antihypertensives_upd

8/8/2019 Antihypertensives_upd

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Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Drugs AffectingDrugs AffectingBlood PressureBlood Pressure


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Blood Pressure ControlBlood Pressure ControlElementsElements

Heart RateHeart Rate

Stroke VolumeStroke Volume

Peripheral Vascular Peripheral Vascular ResistanceResistance


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Blood Pressure ControlBlood Pressure ControlBaroreceptorsBaroreceptors

ReninRenin--Angiotensin System Angiotensin System


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HypertensionHypertensionHigh blood pressureHigh blood pressure

Normal:Normal: Systolic < 130 mmHgSystolic < 130 mmHg

Diastolic < 85 mm HgDiastolic < 85 mm Hg


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Classification of Blood PressureClassification of Blood Pressure

CategoryCategory Systemic BP (mm Hg)Systemic BP (mm Hg) Diastolic BP (mm Hg)Diastolic BP (mm Hg)

NormalNormal


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Classification of Blood PressureClassification of Blood Pressure

Primary HypertensionPrimary Hypertension

Specific cause unknownSpecific cause unknown

90% of the cases90% of the casesAlso known as essential or idiopathic hypertension Also known as essential or idiopathic hypertension

Secondary HypertensionSecondary Hypertension

Cause is known (such as eclampsia of pregnancy,Cause is known (such as eclampsia of pregnancy,renal artery disease, pheochromocytoma)renal artery disease, pheochromocytoma)

10% of the cases10% of the cases


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SteppedStepped- -Care Management of HPNCare Management of HPNby JNC 7by JNC 7Step 1: Lifestyle modificationStep 1: Lifestyle modification

weight reductionweight reduction

reductionreductionmoderation of alcohol intakemoderation of alcohol intake

smoking cessationsmoking cessation

physical activity increasephysical activity increase


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SteppedStepped- -Care Management of HPNCare Management of HPNby JNC 7by JNC 7Step 2 : Inadequate ResponseStep 2 : Inadequate Response

continue lifestyle modificationcontinue lifestyle modification

initial drug selectioninitial drug selection

1. Diuretic or Beta blocker 1. Diuretic or Beta blocker

2. ACE inhibitor, calcium channel2. ACE inhibitor, calcium channelblocker, ARBblocker, ARB


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increase drug dose, or increase drug dose, or

substitute another drug, or substitute another drug, or

add a 2add a 2 ndnd drug from another classdrug from another class


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add a 2add a 2 ndnd or 3or 3 rdrd agent or diuretic if notagent or diuretic if notalready prescribedalready prescribed


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HypotensionHypotension

Hypotensive states:Hypotensive states:

Heart muscle is damagedHeart muscle is damaged


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Blood Pressure = COBlood Pressure = CO x x SVRSVR

CO = Cardiac outputCO = Cardiac output

SVR = Systemic vascular resistanceSVR = Systemic vascular resistance


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Instructors may want to insertInstructors may want to insertEIC Image #69:EIC Image #69:

Blood Pressure: Normal RegulationBlood Pressure: Normal Regulation


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Antihypertensive Agents Antihypertensive Agents

Medications used to treat hypertensionMedications used to treat hypertension


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Antihypertensive Ag ents:Antihypertensive Ag ents:

Cate g oriesCate g oriesSympathetic Nervous SystemSympathetic Nervous SystemBlockers/Adrenergic agentsBlockers/Adrenergic agents

Angiotensin Angiotensin- -converting enzyme inhibitorsconverting enzyme inhibitorsAngiotensin II receptor blockers Angiotensin II receptor blockers

Calcium channel blockersCalcium channel blockers

DiureticsDiuretics

VasodilatorsVasodilators


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Antihypertensive Agents: Categories Antihypertensive Agents: Categories

Sympathetic Nervous System Blockers/ Adrenergic agents

Alpha1 blockers Alpha1 blockers

Beta blockers (cardioselective and nonselective)Beta blockers (cardioselective and nonselective)

