Ch 39

Question 1

HTN

Answer 1

Increase in blood pressure (BP) → systolic blood pressure (SBP) > 90 mm Hg and diastolic blood pressure (DBP) > 90 mm Hg

Question 2

essential HTN (what is it, origin, contributing factors)

Answer 2

Most common: affecting 90% of persons with high blood pressure.

ii. Exact origin is unknown
iii. Contributing factors include
1. Stress
2. Aging
3. Diabetes
4. Obesity
5. Smoking
6. Family history
7. Hyperlipidemia
8. Excessive alcohol
9. African-American background

Question 3

secondary HTN

Answer 3

10% of hypertension cases are related to renal and endocrine disorders and classified as secondary hypertension

Question 4

BP regulators

Answer 4

KIDNEYS (work with blood vessels to regulate/maintain normal BP.)
-Regulate by control of fluid and volume, and RAAS system
-control sodium and water elimination/retention > affecting cardiac output, and arterial blood pressure
BARORECEPTORS: In aorta, carotid sinus, and vasomotor center in the medulla aid in regulation of blood pressure. Catecholamine (norepinephrine and epinephrine) increase blood pressure through vasoconstriction activity.
HORMONES
1. ADH- antidiuretic hormone
2. ANP- atrial natriuretic peptide
3. BNP- brain natriuretic peptide

Question 5

physiologic risk factors for HTN

Answer 5

i. Obesity → affects cardiovascular and sympathetic systems
ii. Alcohol consumption increases renin secretion
iii. Diet high in saturated fat and simple carbohydrates

Question 6

cultural responses to antihypertensive agents

Answer 6

1. African Americans are more likely to develop hypertension at an earlier age. Also have higher mortality rate from hypertension. Susceptible to low-renin hypertension, therefore use of beta blockers and ACE-I are less effective in controlling blood pressure, unless combined with a diuretic. Better response to alpha 1 blockers, calcium channel blockers, diuretics
2. Asian Americans are 2x more sensitive to antihypertensive medication than Caucasians
3. Native Americans have a reduced or lower response to beta blockers compared to Caucasians
4. Caucasians usually have high-renin hypertension and respond well to all antihypertensive agents.

Question 7

HTN with adults

Answer 7

i. 70 million American adults (1 in 3) have hypertension

ii. 65% of individuals > 60 yo have developed hypertension

Question 8

HTN with older adults

Answer 8

iii. Oder adults affected by orthostatic (postural) hypotension with use of antihypertensive medications
1. Sudden drop in BP when going from lying or sitting to upright position, causing dizziness d/t blood pooling in lower extremities

Question 9

nonpharma control of HTN

Answer 9

a. Nonpharmacologic measures should be instituted first, to attempt to decrease blood pressure. These include stress-reduction techniques, exercise, salt restriction, ↓ alcohol intake, smoking cessation
b. Antihypertensive medications are usually initiated with consistent systolic readings of >140

Question 10

JNC BP guidelines

Answer 10

purpose: reduce risk of CVD.
pre: SBP 120-139, DBP 80-89
stage 1: 140/90-159/99
stage 2: 160/100 or up

Question 11

is SBP or DBP more important for CVD risk in HTN?

Answer 11

sbp

Question 12

pharma control of HTN

Answer 12

1. diuretics
2. sympatholytics
3. direct acting arteriolar vasodilators
4. ACE-I (pril)
5. ARBs
6. calcium channel blockers (calcium blockers)

Question 13

how do diuretics control bP

Answer 13

Promote sodium depletion > decreases extracellular fluid volume. Effective for first line drugs for mild hypertension

Question 14

sympatholytics for BP?

