Bi 24: Thuc iu tr tng huyt p Mc tiu hc tp: Sau khi hc xong bi ny, sinh vin c kh nng: 1. Phn loi c cc thuc h huyt p 2. Trnh by c c ch tc dng v p dng iu tr ca cc thuc chn knh calci: nifedipin v verapamil. 1. Trnh by c c ch tc dng v p dng iu tr ca nhm thuc c ch enzym chuyn dng angiotesin. 1. Huyt p v bnh tng huyt p 1.1. Huyt p Huyt p T iu ho Huyt p = cung lng tim sc cn mch ngoi vi Th tch Tn s d lng mch tm thu Tng HA | tin gnh co tht Ph i thnh mch cng g/c V mu tng stress Tng nhp Thn gi | Renin Na + Na + angiotensin Vai tr ca thn trong kim tra th tch tun hon: Khi p lc ti mu cho thn b gim, s c s phn phi li mu trong thn, km theo lm gim p lc mao mch thn v hot tnh giao cm (thng qua receptor ) dn n sn xut renin t tng sn xut angiotensin, gy ra: - Co mch Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa - Kch thch sn xut aldosteron lm gi Na + v nc Tng huyt p thng c chia thnh hai loi: - Tng huyt p th pht: khi huyt p tng ch l mt triu chng ca nhng tn thng mt c quan nh: thn, ni t it, tim mch, no... iu tr nguyn nhn, huyt p s tr li bnh thng. - Tng huyt p nguyn pht: khi nguyn nhn cha r, lc c gi l bnh tng huyt p. C ch bnh sinh ca tng huyt p rt phc tp. Huyt p ph thuc vo lu lng ca tim v sc cn ngoi vi. Hai yu t ny li ph thuc vo hng lot cc yu t khc, nh hot ng ca h thn kinh trung ng v thn kinh thc vt, ca v v tu thng thn, ca hormon chng bi niu (ADH), ca h renin - angiotensin - aldosteron, ca t nh trng c tim, tnh trng thnh mao mch, khi lng mu, thng bng mui v th dch v.v... Mt yu t quan trng trong tng huyt p l lng cc ng mch nh v mao mch thu hp li. Phn ln khng tm c nguyn nhn tin pht ca tng huyt p, v vy phi dng thuc tc ng ln tt c cc khu ca c ch iu ha huyt p lm gin mch, gim lu lng tim dn n h huyt p (xem hnh). Tt c u l thuc cha triu chng v nhiu thuc c trnh by trong cc phn c lin quan (xem bng b). Bng 24.1: Phn loi cc thuc h huyt p theo v tr hoc c ch tc dng 1. Thuc li niu: lm gim th tch tun hon - Nhm thiazid - Thuc li niu quai 2. Thuc hu giao cm - Tc dng trung ng: methyldopa, clonidin - Thuc lit hch: trimethaphan - Thuc phong to nron: guanethidin, reserpin - Thuc chn : propranolol, metoprolol - Thuc hu o: prazosin, phenoxybenzamin 3. Thuc gin mch trc tip - Gin ng mch hydralazin, minoxidil, diazoxid - Gin ng mch v tnh mch: nitroprussid 4. Thuc chn knh calci Nifedipin, felodipin, nicardipin, amlodipin. 5. Thuc c ch enzym chuyn angiotensin Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Captopril, enalapril, ramipril. 