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Hypertension DSM


Hypertension is.... the "silent killer", characterized by elevated peripheral resistance
Hypertension targets what organs? blood vessels, heart, kidney, brain, eyes
Why do we give antihypertensives? Control symptoms, try to prevent organ damage
What factors do we consider when selecting drug therapy? Compliance, side effects, economics
What was JNC VII? guidelines to increase awareness, prevention, and treatment of hypertension based on large clinical trials '97-'03
List the various lifestyle modifications and their effect on SBP Weight reduction (5-10mmHg/Kg), DASH dies (8-14 mmHg), dietary sodium reductuion (2-8mmHg), physical actvity (4-9 mmHg), moderate alcohol consumption (2-4mmHg)
How long should a patient try lifestyle modifications before being put on medication? 3 months-6 months
Normal blood pressure is... Below 120/80
Pre-hypertension is... 120-139/80-89
Stage 1 hypertension is... 140-159/90-99
Stage 2 hypertension is... over 160/over 100
Name some non-pharmacological therapies sodium restriction, weight reduction, exercise, stress reduction, eliminating risk factors (cholesterol,tobacco, alcohol)
When would drugs be used for pre-hypertension? Drugs for compelling indications only (no compelling indication, no drugs)
What is a compelling indication? Other co-morbidities to consider
What drug therapy would be used for stage 1 hypertension (w/o compelling indications)? THIAZIDE-type diuretics for most, may consider ACEI,ARB,CCB,BB or some combo of these
What drug therapy would be used for stage 1 hypertension (w/compelling indications)? THIAZIDE-type diuretics for most, may consider ACEI,ARB,CCB,BB or some combo of these ? Plus drugs for co-morbidities
What drug therapy would be used for stage 2 hypertension (w/o compelling indications)? 2 drug combo (THIAZIDE + ACEI,ARB,BB OR CCB)
What drug therapy would be used for stage 2 hypertension (w/compelling indications)? Other hypertensive drugs (CCB,ACEI, ARB,BB) as needed
List the 6 comorbid conditions to consider when selecting therapy CHF, post MI, High coronary disease risk, diabetes mellitus, chronic kidney disease, recurrent stroke prevention
What was the ALLHAT study? Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, evaluated whether occurrence of fatal CHD or nonfatal MI is lower for high risk pts w/ hypertension treated w/ and ACEI or CCB vs. a diuretic
What drugs did the ALLHAT study compare? amlodipine, lisinopril, and chlorthalidone
What did the ALLHAT study find in reference to diuretics? Thiazide diuretics should be considered in nearly all pts includ. (untreated, inadequately controlled not on diuretics, and those controlled on non-diuretics unless there's a compelling indication for an alt. drug)
What was ALLHAT'S conclusion in regards to second-line agents? Most hypertensives req additional drugs for bp control, but since no direct comparison of 2nd line agents was made with ALLHAT the optimal add-on agent is unknown
Why should diuretics be 1st line therapy for everyone, including pts w. diabetes and asymptomatic LVH? Diuretics=least expensive & most effective
List the classes of antihypertensive agents diuretics, ACEI, ARB, BB,CCB, alpha antagonists, K sparing diurteics, vasodilators, CNS agents, sympatholytics
What drugs does JNC VII recommend for heart failure and why? ACEI (#1), DIURETICS(for edema-mainly loop), BB (reduce mortality but monitor volume-dose lower than pt w/o CHF), ARB(if can't take ACEI), ALDOSTERNONE ANTAG (spironolactone-add to pts w/NYHA II or IV failure or post-MI pts w/ new left ventricular issues
What drugs did JNC VII recommend for MI and why? BB(#1 b/c decr. subsequent MI and sudden cardiac death), ACEI (improves cardiac remodeling & function & reduces later cardiac events), ARB (if pt can't take ACEI), ALDOSTERONE ANTAG (decr. mobidity & mortality if added in 14 days post MI in pts w/ EF<30%
What drugs did JNC VII recommend for coronary artery disease? BB (1st line if stable chronic angina to avoid ISA),CCB (if pts can't do BB-long acting)
What drugs did JNC VII recommend for diabetics? ACEI,ARB (1st-reduce CV risk& nephroprotective), BB (reduce CV risk), CCB (lower BP more, add-on therapy, same CV risk protection as ACEI or ARB)
Why did the JNC VII recommend those certain drugs for diabetics? Diabetes is considered equivalent to coronary artery disease
