1) The document discusses the renin-angiotensin-aldosterone system and its role in regulating blood pressure.
2) Angiotensin-converting enzyme inhibitors (ACEIs) work by preventing the conversion of angiotensin I to angiotensin II, thereby lowering blood pressure.
3) ACEIs, beta blockers, and aldosterone antagonists have been shown to reduce mortality in patients with heart failure by 23%, 35%, and 30% respectively over 2 years.
10. Afterload
α2 Vasomotor center
Volume
Kidneys Cardiac Output
β1 Heart
Renin
β1
V
V
Ang I
Preload
Ang II
BP= CO x TPVR β2 α1
Aldosterone
VSMCs
Vascular
Resistance arterioles Capacitance venules
Smooth
Muscle
Cells
TPVR
Total Peripheral Vascular Resistance (TPVR)
13. Renin-Angiotensin-Aldosterone System
Angiotensinogen
Renin
Angiotensin I
ACE
Angiotensin II
↑ Aldosterone AT I ATII
Vasoconstriction
↑ Blood Pressure
14. Angiotensin Converting
Enzyme
Kininogens Angiotensinogen
Kallikrein Renin
Angiotensin I
Bradykinin
ACEIs
ACEIs ACE
Angiotensin II
Inactive Peptides
BK receptors
AT-1 receptors
16. Pathophysiologic role of Angiotensin II
Angiotensin Receptor Angiotensin II
Blocker
ARB
AT1 Aldosterone
Vasoconstriction Receptor Production
Cell Growth
Fibrosis ↑ Sodium/Water
↑ PVR
Retention
LVH
↑ BP Vascular ↑ BP
Remodeling
25. Beta Blockers
Mechanisms of Action
Effects on myocardium
Suppression of renin release
Inhibition of presynatic β 1 receptors positive
feeback
Decreased central sympathetic outflow
CNS effects
Reduction in peripheral resistance
Improvement in vascular compliance
Resetting of baroreceptor levels
Attenuation of pressor response to catecholamines
(stress, exercise)
27. Beta Blockers
Side Effects
Bronchospasm
Bradicardia/heart block
Mask and prolong the symptoms of hypoglycemia
Abrupt withdrawal can precipitate MI
Cold extremities, Raynaud’s phenomenon, intermittent claudication
Decreased exercise tolerance; fatigue, depression and impotence
CNS: sleep disturbance, vivid dreams, nightmares
Effects of plasma lipids
28.
29. Without Compelling
Indications
Stage 1 Hypertension Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 (SBP >160 or DBP >100 mmHg)
mmHg) 2-drug combination for most
Thiazide-type diuretics for most. (usually thiazide-type diuretic and
May consider ACEI, ARB, BB, CCB, ACEI, or ARB, or BB, or CCB)
until goal blood pressure is achieved
or combination.
Optimize dosages or add additional dru
Blood Pressure
Not at Goal
Initial Drug Choices
Lifestyle Modifications
as needed.
(diuretics, ACEI, ARB, BB, CCB)
Not at Goal Blood Pressure (<140/90 mmHg)
Other antihypertensive drugs
indications
Drug(s) for the compelling
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Indications
With Compelling
Algorithm for Treatment of Hypertension
30.
31. Classification of Heart Failure
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
I Asymptomatic
B Structural heart disease but without
symptoms of heart failure
II Symptomatic with moderate exertion
C Structural heart disease with prior or
current symptoms of heart failure
III Symptomatic with minimal exertion
D Refractory heart failure requiring IV Symptomatic at rest
specialized interventions
1
Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
2
New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
32. Stages of Heart Failure and Treatment Options for Systolic Heart Failure
Jessup, M. et al. N Engl J Med 2003;348:2007-2018
Note: This slide was added to the original IMPACT-HF slide set. Teaching Text Beta-blocker therapy, like ACE inhibitors, acts by interfering with the endogenous neurohormonal system. Beta-blockers inhibit the toxic effects of norepinephrine.
Note: This slide was added to the original IMPACT-HF slide set. Teaching Text Beta-blocker therapy, like ACE inhibitors, acts by interfering with the endogenous neurohormonal system. Beta-blockers inhibit the toxic effects of norepinephrine.
The New York Heart Association (NYHA) classification system is based largely on the assessment of symptoms. 1 The new American College of Cardiology and American Heart Association (ACC/AHA) classification guidelines were designed to compliment the NYHA classification system. These new guidelines focus more on underlying disease and the need to treat early in the disease process, even before overt symptoms of heart failure are present. 2 1 The Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis. 6th ed. Boston, Mass: Little Brown; 1964. 2 Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001;38:2101-2113.