6. Thuc i khng ti receptor angiotesin II Losartan, Irbesartan 2. Thuc chn knh calci 2.1. Khi nim v knh calci Nng Ca ngoi t bo 10.000 ln hn trong t bo (10 -3 M so vi 10 -7 M) v khi ngh mng t bo hu nh khng thm vi Ca, ng thi c bm Ca cng vi s trao i Na + - Ca ++ y Ca ++ ra khi t bo. Ca vo t bo bng 3 ng (knh): 2.1.1. Knh hot ng theo in p (voltage operated chanel -VOC hoc cn gi l POC: potential operated channel): hot ng theo c ch tt c hoc khng c g (hoc hon ton m hoc hon ton khp kn) gy ra do s kh cc mng (t -90mV ln - 40mV). Thuc h knh loi ny cn c c knh Na + , K + . Tu vo s dn (conductance) v s cm th (sensitive) vi in th, knh VOC cn c chia thnh 4 loi knh: - Knh L (long acting): c nhiu trong c tim v c trn thnh mch - Knh T (transient): c trong cc tuyn tit - Knh N (neuron): c trong cc nron - Knh P (purkinje): c trong purkinje tiu no v nron. Knh T, N v P t cm thu vi thuc chn knh Ca. 2.1.2. Knh hot ng theo receptor (receptor operated channel -ROC): p ng vi cc cht ch vn. 2.1.3. Knh d : Tri vi 2 knh trn, knh ny lun c m cho qua lung Ca nh, nhng lin tc. Ca t bo hoc vo li bo tng v t li bo tng ra, lm cho nng Ca trong bo tng t 10 -7 M (nng gin c) tng ln 10 -5 M (nng co c), s kt hp c vi calci protein (troponin/calmodulin-CaM) v gy ra nhiu tc dng sinh l. 2.2. Vai tr sinh l ca Ca trn tim mch Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa 10 -3 M Ca ++ VOC S.R Dn truyn nh tht Ca ++ 10 -7 M 10 -5 M Troponin Calmodulin Tnh t ng tim nhp bo/ xut bo Prot. Co bp Proteinkinase enzyme gii phng TGHH Co bp tim Ch.ha co c trn thnh mch VOC: knh hot ng theo in p SR: li bo tng Hnh 24.1: Vai tr ca Ca ++ sau khi qua knh Trn c tim, Ca ++ gn vo troponin, lm mt tc dng c ch ca troponin trn chc nng co bp, do cc si actin c th tng tc vi myosin, gy co c tim. Trn c trn thnh mch, khi calci ni bo tng s to phc vi calmodulin, phc hp ny s hot ha cc protein-kinase (phosphoryl ha myosin kinase chui nh), thc y s tng tc gia actin v myosin, gy co c trn thnh mch (Hnh 24.1) Sau khi tc ng, nng Ca 2+ ni bo s gim do Ca 2+ c bm li vo ti li ni bo hoc y ra khi t bo do bm v do trao i vi Na + . S trao i Na + /Ca 2+ c th thc hin c hai chiu: Na + vo Ca 2+ ra, hoc Na + ra Ca 2+ vo. Trong iu kin sinh l bnh thng Na + vo v Ca 2+ ra, ngha l s trao i ny c vai tr chnh trong vic gi nng Ca 2+ thp trong t bo. Khi c tr Na + trong t bo (th d digitalis phong ta bm Na + ) th hot ng theo chiu ngc li: Ca 2+ vo t bo trao i vi Na + i ra, gy tc dng tng co bp tim. Khc vi knh Na + , knh calci chu nh hng rt mnh ca cc yu t ngoi lai (trung gian ha hc, hormon) v cc yu t ni ti (pH, ATP). Ni chung, cc knh Ca ch hot ng khi trc c phosphoryl ha. S phosphoryl ha ph thuc vo hot tnh ca adenylcyclase. 