taming the devil inside: pharmacologic management of hypertension
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Taming the Devil Inside:Pharmacologic Management
of Hypertension
Christopher Roe, MSN, ACNP-BC
Lead Nurse Practitioner
Christiana Care Cardiology Consultants
Why Bother?
• 78 million adults have HTN
• Directly linked to myocardial infarction, stroke, heart failure, and kidney disease
• Estimated cost $51 billion in 2009
Statistics from:http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf
Who is the Devil?
Who is the Devil?
• Hormonal Mechanisms
• Neural Mechanisms
• Vascular Mechanisms
• Renal Mechanisms
Hormonal Mechanisms
Neural Mechanisms
Vascular Mechanisms
Renal/Salt Mechanisms
Guidelines for Management of HTNJNC-7 or ESH/ESC
What is the definition?
EHA/ESC Guidelines JNC-7 Guidelines
Treatment of Stage or Grade 1 HTN (without compelling indications)
• JNC-7– Thiazide Diuretic–May consider ACEi, ARB, BB, CCB, or combo
• ESH/ESC– Your choice: no agent is superior– Thiazide Diuretic, BB, CCB, ACEi, or ARB
Thiazide Diuretics• Hydrochlorothiazide• Chlorthalidone• Indapamide (“thiazide-like”)
• Mechanism of Action—diuresis & vasodilation
• Side Effects• Disease related issues
Angiotensin Converting Enzyme Inhibitors (ACEi)
captopril, lisinopril, ramipril, enalapril, trandopril, benazepril
Mechanism of Action
Angiotensin Converting Enzyme Inhibitors (ACEi)
• Side Effects– Cough– Angioedema– Hyperkalemia– Elevated BUN/Cr
• Disease Related issues
Angiotensin Receptor Blockers
• valsartan, losartan, telmisartan, candesartan
• Mechanism of Action
• Side Effects
• Disease related issues
Calcium Channel Blockers
Dihydropyridine Non-dihydropyridine
Calcium Channel BlockersDihydropyridine
• amlodipine, felodipine, nicardipine, nifedipine
• Mechanism of Action
• Side Effects
• Disease related issues
Calcium Channel BlockersNon-dihydropyridine
• diltiazem and verapamil
• Mechanism of Action
• Side Effects
• Disease Related Issues
Beta Blocker
• atenolol, propranolol, metoprolol, nadolol• Subtypes of Beta Recptors– β-1– β-2
• Mechanism of Action• Subgroupings of Beta Blockers– Nonselective– Selective– Nonselective with alpha-1 blocking
Beta Blocker
• Side Effects
• Disease Related Issues
Other Antihypertensives
• Aldosterone Antagonists• Central Acting Alpha-2 Agonists (presynaptic)• Alpha-1 Adrenergic Antagonists (postsynaptic)• Direct Vasodilators• Renin Inhibitors• Others
Novel Pharmacologic Therapies
• Vitamin D
• Fish Oil
• Statins
• Aspirin
Not So Novel Non-Pharmacologic Agents
Reduce Salt Intake
Reduce Alcohol Intake
Increase Aerobic Activity
Novel Interventional Techniques
Renal Nerve Denervation
Questions?
Thank you and Goodbye!
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