MINISTRY OF HEALTH OF UKRAINE
VINNITSYA NATIONAL PIROGOV MEDICAL UNIVERSITY
APPROVED
on a methodical conference
of Clinical Pharmacy and
Clinical Pharmacology department
Head of the department
_____ Prof. O.A. Yakovleva, DM
«___»___________20___
METHODICAL DEVELOPMENT FOR STUDENTS
for preparation to practical lesson
Educational discipline
Rich in content
module № 1
Theme of lesson № 4
Course
Faculty
Clinical pharmacology
Clinical pharmacology of drugs, influencing on the
cardio-vascular system
Clinical pharmacology of hypotensive drugs
5th
Medical
Vinnitsya - 2013
1. Actuality of theme:
Hypertension (HTN) or high blood pressure is a chronic medical condition in
which the systemic arterial blood pressure is elevated. It is classified as either primary
(essential) or secondary. About 90–95% of cases are termed "primary hypertension",
which refers to high blood pressure for which no medical cause can be found. The
remaining 5–10% of cases (Secondary hypertension) are caused by other conditions that
affect the kidneys, arteries, heart, or endocrine system.
Persistent hypertension is one of the risk factors for stroke, myocardial infarction,
heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure.
Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary
and lifestyle changes can improve blood pressure control and decrease the risk of
associated health complications, although drug treatment may prove necessary in
patients for whom lifestyle changes prove ineffective or insufficient.
Despite this knowledge and unequivocal scientific proof that treating
hypertension dramatically reduces its attendant morbidity and mortality, hypertension
remains untreated or poorly treated in the majority of affected individuals in all
countries, including those with the most advanced health care. Inadequate treatment of
hypertension is a major factor contributing to some of the adverse secular trends in the
last decade, including an increased incidence of stroke, heart failure, and renal failure
plus a leveling off of the decline in coronary heart disease mortality.
Thus, it is very important to know and to correctly use knowledge about
pharmacology of hypotensive drugs and tactic of their use in different clinical
situations.
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Concrete aims:
To analyse an epidemiology situation in the world in relation to distribution of
arterial hypertension.
To analyse the mechanisms of development of hypertension.
To analyse classification of diuretics, angiotensin-converting enzyme
inhibitors (iACE), angiotensin receptor blockers (ARB).
To analyse pharmacological mechanisms of diuretics, iACE, ARB.
To analyse pharmacological effects of diuretics, iACE, ARB.
To learn tactic of choice of diuretics, iACE, ARB.
To learn to estimate side effects of pharmacotherapy with diuretics, iACE, ARB.
To interpret indications and contra-indications to application of diuretics, iACE,
ARB.
To write and analyse recipes on drugs which are used for hypotension
therapy.
2.
Base knowledges, abilities, skills, necessary for a study themes
(interdisciplinary integration)
Name of previous
Got skills
disciplines
1. Latin
A department "Pharmacological terminology and
medicine". To own ability of the faithful writing of the
name of drugs by Latin, in obedience to grammar. To
own knowledges about completion in the genitive case
of nouns and adjectives of different cases at excerption
drugs in recipes.
2. Normal physiology
A department "Physiology of the cardio-vascular
system" - to apply knowledge from this department.
3. Biological chemistry
To define the role of angiotensin-converting enzyme
for the organism of man. To apply knowledges from
this department at consideration of mechanisms of
action of separate drugs.
4. Pharmacology
A department «Pharmacology of drugs which
influence on functions of the cardiovascular system».
To apply knowledges of this department at
consideration
of
pharmacodynamics
and
pharmacokinetics of separate drugs.
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3. Base knowledges which a student must own.
Etiology, pathogeny, classification of hypertension.
The main clinical, laboratory and instrumental signs of arterial hypertension.
Principles of pharmacotherapy of hypertension.
The first aid at a hypertensive crisis.
Complication of hypertension, their prophylaxis.
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4. Theoretical questions for preparation to employment.
Mechanisms of development of hypertension.
Classification of diuretics, iACE, ARB.
Mechanisms of action of diuretics, iACE, ARB.
Pharmacodynamic effects of diuretics, iACE, ARB.
Tactic of choice of change between lessons.
Side effects of pharmacoterapy by diuretics, iACE, ARB.
Indications and contra-indications to application of diuretics, iACE, ARB.
8. To write and analyse recipes on drugs which are used for hypotension therapy.
5.
Practical tasks which are executed on employment.
This stage is foreseen by implementation independently of the followings
practical works every student.
Task 1.
