Antihypertensive Drugs

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1 Pharmacology for cardiovascular system Part 6 Antihypertensive Drugs Shi-Hong Zhang shzhang713@zju.edu.cn

2 病例回顾患者, 女,74 岁, 发现血压升高十余年, 胸闷心悸 7 年, 晕厥 3 次现病史 : 患者于十余年前体检发现血压升高, 当时无头晕头痛, 无视物模糊, 无胸闷气促, 无胸痛心悸等不适规律服用复方降压片, 血压控制不理想近 10 年来反复有头晕 8 年前曾爬二楼后出现胸闷心悸后晕厥, 无四肢抽搐, 无口角歪斜, 约 10 秒钟后自醒, 醒后伴冷汗之后反复出现活动后胸闷心悸, 无明显气促, 曾在多家医院住院治疗, 诊断为高血压, 高心病患者有夜尿增多 2-3 年, 夜间睡眠需两个枕头, 无睡眠中憋醒近 2-3 年出现胸骨后隐痛, 无恶心呕吐, 无大汗淋漓, 无后背及手臂放射痛, 胸痛与活动无明显关系, 休息几分钟可缓解平时一直服用麝香保心丸阿司匹林

3 病例回顾昨天下午爬 2 楼后出现胸闷胸口不适, 后又晕厥一次, 伴小便失禁, 约 10 秒钟自醒醒后有冷汗, 四肢乏力, 无肢体活动障碍即至我院, 头颅 CT 示两侧基底节多发腔隙性脑梗塞心电图示窦性心律,I 房室传导阻滞, 完全性右束支传导阻滞今为进一步诊疗入院入院体检 :T 37.2 度,P 72 次 / 分,R 18 次 / 分,BP 145/80mmHg, 呼吸音粗, 右肺可及少许湿罗音心界左下扩大心电图提示右心室扩大可能入院诊断 : 高血压病 2 级 ( 极高危 ) 高血压性心脏病, 心功能 III 级冠状动脉粥样硬化性心脏病, 心绞痛腔隙性脑梗塞

4 病例回顾住院治疗 : 非洛地平速尿单硝酸异山梨酯 ( 欣康 ) 阿司匹林冠心宁心肌保护药物左氧氟沙星安体舒通 ( 螺内酯 ) 培哚普利美托洛尔出院带药 : 培哚普利美托洛尔脑安麝香保心丸阿司匹林肠溶片非洛地平

5 Contents: Overview Classification of antihypertensive drugs Antihypertensive drugs Clinical pharmacology of antihypertensive drugs

6 1. Overview

7 Blood Pressure and Risk for Coronary Heart Disease in Men Age-adjusted annual incidence of CHD per < Age Age Systolic blood pressure (mmhg) < Age Age Diastolic blood pressure (mmhg) Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at baseline Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.

8 Etiology of Hypertension Secondary hypertension(10~15%) Essential hypertension(85~90%) High Risk Factors of Hypertension: Stressful life-style High dietary intake of sodium Obesity and hyperlipidemia Smoking Hereditary factors

9 按危险分层, 量化地估计预后其它危险因素和病史血压 I 级 II 级 III 级 Ⅰ 无其它危险因素低危中危高危 Ⅱ1~2 个危险因素中危中危很高危 Ⅲ 3 个危险因素高危高危很高危 Ⅳ 靶器官损害或糖尿病并存的临床情况很高危很高危很高危

10 The end organ damage of hypertension: Kidney: renal failure Heart: coronary disease, cardiac failure Brain: stroke Kidney Failure 15% Other 2% MI or CHF Stroke Kidney Failure Other MI or CHF 50% Stroke 33%

11 1. Overview The goal of treatment: Lower the blood pressure Protect the target organ Reduce the morbidity and mortality rates Best therapy and minimal risk

12 1. Overview Major factors influencing blood pressure Arterial blood pressure Cardiac output Peripheral resistance arteriolar volume Heart rate Contractility Filling pressure Baroreceptors and sympathetic nervous system RAAS Blood volume Venous tone

