plaque against the artery wall

once plaque has been compressed and the artery has been
sufficiently opened, the balloon catheter will be deflated and
removed.
Bypass surgery

healthy blood vessel is removed from leg, arm or chest

blood vessel is used to create new blood flow path in your heart

the bypass graft! enables blood to reach your heart by flowing

around "bypassing#
the blocked portion
of the diseased
artery. The increased
blood flow reduces
angina and the risk
of heart attack.
DYSLIPIDEMIA
1ad *#ects o$
Dyslipide.ia
Accordng to the Third Report
of the National Cholesterol
Eduation Pro!ra" E#pert
Panel on Detetion,
E$aluation and Treat"ent of
Hi!h Cholesterol in %dults
&NCEP %TP'III()
Hgh LDL eves are a
eadng cause of coronary
heart dsease (CHD) and
shoud be the man target of
any choestero owerng
regmen
!(6 --- ,ipid and ,ipoprotein
Classi7cation
,D, Cholesterol 8.g/dl9 )D, Cholesterol
8.g/dl9
<100 Optma < 40 Low
100-129 Near/Above Optma > 60 Hgh (Desrabe)
130-159 Borderne Hgh
160-189 Hgh
>190 Very Hgh
Categories o$ +is4 that Modi$y ,D, :oals
CHD and CHD rsk equvaents <100
Mutpe (2+) rsk factors <130
Zero to one rsk factor <160
Current !(6 --- :uidelines $or
(reating ,D, Cholesterol
Risk
Risk
Category
Category
LDL Goa
LDL Goa
!"g#$%
!"g#$%
LDL e&e to
LDL e&e to
i'itiate TLC
i'itiate TLC
LDL e&e to
LDL e&e to
(o'si$er R)
(o'si$er R)
t*era+y
t*era+y
CHD or CHD or
,-.i&ae'ts ,-.i&ae'ts
/100
/100
/70 0$ea
/70 0$ea
1 100
1 100
1
1
130
130
!1002129 R) !1002129 R)
o+tio'a% o+tio'a%
23 Risk
23 Risk
4a(tors
4a(tors
/130
/130
1 130
1 130
1 1 130 !10 5ear risk 130 !10 5ear risk
102206% 102206%
1 1 160 !Risk /106% 160 !Risk /106%
021 Risk
021 Risk
4a(tor
4a(tor
/160
/160
1 160
1 160
1 1 190 190
!1602179 R) !1602179 R)
o+tio'a% o+tio'a%
Speci7c Dyslipide.ias0
Very )igh ,D, 8; 1<=.g/dl9
Causes and Diagnosis

Genetc dsorders
Monogenc fama hyperchoesteroema
Fama defectve apopoproten B-100
(Apo B)
Poygenc hyperchoesteroema

Famy testng to detect ahected reatves

Speci7c Dyslipide.ias0 ,ow
)D,
Causes o$ ,ow )D, 8>?= .g/dl9

Eevated trgycerdes

Overweght and obesty

Physca Inactvty

Type 2 dabetes

Cgarette smokng

Very hgh carb. ntakes (>60% energy)

Medcatons (some beta bockers, anaboc

sterods, progestatona agents)
Speci7c Dyslipide.ias0 *levated
(riglycerides
Classi7cation o$ Seru.
(riglycerides
Norma <150 mg/d
Borderne Hgh 150-199 mg/d
Hgh 200-499mg/d
Very Hgh >500 mg/d
Speci7c Dyslipide.ias0 *levated
(riglycerides
Causes o$ *levated (riglycerides

Obesty and overweght

Physca Inactvty

Cgarette smokng

Excess acoho ntake

Hgh carb. dets

Severa dseases (Type 2 DM, chronc rena faure,

nephrotc syndrome

Medcatons (cortcosterods, estrogens, retnods,

hgher doses of beta bockers
Speci7c Dyslipide.ias0 *levated
(riglycerides
Manage.ent o$ Very )igh (riglycerides
8;@== .g/dl9

Goa of therapy: Prevent acute pancreatts

Very ow fat dets (< 15% of caorc ntake)

Trgycerde-owerng drug usuay requred

(brate or ncotnc acd)

