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A1 Chapter 1 Verbs
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A1 Chapter 1 Verbs 2Review with pictures- A1 - Chapter 1_RChapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)Figure 18-11 represents the amount of energy stored as organic material in each trophic level in an ecosystem. The pyramid shape of the diagram indicates the low percentage of energy transfer from one level to the next. On average, 10 percent of the total energy consumed in one trophic level is incor- porated into the organisms in the next. Why is the percentage of energy transfer so low? One reason is that some of the organisms in a trophic level escape being eaten. They eventually die and become food for decomposers, but the energy contained in their bodies does not pass to a higher trophic level. Even when an organism is eaten, some of the molecules in its body will be in a form that the consumer cannot break down and use. For example, a cougar cannot extract energy from the antlers, hooves, and hair of a deer. Also, the energy used by prey for cellu- lar respiration cannot be used by predators to synthesize new bio- mass. Finally, no transformation or transfer of energy is 100 percent efficient. Every time energy is transformed, such as during the reactions of metabolism, some energy is lost as heat. Limitations of Trophic Levels The low rate of energy transfer between trophic levels explains why ecosystems rarely contain more than a few trophic levels. Because only about 10 percent of the energy available at one trophic level is transferred to the next trophic level, there is not enough energy in the top trophic level to support more levels. Organisms at the lowest trophic level are usually much more abundant than organisms at the highest level. In Africa, for exam- ple, you will see about 1,000 zebras, gazelles, and other herbivores for every lion or leopard you see, and there are far more grasses and shrubs than there are herbivores. Higher trophic levels con- tain less energy, so, they can support fewer individuals.A population is a group of organisms that belong to the same species and live in a particular place at the same time. All of the bass living in a pond during a certain period of time make up a pop- ulation because they are isolated in the pond and do not interact with bass living in other ponds. The boundaries of a population may be imposed by a feature of the environment, such as a lake shore, or they can be arbitrarily chosen to simplify a study of the population. The humans shown in Figure 19-1 are part of the pop- ulation of a city. The properties of populations differ from those of individuals. An individual may be born, it may reproduce, or it may die. A population study focuses on a population as a whole—how many individuals are born, how many die, and so on. Population Size A population’s size is the number of individuals that the population contains. Size is a fundamental and important population property but can be difficult to measure directly. If a population is small and composed of immobile organisms, such as plants, its size can be determined simply by counting individuals. Often, though, individ- uals are too abundant, too widespread, or too mobile to be counted easily, and scientists must estimate the number of individuals in the population. Suppose that a scientist wants to know how many oak trees live in a 10 km2 patch of forest. Instead of searching the entire patch of forest and counting all the oak trees, the scientist could count the trees in a smaller section of the forest, such as a 1 km2 area. The scientist could then use this value to estimate the population of the larger area. SECTION 1 OBJECTIVES ● Describe the main properties that scientists measure when they study populations. ● Compare the three general patterns of population dispersion. ● Identify the measurements used to describe changing populations. ● Compare the three general types of survivorship curves. VOCABULARY population population density dispersion birth rate death rate life expectancy age structure survivorship curve FIGURE 19-1 A population can be widely distributed, as Earth’s human population is, or confined to a small area, as species of fish in a lake are. Copyright © by Holt, Rinehart and Winston. All rights reserved. 382 CHAPTER 19 If the small patch contains 25 oaks, an area 10 times larger would likely contain 10 times as many oak trees. A similar kind of sampling technique might be used to estimate the size of the pop- ulation shown in Figure 19-2. To use this kind of estimate, the sci- entist must assume that the distribution of individuals in the entire population is the same as that in the sampled group. Estimates of population size are based on many such assumptions, so all esti- mates have the potential for error. Population Density Population density measures how crowded a population is. This measurement is always expressed as the number of individuals per unit of area or volume. For example, the population density of humans in the United States is about 30 people per square kilome- ter. Table 19-1 shows the population sizes and densities of humans in several countries in 2003. These estimates are calculated for the total land area. Some areas of a country may be sparsely popu- lated, while other areas are very densely populated. Dispersion A third population property is dispersion (di-SPUHR-zhuhn). Dispersion is the spatial distribution of individuals within the popu- lation. In a clumped distribution, individuals are clustered together. In a uniform distribution, individuals are separated by a fairly con- sistent distance. In a random distribution, each individual’s location is independent of the locations of other individuals in the popula- tion. Figure 19-3 illustrates the three possible patterns of dispersion. Clumped distributions often occur when resources such as food or living space are clumped. Clumped distributions may also occur because of a species’ social behavior, such as when animals gather into herds or flocks. Uniform distributions may result from social behavior in which individuals within the same habitat stay as far away from each other as possible. For example, a bird may locate its nest so as to maximize the distance from the nests of other birds. These migrating wildebeests in East Africa are too numerous and mobile to be counted. Scientists must use sampling methods at several locations to monitor changes in the population size of the animals. FIGURE 19-2 TABLE 19-1 Population Size and Density of Some Countries Population size Population density Country (in millions) (in individuals/km2) China 1,289 135 India 1,069 325 United States 292 30 Russia 146 8 Japan 128 337 Mexico 105 54 Kenya 32 54 Australia 20 3 dispersion from the Latin dis-, meaning “out,” and spargere, meaning “to scatter” Word Roots and Origins Copyright © by Holt, Rinehart and Winston. All rights reserved. POPULATIONS 383 The social interactions of birds called gannets, which are shown in Figure 19-3b, result in a uniform distribution. Each gannet chooses a small nesting area on the coast and defends it from other gannets. In this way, each gannet tries to maximize its distance from all of its neighbors, which causes a uniform distribution of individuals. Few populations are truly randomly dispersed. Rather, they show degrees of clumping or uniformity. The dispersion pattern of a population sometimes depends on the scale at which the popu- lation is observed. The gannets shown in Figure 19-3b are uni- formly distributed on a scale of a few meters. However, if the entire island on which the gannets live is observed, the distribution appears clumped because the birds live only near the shore. POPULATION DYNAMICS All populations are dynamic—they change in size and composition over time. To understand these changes, scientists must know more than the population’s size, density, and dispersion. One important measure is the birth rate, the number of births occur- ring in a period of time. In the United States, for example, there are about 4 million births per year. A second important measure is the death rate, or mortality rate, which is the number of deaths in aA1 - Chapter 2 - B1 Category Practice- JA1 - Chapter 2 - Prepositions & Accusative caseA1 - Chapter 2 - Accusative case & B1 Category - PICTURES - LA1 - Chapter 2 - Accusative case - Introduction