Dilations from a Point

Chapter 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 DrugAlpha1 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 DrugsAlpha 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 Inhibitorsaka 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 HTNTreatment 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)

LARGE CARBON MOLECULES Many carbon compounds are built up from smaller, simpler molecules known as monomers (MAH-ne-mers), such as the ones shown in Figure 3-3. As you can also see in Figure 3-3, monomers can bond to one another to form polymers (PAWL-eh-mer). A polymer is a molecule that consists of repeated, linked units. The units may be identical or structurally related to each other. Large polymers are called macromolecules. There are many types of macromolecules, such as carbohydrates, lipids, proteins and nucleic acids. Monomers link to form polymers through a chemical reaction called a condensation reaction. Each time a monomer is added to a polymer, a water molecule is released. In the condensation reac- tion shown in Figure 3-4, two sugar molecules, glucose and fruc- tose, combine to form the sugar sucrose, which is common table sugar. The two sugar monomers become linked by a C—O—C bridge. In the formation of that bridge, the glucose molecule releases a hydrogen ion, H, and the fructose molecule releases a hydroxide ion, OH. The OH and H ions that are released then combine to produce a water molecule, H2O. In addition to building polymers through condensation reac- tions, living organisms also have to break them down. The break- down of some complex molecules, such as polymers, occurs through a process known as hydrolysis (hie-DRAHL-i-sis). In a hydrolysis reaction, water is used to break down a polymer. The water molecule breaks the bond linking each monomer. Hydrolysis is the reverse of a condensation reaction. The addition of water to some complex molecules, including polymers, under certain con- ditions can break the bonds that hold them together. For example, in Figure 3-4 reversing the reaction will result in sucrose breaking down into fructose and glucose. 2H2O Monomers Polymer C C O H OH C OH H CH2OH C H CH2OH C HO H C O H C OH H C CH2OH H C H OH O Sucrose C C O H OH C OH H CH2OH C H CH2OH C HO H C OH OH H C OH H C CH2OH H C H OH O Glucose Fructose H2O The condensation reaction below shows how glucose links with fructose to form sucrose. One water molecule is produced each time two monomers form a covalent bond. FIGURE 3-4 monomer from the Greek mono, meaning “single or alone,” and meros, meaning “a part” Word Roots and Origins A polymer is the result of bonding between monomers. In this example, each monomer is a six-sided carbon ring. The starch in potatoes is an example of a molecule that is a polymer. FIGURE 3-3 Copyright © by Holt, Rinehart and Winston. All rights reserved. 54 CHAPTER 3 ENERGY CURRENCY Life processes require a constant supply of energy. This energy is available to cells in the form of certain compounds that store a large amount of energy in their overall structure. One of these com- pounds is adenosine (uh-DEN-uh-SEEN) triphosphate, more commonly referred to by its abbreviation, ATP. The left side of Figure 3-5 shows a simplified ATP molecule struc- ture. The 5-carbon sugar, ribose, is represented by the blue carbon ring. The nitrogen-containing compound, adenine, is represented by the 2 orange rings. The three linked phosphate groups, —PO4 , are represented by the blue circles with a “P.” The phospate groups are attached to each other by covalent bonds. The covalent bonds between the phosphate groups are more unstable than the other bonds in the ATP molecule because the phosphate groups are close together and have negative charges. Thus, the negative charges make the bonds easier to break. When a bond between the phosphate groups is broken, energy is released. This hydrolysis of ATP is used by the cell to provide the energy needed to drive the chemical reactions that enable an organism to function.

Analyzing Photosynthesis Video I've begun the process of analyzing the video on photosynthesis. My initial goal is to understand the core topics, so I am watching it from beginning to end. I am noting down important terms such as the overall process, inputs and outputs, and the relationship with cellular respiration. Light-dependent and light-independent reactions are key. Pinpointing Core Concepts I'm now focusing on pinpointing core concepts and their corresponding timestamps within the video. I've noted down key terms and will correlate them to their corresponding durations. My next step will be to formulate multiple-choice questions in both English and Chinese, each linked to a specific timestamp, to evaluate understanding of these fundamental principles.

