Hypertension and AntiHypertensives Flashcards
Normal BP
<120mmHg/<80mmHg
Prehypertension
120-129/<80
stage 1 HTN
130-139/80-89
Stage 2 HTN
> 140/>90
White Coat Hypertension
Normal BP other than doctor’s office, Diagnosis is ambulatory BP, 24hr observation
Primary HTN Pathophysiology
Most common- Essential HTN, 95%
Hypersensitive SNS HTN
Increased SNS activity = Norepi on SM= Vasoconstriction= Inc. TPR= Inc. BP
SNS action on Kidneys HTN (Hyperactive RAA AXIS)
JGA= epi= Renin= AT1=AT2= Vasoconstriction (inc ADH and Aldosetrone)= TPR = high BP
SNS action on HEart
SA node= ic. HR= inc. BP
Ventricular Myocardium= inc. contractility= inc. CO and Inc BP
ELderly and Af-Am
Low renin HTN
DEcrease the excretion of Na+ = More Na in blood= Water moves towards Na= inc. BV= Inc. BP= inhibits RAAS= low Renin= Low AT2= and no effect.
Na Retention
Vasoconstriction= TPR inc = Inc BP
Risk Factors for primary HTN
Diabetes, Obesity, Obst. Sleep Apnea, neurosis, FH, Vitamins, Genetic, Ethnicity
Age range of primary HTN
(25-55)
Secondary HTN
5% (uncommon) younger ind. (<25)
Kidneys (parenchyma) in HTN
damage to the parenchyma of kidney= inc. Na, Water, and inc. BP
Glomerulonephritis
Diabetic nephropathy (most common)
Polycystic Kid. Disease
Kidney (blood vessels)
Stenosis of Renal artery (no ACEinhib) Atherosclerosis Wegner's Granulomatosis Polyarteritis Nedosa Vasculitis Fibro-muscular dysplasia (20-30 year old females)
Endocrine cause of HTN
Conn’s Disease (ZG)= Hyperaldosteronism= inc Na and h2o= inc. BV= Inc BP
Cushing’s (ZF)= inc Cortisol= Inc Nor/epi= Vasoconstriction= inc BP
Pheochromocytoma= Large Epi and NorEpi= inc. Contractility, inc SV, Inc RAAS= Inc.BP
Also, look for Electrolyte imbalances, BUN, creatinine, Low GFR
Thyroid HTN
Hyperthyroidism= inc. Nor/epi rec. sensititivity= Inc. Hr= Inc BP
Hypothyroidism cause= low T3 and T4= acts on kidneys= inc. Na retention= inc BV= Inc.BP
T3 and T4 inc. Diastolic BP
hyperparathyroidism= high levels of PTH= inc. Ca conc= osteoclast activty, SM cells= Vasoconstriction= BP
Turner’s Syndrome
Coarctation of aorta= constriction of a part of arota= inc. pressure
high ICP
Cushing’s Triad- Hypertension, Bradycardia and Slow respiration
Pregnancy HTN
2nd Trimester (>20 wks)= High BP risks= Pre-eclampsia- HTN and proteinuria 24 hr protein test, Protein/creatinine ratio
can lead to eclampsia- HTN, Proteinuria, Seizures (bad)
treat with Magnesium sulphate
drugs
Oral contraceptives- E2 inc= inc. Angiotensinogen= Inc.BP
Sympathomimetics- Aderall; Ritalin, cocaine
SSRI excess- serotonin syndrome too much antidepressants= SSRI, SNRI, St.John’s Wort
MAO inhib
Tyramine (cheese), Selegiline (treat resistant depression)= hypertensive crisis
HYPERTENSIVE CRISIS
Retinopathy (flame haemorrages) LVH Arrythmia A. Dissection Abdominal aor. Aneyrysm Atherosclerosis
. TREATMENT STRATEGIES BP goal
> 130/>80
THiazide, ACE inhib, ARB or Ca blocker
General nonelderly
Non Black :Thiazide. ACE Inhibitor, ARB, CCB
Black: thiazide diuretic or CCB
Elderly >65 yean old
Use clinical judgment on blood pressure goal and
drug choice if serious comorbidities
Diabetes
ACE inhib and ARB
CKD without proteinuria (140/90) and with proteinuria= (130/80)
ACE inhib or ARB
Stable ischemic HD
B blockers, ACE in, ARB and CCB
Diabetic HTN
Diuretics, ACe inhib, ARb and CCB
Recurrent stroke
Diuretcs, ACE inhib and ARB
HEART FAILURE
Diuretics, b blocker, ACe inhib, ARB and Aldosterone antagosist
Prev. MI
b blockers, ACE inhib, Ald. inhib
CCD
Ace inhib and ARBs
Thiazide diuretics
Hydrochlorothiazide, Chlorthalidone
Thiazide diuretics MOA
Lower Na and water retention, Dec.\BV, CO, TPR= Dec. BP
Therapeutic use
Thiazides are useful in combination therapy with a variety of
other antihypertensive agents, including p-blockers, ACE inhibitors,
ARBs, and potassium-sparing diuretics. With the exception of metolazone
TD are not effective in patients
low GFR, use Loop diuretics instead
Side effects of TD
hypokalemia, hyperuricemia,
and, to a lesser extent, hyperglycemia in some patients
Loop diuretics
furosemide, torsemide, bumetanide, and ethacrynic acid
LD, MOA
blocking sodium and
chloride reabsorption in the kidneys, even in patients with poor renal
function or those who have not responded to thiazide diuretics. Loop
diuretics cause decreased renal vascular resistance and increased
renal blood flow
Difference in MOa of TD and LD
Thiazides, they can cause hypokalemia. However,
unlike thiazides, loop diuretics increase the calcium content of urine,
whereas thiazide diuretics decrease it. These agents are rarely used
alone to treat hypertension, but they are commonly used to manage
symptoms of heart failure and edema
Potassium-sparing diuretics
Amiloride, Triamterene ( inhibitors of epithelial sodium transport at the late distal and collecting
