It has come to attention that branches are adopting the practice of placing an

“account stop” hold on cheque accounts in an effort to prevent debit orders against the customer’s account.

Should a customer make this request, kindly proceed by asking the customer to complete an

Account Stop Hold on Cheque Account - Absa 4713

Risk Day Agenda 23/07/2020

Good day this is Chris today we will be doing a quick walkthrough on ISO 14001 2015 Environmental Management System and its main clauses let's get started ISO 14001 2015 Environmental Management System is a globally recognized standard for environment Management systems or EMS an EMS is a framework that organizations use to manage their environmental impact comply with regulations and improve their environmental performance the standard outlines are requirements for an EMS including the development of an environmental policy the identification of environmental aspects and impacts the establishment of objectives and targets the implementation of operational control monitoring and measurement systems and the ongoing review and Improvement of the system ISO 14001 is a flexible standard that can be used by organizations of any size or type regardless of their environment impact or level of environment performance it provides a practical framework for organizations to manage their environmental impact reduce environment risks and demonstrate their commitment on sustainability to their stakeholders here is the standard that provides a structured approach to develop an EMS which includes several key steps one organizations must develop an environmental policy that outlines their commitment to environmental sustainability this policy should be communicated to all employees and stakeholders two organizations must identify their environmental aspects and impacts this involves identifying the activities products and services that have an impact on the environment as well as the potential environmental consequences of those impacts three once the environmental aspects and the impacts have been identified organizations must establish environmental objectives and targets these objectives and targets should be specific measurable achievable relevant and time-bound 4. after setting objectives and targets organizations must Implement operational controls and establish monitoring and measurement systems to ensure that they are meeting their objectives and targets finally organizations must review and continually improve their EMS this involves conducting regular audits reviewing the EMS to ensure that it remains relevant and effective and making any necessary changes or improvements the main Clause of iso 14001 2015 apart from its scope normative references and terms and conditions that the main Clauses of iso 14001 2015 can be listed as context of the organization leadership planning support operation performance evaluation and Improvement Clause 4.0 context of the organization is about understanding the organization and its context understanding the needs and expectations of the interested parties determining the scope of the Environmental Management System EMS and Environmental Management System itself Clause 5.0 talks about leadership and commitment Environmental Policy organizational roles responsibility and authorities Clause 6.0 planning focuses on actions to address risk and opportunities as well as environmental objectives and planning to achieve them Clause 7.0 support are detailed requirements on resources competence awareness communication that includes external and internal communication documented information that involves creating updating in control of documented information Clause 8.0 operation talks about operational planning and control as well as emergency preparedness and response overall the design of iso 14001 2015 provides guidelines to form a system that is structured to cater the requirements of stakeholder needs and expectations to drive life cycle perspective and Energy Efficiency as pictured here Clause 9.0 performance evaluation provides guidelines to monitoring measurement analysis and evaluation evaluation compliance and management review an additional note here is that ISO 19011 2018 guidelines for auditing Management Systems which is an audit process that will determine the scope to establish the audit criteria by collecting evidence evaluating the evidence and then draw a conclusion based on the findings as pictured here [Music] finally Clause 10.0 Improvement talks about how Improvement is an integral factor to an effective Environmental Management system through General non-conformity and corrective action and continual Improvement talking about Improvement it is always continual in putting efforts towards the betterment of the existing system here is a snapshot of the main Clauses of iso 14001 2015 [Music] I hope you find this video useful we are industry experts specialized in management system consultancy and Industry relevant corporate training give us a call and let us help you drive your business excellence and upskill your employees to elevate workplace efficiency [Music] CREATE 10 MCQ AND 2 SAQ QUESTIONS BASED ON THE ABOVE PARAGRAPH

Make three questions based on the passage:"The International Labor Organization says the number of people without jobs is increasing. In its latest update on global employment trends, the agency says projections of the number of unemployed people this year range from 210 million to nearly 240 million people. The report warns that 200 million poor workers are at risk of joining the ranks of people living on less than 2 dollars per day in the past three years. The director general of the International Labor Organization Juan Somavia notes that some countries have taken measures to address the effects of the global crisis. However, he points out that many countries have not done so. And based on past experiences, it takes four to five years after economic recovery for unemployment to return to pre-crisis levels. Mr. Somavia says the International Labor Organization is proposing a global jobs' agreement to deal with unemployment. “Its key objective is to place the center of recovery efforts—measures that would generate high levels of employment and provide basic social protection for the most vulnerable."The International Labor Organization says the number of people without jobs is increasing. In its latest update on global employment trends, the agency says projections of the number of unemployed people this year range from 210 million to nearly 240 million people. The report warns that 200 million poor workers are at risk of joining the ranks of people living on less than 2 dollars per day in the past three years. The director general of the International Labor Organization Juan Somavia notes that some countries have taken measures to address the effects of the global crisis. However, he points out that many countries have not done so. And based on past experiences, it takes four to five years after economic recovery for unemployment to return to pre-crisis levels. Mr. Somavia says the International Labor Organization is proposing a global jobs' agreement to deal with unemployment. “Its key objective is to place the center of recovery efforts—measures that would generate high levels of employment and provide basic social protection for the most vulnerable."