What Is Rhythm in Music? Rhythm is the pattern of sound, silence, and emphasis in a song. In music theory, rhythm refers to the recurrence of notes and rests (silences) in time. When a series of notes and rests repeats, it forms a rhythmic pattern. In addition to indicating when notes are played, musical rhythm also stipulates how long they are played and with what intensity. This creates different note durations and different types of accents.Why Is Rhythm Important in Music? Rhythm functions as the propulsive engine of a piece of music, and it gives a composition structure. Most musical ensembles contain a rhythm section responsible for providing the rhythmic backbone for the entire group. Drums, percussion, bass, guitar, piano, and synthesizer may all be considered rhythm instruments, depending on the context. However, all members of a music group bear responsibility for their own rhythmic performances and play the musical beats and rhythmic patterns indicated by the piece's composer.7 Elements of Rhythm in Music Several core elements comprise the fundamentals of musical rhythm. 1. Time signature: A musical time signature indicates the number of beats per measure. It also indicates how long these beats last. In a time signature with a 4 on the bottom (such as 2/4, 3/4, 4/4, 5/4, etc.), a beat corresponds with a quarter note. So in a 4/4 time (also known as "common time"), each beat is the length of a quarter note, and every four beats form a full measure. In 5/4 time, every five beats form a full measure. In a time signature with an 8 on the bottom (such as 3/8, 6/8, or 9/8), a beat corresponds with an eighth note. 2. Meter: Standard Western music theory divides time signatures into three types of musical meter: duple meter (where beats appear in groups of two), triple meter (where beats appear in groups of three), and quadruple meter (where beats appear in groups of four). Meter is not tied to note values; for instance, a triple meter could involve three half notes, three quarter notes, three eighth notes, three sixteenth notes, or three notes of any duration. Musicians and composers regularly mix duple and triple meter in their work; Igor Stravinsky's "The Rite of Spring" is a textbook example of such a technique. 3. Tempo: Tempo is the speed at which a piece of music is played. There are three primary ways that tempo is communicated to players: beats per minute, Italian terminology, and modern language. Beats per minute (or BPM) indicates the number of beats in one minute. Certain Italian words like largo, andante, allegro, and presto convey tempo change by describing the speed of the music. Finally, some composers indicate tempo with casual English words such as “fast,” “slow,” “lazy,” “relaxed,” and “moderate.” 4. Strong beats and weak beats: Rhythm combines strong beats and weak beats. Strong beats include the first beat of each measure (the downbeat), as well as other heavily accented beats. Both popular music and classical music combine strong beats and weak beats to create memorable rhythmic patterns. 5. Syncopation: Syncopated rhythms are those that do not align with the downbeats of individual measures. A syncopated beat will put its emphasis on traditional weak beats, such as the second eighth note in a measure of 4/4. Complex rhythms tend to include syncopation. While these rhythms may be more difficult for a beginning musician to pick up, they tend to sound more striking than non-syncopated rhythmic patterns. 6. Accents: Accents refer to special emphases on certain beats. To understand accents, think of a piece of poetry. A poetic meter, such as iambic pentameter, may dictate a specific mixture of stressed syllables and unstressed syllables. Musical accents are no different. Different rhythms may share a time signature and tempo, but they stand out from one another by accenting different notes and beats. 7. Polyrhythms: To achieve a particularly ambitious sense of rhythm, an ensemble may employ polyrhythm, which layers one type of rhythm on top of another. For instance, a salsa percussion ensemble may feature congas and bongos playing 4/4 time, while the timbales concurrently play a pattern in 3/8. This creates a dense rhythmic stew and, when properly executed, it can yield incredibly danceable rhythm patterns. Polyrhythms originated in African drumming, and they’ve spread to all sorts of genres worldwide, from Afro-Caribbean to Indian to progressive rock, jazz, and contemporary classical.

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