Okay everyone I hope you're doing well today I hope everything is okay and you're welcome back to farm class so you know
Start with tonight right about that I felt like I was moving way too slow so I was moving way too slow so I went and I trailer
So we can go through our homework together tonight so probably about an hour and 15 minutes an hour and 20 minutes to do once we finish now
The remaining time tonight we're going to go back to where we left off in the notes we left on vacation 9596 we're going to go back in
Chapter 4 practice questions together on hypertension and then we're going to talk about congestive heart failure okay so that's her
3 hours we go to 9 o'clock Eastern time
Okay this is your time to ask any questions if you're a little bit unclear as to what's going on but when you look at these times
Remember follow the steps on your strategies and you will get a lot faster at doing these problems you say something ridiculous together
I think these are fun I think these problems are kind of fun but the issue for you is nothing is really that fun on test day,
Because of the pressure but if you practice you will do well
So here our job is to identify two of you we have to figure out what type of drug drug you is are You Ready Step 1 analyzing
Ways to control your blood pressure goes up if the blood pressure is going up we were thinking about blood vessels basil can
That most likely raise the blood pressure here it's going to be all for one you should say that very confidently it
Billy Connolly remember the drugs and the choices here most often to go to The Agonist so you're asking yourself what was
Tacoma looks like
You'll notice that we didn't really see any change in the heart rate yet no change in the heart rate so if you go to the game with your
You'll notice that the ganglia blocker did nothing to the trash can you pre treat with a ganglion blocker you get no effect
There's no influence over reflex
Step 3
We look at the alpha blocker I mean it from the control of course it's different drugs you from having its effect
Proving the fact
Do you have any properties it looks like those properties so at this point is that drug you is pure alpha 1 Agonist now you just have to
Matchup alpha 1 Agonist drug list you should have it has been a left or right you should have identified that drug is phenylephrine
Hoonigans
Maybe some of you are asking this question some of you are asking this question if drug you makes the blood pressure go up
How do we have been doing this over and over again if the blood pressure goes up what do you expect to happen to the heart
Your pressure is up you expect a reflex bradycardia and bothered by the fact that you don't see a reflex bradycardia here okay let me know
Don't worry about that maybe we just didn't wait long enough maybe if we got a little bit longer we would have seen that reflect
Great but let me tell you that did not change how you solve this problem it does not change how you solve this problem you follow the rules
You noticed no effect of the ganglion block or no effect of the beta blocker and a complete blockage of this are the alpha blocker
Alpha 1 Agonist
How many people have thought about tyranny
I mean why would you say that this drug is not hire me because wouldn't hire me give you an alpha-1 effect eventually Hiram
She's going to act like an amphetamine causing the release of norepinephrine if I get one more of an effort my blood vessels are
But what else is tyramine going to do when you increase norepinephrine written that work directly on the heart when that Dorothy is real
Is there a reason why not hire me is because power they would have both Alpha and beta effects and we didn't see any better properties here
The beta-blocker had no effect
So that's how if you thought about tyramine it all
That's how you were really tired now
Okay how we do on that everybody feel okay about that problem solving for drug you identify exactly what type of affected it
Identifying the drug Okay Google 141 let's keep going
This thing right here before you see the eventual drop in the blood pressure
So sometimes I think we get bothered by the break or the unusual part of this diagram that we're not going to focus on the
I want you to focus first on the tree
What is general trend for what drug test does to the blood pressure the general trend is for the pressure to go down
There seems to be a slight increase initially but the overall effect of drug is a low blood pressure to decrease in the blood pressure
This effect would be consistent with drug is stimulating what receptor what receptor do you think drugs that stimulate
Make pressure go down to make the pressure go down that's going to be beta 2
It's clear that drug test was always increasing the heart rate
Your guess was always increasing the heart rate and so that will be what receptor
That would be of course beta 1 so it looks very much like a beta 1 beta 2 effects looks very much like beta 1 beta 2
Some folks are still going to ask this question though what is happening right here
And that's a good question I have two possibilities for what this is one possibility is the slight increase that you see right
Is just due to the beta-1 effect on the heart
Maybe that's kind of an initial increase due to better once the blood vessels really started dilating the general Trend was for the prayer
Did take over at that point
The other possibility is that this is really just the type of an artifact in this experiment artifact make people feel very good
This is clearly not the main point of this type of problem
What is drug is doing overtime is really dropping the blood pressure and increasing the heart rate
So that was step one that looks like beta 1 beta 2
Down step 2
Step to go to the ganglion blocker
Did the ganglion blocker change the control
Ganglion blocker did nothing
So that means everybody knows that means no reflex right no reflexes
But here's the question that you just answer here's the question that you just answered does drugs work directly on beta 1
Address work directly on dated once
Yes it does
Gas Works directly on Baywatch
Because if it was a reflex tachycardia than the ganglion blocker would have stopped it the ganglion block her had no effect
This has to be a direct tachycardia
Okay step through let's answer that question that just went
Dolphin fish
Step 3 with the alpha blocker does dragons have any Alpha Properties does dry gas do anything to Alpha receptors
It does not this is how you know she had no influence all this crap so the alpha blocker had no effect
The beta blocker Propranolol step for the beta blocker stops everything
The beta blocker which is not selected stops beta-1 and beta-2 effects
Who were the beta blockers going to block those things so here's our summer we analyzed the control step to look at the ganglion block
Which of the alpha Blocker still really confirm beta 1 beta 2 Force
So we're looking for Purolator
So maybe what do you think about pure Aveda
Of course will be the drug isoproterenol for terrible
Okay I got 2 questions for you two questions and one of them just got off the phone with us which is how do you know it's not true
How do you know it's not true beautiful which is just a beta 2 Agonist
Now does terbutaline cause direct tachycardia
Does tribunal and caused the wreck tachycardia know you're beautiful and only increases the heart rate because it will be
Tributo a ganglion block of wood in Stockton
We didn't see any effective again we walk that's why
The other thing is this I think this was my question to you guys and I will ask questions