2.2. Cc thuc chn knh calci Fleckenstein (1964) ln u tin a ra khi nim chn knh calci khi m t tc dng ca verapamil trn t bo c tim, l thuc c tng hp phng theo cng thc cu to ca papaverin. Cc thuc thuc nhm ny gn c hiu trn knh v phong ta knh, tuy cu trc ha hc rt khc nhau. 2.2.1. Phn loi Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Theo cu trc ha hc v c im iu tr, c 3 nhm thng thng. Sau li chia thnh th h: th h 1 l thuc chn knh Ca mng t bo v mng ti li ni bo; th h 2 tc dng nh th h 1 nhng chn lc trn t bo c trn thnh mch hoc tim hn. Tc dng ko di. Bng 24.2: Cc thuc chn knh calci Nhm ha hc Tc dng c hiu Th h 1 Th h 2 Dihydropyridin ng mch > tim Nifedipin Felodipin Nicardipin Nimodipin Amlodipin Benzothiazepin ng mch = tim Diltiazem Clentiazem Phenyl alkyl amin Tim > ng mch Verapamil Gallopamid Anipamil Thuc c tc dng trn ng mch mnh hn trn tim do lm gin mch nhanh v mnh, d gy h huyt p nhanh, dn n phn x lm tn g nhp tim, khng li, nht l trn c tim b thiu mu. Verapamil do c tc dng c ch trn tim mch hn trn ng mch nn thng c ch nh trong lon nhp tim (xin xem thm bi Thuc cha lon nhp tim). 2.2.2. Dc ng hc Cc thuc chn knh calci tc dng theo ng ung v chu s chuyn ha qua gan ln th 1, v vy ngi ta nghin cu thay i cc nhm chc trong cng thc cu to, lm cho thuc chm b chuyn ha, chm b thi tr hoc n nh hn, c tnh chn lc hn. Do to ra cc thuc th h 2, 3. Bng 24.3: Dc ng hc mt s thuc chn knh calci Thuc Hp thu (ung) Khi pht tc dng t/2 (gi) Phn phi Nifedipin 45- 70% - tm: < 1 pht - Ngm, ung 5- 20 pht 4 - Gn protein huyt tng90% - B chuyn ha, thi qua thn Nicardipin 35% ung: 20 pht 2- 4 - Gn protein huyt tng 95% - B chuyn ha, thi qua gan Felodipin 15- 20% ung: 2- 5 h 11- 16 - Gn protein huyt tng > 99% - B chuyn ha nhanh gan Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Nimodipin 13% cha c ti liu 1- 2 - B chuyn ha nhiu - Lm gin mch no mnh Nisoldipin < 10% - 2- 6 - B chuyn ha nhiu - Lm gin mch vnh mnh Amlodipin 65- 90% - 30- 50 - Gn protein huyt tng >90% - B chuyn ha nhiu Bepridil 60% Ung: 1 h 24- 40 - Gn protein huyt tng > 99% - B chuyn ha nhiu Diltiazem 40- 65% - Tim tnh mch < 3 pht - Ung:>30 pht 3- 4 - Gn protein huyt tng 70-80% - B chuyn ha, thi qua phn Verapamil 20- 35% - Tim tnh mch: < 1,5pht - Ung: 30 pht 6 - Gn protein huyt tng 90% - Thi qua thn 70% - Thi qua rut 15% 2.2.3. C ch tc dng Cc thuc chn knh Ca gn ch yu vo knh L, l knh c nhiu t bo c tim v c trn thnh mch. Nifedipin v cc thuc nhm dihydropyridin (DHP) gn vo mt v tr mt trong knh, trong khi verapamil v diltiazem gn vo tr tr khc. Knh L c nhiu di n v o 2 , , v o. DHP gn ch yu vo o. Ngoi ra, DHP c th cn c ch nucleotid phosphodiesterase vng nn lm tng nucleotid vng, gy gin c trn: thuc cng phong ta knh hot ng theo receptor, nhng mc km hn. Knh T v N rt km nhy cm vi thuc nn nron v cc tuyn tit t chu nh hng ca cc thuc ny. 2.2.4. Cc tc dng trn c quan 2.2.4.1. Trn c trn Lm gin cc loi c trn: kh - ph qun, tiu ha, t cung, nhng c bit l thnh mch (mao ng mch nhy cm hn mao tnh mch). 