13 2. Classifications of hypertensive Drugs 1. Diuretics 2. Calcium channel blockers 3. Renin-angiotensin system inhibitors - ACEIs - ARBs - Renin inhibitors

14 4. Sympathetic inhibitors - Centrally acting adrenergic drugs - Ganglion blockers - Noradrenergic nerve ending blockers - Adrenoreceptor blockers 5. Vasodilators β receptor blockers α receptor blockers β and α receptor blockers

15 3. Antihypertensive Drugs 3.1 Diuretics ( 利尿药 ) A Actions - Reduce plasma volume(cardiac output ) - Reduce Na + -Ca 2+ exchange in vascular smooth muscle cell (peripheral resistance )

16 3. Antihypertensive Drugs 3.1 Diuretics B Therapeutic uses: Hypertension -Single drug or combined with others - Particularly useful in the treatment of elderly patients, pure systolic hypertension, hypertension with heart failure

17 3. Antihypertensive Drugs 3.1 Diuretics C Adverse effects: plasma level of renin hypokalemia ( 低钾血症 ) hyperuricemia ( 高尿酸血症 ) hyperglycemia ( 高血糖 ) hyperlipidemia ( 高脂血症 )

18 3. Antihypertensive Drugs 3.2 Calcium channel blockers (CCBs) A Actions nifedipine Relaxes vascular smooth muscle B Therapeutic uses: Mild to severe hypertension (usually combined with β blockers )

19 3. Antihypertensive Drugs nifedipine C Adverse effects Peripheral edema Reflex sympathetic activation Renin activity

20 3. Antihypertensive Drugs Other calcium channel blockers: Verapamil Diltiazem Nimodipine ( 尼莫地平 ) Felodipine ( 非洛地平 ) Amlodipine( 氨氯地平 )

21 3. Antihypertensive Drugs 3.3 Renin- angiotensin system inhibitors -- ACEIs -- ARBs -- Renin inhibitors

23 Actions of angiotensin II Constricts vessels, increases peripheral resistance and returned blood volume. Increases sympathetic tension, promotes release of sympathetic transmitter. Stimulates release of aldosterone. Induces expression of c-fos c-myc c- jun rapidly.

24 3. Antihypertensive Drugs 3.3 Renin- angiotensin system inhibitors A Actions ACEIs Inhibit the production of Ang II (dilate vessels, decrease sympathetic activity, inhibit release of aldosterone, anti-hypertrophy) Inhibit the degradation of bradykinin

25 Actions of ACEIs Angiotensin II Inactive peptide Angiotensin I ACEI ( ) ACE Circulation and local tissues Brandykinin B 2 receptor PGI 2 NO ACEI ( ) ACE Circulation and local tissues Vasodilation Anti-proliferation, anti-hypertrophy

26 3. Antihypertensive Drugs ACEIs B Therapeutic uses Hypertension - not reflexly increasing the activity of sympathetic system - effective in the treatment of CHF, diabetes and ischemic heart disease.

27 3. Antihypertensive Drugs ACEIs C Adverse effects - Hypotension ( first dose phenomenon ) - Renal injury (renal artery sclerosis ) - Dry cough and angioneuroedema (bradykinin accumulation) - Hyperkalemia (aldosterone inhibition) - Rashes and altered taste - Fetotoxicity (class C in the first trimester, and D in the second and third trimester)

28 3. Antihypertensive Drugs ACEIs D Contraindications - Renal artery stenosis - Pregnant and lactation women

29 3. Antihypertensive Drugs ACEIs Captopril ( 卡托普利 ) Enalapril ( 依那普利 ) Quinapril ( 喹那普利 ) Benazepril ( 贝那普利 ) Ramipril ( 雷米普利 ) Lisinopril ( 赖诺普利 ) Fosinopril ( 福辛普利 ) Trandopril ( 群多普利 ) Moexipril ( 莫西普利 ) Perindopril ( 培哚普利 )