Exactly
I suppose you could say we didn't say it was going to
Control
Yes
What drug are in the alpha blocker and compare that to do I get a channel blocker so with drug are high blood pressure to normal
High blood pressure and low blood pressure while that's the key isn't it the pressure went from high to low
That's only going to be one thing that's going to decrease the pressure below Baseline that's indicating a drug that has both
1 + b
Specs
Download the beta blocker the beta-blocker definitely takes away the beta 1 properties
That really is not the case this is this is the reversal of course that's an indicator of a beer bottle
When you go from high blood pressure too low blood pressure in the presence of an alpha blocker that's that that's exactly right it's done now
African do but norepinephrine come out
Shazam
See I told you if you did the practice questions in the book that you would find in a reversal
Practice courses
When you do it right there so I know
Burger King right because I think between
And finally we have
Drugs we have wonderful drugs
Low blood pressure
Chase
Effect
You have just answered this question and the question is does drug acts directly on the blood pressure
Go back to your control
NSB girls pointing out we don't really see that tachycardia like we saw for drug ass right we don't really see that effect
And that is probably pretty good evidence to that little initial blip for drug ass was beta 1 mediated
Okay again if you had any trouble with these especially if it was dry gas vs. real gas
Make sure you understand why isoproterenol vs terbutaline
You select between those two drugs
Okay
First question is this do you feel a little better about these types of problems right to feel better about these types of problems
Because once you start getting used to seeing the strategies they actually start to become a little bit easier
Now if this is still a weakness of yours if you still have a weakness in identifying the drugs if you don't you're beautiful
You're beautiful you have to fix that before you work on these problems for her you can't look at your beautiful I don't remember what time
The corner
So you can't go to Laughlin I don't remember that one more after that I remember nothing I remember but I still pretend all I know
Dr. Walker
Remember go through your steps that's how you can solve them quickly
Okay we're going over now to page 68th and on page 68 are some different types of problems
Beta blocker and that previous question the beta blocker blocks beta-1 and beta-2
What is beta 1 and beta 2 will the drug have beta-1 and beta-2 effects
Later one was the beta blockers going to stop direct tachycardia and reflex tachycardia
Doesn't tell you how hard he was changing that's the thing about the beta blocker
Okay now the one something 68 see things are a little bit different one of the things that about the experiment at the top of the
Respiratory resistance
Blood pressure cardiac output thanks blood pressure exactly
We gotta think about
Blood pressure
Which one of those 3 would be the last thing that you do
Which one of those would be the last one the last one you always you always look at the blood vessels
Respiratory resistor
Back to normal
Exchange
Why is not stopping
That's an important conclusion
Okay so that's just what we are right now
Next let's go to blood pressure and remember blood pressure and tpr we can do this at the same time blood pressure and tpr
Give drug x what pressure and tpr go down is that consistent with what we know about drug ex isn't that consistent with
CPR in blood pressure are going to go down so we're still thinking beta 2 Agonist at that corner
We left the TV on and we let the blood pressure go back to normal
And then we give X and Y at the same time and guess what we had what happens here nothing
We give them at the same time and nothing happens
So somehow why is stopping at sunlight is opposing X
What is why opposing it
Preceptors know what is told that it's not working at beta too so it's not a beta 2 blocker it's not a pharmacologic and Tyga
It has to be a different type of antagonist
Maybe it works on the different receptor maybe it's a physiological antagonist so what receptors good drug while I work on that would have
Veda chews off maybe that's the alpha 1 receptor maybe that's the other one so you would think it's either a beta 2 blocker
Which we drove down here that it's not
Reprove down here that is not or it's an alpha 1 Agonist
Okay so that's where we're going right now
That's where we are right now so far so good
Here's the final step the final step in oh by the way are we leaning towards alpha 1 Agonist right now here's the finals
Wiki cardiac output
Only give drug X okay be careful watch the Arrow
Does drug addicts do anything to cardiac output at the arrow
Is it doing anything right up Arrow the answer is no he will right of the arrow CPR goes down right of the arrow blood pressure
What is the aero respiratory resistance goes down all of those are Direct effects
Why did the arrow nothing happens
Food Drug Act is not working directly on the hard no direct effect on cardiac output but if I would wait a little bit of time
Where did what I say I said anything
You all know that is an indicator of a reflex this is a reflex increase in cardiac output
Why did I get a reflex increase in cardiac output why did this thing right here this happened
Because my blood pressure was low due to vasodilation
This is a response to the world what pressure
So now I'm going to run to heart rate cardiac output go back to normal
Now I'm going to get X and Y at the same time and what do I observe
Nothing no change
I did not see your reflex over here why didn't this happen
Because the blood pressure was normal
There was no vasodilation no change in the pressure
So here's what we know about drug addicts drug addicts works on beta-2 receptors
This is going to work on Bluetooth but it definitely has no direct beta 1 properties it doesn't have any direct Big Lots
If it had a direct way to work right here
So I guess she related to dragons
YouTube Agonist
Uruguay
Pure alpha 1 Agonist would like an alpha 1 Agonist so look for the pair that has beta 2 Agonist alpha 1 Agonist
That would be Choice d
Make that would be tasty
So why is not a beta blocker why is not a beta blocker in the reason you know it's not a beta blocker is because it was available
Apple watch beta 1 and beta 2
Propranolol would have stopped
You're having any effect right here
You're asking about timing that's okay first of all you can't base how long I'm going to explain this question on how long is coming
Because we're definitely going slow through the explanation so you have to be careful about that judgment no doubt about it
I would agree with you that this is a slower process this is going to take a little bit longer to go through something a little bit longer
Type of problem only because it's a new type of problem the concepts are still the same
The concepts are still the same the concept of what is the drug is changing tpr a blood pressure what's a drug bust going to Broncos
What's going to happen when you combine two drugs together right does the second rule change the first drug
Because down here at the bottom it didn't hear for tpr and blood pressure
So once again
I agree isn't due for about 72 seconds Maybe not maybe this is more of a 92nd row
Alright maybe two minutes is going to take you a little bit longer but I believe with a problem like this
Definitely has a more chance of showing up on the test he definitely has a chance to show up on the test
