hypertension by: dr. marwa shaalan pharm-d. htn = bp > 140/90 assos. with: premature death...
TRANSCRIPT
HTN = BP > 140/90
Assos. With: premature death vascular disease of brain,
heart,kidneys
HYPERTENSION
Types of Hypertension Primary HTN: also known as
essential HTN. accounts for 95%
cases of HTN. no universally
established cause known.
Secondary HTN: less common
cause of HTN ( 5%).
secondary to other potentially rectifiable causes.
Initial tx. of hypertension Lifestyle modification first No smoking Weight control Reduce alcohol intake Decrease stress Sodium control
Treatment of hypertension Lifestyle modification first Initial tx. drug- diuretic or B-
blocker Low dose first, increase dose if
necessary 2nd med. if needed Most respond with diuretic and one
other medication (stepped care)
Drugs to treat hypertension
5 primary classes1. Diuretics2. Calcium channel blockers3. Angiotesin converting enzyme
(ACE) inhibitors4. Autonomic nervous system agents5. Direct acting vasodilators
1- Diuretics Treats: mild to moderate HTN First drug of treatment of
hypertension. Also treats heart failure or kidney
disease Few adverse side effects Used with other anti-hypertensives
to enhance effectiveness
DiureticsAction
Reduce blood volume through urinary excretion of water and electrolytes
1. Electrolyte imbalances can occur (mainly hypokalemia)
2. Depends on type of diuretic
Diuretics
Most efficient: Loop or High-ceiling Reduce edema associated with CHF Increase Urine output even if blood flow
to kidney is diminished Hypokalemia KCL supplement given Lasix, Demadex, Bumex
Diuretics
Most widely prescribed: Thiazides Mild to moderate HTN-primarily Hydrodiuril – hydrochlorothiazide
(HCTZ) Hypokalemia Potassium supplement- KCL
Diuretics Potassium-sparing:prevent
hypokalemia Mild HTN Used in combination with other
diuretics No supplement taken Watch for hyperkalemia
Side effects Orthostatic hypotension Dry mouth,irritation Report: Electrolyte imbalance-
hypokalemia (potasium<3.5) Disorientation dehydration
Implications for use
Optimal time to admin.= AM Accurate intake and output Daily weights Monitor electrolyte imbalances
2-Calcium Channel Blockers
Emerged as major drug to treats HTN
Used for arrythmias also Alternative to B-blocker ( esp.in
Asthma patients)
Calcium Channel Blockers
Action:blocks ca+ access to muscle cells
contractility + conductivity of the ______________________ demand for oxygen PVR (relaxing arterioles)[peripheral
vascular resistance]
Calcium Channel Blockers Examples Verapamil Very
Procardia (nifedipine)-HTN Nice
Cardizem (diltiazem)-arrythmias Drugs
Calcium Channel Blockers SIDE EFFECTS
BP Bradycardia May precipitate A-V block Headache Abdominal discomfort Peripheral edema
3-Angiotensin-Converting Enzyme Inhibitors “ACE” inhibitors Mainstay of oral vasodilator
therapy Major breakthrough in treatment of
HTN More effective when used with
diuretics
ACE INHIBITORS
Angiotensin Converting Enzyme (ends in PRIL)
captopril enalapril benzapril(Capoten) (Vasotec) (Lotensin)
RENIN-ANGIOTENSIN-ALDOSTERONE AXN. BP
excrete renin
formation of angiotensin I angiotensin II = potent vasodilator Aldosterone release Na and H2O
ACE INHIBITORS ACTION
peripheral vascular resistanse without
Ø cardiac outputØ cardiac rate Ø cardiac contractility
Advantages Infrequent orthostatic hypotension Lack of aggravation of pulmonary
disease. Lack of aggravation with Diabetes
Mellitus Increase renal blood flow
4-Adrenergic ReceptorsReview of ANS
Sympathetic Nervous System Alpha 1 = vasoconstriction Alpha 2 = feedback/vasodilation Beta 1 = increases heart rate Beta 2 = bronchodilation
A-Beta Adrenergic Blocking Agents Known as Beta-blockers Anti-adrenergic: Inhibit cardiac
response to sympathetic nerve stimulation by blocking Beta receptors
Decreases heart rate and Cardiac output
Decreases blood pressure
Implications
Can not be abruptly discontinued
Check baseline b.p. Check patients of resp. condition-
aggravates broncho-constriction
Side effects
Bradycardia Bronchospasm, wheezing Diabetic: hypoglycemia Heart failure:
edema,dyspnea,rhales
Interactions Antihypertensives- additive effect Anti-adrenergic effects.