Reduce trgycerdes before owerng LDL

!nti !nginal Drugs

Or!ani Nitrates

Caliu" Channel *lo+ers

*eta reeptor *lo+ers

Coronary vessels0
Coronary vessels0
blood supply for the
blood supply for the
heart
heart
1% V*+V-*W
1% V*+V-*W
Coronary atherosclerosis0
Coronary atherosclerosis0


cause of cardiac ischemia
cause of cardiac ischemia
Myocardial
Myocardial
oxygen demand
oxygen demand
is
is
diminished
diminished
by:
by:

Reducing contractility
Reducing contractility

Reducing heart rate
Reducing heart rate

Reducing the preload
Reducing the preload

Reducing the afterload
Reducing the afterload
1% V*+V-*W
1% V*+V-*W
Wall Wall
tension tension

1% V*+V-*W
1% V*+V-*W

Myocardial
Myocardial
oxygen
oxygen
supply
supply
is chiefly
is chiefly
determined by:
determined by:
AV oxygen difference AV oxygen difference
Regional myocardial Regional myocardial
distribution distribution
coronary blood flow: coronary blood flow:
vascular resistance, artery pressure
Effects of antianginal drugs:
Effects of antianginal drugs:
Reducing oxygen demands
Reducing oxygen demands
Reducing heart rate and contractility Reducing heart rate and contractility
Dilating systemic arteries and veins Dilating systemic arteries and veins

wall tension by wall tension by

lowering heart loads! lowering heart loads!
"ncreasing oxygen supply
"ncreasing oxygen supply
Dilating conduct coronary arteries Dilating conduct coronary arteries

coronary blood flow! coronary blood flow!

#romoting regional distribution #romoting regional distribution

in ischemic regions! in ischemic regions!

$thers:
$thers:

Anti% platelet coagulation and thrombus formation Anti% platelet coagulation and thrombus formation

1% V*+V-*W
1% V*+V-*W
&'( )itrates
&'( )itrates
)itroglycerin
)itroglycerin
A' #harmacological actions
A' #harmacological actions


Dilating vessels and reducing heart loads
Dilating vessels and reducing heart loads
wall tension wall tension

* * reflex tachycardia reflex tachycardia

Redistribution of coronary circulation
Redistribution of coronary circulation

dilating conduct artery: dilating conduct artery:

collateral circulation collateral circulation
reducing wall tension: reducing wall tension:
blood flow in ischemic subendocardial area blood flow in ischemic subendocardial area
2% !ntianginal drugs
2% !ntianginal drugs
B' +linical uses
B' +linical uses
Angina pectoris:
Angina pectoris: all ,inds- especially stable type all ,inds- especially stable type

Heart failure
Heart failure

reducing heart loads due to vasodilation reducing heart loads due to vasodilation
+' Adverse reactions
+' Adverse reactions

"ncrease in heart rate and contractility
"ncrease in heart rate and contractility
.ymptoms due to vasodilation:
.ymptoms due to vasodilation: headache- flash- postural headache- flash- postural
hypotension- collapse- hypotension- collapse- etc etc' '

$thers:
$thers: methaemoglobinaemia methaemoglobinaemia
/olerance : avoiding steady%state plasma concentration* avoiding steady%state plasma concentration*
supplement of agents containing supplement of agents containing A A.0 .0 captopril! captopril!
2% !ntianginal drugs
2% !ntianginal drugs
&'( $ther nitrates
"sosorbide dinitrate
"sosorbide%1%mononirate
Compared with nitroglycerin:
Compared with nitroglycerin:

.imilar but wea,er effect

Acting slowly but lasting longer

2arger individual variation and more adverse effects

2% !ntianginal drugs
2% !ntianginal drugs
&'&
&'&

receptor bloc,ers
receptor bloc,ers
A' #harmacological action
A' #harmacological action

Reducing oxygen demand:

Reducing oxygen demand:

heart rate and contractility heart rate and contractility

Increasing oxygen supply:

Increasing oxygen supply:

diastolic period diastolic period

: : perfusion time perfusion time

vascular tone in normal regions vascular tone in normal regions

: :
blood flow in ischemic regions blood flow in ischemic regions

Others:
Others:
"mproving myocardial metabolism "mproving myocardial metabolism
"nhibiting coagulation of platelets "nhibiting coagulation of platelets
2% !ntianginal drugs
2% !ntianginal drugs
B' +linical uses
B' +linical uses


stable
stable
and
and
unstable
unstable
pectoris
pectoris
-
- especially associated with especially associated with
hypertension or arrhythmias- even with myocardial infarction hypertension or arrhythmias- even with myocardial infarction
*
*
but not
but not
used for
used for
variant angina pectoris
variant angina pectoris
+' )otes
+' )otes