Surly little bit more challenging
Thinking about thinking about the fact that you're going to have one and so I was at the nephron I should have seen some effect on
It was if it was norepinephrine affect the cardiac output
Because of its beta 1 effects for sure that it was
Again the author want to send cancel out to be the true but it still doesn't stop the later one
Absolutely right
Okay so maybe you didn't have that one right maybe you didn't love that question
But hopefully you understand it
Okay now look down at the bar so if you take a look at the question at the bottom of page 68 look at the bottom of page 68
Once again
Once again take a look at the news
Look at the design of the experiment most people probably didn't take enough time looking at this experiment saying what is it telling me
What is it telling me
So
I'm looking at blood pressure and heart rate blood pressure and heart rate in response to acetylcholine
When I get home
Blood pressure goes down heart rate goes down heart rate goes up but either way once I give acetylcholine I wait and let a
Poems of tax return back to normal please
Why won't you still working are you still working
I've been giving you a call in a second time
The second half of this experiment
Is acetylcholine in the presence of drugs it's basically treatment with drugs and then give us going
The first part of the experiment is acetylcholine all by itself
What was the first part of this so tell me what was going to do that
Blood pressure
Reflex
I'm going to
What's missing from the right side of my pics
There was no reflex
Reflexes
Sympathetic ganglion blockers block reflexes
Ganglion block reflex
William Walker is here
Tony moly
Not going to be satisfied with that
I want to understand I want to understand my blood pressure
Do you remember
Who dominates on the heart
Blood pressure
Going to do the opposite
What's going to happen
Absolutely
Okay
Yes I think I might still be a little bit of confusion about that second part there because your ex is still working when you give it
So compare the drug acts by itself or calling will decrease the heart rate
And then he is so cold and goes away and then it goes away you go back to what was drug acts all by itself
Neostigmine is not going to do anything to the blood pressure neostigmine does nothing to the blood pressure because it cannot
Neostigmine can activate you with all my heart by raising acetylcholine
But I'm not going to get a reflex tachycardia because my pressure was normal so all neostigmine can do is decreased the heart rate
That will be the difference
So what's the heart rate but not the blood pressure numbers are not irritated
That's a good question about where you can find more practice problems like this you know I really don't know of a good resource
Let me try some of your questions to try some of your question but she might
Types of experiments but you know the type
OK Google Now the top of page 69 the next one that we're going to look at I think you have to redo the experiment I think you onesie
What is the experiment tell me hey let's read it together so we can arterial contraction in heart rate contractile force is measured in
Preparation arterial preparations he is like you're playing mad scientist in the laboratory you cut somebody's blood in the water bath
Notice heart rate is measured in an isolated heart preparation when you got the heart in the water bath right but this is not a home
The whole body experiment
The laboratory with a blood vessel and a heart
There are no reflexes in this experiment so there are no reflexes everything that the drug doesn't this experiment is the
That's cool you don't have to worry about reflexes everything that happened is correct on that one
Everything happens to
He also points out between drugs and what that means is that sometimes I'm going to give a drug like drugs and Drug one is going to steal
I'm not always going to wait for the system to reset itself
Okay now take a look at this when you look at your answered forces quickly scan them for me real quick I missed Agnes and Tyga
Agonist Agonist
Recreation challenge the challenge is it could be an Agonist it could be an antagonist
Okay here's what I'm going to suggest that you do on this one I'm going to suggest you think I can ask for
Or go with the simplest explanation. Let's go with
Who is the explanation and if that fails then we'll try something else okay let's watch this when we give drug what it does nothing to the
What does vasoconstriction
Drug one vasoconstrict simplest explanation drug one is stimulating alpha-1 receptors that's the simplest explanation would you do
Don't want to be waiting out here so we believe
Now we're going to get drunk
Constricted
The Vessel returns to normal
Simplest explanation for what drugs was doing
Drug to help blocking drug what was the explanation would be an alpha-1 blocker
Alpha 1 blocker maybe you're thinking like crazy now I don't see it but do you at least see an alpha blocker here I see one
I see her not even to me that's an alpha blocker blocks alpha 1 and Alpha 2 it's definitely going to block out for one so it looks to me
Walker
Drug to increase
203 Basil Drive
Socialist explanation first thing I would think
Go to Walmart later to all the blood vessel
Beta 1 beta 2 Agonist isoproterenol well crap no isoproterenol a second choice if it's beta 1 beta 2 low dose Epi hey maybe
What does it definitely looks like a beta 1 beta 2 Agonist
Okay so we're going to put that down as a maybe a little bit then maybe I'm going to keep going
We keep going we see that would give drug for the drug for you still working
Drug for return to the heart rate to normal and becomes the one that's normal
So it looks like drug for directly block Droid 3
Information about 1 beta 2 blocker
Beta 1 beta 2 blocker hey can we see one of those here absolutely see one of those we see the drug handle second half of the year
Now if you sold for drugs 1 through 4
Android 5 becomes easy but I think your father is the hardest one of all drop 5 hard
Decreased heart rate
What's name two types of drugs that would decrease the heart rate don't you tell me two types of games that would decrease heart rate
Local receptors
What type of drugs are muscarinic Agonist
Muscarinic Agonist or beta blocker
Muscarinic
Will beta blockers is right there
How far from basil dilate when you guys are on the way I think you can go out with three choices are you ready give me three two
What type of drug drug could be at the Azores Islands
So if it's going to be too late I think you're thinking about a beta 2 Agonist
Maybe you're thinking about a muscarinic Agonist
Maybe you're thinking about
An alpha-1 blocker
Kroger Liquor Store all possibilities
No question
The question was about the heart rate really be a beta blocker if there is no I guess that's a great question that's a fantastic question
I'm actually starting to think maybe those antagonists aren't really going to be options after all
But if I started putting my things together what did I think this could be I think it could be an Agonist and the only and it fits for both of them
Is muscarinic Agonist in that case you would get a response from the blood vessel in the heart graduation we have a mustache
Choices
The correct answer would have been yes
Drug to would have been see
Your tree was in fact logos definition
Drug for beta blocker non-selective beta blocker
Muscarinic Agonist
Nothing like that question
Alright, what to do
Now some of you think you could I do that within seventy-two seconds.