ducts)
spironolactone and eplerenone
aldosterone receptor antagonists
Beta·ADRENOCEPTOR-BLOCKING AGENTS
b-Blockers are a treatment option for hypertensive patients with concomitant heart disease or heart failure
MOA of Beta-blockers
The p-blockers reduce blood pressure primarily by decreasing
cardiac output (Figure 16.8). They may also decrease sympathetic
outflow from the central nervous system (CNS) and inhibit the release
of renin from the kidneys, thus decreasing the formation of angiotensin II and the secretion of aldosterone
propranolol
which acts at both B1 and B2
Selective blockers of b1
metoprolol, atenelol
Nebivolol
selective blocker
of receptors, which also increases the production of nitric oxide,
leading to vasodilation. The selective may be administered
cautiously to hypertensive patients who also have asthma. The nonselective p-blockers are contraindicated in patients with asthma due
to their blockade of bronchodilation.
Therapeutic uses of B-bLocker
The primary therapeutic benefits of are seen in hypertensive patients with concomitant heart disease, such as supraventricular
tachyarrhythmia {for example, atrial fibrillation), previous myocardial
infarction, stable ischemic heart disease, and chronic heart failure.
Adverse effects of BEta blocker
decrease libido and
cause erectile dysfunction, which can severely reduce patient
compliance.
decreasing high-density
lipoprotein cholesterol and increased triglycerides.
ACE INHIBITORS
captopril [KAP-toe-pril], enalapril [e-NAL-ah-pril],
and lisinopril [lye-SIN-oh-pril] are recommended as first-line treatment of
hypertension in patients with a variety of compelling indications, including high coronary disease risk or history of diabetes, stroke, heart failure,
myocardial infarction, or chronic kidney disease (
MOA of ACE inhib
lower TPR without inc. CO
breakdown bradykinin- NO, prostacyclin and vasodilaton
Dec. Preload and Afterload
Therapeutic uses of Ace inhib.
slow diabetic nephropathy
dec. albuminuria
MI
systolic HF
Do ace inhib need adjustment in Renal impaired patients
All of the ACE inhibitors are orally bioavailable as a drug or prodrug.
All but captopril and lisinopril undergo hepatic conversion to active
metabolites, so these agents may be preferred in patients with severe
hepatic impairment
only IV ace inhib
Enalaprilat
only ACE ihnib not ecreted by kidneys
Fosinopril- No need to adjust in REnal Failure
Adverse effects of ACE
Dry cough
angioedema
K+ diuretics should be used
Contraindicated in Pregnant
ANGIOTENSIN II RECEPTOR BLOCKERS
Lorsartan
MOA of AT2 Blockers
block AT1 levels= block AT2= Low BP
RENIN INHIBITOR
aliskiren
MOA
acts on RAAS by blocking Renin
CCBs
Calcium channel blockers are a recommended first-line treatment option
in black patients. They may also be useful in hypertensive patients with
diabetes or stable ischemic heart disease
Diphenylalkylamines
Verapamil
Angina, SVT
Benzothiazepines
Diltiazem
Relax cardiac and smooth muscle
more favorable than Verapamil
Dihydropyridines
nifedipine, amlodipine, felodipine, isradipine, nicardipine, nisoldipine
MOA of DHPY
dihydropyridines have a much greater affinity for vascular
calcium channels than for calcium channels in the heart. They are,
therefore, particularly beneficial in treating hypertension. The dihydropyridines have the advantage in that they show little interaction
with other cardiovascular drugs, such as digoxin or warfarin, which
are often used concomitantly with calcium channel blockers
Adverse effects of CCBs
Flushing, Dizziness, Headache, hypotension, per. edema
a-ADRENOCEPTOR-BLOCKING AGENTS
Prazosin, Doxazosin, Terazosin
MOA of a-adrenoreceptor
They decrease peripheral vascular resistance and lower arterial blood
pressure by causing relaxation of both arterial and venous smooth muscle. These drugs cause only minimal changes in cardiac output, renal
blood flow, and glomerular filtration rate
Side-eff. of a-ARB
. Reflex tachycardia
and postural hypotension often occur at the onset of treatment and with
dose increases, requiring slow titration of the drug in divided doses
a-/p-ADRENOCEPTOR-BLOCKING AGENTS
Labetalol, carvedilol
uses of a,b ARB
Carvedilol is indicated in the treatment of heart failure and
hypertension. It has been shown to reduce morbidity and mortality associated with heart failure. Labetalol is used in the and hypertensive emergencies
management of
gestational hypertension
Labetalol
CENTRALLY ACTING ADRENERGIC DRUGS
Clonidine, Methyldopa
Clonidine
a2 agonist- inhibition of sympathetic vasomotor centers, decreasing sympathetic
outflow to the periphery. This leads to reduced total peripheral resistance and decreased blood pressure
e treatment of hypertension that has not responded adequately to
treatment with two or more drugs.
