CARDIVASCULAR DRUGSCARDIVASCULAR DRUGSSanjukta (2009)Sanjukta (2009)

CARDIOVASCULAR DISEASE AND CARDIOVASCULAR DISEASE AND DRUGSDRUGS

► Basic cardiovascular physiology and pathology Basic cardiovascular physiology and pathology depends on the control of heart rate, cardiac depends on the control of heart rate, cardiac output, blood pressure, blood flow, ionic output, blood pressure, blood flow, ionic composition, RAAS, vascular endothelium, composition, RAAS, vascular endothelium, regulation of tissue perfusion, hypertension, regulation of tissue perfusion, hypertension, dislipidaemias, atherosclerosis, blood clotting, dislipidaemias, atherosclerosis, blood clotting, ischaemic heart disease, cardiomyopathies, cardiac ischaemic heart disease, cardiomyopathies, cardiac arrhythmias and cardiac failure. arrhythmias and cardiac failure.

► Cardiovascular drugs: inotropic agents, b blockers, Cardiovascular drugs: inotropic agents, b blockers, calcium antagonists, organic nitrates, anti-calcium antagonists, organic nitrates, anti-arrhythmics, ACE inhibitors, ATII (=AT1) arrhythmics, ACE inhibitors, ATII (=AT1) antagonists, diuretics, cholesterol lowering drugs, antagonists, diuretics, cholesterol lowering drugs, clot-busters, anti-coagulants, anti-platelet drugs. clot-busters, anti-coagulants, anti-platelet drugs.

DRUGS TO TREAT ANGINA DRUGS TO TREAT ANGINA PECTORISPECTORIS

► Angina pectoris refers to a strangling or Angina pectoris refers to a strangling or pressure like pain caused by cardiac pressure like pain caused by cardiac ischaemia.ischaemia.

► It’s a pain syndrome due to induction of an It’s a pain syndrome due to induction of an adverse oxygen supply / demand situation adverse oxygen supply / demand situation in portion of myocardium.in portion of myocardium.

►Drugs used exploit two main strategies: Drugs used exploit two main strategies: reduction of oxygen demand and increase of reduction of oxygen demand and increase of the oxygen delivery to myocardium.the oxygen delivery to myocardium.

► Three types of anginal attack: stable angina, Three types of anginal attack: stable angina, unstable angina and variant angina.unstable angina and variant angina.

ANTI ANGINAL DRUGSANTI ANGINAL DRUGS► 1) ORGANIC NITRATES: Glyceryl trinitrate (Nitroglycerin), 1) ORGANIC NITRATES: Glyceryl trinitrate (Nitroglycerin),

Isosorbide dinitrate, etcIsosorbide dinitrate, etc

► 2) BETA BLOCKERS: Propranolol, Atenolol, Metroprolol, 2) BETA BLOCKERS: Propranolol, Atenolol, Metroprolol, Carvedilol, etcCarvedilol, etc

► 3) CALCIUM ANTAGONIST: Nifedipine, Diltiazem, Verapamil3) CALCIUM ANTAGONIST: Nifedipine, Diltiazem, Verapamil► 4) SELECTIVE If- INHIBITORS: Ivabradine 4) SELECTIVE If- INHIBITORS: Ivabradine

ANTI ARRHYTHMIC DRUGSANTI ARRHYTHMIC DRUGS

Cardiac arrythmias commonly occur in presence of Cardiac arrythmias commonly occur in presence of pre-existing heart disease.pre-existing heart disease.

1) CLASS I: Membrane stabilizing drugs; sodium 1) CLASS I: Membrane stabilizing drugs; sodium channel blockers-channel blockers-

CLASS I a- Quinidine, disopyramideCLASS I a- Quinidine, disopyramide CLASS I b- Lidocaine, PhenytoinCLASS I b- Lidocaine, Phenytoin CLASS I c- PropafenoneCLASS I c- Propafenone 2) CLASS II: BETA BLOCKERS- Acebutolol, Atenolol, 2) CLASS II: BETA BLOCKERS- Acebutolol, Atenolol,

Esmolol,Metoprolol, PropranololEsmolol,Metoprolol, Propranolol 3) CLASS III: POTASSIUM CHANNEL BLOCKERS- 3) CLASS III: POTASSIUM CHANNEL BLOCKERS-

Amiodarone, SotalolAmiodarone, Sotalol 4) CLASS IV: CALCIUM CHANNEL BLOCKERS- 4) CLASS IV: CALCIUM CHANNEL BLOCKERS-

Verapamil, DiltiazemVerapamil, Diltiazem

CLINICAL CLASSIFFICATION OF CLINICAL CLASSIFFICATION OF ANTIDYSRHYTHMIC DRUGSANTIDYSRHYTHMIC DRUGS

► I GROUP: (decrease AV conductance, for treatment I GROUP: (decrease AV conductance, for treatment of SV tacharrhythmia)- Verapamilof SV tacharrhythmia)- Verapamil

► II GROUP: (for treatment of ventricular II GROUP: (for treatment of ventricular tachyarrhythmia)- Lidocaine (i.v.), Propafenone, tachyarrhythmia)- Lidocaine (i.v.), Propafenone, PhenytoinPhenytoin