What was the 5 questions
That's five questions you get 6 minutes
You could probably do 2:40
Different question that you're actually
So I definitely like that
Claire's
Good though you know what you think about that the better boy
What you're talking about and why you don't have partial Agonist so certainly by itself it's going to have a stimulant effect
Types of beta-blockers on the Block
I've been a guy that's for sure
Okay so I definitely like that one I like that one hey let's do one more what's the one of the bottom of the page and then we'll take her
Once again
Hopefully you're starting to catch on with this message right here the messages think about the experiment first think about the
126. Gotta pay
My God Is Bigger Than The left. That's
Interesting
We're going to compare to drugs
Amphetamine vs. Finn
Hey Chris we already know that phenylephrine is an alpha 1 Agonist everybody knows this by now
Amphetamines can you describe amphetamines so really sir aren't becoming indirect
You're going to cause the release of norepinephrine so we get this you're actually comparing an indirect Agonist to a direct Act
One of these drugs amphetamine needs to learn the other one does not
The person's right eye is bigger than your left eye
When you get amphetamine you can dilate the right eye but you have no effect on the left eye
When you get phenylephrine you can violate the right away
Boy you can really dilate the left eye
That's pretty interesting don't you think
Pretty interesting
If you'll notice
Only and the only Ivan Infinity works on his the right eye because it has no effect on the left side but family
On both sides so let me ask you this question if I ask you this question
Does the left eye
Contain alpha 1 receptors does the rest I have alpha 1 receptors
Left I definitely have alpha 1 receptors it's responding to phenylephrine it definitely has alpha-1 receptors so that's not good
You gotta figure out what might be the problem with the left eye it's got receptors but maybe it doesn't have enough because the you
Doesn't work out maybe it's been denervated or maybe there's been damaged so that nerve going to the left.
Where is the responses are compatible with the conclusion that the left I had one and we go down we find hey dinner vacation
Probably would have made your list of things to be thinking about except now you're comparing indirect to direct indirect
Who directed question for you
3 hours is this why in the world did the left I get so big
Why do I get so big
So we know the left I wasn't being stimulated before
If the left eye is not being stimulated it's really going to upgrade to latest alpha 1 receptors to upgrade to be stimulated
Dragons wow you got a pretty significant effect
And you guys are commenting on this are absolutely correct this is what we called Innovation supersensitivity if you don't have the correct answer
Location of the radial muscle some of you might be thinking what an odd experiment really is the Step 1 exam what I just cut out the
Somebody I can pick between two drugs and they want to see if I understand what incredibly does vs. phenylephrine
Can you think of a situation where the generation of the sympathetic pathway going to the eye
You know so you can think about certainly other things I'm thinking about that's what I was thinking about
Drugs like cocaine
Okay so welcome back so we have one more problem to solve that problem of course on page 77 to look at the pretty cold but
Diagrams you really trying to solve for for drugs here so once again don't put too much pressure on yourself to solve this and about
Got 5 minutes to solve this problem but of course it's a little differently but it's got the same strategies that's the good news
Same strategies that we're going to analyze the control step to analyze the ganglion blocker and you don't answer when you can
Walker I bet you're going to have a pretty good idea of what you might also then have to go to atropine for some help
But you really probably don't have to go even to phenoxybenzamine for most of these drugs by the time I looked at the control and the
Walker I'm pretty sure I know what the drug is maybe one time I need to go to atropine to be sure all right so what's our first four
Looking at heart rate and we already know the heart rate can be a direct effect or reflex so direct or reflex got to be aware of that
Tachycardia causes
One step to go to the game Locker make it real simple do the ganglia blocker change the control analyze the changes
Answer did the ganglion block or change it yes
The ganglion blocker change the control the only time
Getting was going to change the control is it
This is definitely a reflex tachycardia this is a reflex tachycardia
Now you have to think about it ask yourself this question in order to get a reflex tachycardia
What had to happen to my blood pressure in order for that to happen what happened to my blood pressure causes a reflex tachycardia
You must have gone down my pressure must have gone down and what was my blood vessel doing for my blood vessels doing because the
Like a vasodilator was the drug hear that cause a drop in pressure causing a reflex tachycardia it looks like drug he is amazing
Let's go to each of the answer to how many days are we got here at first as a drug it's going to be
Change it
How many choices do we have
Hydralazine
Drug bust hydralazine
Challenge
Reflex
Vasoconstriction
Tell me how many vasoconstrictors you say how many days are constrictors do you see out of those 5 choices
I see one
There's only one basil constrictor there and that is norepinephrine hey I got it
There's only one vasoconstriction there is norepinephrine
But I bet you folks are probably curious right you're not just satisfied with that explanation of pictures too
Picture of drug p the ganglia
Steakhouse normal heart rate but in the case of drug Cube it flipped it went from down to up I want to know why this happened
Well let's think about who is norepinephrine what do we know about norepinephrine stimulate Alpha and beta 1
Because nobody stimulates beta 1 beta 1 cause tachycardia
Because normally stimulate powerful ones that raises the pressure and causes a reflex bradycardia mean isn't it true
