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Captopril (Capoten)
Antihypertensive, ACE Inhibitor (I: HT, Heart failure, renal preservation C:Renal failure with renal stenosis, pregnancy AE: Cough, headache, hypotension, hyperkalaemia)
Enalapril (Renitec)
Antihypertensive, ACE Inhibitor (I: HT, Heart failure, renal preservation C:Renal failure with renal stenosis, pregnancy AE: Cough, headache, hypotension, hyperkalaemia)
Perindopril (Coversyl)
Antihypertensive, ACE Inhibitor (I: HT, Heart failure, renal preservation C:Renal failure with renal stenosis, pregnancy AE: Cough, headache, hypotension, hyperkalaemia)
Isosartan (Cozaar)
Antihypertensive, ARB, decreased TPR (vasodilation), increased Na and H2O excretion (I: HT, heart failure, diabetic neuropathy, intolerance to ACE inhibitors C: pregnancy, renal artery stenosis AE: Cough, headache, hypotension, hyperkalaemia)
Irbesartan (Avapro)
Antihypertensive, ARB, decreased TPR (vasodilation), increased Na and H2O excretion (I: HT, heart failure, diabetic neuropathy, intolerance to ACE inhibitors C: pregnancy, renal artery stenosis AE: Cough, headache, hypotension, hyperkalaemia)
Candesartan (Atacand)
Antihypertensive, ARB, decreased TPR (vasodilation), increased Na and H2O excretion (I: HT, heart failure, diabetic neuropathy, intolerance to ACE inhibitors C: pregnancy, renal artery stenosis AE: Cough, headache, hypotension, hyperkalaemia)
*pril
Angiotensin Converting Enzyme (ACE) Inhibitors
*sartan
Angiotensin-1 Receptor Blockers (ARB)
Aliskiren
Antihypertensive, Renin inhibitor, decreased TPR (vasodilation), increased Na and H2O excretion (I: HT, reno-protective-diabetic nephropathy AE: Hypotension, hyperkalaemia)
*olol
Beta-blockers
Carvedilol
Antihypertensive, Beta-Blocker, Inhibits SNS activity to vascular smooth muscle/cardiac muscle, decreases HR and TPR, inhibits renin release, increases excretion (I: HT, angina, post MI, arrhythmia, clinically stable heart failure, C: Asthmatics AE: Bronchoconstriction, decreased cardiac contractility, 2o AV block, depression, sleep disturbance, masked hypoglycaemia)
Atenolol (Tenormin)
Antihypertensive, Beta-Blocker (B1>B2), Inhibits SNS activity to vascular smooth muscle/cardiac muscle, decreases HR and TPR, inhibits renin release, increases excretion (I: HT, angina, post MI, arrhythmia, C: Asthmatics AE: Bronchoconstriction, decreased cardiac contractility, 2o AV block, depression, sleep disturbance, masked hypoglycaemia)
Propanolol (Inderal)
Antihypertensive, Beta-Blocker (B1 and 2), Inhibits SNS activity to vascular smooth muscle/cardiac muscle, decreases HR and TPR, inhibits renin release, increases excretion (I: HT, angina, post MI, arrhythmia, C: Asthmatics AE: Bronchoconstriction, decreased cardiac contractility, 2o AV block, depression, sleep disturbance, masked hypoglycaemia)
Metoprolol (Betaloc)
Antihypertensive, Beta-Blocker (B1), Inhibits SNS activity to vascular smooth muscle/cardiac muscle, decreases HR and TPR, inhibits renin release, increases excretion (I: HT, angina, post MI, arrhythmia, C: Asthmatics AE: Bronchoconstriction, decreased cardiac contractility, 2o AV block, depression, sleep disturbance, masked hypoglycaemia)
Verapamil (Isoptin) and Diltiazem
Antihypertensive, Ca2+ Channel blocker, reduces Ca2+ entry into vascular
Nifedipine (Adalat) and Amlodipine (Norvasc)
Antihypertensive, Ca2+ Channel blocker, reduces Ca2+ entry into vascular>cardiac muscle thus relaxes muscle (I: HT, angina, SVT C: heart failure, B-blockers AE: cardiac depression, bradycardia, flushing, oedema, dizziness, headache, constipitation, nausea)
Thiazides act on...
Distal tubule
Loop diuretics act on...
Loop of Henle
Potassium sparing diuretics act on...
Collecting tubules and ducts
Mechanism of action of Thiazides
Inhibit, at the distal tubule the Na+/Cl- symporter, resulting in decreased Na reabsorption, thus increased secretion of H2O. As a side effect, Thiazides will also enhance Ca2+ reabsorption at the distal convoluted tubule.
Mechanism of action of loop diuretics (fruseamide)
Inhibit, at the loop of henle, the Na/Cl/K pump and Mg2+ and Ca2+ reabsorption through disruption of the electrochemical gradient.
*pine
Ca2+ Channel Blockers
Events at the T4/5 Transverse Plane
PATELLA
Passage of the thoracic duct to the left
Angle of Louis
Tracheal bifurcation
Ends of the aortic arch
Ligamentum arteriosum
Loop of the left recurrent laryngeal nerve
Azygous vein ends
Branches of the Abdominal Aorta
Prostitutes Cause Sagging Swollen Red Testicles: Living In Sin
Phrenic, Coeliac, Superior Mesenteric, Suprarenal (Middle Suprarenal), Renal, Testicular (Gonadal), Lumbar, Inferior Mesenteric, Sacral (Middle Sacral)
Secondary Hypertension
High BP secondary to abnormality or drug

