Hypertension

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Presentation Transcript

Hypertension: 

Brooke Y. Patterson, PharmD, BCPS Adjunct Professor Research college of nursing Hypertension

Introduction: 

Introduction American Heart Association estimates that 65 million Americans have HTN Major cardiovascular risk factor JNC 7 Guidelines

Overview: 

Overview Systolic BP more predictive of CVD than diastolic Patients age 50 or older Risk of CVD doubles with every 20/10 mmHg increase in BP Starting at value of 115/75 mmHg BP = CO X SVR

Overview: 

Overview BP = CO X SVR

Diagnosis: 

Diagnosis Repeated BP measurements Secondary HTN ruled-out Classification of blood pressure in adults according to JNC-7 (Table 15-3) BP goals and classification changes based on co-morbidities

Etiology: 

Etiology Essential HTN No identifiable cause Secondary HTN (10%) Primary aldosteronism Renal parenchymal disease Thyroid or parathyroid disease Medication-related

Therapeutic Goals: 

Therapeutic Goals Prevent associated morbidity and mortality Goal of BP < 140/90 mmHg (most patients) DM goal <130/80 mmHg Chronic kidney disease goal <130/80 mmHg Heart failure goal <120/80 mmHg

Non-Pharmacologic Interventions: 

Non-Pharmacologic Interventions Table 15-4 Weight loss and DASH diet provide profound BP-lowering Benefit in prevention of other disease states Recommend for all patients, but rarely singular intervention

Therapeutic Management: 

Therapeutic Management JNC-7 Thiazide diuretic first DOC ACE inhibitor/ARB, Beta-blocker or CCB next Compelling Indications (Figure 15-3) DM and ACE Inhibitors Beta-Blockers and status post-MI Appropriate dosing and frequency in Table 15-5

Diuretics: 

Diuretics Thiazide diuretics PREFERRED HCTZ most common Chlorthalidone Loop diuretics For patients with renal insufficiency ONLY Potassium-sparing diuretics Mechanism of Action Sodium diuresis Volume depletion

Thiazide Diuretics: 

Thiazide Diuretics Side Effects Erectile dysfunction Diuresis Take QAM to prevent nocturnal diuresis Hypokalemia Caution in persons with gout

After you add a thiazide diuretic…..what is next?: 

Based on compelling indications and/or hypertension 'driving force' After you add a thiazide diuretic…..what is next?

Beta-Blockers: 

Beta-Blockers Mechanism of Action Reduce cardiac output Decrease cardiac contractility Reduce release of adrenergic agents Decrease renin release 3 types of Beta-Blockers (BBs) Nonselective Cardioselective Intrinsic sympathomimetic activity (ISA)

Beta-Blockers: 

Beta-Blockers Adverse Effects Fatigue Insomnia Bradycardia Erectile dysfunction Depression Bronchospasm (caution with severe COPD)

Beta-Blockers: 

Beta-Blockers Mechanism of Action Reduce cardiac output Decrease cardiac contractility Reduce release of adrenergic agents Decrease renin release 3 types of Beta-Blockers (BBs) Nonselective Cardioselective Intrinsic sympathomimetic activity (ISA)

Beta-Blockers: 

Beta-Blockers Adverse Effects Fatigue Insomnia Bradycardia Erectile dysfunction Depression Bronchospasm (caution with severe COPD)

ACE Inhibitors: 

ACE Inhibitors Mechanism of Action Produce vasodilation Decrease aldosterone secretion Reno-protective Preferred agent in diabetics

ACE Inhibitors: 

ACE Inhibitors ACE cough Dry cough Drug-related vs. other cause Angioedema Renal failure Renal artery stenosis Hyperkalemia Renal dysfunction

Angiotensin Receptor Blockers (ARBs): 

Angiotensin Receptor Blockers (ARBs) Mechanism of Action Vasodilation Prevents aldosterone release Minimal morbidity and mortality data—should be reserved for use in patients who cannot tolerate ACE inhibitors

Calcium Channel Blockers: 

Calcium Channel Blockers Mechanism of Action Relaxation of cardiac and smooth muscle Vasodilation 2 classes DHPs Potent vasodilators Non-DHPs (verapamil, diltiazem) Negative inotropes

Calcium Channel Blockers: 

Calcium Channel Blockers Adverse Effects HA Flushing (esp. redheads) Peripheral edema (DHPs) Constipation (verapamil) AV block Bradycardia (verapamil, diltiazem)

Aldosterone Receptor Antagonists: 

Aldosterone Receptor Antagonists Mechanism of Action Increased excretion of sodium and water Decreased excretion of potassium Spironolactone (Aldactone®) 25-50mg PO QD Eplerenone (Inspra®) 50-100mg PO QD Hyperkalemia, gynecomastia

Alpha Blockers: 

Alpha Blockers Mechanism of Action Arteriolar and venous dilation Adverse Effects Postural hypotension Dizziness Headaches Drowsiness 3 agents Doxazosin (Cardura®) 1-16mg PO QD Prazosin (Minipress®) 2-30mg PO TID Terazosin (Hytrin®) 1-20mg PO QD

Central Alpha Adrenergic Agonists: 

Central Alpha Adrenergic Agonists Alternative therapy Mechanism of Action Inhibit sympathetic outflow Peripheral vasodilation Adverse Effects Rebound hypertension Sedation Drowsiness HA Mucosal drying Nervousness

Special Considerations: 

Special Considerations Elderly patients Drugs with multiple indications Lowest dose first African-Americans ACE inhibitors? (controversial) Preganancy Table 15-7

Case: 

Case DM is a 44 yo WF with a history of HTN. Her current medications include HCTZ 25mg PO QD and atenolol 25mg PO QD. Her BP today is 155/95 mmHg and her pulse is 88 bpm. Patient says she is compliant with her medication.