2.2.4.2. Trn c tim Hot ng ca tim ph thuc nhiu vo dng Ca (xem in sinh l ca tim). Thuc chn knh Ca lm gim to xung tc, gim dn truyn v gim co bp c tim, v th lm gim nhu cu oxy trn bnh nhn c co tht mch vnh. Mc tc dng gia cc thuc c khc nhau. 2.2.4.3. Mch no Nimodipin c i lc cao vi mch no, v vy c dng cho bnh nhn c tai bin mch no (chy mu di mng nhn gy co mch do chn p; t qu c vim tc mch). Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Nhng cn cha r kt qu iu tr l do gin mch no hay l do lm gim nhu cu oxy ca nron. 2.2.5. Tc dng khng mong mun v c tnh - Tc dng nh, khng cn ngng iu tr: cn nng bng, nhc u, chng m t (do phn x gin mch, tng nhp tim nn dng cng vi thuc chn giao cm), bun nn, to. - Tc dng nng hn, lin quan n tc dng iu tr do c ch qu mnh knh Ca: tim p chm, nghn nh tht, suy tim xung huyt, ngng tim. Him gp. 2.2.6. p dng lm sng trong iu tr THA - Do lm gim lc co bp c tim, gim nhu cu oxy ca c tim, gim trng lc v sc cn mch ngoi bin nn cc thuc ny c dng iu tr THA. Cho ti nay, cc thuc chn knh calci c coi l thuc iu tr THA an ton v c hiu qu. Verpamil, nifedipin, nicardipin v diltiazem u c hiu qu h p nh nhau. Tuy nhin, do c s khc nhau v hiu qu huyt ng hc nn vic chn la iu tr c khc nhau: Nifedipin c tc dng chn lc nht trn mch v tc dng c ch tim li yu nht. Phn x giao cm hi lm tng nhp tim v lm tng hiu sut tim. Verapamin c tc dng trn tim mnh nht, lm gim nhp tim v gim hiu sut tim. Diltiazem c tc dng trung gian - Ngn cn co tht mch vnh khu tr, c ch ch nh ca cn au tht ngc - Verapamil, diltiazem lm gim dn truyn nh tht, c ch nh trong nhp tim nhanh trn tht do ti nhp (xin xem bi Thuc chng lon nhp tim). 2.2.7. Ch phm - Amlodipin: vin nn 2,5- 5- 10 mg - Diltiazem: vin nn 30- 60- 90- 120 mg Vin nang gii phng chm: 60- 90- 120- 180 mg Thuc tim 5 mg/ mL - Felodipin (Plendil): vin gii phng chm 2,5 - 5- 10 mg - Nifedipin (Adalat): vin nang 10- 20 mg Vin gii phng chm 30- 60- 90 mg - Nimodipin (Nimotop): vin nang 30 mg - Verapamil: vin nn 40- 80- 120 mg Vin gii phng chm 120- 180- 200 mg Thuc tim 5 mg/ 2mL 3. Thuc c ch enzym chuyn angiotensin (ECA) Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Enzym chuyn angiotensin (ECA) hay bradykinase II l mt peptidase c tc dng: - Chuyn angiotensin I (decapeptid khng c hot tnh) thnh angiotensin II (octapepetid c hot tnh) l cht c tc dng co mch v chng thi tr Na + qua thn. - Lm mt hot tnh ca bradykinin, l cht gy gin mch v tng thi Na + qua thn. Sau khi c hnh thnh, angiotensin II s tc ng trn cc receptor ring, hin c bit l AT 1 , AT 2 , AT 3 , AT 4 , trong ch c AT 1 l c bit r nht (s ). Hnh 24.2: Tc dng ca ECA v thuc c ch ECA Cc receptor AT 1 c nhiu mch mu, no, tim, thn, tuyn thng thn. Vai tr sinh l : co mch, tng gi Na + , c ch tit renin, tng gii phng aldosteron, kch thch giao cm, tng co bp c tim v ph i tht tri. Cc receptor AT 2 