Norepinephrine can cause both tacky and Brady
More if you can do both one is directing what is a reflex
What is the ganglion blocker taking away what is the ganglion block for taking away it's taking away the reflex which leaves
Direct me to watch the rectangle one from the weapon ever
If you take away the reflex Northeast stimulates better ones and gives you tachycardia
Besides a ganglion blocker besides a ganglion blocker
What's the other type of drug that can stop a reflex Brady from happening who else can stop a reflex Brady besides a ganglion block
The Bradenton atropine also stopped a reflex Brady
Atropine Augusta
Ganglion
Atropine takes away the reflex Brady what you're left with is the direct tachycardia
So the question there shouldn't judge you have been in the center and the control halfway in between well that's a great comment
What you don't know you don't know how much time has passed when we see the bradycardia clearly we must have left enough time
Bradycardia to overcome the direct tachycardia it's a great question but what you have to figure out what could it be
Summarize drug
Heart rate
Hexamethonium says it wasn't me
But I actually think that if you only go from the standpoint of drugs he was a basal constrictor there's only one boa constrictor
So that would have made it a little bit easier if you try to explain why the heart rate
Proving drug has both direct and indirect effects on the heart
Reflex
Absolutely
How much time has passed
It was going to be there long enough
She went down that was due today so no dilation
Basil dilators on the list of hydralazine and we already picked hydralazine earlier
But let's go with this logic
If it was acetylcholine
Atropine when stopping Accutane stop it
If atropine has an effect it's got to be muscarinic mediated it looks like a few calling you
Summarize drug acid increase the heart rate
Hexamethonium showed it was a reflex proving a vasodilator
Atropine blocks it
So it must be a muscarinic effect therefore it is your calling
Now again some of you were going to go but can you one more time can you explain why the graph flips
Why does the graph flip
You see this so it's not even
Little basil garlic sauce
Low basal dilation
So if you're thinking about this we did the other night if you give somebody acetylcholine as a drug we know this when you give a seed
The heart rate goes down first bradycardia first and then you get a reflex tachycardia right so here we are seeing the reflex
What if we used a ganglion blocker have a ganglion block or stops reflexes leaving you with only acetylcholine causing breaker card
You won't see the reflex tachycardia
I'll tell you what I'll tell you I'll tell you what's interesting is that I gave you this exact same experiment exactly
The heart rate
Hopefully you'll be able to get those
Computer
Very very
We love these drugs on the exam so you work at the renin-angiotensin Alba
Probably that's fantastic
Now let's look at it through the eyes of the drugs now let's look at it I will just write down the password to all the drugs in it
Remember what those drugs you're going to do to this pathway
So when you look at the drug called illiterate when you look at a list of Lutheranism
Watch free that you can work through direct renin inhibitor you can memorize that fact but the question on the test is not going
Which of the following is a direct renin inhibitor you just not going to be that lucky
Question is going to rule
The question is going to want to know something like this if you place a patient on a listing
When you play somebody on the list.
The following substances is going to accumulate
What accumulates when you put somebody on the list
So a whisker and is going to cause the accumulation of angiotensinogen it's the precursor
You accumulate angiotensinogen
Because if you use this drug you're blocking the conversion of angiotensin engine into Angiotensin 1
Maybe the question goes this way because of using the drug ellipse during the immediate synthesis of which of the following cell
Going to be inhibited what's immediately going to be in the production of angiotensin 1 that's how I want you to look at this diagram
Remember I imagine what they might actually ask you what is going to accumulate what is going to be directly inhibited
Okay let's keep going Angiotensin 1 is converted to Angiotensin II by the enzyme known as a
What is conversion so it would cause the accumulation of angiotensin 1
And directly decrease the production of Angiotensin II that's how you have to look at it
But you know that's not enough with an Ace inhibitor right you have to remember that ACE inhibitors affect another pathway
Brady kind of is broken down by the Asians are sometimes called this is all my kindness
Old kind as to that breaks down because it was just another name for a
So if you're on an Ace inhibitor
If you're on an Ace inhibitor
Not only will you not be able to convert and you can someone to Angiotensin 2 you can't break down Brady kind of
So Brady kind of levels are going to accumulate
And you know as was just pointed out you know that will lead to the most common
The most common side
We believe that coffee is vibrating
Simulation of Brady kind of side effects
The enzyme known as I guess you can call it kind of the same
Is going to convert
At the same time
People always get confused by this
Most popular
Who stars on the new drug for hypertension complains of a nagging cough
The cartoon
How long does it take to talk
Yes
Brady is going to go up
Is going to go up
What's going to go down when I put them on and hear what's going down
The most immediate thing here
Aldosterone Goes to Hell
What happens to tpr tpr Goes to Hell
Blood pressure goes down
So once again you create your own image of what goes up and what goes down so maybe you're looking at this diagram diagram
Would you ever have before because when you only thought about it from a physiology standpoint it's just a matter of making sure you
Now I'm asking you again
And tell me what's going to change and the people who write test questions that's what they think about
That's what they think about
So good?