To write recipes and conduct them pharmacotherapy analysis (to specify group
belonging, indications to application, possible complications).
Task 2.
To familiarize with drugs of educational collection on the topic, to define their
belonging to the pharmacological group and indications to use.
Task 3.
To ground the choice of drug, its medical form, dosage, concentration and way
of introduction.
1. Name the drug of choice from the group of іАCE for cupping of hypertensive
crisis.
2. Name the drug of choice from the group of diuretics for cupping of
hypertensive crisis.
3. Name the diuretic for treatment of arterial hypertension.
4. Name the diuretic for treatment of arterial hypertension for patients with
diabetes mellitus.
5. Name the diuretic for warning of cerebral edema.
6. Name the diuretic for treatment of glaucoma.
7. Name combined drug, which contains іАCE and diuretic, for treatment of
hypertention.
8. Name combined drug which contains ARB and diuretic, for treatment of
arterial hypertension.
Task 4
Fill a table "Mechanism of action of hypotensive drugs"
Preparation
Mechanism of action
Lisinopril
Perindopril
Telmisartan
Valsartan
Spironolactone
Furosemide
Indapamide
Torasemide
Hydrochlorthiazid
Acetazolamide
Tasks for self-control.
Task 1.
Name the drug from the group of іАCE, which is an active lipophilic matter, with
onset of action of the drug in 30 min., duration of action in 4-6 hours, that is why
appointed mainly with the aim of cupping of hypertensive crisis.
Task 2.
Name the drug from the group of іАCE, which is an active hydrophilic matter,
with t½ 12,5-30 hours.
Task 3.
Lipofilic drug which belongs to prodrugs and contains a phosphoryl group.
Final stage - 15 min.
Final test control is carried out.
Tasks in obedience to a base of Step-2 center of testing of MH of Ukraine.
1. A 55-year-old woman, with an ovenweight, which suffers on a hypertension,
has the rare attacks of shortness of breath at loading. Objectively: Ps is 70 in min.,
rhythmic. BP is 185/95 mm Hg. Blood glucose - 5,6 mmol/l. Hypertrophy of the left
ventricle, PQ-0,24 sec. are found on EKG. Choose the most optimum hypotensive drug.
A. Hydrochlorthiazid
B. Atenolol
C. Verapamil
D. Clonidine
E. Reserpine
2. A 48-year-old patient complains of the shortness of breath, pain behind of
the sternum at the physical loading, headache. Objectively: Ps is 92 in min., PB is
180/95 mm Hg, systolic murmur at the apex of the heart. EKG: asymmetric thickening
of the walls of the left ventricle, diminishing of cavity of the left ventricle. Choose the
most optimum hypotensive drug.
A. Metoprolol
B. Dyazide (triamterene + hydrochlorothiazide)
C. Verapamil
D. Clonidine
E. Prazosin
3. A 64-year-old patient suffering from hypertension during 14 years.
Objectively: Ps is 84 in min., rhythmic, BP is 170/110 mm Hg, blood glucose - 7,2
mmol/l, cholesterol - 8,2 mmol/l, β-lipoproteins - 65 units, triglycerides - 2,4 mmol/l,
level of urinary acid is 0,48 mmol/l. What from diuretic drugs is it most expedient to
appoint to the patient?
A. Furosemide
B. Hydrochlorthiazid
C. Indapamide
D. Aldactone
E. Dyazide (triamterene + hydrochlorothiazide)
4. Patients have diminishing of blood pressure at setting of thiazide diuretics.
This group of diuretic is used for long-term treatment of hypertension. What is the basic
mechanism of hypotensive action of the indicated group of drugs?
A. Sharp oppression of activity of carbonic anhydrase
B. Normalization of function of kidneys with diminishing of secretion of renin.
C. Excretion of sodium and water from a vascular wall, diminishing of its
thickness and sensitiveness to pressor influences.
D. The purposeful action on vaso-motor centers in the CNS.
E. Increase of amount of ions of sodium and magnesium in the organism.
5. A 58-year-old patient, who suffers on an urarthritis, complains of headache,
increase of BP. Objectively: pulse is 56 in min., rhythmic, BP is 190/100 mm Hg.
Cardiac tones are sonorous, noise does not listen, accent 2 tones of the aorta is found at
auscultation. Level of urinary acid of blood is 0,52 mmol/l. What from hypotensive
drugs is it most expedient to appoint to the patient?
