Vascular system dilatation

Histamine is a substance present in various tissues of die body, such as die heart, lungs, gastric mucosa, and skin (Pig. 36-1). The highest concentration of histamine is found in die basophil (a type of white blood cell) and mast cells diat are found near capillaries. Histamine is produced in response to injury. It acts on areas such as die vascular system and smooth muscle, producing dilatation of arterioles and an increased permeability of capillaries and venules. Dilatation of die arterioles results in localized redness. An increase in die permeability of... 

Tolazoline dilates the pulmonary vascular system by stimulating both Hp and H2-receptors. Cimetidine and ranitidine block H2-receptors so that at least part of the effects of tolazoline are abolished. It has been suggested that this interaction is confined to children. ... 

Nifedipine acts by antagonising L-type Ca channels in myocardial and vascular tissues leading to inhibition of Ca + influx. An inhibition of extracellular Ca + influx will reduce the availability of the intracellular Ca required for muscle contraction in the myocardium and smooth muscles of the vascular system leading to an improvement in the oxygen supply for myocardial tissue, dilation of the coronary and systemic arteries, and a decreased peripheral and systemic blood pressure. 

Systemic and coronary arteries are influenced by movement of calcium across cell membranes of vascular smooth muscle. The contractions of cardiac and vascular smooth muscle depend on movement of extracellular calcium ions into these walls through specific ion channels. Calcium channel blockers, such as amlodipine (Norvasc), diltiazem (Cardizem), nicardipine (Cardene), nifedipine (Procardia), and verapamil (Calan), inhibit die movement of calcium ions across cell membranes. This results in less calcium available for the transmission of nerve impulses (Fig. 41-1). This drug action of the calcium channel blockers (also known as slow channel blockers) has several effects on die heart, including an effect on die smooth muscle of arteries and arterioles. These drug dilate coronary arteries and arterioles, which in turn deliver more oxygen to cardiac muscle. Dilation of peripheral arteries reduces die workload of die heart. The end effect of these drug is the same as that of die nitrates. 

Pharmacology The principal pharmacological action of nitrates is relaxation of the vascular smooth muscle and consequent dilation of peripheral arteries and especially the veins. Dilation of the veins promotes peripheral pooling of blood and decreases venous return to the heart, thereby reducing left ventricular end-diastolic pressure and pulmonary capillary wedge pressure (preload). Arteriolar relaxation reduces systemic vascular resistance, systolic arterial pressure, and mean arterial pressure (afterload). Dilation of the coronary arteries also occurs. The relative importance of preload reduction, afterload reduction, and coronary dilation remains undefined. 

Pharmacology Iloprost is a synthetic analog of prostacyclin PGl2- Iloprost dilates systemic and pulmonary arterial vascular beds. 

This xanthine derivative is an only a modest bron-chodilator in COPD, and because of its narrow therapeutic range, frequently seen adverse effect and drug interactions, it is becoming less frequently used, some patients experience side effects even within the therapeutic range. The non-bronchodilator effects of theophylline such as systemic and pulmonary vascular dilatation, central nervous system stimulation, improvement of the strength and effectiveness of respiratory muscles and possibly anti-inflammatory effects are of disputed clinical significance at usual therapeutic levels. 

Mechanism of Action A nitrite vasodilator that relaxes smooth muscles. Reduces afterload and improves vascular supply to the myocardium. Therapeutic Effect Dilates coronary arteries, improves blood flow to ischemic areas within myocardium. Following inhalation, systemic vasodilation occurs. 

Mechanism of Action An antihypertensive that directly dilates pulmonary and systemic arterial vascular beds and inhibits platelet aggregation. Therapeutic Effect Reduces right and left ventricular afterload increases cardiac output and stroke volume. 

Mecfianism of Action A prostaglandin that dilates systemic and pulmonary arterial vascular beds, alters pulmonary vascular resistance, and suppresses vascular smooth muscle proliferation. Therapeutic Effect Improves symptoms and exercise tolerance in patients with pulmonary hypertension delays deterioration of condition. Pharmacokinetics Protein binding 60%. Metabolized in liver. Primarily excreted in urine minimal elimination in feces. Half-life 20-30 min. 

Mechanism of Action An antiplatelet that directly dilates pulmonary and systemic arterial vascular beds, inhibiting platelet aggregation. Therapeutic Effect Reduces symptoms of pulmonary arterial hypertension associated with exercise. Pharmacokinetics Rapidly, completely absorbed after subcutaneous infusion 91% bound to plasma protein. Metabolized by the liver. Excreted mainly in the urine with a lesser amount eliminated in the feces. Half-life 2-4 hr... 

ACE). Hence, angiotensin II production is inhibited. Decrease in angiotensin II results in dilatation of peripheral vessels leading to a reduction in systemic vascular resistance and a decreased aldosterone secretion. They can be administered safely in patients of hypertension with diabetes mellitus or bronchial asthma. ACE inhibitors are efficacious drugs, are well tolerated and are useful antihypertensive drugs. ACE inhibitors are also used in coronary artery... 

Sevoflurane, in common with all volatile agents, reduces cardiac output and systemic blood pressure. It does so mainly through a reduction in peripheral vascular resistance. Although it is a systemic vasodilator it does not appear to produce significant dilatation of small coronary vessels and there is no possibility of coronary steal as hypothesised for isoflurane. A small increase in heart rate may be observed. This is less pronounced than with isoflurane and desflurane and is almost certainly the result of reflex activity secondary to the reduction in peripheral vascular resistance. Sevoflurane is associated with a stable heart rhythm and does not predispose the heart to sensitisation by catecholamines. In children, halothane causes a greater decrease in heart rate, myocardial contractility and cardiac output than sevoflurane at all concentrations. For these reasons sevoflurane is advocated for use in outpatient dental anaesthesia, especially in children. 

Most blood vessels receive no direct innervation from the parasympathetic system. However, parasympathetic nerve stimulation dilates coronary arteries, and sympathetic cholinergic nerves cause vasodilation in the skeletal muscle vascular bed (see Chapter 6). Atropine can block this vasodilation. Furthermore, almost all vessels contain endothelial muscarinic receptors that mediate vasodilation (see Chapter 7). These receptors are readily blocked by antimuscarinic drugs. At toxic doses, and in some individuals at normal doses, antimuscarinic agents cause cutaneous vasodilation, especially in the upper portion of the body. The mechanism is unknown. 

Physiologically, in both normal and hypertensive individuals, blood pressure is maintained by moment-to-moment regulation of cardiac output and peripheral vascular resistance, exerted at three anatomic sites (Figure 11-1) arterioles, postcapillary venules (capacitance vessels), and heart. A fourth anatomic control site, the kidney, contributes to maintenance of blood pressure by regulating the volume of intravascular fluid. Baroreflexes, mediated by autonomic nerves, act in combination with humoral mechanisms, including the renin-angiotensin-aldosterone system, to coordinate function at these four control sites and to maintain normal blood pressure. Finally, local release of vasoactive substances from vascular endothelium may also be involved in the regulation of vascular resistance. For example, endothelin-1 (see Chapter 17) constricts and nitric oxide (see Chapter 19) dilates blood vessels. 

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