HTN Flashcards
JNC Joint National Committee
sets standards of treatment
Diuretics
Ions drive the action
Increase osmolality of filtrate
Requires good blood flow to Kidney
GFR> 30
Thiazide Diuretics
African American Male (good response)
Works at Distal convuluted tubule
Blocks Na+ channels–no reabsorption of Na+/ Cl.-filtrate stays in kidney for excretion.
Contraindicated with Gout DX’
NO Na+ in and NO uric acid out—> risk
Gout.
Thiazide Diuretics
Contraindicated in DX
Gout, Renal Insuffiency
Chlorothiazide 250 mg -1gm/day Hydrochlorothiazide ** most common 12.5-100mg/day Metolazone 2.5-5mg/day Chlorthalidone -more potent/ longer half life
Loop Diuretics
Blocks Na+ at loop of Henle
Blocks Cl binding at NA+/K+/Cl transporter
increased risk of K+ loss
increased effectiveness due to increased Na+ absorption in loop of Henle.
Loop Diuretics
Standard of treatment in Renal Disease
Furosemide 20-80 mg/day
Bumetidine (Bumex) 0.5-2mg/day
Monitor K+, NaCl, Ca+, and renal fx
K+ supplementation
K+ Sparing Diruetics
Monitor for hypercalemia
esp with combinations of K= sparing meds (prils and birth contorl Yaz/yasman)
Blocks Na+/K+ pump–blocks Na+ reabsorption to body–increases Na+ in filtrate–K+ reabsorbs into body- no loss of K+.
K+ sparing Diuretics
Spironolactone 25-100mg/day
Amiloride 5-20mf/day
Triamterene 100-200mg/day
K+ sparing Diuretics
Aldosterone Receptor Antagonist
Used with liver failure/heart failure
Used in PCOS (block of androgen effect)
Spironolactone.
Blocks action of aldosterone at the collecting duct. Na= stays out/K= stays in
caution K+ levels with other K+ sparing meds.
MI compelling indication for
Beta Blocker
Beta blockers
Categories
Non selective with alpha blocking
Non selective Beta - blocks Beta1/Beta2
Selective blocks only Beta1
Non selective Beta Blocker
Beta 1 & Beta 2 antagonist
***Contraindicated with DX lung Disease
Propranolol (Inderal)
Nadolol
Timolol
Uses hyperthyroidism, tremor, migraine prevention
Non selective Beta Blocker
Effects
decreased HR (-chronotrope) decreased contraction (-inotrope) decreased Renin secretion Bronchoconstriction increased GI distress
Selective Beta Blocker
Beta 1 Antagonist
Atenolol (Tenormin) Metroprolol tartate -regular succinate-ER (Toprol XL) Uses Cardiac
Selective Beta blocker
Effects
**Can lose selectivity at higher doses (MAX DOSE)
decreased HR (-chronotrope) decreased contraction (-inotrope) decreased Renin secretion
Nebivolol- Bystolic
Selective Beta blocker Beta 1
Very cardio selective
good safety record in RAD (reactive Airway Disease)
increases release of NO (Nitrous Oxide)= vasodilation=decrease BP
Labetolol
Carvedilol (coreg)
Non selective Beta blocker +
Beta 1, Beta 2, Alpha 1
1st line drug for HF
carefully watch lung fx. (trial low dose )
Alpha 1 antagonist effects--- Vasodilation=decreased vascular resistance. Beta 1 antagonist effects-- decreased HR (-chronotrope) decreased contraction (-inotrope) decreased Renin secretion Beta 2 antagonist effects---
Beta blockers & Prescribing indications HTN
Compelling indications
S/P MI, HF, DM2 combined DM/HF
other uses HF migraine prevention
Start low-titrate slowely
Hold if HR <60
Consider dx lung disease
**note blunting SNS response masks s/s of hypoglycemia
Beta Blocker SE
<HR Dizziness depression GI upset sexual dysfunction **fatigue malaise Rebound HTN with sudden withdrawl
Beta Blocker Contraindications
> 1st degree heart block
Bradycardia
RAD (Reactive Airway Disease)
Common interaction– Separate dosing time
Antacids
Anti-cholinergics-increase absorption
Alpha Blockers for HTN
Never 1st line tx
3rd or 4th line drug
Good to treat stress component of HTN etiology.
Vasodilation
Selective alpha 1 blocker
***do not combine with Nitrates= unsafe drop in BP
Use in conjunction with a diuretic.