Enzyme inducing agents-enhance metabolism
Indomethacin and salicylates:< controll
B-Alpha-1 adrenergic blockers
Alternative if B-blockers and diuretics do not work
Also used to treat mild to mod. urinary obstructive disease. (BPH)
Alpha-1 Adrenergic Blocking Agents
Action: Block postsynaptic alpha-1
adrenergic receptors to produce arteriolar and venous vasodilation
Reduces peripheral-vascular resistance
Side effects Drowsiness Headache Dizziness,tachycardia,fainting Weakness,lethargy
Interactions: other antihypertensives (enhance effects)
Clinical Implications Side effects most prevalent with
first dose Warn patient that this is normal Instruct pt. to lie down if
dizzy ,weak ….,etc.
C-Centrally Acting Alpha-2 Agonists
Stimulate Alpha-2 receptors in brainstem
Decreases HR, SBP and DBP More frequent side effects –
drowsiness, dry mouth, dizziness Never suddenly Discontinued =
rebound HTN Clonidine [ Catapress] Methyldopa [Aldomet]
5-Direct Acting Vasodilators Action: direct arteriolar smooth
muscle relaxation, decreasing PVR Uses: HTN, renal disease, toxemia
of pregnancy Ex: Apresoline, Minoxedil SE: tachycardia, orthostatic
hypotension , dizziness, palpitations, nausea, nasal congestion
Patient Teaching forAntihypertensive drugs Take medication as prescribed Never discontinue without approval of
healthcare provider Incorporate lifestyle changes, even if
medication brings BP within normal Limits
Check BP on regular basis and report significant variations (and pulse)
Get out of bed slowly
Patient Teaching forAntihypertensive drugs Increase intake of potassium-rich
foods, unless taking potassium sparing diuretics
Weigh regularly and report abnormal weight gains or losses
Do not take OTC drugs without checking with healthcare provider
Special notes on Treatment of Hypertension.
Never combine: 1-Alpha or beta blocker and clonidine - antagonism 2-Nifedepine and diuretic synergism 3-Hydralazine with DHP or prazosin – same type of
action 4-Diltiazem and verapamil with beta blocker –
bradycardia 5-Methyldopa and clonidine
Hypertension and pregnancy: No drug is safe in pregnancy Avoid diuretics, propranolol, ACE inhibitors, Sodium
nitroprusside ..etc Safer drugs: Hydralazine, Methyldopa,
cardioselective beta blockers and prazosin
Hypertensive Crisis
Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated Hypertension)
Hypertensive Emergencies: Progressive end-organ dysfunction. (Malignant Hypertension)
Hypertensive Urgencies Severe elevated BP in the upper
range of stage II hypertension. Without progressive end-organ
dysfunction. Examples: Highly elevated BP
without severe headache, shortness of breath or chest pain.
Usually due to under-controlled HTN.
Hypertensive Emergencies Severely elevated BP (>180/120mmHg). With progressive target organ
dysfunction. Require emergent lowering of BP.
Examples: Severely elevated BP with: - Hypertensive encephalopathy -Acute left ventricular failure with
pulmonary edema -Acute MI or unstable angina pectoris -Dissecting aortic aneurysm
Hypertensive Emergencies 1-Cerebrovascular accident or head injury with high BP 2-Hypertensive encephalopathy 3-Angina or MI with raised BP 4-Acute renal failure with high BP 5-Eclampsia[ pregnancy hypertension ] Drugs:
Sodium Nitroprusside (20-300 mcg/min) – dose titration and monitoring
GTN (5-20 mcg/min) – cardiac surgery, LVF, MI and angina Esmolol (0.5 mg/kg bolus) and 50-200mcg/kg/min - useful
in reducing cardiac work