hypertension Flashcards
What are the two types of HTN?
primary(essential)
secondary
What does HTN being secondary mean?
it is caused by something
What can secondary HTN be caused by?
obstructive sleep apnea, renal impairment, diet, certain meds, etc.
HTN causes ___________ injury leading to impaired synthesis & release of ______ _________
endothelial; nitric oxide
What does HTN promote?
inflammatory mediators
What disease process does HTN accelerate?
the development of artherosclerosis
____ of the population over 18 have HTN
45%
What causes increased cardiac afterload & ventricular hypertrophy?
HTN
If HTN is left untreated it can lead to end-stage organ damage affecting what organs?
heart
brain
kidneys
arteries
eyes
What are the 7 players involved in HTN?
Norepinephrine
epinephrine
angiotensin II
histamine
serotonin
bradykinin
prostoglandin
What hormone is a strong vasoconstrictor?
norepinephrine
What is epinephrine a part of?
SNS stimulation
stimulation of the SNS during stress or exercise causes ______ constriction of veins & arterioles because of the release of _____________ from sympathetic nerve endings
local; norepinephrine
What does sympathetic stimulation cause the adrenal medulla to secrete?
norepinephrine & epinephrine
What does angiotensin II act as?
a very strong vasoconstrictor from RAAS
angiotensin II increases what?
BP
what effect does histamine have on arterioles?
vasodilator
What is serotonin released by?
the platelets
What does serotonin do?
causes vasoconstriction & can cause vascular spasm
What does bradykinin cause?
- intense dilation of arterioles
- increased capillary permeability
- constriction of venules
What does bradykinin play a special role in?
- regulating blood flow & capillary Leakage in inflamed tissues
What does bradykinin help regulate?
blood flow in the skin as well in the salivary & GI tract
What are prostaglandins made from?
arachidonic acid
What does tissue injury cause the release of?
arachidonic acid from the cell membrane, which initiates prostaglandin synthesis
What does prostaglandin cause?
some prostaglandins cause vasoconstriction & others cause vasodilation
What do corticosteroids do?
produce anti-inflammatory response by blocking release of arachidonic acid & preventing prostaglandin synthesis
What is BP?
cardiac output x arteriole resistance
What is first-ine treatment for HTN?
non-pharmacologic interventions
- diet
- exercise
- life-style management
What patient education should be focused on during the first-line tx?
diet
exercise
lifestyle management
- quality sleep
- smoking cessation
- alcohol consumption
What are first-line medication tx for HTN?
- ACE inhibitors
- ARBs
- thiazide diuretics`
What type of medication is not really a first-line tx?
beta blockers
What should we do if BP goal is not met?
- increased med dose
- add second or third drug
- change to a different drug
What does pharmacologic management of HTN do?
works to alter the body regulatory mechanisms
Are HTN medications a cure to HTN?
NO; they are a band-aid
What must you take into account when picking a medication for HTN?
comorbid diseases
Why may those with HTN need more than one medication to treat HTN?
- to avoid maxing out the dose
- to minimize/ avoid side effects
- synergistic effect
What are the 6 classes of medications used to treat HTN?
- ACE inhibitors
- ARBs (angiotensin II receptor blockers
- thiazide diuretics
- beta blockers
- calcium channel blockers
- renin inhibitors
What are medications that are ACE inhibitors?
lisinopril
enalapril
ramipril
What are medications that are ARBs?
losartan
irbesartan
valsartan
What are medications that are thiazide diuretics?
hydrochlorothiazide (HCTZ)
chlorthalidone
What are medications that are beta blockers?
metoprolol
atenolol
bisoprolol
labetalol
What are medications that are calcium channel blockers?
amlodipine
felodipine
diltiazem
verapamil
What medication is a renin inhibitor?
aliskiren (tekturna)
Are renin inhibitors frequently used?
no; they are rarely used
How do thiazide diuretics work?
- inhibit reabsorption of sodium & chloride from the distal tubules in the kidneys
- decrease peripheral resistance
- decrease preload
What are thiazide diuretics better for?
sodium sensitive HTN as in african americans & older adults
Are thiazide diuretics tolerated?
yes; generally well tolerated
What are the adverse effects of thiazide diuretics?
- hypokalemia
- hyperglycemia
- gout exacerbation
- other electrolyte imbalances (calcium)
- orthostasis (orthostatic hypotension)
Should patients with a hx of gout be given thiazide diuretics?
no
why do thiazide diuretics cause gout exacerbations?
they increase uric acid
What are contraindications for thiazide diuretics?
sulfa allergy
renal impairment/ failure
What are the nursing considerations for thiazide diuretics?
