The Cardiovascular System Jessica Tagerman, PharmD, RPh

What is Coronary Artery Disease?

Coronary Artery Disease When blood vessels that supply the heart with oxygen become narrowed as the result of atherosclerosis, caused by fatty deposits (plaque) in the inside of blood vessels. Deprivation of oxygen can lead to heart attack (myocardial infarction) or abnormal heart rhythm (arrhythmia) See next slide for visual Atherosclerosis: a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls.

Cholesterol Cholesterol measured as: Total Cholesterol = LDL+ HDL LDL = low density lipoprotein= “bad cholesterol” HDL = high density lipoprotein = “good cholesterol” Goal= ↑ HDL & ↓LDL

Good vs. bad cholesterol

Diet and exercise come before pharmaceutical therapy! Remember… Diet and exercise come before pharmaceutical therapy!

Cholesterol Lowering Agents HMG-CoA Reductase Inhibitors (Statins) Generic Name Brand Name® Mechanism of Action Atorvastatin Lipitor® Prevent the formation of cholesterol from fats in the liver. Fluvastatin Lescol® Pravastatin Pravachol® Simvastatin Zocor® Rosuvastatin Crestor® 1st line therapy for lowering LDL May cause muscle pain or liver damage

Cholesterol Lowering Agents Bile Acid Sequestrants Generic Name Brand Name Mechanism of Action Cholestyramine Questran® Binds bile in the intestines and prevent it from being reabsorbed- excreted in feces Body feels like it needs to make more bile, so it takes the cholesterol and makes its own bile. Leads to decrease in LDL and total cholesterol Colestipol Colestid® Colesevelam Welchol® Many side effects Caution of drug interactions Taken orally Some need to be reconstituted- poor taste.

Cholesterol Lowering Agents Fibrates Generic Name Brand Name Mechanism of Action Gemfibrozil Lopid® Unknown Fenofibrate, Fenofibric acid Tricor®, Trilipix®, etc. Side effects: nauseas, GI symptoms, muscle and joint aches, gall stones, decreased white and/or red blood cells HDL is known as “good cholesterol” because it transports cholesterol to your liver to be expelled from your body. HDL helps rid your body of excess cholesterol so it’s less likely to end up in your arteries. LDL is called “bad cholesterol” because it takes cholesterol to your arteries, where it may collect in artery walls.

Cholesterol Lowering Agents Misc. and Combination Agents Generic Name Brand Name Mechanism of Action Amlodipine/atorvastatin Caduet® Ezetimibe Zetia® Decreases absorption of cholesterol in the intestine Ezetimibe/Simvastatin Vytorin® Niacin/Lovastatin Advicor® Niacin/Simvastatin Simcor® Nicotinic Acid Niacin® Form of vitamin B that reduces serum cholesterol and triglycerides Omega-3 fatty acids Lovaza® Niacin- flushing Omega-3 fatty acids (fishy burp)

Knowledge Check Johnny Depp walks into the pharmacy to pick up his new prescription for Lipitor®. Which of following would the pharmacist be least likely to say during consultation? Contact the doctor immediately if you experience any sort of muscle pain Do not consume grapefruit & grapefruit juice while taking this medication Take 1 tablet of rosuvastatin every day Take 1 tablet of atorvastatin every day Take 1 tablet of rosuvastatin every day- the generic name is atorvastatin

What is hypertension?

Hypertension Occurs when the normal regulation of blood pressure is disrupted and the diastolic pressure remains chronically elevated “High Blood Pressure” >120/<90 Uncontrolled BP increases risk for: Stroke Heart Attack Heart Failure Kidney Damage Retinal Damage

Hypertension treatment- Diuretics Decrease blood pressure by decreasing blood volume 3 types of diuretics Thiazide Usually effective for high blood pressure Loop Usually effective in patients with mild kidney failure Potassium Sparing Weak diuretics, but may be given in combination to prevent potassium loss from other agents Diuetics also used for patients who have edema (water build up)

Hypertension treatment- Diuretics Thiazide Diuretics Loop Diuretics Potassium Sparing Diuretics Generic Name Brand Name Hydrochlorothiazide (HCTZ) Microzide® Furosemide Lasix® Eplerenone Inspra® Chlorothiazide Diuril® Bumetanide Bumex® Spironolactone Aldactone® Metolazone Zaroxolyn® Torsemide Demadex® Triamterene Dyrenium® Ethacrynic Acid Edecrin®

Hypertension treatment- beta blockers Beta-Blockers work by decreasing the volume of blood pumped by each contraction of the heart, thus slowing heart rate. However, may also cause bronchoconstriction. 2 types of beta receptors in the body β1 Found in heart and kidney Stimulation leads to increase in HR and contractility β2 found in lungs, arterioles, pancreas, and liver Stimulation leads to vasodilation and bronchodilation

Hypertension treatment- beta blockers Generic Name Brand Name Cardioselective? Atenolol Tenormin® Y Bisoprolol Zebeta® Carvedilol Coreg® N Labetalol Trandate® Metoprolol Tartrate Lopressor® Metoprolol Succinate Toprol-XL® Nadolol Corgard® Propranolol Inderal® Sotalol Betapace® Nebivolol Bystolic® Look for –olol ending