Centrally acting alpha blockersCentrally acting alpha blockers

Combined alphaCombined alpha- -beta blockersbeta blockers

PeripheralPeripheral- -acting adrenergic agentsacting adrenergic agents


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Antihypertensive Agents: Antihypertensive Agents:

Mechanism of ActionMechanism of ActionAdrener g ic Ag entsAdrener g ic Ag ents

Alpha1 Blockers Alpha1 Blockers (peripherally acting)(peripherally acting)Block the alpha1Block the alpha1- -adrenergic receptorsadrenergic receptorsThe SNS is not stimulatedThe SNS is not stimulated

Result: DECREASED blood pressureResult: DECREASED blood pressure

Stimulation of alpha1Stimulation of alpha1- -adrenergic receptorsadrenergic receptorscauses HYPERtensioncauses HYPERtensionBlocking alpha1Blocking alpha1- -adrenergic receptors causes decreasedadrenergic receptors causes decreasedblood pressureblood pressure


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Adrenergic Agents Adrenergic Agents

Alpha1 Blockers Alpha1 Blockers

doxazosin (Cardura)doxazosin (Cardura)

prazosin (Minipress)prazosin (Minipress)

terazosin (Hytrin)terazosin (Hytrin)


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Mechanism of ActionMechanism of Action Adrenergic Agents Adrenergic Agents

CentralCentral- -Acting Adrenergics Acting Adrenergics

Stimulate alpha2Stimulate alpha2- -adrenergic receptorsadrenergic receptors

Sympathetic outflow from the CNS is decreasedSympathetic outflow from the CNS is decreased

Result: decreased blood pressureResult: decreased blood pressure


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clonidine (Catapres)clonidine (Catapres)

methyldopa (Aldomet)methyldopa (Aldomet)(drug of choice for hypertension in pregnancy)(drug of choice for hypertension in pregnancy)


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Mechanism of ActionMechanism of Action Adrenergic Agents Adrenergic Agents

Adrenergic Neuronal Blockers Adrenergic Neuronal Blockers(peripherally acting)(peripherally acting)

Inhibit release of norepinephrineInhibit release of norepinephrine

Also deplete norepinephrine stores Also deplete norepinephrine stores

SNS (peripheral adrenergic nerves) is not stimulatedSNS (peripheral adrenergic nerves) is not stimulated



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Adrenergic Neuronal Blockers Adrenergic Neuronal Blockers(peripherally acting)(peripherally acting)

reserpinereserpine

guanadrel (Hylorel)guanadrel (Hylorel)

guanethidine (Ismelin)guanethidine (Ismelin)


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Antihypertensive Agents: Antihypertensive Agents: Adrenergic Agents Adrenergic AgentsTherapeutic UsesTherapeutic Uses

Alpha1 blockers (peripherally acting) Alpha1 blockers (peripherally acting)

Treatment of hypertensionTreatment of hypertension

Relief of symptoms of BPHRelief of symptoms of BPH

Management of of severe CHF when usedManagement of of severe CHF when usedwith cardiac glycosides and diureticswith cardiac glycosides and diuretics


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Adrenergic Agents Adrenergic AgentsTherapeutic UsesTherapeutic Uses


Treatment of hypertension, either alone or Treatment of hypertension, either alone or with other agentswith other agents Usually used after other agents have failedUsually used after other agents have failed

due to side effectsdue to side effects Also may be used for treatment of severe Also may be used for treatment of severe

dysmenorrhea, menopausal flushing, glaucomadysmenorrhea, menopausal flushing, glaucoma Clonidine is useful in the management of Clonidine is useful in the management of

withdrawal symptoms in opioidwithdrawal symptoms in opioid- - or nicotineor nicotine- -dependent personsdependent persons


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Adrenergic Agents Adrenergic AgentsTherapeutic UsesTherapeutic Uses

Adrenergic neuronal blockers Adrenergic neuronal blockers(peripherally acting)(peripherally acting)

Treatment of hypertension, either alone or withTreatment of hypertension, either alone or withother agentsother agents

Seldom used because of frequent side effectsSeldom used because of frequent side effects