What drugs did JNC VII recommend for chronic kidney disease? ACEI/ARB-reduce BP &intrarenal pressure, also ACEI+ARB may be more effective than monotherapy
What is an early warning sign of Chronic Kidney Disease? Microalbuminuria
What was JNC VII's drug recommendations for recurrent stroke? Diuretic +ACEI b/c reduces incidence of stroke in pts w/ prior stroke or TIA
What is the major issue in regard to preventing secondary stroke? Reduction of BP
What special factors should be considered in elderly pts? Least BP control, isolated SBP common, more than 50% need combo therapy, sensitive to vol. depletion & inhibition of SNS, altered drug metabolism, cognitive impairment, polypharmacy and economics (fixed income) should be considered
What is the first line tx for the elderly and how does the dose differ from normal? THIAZIDE but lower than normal dose
What special factors should be considered in female patients? Prevalence of hypertension higher after age 50, also oral contraceptives can cause 2ndary hypertension so bp should be checked every 6 mo if on bc or hormone replacement
What special factors should be considered for african american patients? They have a higher incidence of hypetension & organ damage, monotherapy w/ BB, ACEI, and ARBS not as effective; THIAZIDES & CCB more effective, high risk for angioedema and cough
What is the ISHB and what are their guidelines? ISHB= International Society for Hypertension in Blacks; guidelines similar to JNC-lifestyle mods, THIAZIDES 1st, combo therapy if SBP
What drug therapies should be considered if the pt has dyslipidemia? ALPHA BLOCKERS have favorable effects THIAZIDES and BB may INCREASE lipids-BAD ACEI, ARB, CCB-NEUTRAL
What drug therapies should be considered in pts w/ left ventricular hypertrophy? ACEI and ARB (improved bp control improves LVH)
What should be considered in pts w/ erectile dysfunction? Hypertension=risk factor for erectile dysfunction, diabetes is also a risk factor, major concerns are CNS acting agents, BB, sympatholytics
Which thiazide-type duiretics do we have to know? It's easy-just the ones that end in thiazide
Name the 2 loops diuretics mentioned? Furosemide (lasix) and ethacrynic acid (edecrin)
Name 3 K sparing diuretics Amiloride (Midamor), Spironolactone (Aldactone), Triamterence (Dyrenium)
What is the MOA of diuretics? Produce a moderate but persistent decr. in ECF and plasma vol, inital decr. BP due to reduced CO, long term decr.BP due to autoreg which decr. TPR
List some advantages of diuretics effective in many pts, inexpensive, few SE, docs know about them
Name some disav. of diuretics can cause electrolyte imbalances, can elevate serum lipids,can cause metabolic alkalosis, carb metabolism can be impaired, hyperuricemia can occur or incr.
When do we use diuretics? 1st line tx in obese, elderly, or black but less effective in lean ppl, can minimize SE of other agents, decr. intracranial pressure, decr. intraoccular pressure, reduce edema, tx of CHF
Why do we use the lowest effective dose of diuretics? Max decr. in BP occurs over a relatively small dosage & if dosage is pushed SE incr.
How are diuretics dosed? Continue therapy for at least 2 weeks be changing dose or drug, dose pt qam to reduce nocturia
What is the most common problem with diuretics and what can this problem manifest as? Problem=loss of electrolytes--causes dizziness, cramps, nausea, postural hypotension but effects diminish after a few days
What is a renal SE of thiazides? May reduce GFR so don't use in pts with decr. renal function
Name 2 general side effects of diuretics may precip gout by decr. secr. of uric acid &n use cautiously in diabetics-can produce hyperglycemia
List some characteristics of spironolactone K sparing diuretic, aldosterone antagonist, weak progesterone, hyperkalemia can occur, gynecomastia can also occur
List some characteristics of direct-acting K sparing diuretics Include trimterene and amiloride, DON'T antag. aldosterone so effective regardless of aldosterone status, more reliable than spironolactone, can cause hyperkalemia
List 3 characteristics of loop diuretics urine vol is greater than w/ other agents, can cause hyperuricemia, misuse can be life-threatening
Name 4 CNS antihypertensive drugs Methyldopa (Aldomet), Clonidine (Catapres),Guanabenz (Wytensin), Guanfacine (Tenex)
Many BB agents have what kind of activity? CNS actions
What is methyldopa's MOA? must be taken into the neuron, converted to methylNE and acts as false transmitter, stimulates central alpha-2 receptors to decr. SNS outflow