A. Dyazide (triamterene + hydrochlorothiazide)
B. Verapamil
C. Hydrochlorthiazid
D. Propranolol
E. Amlodipine
6. In a 48-year-old patient, with a chronic glomerulonephritis, CRF І st., was
found a hypertension 3 years ago. Objectively: Ps is 64 in min., rhythmic, BP is 200/110
mm Hg. Blood test: Hb- 100g/l, ESR – 38 mm/h. Proteinuria is 0,5 g/l. EKG: a
hypertrophy of the left ventricle. Choose most optimum from hypotensive drugs for
initial therapy?
A. Atenolol
B. Enalapril
C. Hydrochlorthiazid
D. Clonidine
E. Dyazide (triamterene + hydrochlorothiazide)
7. A patient has MKD cirrhosis. The shortness of breath, edema of both feet,
ascites appeared last two months. A patient accepted hepatoprotectors and
corticosteroids. What combination of drugs is it most expedient to add to treatment
which is already conducted?
A. Aldactone + ascorutin
B. Lipocainum + hypothiazide
C. Nerobol + furosemide
D. Aldactone + furosemide
E. Albumin + ascorutin
8. In a 54-year-old patient complains of headache in the neck, feeling of
heaviness in the head, sometimes - flicker flies before the eyes. He has a high BP 150/100 mm Hg during the year and diabetes mellitus during 4th years, which treats by
glibenclamide. Objectively: t - 36,5°С, respiration rate – 20 in min., pulse – 78 in min.,
heart rate – 78 in min., BP is 152/98 mm Hg, normal skin color; vesicular breathing. the
left border of the heart is on the left mid-clavicular line, heart sounds are muffled,
accent II tone of the aorta, a rhythm is correct. A liver is at the edge of the right costal
arch. Name the group of drugs for hypotensive therapy which is necessary at this
situation.
A. Inhibitors of angiotensin-converting enzyme.
B. Cardioselective beta-blocker.
C. Non-cardioselective beta-blocker
D. Thiazide diuretics
E. Loop diuretics
9. A 68-year-old man has hypertension, takes inhibitor of ACE (enalapril – 10
mg in day). Objectively: pulse is 60 in min., heart sounds muffled, accent ІІ tone of the
aorta. Ultrasound of the heart: signs of hypertrophy of myocardium of the left ventricle.
Efficiency of treatment decreased recently. BP does not go down below 160/110 mm
Hg. What drug is expedient to add to enalapril:
A. β-blocker
B. Derivatives of Verapamil
C. Diuretics
D. Angiotensin receptor blocker
E. Derivatives of Rauvolfia
10. A 65-year-old patient complains of the increase of BP, headache, dizziness.
He marks a hypertension during 2 last years. Objectively: PS – 60 in min., rhythmic, BP
– 190/110 mm Hg. Systolic murmur is over the aorta. Setting of combination of
enalapril with hydrochlorthiazid brought the decline of BP to 170/96 mm Hg. What
drug is it necessary to strengthen this combination?
A. Verapamil with prolonged action.
B. Nifedipin with prolonged action.
C. Metoprolol with prolonged action
D. Diazepam
E. Clonidine
11. Stable stenocardia of 2nd functional class is diagnosed in a 46-year-old
patient on a background of arterial hypertention of the 2 stage. The BP is within the
limits of 160/105 mm Hg. Which antihypertensive drug you give an advantage?
A. Metoprolol
B. Enalapril
C. Doxazosin
D. Clonidine
E. Adelfan (reserpine+dihydralazine)
12. A 38-year-old patient, who carried an acute glomerulonephritis 10 years ago,
is hospitalized with complaints of the edema of face, feet, loin, headache, aching pain in
a loin. The BP is 200/110 mm Hg. In an urinalysis: albumen - 3,9 g/l, leucocytes - 3-4,
erythrocytes - 10-12, hyaline cylinders 3-4 in sight, waxy cylinders - 2-3 in preparation.
creatinine of blood - 102 umol/l. What from the hypotensive drugs is it most expedient
to apply for this patient?
A. Prazosin
B. Propranolol
C. Dopegyt
D. Captopril
E. Clonidine
13. The woman of middle age, who has aortic stenosis of rheumatic genesis,
appealed with complaints of the shortness of breath. Objectively: general state is
satisfactory, skin is pale. In the lungs is heard vesicular breathing. The border of the
heart extended to the left, tones are weak, rough systolic murmur is over the aorta which
is conducted on the vessels of neck. Heart rate - 100 in min., BP is 90/60 mm Hg. A
liver is enlarged by 2 cm, an edge is soft, sensible at palpation. There is edema of lower
extremities. Which of drugs is contraindicated to the patient?