  • Renal/Vascular disease

  • Drugs

  • Coarcation of aorta

  • Hyperaldosteronism

  • Glucocorticoid excess

  • Phaeochromocytoma (tumour)

Essential Hypertension
HT of unknown aetiology, risk factors include

  • Genetics

  • Smoking

  • Stress

  • Environment

  • Diet

BP is determined by...
(BP = 'X' x 'Y')
BP = CO x TPR
BP = SV x HR x TPR
HR determined by SA node
TPR inversely proprtional to vessel radius^4
Commonly used anti-HT's
(ABCD)
Angiotensin converting enzyme inhibitors (ACEI)
Beta blockers (βB's)
Calcium channel blockers
Diuretics (thiazides, loop, potassium sparing)
ACEI's
*pril's
Captopril (Capoten)
Enalapril (Renitec)
Perindopril (Coversyl)
Prevent AngII formation and inhibit bradykinin breakdown (↓AngII, ↑BK)
ACEI adverse effects
Common:
Cough
Marked hypotension
Hyperkalaemia (beware K+ supplements or K+ sparing diuretics)
Infrequent:
Rash/itch
Taste disturbances
Angioedema
Contraindications:
Renal failure if renal artery stenosis
Pregnancy
ARB's
*sartan
Iosartan (Cozaar)
Irbesartan (Avapro)
Candesartan (Atacand)
Inhibit angiotensin-induced vasoconstriction and aldosterone output (↑AngII, unchanged BK with ACEI)
For Pt's intolerant to ACEI
ARB adverse effects
Similar to ACEI... Hypotension, hyperkalaemia etc.
Avoid in pregnancy, beware renal artery stenosis...
Renin Inhibitor
New Kid On The Block
Aliskiren
Direct inhibition of Renin;
↓TPR, ↑Na2+ and H2O excretion
Indications: HT, renoprotective diabetic nephropathy
Adverse effects: Not sure yet... ?hypotension ?hyperkalaemia
Beta Blockers
β Blockers
*olol
Propanolol (Inderal) β1 and 2 antag
Atenolol (Tenormin) β1>β2
Metoprolol (Betaloc) β1 selective
Carvedilol (Dilatrend) α1, β1 and β2
β Blocker adverse effects
Bronchoconstriction (β2), decreased cardiac contractility (β1) leading to 2o AV block, exercise inteollerance, claudication and impotence,
Depression, sedation, sleep problems (vivid dreams)
Exacerbation and masking of Hypoglycaemia with diabetes
Ca2+ channel blockers / antagonists
No fixed... *ipine
Cardiac selective;
Verapamil (Isoptin) - Cardiac +++, ↓BP,HR,TPR
Diltiazem - Cardiac ++, ↓BP,HR,TPR
Vasoselective;
Nifedipine (Adalat)
Amlodipine (Norvasc) - Cardiac +, ↓↓BP,TPR, ↑↑HR
Cause vasodilation, reduced cardiac contractility/AV conduction (verapamil>diltiazem>nifedipine)
Indications: HT, angina, SVT
Ca2+ channel blocker adverse effects
Cardiac depression, bradycardia, flushing, oedema, dizziness, headache, constipation, nausea
Contraindications:
Heart failure, concurrent β blocker use (verapamil or diltiazem)
Where do thiazides, loop diuretics and potassium conserving diuretics work?
Thiazides: Distal convoluted tubule (eg Dithiazide)
Loops: Loop of henle (eg Ferusamide)
Potassium sparing: Collecting ducts (eg Spironolactone)
Therapeutic use of thiazides
Mild/Moderate HT
Oedema due to mild/moderate heart failure
Diabetes insipidus
Blocks sodium/chloride symporter, enhances Ca2+ reabsorption
Adverse effects of thiazides
Hypokalaemia, hyperuricaemia (gout), hypercholesterolaemia, hyperglycaemia, increases digoxin toxicity
Loop diuretics
Inhibit Sodium, Potassium, Chloride symporter
"Other sympathetic inhibitors for HT"
α1 blockers (vasodilation)
Brain α2 blockers (e.g. methyl dopa) (vasodilation)