List the side effects of Methyldopa Sexual dysfunction, othostatic hypotension, adverse effects on lipis profiles, somnolence esp. in 1st weeks of therapy, depression can be unmasked or exacerbated
How does Clonidine work? direct alpha 2 receptor agonist, can stim. alpha 1 receptors in the periphery and incr. BP
What was the first antihypertensive agent incorporated into a cutaneous patch? Clonidine
List the side effects of Clonidine Anti-SLUD, dizziness, sedation, orthostatic hypotension, sexual dysfunction, insomnia, depression, nervousness, agitation, restlessness, anxiety
What are two factors to consider if clonidine patches are being used? SE lower incidence w/ the patch but skin rxn with the patch are more common in women and those w/ fair skin
How is Clonidine dosed? qd or bid, split dosage can be taken at bedtime to prevent daytime sedation and limit daytime sedation
What is Guanfacine and how is it used? similar to clonidine, longer doa, SE less than clonidine, unlabeled use for heroin withdrawal and migraine
What is withdrawal syndrome? Occurs 18-36h after abrupt d/c of CNS acting antihypertensives, BP elevated(can exceed pre-tx levels), anxiety, tremors, tachycardia, excessive SNS effects, may involve a central opiodergic component
What is the last resort for sympatholytics? Guanfacine
List the nonselective Beta blockers Propanolol (Inderal), Nadolol (Corgard0, Timolol (Blocadren, Timoptic), Penbutolol (Levatol)
List the Beta 1 selective blockers Atenolol (Tenormin), Acebutolol (Sectral),Metoprolol (Lopressor),Bisoprolol (Zebeta), Betaxolol (Kerlone)
Which 2 beta blocking drugs are non-selective and have intrinsic sympathomimetic activity? Pindolol (Viskin) and Carteolol (Cartrol)
Name the vasodilatory beta blocking drug Celiprolol (Selecor)
What is the MOA of Beta Blockers? complex-Beta blockade decr. CO, adrenergic blocking action (taken up by presynaptic nueron, displaces NE, acts as false transmitter), acts in CNS to reduce SNS outflow, inhibits renin rls
Name some general considerations of BB therapy? 1st gen nonselective, 2nd gen more selective, 1st and 2nd gen may decr. CO and incr.TPR (decr.exercise resistance b/c of airway resistance and metabolic actions),3rd gen have ancillary prop (ISA, Beta 2 agonists, direct vasdoilation),
Name some nonselective Beta blocking drugs PROPANOLOL (prototype-highly protein bound, subject to 1st pass), Nadolol (long half life, not extensively protein bound), Timolol (for glaucoma)
When are Beta 1 selective blocking agents used and what is the prime example? Used when beta 2 blockade must be avoided (B2 blockade worsens cardiac issues), selectivity is a functiion of dose, ATENOLOL (minimal 1st pass & qd dosing)
Why are Nonselective Beta Blockers used with ISA? cardioselectivity as a result of partial Beta agonism, maintain HR and CO better than other ganes
When are vasodilatory Beta blocking drugs used and how do they work? B/C of incr. TPR w/ traditional agents, vasodilation due to Beta 2 agonism or direct action, effective in pts w/ peripheral vascular disease or pulmonary probs
What are the side effects of Beta blocking drugs? Excessive beta blockade (bradycardia, hypotension, heart failure, pulmonary dysfunction), CNS effects (depression, nightmares, insomnia), fatigue, withdrawal syndrome, may worsen pulmonary dysfunction, affects plasma lipids, mask hypoglycemia in diabetics
What are 2 ex of mixed blocking agents? Labetolol (Normodyne, Tarnsdate) and Carvedilol (Coreg) both combine alpha 1 and beta 1 blockade
How does carvedilol work, what are its specific problems, and what is the max dose? Carvedilol has alpha 1 antagonism and nonselective Beta blockade, the nonselective Beta blockade is an issue, it is well tolerated up to 50 mg
What are the side effects of mixed blocking agents? BP decr. due to HR and CO (Beta 1 blockade) and decreased TPR (alpha 1 blockade), bradycardia occurs but w/lower freq., orthostatic hypotension during intial therapy-worse w. warm temp
What are three examples of alpha antagonists? Pazosin (Minpres),terazosin (Hytrin) and Doxazosin (Cardura)
How has the MOA of alpha antagonists changed? now selective blockade of alpha 1 receptors but early agents were nonselective
Name 2 characteristics of prazosin prototype agent, highly protein bound
Name 3 characteristics of terazosin higher bioavail. than prazosin, lower DOA, lower incidence of postural hypotension
Name 3 characteristics of doxazosin highly protein bound, longer half life than prazosin, 1st dose effest less