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Adrenergic Agents Adrenergic AgentsSide EffectsSide Effects

Most common:Most common: dry mouthdry mouth drowsinessdrowsinesssedationsedation constipationconstipation

Other:Other: headachesheadaches sleep disturbancessleep disturbancesnauseanausea rashrashcardiac disturbances (palpitations)cardiac disturbances (palpitations)

HIGH INCIDENCE OF ORTHOSTATIC HYPOTENSIONHIGH INCIDENCE OF ORTHOSTATIC HYPOTENSION


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CategoriesCategories Angiotensin Angiotensin- -Converting Enzyme InhibitorsConverting Enzyme Inhibitors

(ACE Inhibitors)(ACE Inhibitors)

Large group of safe and effective drugsLarge group of safe and effective drugs

Often used as firstOften used as first- -line agents for CHFline agents for CHFand hypertensionand hypertension

May be combined with a thiazide diureticMay be combined with a thiazide diureticor calcium channel blocker or calcium channel blocker


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Mechanism of ActionMechanism of Action ACE Inhibitors ACE Inhibitors

Aldosterone stimulates water and sodium resorption. Aldosterone stimulates water and sodium resorption.

Result: increased blood volume, increased preload,Result: increased blood volume, increased preload,and increased Band increased B


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Antihypertensive Agents Antihypertensive Agents ACE Inhibitors ACE Inhibitors

captopril (Capoten)captopril (Capoten)

Short half Short half- -life, must be dosed more frequentlylife, must be dosed more frequentlythan othersthan othersenalapril (Vasotec)enalapril (Vasotec)

The only ACE inhibitor available in oral andThe only ACE inhibitor available in oral andparenteral formsparenteral forms

lisinopril (Prinivil and Zestril) and quinapril (Accupril)lisinopril (Prinivil and Zestril) and quinapril (Accupril)

Newer agents, long half Newer agents, long half- -lives, oncelives, once- -aa--day dosingday dosing

Several other agents availableSeveral other agents available


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Therapeutic UsesTherapeutic Uses ACE Inhibitors ACE Inhibitors

HypertensionHypertension

CHF (either alone or in combination with diureticsCHF (either alone or in combination with diureticsor other agents)or other agents)

Slows progression of left ventricular hypertrophySlows progression of left ventricular hypertrophy

after an MIafter an MIRenal protective effects in patients with diabetesRenal protective effects in patients with diabetes

Drugs of choice in hypertensive patients with CHFDrugs of choice in hypertensive patients with CHF


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Side EffectsSide Effects ACE Inhibitors ACE Inhibitors

FatigueFatigue DizzinessDizziness

HeadacheHeadache Mood changesMood changesImpaired tasteImpaired taste

Dry, nonproductive cough, reverses when therapy is stoppedDry, nonproductive cough, reverses when therapy is stopped

NOTE: firstNOTE: first- -dose hypotensive effect may occur!!dose hypotensive effect may occur!!


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CategoriesCategories Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers

(A II Blockers or ARBs)(A II Blockers or ARBs)

Newer classNewer class

WellWell--toleratedtolerated

Do not cause coughingDo not cause coughing


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Mechanism of ActionMechanism of Action Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers

Allow angiotensin I to be converted to angiotensin II, Allow angiotensin I to be converted to angiotensin II,but block the receptors that receive angiotensin IIbut block the receptors that receive angiotensin II

Block vasoconstriction and release of aldosteroneBlock vasoconstriction and release of aldosterone


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Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers

losartan (Cozaar)losartan (Cozaar)

eposartan (Teveten)eposartan (Teveten)

valsartan (Diovan)valsartan (Diovan)

irbesartan (Avapro)irbesartan (Avapro)

candesartan (Atacand)candesartan (Atacand)

telmisartan (Micardis)telmisartan (Micardis)


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Therapeutic UsesTherapeutic Uses Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers


Adjunctive agents for the treatment of CHF Adjunctive agents for the treatment of CHF

