Hypertension 2

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Hypertension definition: >140/90
Hypertension complications: Cardiovascular (CHF PAD, MI)
Renal
Cerebrovascular (Stroke)
Opthalmic
BP calculation: Stroke volume X Heart rate X Peripheral Resistance
BP goal in kidney disease: 130/80
BP goal in diabetes: 130/80
Drug Induced Hypertention: Steroids
Estrogens
Alcohol
Cocaine
Cyclosporine and Tacrolimus
Sympathomimetics
Erythropoietin
Licorice
MAOIs
TCAs
NSAIDs
Hypertension Goals of therapy: Reduce end organ damage
Minimize risk factors for heart disease
Hypertension goal in proteinuria >1g/24h: 125/75
HTN initial drug choices Stage 1 140-159/90-99: Thiazides for most
May consider ACEI, ARB, BB, CCB, or combo
HTN initial drug choices Stage 2 >160/>100: 2 drug combination
Usually thiazide and ACEI, ARB, BB, or CCB
HTN drugs in Heart failure: Diuretic
Beta Blocker
ACEI
ARB
Aldosterone Antagonist
HTN drugs post MI: BB
ACEI
Aldosterone Antagonist
HTN drugs High coronary disease risk: Diuretic
BB
ACEI
CCB
HTN drugs in Diabetes: Diuretic
BB
ACEI
ARB
CCB
HTN drugs in Chronic kidney disease: ACEI
ARB
HTN Drugs recurrent stroke prevention: Diuretic
ACEI
Lifestyle modifications to manage hypertension: Weight reduction
DASH diet
Sodium restriction
Exercise
Decrease Alcohol comsumption
Thiazide diuretics Mechanism of Action: Direct arteriole dilation
Reduce total fluid volume by inhibiting sodium reabsorption - increases excretion of sodium, mater, potassium, and hydrogen
Efficacy decreased if GFR < 30
Thiazides Adverse drug events: Decreased potassium, sodium and magnesium
Increased uric acid and calcium
Rare: blood dycrasias, photosensitivity, pancratitis, hyponatremia, sulfonamide-type immune reactions
Other: impotence, fatigue, HA, rash, vertigo
Thiazide patient instructions/counseling: Can be taken with food or milk
Take early in day to avoid nocturia
May become more sensitive to sunlight - wear sunscreen
May increase blood glucose in diabetics
Muscle cramps may indicate decreased potassium level
Thiazide Drug interactions: Steroids: Salt retention and antagonize thiazide action
NSAIDs: Blunt thiazide response
Class IA or III antiarrhythmics - may cause torsades de pointes
Probenecid and lithium: block thiazide effects
Loop diuretics Mechanism of action: Reduce fluid volume by inhibiting sodium and chloride reabsorption in ascending loop of Henle, which causes incrased excretion of water, sodium, chloride, magnesium, and calcium
More effective than thiazides in patients with renal failure (GFR <30)
Loop Diuretics Adverse drug events: Ototoxicity at high doses
Loop diuretics patient counseling: Can be taken with food or milk
take early in the day to avoid nocturia
May become more sensitive to sunlight
May incrase blood glucose in diabetics
muscle cramps may indicate decrased potassium
rise slowly from lying or sitting position
Loop Drug interactions: Aminoglycosides: Ototoxicity
NSAIDs: blunt diuretic response
Class IA or II antiarrhytmics: torsades de pointes
Probenecid: blocks effect
Loop Diuretics Monitoring: Weight
Electrolytes
BUN/Creatinine
Uric acid
Hearing
Potassium-sparing diuretics Mechanism of Actions: Interferes with Potassium/Sodium exchange in disat tubule, decreases calcium excretion, increases magnesium loss
Potassium sparing Adverse drug events: Hyperkalemia
Avoid with history of kidney stones or hepatic disease
Potassium sparing diuretics Patient counseling: Take early in day to avoid nocturia
Take after meals
Avoid high potassium foods
May increase blood glucose in diabetics
muscle cramps may indecate decreased potassium levels
Sexual dysfunction
Potassium sparing diuretics drug interactions: ACEIs: May increase risk of hyperkalemia
Indomethacin: Combo with triamterene can cause decrease in renal function
Cimetidine: increases bioavailability and decreases clearance of triamterene
Potassium sparing diuretics Monitoring: Weight
Electrolytes (potassium)
BUN/SCr