c nhiu tuyn thng thn, tim, no, c t cung, m bo thai. Vai tr sinh l: c ch s tng trng t bo, bit ha t bo, sa cha m, kch hot prostaglandin, bradykinin v NO thn. 3.1. C ch v c im tc dng Cc thuc do c ch ECA nn lm angiotensin I khng chuyn thnh angiotensin II c hot tnh v ngn cn ging ha bradykin, kt qu l lm gin mch, tng thi Na + v h huyt p. Trong iu tr tng huyt p, cc thuc ny c cc c im sau: - Lm gim sc cn ngoi bin nhng khng lm tng nhp tim do c ch trng lc giao cm v tng trng lc ph giao cm. - Khng gy tt huyt p th ng, dng c cho mi la tui. - Tc dng h huyt p t t, m du, ko di. - Lm gim c huyt p tm thu v tm trng. - Lm gim thiu mu c tim do tng cung cp mu cho mch vnh. - Lm chm dy tht tri, gim hu qu ca tng huyt p. Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa - Trn thn kinh trung ng: khng gy trm cm, khng gy ri lon gic ng v khng gy suy gim tnh dc. 3.2. Ch nh - Thuc c tc dng iu tr tt cho mi loi tng huyt p: . Trn ngi c tui, h huyt p khng nh hng n tun hon no v kh ng nh hng n phn x p lc. . Trn ngi c i tho ng: khng nh hng n chuyn ha glucid, lipid. Mt khc, insulin lm K + vo t bo, gy h K + mu; thuc c ch ECA lm gim aldosteron nn gi li K + . . Trn ngi c bnh thn, do angiotens in II gim, lm lu lng mu qua thn tng nn lm gim bi tit - Suy tim sung huyt sau nhi mu c tim. 3.3. Tc dng khng mong mun - H huyt p mnh c th xy ra khi dng liu u trn nhng bnh nhn c th tch mu thp do ang s dng thuc li niu, ch n gim mui hoc mt nc qua tiu ha. - Suy thn cp nht l trn bnh nhn c hp mch thn. - Tng Kali mu khi c suy thn hoc i tho ng. - Ho khan v ph mch l do bradykinin khng b ging ha, prostaglandin tch lu phi gy ho (nhiu khi lm bnh nhn phi b thuc). - Khng dng cho ph n c thai 3 - 6 thng cui v thuc c th gy h huyt p, v niu, suy thn cho thai, hoc gy qui thai, thai cht. 3.4. Phn loi v dc ng hc 3.4.1. Thuc c ch ECA Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Thuc Cc thng s Captopril Enalapril Perindopril Benezepril Lisinopril Sinh kh dng % 70 40 70 17 25 Gn protein huyt tng % 30 50 9- 18 95 3- 10 t/2 (h) 2 11 9 11 12 Khi pht tc dng (h) 0,25 2- 4 1- 2 0,5 1- 2 Thi gian tc dng (h) 4- 8 24 24 24 24 Liu ung 24h (mg) 75- 300 5- 20 2- 8 5- 20 5- 20 Enalapril, perindopril, benezepril u l tin thuc, vo c th phi c gan chuyn ha mi c tc dng. 3.4.2. Thuc c ch ti receptor ca angiotensin II Do vic chuyn angiotensin I thnh II cn c s tham gia ca cc enzym khc (nh chymase) khng chu tc ng ca thuc c ch ECA nn s to thnh angiotensin II vn cn. Mt khc, do thuc c ch ECA ngn cn s ging ha ca bradykinin nn bradykinin phi tng, kch ng gy cn ho khan rt kh tr. V vy kch thch vic nghin cu cc thuc c ch angiotensin II ngay ti receptor ca n: thuc c ch AT 1 . Cc thuc ny cn ang c nghin cu, nh gi trn cc th nghim lm sng. V nguyn tc, do c