Narrated Hypertension Meds

Chapter 46: 

Chapter 46 Drugs for Hypertension

Classification of Blood Pressure (BP): 

Classification of Blood Pressure (BP) Four BP categories (defined by JNC 7): Normal Systolic BP below 120 mm Hg and diastolic BP below 80 mm Hg Prehypertension Systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg Hypertension Systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg Stage 2 hypertension – s ystolic BP and diastolic BP in different categories (eg, 160/92 mm Hg)

Types of Hypertension: 

Types of Hypertension Two broad categories of hypertension Primary (essential) hypertension No identifiable cause Chronic, progressive disorder Population: older adults, African Americans, Mexican Americans, postmenopausal women, obese patients Treated but not cured (lifelong condition) Referred to as “ essential hypertension ” Secondary hypertension Identifiable primary cause Possible to treat the cause directly Some individuals can actually be cured

Consequences of Hypertension: 

Consequences of Hypertension Heart disease Myocardial infarction (MI) Heart failure Angina pectoris Kidney disease Stroke See Box 46-1

Basic Considerations: 

Basic Considerations Benefits of lowering blood pressure Patient evaluation Hypertension with a treatable cause Factors that increase cardiovascular risk Diagnostic tests Treatment goals Therapeutic interventions

Lifestyle Modifications: 

Lifestyle Modifications Weight loss Sodium restriction DASH eating plan Alcohol restriction Aerobic exercise Smoking cessation Maintenance of potassium and calcium intake

Pharmacologic Therapy: 

Pharmacologic Therapy Review of blood pressure control Principal determinants of blood pressure Arterial pressure = cardiac output × peripheral resistance Cardiac output Heart rate Myocardial contractility Blood volume Venous return Systems that help regulate blood pressure Sympathetic baroreceptor reflex Renin-angiotensin-aldosterone system Renal regulation of blood pressure

Slide 10: 

Fig. 46-1. Primary determinants of arterial blood pressure.

Pharmacologic Therapy: 

Pharmacologic Therapy Antihypertensive mechanisms: sites of drug action Brainstem Sympathetic ganglia Terminals of adrenergic nerves Beta 1 -adrenergic receptors on the heart Alpha 1 -adrenergic receptors on blood vessels Vascular smooth muscle Renal tubules Beta 1 receptors on juxtaglomerular cells Angiotensin-converting enzyme Angiotensin II receptors Aldosterone receptors

Slide 12: 

Fig. 46-2. Sites of action of antihypertensive drugs. Note that some antihypertensive agents act at more than one site: beta blockers act at sites 4 and 8a, and thiazides act at sites 6 and 7. The hemodynamic consequences of drug actions atthe sites depicted are summarized in Table 46–4. (ACE = angiotensin-converting enzyme, ARB = angiotensin II receptor blocker.)

Pharmacologic Therapy: 

Pharmacologic Therapy Classes of antihypertensive drugs Diuretics Thiazide diuretics High-ceiling (loop) diuretics Potassium-sparing diuretics Sympatholytics (antiadrenergic drugs) Beta-adrenergic blockers Alpha 1 blockers Alpha/beta blockers: carvedilol and labetalol Centrally acting alpha 1 agonists Adrenergic neuron blockers

Pharmacologic Therapy: 

Pharmacologic Therapy Sympatholytics (antiadrenergic drugs) (cont ’ d) Direct-acting vasodilators: hydralazine and minoxidil Calcium channel blockers Drugs that suppress RAAS ACE inhibitors Angiotensin II receptor blockers Aldosterone antagonists Direct renin Inhibitors

Pharmacologic Therapy: 

Pharmacologic Therapy Fundamentals of hypertension drug therapy Treatment algorithm Initial drug selection Patients WITHOUT compelling indications Patients WITH compelling indications Adding drugs to the regimen Rationale for drug selection Benefits of multidrug therapy Dosing Step-down therapy

Slide 16: 

Fig. 46-3. Algorithm for treating hypertension. (ACE = angiotensin-converting enzyme; ARB = angiotensin II receptor blocker; CCB = calcium channel blocker; DASH = Dietary Approaches to Stop Hypertension; DRI = direct renin inhibitor.) *A “ compelling indication ” is a comorbid condition (eg, heart failure, diabetes) for which a specific class of antihypertensive drugs has been shown to improve outcomes. See text for details.

Pharmacologic Therapy: 

Pharmacologic Therapy Individualizing therapy Patients with comorbid conditions Renal disease Diabetes Patients in special populations African Americans Children and adolescents The elderly

Pharmacologic Therapy: 

Pharmacologic Therapy Minimizing adverse effects Promoting adherence Why adherence can be difficult to achieve Ways to promote adherence Educate the patient Teach self-monitoring Minimize side effects Establish a collaborative relationship Simplify the regimen Other measures

Drugs for Hypertensive Emergencies: 

Drugs for Hypertensive Emergencies Sodium nitroprusside Labetalol

Drugs for Hypertensive Disorders of Pregnancy: 

Drugs for Hypertensive Disorders of Pregnancy Chronic hypertension and pregnancy ACE inhibitors, ARBs, and DRIs are contraindicated during pregnancy Most other antihypertensives can be continued during pregnancy Preeclampsia and eclampsia Hydralazine Magnesium sulfate (anticonvulsant)