Answer 14

five groups of medications: (1) Beta-adrenergic blockers (2) alpha2 agonists (3) alpha adrenergic blockers (4) adrenergic neuron blockers (5) alpha 1 and beta1 adrenergic blockers. (lecture focus on 1, 2 and 3)

Question 15

beta adrenergic blockers

Answer 15

sympatholytics.
(beta blockers).
Used as antihypertensive drugs, or in combination with diuretics. Can also be used as antianginals and antidysrhythmics. Reduce cardiac output by diminishing sympathetic nervous system response to decreased basal sympathetic tone. Reduce heart rate, contractility, and release of renin. Nonselective and selective
i. Nonselective - affect beta 1(heart) & beta 2 (bronchial) receptors: Heart rate slows, BP ↓, bronchoconstriction occurs
ii. Selective – preferred because they affect mainly beta1 heart receptors, so bronchoconstriction is less likely to occur

Question 16

metoprolol (lopressor) PD/PT/CI/PREC

Answer 16

pd: blocks beta1 receptors (cardioselective).
PT: HTN, HF, acute MI, angina.
CI: heart block, cardiogenic shock, hypotn, acute HF, sinus brady.
prec: hep/renal, thyroid dysfx, asthma, PVD, DM, depression

Question 17

metoprolol adv/se/dfl/ni/pt ed

Answer 17

adv: Bradycardia, thrombocytopenia, stroke, diabetes mellitus
-Life threat: AV heart block, bronchospasm, agranulocytosis, HF
SE: Fatigue, weakness, dizziness, dry mouth, n/v/d, short-term memory loss, drowsiness, headache, blurred vision, photosensitivity, nasal congestion, peripheral edema, tinnitus, erectile dysfunction, depression
Drug: Increased bradycardia with digitalis, clonidine, SSRIs, MAOIs, cimetidine. Increased hypotensive effect with other antihypertensives, alcohol, anesthetics.
NSAIDs decrease effect of beta blockers
Lab:Increased hepatic enzymes
NI: Obtain medication/herbal hx for possible interactions, base VS. Baseline liver and renal labs and cardiac enzymes. Monitor vital signs, especially BP and pulse, Monitor lab values: BUN, CRT, AST, LDH
PT ED: Check blood pressure and pulse (heart rate) before taking. Report any adverse effects to your healthcare provider immediately. If diabetic educate potential for hypoglycemia. Rise slowly from sitting to standing due to risk of orthostatic hypotension. Wear a medic-alert bracelet. Avoid taking herbs and OTC medications without first discussing with healthcare provider. Teach nonpharmacologic methods to decrease BP

Question 18

centrally acting alpha 2 agents

Answer 18

Decrease sympathetic response from the brainstem into peripheral vessels

b. Stimulate Alpha2 receptors > decreases sympathetic activity > increased vagus activity > decreases cardiac output > all result in reduce peripheral vascular resistance, and increased vasodilation
c. Minimal effect on cardiac output, and blood flow to the kidneys

Question 19

clonidine (catapres)

Answer 19

centrally acting alpha 2 agonist.

i. Can cause sodium and water retention in high doses > peripheral edema
ii. Frequently administered with diuretics
iii. Available as a transdermal patch worn for 7 days at a time
iv. Cannot abruptly discontinue > risk for rebound hypertension

Question 20

alpha adrenergic blockers

Answer 20

a. Block alpha-adrenergic receptors> vasodilation, and decreased blood pressure
b. Help maintain renal blood flow rate
c. Useful in treating hypertension in patients with lipid abnormalities  can decrease VLDL, and LDL responsible for buildup of fatty plaques in the arteries, and increase HDL
d. Safe for patients with diabetes; they do not affect glucose metabolism
e. Do not affect respiratory funcion
f. Given to patients with BPH (benign prostatic hypertrophy)

Question 21

prazosin (minipress) PD, PT, CI, PREC

Answer 21

PD: Dilates peripheral blood vessels by blocking alpha-adrenergic receptors
PT: HTN, refractory HF, bPH
CI: Renal disease
PREC: Angina, orthostatic HT, syncope, pregnancy, breastfeeding

