Zdravila s farmakološkim učinkom na srcu
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1 Zdravila s farmakološkim učinkom na srcu Prof. dr. Mojca Kržan Inštitut za farmakologijo in eksperimentalno toksikologijo, Medicinska fakulteta, Univerza v Ljubljani
2 Zdravila s farmakološkim učinkom na srcu vpliv na porabo kisika in metabolizem vpliv na krčenje vpliv na prevajanje
3 Ishemična bolezen srca Stabilna angina pektoris Nestabilna angina pektoris Prinz-Metalova angina
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5 Zdravila, za zdravljenje ishemične bolezni srca Zaviralci adrenergičnih receptorjev β Organski nitrati Zaviralci kalcijevih kanalov
6 Zaviralci adrenergičnih receptorjev β β-blockers continue to surprise us (Cruckshank, 2000)
7 Generacije zaviralcev adrenergičnih 1. generacija: neselektivni propranolol receptorjev β 2. generacija: selektivni za receptorje β1 atenolol, metoprolol, acebutolol, bisoprolol 3. Generacija: + vazodilatatorji β2 intrinzična simpatikomimetična aktivnost pindolol α1-adrenergična blokada labetalol, karvedilol Sproščanje NO: nebivolol
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10 Neželeni učinki Spazem gladke mišice: bronhospazem, mrzle ekstremitete Pretirani učinki na srce: bradikardija, bloki prevajanja, pretiran negativni inotropni učinek Prehajnje skozi krvnomožgansko pregrado: nespečnost, depresija
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12 Pozor Zaviralci adrenergičnih receptorjev β Regulatorno zvečanje števila receptorjev Postopna prekinitev zdravljenja
13 Organski nitrati As is often true in matters of the heart, absence (nitrate-free intervals) makes the heart grow fonder (more nitrate responsiveness) (Opie, 1991)
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15 Organski nitrati Nitroglicerin Isosorbid dinitrat Pentaeritritol tetranitrat Eritritil tetranitrat
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17 Neželeni učinki glavobol hipotenzija bradikardija / tahikardija methemoglobinemija rezistenca na heparin toleranca
18 Toleranca ob jemanju organskih nitratov Neznan mehanizem Kako rešujemo: 12 ur na dan brez organskih nitratov
19 Zaviralci kalcijevih kanalov
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21 Zaviralci kalcijevih kanalov Verapamil, diltiazem Dihidropiridinski: nikardipin, nifedipin, amlodipin, felodipin, isradipin, nitrendipin, nisoldipin
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24 Neželeni učinki Vsi glavobol, edemi, naval krvi v glavo, omotičnost, možna srčna odpoved Verapamil konstipacija
25 Povzetek
26 Farmakološko zdravljenje srčnega popuščanja
27 Akutno popuščanje srca Kronično popuščanje srca
28 Cilji zdravljenja srčnega popuščanja Olajšanje simptomov Upočasnitev bolezni Izboljšanje preživetja
29 Zdravila z akutnim inotropnim učinkom simpatikomimetiki in druga zdravila Dobutamin β1 >β2 > α Dopamin β1 (β2), α, D1, D2 Adrenalin β1 > α > β2 Noradrenalin β1 = β2 > α Levosimendan
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31 1. Hemodinamske spremembe simptomi 2. Nevrohumoralna aktivacija 3. Remodeliranje prekata Napredovanje bolezni
32 Zdravljenje kroničnega srčnega popuščanja ACE inhibitorji Zaviralci adrenergičnih receptorjev β Diuretiki Inotropna zdravila Neposredni vazodilatatorji Antagonisti aldosterona
33 Učinki zdravljenja kroničnega srčnega popuščanja Zmanjšanje obremenitve miokarda Zmanjšanje volumna zunajcelične tekočine Izboljšana kontraktilnost srca Upočasnitev preoblikovanja/remodeliranja
34 Zaviralci ACE The benefits of ACEI exceed our expectations. (Francis, 2000)
35 Generacije inhibitorjev ACE razred I kaptopril razred II prozdravila benazepril, enalapril, fosinopril, kvinapril razred III vodotopni lisinopril
36 Mehanizem delovanja ACE inhibitorjev
37 Neželeni učinki inhibitorjev ACE Kašelj Ortostatska hipotenzija Reverzibilna ledvična odpoved Angioedem Hiperkaliemija Embriopatije Nevtropenija /agranulocitoza (visoki odmerki) Izguba okusa
38 Antagonisti receptorjev za angiotenzin- II primeri: losartan, irbesartan, telmisartan, valsartan Prednosti: ni učinkov, ki jih posreduje bradikinin (npr. kašelj), padec holesterola v serumu Pomanjkljivosti: ni vazodilatacije v ledvicah, ni zaščite endotelija.
39 Digoksin Digitalis is effective, but is it safe? Marcus 1993
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41 Kardiotonični glikozidi mehanizem delovanja
42 Farmakokinetika digoksina Absorpcija 75% Inaktivacija prek bakterij v GITu Terepevtska konc. 1-2 ng/ml, zdaj ng/ml Veže se na receptorje v srcu in skeletni mišici Prehaja v CŽS Večina se ga izloči nespremenjenega z urinom, 30% prek jeter Kronična odpoved ledvic manjši Vd Izguba telesne mase manjša vezava na skeletne mišice
43 Stanja, ki vplivajo na delovanje digoksina Povečajo Hipokaliemija Hipomagneziemija Hiperkalcemija Hipoksemija hipotiroidizem Zmanjšajo Hiperkaliemija Hipokalcemija Hipertiroidizem
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45 Neželeni učinki digitalisa GIT: anoreksija, navzeja, bruhanje, diareja CŽS: utrujenost, zmedenost, bolečine po obrazu, nespečnost, vertigo, motnje vida Srce: palpitacije, aritmije, sinkopa
46 Povzetek
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