Clonidine
useful in the treatment of hypertension complicated by renal disease.
Clonidine does not decrease renal
blood flow or glomerular filtration
Adverse effects Clonidine
y. It is
also available in a transdermal patch. Adverse effects include sedation, dry mouth, and constipation (Figure 16.14}. Rebound hypertension occurs following abrupt withdrawal of clonidine. The drug should,
therefore, be withdrawn slowly if discontinuation is required
Methyldopa
a2 agonist- methylepinephrine, dec. adreneric outflow
common side effects of methyldopa
sedation
and drowsiness. Its use is limited due to adverse effects and the need
for multiple daily doses. It is mainly used for management of hypertension in pregnancy, where it has a record of safety
VASODILATORS
The direct-acting smooth muscle relaxants, such as hydralazine [hyeDRAL-a-zeen] and minoxidil/[min-OX-i-dill], are not used as primary drugs
to treat hypertension.
VD mOA
relaxation of
vascular smooth muscle, primarily in arteries and arterioles. This results
in decreased peripheral resistance and, therefore, blood pressure
inc Contractility, HR and O2 consump.
adv. eff of vasodialtion
inc. MI and AP Na and H2O retention Headache Tachycardia nausea sweating arrhythmia high dose- lupus-like syndrome can occur with high dosages, but it is reversible upon discontinuation of the drug
Indicated in
Hydralazine
is an accepted medication for controlling blood pressure in pregnancy-induced hypertension.
HYPERTENSIVE EMERGENCY
severe elevations in blood pressure (systolic greater than
180 mm Hg or diastolic greater than 120 mm Hg)
A severe elevation in blood pressure without
evidence of target organ damage is considered a hypertensive urgency
managemetn of HTN emer
Hypertensive emergencies require timely blood pressure reduction with
treatment administered intravenously to prevent or limit target organ
damage. A variety of medications are used, including calcium channel
blockers (nicardipine and clevidipine), nitric oxide vasodilators (nitroprusside and nitroglycerin), adrenergic receptor antagonists (phentolamine,
esmolol, and the vasodilator hydralazine, and the dopamine
agonist fenoldopam. Treatment is directed by the type of target organ
damage and/or comorbidities present.
Diuretics (Thiazides, Loop
agents)
Minimal
Centrally acting
Salt & water
retention
Ganglion blocker
Salt & water retention
Alpha1-selective
blockers
Salt & water
retention, slight
tachycardia
Beta blockers
Minimal
Vasodilator, CCB amd Nitroprissude
tention, moderate tachycardia Marked salt & water retention, moderate tachycardia Minor salt & water retention Salt & water retention
Left ventricular
hypertrophy
ACEI, ARB, CCB
Asymptomatic
atherosclerosis
CCB
Microalbuminemia
ACEI, ARB
Renal dysfunction
ACEI, ARB
Previous stroke
ACEI, ARB, Diuretics
Previous MI
ACEI, ARB, BB
Coronary artery
disease
ACEI, ARB, BB
Angina pectoris
BB, CCB
Heart failure
ACEI, ARB, Diuretic, MRA
BB
Aortic aneurysm
BB
Atrial fibrillation
ACEI, ARB, BB
prevention
Atrial fibrillation, rate
control
BB, CCB
(nondihydropyridines)
ESRD, proteinuria ACEI
Peripheral artery
disease
ACEI, CCB
isolated systolic HTN
ACEI, ARB, CCB,
Diuretic
Metabolic syndrome
ACEI, ARB, CCB
Diabetes mellitus
ACEI, ARB, CCB,
Diuretic
DM with proteinuria
ACEI, ARB
Hyperaldosteronism
MRA
Pregnancy
BB, CCB, Methyldopa
Black ethnicity
CCB, Diuretics