30 3. Antihypertensive Drugs ARBs Compared with ACEIs: Block actions of angiotensin II directly No influence on bradykinin metabolism Protect renal function Used for mild to moderate hypertension Less adverse effects

31 3. Antihypertensive Drugs Inhibit whole RAAS Renin inhibitors Include renin antibody, peptide and nonpeptide renin inhibitors (eg. remikiren)

32 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Adrenoreceptor blockers β receptor blockers A Actions Decrease cardiac output Inhibit the release of renin from kidney (formation of angiotension and secretion of aldosterone )

33 3. Antihypertensive Drugs A Actions β receptor blockers Decrease sympathetic outflow from CNS and release of noradrenalin from peripheral nerve endings Increase production of PGs Increase sensitivity of baroreceptor

34 3. Antihypertensive Drugs B Therapeutic uses β receptor blockers Hypertension: all kinds of hypertension - more effective in young patients than elderly - useful in treating coexisting conditions such as supraventricular tachycardia, previous myocardial infarction, angina pectoris, glaucoma and migraine headache

35 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Adrenoreceptor blockers α 1 receptor blockers (Prozosin) A Actions Relax arterial and venous smooth muscle, decrease peripheral resistance Alterations in serum lipid patterns

36 3. Antihypertensive Drugs α 1 receptor blockers B Therapeutic uses Hypertension: mild to moderate (single) and severe hypertension(combined with diuretics and β blockers) minimal changes in cardiac output, renal blood flow renin release and glomerular filtration

37 3. Antihypertensive Drugs C Adverse effects α 1 receptor blockers First dose phenomenon (postural hypotension) sodium retention

38 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Adrenoreceptor blockers β and α 1 receptor blockers (labetalol) Mild decrease of blood pressure Minimal changes in cardiac output and heart rate Used for all kinds of hypertension, including hypertensive emergency Less adverse effects

40 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Centrally-acting drugs Clonidine ( 可乐定 ) A Actions Diminishes central adrenergic outflow - activates α 2 receptor in medulla - activates I 1 receptor in medulla

41 3. Antihypertensive Drugs Clonidine B Therapeutic uses Hypertension: mild to moderate - minimal changes in renal blood flow and glomerular filtration - inhibits gastrointestinal secretion and mobility

42 3. Antihypertensive Drugs C Adverse effects Clonidine Atropine-like effects Water and sodium retention (renal filtration ) Rebound phenomenon

43 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Centrally-acting drugs I 1 receptor agonists Rilmenidine ( 利美尼定 ) Moxonidine ( 莫索尼定 )

44 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Ganglion blockers Trimetaphan( 米噻芬 ) Mecamylamine( 美卡拉明 )

45 3. Antihypertensive Drugs 3.4 Sympathetic system inhibitors Noradrenergic nerve ending blockers Reserpine ( 利舍平, 利血平 ) Guanethidine ( 胍乙啶 )

46 3. Antihypertensive Drugs 3.5 Vasodilators Hydralazine ( 肼屈嗪 ) Dilates arteries and arterioles Decreases peripheral resistance Reflexly elevates heart rate, cardiac output and renin release. Administrated with β blockers and diuretics. Adverse effects due to vasodilation and lupuslike syndrome can occur.

47 3. Antihypertensive Drugs 3.5 Vasodilators Nitroprusside sodium ( 硝普钠 ) Dilates small arteries and veins Used for treatment of emergency hypertension, hypertension with CHF, controlled hypotension and obstinate CHF Adverse effects due to hypotension in excess and sulfocyanate poisoning.

