Renin-angiotensin-aldosterone System – Cardiovascular Pharmacology

by Joseph Alpert, MD

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    00:00 Okay. Let's take a look now at another drug category.

    00:06 Let's look at the renin-angiotensin system.

    00:10 This is part of the system that your body has for regulating blood pressure and blood volume.

    00:16 Remember in the physiology area, we talked about the meticulous control that the central nervous system maintains over the circulation.

    00:25 For example, if you suddenly walk into the dessert where I live in Arizona on a hot day, you're going to get very, very dehydrated if you're not drinking water.

    00:36 Well, the body has a system, the renin-angiotensin system, for holding on to salt and water.

    00:42 It doesn't allow the kidneys to make as much urine and eliminate salt and water.

    00:47 You hold on to fluids more because you stimulate the renin-angiotensin system.

    00:52 The body has a whole series of nervous connections and little monitors throughout the cardiovascular system that enable it to tell, "Hey, things are dehydrating, blood volume is going down, let's rev up the renin-angiotensin system." Chemicals are released renin from the kidney that converts in the blood stream to an agent called angiotensin that clamps down the blood vessels, raises the blood pressure, and also has effect on the kidney to prevent salt and water excretion.

    01:23 Now, it turns out in heart failure, often the body misreads the signal.

    01:31 It sees there's decreased circulating blood volume and it thinks, "Oh, it's dehydration." Or, "Oh, it's blood loss. I better hold on to salt and water," but actually the problem isn't dehydration and it isn't hemorrhage.

    01:45 It's that the heart is just pumping less and when that happens, the body misreads it.

    01:51 It holds on to salt and water and that results in excess salt and water in the lungs, leading to shortness of breath and remember when we did the physical exam, I showed you the edema on somebody's leg, that's also the result of excess renin-angiotensin activity in heart failure.

    02:08 So, in that setting, we would like to block the renin-angiotensin system.

    02:13 We'd like to say, "No, no. Don't hold on to salt and water." We wanna have the kidney excrete salt and water because we already have too much on board because of the heart failure state.

    02:23 And so, blockers were developed for the renin-angiotensin system just as we had blockers for the beta-stimulated sympathetic nervous system.

    02:33 Now, we have blockers for the renin-angiotensin system.

    02:37 There's two classes of blockers for the renin-angiotensin system.

    02:40 So called ACE inhibitors, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers.

    02:47 They block the pathway in different places.

    02:51 I'm gonna show you the pathway in a moment.

    02:53 I'm not showing to you yet cuz it's fairly complex and I don't expect you to be memorizing it but I’m gonna show it to you.

    03:00 It's one of the critical things that we teach to medical students early in their career and continue to emphasize throughout their clinical training.

    03:08 Now, let's talk a little bit about using the ACE inhibitors, angiotensin-converting enzyme inhibitors and the angiotensin receptor blockers for the heart failure state.

    03:21 What do they do? They dilate the blood vessels and particularly they tell the kidney, "Hey, let's excrete more salt and water." They do this through a complex system that involves the adrenal and hormones from the adrenals.

    03:36 I don't wanna go into this in great detail cuz it would take quite a long time and it's beyond what you need to know.

    03:43 But the important thing for you to know is that the angiotensin blocking enzyme and the receptor blockers work in the kidney and they allow the kidney to excrete salt and water.

    03:55 Now, if you are dehydrated, you wouldn't want to take one of these because it's gonna make the dehydration situation worse and lower your blood pressure and so forth but if you're in a heart failure state, you want to excrete that salt and water and guess what? You get a second bonus, you lower blood pressure.

    04:12 So just like the beta blockers, you are decreasing the work of the heart.

    04:16 So, there's sort of double benefit, if you will.

    04:19 In the heart failure patient, you're actually making the work of the heart less at the same time that you're encouraging excretion of salt and water so that the edema, the swelling in the legs, the swelling in the liver, the swelling in the lungs gets better.

