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Pharmacology > Chapter 22 Antihypertensive drugs > Flashcards

Chapter 22 Antihypertensive drugs Flashcards

1
Q

Hypertension, defined as a persistent systolic blood pressure (SBP) of greater than?

A

150 mm Hg and/or a diastolic blood pressure (DBP) greater than 90 mm Hg for patients 60 years or older and SBP greater than 140 and DBP greater than 90
for patients younger than 60 and those who have chronic kidney disease or diabetes.

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2
Q

Hypertension is a major risk factor?

A

coronary artery disease, cardiovascular disease, and death resulting from cardiovascular causes. It is the most important risk factor for stroke and heart failure, and it is also a major risk factor for renal failure and peripheral vascular disease.

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3
Q

Blood pressure is determined by the product of cardiac

output and systemic vascular resistance (SVR). All antihypertensives in some way affect?

A

cardiac output

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4
Q

Cardiac output is the amount of blood that is ejected from the left ventricle. SVR is the resistance to blood flow that is determined by the diameter of the blood vessel and the vasculature musculature. If the cause of hypertension is unknown, it may be called?

A

essential, idiopathic, or primary hypertension, comprising 90% of cases.

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5
Q

Secondary hypertension is most commonly the result of

another disease such as?

A

pheochromocytoma, preeclampsia of pregnancy, renal artery disease, sleep apnea, thyroid disease, or parathyroid disease or the use of certain medications.
If the cause of secondary hypertension can be eliminated,
blood pressure usually returns to normal.

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6
Q

If untreated, hypertension can cause damage to?

A

end organs such as the heart, brain, kidneys, and eyes.

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7
Q

According to the JNC-8, therapy should be started if blood pressure is at or greater than?

A

150/90 for patients over 60 years and 140/90 for patients younger than 60 and those who have chronic kidney disease or diabetes.

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8
Q

Seven main categories of pharmacologic drugs used to treat hypertension include:

A

(1) diuretics
(2) adrenergic drugs
(3) vasodilators
(4) angiotensin-converting enzyme (ACE)
inhibitors
(5) angiotensin receptor blockers (ARBs)
(6) calcium channel blockers (CCBs)
(7) direct renin inhibitors
-All of these antihypertensive drugs (with the exception
of diuretics) have some vasodilatory action. Those drugs in the vasodilator category are also called direct vasodilators
-Drugs in any of these classes may be used either alone or in combination

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9
Q

Adrenergic Drugs

• Five specific drug subcategories are included in the adrenergic antihypertensive drugs, which have?

A

central action (in the brain) or peripheral action (at the heart and blood vessels).

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10
Q

The centrally acting adrenergic drugs work by?

A

stimulating the alpha2-adrenergic receptors in the brain. This results in a lack of norepinephrine production, which reduces blood pressure

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11
Q

Stimulation of the alpha2-adrenergic receptors also affects the?

A

kidneys, reducing the activity of renin. Renin is the hormone and enzyme that converts the protein precursor angiotensinogen to the protein angiotensin I, the precursor of angiotensin II (AII), a potent vasoconstrictor that raises blood pressure.

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12
Q

In the periphery, the alpha1 blockers doxazosin, prazosin,
and terazosin also modify the function of the sympathetic
nervous system. They do so by?

A

blocking the alpha1- adrenergic receptors. When these receptors are blocked, blood pressure is decreased.

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13
Q

The beta blockers also act in the periphery and include propranolol, metoprolol, and atenolol as well as several other drugs. Their antihypertensive effects are related to their?

A

reduction of the heart rate through beta1-receptor blockade. Beta blockers also cause a reduction in the secretion of the hormone renin, which in turn reduces both AII-mediated vasoconstriction and aldosterone-mediated volume expansion. Long-term use of beta blockers also reduces peripheral vascular resistance.

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14
Q

Nebivolol (Bystolic) is the newest beta blocker, released in 2008. It is a?

A

beta1-selective beta blocker approved for use in

hypertension. It is also used for the treatment of heart failure.

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15
Q

The most common adverse effects of adrenergic drugs are?

A

bradycardia with reflex tachycardia, postural and postexercise hypotension, dry mouth, drowsiness, dizziness, depression, edema, constipation, and sexual dysfunction. Other effects include headaches, sleep disturbances, nausea, rash, and palpitations.

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16
Q

There is a high incidence of orthostatic hypotension in

patients taking?