48 3. Antihypertensive Drugs 3.5 Vasodilators Potassium channel openers Including minoxidil, nicorandil, diazoxide, etc. Dilates arteries (Ca influx ) Reflexly elevates heart rate, cardiac output and renin release. Used for treatment of obstinate and severe hypertension Adverse effects include sodium retention, palpitation, etc

49 4. Clinical pharmacology of Antihypertensive Drug 4.1 General information The diagnosis of hypertension should be established by finding an elevated blood pressure on at least three different office visits The physician must establish with certainty that hypertension is persistent and requires treatment and must exclude secondary causes of hypertension that might be treated by definitive surgical procedures.

50 4. Clinical pharmacology of Antihypertensive Drug 4.1 General information Consider the level of blood pressure, the age and sex of the patient, the severity of organ damage (if any) due to high blood pressure, and the presence of cardiovascular risk factors must all be considered Begin the drug treatment or not. Selection of drugs is dictated by the level of blood pressure, the presence and severity of end-organ damage, and the presence of other diseases. Educate the patient about the nature of hypertension, the importance of treatment and the potential side effects of drugs.

51 4. Clinical pharmacology of Antihypertensive Drug 4.2 Out-patient therapy In general: Sodium restriction: A reasonable dietary goal in treating hypertension is meq of sodium per day Weight reduction; Regular exercise;

52 Lifestyle modifications to manage hypertension

53 Monotherapy Versus Polypharmacy

54 4. Clinical pharmacology of Antihypertensive Drug Prescribe according to the severity of hypertension Mild: diuretics, β blockers, ACEIs, CCBs, α 1 blockers, ARBs (first line, single drug) Moderate: combine two above drugs Severe: add centrally acting drugs or vasodilators on the two combined drugs

55 4. Clinical pharmacology of Antihypertensive Drug Prescribe according to complications Complications Options Avoidance Severe CHF and/or COPD Diuretics, ACEIs, prazosin β blockers Renal failure Tachycardia ACEIs, CCBs β blockers GI ulcer Clonidine Reserpine Diabetes and gout ACEIs, prazosin Thiazide

56 4. Clinical pharmacology of Antihypertensive Drug Prescribe according to complications hypertensive emergency: vasodilators (nitroprusside sodium, diazoxide), labetalol, loop diuretics elderly patients:avoiding drugs that could induce postural hypotension and influence the cognizant ability (clonidine)

57 4. Clinical pharmacology of Antihypertensive Drug Avoid blood pressure to decrease too rapidly and excessively

58 Pharmacology for cardiovascular system Part 3 Drugs for Treatment of Congestive Heart Failure

59 病例回顾患者, 男,61 岁因反复胸闷气促 3 年, 再发伴加重半月入院现病史 : 患者 3 年前无明显诱因出现胸闷气促, 好高枕卧位无胸骨后疼痛, 无畏寒发热, 无咳嗽, 无头晕黑蒙, 无晕厥及视物模糊前往某医院就诊, 诊断为扩张型心肌病, 急性左心衰, 给予地高辛双克氨苯蝶啶鲁南欣康参麦葛根素等治疗, 症状好转后出院此后上述症状反复发作, 曾多次入院治疗半个月前患者因感冒咳嗽咳痰导致上述症状再次发作, 静息时即感到胸闷气促, 稍作体力活动后症状加重夜间睡眠不能平卧, 有时端坐呼吸无发热畏寒, 有咳嗽, 咳大量白色粘痰, 为求进一步诊治, 以扩张型心肌病肺部感染心功能不全 III 度收住入院入院体检 :T 36.5,P 90 次 / 分,R 20 次 / 分,BP 125/95mmHg, 呼吸音粗, 左下肺有湿罗音, 心浊音界扩大, 双下肢轻度水肿

60 病例回顾入院医嘱 : 第一天 2pm: 心内科护理常规 I 级护理低盐普食吸氧必要时速尿 ( 呋塞米 ) 20mg qd 安体舒通 ( 螺内酯 )20mg qd 欣康 ( 单硝酸异山梨酯 ) 40mg qd FDP( 果糖二磷酸钠 ) 10g qd 来立信 ( 左氧氟沙星 )0.3g, 静滴,bid ( 各种检查 )

