1. The Cardiovascular System
Jessica Tagerman, PharmD, RPh

2. What is Coronary Artery Disease?

3. 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.

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

6. Good vs. bad cholesterol

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

8. 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

9. 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.

10. 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.

11. 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)

12. 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

13. What is hypertension?

14. 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

15. 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)

16. 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®

17. 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

18. 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

19. 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

20. 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®

21. 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

22. 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

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

24. 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)

25. 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.

26. 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.

27. What is a stroke?

28. 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)

29. What is angina pectoris?

30. 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

31. What is Heart Failure?

32. 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)

33. 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

34. 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

35. What is venous thromboembolism?

36. 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

37. What are Arrhythmias & Dysrhythmias?

38. 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

39. 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

40. Questions?