    04:34 Now, this is the entire angiotensin-renin receptor sequence in the body and it's complicated, but you can see with the little red arrows, the one that says, ACE-1, that's the ACE inhibitors where it blocks the system and off to the left, you can see the angiotensin receptor blockers, it blocks the system a little later on.

    04:57 The important thing to remember here is again, we're doing what we did with beta blockers.

    05:02 We are blocking an excessive effect of one of the body's natural defenses because the body has misinterpreted the situation.

    05:12 It's thinking there's dehydration or loss of blood when in fact, the problem is decreased pumping by the heart.

    05:20 Now, if you'd like, you're more than welcome at your leisure to go over this and understand the whole sequence.

    05:25 It starts with release of renin from the kidney that's converted in the bloodstream to angiotensin.

    05:31 Angiotensin I goes to angiotensin II, that stimulates the adrenals to release a hormone aldosterone that holds on to salt and water.

    05:39 You can see all of these works in an attempt to restore blood volume.

    05:44 With the blockers, we don't wanna restore blood volume. It's already excessive.

    05:49 The body has misread the signal.

    05:51 We wanna release salt and water, and the ACE inhibitors and the angiotensin receptor blockers help.

    05:57 Now, it turns out, there are a number of side effects.

    06:00 If the patient has decreased kidney function, these drugs can actually make the kidney function worse.

    06:05 Another thing that happens is with ACE inhibitors, it is possible that you will lower the blood pressure too much and also there can be allergic reactions with the ACE inhibitors.

    06:17 There's much less problem with the angiotensin receptor blockers.

    06:20 They're much better tolerated and so in elderly and frail individuals, we often will go with the angiotensin receptor blockers.

    06:28 Here's a list of all the drugs. You can see all the drugs that end in pril are ACE inhibitors and all the drugs that end in artan, for example, Losartan are the angiotensin receptor blockers.

    06:41 You're not going to memorize these or the doses.

    06:43 I just put them up to show you there's a whole variety of these and guess what the good news is? Almost all of these are generic, and so therefore, very reasonably priced and they are among the most commonly prescribed drugs.

    06:57 They're used as first line for hypertension.

    07:00 They're used as first line for heart failure.

    07:02 They're used as first line for ischemic heart disease for atherosclerotic heart disease.

    07:07 Now, as I said before, the side effect potential is a little more with ACE inhibitors and a little less with angiotensin receptor blockers but both of them can cause worsening of kidney function when they are given to patients particularly who already have some kidney disease.

    07:26 For example, diabetics who always have a tendency towards kidney disease.

    07:31 Often, you can make that worse so you have to monitor kidney function.

    07:34 Again, you have to have an integrated clinical plan and you have to follow-up carefully on the patient.

    About the Lecture

    The lecture Renin-angiotensin-aldosterone System – Cardiovascular Pharmacology by Joseph Alpert, MD is from the course Introduction to the Cardiac System.

    Included Quiz Questions

    1. Cough is a well-known side effect of their use.
    2. ACE inhibitors exert their antihypertensive effect through blocking alpha receptors.
    3. ACE inhibitors can be used safely during pregnancy.
    4. They should not be used in patients with heart failure.
    5. ACE inhibitors may precipitate hypokalemia.
    1. ...decreased renal perfusion.
    2. ...decreased body sodium.
    3. ...high aldosterone levels.
    4. ...constriction of blood vessels.
    5. ...dilatation of blood vessels.
    1. Water and salt retention as a result of the renin-angiotensin-aldosterone system overactivation.
    2. Decreased hydrostatic pressure as a result of decreased stoke volume.
    3. Increased capillary permeability as a result of a widespread inflammatory process.
    4. Decreased oncotic pressure as a result of liver dysfunction.
    5. Increased hydrostatic pressure as a result of venous insufficiency.
    1. Losartan
    2. Captopril
    3. Propranolol
    4. Methyldopa
    5. Atorvastatin

    Author of lecture Renin-angiotensin-aldosterone System – Cardiovascular Pharmacology

     Joseph Alpert, MD

    Joseph Alpert, MD

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