A

alpha blockers. When the patient changes positions, a situation known as first-dose syncope, in which the hypotensive effect is severe enough to cause the patient
to lose consciousness with even the first dose of medication, can occur. Educate the patient to change positions slowly.

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17
Q

The abrupt discontinuation of the centrally acting alpha2-

receptor agonists can result in?

A

rebound hypertension, characterized by a sudden and very high elevation of blood pressure.

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18
Q

Nonselective blocking drugs are also commonly associated with?

A

bronchoconstriction as well as metabolic inhibition of

glycogenolysis in the liver, which can lead to hypoglycemia.

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19
Q

Any change in the dosing regimen for cardiovascular medications should be?

A

undertaken gradually and with appropriate patient monitoring and follow-up.

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20
Q

ACE inhibitors work by?

A

blocking a critical enzyme system responsible for the production of AII (a potent vasoconstrictor). They prevent vasoconstriction caused by AII, prevent aldosterone secretion and therefore sodium and water resorption, and prevent the breakdown of bradykinin (a potent vasodilator) by AII.

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21
Q

Currently, there are 10 ACE inhibitors available for clinical
use, including:

A

(1) captopril (Capoten)
(2) enalapril (Vasotec)
(3) lisinopril (Prinivil)
• These drugs are very safe and efficacious and are often used as first-line drugs in the treatment of both heart failure and hypertension.

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22
Q

The therapeutic effects of the ACE inhibitors are related to their?

A

potent cardiovascular effects. They may be used alone

or in combination with other drugs, such as diuretics, in the treatment of hypertension or heart failure.

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23
Q

Because of their ability to decrease SVR and preload, ACE inhibitors can stop the progression of?

A

left ventricular hypertrophy (sometimes seen after a myocardial infarction [MI]), a pathologic process known as ventricular remodeling. The ability of ACE inhibitors to prevent this is termed a cardioprotective effect.

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24
Q

ACE inhibitors have been shown to have a protective effect on the?

A

kidneys because they reduce glomerular filtration

pressure. This is one of the reasons that they are among the cardiovascular drugs of choice for diabetic patients.

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25
Q

Central nervous system effects of the ACE inhibitors include?

A

fatigue, dizziness, mood changes, headaches, and a characteristic dry, nonproductive cough reversible with discontinuation of the therapy

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26
Q

The most pronounced symptom of an overdose for ACE inhibitors is?

A

hypotension.
Treatment is symptomatic and supportive and includes
the administration of intravenous (IV) fluids to expand
volume.

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27
Q

All ACE inhibitors have detrimental effects on?

A

the unborn fetus and neonate.

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28
Q

ARBs are similar to the ACE inhibitors. The class includes?

A

losartan (Cozaar)

valsartan (Diovan)

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29
Q

In contrast to ACE inhibitors, the ARBs affect primarily?

A

vascular smooth muscle and the adrenal gland. By selectively blocking the binding of AII to the type 1 AII receptors in these tissues, ARBs block vasoconstriction and the secretion of aldosterone. The end result is a decrease in blood pressure. Clinically, ACE inhibitors and ARBs appear to be equally effective for the treatment of hypertension, but ARBs do not cause cough. ARBs are better tolerated and are associated with lower mortality after MI than ACE inhibitors. It is not yet clear whether ARBs are as effective as ACE inhibitors in treating heart failure (cardioprotective effects) or in protecting the kidneys, as in diabetes.

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30
Q

Both types of drugs, ARBs & ACE inhibitors, are contraindicated for use in?

A

the second or third trimester of pregnancy.

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31
Q

The therapeutic effects of ARBs are related to their?

A

potent vasodilating properties. The beneficial hemodynamic effect of ARBs is their ability to decrease SVR (measure of afterload)

  • they are excellent antihypertensives and adjunctive drugs for Tx of heart failure
  • may be used alone or in combination w/other drugs such as diuretics in the Tx of HTN or heart failure
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32
Q

The most common adverse effects of ARBs are?

A

upper respiratory tract infections and headache. Occasionally, dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, and fatigue can occur. Hyperkalemia is less likely than with the ACE inhibitors

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33
Q

ARBs Overdose may manifest as?

A

hypotension and tachycardia; bradycardia occurs less often. Treatment is symptomatic and supportive.

34
Q

Calcium Channel Blockers (CCBs) may be used to treat?

A

angina, dysrhythmias, and hypertension and help to reduce blood pressure by causing smooth muscle relaxation and dilatation of blood vessels. If calcium is not present, then the smooth muscle of the blood vessels cannot contract. CCBs are also effective antidysrhythmics.