May be used alone or with other agents suchMay be used alone or with other agents suchas diureticsas diuretics


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Side EffectsSide Effects Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers

Upper respiratory infectionsUpper respiratory infections

HeadacheHeadache

May cause occasional dizziness, inability to sleep,May cause occasional dizziness, inability to sleep,diarrhea, dyspnea, heartburn, nasal congestion,diarrhea, dyspnea, heartburn, nasal congestion,back pain, fatigueback pain, fatigue


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CategoriesCategoriesCalcium Channel BlockersCalcium Channel Blockers

BenzothiazepinesBenzothiazepines

DihydropyridinesDihydropyridines

PhenylalkylaminesPhenylalkylamines


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Mechanism of ActionMechanism of ActionCalcium Channel BlockersCalcium Channel Blockers

Cause smooth muscle relaxation by blocking theCause smooth muscle relaxation by blocking thebinding of calcium to its receptors, preventingbinding of calcium to its receptors, preventingmuscle contractionmuscle contraction

This causes decreased peripheral smooth muscleThis causes decreased peripheral smooth muscletone, decreased systemic vascular resistancetone, decreased systemic vascular resistance



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Calcium Channel BlockersCalcium Channel Blockers

Benzothiazepines:Benzothiazepines:

diltiazem (Cardizem, Dilacor)diltiazem (Cardizem, Dilacor)

Phenylalkamines:Phenylalkamines:

verapamil (Calan, Isoptin)verapamil (Calan, Isoptin)

Dihydropyridines:Dihydropyridines: amlodipine (Norvasc), bepridil (Vascor),amlodipine (Norvasc), bepridil (Vascor),

nicardipine (Cardene)nicardipine (Cardene)

nifedipine (Procardia), nimodipine (Nimotop)nifedipine (Procardia), nimodipine (Nimotop)


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Therapeutic UsesTherapeutic UsesCalcium Channel BlockersCalcium Channel Blockers

Angina Angina


DysrhythmiasDysrhythmias

Migraine headachesMigraine headaches


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Side EffectsSide EffectsCalcium Channel BlockersCalcium Channel Blockers

Cardiovascular Cardiovascular

hypotension, palpitations, tachycardiahypotension, palpitations, tachycardia

GastrointestinalGastrointestinal

constipation, nauseaconstipation, nausea

Other Other

rash, flushing, peripheral edema, dermatitisrash, flushing, peripheral edema, dermatitis


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Antihypertensive Agents: Diuretics Antihypertensive Agents: Diuretics

Decrease the plasma and extracellular fluid volumesDecrease the plasma and extracellular fluid volumes

Results:Results: decreased preloaddecreased preload

decreased cardiac outputdecreased cardiac outputdecreased total peripheral resistancedecreased total peripheral resistance

Overall effect:Overall effect: decreased workload of the heart,decreased workload of the heart,and decreased blood pressureand decreased blood pressure


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VasodilatorsVasodilators

diazoxide (Hyperstat)diazoxide (Hyperstat)

hydralazine HCl (Apresoline)hydralazine HCl (Apresoline)

minoxidil (Loniten, Rogaine)minoxidil (Loniten, Rogaine)

sodium nitroprusside (Nipride, Nitropress)sodium nitroprusside (Nipride, Nitropress)


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Antihypertensive Agents: Side Antihypertensive Agents: Side

EffectsEffectsVasodilatorsVasodilators

Hydralazine:Hydralazine:

dizziness, headache, anxiety, tachycardia,dizziness, headache, anxiety, tachycardia,nausea and vomiting, diarrhea, anemia,nausea and vomiting, diarrhea, anemia,dyspnea, edema, nasal congestiondyspnea, edema, nasal congestion

Sodium nitroprusside:Sodium nitroprusside:

bradycardia, hypotension, possiblebradycardia, hypotension, possiblecyanide toxicitycyanide toxicity


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Nursing ImplicationsNursing ImplicationsBefore beginning therapy, obtain a thoroughBefore beginning therapy, obtain a thoroughhealth history and headhealth history and head- -toto--toe physicaltoe physicalexamination.examination.

