Hypertension Flashcards
ACE inhibitor means …
Angiotensin converting enzyme inhibitor
MOA
ACE inhibitor
- block angiotensin I conversion to angiotensin II
- inhibit breakdown of bradykinin (contribute to vasodilation)
- reduce sodium retention
- reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)
ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP
Indication
ACE inhibitors
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Diabetic nephropathy
Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)
Post MI
Adverse reactions
ACE inhibitors
- hypotension
- headache
- dizziness
- cough (dry / non productive)
- hyperkalaemia
- fatigue
- nausea
- renal impairment
Practice points
*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.
Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*
When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment
Drug class and indication
Captopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)
Drug Class and indication
Enalapril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction
Drug class and indication
Enalapril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Fosinopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Fosinopril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Lisinopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment
Drug class and indication
Perindopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure
Drug class and indication
Perindopril with amlodipine
ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease
Drug class and indication
Perindopril with indapamide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Quinapril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Quinapril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* hypertension
Drug class and indication
Ramipril
ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors
Drug class and indication
Ramipril with felodipine
ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension
Drug class and indication
Trandolapril
ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction
Generic names of ACE inhibitors
Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril
Drug interactions
ACE inhibitor
Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).
Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.
ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.
Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.
Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.
ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.
SARTANs a.k.a. …
angiotensin receptor agonists (ARA)
MOA
sartans / ARA
Competitively block binding of angiotensin II to type 1 angiotensin (AT1) receptors. They reduce angiotensin II-induced vasoconstriction, sodium reabsorption and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
Indication
sartans / ARAs
- Hypertension
- Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
Adverse effects
sartans
dizziness, headache, hyperkalaemia
Precautions / contradictions
sartans / ARAs
Peripheral vascular disease or atherosclerosis—patients may be more likely to have renal artery stenosis.
Volume or sodium depletion—Monitor combination w/ diuretics (both affect sodium and BP)
Black African or Caribbean descent
Treatment with drugs that can increase potassium concentration,
Practice points
sartans / ARAs
- stop K+ and K+ sparing diuretics
- review use of NSAIDs
- check renal function
- used when ACE inhibitors are not tolerated for HTN and chronic heart failure
You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.
Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.
when starting a sartan:
stop potassium supplements and potassium-sparing diuretics
in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan
review use of NSAIDs (including selective COX‑2 inhibitors)
start with a low dose
check renal function and electrolytes before starting a sartan and review after 1–2 weeks
unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they:
cause less cough than ACE inhibitors
may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence)
maximum antihypertensive effect occurs about 4–6 weeks after starting treatment
encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment
Drug class and indication
Candesartan
sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
Drug class and indication
Candesartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Eprosartan
sartan / ARA
Hypertension
Drug class and indication
Eprosartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Irbesartan
sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)
Drug class and indication
Irbesartan with hydrochlorothiazide
sartan /ARA + thiazide diuretic
Hypertension
Drug class and indication
Losartan
sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)
Drug class and indication
Olmesartan
sartan / ARA
Hypertension
Drug class and indication
Olmesartan with amlodipine
sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension
Drug class and interaction
Olmesartan with amlodipine and hydrochlorothiazide
sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic
Hypertension
Drug class and interaction
Olmesartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Telmisartan
sartan / ARA
* Hypertension
* Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA
Drug class and indication
Telmisartan with amlodipine
sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension
Drug class and indication
Telmisartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Valsartan
Sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
* Left ventricular failure/dysfunction after MI, when clinically stable
Drug class and indication
Valsartan with hydrochlorothiazide
Sartan / ARA + Thiazide diuretic
Hypertension
Generic names of Sartans / ARA
Candesartan
Candesartan with hydrochlorothiazide
Eprosartan
Eprosartan with hydrochlorothiazide
Irbesartan
Irbesartan with hydrochlorothiazide
Losartan
Olmesartan
Olmesartan with amlodipine
Olmesartan with amlodipine and hydrochlorothiazide
Olmesartan with hydrochlorothiazide
Telmisartan
Telmisartan with amlodipine
Telmisartan with hydrochlorothiazide
Valsartan
Valsartan with hydrochlorothiazide
Tripple Whammy
NSAID + Sartan + ACE
Sounds like satan ate enough said
Generic names: Thiazide diuretics and Thiazide-related diuretics
Thiazide
Hydrochlorothiazide
Thiazide-related
Chlortalidone
Indapamide
Indication
Thiazide and related diuretics
- Hypertension
- Oedema associated with heart failure or hepatic cirrhosis
- Nephrogenic diabetes insipidus
MOA
Thiazide and related diuretics
Inhibit reabsorption of sodium and chloride in the proximal (diluting) segment of the distal convoluted tubule, increased potassium excretion.
When used in recommended low doses for hypertension, thiazides lower BP mostly by a vasodilator effect.