35
Q

the CCB most commonly used for hypertension.

A

Amlodipine (Norvasc) is the CCB most commonly used for hypertension.

  • Nimodipine can prevent the cerebral artery spasms that can occur after a subarachnoid hemorrhage.
  • CCBs are also sometimes used in the treatment of Raynaud’s disease and migraine headache.
36
Q

CCBs are used in combination with other drugs, such as
amlodipine/atorvastatin (Caduet), which is both an antihypertensive and a cholesterol-lowering drug, and amlodipine/benazepril (Lotrel), amlodipine/olmesartan (Azar), and amlodipine/valsartan (Exforge), which each combine a CCB with an ARB to treat hypertension.

A

.

37
Q 
Diuretics are a highly effective class of antihypertensive
drugs. They are listed as the?
A

current first-line antihypertensives in the JNC-8 guidelines for the treatment of hypertension.
-may be used in monotherapy (single drug therapy) or in combination w/drugs of other antihypertensive classes

38
Q

Diuretics primary therapeutic effect is?

A

decreasing the plasma and extracellular fluid volumes, which results in decreased preload, cardiac output, and total peripheral resistance, thereby decreasing the workload of the heart.

39
Q

The most commonly used diuretics for treatment of hypertension.

A

The thiazide diuretics

40
Q

Vasodilators act directly to?

A

relax arteriolar and/or venous smooth muscle; they include hydralazine (Apresoline), Sodium Niropress (ICU)
-do NOT work through adrenergic receptors.

41
Q

Direct-acting vasodilators are useful because of their ability to?

A

Directly cause peripheral vasodilation, resulting in a
reduction in SVR.
-produce significant hypotension

42
Q

Sodium nitroprusside and IV diazoxide are reserved for?

A

the management of hypertensive emergencies, in which blood pressure is severely elevated.

43
Q

Diazoxide has many undesirable adverse effects, including?

A

Dizziness, headache, orthostatic hypotension, dysrhythmias, sodium and water retention, nausea, vomiting, and hyperglycemia in diabetic patients.

44
Q

A new combination drug product is a tablet that contains
both 37.5 mg of hydralazine and 20 mg of the antianginal
drug isosorbide dinitrate. This drug, known as BiDil, has
demonstrated?

A

improved patient survival and prolonged time to hospitalization for heart failure in African-American
patient populations.

45
Q

Vasodilator: Adverse effects of hydralazine include?

A

dizziness, headache, anxiety, tachycardia, edema, dyspnea, nausea, vomiting, diarrhea, hepatitis, systemic lupus erythematosus, and rash, vitamin B6 deficiency

46
Q

Adverse effects of sodium nitroprusside include?

A

bradycardia, decreased platelet aggregation, rash, hypothyroidism, hypotension, methemoglobinemia, and, rarely, cyanide toxicity.

47
Q

Nursing assessment for antihypertensives: Obtain a thorough health history and perform a head-to-toe
physical assessment. Measure and document?

A

blood pressure, pulse rate, respirations, pulse oximetry readings, and monitor laboratory tests.

48
Q

Nursing assessment for antihypertensives: Determine whether the patient has any underlying causes of
hypertension, such as?

A

renal/liver dysfunction, a stressful lifestyle, Cushing’s disease, Addison’s disease, renal artery stenosis,
peripheral vascular disease, or pheochromocytoma.

49
Q

Nursing assessment for antihypertensives: Always assess for the presence of contraindications, cautions,
and potential drug interactions before administering any of the antihypertensive drugs.
- Contraindications include?
-Cautious use is recommended in?
- Drugs that interact with antihypertensive drugs include?

A

-Contraindications include: history of MI or chronic renal disease
-Cautious use is recommended in: patients with renal insufficiency or glaucoma.
-Drugs that interact with antihypertensive drugs include:
other antihypertensive drugs, anesthetics, and diuretics.

50
Q

Nursing assessment for antihypertensives: Exercise caution with the use of these drugs in the elderly
and those with chronic illnesses because of?

A

further compromise of the physical condition of these patients due to uncontrolled or untreated hypertension or the adverse effects of antihypertensives

51
Q

Use of alpha-adrenergic agonists demands close assessment of the patient’s?

A

blood pressure, pulse rate, and weight before and during treatment.

