Hypertension Flashcards
Hypertension in 30 sec
- Excessive vascular volume
- Low Compliance of vasculature
- Increased activity of the Renin Anginotensin System
Renin
Proteolytic enzyme that is released into the circulation primarily by the kidneys.
Stimulated by
1.sympathetic nerve activation
2.renal artery hypotension
3.decreased sodium delivery to the distal tubules of the kidney.
Essential Hypertension
No clear cause
Secondary Hypertension
increase in BP due to a specific, known cause
Blood pressure target
<140/90
First line hypertension medications
- Thiazide diuretics
- ACE inhibitors
- Angiotensin receptor blockers (ARBs)
- Calcium channel blockers (CCBs)
Second/third line HTN medications
- Beta-blockers
- Aldosterone antagonists
- Loop diuretics
- Direct vasodilators, alpha-1 blockers, alpha-2 blockers
Direct Cardiac agents
Impact Heart rate (HR), contractility, conductivity
•Beta Blockers
•Calcium Channel Blockers
Peripheral Vascular Agents
Impact peripheral resistance, pre-load, vascular health, vasodilation
•Hydralazine
•Alpha 1 Antagonists
•Alpha 2 Agonists
Renal Agents
Impact fluid volume, metabolites
•ACE Inhibitors
•Angiotensin2 Inhibitors
•Diuretics
Diuretics: Therapeutic Use
- Hypertension –thiazides are first line
- Heart Failure
- Edema (peripheral/pulmonary)
Diuretics: Side Effects
- Hypotension
- Renal dysfunction
- Volume depletion
- Electrolyte disturbances
diuretics: cautions/contraindications
- Sulfa allergy (loops)
- Anuricpatients
- Concomitant use of other nephrotoxic agents
Thiazide Diuretic Agents
•Inhibition of Sodium/Cl reuptake
–Excretes sodium
–Loosely coupled with Potassium excretion
–Moderate diuresis & afterload reduction
Loop diuretics
- Inhibit Na, K, Ca, Mg reabsorption in the loop of Henle
- Powerful diuresis and volume reduction
- Decreased afterload
- Not used much for BP reduction
- Useful in patients with edema andheart failure
- Most common is furosemide (Lasix)
Potassium Sparing Diuretics –Aldosterone Antagonists
•Inhibits aldosterone by inhibiting sodium-potassium exchange site in the distal tubule –Excretes sodium –Excretes water –Retains potassium •Used for resistant hypertension •Also used to treat heart failure
ACE Inhibitors
“prils”
•Inhibition of Angiotensin Converting Enzyme (ACE)–Inhibition of the conversion of Angiotensin I to Angiotensin II
•Peripheral Vasodilation–ATII causes peripheral vasoconstriction
•Reduced Antidiuretic Hormone (ADH) Production–Reduced fluid volume
•Reduced Aldosterone Production–Reduced fluid volume
•First line option
Ace inhibitors: therapeutic uses
- Hypertension
- Post MI (with LVSD) -remodeling
- Heart Failure
- Diabetic patients
Ace inhibitors: side effects
- Angioedema
- Cough
- Orthostasis/hypotension
- Hyperkalemia
Ace inhibitors: cautions/contraindications
acute kidney injury
bilateral renal artery stenosis
hypotension
history of angioedema
Angiotensin Receptor Blocker
“-sartan”
•Inhibition of Angiotensin II receptor–Action of angiotensin II is blocked despite its production
•Peripheral Vasodilation–ATII causes peripheral vasoconstriction
•Reduced Antidiuretic Hormone (ADH) Production–Reduced fluid volume
•Reduced Aldosterone Production–Reduced fluid volume
•First line option–Should not be combined with ACE inhibitors
ARB: therapeutic use
- Hypertension
- Post MI (with LVSD) -remodeling
- Heart Failure
- Diabetic patients
Arb: Side effects
- Angioedema
- Orthostasis/hypotension
- Hyperkalemia
ARB: cautions/contraindication
acute kidney injury
bilateral renal artery stenosis
hypotension
history of angioedema
Calcium Channel blockers
“pine”
•Inhibition of sympathetic simulation of vascular smooth muscle–That means reduced afterload, but also reduced cardiac muscle contractility!
•Mechanism is by blocking calcium re-entry–Reduced contractility, reduced HR–Preserve renal function in those with HTN-related renal disease
- vasodilation of vasculature- decrease BP, alleviate chest pain
- first line option for HTN
CCB therapeutic uses
- Hypertension
- Angina
- Atrial Fibrillation
- Subarachnoid hemorrhage
- Raynaud’s Phenomenon
CCB side effects
- Hypotension
- AV Block
- Reflex tachycardia (dihydropyridine agents)
- Headache, dizziness, flushing, drowsiness
- Edema
- Nausea
- Constipation
What to monitor with CCB
BP, HR
Beta Blockers
“olol” “lol”
•Primarily a function of Beta 1 Blockade–Inhibition of sympathetic cardiac stimulation of the SA node–Inhibition of Reninsecretion
•Secondary effects of Beta 2 Blockade–Va sodilation of GI Vasculature
•Place in Therapy–Second line for hypertension when first line agents are optimized–Can decrease exercise tolerance initially
Important for htn with Ischemic heart disease, MI, CHF
BB 1 targets
–“Cardioselective”
–Inhibits sympathetic contractility, inotropy, and conductivity of the heart
–Inhibits sympathetic renin secretion in the kidneys
BB2 target
–Beta 2 receptors inhibit smooth muscle contractions in the lungs and GI tract
–Beta 2 blockade is useful for restricting hepatic blood flow for patient with Liver Cirrhosis, but generally not a therapeutic effect for CVD
–Beta 2 blockade may cause bronchospasm
combined alpha and non-selective BB
- Alpha 1 blockade–Causes peripheral vasodilation
* Combined alpha and nonselective beta-blockers lower blood pressure more than beta-blockers without alpha blockade
HTN management on Rehab
- Primary concern is the presence of hypotension and postural-related hypotension
- Reduced cardiovascular response to exercise, especially with Beta-Blockers and Calcium Channel Blockers
- Physical therapists can increase compliance through education–Emphasize “silent killer” nature of hypertension
Non-pharm management of HTN
- Diet modification
- Low fat
- Low sodium
- Omega-3 fatty acids
- Exercise
- Limit alcohol
- Smoking cessation
PT and HTN
- Lots of patients with hypertension (both treated and untreated), watch for:-Orthostasis-Hypotension-Dizziness-Fatigue
- Use caution when doing activities that may cause vasodilation and further drops in blood pressure
- Be aware of the patient’s ability to exercise
- Help with compliance (pharm and non-pharm)
KEY POINTS
- Hypertension is a common disease marked by sustained increase in blood pressure that can lead to serious disease
- Diauretics, sympatholytics, vasodialators, renin-ang. system inhibitors, and calcium channel blockers used to treat hypertension
- The magnitude of the hypertension and presence of other comorbidities determine which drugs to prescribe.
- PT/OTs have important role in making patients aware of impact of hypertension on function and how pharmacological and other active treatments can manage BP