Create questions based on the following text Not long ago, I grabbed breakfast at a hotel in southern Spain. The only cereal available was a local version of frosted corn flakes, so I readied myself to enjoy a bowl of my childhood favorite. But my sweet indulgence wasn't what I'd expected: The cereal milk was heated — apparently standard in this part of Spain — and my poor frosted flakes immediately turned to mush. Not so grrrrrrreat. Soggy flakes or not, I find breakfast to be a fun part of my travel day, especially because the experience varies so much from one country's breakfast table to the next. The farther north you go in Europe, the heartier the breakfasts. The heaviest is the traditional British "fry." Also known as a "Plate of Cardiac Arrest," the fry is a fundamental part of the bed-and-breakfast experience, and is generally included in your room price. A standard fry comes with cereal or porridge, a fried egg, Canadian-style bacon or sausage (and sometimes mackerel or haggis), a grilled tomato, sautéed mushrooms, baked beans, and fried bread or toast. This protein-stuffed meal can tide me over until dinner. You'll quickly figure out which parts of the fry you like. Your host will likely ask you up front which breakfast items you actually like, rather than serve you the whole shebang and risk having to throw out uneaten food. The Scandinavian breakfasts buffet is the perennial favorite for the "most food on the table" award. It pays to take advantage of breakfast smorgasbords when you can. For about $20 (a cheap meal in these parts), you can dig into an all-you-can-eat extravaganza of fresh bread, cheeses, yogurt, cereal, boiled eggs, herring, cold cuts, and coffee or tea. In place of cereal and milk, Scandinavians like to pour thick yogurt over their granola. Throughout the Netherlands, Belgium, Germany, Austria, Switzerland, and most points east of there, expect a more modest buffet — but still plenty of options (rolls, bread, jam, cold cuts, cheeses, fruit, yogurt, and cereal). In these countries, there's a good chance of finding hard-boiled eggs, but scrambled or fried eggs are relatively rare. In Poland, track down jajecznica, the local wake-up call of eggs scrambled with kielbasa sausage, served with a side of potato pancakes. The breakfast of choice in Russia is oladi, pancakes perfectly fried to be crisp on the outside but soft in the middle, then topped with sour cream, honey, or berries. Germans have an endearing habit of greeting others in the breakfast room with a slow and dour "Morgen" ("Morning" — short for "good morning"), though they have plenty to be happy about. Breakfast is usually included, and offers hearty fuel for the day: ham, eggs, cheese, bread, rolls, and pots of coffee. In Switzerland, don't miss an opportunity to try Bircher Muesli, a healthful mix of oats, nuts, yogurt, and fruit that tastes far more delicious than it looks. If breakfast is optional, take a walk to the nearest bakery — every German, Austrian, and Swiss town has at least a few bakeries offering a world of enticing varieties of bread and pastries, baked fresh every morning. As you move south and west (France, Italy, Spain, and Portugal), skimpier "continental" breakfasts are the norm. You'll mostly likely get a roll with marmalade or jam, occasionally a slice of ham or cheese, and coffee or tea. The good news? These little breakfasts compel you to sample regional favorites: In Spain, look for chocolate con churros (fritters served with a thick, warm chocolate drink), pan con tomate (a toasted baguette rubbed with fresh garlic and ripe tomato), or a tortilla española (a hearty slice of potato omelet). Italian breakfasts are particularly tiny, but the delicious red orange juice you get is made from Sicilian blood oranges. And you can buy a delightful toasted sandwich from a corner bar anywhere, anytime in Italy to make up for the minuscule breakfast. In France, locals just grab a warm croissant and coffee on the way to work. Queue up with the French and consider the yummy options: croissants studded with raisins, packed with crushed almonds, or filled with chocolate or cream. If you expect breakfast to be too sparse, plan ahead to supplement it with a piece of fruit and a wrapped chunk of cheese from a local market. Being a juice man, I keep a liter box of OJ in my room for a morning eye-opener. Coffee drinkers know that breakfast is the only cheap time to caffeinate yourself. Some hotels will serve you a bottomless cup of a rich brew only with breakfast. After that, the cups acquire bottoms and refills will cost you. Juice is generally available at breakfast, but in Mediterranean countries, you have to ask…and you'll probably be charged. In many countries, breakfast is included in your hotel bill, though if you make prior arrangements with the hotelier, you may be able to skip breakfast and pay a lower price for the room. If breakfast costs extra, it's often optional, and you can usually save money and gain atmosphere by buying coffee and a roll or croissant at the café down the street or by brunching picnic-style in the park. When deciding whether to request breakfast, consider your timing; if you need to get an early start, skip the breakfast — few hotel breakfasts are worth waiting around for. Come to the European breakfast table with an adventurous spirit. I'm a big-breakfast traditionalist at home, but when I feel the urge for an American breakfast in Europe, I beat it to death with a hard roll.