Possibly going to do to baby heart rate
Any drug that drops your blood pressure if you're treating somebody with hypertension if you're going to decrease the blood pressure
The heart can possibly compensate for that the heart may try to compensate because we know that these drugs are going to work on
What are also going to work on the kidneys if you're working on the blood vessels in the kidney maybe you do see you attack a card
Maybe you do see you tachycardia as a compensation for the bodies drop in blood pressure it wouldn't be beneficial but certainly that's why
Think about what goes down must go through it what does that is Angiotensin 2
Aldosterone goes down
Tpr goes down
Blood pressure goes down
So those are all things that are going to go down
So I need your attention to aldosterone tpr blood pressure that you're welcome
When you would you think about those things don't really costing you about just writing out a list and saying I need to memorize
The barber did to my brain if you know this diagram you can look at it and think about those and that'll be the best thing for you
What's at the bottom of the page
You want babysitters because they have a common enemy
Beautiful Frills No Frills captopril life
Lisinopril is the most commonly prescribed
Question about a list for Karen has some risk of course it's not nearly as high as an Ace inhibitor may but there is a little bit of a risk
With those drugs
It's definitely going to be more expensive it's definitely going to be more expensive so I still the primary drugs for sure
Since we don't want to take it then you can switch into an ARB or consider religion
So ACE inhibitors are pills they are bees are sharks losartan and the other sorts so easy to recognize these trucks
Meaning of the director isn't it blocks the formation of angiotensin 1
The same results of ACE inhibitors on blood pressure medication so there's a pretty low risk call Over All
It's only been out for about 5 years now not a real compelling argument for that drug over the old standbys
At the bottom of arms
Who have
You can call you
The much more serious side effects
Angioedema is going to present as a rapid swelling in the face
Nose mouth lips tongue all of those things
Squirrel
All of those things can swell up
City of the C1 esterase
About it would be more ready to angioedema
Can you call me can buy a nice and then or if you do come by the station tomorrow that's when you're really increased risk for hyper
Hyperkalemia happens because these drugs stop aldosterone and aldosterone
Potassium you stop aldosterone you're going to say
Doesn't happen very often doesn't happen very often
But it is more serious
He is probably going to be exactly like this
Shortly after the first dose shortly after the first dose of the new drug for hypertension
The patient experience
That was causing angioedema
One of my favorite things like we're doing right now but one of my favorite things is actually going to be one of the things I really really
I enjoy it so could you guys send me an email after you were still want exam and say hey look how I did on Step 1 I love that Coco
I love that
No I want to I like when my current students here in Kentucky I like when we go out of clinical rotations think they would listen to me in class
Side effects of Naprosyn side effects on clinical rotations and she was like hey guess what I saw what I saw
Just kidding just kidding I got that phone call a lot a lot of students have called me
What is that going to do
How does that help how does that help your diabetic
Control control
It's really important
Proteinuria
Left protein in the urine if you use an ace or an orb in your diabetic what does the kidneys are not filtering as much
Decreased GFR will go in as a result
These types of drugs might cause renal failure
Why would they cause renal failure will it only happens and somebody who's got bilateral renal artery stenosis
If you got renal artery stenosis that a ferret side has already been constructed this side blood flows already reduced
If you see construction here
The only thing that's helping to maintain GFR the only thing that's helping to maintain GFR and somebody with renal artery stenosis
Is the fact that you constricting on the efferent side
If you dilate on the even side you lose all of your filtration pressure
So you never wanted to die with all the efferent side and somebody who's already got a really low GFR renal artery stenosis
Does back pain cause
So different when your patient tolerate
Grr to decrease in the GFR
Most diabetics specially if you catch them early on most diabetics can and you can protect your kidneys for a long time
But don't do that and somebody with renal artery stenosis
Final part of this picture is this
Where's the role of NSAIDS on this diagram how would an incense affect this diagram NSAIDs stop prostaglandin stock price today
So you said would be more likely to promote constriction of the affair and arterial
If you constrict the afferent arteriole that can also lead to acute renal failure
And you probably know this what are the side effects of high doses
Walgreens
Renal problems renal dysfunction possibly acute renal failure from high doses of NSAIDs
That's what I like a medication that's going to promote real artery stenosis check of analogous
Okay thanks on my way there
We come back we'll have our last hour of class so you back in 10 minutes
Okay everyone welcome back to this will be our last hour for tonight yes we have a three-hour class once again tonight
But we just seem to have a lot of for our classes but we are going to have a couple for our class is coming up on Friday and Saturday
Do we have something for our class coming
4230 classes actually.