Precautions
Thiazide and related diuretics
Gout—may be aggravated by diuretic-induced hyperuricaemia
Heart failure with significant oedema—hyponatraemia may occur, particularly if higher doses are used with a salt-restricted diet and/or potassium-sparing diuretics and excess water intake.
Conditions or drugs that may cause hypokalaemia—further increases risk of hypokalaemia; monitor potassium concentration.
Conditions or drugs that cause volume depletion—further increases risk of renal impairment and hypotension (particularly in patients with heart failure); monitor renal function and BP (sitting and standing).
Adverse effects
Thiazide and related diuretics
Effects on electrolytes, blood glucose and lipids are dose-dependent.
dizziness, weakness, muscle cramps, polyuria, orthostatic hypotension, electrolyte disturbances (eg hyponatraemia, hypokalaemia, hyperuricaemia, hypochloraemic alkalosis, hypomagnesaemia, hypercalcaemia)
Nursing considerations
Thiazide and related diuretics
You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy.
most adverse effects are dose-related; start with a low dose and increase slowly
Heart failure
* may be given with loop diuretics to relieve symptoms of fluid retention; seek specialist advice
* start with a low dose and adjust according to clinical response; use small, intermittent doses with careful monitoring of renal function, electrolytes, BP and volume status
* advise patients to report any dizziness, thirst, or increased fluid loss due to diarrhoea, vomiting or excessive sweating
Diuretic-induced hypokalaemia
* reduce risk by using a low dose
* is less likely when also taking an ACE inhibitor, sartan or potassium-sparing diuretic
* potassium supplements may be used to treat mild hypokalaemia (each potassium chloride 600 mg tablet contains 8 mmol potassium; daily potassium replacement requirement is around 20–60 mmol (3–8 tablets))
Drug interactions
Thiazide and related diuretics
ACE inhibitors + thiazide diuretics = hypotension
sartans + thiazide diuretics = Hypotension
loop diuretics + thiazide diuretics = hypokalemia + hypotension
NSAIDs + thiazide diuretics = reduced renal function
Hydrochlorothiazide is a thiazide diuretic; chlortalidone and indapamide are related to the thiazide diuretics and behave in the same way.
Thiazide diuretics cause hypotension; administration with other drugs* with this effect may result in additional hypotension.
They also cause hypokalaemia; additional potassium loss may occur if they are given with other drugs* that reduce potassium concentration; monitor potassium concentration and give potassium supplements if necessary. See also Prolonged QT interval.
High doses of thiazide diuretics can increase blood glucose concentration
Two kinds of Calcium channel blockers
Dihydropyridines
Non-dihydropyridines
suffix
Dihydropyridines Calcium channel blocker
Pine
Generic names of Dihydropyridines Calcium channel blocker
Amlodipine
Amlodipine with atorvastatin
Amlodipine with valsartan
Amlodipine with valsartan and hydrochlorothiazide
Clevidipine
Felodipine
Lercanidipine
Lercanidipine with enalapril
Nifedipine
Nimodipine
Generic names of Non-dihydropyridines Calcium channel blockers
Diltiazem
Verapamil
Trandolapril with verapamil
Indication
Calcium channel blockers
Hypertension
Angina
MOA
Calcium channel blockers
Block inward current of calcium into cells in vascular smooth muscle, myocardium and cardiac conducting system via L‑type calcium channels.
Act on coronary arteriolar smooth muscle to reduce vascular resistance and myocardial oxygen requirements, relieving angina symptoms.
Dihydropyridines act mainly on arteriolar smooth muscle to reduce peripheral vascular resistance and BP. They have minimal effect on myocardial cells.
Non-dihydropyridines: diltiazem and verapamil act on cardiac and arteriolar smooth muscle. They reduce cardiac contractility, heart rate and conduction, with verapamil having the greater effect. Diltiazem has a greater effect on arteriolar smooth muscle than verapamil.
Precautions
Calcium channel blockers
Myasthenia-like neuromuscular disease—calcium channel blockers may increase risk of muscle weakness and respiratory depression (most case reports with verapamil).
Peritoneal dialysis—cloudy peritoneal fluid (with no signs of infection) has been reported, mostly with lercanidipine; it is not clear if this is a class effect.
Adverse effects
Calcium channel blockers
Most listed adverse effects occur with all calcium channel blockers.
Adverse effects vary between the calcium channel blockers according to their relative effects on vascular, myocardial and conducting tissue.
Dihydropyridines have more pronounced vasodilatory effects than diltiazem and verapamil. Verapamil, and to a lesser extent, diltiazem, reduce cardiac contractility, heart rate and conduction.
Peripheral oedema
Dihydropyridines commonly cause peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention); this does not respond to treatment with diuretics, which may put patient at risk of volume depletion.