Explain the side effects of alpha antagonists most due to excessive vasodilation, postural hypotension (b/c of dose size, fasting state, posture, low Na diet, BB,unexpanded plasma vol), 1st dose effect (sudden dizziness, palps b/c of decr. venous return & vasodilation), headache, drowsiness, fatigue
How are alpha antagonists dosed and why? low initial dose and incr. over 2 weeks (avoid 1st dose effect), divide dose unequally w/ higher dose at bedtime
Other than hypertension, what other disease state are alpha antagonists used for? BPH
Name 4 sympatholytics Rauwolfia (Raudixin), Reserpine (Serpasil, Serapase, Sandril), Guanethidine (Ismelin), Guanadrel (Hylorel)
How does Reserpine work? Depletes NE from neuron(prevent storage of NE in granules), inhibits amine transport sys of granules--hypotensive develops over 2-3 weeks
List some side effects of Reserpine sedation, depression, nightmare, n/v, diarrhea, fluid retention, impotence, bradycardia, orthostatic hypotension, nasal congestion
What are some contraindications of reserpine? d/c @ first sign of depression, don't use w/ MAOI or tricyclic antidepressants
Besides hypertension, what other disease state is Reserpine use for? Relief of agitated psychotic states like schizophrenia
How does Guanethidine work? Adrenergic neuronal blockade b/c of inhibition of action potential induced rls of NE, inhibition of NE uptake, displacement of NE--may take 1 week to work
When is Guanethidine used? severe or refractory hypertension-last resort
List some side effects of guanethidine impaired reflexes, fluid retention, sexual dysfunction
List 2 vasodilators Hydralazine (apresoline) and minoxidil (loniten)
when are vasodilator used? hypertension, hypertensive crisis, and hypotensive surgery, NEVER A MONOTHERAPY
What are some side effects of hydralazine? tachycardia, fluid retenion, headaches, flushing, hypotension, Lupus (@ doses >400mg/day)
True or false: hydralazine is orally effective True
True or false: Minoxidil is orally effective True but reserved for severe or refractory hypertension
List some side effects of minoxidil fluid and H20 retention, activation of reflexes, hypertrichosis
Besides hypertension, minoxidil is used to treat what other disease? male pattern baldness
List some Angiotensin Converting Enzyme Inhibitors Captopril(Capotrn), Enalapril (Vasotec), Enalaprilat, Lisinopril(Prinivil, Zestril), Quinapril (Accupril), Benazepril (Lotensin), Ramipril (Altace), Fosinopril (Monopril), Moexipril (Univasc)
How do ACEI work? percent conversion of angiotenin 1 to angiotensin 2, competitiively inhibit converting enzyme, lower BP w/ minimaln effects on CO and HR
List the side effects of ACEI Hypotension (worse w/ diurteic, low salt intake, high renin levels), cough, angioedema, taste issues
ACEI should not be prescribed to pts taking what other drug? K sparing diuretics b/c can cause hyperkalemia
Explain how Alpha 2 antagonists like Losartan (Cozaar) work direct blockade of alpha 2 receptor, had an active metabolite
List some SE of alpha 2 antagonists diarrhea, dyspepsia, myalgia
Name 5 possible drug combination therapies for hypertension diuretic +BB, diuretic + CNS acting drug, diuretic +ACEI, diuretic +BB+ vasodilator, diuretic +BB + vasodilator + CNS acting agent
List some Calcium antagonists Verapamil (Calan, Isoptin), Nifedipine (Procardia, Adalat), Diltiazem (cardizem), Nimodipine (Nimotop), Nicardipine (cardene), Isradipine (Dynacirc, Lomir, Prescal),Amlodipine (norvasc), felodipine (plendil), Nisoldipine, Nitrendipine, Nepridil (vascor)
How do calcium antagonists work? inhibit voltage gated calcium channels, reduce calcium mediate signalling leading to vasodilation, high doses cause alpha blockade
Which calcium antagonist has the greatest effect on cardiac conduction (dromotropic effect) Verapamil
Which calcium antagonist has minimal side effects? diltiazem
For which diseases are calcium antagonists used? angina, hypertension, arrhythmias (verapamil), raynaud's, hypertrophic cardiomyopathy
List some side effects of calcium antagonists cardiodepression, hypotension, peripheral edema (unresponsive to diuretics), constipation, dyspepsia, nausea, headache, facial flush, tingling, burning
List 4 characteristics of calcium antagonists do not change blood lipids, maintain or incr. GFR, DON'T interfere w/ exercise, may induce slight natriuresis
Created by: lulu5745



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