► III GROUP: (for treating SV and V tachyarrhythmia)- III GROUP: (for treating SV and V tachyarrhythmia)- Amiodarone, Beta blockersAmiodarone, Beta blockers

► IV GROUP: (drugs for AV block)- Atropine {M-IV GROUP: (drugs for AV block)- Atropine {M-cholinolytic}, Ephedrine {indirect adrenomimetics}cholinolytic}, Ephedrine {indirect adrenomimetics}

► V GROUP: (inhibitors of AV conduction)- Adenosine V GROUP: (inhibitors of AV conduction)- Adenosine [potassium channel opener], Digoxin [cardiac [potassium channel opener], Digoxin [cardiac glycoside]glycoside]

ANTIHYPERTENSIVE DRUGSANTIHYPERTENSIVE DRUGS

►DRUGS AFFECTING RAAS [renin DRUGS AFFECTING RAAS [renin angiotensin aldosterone system]-angiotensin aldosterone system]-

RENIN INHIBITOR: Beta blockers RENIN INHIBITOR: Beta blockers [Propranolol, Atenolol, etc][Propranolol, Atenolol, etc]

ACE INHIBITORS: Enalapril, RamiprilACE INHIBITORS: Enalapril, Ramipril ANGIOTENSIN II RECEPTOR [AT1-ANGIOTENSIN II RECEPTOR [AT1-

receptor] BLOCKERS: Eprosartan, Losartanreceptor] BLOCKERS: Eprosartan, Losartan ALDOSTERONE ANTAGONIST ALDOSTERONE ANTAGONIST

[ potassium sparing diuretic ]: [ potassium sparing diuretic ]: SpironolactoneSpironolactone

► CALCIUM ANTAGONIST: Nifedipine, CALCIUM ANTAGONIST: Nifedipine, Amlodipine, Diltiazem, VerapamilAmlodipine, Diltiazem, Verapamil

► DRUGS DECREASING SYMPATHETIC ACTIVITY-DRUGS DECREASING SYMPATHETIC ACTIVITY-

BETA BLOCKERS: Nebivolol, Atenolol, BETA BLOCKERS: Nebivolol, Atenolol, Bisprolol, Pindolol, CarvedilolBisprolol, Pindolol, Carvedilol

ALFA BLOCKERS: Prazosin, PhentolamineALFA BLOCKERS: Prazosin, Phentolamine

OTHER: Reserpine, clonidineOTHER: Reserpine, clonidine► DIURETICS: Hydrochlorothiazide, Indapamide, DIURETICS: Hydrochlorothiazide, Indapamide,

Furosemide Furosemide

PERIPHERAL VASODILATORSPERIPHERAL VASODILATORS

►Alfa blockers- Prazosin, ErgotoxineAlfa blockers- Prazosin, Ergotoxine►Phosphodiesterase inhibitors- Phosphodiesterase inhibitors-

PentoxifyllinePentoxifylline►Prostaglandin analogue- [activators of Prostaglandin analogue- [activators of

AC] Alprostadil (PG1), Iloprost (PG2)AC] Alprostadil (PG1), Iloprost (PG2)►CEREBRAL VASODILATORS:CEREBRAL VASODILATORS:

Nimodipine (calcium antagonist), Nimodipine (calcium antagonist), Naftidrofuryl (5-HT2 receptor blocker)Naftidrofuryl (5-HT2 receptor blocker)

DRUGS TO TREAT HEART DRUGS TO TREAT HEART FALIUREFALIURE

►Clinical syndrome thatClinical syndrome that

can result from any can result from any

structural or functional structural or functional

cardiac disorder that cardiac disorder that

impairs the abilty of theimpairs the abilty of the

ventricle to fill with or ventricle to fill with or

eject blood.eject blood.

► Therapeutic Uses ofTherapeutic Uses ofDigitalis CompoundsDigitalis Compounds

► Heart FailureHeart Failure► ↑ ↑ inotropy inotropy ► ↑ ↑ ejection fraction ejection fraction ► ↓ ↓ preload preload ► ↓ ↓ pulmonary congestion/edema pulmonary congestion/edema ► ArrhythmiasArrhythmias► ↓ ↓ AV nodal conductionAV nodal conduction

(parasympathomimetic effect) (parasympathomimetic effect) ► ↓ ↓ ventricular rate in atrial flutterventricular rate in atrial flutter

and fibrillation and fibrillation ► Digitalis compounds have historically been used in the Digitalis compounds have historically been used in the

treatment of chronic heart failure owing to their cardiotonic treatment of chronic heart failure owing to their cardiotonic effect. effect.

► Ex: Digoxin, digitoxinEx: Digoxin, digitoxin

►To treat CHF:To treat CHF:

Ionotropic drugs: Digoxin, Ionotropic drugs: Digoxin, DobutamineDobutamine

Diuretics: Furosemide, ThiazideDiuretics: Furosemide, Thiazide

Vasodilators: ACE inhibitors,AT1 Vasodilators: ACE inhibitors,AT1 antagonist, Nitrateantagonist, Nitrate

Beta blockers: MetroprololBeta blockers: Metroprolol

THANK YOU THANK YOU

BY: SANJUKTA GHOSEBY: SANJUKTA GHOSE