61 病例回顾第二天 1am: 计 24 小时尿量米力农 10mg, 静滴,qd 地高辛 0.125g qd 洛汀新 ( 贝那普利 )10mg qd 第三天.( 利尿药 ) 第七天达力全 ( 卡维洛尔 )3.125mg qd 倍他乐克 ( 美托洛尔 )120mg bid 吉诺通 ( 粘痰溶解药 )1 tid

62 Outline Overview Drugs for treatment of CHF Cardiac glycoside Diuretics and vasodilators ACE inhibitors β receptor blockers Others

63 1. OVERVIEW---Types of Heart Failure (1) Systolic failure: the mechanical pumping action (contractility) and the ejection fraction of the heart are reduced. (2) Diastolic failure: stiffening and loss of adequate relaxation plays a major role in reducing cardiac output and ejection fraction may be normal. e.g. Pericarditis ( 心包炎 ) (3) High-output failure: can result from hyperthyroidism ( 甲亢 ), beriberi( 脚气病 ), anemia( 贫血 ), and arteriovenous shunts.

64 1. OVERVIEW---Grades Grades of CHF according to symptoms: Class I: no limitation is experienced in any activities; no symptoms from ordinary activities. Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion. Class III: marked limitation of any activity; the patient is comfortable only at rest. Class IV: any physical activity brings on discomfort and symptoms occur at rest.

65 At risk HF 1. OVERVIEW---Grades Grades of CHF according to progress: Stage A: a high risk HF in the future but no structural heart disorder; Stage B: a structural heart disorder but no symptoms at any stage; Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment; Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care

66 1. OVERVIEW---Pathological changes of CHF: Intrinsic compensatory: Myocardial hypertrophy: helps maintain cardiac performance at the beginning but can lead to ischemic changes, impairment of diastolic filling, and alterations in ventricular geometry. Remodeling: proliferation of connective tissue cells as well as abnormal myocardial cells with some biochemical characteristics of fetal myocytes.

67 1. OVERVIEW--Pathophysiological changes of CHF Myocardial injury Fall in cardiac output Activation of SNS, RAAS and others Myocardial toxicity ANP BNP Peripheral vasoconstriction Hemodynamic alterations Morbidity and mortality Remodeling and progressive worsening of LV function Heart failure symptoms Fonarow GC. Rev Cardiovasc Med..2001;2:7 12.

68 Changes of β receptor signal transduction in CHF Uncoupling of β 1 receptors and Gs protein ---Density of β 1 receptors ---Amount and/or activity of Gs protein

69 Actions of angiotensin Ⅱ 1. Contracts vessels, increase peripheral resistance and returned blood volume. 2. Increases sympathetic tension, promotes release of sympathetic transmitter. 3. Stimulates release of aldosterone. 4. Induces expression of c-fos c-myc c- jun rapidly.

70 Cardiac failure Cardiac output Venous pressure Venous hyperemia Blood pressure Renal blood flow Renin, angiotension II Aldosterone Pulmonary circulation (cough, emptysis, dyspnea) Systemic circulation (jugular vein distension, edema) Sodium and water retention Changes of hemodynamics in CHF

71 1. OVERVIEW--- Therapeutic strategies in CHF A To increase contractility of the cardiac muscle: glycosides, PDE III inhibitors, other positive inotropes B To inhibit RAAS: ACEIs, ARBs C To decrease sympathetic activity: ACEIs, βblockers D To dilate vessels: vasodilators E To decrease circulation volume: diuretics

72 2. Drugs for treatment of CHF 2.1 Cardiac glycoside (digitalis, 洋地黄 ) Digoxin( 地高辛 ) A ACTIONS Positive inotropic action - inhibitor of Na + -K + ATPase