Dose individuali3ation:
Dose individuali3ation: starting from small dose starting from small dose

4ithdraw gradually and slowly:
4ithdraw gradually and slowly: symptom symptom
rebound rebound

+ombination with nitroglycerin
+ombination with nitroglycerin
2% !ntianginal drugs
2% !ntianginal drugs
&'5 +alcium channel bloc,ers
&'5 +alcium channel bloc,ers
2% !ntianginal drugs
2% !ntianginal drugs
&'5 +alcium channel bloc,ers
&'5 +alcium channel bloc,ers
A' #harmacological actions
A' #harmacological actions
Reducing myocardial oxygen remand:
Reducing myocardial oxygen remand:

heart loads heart loads

: : nifedipine nifedipine

heart rate and contractility heart rate and contractility

: : verapamil and diltia3em verapamil and diltia3em
Increasing myocardial blood supply
Increasing myocardial blood supply
rotecting ischemic myocardial cells
rotecting ischemic myocardial cells
Inhibiting coagulation of platelets
Inhibiting coagulation of platelets
2% !ntianginal drugs
2% !ntianginal drugs
!ctions o$ calciu. channel bloc4ers !ctions o$ calciu. channel bloc4ers
B' +linical uses
B' +linical uses


stable and variant type:
stable and variant type:

nifedipine- verapamil- diltia3em nifedipine- verapamil- diltia3em


unstable type:
unstable type:

verapamil- diltia3em verapamil- diltia3em
2% !ntianginal drugs
2% !ntianginal drugs
!ctions o$ D)6 8li4e ni$edipine9 are si.ilar to those o$ !ctions o$ D)6 8li4e ni$edipine9 are si.ilar to those o$
nitroglycerin nitroglycerin
!ctions o$ verapa.il and diltiaBe. are si.ilar to those !ctions o$ verapa.il and diltiaBe. are si.ilar to those
o$ o$ bloc4ers bloc4ers
&'6 $ther drugs
&'6 $ther drugs
A+E"s
A+E"s

!reating hypertension and preventing ischemic heart !reating hypertension and preventing ischemic heart
disease disease

Reducing heart loads Reducing heart loads

Inhibiting cardial remodeling Inhibiting cardial remodeling

)icorandil
)icorandil

Opening "!#sensitive $ Opening "!#sensitive $

% %
channel &$ channel &$
"! "!
' '

(owering intracellular Ca (owering intracellular Ca

)% )%

roviding *O &li+e nitroglycerin' roviding *O &li+e nitroglycerin'

Inducing ischemic preconditioning Inducing ischemic preconditioning

2% !ntianginal drugs
2% !ntianginal drugs
Molsidomine
Molsidomine

Inhibiting adenosine upta+e and c", degradation Inhibiting adenosine upta+e and c", degradation

Inhibiting pletelet aggregation Inhibiting pletelet aggregation

romoting collateral circulation after long#term use romoting collateral circulation after long#term use
Dipyridamole
Dipyridamole

Inhibiting adenosine upta+e and c", degradation Inhibiting adenosine upta+e and c", degradation

Inhibiting pletelet aggregation Inhibiting pletelet aggregation

romoting collateral circulation after long#term use romoting collateral circulation after long#term use
2% !ntianginal drugs
2% !ntianginal drugs

nitroglycerin nitroglycerin bloc,ers bloc,ers +a +a
&7 &7
antagonists antagonists combination8 combination8
0eart rate 0eart rate
+ontractility +ontractility 9 9
4all tension 4all tension 9 9 9 9
$xygen demand $xygen demand
Blood pressure Blood pressure
: increase- : increase- : mar,edly increase* : mar,edly increase* : decrease- : decrease- : mar,edly : mar,edly
decrease* decrease* : variable according to the dose and effect of each drug * : variable according to the dose and effect of each drug *
8 8 bloc,ers bloc,ers
combined with nitroglycerin or +a combined with nitroglycerin or +a
&7 &7
antagonists antagonists nifedipine* nifedipine*
combination with verapamil9diltia3em not be recommendated combination with verapamil9diltia3em not be recommendated! !
+aution:
+aution: +ombination may potentiate the antianginal +ombination may potentiate the antianginal
effects- but may induce severe hypotension effects- but may induce severe hypotension
&% Su..ary o$ antianginal
&% Su..ary o$ antianginal
drugs
drugs