Practice points
Calcium channel blockers
vasodilatory adverse effects usually subside with continued treatment (may require dose reduction)
Drug class and indication
Amlodipine
Dihydropyridine Calcium channel blocker
Hypertension
Angina
Drug class and indication
Amlodipine with atorvastatin
Dihydropyridine Calcium channel blocker + statin / HMG-CoA reductase inhibitors
Hypertension or angina, in patients with hypercholesterolaemia or multiple cardiovascular risk factors
Drug class and indication
Amlodipine with valsartan
Dihydropyridine Calcium channel blocker + sartan (ARA)
Hypertension
Sartan a.k.a. angiotensin II antagonists and angiotensin receptor antago
Drug class and indication
Amlodipine with valsartan and hydrochlorothiazide
Dihydropyridine Calcium channel blocker + Sartan (ARA / ARB/ angiotensin II receptor blocker + Thiazide diuretic
Hypertension
Drug class and Indication
Clevidipine
Dihydropyridine calcium channel blocker
Hypertension (short-term use when oral treatment not appropriate)
Drug class and indication
Felodipine
Dihydropyridine calcium channel blocker
Hypertension
Drug class and indication
Lercanidipine
Dihydropyridine calcium channel blocker
Hypertension
Drug class and Indication
Lercanidipine with enalapril
Dihydropyridine calcium channel blocker + ACE inhibitor
Hypertension
Drug class and indication
Nifedipine
Dihydropyridine calcium channel blocker
Hypertension
Angina
Drug class and indication
Diltiazem
Non-Dihydropyridine calcium channel blocker
Angina
Hypertension (controlled release tablet)
Drug class and indication
Verapamil
Non-dihydropyridine calcium channel blocker
SVT
AF or atrial flutter (ventricular rate control)
Hypertension
Angina
Drug class and indication
Trandolapril with verapamil
ACE inhibitor + Non-dihydropyridine calcium channel blocker
Hypertension
Suffix:
Beta-blocker
lol
Drug class
lol
Beta-blockers
Indication
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Chronic heart failure with reduced ejection fraction as part of standard treatment
Prevention of migraine
MOA
Beta-blocker
Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.
Beta-blockers reduce heart rate, BP and cardiac contractility; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.
Precautions / adverse effects
Beta-blockers
Shock (cardiogenic and hypovolaemic)—contraindicated.
Hyperthyroidism—beta-blockers may mask clinical signs, eg tachycardia.
Phaeochromocytoma—beta-blockers may aggravate hypertension; an alpha-blocker should be given first.
History of anaphylactic reactions—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis.
Myasthenic symptoms—may worsen.
CARDIACContraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure.
Respiratory contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD
Myasthenic symptoms (muscle weakness)
Adverse effects
Beta-blockers
- bradycardia,
- hypotension,
- orthostatic hypotension
- bronchospasm,
- dyspnoea,
- fatigue, dizziness
- Mask Hypoglycemia
Can mask signs of hypoglycemia in diabetics
Counselling / practice points
Beta-blockers
Counselling
This medicine may cause dizziness or tiredness
Do not stop taking this medicine suddenly
Practice points
beta-blockers are not usually recommended first line for uncomplicated essential hypertension; they are associated with reduced protection against stroke in the elderly
**when stopping treatment, reduce dosage gradually
Drug class and indication
Atenolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Drug class and indication
Bisoprolol
Beta-blocker
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and Indication
Carvedilol
Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Labetalol
Beta-blocker
Hypertension
Hypertensive emergency
Drug class and Indication
Metoprolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Prevention of migraine
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and Indication
Nebivolol
Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Propranolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
Tetralogy of Fallot, seek specialist advice
MI
Prevention of migraine
Essential tremor
Phaeochromocytoma (with an alpha-blocker)
Generic drug names
Beta-blockers
Atenolol
Bisoprolol
Carvedilol
Esmolol
Labetalol
Metoprolol
Nebivolol
Propranolol
Sotalol
Pathophysiology
Hypertension
The pathophysiology of hypertension involves the impairment of renal pressure natriuresis, the feedback system in which high blood pressure induces an increase in sodium and water excretion by the kidney that leads to a reduction of the blood pressure.
Signs and symptoms
Hypertension
- Early morning headache
- Nosebleeds
- Irregular heart rhythms
- Vision changes
- Buzzing in ears
Rationale for drug use
Hypertension
Reduce premature cardiovascular morbidity and mortality and microvascular disease affecting the brain, kidneys and retinas
Drug choice
Hypertension
For uncomplicated hypertension, unless there is a contraindication or a specific indication for another drug, first consider:
- an ACE inhibitor (or sartan) or
- a dihydropyridine calcium channel blocker or
- if 65 or older, a thiazide diuretic (low dosage).