tc dng chn lc trn AT 1 nn trnh c tc dng ph ca bradykinin (ho, ph mch). Bng 24.4: Mt s c im dc ng hc ca cc thuc c ch AT 1 Thuc Cc thng s Losartan Valsartan Irbesartan Telmisartan i lc gn vo AT 1 + +++ ++++ +++ Sinh kh dng 33 25 70 43 t/2 (h) 2 (6- 9)* 9 11- 15 24 Thi tr Thn v gan Gan 70%; thn 30% Gan 80%, thn 20% Gan Liu ung (mg/ 24 h) 50- 100 80- 320 150- 300 40- 80 * t/2 ca loscartan l 2 gi, nhng ca cht chuyn ha cn hot tnh l 6-9 gi. 4. Cc thuc h huyt p khc Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa 4.1. Clonidin (2,6 diclorophenyl - amino - 2 imidazolin - catapres) L thuc kch thch receptor o 2 ca h giao cm trung ng nn lm gim trng lc giao cm ngoi bin. 4.1.1. Tc dng - Lm h huyt p do: . Lm gim cng nng tim, gim nhp tim . Lm gim sc cn ngoi bin, nht l khi trng lc giao cm tng. . Lm gim sc cn mch thn, duy tr dng mu ti thn. . Nh methyl dopa, clonidin rt t khi gy tt huyt p th ng. - Cc tc dng khng lin quan n h huyt p: . An thn (do hu giao cm trung ng?) khong 50% trng hp. . Kh ming do c ch trung ng: khong 50% trng hp. . Gim au do gim hot tnh nron sng sau tu sng. Nhng tc dng ny l do thuc gn vo receptor imidazolin c trong thn kinh trung ng. 4.1.2. Dc ng hc Thuc tan nhiu trong m, vo thn kinh trung ng nhanh. Ung hp thu tt, sinh kh dng ti 100%, t c pic huyt tng sau 1 -3gi, t/2 khong 12gi. Thi tr qua thn 50% di dng nguyn cht. 4.1.3. Ch nh - Tng huyt p - Tin m: do c tc dng an thn, gim au nn lm gim c lng thuc m v tng n nh huyt ng. - Cai nghin: ma tu, ru, thuc l. 4.1.4. c tnh - Kh ming, an thn: l tc dng trung ng, lin quan n liu dng. - Ngng thuc sau dng lu v liu cao (>1mg/ngy) c th gp cn tng huyt p kch pht do tng trng lc giao cm: bun nn, tim nhp nhanh, nhc u, v m hi. Cn gim liu dn v dng thuc thay th. iu tr nn tng huyt p ny bng dng li clonidin v dng cc thuc chn o, chn giao cm. 4.1.5. Ch phm v liu lng Clonidin (Catapres) Vin nn: 0,1 - 0,2 - 0,3mg Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa Ung 0,2 -1,2 mg/ngy, chia lm 2 ln Cao dn: Gii phng 0,1 - 0,2 - 0,3mg/24gi. C tc dng 7 ngy cho 1 ln dn. C th c phn ng ti ch dn. 4.2. Natri nitroprussid L thuc gin mch mnh dng theo ng tim iu tr cp cu cn tng huyt p v suy tim nng. Lm gin c ng mch v tnh mch. C ch: hot ho guanyl cyclase do tc dng kch thch trc tip hoc th ng qua gii phng NO, dn n lm tng GMPv, gy gin c trn. Nitroprussid l mt phc hp ca st, cc nhm cyanid v phn nitroso. c tnh nng nht lin quan n s tch lu cyanid; ngoi ra cn gp nhim acid, lon nhp, tt huyt p. Hydroxocobalamin (vitamin B 12 ) kt hp vi cyanid to cyanocobalamin khng c, do c dng gii c nitroprussid. CN CN | 2Na NC Fe CN | ON CN Natrinitroprussid c ch nh trong cn tng huyt p, suy tim sung huyt (do lm gim c tin gnh v hu gnh) v lm gim nhu cu oxy ca c tim