05. VASODILATING AGENTS AND DRUGS ACTING ON VESSELS

Activities in the class

1. RISK FACTORS OF CARDIOVASCULAR DISEASES

What are the risk factors of cardiovascular diseases? Which of them can be prevented or minimized and how? If we think about pharmacotherapy, which groups of drugs are we talking about? What do we mean by "metabolic syndrome"?

Task: Try to describe individuals with MAXIMAL / MINIMAL risk of cardiovascular disease? 


2. SCORE = Systematic  COronary Risk Estimation

Today, more than 300 risk factors related to cardiovascular diseases are known. The main ones are:

  • tobacco smoking
  • unsuitable diet including excessive amounts of alcohol
  • obesity (namely of abdominal type)
  • insufficient physical activity
  • hypercholesterolemia
  • hypertension

SCORE algorithm can be used for prediction of fatal atherosclerotic CVD events over a ten year period. It is based on the following factors: AGE, GENDER, TOBACCO SMOKING, SYSTOLIC BLOOD PRESSURE and TOTAL CHOLESTEROL LEVEL. Age and gender are uninfluenceable factors, the risk increases with age and in males. The rest of the factors can be prevented by both suitable lifestyle/diet and rational pharmacotherapy.

Risk regions
Score charts

 There are many on-line calculators of SCORE, the following one can be found on the EAPC web

Score calculator for the evaluation of 10 year risk of fatal CVD

It is an electronic and interactive version of SCORE charts that are a part of European Guidelines on CVD Prevention.

One of the most important factors of the CVD risk is age. That is related to time for which other risk factors acts on the cardiovascular system. Age is therefore one of the most important factors that cannot be prevented.

Which of the influenceable factors plays the major role in CVD risk?


3.  HYPOLIPIDEMICS

Hypolipidemics is a group of drugs with various modes of action used for the treatment of dyslipidemia. Dyslipidemia is a major risk factor of atherosclerosis. The process of atherogenesis also continues in patients with IHD when dyslipidemia is not effectively cured. Therefore the vessel diameter is decreased as well as blood perfusion and the risk of thrombus increases.

1. What are the causes of dyslipidemia?
2. What are the modes of action of hypolipidemics?
3. Fill in the following chart, based on the effect of single hypolipidemics.
4. What are the typical adverse effects of hypolipidemics?
5.  What are the contraindications of hypolipidemics?
6. Which of hypolipidemics are safe in pregnancy/breast feeding?

Combinations of hypolipidemics and their drug-drug interactions

With respect to the fact that hypolipidemics are a "standard" part of medication in patients with IHD and because it is common that more types of dyslipidemias are treated simultaneously, hypolipidemics are often combined together or with drugs from other pharmacotherapeutic classes. Some drugs can interfere either in a positive or negative way. Therefore, the knowledge of DDI interactions of hypolipidemics is of clinical relevance.


rosuvastatin + olanzapine
atorvastatin + ezetimibe
atorvastatin + colesevelam
atorvastatin + verapamil
atorvastatin + fenofibrate


4. ANTIOBESITY DRUGS

Which drugs are used for the treatment of obesity? What is their mode of action? What are their adverse effects and resulting contraindication? Are antiobesity drugs used in combinations, too? Which drugs, that you know from the autumn semester cause weight gain and which reduce it?

5. OVERVIEW OF VASODILATING AGENTS

Find out the possible mechanisms of how vasodilation can be caused and evaluate whether these modes of action can be therapeutically used. Match your modes of action with groups of drugs below:
  • nitrates and NO donors
  • calcium channel blockers
  •  ATP-sensitive K- channel activators
  • PDE-5 inhibitors
  • prostacyclin analogues
  • endothelin antagonists

Nitrates and NO donors

  • What is the mode of action of these two groups of drugs? Find all differences in their modes of action?
  • In which indications and drug dosage forms do we use these drugs?
  • What are their characteristic adverse effects? Are they related to the mode of their action?

Calcium channel blockers

Tasks for groups

1. What are the differences between dihydropyridines (DHP) and non-dihydropyridines (non-DHP)?

2. Try to identify a patient in which dihydropyridine CCB (alternatively non-DHP) would be contraindicated (think about his diagnosis, drug anamnesis, ......)

3. Patient comes to your office. He complains about some adverse effects of the CCB DHP (alternatively non-DHP). What could he complain about? What kind of adverse effects of CCB can be self-monitored? Are these related to the mode of action of CCB?

4. Describe the differences in PK of nifedipine, felodipine and amlodipine. What do you know about drug dosage forms of these drugs?

Try to create a schema describing differences between DHP and non-DHP CCBs.

CCBs - review of DHP and non-DHP

6. ISCHEMIC HEART DISEASE 

What is the clinical manifestation of IHD?
Which symptoms can be influenced by pharmacotherapy?
Which groups of drugs can we use?
What does the "standard" therapy of patients with chronic IHD look like?
Which drugs (in general) can worsen the IHD?

This chart can help you.

IHD chart

Case reports

Now you know everything to solve the following case reports.

Case 1 

Woman, with a nasogastric tube due to dysphagia related to oesophagal carcinoma. Treatment: verapamil SR 240 mg 1-0-0; atorvastatin 40 mg 1-0-0, glycerol trinitrate spray in case of angina; acetylsalicylic acid 100 mg 1-0-0. What is/are her probable diagnosis? On the third day after the insertion of the nasogastric tube, the patient was found laying on the floor in the bathroom. Physical examination: bradycardia 40 bps, hypotension 110/70. Before the fall she was feeling sick. What can be the cause of the fall?

Case 2  
Male, comes to GP because of tiredness. On his last visit, his medication was changed, but he is not able to describe how. He just knows, that physician started some medication for his heart problems. Physical examination: HF 48 bps, BP 120/80. Which drugs can be involved?

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