Assess for contraindications to specific Assess for contraindications to specificantihypertensive agents.antihypertensive agents.

Assess for conditions that require cautious Assess for conditions that require cautioususe of these agents.use of these agents.


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Nursing ImplicationsNursing ImplicationsEducate patients about the importance of notEducate patients about the importance of notmissing a dose and taking the medications exactlymissing a dose and taking the medications exactlyas prescribed.as prescribed.

Patients should never double up on doses if a dosePatients should never double up on doses if a doseis missed; check with physician for instructions onis missed; check with physician for instructions onwhat to do if a dose is missed.what to do if a dose is missed.

Monitor BP during therapy. Instruct patients toMonitor BP during therapy. Instruct patients tokeep a journal of regular BP checks.keep a journal of regular BP checks.


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Nursing ImplicationsNursing ImplicationsInstruct patients that these drugs should not beInstruct patients that these drugs should not bestopped abruptly, as this may cause a reboundstopped abruptly, as this may cause a reboundhypertensive crisis, and perhaps lead to CVA.hypertensive crisis, and perhaps lead to CVA.

Oral forms should be given with meals so thatOral forms should be given with meals so thatabsorption is more gradual and effective.absorption is more gradual and effective.

Administer IV forms with extreme caution and Administer IV forms with extreme caution anduse an IV pump.use an IV pump.


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Nursing ImplicationsNursing ImplicationsRemind patients that medications is only part of Remind patients that medications is only part of therapy. Encourage patients to watch their diet,therapy. Encourage patients to watch their diet,stress level, weight, and alcohol intake.stress level, weight, and alcohol intake.

Patients should avoid smoking and eating foodsPatients should avoid smoking and eating foodshigh in sodium.high in sodium.

Encourage supervised exercise.Encourage supervised exercise.


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Nursing ImplicationsNursing ImplicationsInstruct patients to change positions slowly to avoidInstruct patients to change positions slowly to avoidsyncope from postural hypotension.syncope from postural hypotension.

Patients should report unusual shortness of breath;Patients should report unusual shortness of breath;difficulty breathing; swelling of the feet, ankles, face,difficulty breathing; swelling of the feet, ankles, face,or around the eyes; weight gain or loss; chest pain;or around the eyes; weight gain or loss; chest pain;palpitations; or excessive fatigue.palpitations; or excessive fatigue.


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Nursing ImplicationsNursing ImplicationsMen taking these agents may not be aware thatMen taking these agents may not be aware thatimpotence is an expected effect. This may influenceimpotence is an expected effect. This may influencecompliance with drug therapy.compliance with drug therapy.

If patients are experiencing serious side effects,If patients are experiencing serious side effects,or believe that the dose or medication needs toor believe that the dose or medication needs tobe changed, they should contact their physicianbe changed, they should contact their physicianimmediately.immediately.


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Nursing ImplicationsNursing ImplicationsHot tubs, showers, or baths; hot weather; prolongedHot tubs, showers, or baths; hot weather; prolongedsitting or standing; physical exercise; and alcoholsitting or standing; physical exercise; and alcoholingestion may aggravate low blood pressure,ingestion may aggravate low blood pressure,

leading to fainting and injury. Patients shouldleading to fainting and injury. Patients shouldsit or lie down until symptoms subside.sit or lie down until symptoms subside.

Patients should not take any other medications,Patients should not take any other medications,including OTC drugs, without first getting theincluding OTC drugs, without first getting theapproval of their physician.approval of their physician.


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C i h 2002 1998 El i S i (USA) All i h d


Nursing ImplicationsNursing ImplicationsMonitor for side/adverse effectsMonitor for side/adverse effects(dizziness, orthostatic hypotension, fatigue)(dizziness, orthostatic hypotension, fatigue)and for toxic effects.and for toxic effects.

Monitor for therapeutic effectsMonitor for therapeutic effects

Blood pressure should be maintained at lessBlood pressure should be maintained at lessthan 140/90 mm Hgthan 140/90 mm Hg

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