A. Verapamil
B. Furosemide
C. Asparkam (potassium asparaginate)
D. Captopril
E. Inosine
14. A 52-year-old patient has arterial hypertension of the 2nd stage. Smokes.
Does not treat oneself regularly. Objectively: BP - 175/105 mm Hg, heart rate - 92/min.,
in lungs - diffuse dry rales on a background of weakened breathing. Liver is enlarged by
2 cm, edema is in the area of talocrural joints. Choose optimum hypotension drug:
A. Adelfan (reserpine+dihydralazine)
B. Propranolol
C. Nifedipin
D. Enalapril
E. Clonidine
15. In 30-year-old patient, in a term of pregnancy 28 weeks, there is an increase
of BP to 170/110 mm Hg. Objectively: accent of 2 tone above an aorta, ankle edema. In
urine: specific gravity is 1016, albumen is 0,33 g/l, leukocytes are 8-10 in in sight,
erythrocytes are 5-6 in sight. Ultrasound of the heart: end-diastolic dimension 5,4 cm,
thickness of the interventricular septum 1,1 cm. What hypotensive drug is most
dangerous in this case?
A. Dopegyt
B. Clonidine
C. Reserpine
D. Captopril
E. Nifedipin
16. A 53-year-old patient is under the supervision of doctor about hypertension
during 5 years. BP was not less than 160/110 mm Hg last month. Pulse is 60 in a min.
On EKG – signs of hypertrophy of the left ventricle of heart. Which of the hypotensive
groups is it necessary to prescribe to the patient as pathogenetically substantiated group?
A. Antagonists of calcium from the sub-group of Verapamil
B. β-blockers
C. Drugs from the group of Rauvolfia
D. Antagonists of calcium from the sub-group of Nifedipin
E. Drugs of group of Clonidine
17. A 58-year-old patient has arterial hypertension of 2nd stage, which became
complicated by HF of 2A st. What drug is it most expedient to appoint to the patient?
A. Inhibitors of ACE
B. Propranolol
C. Raunatin (Derivatives of Rauvolfia)
D. Antagonists of calcium
E. Clonidine
18. Drug was prescribed to the 40-year-old man with hypertension. This drug
improved the state of patient and normalized the level of BP for 3 days. After some time
a patient appealed to the doctor with complaints of an unproductive cough which did not
change under act of antitussives and violated sleep of patient. Obstructive diseases of
lungs are not in anamnesis. What drug did patient take most probably?
A. Reserpine
B. Propranolol
C. Clonidine
D. Verapamil
E. Enalapril
19. A patient has a chronic glomerulonephritis with chronic kidney failure and
reno-parenchymal hypertension. What diuretics contraindicated to use for treatment of
such hypertension?
A. Chlortalidone
B. Spironolactone
C. Hydrochlorothiazide
D. Furosemide
E. Dyazide (triamterene and hydrochlorothiazide)
20. 38-year-old patient complaints of the inspiratory dyspnea. In anamnesis:
hypertension, IHD. Objectively: acrocyanosis, gurgling breath. Breathing frequency is
30 in a minute, BP is 230/130 mm Hg, in the heart is an accent of 2nd tone above a
pulmonary artery. Choose combination of drugs for treatment.
A. Euphillin, furosemide
B. Prednisolone, Euphillin.
C. Salbutamol, atropine, papaverine
D. Strophantin, potassium salts, platyphylline
E. Morphinum, furosemid, pentamini.
At the end of employment verification and analysis of job results is conducted
with the exposure of the proper points and marks.
Algorithm of evaluation of students knowledges:
1. An initial level of knowledges is 5 tests;
2. Final level of knowledges:
- tests to Step-2 – № 10;
- excerption of recipes and pharmacotherapy tasks;
3. Situatioonal task;
4. Verbal answers.
Distributing of points, appropriated to the students at mastering of theme
"Clinical pharmacology of drugs, influencing on the cardio-vascular system» of the rich
in content module 1 for educational activity of student, is following:
Traditional Mark
"5"-fine
"4"- well
"3 "-satisfactorily
"2" - unsatisfactorily
Points
16
13
10
0
1.
2.
3.
Recommended literature:
Basic & Clinical Pharmacology/ edited by Bertram G. Katzung. - 10th edition. –
USA, 2007.
Goodman & Gilman's the pharmacological basis of therapeutics / edited by
Laurence L. brunton. - 11th ed. – USA, 2006.
Color atlas of Pharmacology/ edited by Heinz Lullmann, Klaus Mohr, Albrecht
Ziegler, Detlef Bieger. - 2nd edition. - New York, 2000.