Hypertension treatment- Ace Inhibitors Angiotensin-Converting Enzyme Inhibitor- Prevents an enzyme in your body from producing angiotensin II, a substance in your body that narrows your blood vessels and releases hormones that can raise your blood pressure. May also slow or prevent the development of kidney disease in diabetic patients and increase survival, alleviate symptoms, and decrease hospitalization in patients with heart failure. Look for the -PRIL ending

Hypertension treatment- Ace Inhibitors Generic Name Brand Name Benazepril Lotensin® Captopril Capoten® Enalapril Vasotec® Fosinopril Prinivil® Quinapril Accupril® Perindopril Aceon® Ramipril Altace® Lisinopril Zestril® Trandolapril Mavik®

Hypertension treatment- Angiotensin receptor blockers Generic Name Brand Name Candesartan Atacand® Losartan Cozaar® Irbesartan Avapro® Olmesartan Benicar® Valsartan Diovan® ARBs Similar to ACE inhibitors, but instead of blocking the enzyme from producing angiotensin II, it blocks the angiotension receptors so angiotensin cannot bind and cause a response

Hypertension treatment- Calcium Channel Blockers Inhibit movement of calcium in and out of cells, which results in a decreased force of contraction of the heart, blocked contraction of smooth muscles resulting in dilation of blood vessels, and slowed conduction of nerve impulses through the heart resulting in a slowed heart rate Many uses, besides treatment of hypertension: Heart rhythm disturbances Migraine headaches Disease of the heart muscle Hypertension Chest pain

Hypertension treatment- Calcium Channel Blockers Generic Name Brand Name Amlodipine Norvasc® Nifedipine Procardia® Diltiazem Cardizem, Tiazac® Verapamil Calan®

Hypertension treatment- vasodilators Generic Name Brand Name Aliskiren Tekturna® Clonidine Catapres® Hydralazine Apresoline® Minoxidil (Topical version rogaine) Class includes alpha-2 agonists, direct renin inhibitors, and direct vasodilators Dilate the blood vessels and reduce blood pressure People often get postural hypotension- blockage of constriction causes dizziness or faintness (low blood pressure)

Knowledge Check Although Jack Nicholson seems to be aging gracefully, he has high blood pressure and occasionally has trouble controlling his bladder. His doctor prescribes him Lasix®. What do you think about this therapy choice? Lasix greatly increases the frequency of urination. If he has trouble controlling his bladder, there is probably a better option for him.

Knowledge Check Snoopy is a dog being treated like a human for high blood pressure. He is dieting and starting to exercise, but the doctor also wanted him on medication to decrease his blood pressure. The last time you saw him, he had a dry cough. Of the following medications, which is the most likely to be causing this symptom? Amlodipine Carvedilol Metoprolol Lisinopril Lisinopril- ace inhibitors are likely to cause a cough.

What is a stroke?

Stroke When there is an acute decrease or stoppage of blood flow to a part of the brain. Types: Ischemic Stroke Blood clot that blocks the flow of blood in the vessels Hemorrhagic Stroke Blood vessel ruptures, preventing blood flow to the brain Possible causes: atrial fibrillation, atherosclerosis, aneurysm, high blood pressure. AKA Cerebrovascular accidents (CVAs)

What is angina pectoris?

Angina Pectoris Chest pain of short duration that is due to a lack of oxygen in the cardiac muscle cells. Pain subsides when the imbalance between the amount of oxygen needed by the cells and the amount of oxygen supplied to the cells is corrected. Treatment: Nitrates (nitroglycerin) Increase the amount of oxygen delivered to the heart and decrease the oxygen needs of the heart Need nitrate free period to reduce tolerance Can also use beta blockers and calcium channel blockers Heart attack: Myocardial Infarction

What is Heart Failure?

Heart Failure The heart cannot eject adequate blood from the ventricles of the heart Symptoms of tiredness, SOB, swelling, and increased heart rate (pulse) Caused by: Heart attack, high blood pressure, CAD, abnormal heart valves, and heart defects. AKA Chronic or Congestive Heart Failure (CHF)

Heart Failure Treatment may include ACE inhibitors, diuretics, beta blockers and digoxin. Fluid restriction and low sodium diet used to reduce amount of fluid retention Digoxin: Shown to increase force of heart muscle contraction in selected patients- improves pumping of blood and slowing heart rate Caution: Digoxin toxicity, narrow therapeutic index

Fun Fact- Digoxin Digoxin is a genus of the Digitalis plant (Foxglove) Digoxin toxicity is often characterized by changes in vision It has been theorized that Van Gogh was suffering from digoxin toxicity near the end of is life, which is why his paintings had a yellow undertone & yellow halos

What is venous thromboembolism?

Venous Thromboembolism When a clot forms in the veins of the body Pulmonary embolism- when a clot forms somewhere in the body, but breaks away and travels to the lungs

What are Arrhythmias & Dysrhythmias?

Arrhythmias/Dysrhythmias Abnormal Rhythms of the heart Bradycardia- Heart beating too slowly Tachycardia- Heart beating too rapidly Abnormal Electric activity Common arrhythmias: Atrial fibrillation Atrial flutter No regular rhythm vs. abnormal rhythm

Arrhythmias/Dysrhythmias Antiarrhythmic Agents Generic Name Brand Name Quinidine Procainamide Pronestyl® Flecainide Tambocor® Propafenone Rythmol® Atenolol Tenormin® Metoprolol Lopressor®, Toprol® XL Amiodarone Pacerone® Sotalol Betapace® Treatment: Many of the drugs used to treat arrhythmias also cause arrhythmias

Questions?