Commonly used for prostate
Doxazosin mesylate (Cardura) Prazosin HCl (minipress) Terazosin HCl (hytrin)
alpha blockers SE
***Severe orthostatic hypotension (biggest) fatigue Na+/H2O retension=edema HA, N/V educate prostate pts--get up slowly
alpha 1 blockers contraindications
hepatic dysfunction
drug interactions NSAIDS attenuate antihypertensive effect
Alpha 2 agonist
Labs decrease urine catecholamines and vanillylmandelic acid (+for DX of phenochromacytoma- tumor causing very high BP)
Alpha 2 receptors put breaks on SNS.
decrease SNS activity in peripheral vessels
increases vagus activity para SNS
vasodilation
decreased CO cardiac output
decreased catecholamine& renin release
Alpha 2 agonist
Uses
drug withdrawl, tourettes,anger management and menopause (calming)
Methyldpoa (Aldomet) oldest BP med
pregnancy approved
Clonidine weekly patch or po.
alpha 2 agonist effects
Caution in recent MI& depression
drug reaction with TCA Tricyclic antidepressants
CNS depression/sedation in addition of alpha 1 responses
Severe orthostatic hypotension, fatigue
Na+/H2O retension=edema, HA, N/V
CCB Calcium Channel Blockers
3 channels for calcium to enter cells.
l type, N type and T type.
focus on
L type long lasting--contractile muscle
Heart and smooth muscle
T type - found only in pace making cellsCCB Calcium Channel Blockers
Non-dihydropyridines
Diltiazem (Cardizem) A FIB
Verapamil (calan SR) A FIB
Greater effect on T-type channels Pacing cells but modest impact on HTN
CCB Calcium Channel Blockers
Dihydropyridines
1st pril then ipine
Used for HTN
other uses HF and esophageal spasm
Nifidipine (Procardia XL) Amlodipine (Norvasc) Cleridipine emergency use drugs ending in IPINE Greater effect on L type channels decreased contractility heart and arterial smooth muscle---HTN tx
CCB- Adverse reactions
CCB contraindications
2nd/3rd degree heart block SBP< 90
Sick Sinus Syndrome Aortic stenosis
Severe CHF
***Flushing
Dizziness/HA/Dry mouth/nausea and constipation (decreased in smooth muscle contraction).
Peripheral edema (give in combo with ACE/pril to decrease edema)
heart dysrhythmias
photosensitivity
Direct acting Vasodilators
Cause direct relaxation and dilation of arteriolar smooth muscle-decrease vascular resistance
Hydralazine (Apresoline)
slow IV admin
\+ reflex tachycardia& HTN
Minoxidil (Loniten)
Used primarily for side effect of hair
growth--not used much for HTN
Nitroprusside (Nitropress)
*****Emergency only
keep away from lightEndothelial Dysfunction
Players
Nitric Oxide–Vasodilation
RAAS– Angiotension II (called AT1 receptor)–vasoconstriction
Thromboxane A2
ACE Inhibitors Pregnancy class D
Decreased BP, stroke, and MI
ACE blocks angiotension I from changing to angiotension II by blocking angiotension converting enzyme—vascular changes (AT1) & decreased aldosterone activity (AT2)–increased Na+ & H2O excretion, increased K+ retension
PO/IV administration
.
ACE SE
Dry cough–AT2 breaks down Bradykinin in lungs. Blocking AT2=increased Bradykinin in lungs
r/t antihypertensive effects (HA,dizziness, tachycardia, cough, Maculopapular rash, neutropenia/agranulocytosis, angioedema (swelling lips and rash, incidence increasing)
ARBS Angiotension II receptor blockers
End in sartan
Blocks angiotension II at receptor site in tissue–decreased vascular resistance
Benicar
Diovan
ARBS SE
FEW No cough
K+ sparing -careful in combo with other K= sparing meds >K+
? same Benefits as ACE
?use in renal impairment
Renin Inhibitors
Newest class of antihypertensives
Aliskiren
Direct Renin inhibitor–, conversion of angiotensinogen to angiotension I.
effects RAAS without increasing the plasma renin activity
Dosage 150-300mg daily
ReninInhibitors Adverse Effects
Drug interactions
Angioedema, diarrhea, cough
Substrate of P450 3A4
reduced loop diuretic activity
Do not combine with ACE/ARB
?safety/efficacy in renal disease