Not long ago, I grabbed breakfast at a hotel in southern Spain. The only cereal available was a local version of frosted corn flakes, so I readied myself to enjoy a bowl of my childhood favorite. But my sweet indulgence wasn't what I'd expected: The cereal milk was heated — apparently standard in this part of Spain — and my poor frosted flakes immediately turned to mush. Not so grrrrrrreat. Soggy flakes or not, I find breakfast to be a fun part of my travel day, especially because the experience varies so much from one country's breakfast table to the next. The farther north you go in Europe, the heartier the breakfasts. The heaviest is the traditional British "fry." Also known as a "Plate of Cardiac Arrest," the fry is a fundamental part of the bed-and-breakfast experience, and is generally included in your room price. A standard fry comes with cereal or porridge, a fried egg, Canadian-style bacon or sausage (and sometimes mackerel or haggis), a grilled tomato, sautéed mushrooms, baked beans, and fried bread or toast. This protein-stuffed meal can tide me over until dinner. You'll quickly figure out which parts of the fry you like. Your host will likely ask you up front which breakfast items you actually like, rather than serve you the whole shebang and risk having to throw out uneaten food. The Scandinavian breakfasts buffet is the perennial favorite for the "most food on the table" award. It pays to take advantage of breakfast smorgasbords when you can. For about $20 (a cheap meal in these parts), you can dig into an all-you-can-eat extravaganza of fresh bread, cheeses, yogurt, cereal, boiled eggs, herring, cold cuts, and coffee or tea. In place of cereal and milk, Scandinavians like to pour thick yogurt over their granola. Throughout the Netherlands, Belgium, Germany, Austria, Switzerland, and most points east of there, expect a more modest buffet — but still plenty of options (rolls, bread, jam, cold cuts, cheeses, fruit, yogurt, and cereal). In these countries, there's a good chance of finding hard-boiled eggs, but scrambled or fried eggs are relatively rare. In Poland, track down jajecznica, the local wake-up call of eggs scrambled with kielbasa sausage, served with a side of potato pancakes. The breakfast of choice in Russia is oladi, pancakes perfectly fried to be crisp on the outside but soft in the middle, then topped with sour cream, honey, or berries. Germans have an endearing habit of greeting others in the breakfast room with a slow and dour "Morgen" ("Morning" — short for "good morning"), though they have plenty to be happy about. Breakfast is usually included, and offers hearty fuel for the day: ham, eggs, cheese, bread, rolls, and pots of coffee. In Switzerland, don't miss an opportunity to try Bircher Muesli, a healthful mix of oats, nuts, yogurt, and fruit that tastes far more delicious than it looks. If breakfast is optional, take a walk to the nearest bakery — every German, Austrian, and Swiss town has at least a few bakeries offering a world of enticing varieties of bread and pastries, baked fresh every morning. As you move south and west (France, Italy, Spain, and Portugal), skimpier "continental" breakfasts are the norm. You'll mostly likely get a roll with marmalade or jam, occasionally a slice of ham or cheese, and coffee or tea. The good news? These little breakfasts compel you to sample regional favorites: In Spain, look for chocolate con churros (fritters served with a thick, warm chocolate drink), pan con tomate (a toasted baguette rubbed with fresh garlic and ripe tomato), or a tortilla española (a hearty slice of potato omelet). Italian breakfasts are particularly tiny, but the delicious red orange juice you get is made from Sicilian blood oranges. And you can buy a delightful toasted sandwich from a corner bar anywhere, anytime in Italy to make up for the minuscule breakfast. In France, locals just grab a warm croissant and coffee on the way to work. Queue up with the French and consider the yummy options: croissants studded with raisins, packed with crushed almonds, or filled with chocolate or cream. If you expect breakfast to be too sparse, plan ahead to supplement it with a piece of fruit and a wrapped chunk of cheese from a local market. Being a juice man, I keep a liter box of OJ in my room for a morning eye-opener. Coffee drinkers know that breakfast is the only cheap time to caffeinate yourself. Some hotels will serve you a bottomless cup of a rich brew only with breakfast. After that, the cups acquire bottoms and refills will cost you. Juice is generally available at breakfast, but in Mediterranean countries, you have to ask…and you'll probably be charged. In many countries, breakfast is included in your hotel bill, though if you make prior arrangements with the hotelier, you may be able to skip breakfast and pay a lower price for the room. If breakfast costs extra, it's often optional, and you can usually save money and gain atmosphere by buying coffee and a roll or croissant at the café down the street or by brunching picnic-style in the park. When deciding whether to request breakfast, consider your timing; if you need to get an early start, skip the breakfast — few hotel breakfasts are worth waiting around for. Come to the European breakfast table with an adventurous spirit. I'm a big-breakfast traditionalist at home, but when I feel the urge for an American breakfast in Europe, I beat it to death with a hard roll. Can you make 5 questions based on the text