Anti-HT combination therapy
ACEI or a AT2R blocker
PLUS
A Calcium channel blocker
ACEI or a AT2R blocker
PLUS
Thiazide diuretic
ACEI or a AT2R blocker
PLUS
Beta blocker
Thiazide diuretic
PLUS
Calcium channel blocker
Thiazide diuretic
PLUS
Beta blocker
DO NOT USE
Hyperkalaemia
ACEI or a AT2R blocker
PLUS
Potassium sparing diuretic (Spironolactone)
Heart block
Beta Blockers (Verapamil)
PLUS
Beta blocker
Significance of a displaced apex beat
Myocardial hypertrophy (left ventricular, cardiac tamponade or dextocardia)
Significance of sternal thrus
Right ventricular hypertrophy
Explain the significance of valve stenosis or regurgitation. Contrast the implications for heart valves of chambers on the right with those on the left.
Stenosis: Stiffened, harder for blood to get through or close
Regurgitation: Unable to remain closed/Incompetent valve leading to backflow/turbulant flow of blood
Mitral/Aortic: Backflow into lungs (dyspnoea and pulmonary oedema), decreased cardiac output (exercise intollerance), chamber hypertrophy with stenosis (mitral: atrial, aortic: ventricular) or chamber dilation (mitral: atrial dilation, aorta: ventricular dilation)
Pulmonary/Tricuspid: Backflow into systemic circulation (oedema, particularly pedal oedema, raised JVP), downstream circulation insufficiency (dyspnoea), Stenosis (tricuspid: increased central venous pressure, pulmonary: right ventricular hypertrophy, sternal thrust) or regurgitation (tricuspid: increased central venous pressure, pulmonary: RV dilation)
Coronary artery anastomoses
Between the LCA's Anterior Interventricular Branch and the RCA's Posterior Interventricular branch
Between the LCA's Circumflex branch and the RCA's Posterior Interventricular branch
Supply of cardiac areas
RCA: RA, most of RV, part of LV, part of AV septum, in 55% of people the SA node, AV node
LCA: LA, most of LV, part of RV, most of IV septum, in 45% of people the SA node, AV bundle
Posterior IV usually by RCA (85% of population)
Lower limb pulse points
Femoral, Popliteal, Posterior tibial, Dosalis pedis
Vessels in limbs endangered by injury
 Upper limbs

  • Palms (Palmar arches)

  • Wrist or Forearm # (Radial and Ulnar a.)

  • Cubital fossa (End of Brachial a.)

  • Axilla (axilla a.)

  • Scaphoid # (scaphoid arterial supply)

  • Midshaft humerus # (deep brachial a.)

  • Surgical neck of humerus # (posterior circumflex a.)

  • Clavicle # (subclavian a.)


Lower limbs

  • Groin or #NOF (Femoral a.)

  • Midshaft femur (deep femoral a. and perforating a.)

  • Dislocated patella / popliteal stab (popliteal a.)

  • Midshaft tibial (anterior/posterior tibial a.)

  • Dislocation of ankle (posterior tibial a.)

  • Stepping on glass (plantar arch arteries of foot)

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