Question 22

prazosin (minipress) ADV, SE, DFL, NI, PT ED

Answer 22

ADV: Orthostatic hypotension, palpitations, tachycardia, pancreatitis, elevated liver enzymes
SE: Dizziness, drowsiness, nervousness, blurred vision, tinnitus, fatigue, headache, depression, nasal congestion, dry mouth, n/v/d/c, abdominal pain, impotence, urinary incontinence, peripheral edema, erectile dysfunction
DRUG: Increased hypotensive effect with other antihypertensives, nitrates, alcohol. Decreased effects with NSAIDs
LAB: Increased hepatic enzymes
NI: Baseline VS, Medication history. Report probable drug/herbal interactions. Check urinary o/p →drug contraindicated if renal dx present. report sudden decrease in BP and tachycardia. Check for peripheral edema and ↑weight. Prazosin may cause sodium and water retention
PT ED: Check blood pressure and pulse (heart rate) before taking. in high doses > impotence can occur in males > contact healthcare provider. Report any adverse effects to your healthcare provider immediately. Rise slowly from sitting to standing due to risk of orthostatic hypotension. Must take exactly as prescribed > do not abruptly stop > risk of rebound hypertension. Avoid taking OTC medications without first discussing with healthcare provider. Wear a medic-alert bracelet. May cause peripheral edema > monitor weight due to risk of fluid retention

Question 23

direct acting arteriolar vasodilators

Answer 23

i. Act by relaxing smooth muscles of the blood vessels, mainly arteries
ii. Promote increased blood flow to brain and kidneys
iii. Vasodilation> decrease in blood pressure, however, sodium and water are retained > peripheral edema > may need to give with diuretic

Question 24

hydralazine (apresoline) PD, PT, CI, PREC

Answer 24

direct acting arteriolar vasodilator.
PD: Relaxes smooth muscles > vasodilation
PT: Hypertension, hypertensive emergency, preeclampsia, eclampsia. May be used in conjunction with diuretic or beta blocker
CI: Pregnancy category C
PREC: tachycardia

Question 25

hydralazine (apresoline) ADV, SE, NI, PT ED

Answer 25

ADV/SE: Dizziness, tremors, headache, reflex tachycardia, palpitations, edema, nasal congestion, GI bleeding, numbness and tingling NI: Assess baseline vital signs, before administering, Monitor HR and BP regularly throughout treatment. PT ED: Check blood pressure before taking. Notify healthcare provider if palpitations develop or become short of breath

Question 26

ACE inhibitors

Answer 26

end in pril. i. Names of some ACE inhibitors are benazepril, captopril, enalapril maleate, fosinopril, lisinopril ii. Inhibits formation of angiotensin II (potent vasoconstrictor) blocking the release of aldosterone 1. When aldosterone is blocked, sodium is excreted along with water, potassium is retained, and BP is lowered iii. Primarily used to treat hypertension, and some agents are effective in treatment of heart failure iv. Cannot be given during pregnancy due to decrease in placental blood flow v. Need to reduce dose, if renal insufficiency is present vi. Can cause a chronic, dry hacking cough if present, need to change medications vii. Should not be taken with potassium-sparing diuretics like spironolactone due to risk of hyperkalemia

Question 27

benazepril (lotensin) PD/PT/CI/PREC

Answer 27

ace II drug. PD: Inhibit ACE> inhibiting formation of angiotensin II, and blocks release of aldosterone PT: Hypertension CI: Pregnancy category D. Do not take with potassium-sparing diuretics PREC: Hypotension