sau nhi mu c tim. Trong ngoi khoa cn dng lm h huyt p c kim tra khi gy m lm gim chy mu do phu thut. Nitroprussid (Nipride): l 50mg. Khi dng pha trong dextrose 5% - 250 - 1000 ml, truyn tnh mch 0,5 ug/kg/pht, c th tng ti 10 ug/kg/pht. Chai thuc phi bc trong giy mu, trnh nh sng. Kim tra huyt p thng xuyn. 5. Chin thut iu tr tng huyt p v cn V THA v cn mang tnh cht rt a dng nn vic iu tr cng cn c th ha va c hiu qu, va c th dung np c. 5.1. Ai cn c iu tr - Mi ngi khi c HA 140- 90 mmHg - Khi c tn thng c quan ch hoc c i tho ng, mc du HA cn gii hn trn (130-139/85-89 mmHg). Mc tiu iu tr l a HA v chun < 140/99mmHg, nhng khng n gin, M ch 27% bnh nhn THA t c ch t iu ny. Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa 5.2. Cch iu tr 5.2.1. Phng php khng dng thuc - n gim mui, gim ru, gim cn (bo)... - Th dc u, nh nhng 5.2.2. Thuc Cn c th ha, vi th cn iu tr th - Lc u dng li niu, chn , chn knh calci v thm ch c cc t huc khc (chn o 1 c ch ECA). iu cn tu thuc vo bnh km theo: thuc c ch ECA khi c i tho ng; chn khi c bnh mch vnh; chn knh Ca (loi dihydropyrindin) khi c THA tm thu ring bit ngi cao tui. Lc u nn chn mt loi thu c. - Khi mt thuc khng cho kt qu mong mun: Khng nn tng liu v s c tc dng ph: thuc li niu (ri lon chuyn ha), chn (tc dng trung ng, chm nhp tim), chn knh Ca (ph, nh trng ngc, nhc u, nng mt), chn o 1 (h HA th ng). Thay thuc khc Phi hp thuc c c ch khc nhau Mt thuc h HA c th gy phn ng b tr, lm gim tc dng ca chnh n. Dng thuc phi hp ngn chn phn ng b tr. Th d thuc li niu lm thi Na, gy tng renin (dng thm thuc c ch ECA); thuc chn knh Ca gy tng nhp tim phn x (dng chn ). Hin c vin thuc phi hp sn. Tin dng nhng khng hay v khng c th ha c. Trong nhng nm gn y, vic iu tr THA tr nn n gin hn trc rt nhiu nh c nhiu loi thuc hiu qu. Vn l phi c th ha trong iu tr mi bnh nhn c th tm c cho mnh mt thuc thch hp va c hiu qu, va dung np tt. 5.3. Tiu chun thuc h huyt p l tng - C tc dng h huyt p tt . H HA t t, m du, ko di . Gim c s ti a v s ti thiu . Gim c ngi tr v ngi cao tui . Lm mt nh tng huyt p trong ngy - Khng lm mch nhanh do khng lm tng cng c tim v tng nhu cu oxy. - Khng lm mch chm, trnh c nghn nh - tht Dc l hc 2007 - i hc Y H ni sch dng cho sinh vin h bc s a khoa - Khng lm gim sc co bp ca c tim, nht l tht tri - Dng c cho nhiu i tng: suy thn, tiu ng, tng lipid mu - Khi ngng thuc, khng c nguy c "phn hi". cu hi t lng gi 1. Phn loi cc thuc iu tr tng huyt p theo c ch tc dng ca th uc 2. Trnh by c ch tc dng v phn loi cc thuc chn knh calci. 3. Trnh by cc tc dng iu tr v tc dng khng mong mun ca thuc chn knh calci. 4. Trnh by c ch tc dng ca thuc c ch enzym chuyn angiotensin (ECA). 5. Nu c im tc dng v ch nh iu tr ca ECA. 6. So snh u- nhc im ca thuc chn knh calci v ECA trong iu tr tng huyt p.