Vocabulary List 1. Avocation Definition: A hobby or activity someone enjoys doing in addition to their main work. Example: Drawing cartoons was his favorite avocation after school. 2. Supercolossal Definition: Extremely large; even bigger than enormous. Example: They ordered a supercolossal pizza to share. 3. Repress Definition: To hold back or keep feelings or thoughts hidden. Example: She tried to repress her anger during the argument. 4. Subliminally Definition: In a way that affects the mind without someone realizing it. Example: The music subliminally made the store feel calmer. 5. Thrombosis Definition: A medical condition where a blood clot forms inside a blood vessel. Example: The doctor warned that lack of exercise can increase the risk of thrombosis. 6. Sclerosis Definition: A hardening of body tissue, especially arteries or organs. Example: The patient was diagnosed with sclerosis that affected his mobility. 7. Distortion Definition: A change that makes something appear different from what it really is. Example: The funhouse mirror caused a distortion of her reflection. 8. Philanthropy Definition: The act of giving money or help to improve the lives of others. Example: His philanthropy helped build a new library for the town. 9. Prevarications Definition: Lies or evasive statements used to avoid telling the truth. Example: The teacher grew tired of the student’s prevarications about missing homework. 10. Syndrome Definition: A group of symptoms or behaviors that occur together. Example: The doctor studied the syndrome to better understand the illness. 11. Schizophrenic Definition: Relating to a mental disorder where a person may have difficulty distinguishing reality from imagination. Example: The character in the story showed schizophrenic behavior. 12. Subsidize Definition: To support financially, usually with money from the government or an organization. Example: The city decided to subsidize public transportation. 13. Phenomenal Definition: Very remarkable or impressive. Example: The athlete gave a phenomenal performance in the race. 14. Demented Definition: Showing disturbed or irrational behavior. Example: The villain in the movie had a demented laugh. 15. Patron Definition: A person who supports or regularly visits a business, artist, or organization. Example: She was a loyal patron of the local bookstore. 16. Cultural Lag Definition: When ideas and beliefs take longer to change than technology or society. Example: Cultural lag can make it hard for laws to keep up with new technology. 17. Omens Definition: Signs believed to predict something that will happen in the future. Example: Some people think black cats are omens of bad luck. 18. Antagonistic Definition: Showing hostility or opposition. Example: The rival teams were antagonistic toward each other. 19. Voluptuous Definition: Curvy and attractive in a full, rich way. Example: The sculpture showed a voluptuous figure. 20. Oscilloscope Definition: A device used to view and measure electrical signals. Example: The scientist used an oscilloscope to study the sound waves. 21. Putrid Definition: Rotting and giving off a very bad smell. Example: The garbage smelled putrid after sitting in the sun. 22. Fixated Definition: Focused or obsessed with something. Example: He became fixated on winning the competition. 23. Mundane Definition: Ordinary, dull, or routine. Example: She was tired of the mundane chores she had to do every day. 24. Ghouls Definition: Evil or ghost-like creatures that feed on the dead in stories or legends. Example: The haunted house story was filled with ghouls and monsters. 25. Maladjusted Definition: Unable to cope well with the demands of life or society. Example: The counselor helped the maladjusted student deal with stress. 26. Incongruous Definition: Not fitting in; out of place. Example: The fancy chandelier looked incongruous in the small cabin. 27. Tribute Definition: Something done or given to show respect or admiration. Example: The concert was a tribute to the famous musician. 28. Audibly Definition: In a way that can be heard clearly. Example: He audibly sighed when the test ended. 29. Proficiency Definition: Skill or competence in doing something. Example: Her proficiency in math helped her tutor other students.

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)

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