- increased risk of digoxin toxicity
- decrease effectiveness of DM meds
- increased risk of lithium toxicity
When should a thiazide diuretic be given?
early in the morning
What labs should be watched with a pt on thiazide diuretics?
potassium & glucose
What vitals should be monitored with a pt on thiazide diuretics?
BP & HR
What patient education should be given to a pt on a thiazide diuretics?
watch diet - be very clear
exercise
minimize alcohol
stop smoking
avoid NSAID (increase BP)
What are indications for angiotensin-converting enzymes (ACE) inhibitors?
- HTN
- heart failure
- diabetes
- post MI & PCI
What is the route of administration for most ACE inhibitors?
PO
enalapril can be given IV
How do ACE inhibitors work?
- decrease aldosterone production
- inhibit angiotensin II production
- decrease vasoconstriction
- interferes with RAAS
- keep the vasodilation effects of bradykinin
- increase preload & afterload
Are ACE inhibitors usually tolerated?
yes; generally well tolerated and absorbed
What are adverse effects of ACE inhibitors?
hyperkalemia
dizziness
cough
angioedema
Why do ACE inhibitors cause a dry cough?
related to kinins & activation of arachidonic pathway & prostaglandin production
When does the cough usually begin once you have started an ACEI?
begins within 1 to 2 weeks of initiation
When does the ACEI cough typically stop once discontinuing the medication?
typically resolves within a few days of stopping medication
With what ethnic group do ACEI have an increased incidence/ worsened cough?
Chinese people
Why does angioedema happen when taking an ACEI?
- occurs because of elevated bradykinin causing vasodilation
- angiotensin II responsible for inactivating bradykinin
How often does angioedema occur with ACEI ?
rare & usually not causing any real harm; just looks bad
What is the blackbox warning for ACEI?
- serious fetal abnormalities; not given to women in pregnancy & use cautiously in childbearing women
- contraception very important
Why should ACEI not be given in the 3rd trimester of pregnancy?
it dries up amniotic fluid
What are the nursing considerations for taking ACEI?
- be aware of renal function & potassium
- assess for orthostatic hypotension
- awareness of administration to childbearing women
- know when to hold
What class of medications should not be taken with ACEI?
NSAIDs
Should ACEI be taken with or without food?
should be taken on an empty stomach
What are the indications for angiotensin II receptor blockers (ARBs)?
- hypertension
- when an ACEI cannot be used
How do angiotensin II receptor blockers (ARBs) work?
- bind with AG-II receptors in vascular smooth muscle & adrenal cortex to stop vasoconstriction & aldosterone production
- blocks AG-II from binding at the receptor sites in the brain, kidneys, heart, periphery & adrenal tissue
What are the adverse effects of ARBs?
- cough
- hyperkalemia
- headaches
- dizziness & syncope
- GI complaints
- xerostomia (dry mouth)
- alopecia
Is the cough with ARBs more or less than with ACEI?
less
Is the hyperkalemia with ARBs more or less than with ACEI?
less
When taking ARBs there is an ________ in creatinine due to possible ________ glomerular filtration rate (GFR)
increase; decreased
What should ARBs never be given with?
ACE inhibitors
What are drug interactions with ARBs?
diltiazem & oral anti-fungals
Are ARBs safe for pregnancy?
no; should be avoided during pregnancy
What are nursing considerations for ARBs?
- monitor renal function
- some drug interactions related to cytochrome P450
- can be given with or without food
ARBs may have to be adjusted based on what?
the cytochrome P450 system of an individual
What are indications for calcium channel blockers?
- HTN
- angina
- rate control in FIB
- supraventricular tachycardia (SVT)
- raynaud syndrome
- migraines (verapamil)
What are the two types of calcium channel blockers?
dihydropyridine
non-dihydropyridine
How do calcium channel blockers work?
- decrease cardiac workload & myocardial O2 consumption
- inhibits the movement of calcium across the membranes of the myocardial/ arterial muscle cells
- alter action potential & block muscle cell contractions
- decreases contractility & slow AV conduction
- relax & dilate arteries
dihydropyridine CCBs are more __________ ___________
vascular selective
dihydropyridine CCBs have more of a direct effect on ____________ & less reduction of ____________
vasodilation; calcium
dihydropyridine has no effect on __ __________ and may ________ HR due to vasodilation
AV contraction; decrease
What do DIhyropyridine CCBs end in?
“Pine”
Dihydropyridines CCBs don’t affect the _______ as much
kidneys
What are the side effects of dihydropyridine CCBs?
peripheral edema - common
headache
flushing
lightheadedness
dizziness
GI side effects
increased HR
What should you not eat when taking CCBs?
grapefruit
why should you not have grapefruit when taking CCBs?
increase the risk of hypotension
What are the indications for non-dihydropyridine CCBs?
