Practical pharmacology_CVS_Dr_Aboshousha 2nd year medical students

1. PRACTICAL PHARMACOLOGY
2ND year module X (C.V.S)
BY: DR. H. Abo Shousha
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2. Hypertension
1ry (essential)
(controllable)
<55 y Renin
>55y Renin
2ry
(curable)
Disease
Drugs
1

3. Factors
controlling
blood
pressure
Adrenergic system α
β
RAAS
Bl. Vessel diameter
Blood Vol.
Renal blood flow,
function
Electrolyte
Fluids
Hormones
Corticosteroids
Vasopressin
Thyroid
Endothelium
NO
Bradykinin
Prostacyclin
Endothelin 2

4. ANTI-HYPERTENSIVE MEDICATIONS
A
• ACEI, ARBS
B
• Beta blockers
C
• Calcium channels blockers
D
• Diuretics
E
• Vasodilators, alpha blockers, centrally acting
3

5. Effect of Some Drugs on Systemic Blood Pressure
Pithed rat Artificial respiration
4

6. Effect of sympathetic innervation and Angiotensin II on blood pressure
Sympathetic
(heart)
Sympathetic
(kidney)
Sympathetic
(general)
Ang. II
0.2 μg/kg
Sustained
moderate rise in BP
Due to Renin
release
Tachycardia
Due to HR
Higher rise in BP
Due to activation of
both cardiac (β1) and
vascular (α1)
Sustained moderate rise in BP
Similar to renal sympathetic
stimulation
5

7. Comparing Renal Sympathetic Stimulation To Ang. μ0.2 Μg/Kg
Sympathetic
(kidney)
Sympathetic
(general)
Ang. II
0.2 μg/kg
6

8. Effect of Different Doses of Angiotensin II on blood pressure
Ang. II
0.2 μg/kg
Ang. II
0.5 μg/kg
Dose dependent vasoconstriction occur
Due to effect of Ang. II on AT1 receptors
No change in HR
As the rat is pithed (not working baroreceptors)
7

9. Testing Antihypertensive Act By Inhibiting The RAS System
8

10. Angiotensinogen
Angiotensin I
Angiotensin II
AT1
Vasoconstriction Aldosterone Hypertrophy Sympathetic
Renin
Angiotensin
converting enzyme
ACE I
ARBs
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11. Testing Antihypertensive Act By Inhibiting The RAS System
Ang. II
0.5 μg/kg
Captopril
5 μg/kg Ang. II
0.5 μg/kg
Captopril fail to  blood pressure
Captopril act by  formation of Ang. II by
inhibiting ACE
10

12. Testing Antihypertensive Act By Inhibiting The RAS System
Ang. II
0.5 μg/kg Ang. II
0.5 μg/kgLosartan
5 μg/kg
BP show some  after Losartan injection
As Losartan blocks AT1 receptor
Vasoconstriction effect of Ang. II is  after Losartan
This confirm the mechanism of action 11

13. Effect of Sympathetic Stimulation After Inhibition of RAAS
Losartan
5 μg/kg
Ang. II
0.5 μg/kg
Sympathetic
(general)
VC effect and tachycardia are still present but to lesser
amplitude
As Losartan blocks the facilitator effect of RAAS on sympathetic
system
12

14. PRESCRIPTION WRITING FOR HYPERTENSION
Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
13

15. Case 1
Prescribe a suitable antihypertensive drug for a 64
years old female with a newly diagnosed essential
hypertension ( 155/90). Her medical history and
current physical examination reveal no other
abnormality.
14

16. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Essential
Hypertension
Thiazide tablets 12.5 mg /
tablet
One tablet twice daily (before
meal)
15

17. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Ramipril tablets 2.5 mg /
tablet
One tablet once daily (before
meal)
Essential
Hypertension
16

18. Case 2
A 60 years old male complained of frequent
retrosternal chest pain since 3 weeks. This pain is
exertional, precipitated by effort like walking and
subside upon rest. Physical examination revealed BP
170/95, pulse 73 bpm. ECG showed sinus rhythm
without evidence of myocardial infarction. Write a
prescription form for this patient.
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19. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Hypertension with stable
angina
Bisoprolol tablets 10 mg /
tablet
One tablet once daily at
morning
18

20. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Hypertension with stable
angina
Diltiazem SR capsules 120 mg /
capsule
One tablet once daily at morning
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21. Case 3
A 35 years old asthmatic female presented with headache and
dizziness, her BP is 150/95 and the fasting blood sugar is 180
mg/dl.
A- prescribe a suitable antihypertensive drug for this PT.
B- what are the antihypertensive drugs contraindicated in
diabetes?
C- what are the antihypertensive drugs contraindicated in
asthmatics
20

22. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Hypertension in asthmatic
diabetic PT
Amlodipine tablets 5 mg /
tablet
One tablet once daily
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34. Angina results from
O2
supply
O2
demand
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36. CCB
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37. • Langendorff heart is the isolated perfused heart
• For maintaining cardiac activity isolated heart is to perfuse oxygenated perfusate via coronary
arteries using a cannula inserted in the ascending aorta
• During diastole when the aortic valves are closed the perfusate flows through the coronary
arteries After passing through the coronary vascular system, the perfusate enters the right
atrium via coronary sinus and finally flows out via the right ventricle and pulmonary artery
• The perfusate might be blood, Tyrode or Krebs-Henseleit bubbled with carbogen at
physiological temperature
Langendorff Heart
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38. Langendorff Heart
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39. Langendorff Heart
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40. ADRENALINE NORADRENALINE
Force of contraction 3.5 3.5
Heart rate 2 2
CBF 2 1
Effect of ADRENALINE and NORADRENALINE on Langendorff Heart
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41. ADRENALINE :
•  contractile force and HR by stimulation of β1 and β2
•  CBF (ml/min) due to:
• stimulation of in smooth muscle of coronary blood v.
•  contractile force and HR
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42. • Total CBF (ml/min) = ……….ml/beat X HR
• At normal HR:
• CBF = 0.2 ml/beat
• HR = 60 beat/ min
So total CBF = 0.2 X 60 = 12 ml/min
• Effect of tachycardia
• Adrenaline causes VD of coronary add 0.02 ml/beat
• But as adrenaline causes tachycardia   diastolic time
• So coronary BF drops from 0.2 ml/beat to 0.13 ml/beat
• So the Net effect
• CBF= 0.13 ml/beat + 0.02 ml/beat X 100 beat/min = 15 ml/min
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43. NORADRENALINE :
•  contractile force and HR due to β1 stimulation
• CBF due to  contractile force and HR
• But less than adrenaline
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44. ADRENALINE ADRENALINE WITH PROPRANOLOL
Force of contraction 3 1
Heart rate 2 1
CBF 2 -0.5
Effect of ADRENALINE alone and ADRENALINE with
PROPRANOLOL on Langendorff Heart
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46. N I T R O G LYC E R I N E V E R A PA M I L
Force of contraction 0 -0.5
Heart rate 0 -0.5
CBF 1 1.5
Effect of NITROGLYCERINE and VERAPAMIL on Langendorff Heart
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47. • VERAPAMIL is non DHP has –ve inotropic and –ve chronotropic effect and it
is also has vasodilator effect
• So it causes diastolic time  coronary filling
• So CBF  from 0.2 ml/beat to 0.3 ml/beat
• So CBF  by 0.1 ml/beat:
• 0.08 ml/beat 2ry to  diastolic time
• 0.02 ml/min 2ry to coronary VD
• So CBF = 0.3 ml/beat X 50 beat/min = 15 ml/min
46

48. • Nitroglycerine causes VD in coronary without  HR (in vitro only)
• CBF = 0.24 ml/beat X 60 beat/min = 14.4 ml/min
• So Nitroglycerine  CBF by 0.04 ml/beat compare to 0.02 ml/beat of CCB
• So Nitroglycerine is more potent coronary VD than CCB
47

49. PRESCRIPTION WRITING FOR IHD
Case 1
Prescribe for a male patient of 58 years old admitted to the
hospital with chest pain radiating to the shoulder and lower jaw.
His BP was 110/70, HR 70 bpm and respiratory rate 16/min. ECG
proved to be acute attack of angina
48

50. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Acute attack of
angina
Nitroglycerine tablets 2.5 mg /
tablet
One tablet sublingually & repeated
when needed
49

51. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Acute attack of
angina
Isosorbide dinitrate tablets 5 mg /
tablet
One tablet sublingually & repeated when
needed
50

52. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Angina pectoris
(between
attacks)
Isosorbide dinitrate tablets 20 mg
/ tablet
One tablet orally twice daily
(morning & after 8hs)
Prescribe a drug to be used in between attacks?
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53. Case 2
Prescribe for a male patient diagnosed to have vasospastic
angina (prenzimetal angina)
A- in acute attack
B- in between attacks
52

54. Patient’s name:
Patient’s address:
Doctor’s name:
Doctor’s address:
Date:
Diagnosis:
R/
Doctor Signature
Vasospastic angina
-Isosorbide dinitrate tablets 5 mg /
tablet
One tablet sublingually & repeated when needed
At acute attack
-Diltiazem SR capsules 120 mg
/capsule
One capsule once daily
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