52
Q

If the drug is a nonselective beta blocker, it blocks both beta1 and beta2 receptors and will have both cardiac and respiratory effects, whereas if a drug is only a beta1-blocking drug, the cardiac system will be affected but there will be no beta2 effects, which limits any concern regarding respiratory problems, such as bronchoconstriction. With the use of beta
blockers, assess?

A

blood pressure and apical pulse rate immediately
before each dose. If the systolic blood pressure is less
than 90 mm Hg or the pulse rate is less than 60 beats/min, notify the prescriber because of the risk of adverse effects.
-In addition, for patients with heart failure, understand that beta blockers also have a negative inotropic effect on the heart (decreased contractility); their use would lead to worsening of heart failure.

53
Q

With ACE inhibitors, assess?

A

blood pressure, apical pulse rate, and respiratory status.

54
Q

with the use of vasodilators perform a?

A

baseline neurologic assessment, with attention to level of consciousness and cognitive ability.
-Use these drugs with extreme caution with the elderly
because they are more sensitive to the drugs’ effects and
experience more problems with hypotension, dizziness, and syncope.

55
Q

Other factors to be assessed in any patient receiving these drugs, as well as most other drugs, include the patient’s?

A

cultural background, racial or ethnic group, reading level,
learning needs, developmental and cognitive status, financial status, mental health status, available support systems, and overall physical health.

56
Q

Consideration of the patient’s cultural and ethnic group
is particularly important with antihypertensives because
research studies have documented?

A

differences in responses to antihypertensives among different racial and ethnic groups.

57
Q

Implementation for antihypertensives: Goals should include?

A

making sure the patient understands the nature of the disease, its symptoms and treatment, and the importance of adhering to the treatment regimen.

58
Q

Hypertension is managed by both pharmacologic and nonpharmacologic measures. Patients need to?

A

consume a diet low in fat, make any other necessary modifications in their diet, engage in regular supervised exercise, and reduce the amount of stress in their lives.

59
Q

Many patients have problems complying with antihypertensive treatment because?

A

the disease itself is silent or without symptoms.

60
Q

Inform patients that any abrupt withdrawal of a antihypertensive is a serious concern because of?

A

the risk of developing rebound hypertension, a sudden and very high elevation of blood pressure.

61
Q

Patients taking alpha-adrenergic agonists will need to

monitor their?

A

blood pressure and pulse rate at home or have these parameters measured by a family member who has
received instructions or by other professionals.

62
Q

If a beta1 blocker causes shortness of breath, it is most likely due to?

A

Edema and/or exacerbation of heart failure. Report any dizziness, postural hypotension, edema, constipation, or sexual dysfunction to the prescriber immediately.

63
Q

If angioedema occurs with?

A

ACE inhibitors, contact the prescriber immediately.

64
Q

If any drug must be discontinued, weaning is recommended to avoid?

A

rebound hypertension.

65
Q

If hypovolemia or hepatic dysfunction occurs with ARBs, the?

A

dose may need to be reduced.

66
Q

The most important aspect of the evaluation process is collecting data and monitoring patients for evidence of controlled blood pressure. Blood pressure must be maintained at?

A

values lower than the parameters established by the Joint
National Committee or below the levels set by the Joint
National Committee for “prehypertension,” namely, a systolic blood pressure of 120 to 139 mm Hg and/or a diastolic blood pressure of 80 to 89 mm Hg. If compelling indications are present, such as diabetes mellitus or kidney disease, the blood pressure goal is often lower.

67
Q

Assess for contraindications associated with epleronone

(Inspra), such as?

A

elevated serum potassium levels (>5.5 mEq/L) or severe renal impairment.

68
Q

Changes in the fundus have been found to be a more reliabl indicator of the long-term effectiveness of treatment than blood pressure readings because of the?

A

Changes in the vasculature of the eye caused by high blood pressure.

69
Q

Therapeutic effects of antihypertensives in general include?

A

an improvement in blood pressure and in the disease process, with improved energy levels and decreased signs and symptoms of hypertension, such as less edema, improved breath sounds, no abnormal heart sounds, capillary refill in less than 5 seconds, and less shortness of breath (dyspnea).

70
Q 
Which medication should the nurse question if prescribed together with ACE inhibitors?
  Furosemide (Lasix)
  Morphine
  Docusate sodium (Colace)
  Potassium chloride (K-Dur)
A

Potassium chloride (K-Dur)

ACE inhibitors block the conversion of angiotensin I to angiotensin II, thus also blocking the stimulus for aldosterone production. Aldosterone is responsible for potassium excretion; thus, a decrease in aldosterone production can result in an increase in serum potassium.