73 Mechanism of digitalis 3 Na + 2K + NKA Na + -K + -ATPase [Na + ] i [K + ] i AP [Ca 2+ ] i NCE Na + -Ca 2+ exchange

74 2. Drugs for treatment of CHF Digoxin A ACTIONS Negative chronotropic action - inhibits sympathetic activities - improves vagal activities

75 2. Drugs for treatment of CHF Digoxin A ACTIONS Actions on cardiac electrophysiology - decreases automaticity of sinoatrial node - slows conduction - increases automaticity of Pukinje fibres - shortens ERP of fast reaction cells

76 2. Drugs for treatment of CHF Digoxin A ACTIONS Actions on nervous system - autonomic nervous system - central nervous system (D 2 receptor) Actions on neuroendocrine system - inhibits RAAS - increases ANP ( 心房钠尿肽 )

77 2. Drugs for treatment of CHF A ACTIONS Digoxin Actions on kidney (diuretic effect) - increases blood supply of kidney - decreases Na + resorption (inhibition of Na + -K + ATP ase)

78 2. Drugs for treatment of CHF Digoxin B Therapeutic uses: CHF Especially associated with atrial fibrillation and ventricular tachycardia

79 2. Drugs for treatment of CHF Digoxin B Therapeutic uses: Some arrhythmias - atrial fibrillation - atrial flutter - paroxysmal surpraventricular tachycardia

80 2. Drugs for treatment of CHF C Adverse effects: Digoxin Gastrointestinal responses - severe nausea, vomit, diarrhea Symptoms of central nervous system: - alteration of color perception (chromatopsia) - headache, fatigue, confusion

81 2. Drugs for treatment of CHF Digoxin C Adverse effects: Cardiac effects - arrhythmias:tachycardia atrioventricular block sinus bradycardia

82 Symptoms to stop digitalis administration: - Severe vomit - Chromatopsia - Ventricular premature - Heart rate < 60 /min

83 2. Drugs for treatment of CHF Digoxin C Adverse effects: Treatments: - KCl, phenytoin sodium or lidocaine, iv. - Atropine, isoprenaline - Fab segment of digoxin antibody, iv.

84 2. Drugs for treatment of CHF Digoxin D Directions: Typical method: full dose(digitalization)+maintaining dose No-loading method: maintaining dose everyday

85 Effect of Digoxin on Mortality in Heart Failure 50 CV Mortality 0% Hospitalizations 28% Total Hospitalizations 6% Mortality From Any Cause (%) Relative Risk % CI P=.80 Placebo Digoxin All-cause mortality rates: Placebo 35.1%; Digoxin 34.8% Months DIG (Digitalis Investigation Group): 6,800 patients with LVEF <45% randomized to digoxin (n=3,403) or placebo (n=3,397) in addition to therapy with diuretics and ACEI followed for 37 months. The DIGITALIS Investigation Group. N Engl J Med. 1997;336:

86 2. Drugs for treatment of CHF 2.1 Digitalis Digitoxin ( 洋地黄毒苷 ): long-term actions digitalization+maintaining dose Deslanoside( 西地兰, 去乙酰毛花苷 ) acute attack of CHF

88 2. Drugs for treatment of CHF 2.2 ACEIs (angiotensin converting enzyme inhibitors) and ARBS (AT1 receptor blockers ) ACEIs (captopril, enalapril) A ACTION mechanisms Inhibit the production of Ang II Inhibit the degradation of bradykinin Increase ANP and scavenge free radical

89 Actions of ACEI Angiotensin II Inactive peptide Angiotensin I ACEI ( ) ACE in Circulation and local tissues Brandykinin B 2 receptor PGI 2 NO ACEI ( ) ACE in Circulation and local tissues Vasodilation Anti-proliferation, anti-hypertrophy

90 2. Drugs for treatment of CHF B ACTIONS ACEIs Decrease resistance of peripheral vessels Dilate coronary artery, increase blood supply of heart and kidney, improve cardiac and renal function Reverse myocardial hypertrophy and ventricular remodeling