- HTN
- angina
- arrhythmias ( a-Fib or SVT)
Non-dihydropyridines CCBs have a _________ inotropic effect
negative
What are examples of dihydropyridine CCBs?
amlodipine
felodipine
nifedipine
How do non-dihydropyridine CCBs work?
- slow AV conduction & the rate of SA node
- decrease force of contraction
What are the two medications that are non-dihydropyridines CCBs?
verapamil
diltiazem
How can both non-dihydropyridines be given?
both can be given IV
What are the adverse effects of non-dihydropyridine CCBs?
bradycardia
decreased cardiac output
GI side effects
When should non-dihydropyridine CCBs not be used?
should not be used in those with heart block
What should be monitored when taking CCB?
BP & HR
What can CCBs cause?
hypotension & bradcardia
What are the nursing considerations for CCBs?
- be aware of conduction issues
- avoid grapefruit; especially with diltiazem
- no lab monitoring
- monitor for orthostatic hypotension
What should you check before taking CCBs?
always do apical HR prior to administration; call MD if under 60
When should you avoid using CCBs?
in those with HF
What kind of medications does grapefruit inhibit?
CYP3A medications
grapefruit can increase levels of med in the blood which increased risk of what?
iadverse effects & events
When CYP3A meds are inhibited what happens?
there is decreased metabolism of the medication
What kind of medications should not be taken with grapefruit?
oral antifungals
diltiazem
statins
What are indications for beta blockers?
- HTN (not first line)
- decrease risk of sudden death after MI
- all pt after MI & PCI
- HR reduction in AFib
- palpitations
- HF
- migraines
- performance anxiety
- hyperthyroidism
What do beta blockers do?
- decrease HR & BP
- decrease muscle contraction
- increase blood flow to the kidneys
- decrease renin release
- blocks SNS responses
What do beta blockers end in?
“olol”
What are adverse effects of beta blockers?
fatigue
depression
impotence
sleep issues
bradycardia
What are the special uses of metoprolol?
HF & post MI
What are the special uses of propranolol?
social anxiety & headaches
Why should you check the glucose of someone on beta blockers?
beta blockers can mask hypoglycemia episodes
With what respiratory condition should you use caution when taking beta blockers?
use in chronic lung disease; may increase risk of asthma attacks
In what heart issue should you use caution with beta blockers?
in those with brady arrhythmias
What should you do before administering beta blockers?
check apical pulse; call MD if under 60
What should you never do when taking beta blockers?
never stop abruptly; pt should always be slowly weaned off to avoid sympathetic surge
What are nursing considerations for beta blockers?
- check for orthostatic hypotension
- monitor glucose, esp if pt is diabetic
- make sure pt is given med even when NPO
- assess for side effects
- no major lab concerns
What are the medications that are selective beta 1 blockers?
metoprolol
atenolol
esmolol
bisoprolol
What are the medications that are nonselective beta blockers (effects both 1 & 2 receptors)?
propanolol
carvedilol
nadolol
sotalol
When are non- selective beta blockers contraindicated?
- asthma
- bronchospasms
- heart failure
- chronic lung disease
- use in those with brady arrhythmias
Cardio-selective beta blockers are ______ likely to have sx but ______ doses can cause lung sx
less; higher
What are the two types of metoprolol?
succinate
tartrate
What is metoprolol succinate used for?
tx of HF
tx of HTN
is metoprolol succinate long or short acting?
long acting
When is metoprolol succcinate usually usually taken?
usually dosed daily
is metoprolol short or long acting?
short-acting
When is metoprolol tartrate used?
used post MI
used for rate control in arrhythmias
how can metoprolol tartrate be given?
IV
Can metoprolol succinate & tartrate be used interchangeably?
no; not unless order specifically
What should you know when a pt is taking metoprolol?
if they are on succinate or tartrate
What do alpha blockers do?
- inhibit alpha synapse at the alpha adrenergic receptors (blocks SNS)
- prevent feedback of norepinephrine
What can alphia blockers do?
can block beta receptors
Are alpha blockers used often of HTN?
not really used in BP control; considered 3rd-4th line tx
What are alpha blockers really good at acting as?
work really well as antihypertensive
What should you do when giving a pt an alpha blocker?
watch pt closely especially for the 1st hr; monitor for hypotension & bradycardia
What are the adverse effects of alpha blockers?
- first dose effect
- syncope & dizziness
- orthostatic hypotension
- tachycardia
- vertigo
- sexual dysfunction
What are the examples of alpha blockers?
doxazosin (cardura)
prazosin (minipress)
In what population shoul you avoid giving alpha blockers and why?
avoid in use in older adults due to increased sedation/confusion