71
Q 
The nurse should question a prescription for a calcium channel blocker in a patient with which condition?
  Dysrhythmia
  Hypotension
  Angina pectoris
  Increased intracranial pressure
A

Hypotension
Calcium channel blockers cause smooth muscle vasodilation and thus a drop in blood pressure. They are contraindicated in the presence of hypotension.

72
Q 
The nurse is conducting a community education program. When explaining different medication regimens to treat hypertension, it would be accurate to state that African Americans probably respond best to which combination of medications?
  ACE inhibitors and diuretics
  Diuretics and calcium channel blockers
  Diuretics and beta blockers
  ACE inhibitors and beta blockers
A

Diuretics and calcium channel blockers

Research has demonstrated that African Americans do not typically respond therapeutically to beta blockers or ACE inhibitors. They respond better to diuretics and calcium channel blockers.

73
Q 
A patient who is prescribed tamsulosin (Flomax) does not have a history of hypertension. The nurse knows this medication is also used for what condition?
  Migraine headache
  Pulmonary emboli
  Subarachnoid hemorrhage
  Benign prostatic hyperplasia (BPH)
A

Benign prostatic hyperplasia (BPH)

Alpha1 blockers have beneficial in the treatment of BPH. The blocking of alpha1-adrenergic receptors decreases the urine outflow obstruction related to BPH by preventing smooth muscle contractions in the bladder neck and urethra.

74
Q

ACE inhibitors and ARBs both work to decrease blood pressure by which action?
Prevent aldosterone secretion
Increase the breakdown of bradykinin
Enhance sodium and water resorption
Prevent the formation of angiotensin II

A

Prevent aldosterone secretion

Whereas ACE inhibitors block the formation of angiotensin II, ARBs allow the formation of angiotensin II but block its effect at the receptors. Without the receptors stimulated (because of either drug), aldosterone secretion is inhibited, preventing the reabsorption of sodium and water.

75
Q

Contraindications for vasodilators

A
  • Known drug allergy
  • hypotension
  • cerebral edema
  • head injury
  • acute MI
  • CAD
  • in cases of heart failure that is secondary to diastolic dysfunction
76
Q

Vasodilator: Hydralazine toxicity

A

Hypotension, tachycardia, HA, generalized skin flushing
-Tx is supportive and symptomatic and includes administration of IV fluids, digitalization if needed, and the administration of beta blockers for control of tachycardia

77
Q

Toxicity and management of vasodilator: Sodium nitroprusside

A

Severe hypotension

  • normally only administered to patients receiving intensive care
  • Tx: discontinue infusion has immediate effect because the drug is metabolized rapidly (half life of 10 minutes)
  • chemical structure does not contain cyanide groups, which are released upon its metabolism in the body and can result in cyanide or thiocyanate toxicity. If this occurs Tx administered using a standard cyanide antidote kit that includes sodium nitrate and sodium thiosulfate for injection and amyl nitrite for inhalation
78
Q

Vasodilators interactions

A

Low for direct-acting vasodilators as a class. Hydralazine can produce additive hypotensive effects when given with adrenergic or other antihypertensive drugs

79
Q

Vasodilator: Hydralazine (Apresoline)

A
  • taken orally to treat routine cases of essential HTN
  • also given IV & is useful for pt’s who can’t tolerate oral therapy in the hospital or for hypertensive emergencies
  • contraindications: drug allergy, CAD, mitral valve dysfunction
80
Q

Vasodilator Sodium Nitroprusside (Nitropress)

A
  • used in intensive care setting for severe HTN emergencies & is titrated to effect by IV infusion
  • contraindicated in pt’s w/known hypersensitivity to the drug, severe heart failure, known adequate cerebral perfusion (especially during neurosurgical procedures)
81
Q

ARBs must be taken exactly as prescribed. Often tolerated best with?

A

Meals, as with many antihypertensives

  • dosage must not be changed nor modification discontinued except on prescriber order
  • if pt suffers from hypovalemia or hepatic dysfunction, dosage may need to be reduced
  • diuretic such as hydrochlorothiazide may be ordered in combination w/an ARB for pt’s who have HTN w/left ventricular hypertrophy
  • losartan also an option for pt’s at risk for stroke and for those who are hypertensive and have left ventricular hypertrophy
  • report any unusual dyspnea, dizziness, or excessive fatigue to prescriber immediately

Pharmacology (28 decks)

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