91 2. Drugs for treatment of CHF ACEIs B Therapeutic uses: CHF - increase motor tolerance - decrease mortality Hypertension

92 2. Drugs for treatment of CHF C Adverse effects: Hypotension ACEIs Cough and angioedema Hyperpotassemia: aldosterone inhibition Contraindication: Pregnant or lactation women, stenosis of renal artery

94 2. Drugs for treatment of CHF ARBS Compared with ACEI: Block actions of angiotensin II directly No influence on bradykinin metabolism Protect renal function Used for CHF and hypertension

95 CV Risk: reduction in future cardiovascular events; DN: diabetic nephropathy; H: hypertension; HF: heart failure; Post MI: reduction in heart failure or other cardiac events following myocardial infarction.

96 2. Drugs for treatment of CHF Additional: Aldosterone antagonists Spironolactone and Eplerenone get additional function to decrease morbidity and mortality in patients with severe heart failure who are also receiving ACE inhibitors and other standard therapy.

97 RALES: Aldosterone Antagonist Reduces All-Cause Mortality in Chronic HF Probability of Survival (%) P<.001 Spironolactone (25 mg) + standard care (n = 822) Placebo + standard care (n = 841) HR = 0.70 (95% CI, 0.60 to 0.82) Months HR = hazard ratio; RR = risk reduction. *Ejection fraction 35% Class III or IV symptoms at some point in prior 2 months. Pitt B et al. N Engl J Med. 1999;341:

98 EPHESUS Co-Primary Endpoint: Total Mortality Cumulative Incidence (%) Eplerenone + standard care (n = 3319) Placebo + standard care (n = 3313) HR = 0.85 (95% CI, 0.75 to 0.96) P = (16.7%) (14.4%) HR = hazard ratio. Months Since Randomization Adapted from Pitt B et al. N Engl J Med. 2003;348:

99 2. Drugs for treatment of CHF 2.3 Diuretics A ACTIONS Reduce plasma volume Reduce Na + -Ca 2+ exchange in vessel smooth muscle cell

100 2. Drugs for treatment of CHF 2.3 Diuretics B Therapeutic uses: CHF -Ⅱ ~ Ⅲ CHF - used alone or combined with other drugs Edema, hypertension, etc

101 2. Drugs for treatment of CHF 2.3 Diuretics C Adverse effects: plasma level of renin hypokalemia ( 低钾血症 ) hyperuricemia ( 高尿酸血症 ) hyperglycemia ( 高血糖 ) hyperlipidemia ( 高脂血症 )

102 2. Drugs for treatment of CHF 2.4 β blockers (metoprolol, carvedilol, etc) A ACTIONS Up-regulate β receptors Block effects of catecholamine on myocardium Inhibit RAAS and VP (vosopressin, 加压素 ) Decrease heart rate and cardiac oxygen demand

103 2. Drugs for treatment of CHF 2.4 β blockers A ACTIONS Anti- arrhythmias and hypertension Anti- myocardial hypertrophy and remodeling Block α-receptor and anti- free radical

104 2. Drugs for treatment of CHF 2.4 β blockers B Therapeutic uses: CHF -Ⅱ ~ Ⅲ - decrease mortality Hypertension, arrhythmias, angina, etc

105 The Use of Beta Adrenergic Blocking Agents in Heart Failure 15 LVEF % change Time (weeks) Initial hemodynamic deterioration followed by reverse remodeling (decrease in EDV and ESV) with improved ventricular function over time (increased LVEF)

106 US Carvedilol Heart Failure Trials Program 100 Survival Proportion P< % Carvedilol Placebo Follow-up (days) 1094 Class II-IV CHF pts on triple therapy (ACEI, digoxin, diuretics) Carvedilol 6.25 bid test 2 weeks, then 12.5 bid, then 25 bid vs placebo Packer NEJM 1996;334:

107 Effect of Metoprolol CR/XL in Heart Failure MERIT-HF Survival Proportion RR 0.66 ( ) P= Metoprolol CR/XL Placebo Follow-up (months) 3991 pts with CHF Class II-IV, ave age 64 and LVEF 0.28 Randomized to Metoprolol CR/XL 12.5 mg or 25 mg PO qd, target dose 200 mg qd Lancet 1999;353:

108 β-blockers Differ in Their Long- Term Effects on Mortality in HF Bisoprolol 1 Bucindolol 2 Carvedilol 3-5 Metoprolol tartrate 6 Metoprolol succinate 7 Nebivolol 8 Xamoterol 9 Beneficial No effect Beneficial Not well studied Beneficial No effect Harmful 1 CIBIS II Investigators and Committees. Lancet. 1999;353: The BEST Investigators. N Engl J Med 2001; 344: Colucci WS, et al. Circulation 1996;94: Packer M, et al. N Engl J Med 2001;344: The CAPRICORN Investigators. Lancet. 2001;357: Waagstein F, et al. Lancet. 1993;342: MERIT-HF Study Group. Lancet. 1999;353: SENIORS Study Group. Eur Heart J. 2005; 26: The Xamoterol in Severe heart Failure Study Group. Lancet. 1990;336:1-6.

109 2. Drugs for treatment of CHF 2.4 β blockers C Adverse effects: Inhibition of cardiac function Contraindications: severe heart failure severe AV block hypotension bronchial asthma

110 2. Drugs for treatment of CHF 2.5 Vasodilators Reduction in preload (through venous dilation), or reduction in afterload (through arteriolar dilation), or both. Long-term use of hydralazine and isosorbide dinitrate can also reduce damaging remodeling of the heart.

111 I/H: isosorbide dinitrate/hydralazine J Cardiac Fail 2007;13:

112 2. Drugs for treatment of CHF 2.5 Other drugs PDE-III inhibitors (milrinone, vesnarinone) Catecholamines (dopamine) Calcium channel blockers Amlodipine Felodipine Calcium sensitizers

113 病例回顾入院医嘱 : 第一天 2pm: 心内科护理常规 I 级护理低盐普食吸氧必要时速尿 ( 呋塞米 ) 20mg qd 安体舒通 ( 螺内酯 )20mg qd 欣康 ( 单硝酸异山梨酯 ) 40mg qd FDP( 果糖二磷酸钠 ) 10g qd 来立信 ( 左氧氟沙星 )0.3g, 静滴,bid ( 各种检查 )

114 病例回顾第二天 1am: 计 24 小时尿量米力农 10mg, 静滴,qd 地高辛 0.125g qd 洛汀新 ( 贝那普利 )10mg qd 吉诺通 ( 粘痰溶解药 )1 tid 第三天.( 利尿药 ) 第七天出院达力全 ( 卡维洛尔 )3.125mg qd 倍他乐克 ( 美托洛尔 )120mg bid

115 Limit Na + Limit activity Low Na + ACEI strategies β blockers Digitalis thiazides Loop diuretics combined Dilator Positive inotropic drugs grades Ⅱ Ⅲ Ⅳ

116 References Basic & Clinical Pharmacology (10 th edition), Lipincott s illustrated reviews pharmocology (2 nd edition), 2002 药理学, 杨世杰主编, 人民卫生出版社, 2005 基础医学教程各论, 陈季强主编, 科学出版社,2004

Antiarrhythmic Drugs 抗心律失常药物. Shi-Hong Zhang ( 张世红 ) Pharmacology, Dept. of

Antiarrhythmic Drugs 抗心律失常药物. Shi-Hong Zhang ( 张世红 ) Pharmacology, Dept. of 抗心律失常药物 Shi-Hong Zhang ( 张世红 ) Pharmacology, Dept. of shzhang713@zju.edu.cn 1 Outline Physiology of cardiac rhythm Mechanisms of arrhythmias Classification of antiarrhythmic drugs Antiarrhythmic drugs