Who won the Iowa
Are there that looks at the use of drugs for hypertension and also in comorbid conditions the idea of if you're going to use
What other condition might be also be used for will point out a couple of these things that are sold for diabetes and are
Facial somebody with hypertension they're going to be very very effective
For heart failure once again a beta blockers are also used in heart failure so that's another group of drugs that look like candy
Who's the blockers are very effective at preventing a second am I so big it was useful post MI
For patients with hypertension and BPH we already know that the alpha 1 blockers we already know that they're very effective
Hypertension alpha 1 blockers
On purpose only because that's the chapter that's coming up we will talk about that chapter on Friday night but beta blockers and
The Walkers are both very good
The river flow sometimes it'll be just for BPH but not useful for somebody who also has hypertension you have to use one of those
When it comes to this look at some of these drugs don't harm your lips somebody's will not harm your liver to raise your weapons
Blockers calcium channel blockers aces are our souls are going to be okay for your lipid profile but folks tell me can you name
Two types of drugs for hypertension that are going to raise your limit so clearly beta blockers are on that list beta blockers
Butt
Fireside diuretics can
Five nights will also Raise Your Weapon so they're not in this must either because those drugs could be harmful for somebody
Definitely focus on diabetes and heart failure focus on these two for sure take a look at BPH
Beta blockers post them on again mostly were thinking about beta 1 selective drugs post-mi for their survival benefit
Okay let me show you my way to remember let me show you my way to remember some of the more commonly you
Baltimore hypertension so I called the ABCD of hypertension so the ABCD would be Aces at Arms
Beta blockers and calcium channel blockers and diuretics so that's what I called the ABCD of hypertension so these are some of our war
Top drugs
The only one of these four groups of drugs today that is not coming with you
Knock on wood uses
The block will be a little bit farther down this way but Aces arbs calcium channel blockers and diuretics very very coffee
As the first initial
Mini from accommodations for
Okay you supposed to be an easy quick flow chart for you to come to think about some of the more commonly
Okay let me know when you're done give me a give me a song that was good let me know when you're done
The question of why beta blockers
Chapter one that's coming up next
All right before we finish up the hypertension chapter Bugatti short sectional pulmonary hypertension okay watch this if you're going to treat
Pulmonary hypertension is one strategy that one strategy that I think will use basil dilators to treat pulmonary hypertension
What is a drug called boat in Tennessee with a receptor blocker ending with what is a very very powerful vasoconstrictor it's going to be
Stripped by binding to its receptor is known as a TA in a TV
This wasn't an interview in a receptor blocker so it blocks the actions of interference blocking this phase of constrictor
So the mechanism for bows and ham and receptor blocker used for pulmonary hypertension
The oldest drug for pulmonary hypertension is the drug Propranolol is a prostaglandin drug specifically it's across the side
It's a PDI to analog and pgi2 is going to cause vasodilation once again
Easily My Favorite Drug easily My Favorite Drug for pulmonary hypertension is sildenafil hate you know why it's my favorite drug for
Everybody knows the other thing that you use the benefit for everybody knows the other thing so if you know something to feel for
Don't forget it's also used for pulmonary hypertension right and it's going to
Navigate to increase cyclic GMP and pulmonary arteries
Good for pulmonary hypertension hypertension
Eros
Blood pressure is down and every one of those
Either one of those
You're going to have
Christian diastolic volume
When you depress contractility you're going to see an increase in end systolic volume
Rustoleum so the correct answer is going to be worse than it was the most popular answer about 38% of the group said that
5% said see so once again the three parts of this correct watch out for ejection time in my stolen phone that was a little bit
Okay so good job on that
Question number 2
I'm going to really like this question
Okay we're going to get you a new phone just a second
Okay so just a few more seconds on this phone
So you look at this question you have to decide how many problems does this guy have does he have one problem or two
Do you notice that
He's bound to have BPH but his blood pressure is 148 over 92 which is above our criteria of 140 over 90 he has two problems
What's the best single agent for person who has hypertension and BPH for folks that's going to be exhausted that's going to be it
Hansen Hansen good for the BPH with no effect on the blood pressure so how about 79%
Pretty good response right they're pretty happy with that remember
Comorbid conditions drive you there so if it's two conditions hypertension and something else there is going to be a 01 best choice
Russian White Castle
Okay maybe a challenging question though
Tumblr Apple Mail
Okay so that's the idea that he would have been reversed by even the first dose of physiological you would have had to overcome
You don't know the comment about Easter
Well I think if you know what you're going to give him an alpha 1 Agonist just like we did in this and this case
Absolutely but nothing else that you're going to do that kind of go over around that mechanism
Alright question over 4
Question number 4
On this one if you haven't voted yet
Okay last chance to vote if you haven't got your voting yet
So I think this was a challenge as well but I think most of you kinda like this
I'm difficult but I think you'll like this one so I got to go with an aneurysm in the aorta Krueger
Hypertensive crisis so we giving nitroprusside Will nitroprusside very powerful vasodilator very powerful vasodilator it's going to lower
Cyanide poisoning and things like that but that's what drug do you get along with minimize the risk of aneurysm rupture
The pressure was high
Can you give them nitroprusside and the pressure starts to come down other organs start to fight that drop in blood pressure
Including your heart might try to compensate your heart might increase you might be a sympathetic effect to try to call her
To overcome the drop in the blood
Will a tachycardia would be really bad for somebody with an aneurysm in the aorta crew what drug do you give them to minimize
Look for a beta blocker like metoprolol absolutely got that question correct that is a very good response they're very good
Your answers are scattered almost each of the other entrance got about the same attention there but the real riskier was attacked
Drop in blood pressure
Compressor
Okay very good very good on that one
And you know what I always say it like this for now is a good time to miss questions the stakes are very low right now but you know
Missing questions right now is a good thing missing questions right now is it
You will remember that you missed that question and you know what you're going to do yours like I will never get that question again
Drug again and that's a good thing that's a good thing
Origin of the last one of this
Okay
So you got a ten year old girl rare form
Familial dysautonomia that maybe you will