Centrally active Alpha agonists Mechanism of action - Hypertension: Decreases sympathetic outflow to cardiovascular system
Centrally active alpha agonists adverse events: sedation, dry mouth, bradycardia, withdrawal hypertension, orthostatic hypotension
Centrally active alpha agonists Patient counseling: Report dizziness or hypotension
Sedation precautions
Fever and flu like symptoms may represent hepatic dysfunction in methyldopa
Sexual dysfunction
Centrally active alpha agonists drug disease interactions: Use cautiously with other sedating meds
use cautiously in patients with angina, MI, CVA, and hepatic or renal disease
Alpha Blockers mechanism of action: Vasodilation in both arteries and veins
Alpha Blockers Adverse drug events: Postural hypotension, diarrhea, weight gain, dry mouth, urinary urgency, constipation, priapism
Alpha blockers patient counseling: Take first dose of no more than 1 mg of any agent at bedtime
Rise slowly from lying or sitting position
Priapism
Alpha blockers drug interactions: NSAIDs: decrease antihypertensive effects
Beta Blockers Mechanism of action: Blocks secretion of renin
Decreased cardiac contractility
Decreases central sympathetic output
Decreased heart rate
Beta Blockers Adverse events: Bronchospasm, bradycardia, heart failure, may mask insulin-induced hypoglycemia, fatigue, decreased exercise toerance, hypertriglyceridemia
Beta Blockers Patient counseling: Dizziness/hypotension
Sedation precautions
Abrupt withdrawal should be avoided
Sexual dysfunction
Beta blockers Drug interactions: Sulfonylureas: Beta blockers decrease effectiveness of sulfonylureas
Nondihydropyridines: may increase effect/toxicity of Beta Blockers
Beta Blockers Monitoring: ECG
Rebound hypertension
Cholesterol
Pulse
Glucose levels
Calcium Channel Blockers best suited for what patients?: Low-renin hypertensive
black patients
Elderly patients
Calcium Channel Blockers mechanism of action: Causes relaxation of both coronary and peripheral arteries
Sinoatrial and atrioventricular notal depression and decrease in mycardial contractility
Calcium Channel Blockers - Nondihydropyridines Adverse events: Conduction defects
Worsening of systolic dysfunction
Gingival hyperplasia
Diltiazem: Nausea, headache
Verapamil: Constipation
Calcium Channel Blockers - Dihydropyridines Adverse events: Conduction defects
Gingival hyperplasia
Worsening of systolic dysfunction
Edema of ankle
Flushing
Calcium Channel blockers Patient Counseling: Report dizziness or hypotension
Constipation (Verapamil)
Report SOB, fatigue, or increased swelling
Calcium Channel Blockers Drug interactions: Use nondihydropyridines with caution with beta blockers - increase CHF and bradycardia
Grapefruit juice may increase levels of some dihydropyridines
Calcium Channel Blockers Monitoring: ECG
Peripheral edema
pulse
Bowel habits
symptoms of conduction disturbances
ACE Inhibitors Black population: Ineffective as monotherapy
Addition of diuretic has shown to sensitize black patients
ACEIs Mechanism of action: inhibit Angiotensin I to angiotensin II (a potent vasoconstrictor)
ARBs Mechanism of action: Alternative therapy to ACEIs when cough is present
ACEI Adverse events: Cough
Angioedema, hyperkalemia, rash, loss of taste, leukopenia
ARBs Adverse events: Angioedema, hyperkalemia
ACEI and ARB counseling: Symptoms of swelling of lips, mouth, or face should be considered an emergency
Report new rashes (especially captopril)
Do not use salt substitutes containing potassium, or OTC potassium supplements
ACEI and ARB Drug interactions: NSAIDs will decrease effectiveness of ACEI and ARBs
Potassium sparing diuretics, potassium supplements increase risk of hyperkalemia
Avoid in patients with Renal artery stenosis
Avoid in pregnancy
ACEI and ARB Monitoring: Electrolytes (especially creatinine and potassium)
Aymptoms of angioedema
CBC for neutropenia (captopril and enalapril)
Cough

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