Question 28

benazepril ADV/SE/NI/PT ED

Answer 28

ADV: i. Hyperkalemia ii. First-dose hypotension iii. Angioedema: swelling of face, larynx, mucous membranes, extremities SE: Hyperkalemia, headache, dizziness, nausea, diarrhea, constipation, hypotension, and !!!dry irritating cough!!!! NI: obtain drug/herbal hx for interactions, assess baselin VS BEFORE admin, assess bUN/Cr, K, protein. report sudden drop in bP. monitor labs for renal fx and blood glucose (hypoglycemic rxn in pt with dm). pt ed: dry irritating cough, call doc. check/record BP before med. report adv eff immediately. dont abruptly stop: rebound htn. dont take salt substitutes (contain K) or additional potassium sparing meds. if become pregnant or planning, let doc know(may harm fetus)

Question 29

ARBs

Answer 29

angiotensin II receptor blockers. i. Losartan, valsartan, irbesartan, candesartan, eprosartan are examples of some ARBs ii. ARBs are similar to ACE-I because they both prevent the release of aldosterone iii. Acts on RAAS system iv. Main difference between ACE-I and ARB’s is: 1. ARB’s block Angiotensin II from the Angiotensin I receptors found in tissues 2. ACE inhibitors inhibit angiotensin-converting enzyme from forming angiotensin II 3. ARBs do not cause the constant, irritated cough like ACE inhibitors v. Cause vasodilation, and decreased peripheral vascular resistance vi. Should not be taken during pregnancy

Question 30

valsartan (diovan) PT/PT/CI/PREC

Answer 30

ARB. PD: Potent vasodilator, inhibits binding of angiotensin II PT: Hypertension and heart failure CI: Hypersensitivity PREC: Pregnancy, breastfeeding, Renal and hepatic impairment, hypotension, heart failure hypovolemia, hyperkalemia ADV: Orthostatic hypotension, hyperkalemia, elevated hepatic enzymes, rhabdomyolysis -Life threatening: Renal dysfunction, neutropenia SE: Dizziness, drowsiness, cough (rare), palpitations, blurred vision, headache, diarrhea, arthralgia, fatigue, erectile dysfunction DRUG: Antihypertensives, diuretics, MAOI’s, and alcohol may increase hypotensive effects -ACEI and ASA may increase hyperkalemia and renal dysfunction LAB: May increase AST, ALT, ALP, bilirubin, BUN, creatinine, Hct, Hgb NI: Obtain drug and herbal hx for possible interactions ii. Assess baseline vital signs iii. Assess baseline labs including: BUN, creatine, potassium, WBCs. Assess if patient is pregnant > cannot be taken during pregnancy. Monitor BP and report a sudden drop. Monitor labs including: renal function, blood glucose and potassium PT ED: Check and record blood pressure before taking b. Inform patients not to take OTC medication w/o consulting provider c. Report any adverse effects to your healthcare provider immediately d. Do not take salt substitutes as they contain potassium, or additional potassium sparing medications e. If you become pregnant, or are planning on becoming pregnant notify your healthcare provider immediately

Question 31

Calcium channel blockers

Answer 31

(aka calcium blockers) i. Names of some calcium blockers: Verapamil, diltiazem, amlodipine, nifedipine ii. Block calcium channels in the vascular smooth muscle (VSM) > vasodilation Calcium channels are found in the myocardium (heart muscle) and VSM cells ---- Large central arteries are not as sensitive to calcium blockers as coronary and cerebral arteries, and peripheral vessels

Question 32

amlodipine (Norvasc) PD/PT/CI/PREC

Answer 32

PD: Blocks calcium channels in vascular smooth muscle> vasodilation PT: (KNOW WHY YOUR PATIENT IS TAKING THE MEDICATION) a. Angina b. Hypertension c. Dysrhythmia 3. Contraindications a. Pregnancy category C b. Bradycardia, AV block c. Beta blocker usage due to decreased myocardial contractility ADV/SE: Flushing, headache, dizziness, ankle edema, bradycardia, AV block NI: Assess baseline vital signs, before administering PT ED: Check blood pressure before taking b. Report any adverse effects to your healthcare provider immediately c. When would you need to recheck the blood pressure? (see onset, peak and duration)