Okay keep going keep going it'll be okay
Noticed she's got a debilitating orthostatic hypotension she's got the rotating orthostatic hypotension now we're going to give her
That I talked about your quarters I was about like giving somebody aldosterone fludrocortisone is a very powerful man
Water retention and as for giving the Trotter
How to add a second drug an oral medication to further increase your blood pressure will if we're giving a drug that's going to help the
II want to go after they try to raise blood pressure I would say would be the blood vessels best thing for the blood vessels
Alpha Agonist pure Alpha Agonist
So about 67%. That question Curry
Good job on that going to stimulate the heart is just as powerful as the drug that works on the blood so that if it's hard
In that case questions good way to finish out the chapter on hypertension
Okay we're going to go probably not supposed to talk about it
One of the major things
Too much money
Too much of a good thing
Control control control
Call
What increase preload
What's Identify two ways that we can decrease preload will preload is due to the increase in volume so diuretics diuretics
Remote
Also an increase in preload
Happens when you get a constriction of the veins so what's a way to decrease preload Reno diet
You can be no doubt it so you can use diuretics to lower preload or you can use Aveeno dilators to decrease preload
So let's review those three strategies one more time before she was using beta blockers to control sympathetic activity to the heart
The second one was using drugs that dilate arterioles to decrease afterload the third one was using drugs that decrease preload
Provino's hours
And the whole thing will be to Simply use drugs that are going to increase the strength of contraction we want to increase this
Attraction to help increase contractor
Will be increasing contractility
So from that you should see some of our major major strategies in order to do that
Alpha and beta blocker Carvedilol non-selective Bay
The Hart bus
We talked about left ventricular hypertrophy the heartland
Comedy
Increase in stress that's put on it and hypertrophy is good to a point
Good to a point
But we do not want to see happen in a heart failure patient we don't want this to progress to cardiac remodeling the 4th Street
Increase contractor
We don't want this to progress to increased are two cardiac remodeling
Cardiac remodeling let's see it real plain and simple folks cardiac remodeling is harmful potentially fatal
You feel loss of cardiac myocytes and fibrosis so remodeling is basically a loss of function
It's basically a loss of function
Now if you want to predict the most commonly
Strategies of heart failure today the most popular strategies of heart failure today
Drugs that stop remodeling
How do you predict who's going to stop remodeling remember this you remember that the sympathetic nervous system
And specifically aldosterone are major contributors to remodeling
Angiotensin II also contributes to remodeling it's kind of part of the sympathetic to activate the renin-angiotensin-aldosterone
Subway sympathetic Stampy and norepi to Randy Orton
Aldosterone
The bubbles molecules
Aldosterone Haiti on aldosterone this is going to help you drugs that stop aldosterone
Are going to stop Remodeling and those are some of our favorites those are some of our favorites
So use this picture use this picture to help to formulate your strategies are think about your strategies
Let's go over to page 100 let's go to page 100 and let's review those one more time
So at the top of the page there decreasing preload
Decreasing preload
Diuretics will do that
Any Vino dilator will do that including Aces and ours so it's hard to decrease preload
Hey can you see this can you see the faces and arms decrease preload by both of the ways that we talked about earlier
2 Ways to Die
What can decrease preload and have a diuretic effect and baby Rhode Island
Decrease afterload anybody who does arterial including
No contract if not we'll talk about it
Aldosterone receptor blocker
Beta blockers
Going to ask you this question ask you about survival
Survival survival survival
Luke
Doctors that do that
We still have to talk about the positive inotropes the trolls are sometimes used in heart failure so let's review this guy's real
When you think about the positive inotropes
Notice we got a cardiac muscle cell is the cardiac muscle cell
Here's where did Jackson is going to work two jobs and is going to block the sodium potassium ATP
When you block this caller you're going to see an immediate increase in intracellular sodium
Because you can't pump sodium out
Second when there's an increase in intracellular sodium
You're going to influence the sodium calcium exchanger this exchanger is going to also stop working effect of what you're going to see it
Calcium
So an increase in intracellular calcium
What is this cell going to do with that calcium this I was going to put that calcium into the SR what are they call that increased
Calcium loading you're going to load up the car with calcium so that Kelsey was going to stay there until it's time to be real
Where can you get a greater contraction that's how the job was going to increase contractility
The comment about the beta blocker decrease in heart rate
Remember the benefit of the beta-blocker the benefit of the beta blocker is inhibiting remodeling we'll talk about those in a little bit
Benefit and remodeling you got to be careful with your block the sodium potassium atpase
This increase affects the sodium calcium exchanger
Sodium calcium exchanger
Calcium increase contractility
Good for
Next to indirect effect good for arrhythmias this will help you later on
So let me explain how does digoxin help in Richmond
What is an indirect effect which means is happening outside of the heart we believe that digoxin can inhibit new role
Perhaps on the vagus nerve itself here's what we think
Increases Bagel firing
When the biggest fires to the hardest stimulates them to receptors on the heart when you stimulate them to receptors on the heart
Great horned owl
Are found in high concentrations in the sa and AV nodes are found in high concentrations in the so tell me again what type of
Ford SVT good for SVT exactly right exactly
When would you use
Somebody
Enhance
Visual
Remember
Fast response
Class 1 and class 3 1 & 3
Fast Response fibers so we prefer class 1A
For class 3 drugs why you think 1818 is sodium and potassium
31 class 3 igloo
Radiodrome does it all right he's your friend is the one that works in all arrhythmias so procainamide
Or any other owner really good
But you know what you don't want to do in the most cases of wolff-parkinson-white
Slow down baby conduction you don't want to slow down a TV conduction because that can actually enhance the arrhythmia
Who are the drugs that slow AV conduction is the same list of drugs we gave last night for SVT Class 2 beta blockers class
Calcium channel blockers to others adenosine digoxin
Amiodarone will slow down conduction
Directly on those accessory Pathways so I will take care of the Fast Response fibers as well
One of your beta blocker won't do that so that's why
Okay folks I think that is a good place for us to stop tonight my mom said if we can get halfway down page 101 we run perfectly
Virginia Friday night so that's where we're going to stop tomorrow I don't know you guys have class tomorrow but
Call tomorrow come back on Friday night for hours in class everyone enjoy the next couple of days I will see you again
On Friday night thanks so much again for being here