HYPERTENSION
INTRODUCTION
AFFLICTS OVER 60 MILLION AMERICANS
DIAGNOSIS
DIASTOLIC>90 SYSTOLIC>140
AGE
# OF READINGS
ETIOLOGY
ESSENTIAL (PRIMARY)
SECONDARY (high renin, Cushing’s, drugs)
INTRODUCTION
LONG TERM CONSEQUENCES
renal, cardiac, vascular
NON-PHARMACOLOGIC THERAPY
DIET - decrease weight, decrease sodium, decrease alcohol, decrease fats
DECREASED SMOKING
INCREASED EXERCISE
RELAXATION TECHNIQUES
PHARMACOLOGIC THERAPY
SHORT TERM BENEFITS VERSUS LONG TERM
VHA Coop Study - benefits demonstrated
Mortality and morbidity consequences
CAUSES OF THERAPEUTIC FAILURES
COMPLIANCE - drug side effects
INSUFFICIENT DOSE
NON-COMPLIANCE TO DIET/EXERCISE
DRUG INTERACTIONS
ACQUIRED RESISTANCE
STEP APPROACH
STEP 1
DIURETIC
BETA BLOCKER
ALPHA ADRENERGIC BLOCKER
ACE INHIBITOR
CALCIUM CHANNEL BLOCKER
STEP 2
SYMPATHOLYTIC
BETA BLOCKER
ALPHA ADRENERGIC BLOCKER
ACE INHIBITOR
CALCIUM CHANNEL BLOCKER
STEP APPROACH
STEP 3
VASODILATOR
STEP 4
SYMAPATHOLYTIC
guanethidine
DIURETICS
DEFINITION - increases formation of urine
USE
Management of edema - CHF, cranial, ascites
Hypertension
Maintain Urine Flow - shock
Protect from nephrotoxic agent
Glaucoma
OSMOTIC DIURETICS
NON-ELECTROLYTE
FREELY FILTERABLE AT GLOMERULUS
PHARMACOLOGICALLY INERT
OSMOTICALLY PULL ACTIVE PARTICLES INTO BLOOD STREAM AND INTO URINE
NO EFFECT ON SERUM ELECTROLYTE BALANCE
OSMOTIC DIURETICS
TOXICITIES - increased cardiac work load
USE
MAINTAIN URINE VOLUME DURING SHOCK OR RENAL FAILURE
PROTECT AGAINST NEPHROTOXIC AGENTS
GLAUCOMA
CEREBRAL EDEMA
CARBONIC ANHYDRASE INHIBITORS
PHARMACOLOGY
INCREASES LOSS OF BICARBONATE IN URINE AND LOSS OF SODIUM
DIURETIC EFFECT WORKS FOR ONLY 3 DAYS
DECREASED INTRA OCULAR PRESSURE EFFECT CONTINUES INDEFINITELY
CARBONIC ANHYDRASE INHIBITORS
THERAPEUTIC USE
SHORT TERM DIURETIC
GLAUCOMA
TOXICITIES
DROWSINESS
METABOLIC ACIDOSIS
THIAZIDE DIURETICS
PHARMACOLOGY
BLOCKS REABSORPTION OF SODIUM AND WATER IN DISTAL TUBULE OF KIDNEY
METOLAZONE ALSO BLOCKS REABSORPTION IN THE PROXIMAL TUBULE OF KIDNEY
INCREASES SECRETION OF POTASSIUM INTO URINE
THIAZIDE DIURETICS
OTHER METABOLIC EFFECTS
INCREASES BLOOD URIC ACID, SUGAR, CHOLESTEROL AND TRIGLYCERIDE
INCREASES BLOOD CALCIUM
DECREASES BLOOD POTASSIUM AND MAGNESIUM
THIAZIDE DIURETICS
USE
HYPERTENSION
MANAGEMENT OF EDEMA (metolazone with or without a loop diuretic)
Hypercalcemia
LOOP DIURETICS
PHARMACOLOGY
BLOCKS REABSORPTION OF SODIUM AND WATER IN ASCENDING LOOP OF HENLE
INCREASES SECRETION OF POTASSIUM INTO URINE
LOOP DIURETICS
TOXICITIES
Ototoxicity, nephrotoxicity
OTHER METABOLIC EFFECTS
INCREASES BLOOD URIC ACID, SUGAR, CHOLESTEROL AND TRIGLYCERIDE
DECREASES BLOOD CALCIUM
DECREASES BLOOD POTASSIUM AND MAGNESIUM
LOOP DIURETICS
USE
HYPERTENSION
MANAGEMENT OF EDEMA
HYPERCALCEMIA
POTASSIUM SPARING DIURETICS
DIRECT ACTING
TRIAMTERENE
AMILORIDE
BLOCKS REABSORPTION OF SODIUM AND WATER IN COLLECTING DUCT OF NEPHRON
INDIRECT ACTING
SPIRONOLACTONE
COMPETITIVE INHIBITOR OF ALDOSTERONE
POTASSIUM SPARING DIURETICS
PHARMACOLOGY
MINIMIAL DIURETIC EFFECT
DECREASES SECRETION OF POTASSIUM INTO URINE
POTASSIUM SPARING DIURETICS
THERAPEUTIC USE
Spare potassium loss of diuretics
Additional uses of spironolactone - edema associated with liver failure and congestive heart failure
POTASSIUM SPARING DIURETICS
TOXICITIES
Hyperkalemia - therefore potassium is not administered concurrently
THERAPEUTIC ALTERNATIVES
Foods high in potassium
potassium supplement
caution with IV administration
SYMPATHOLYTICS
STEP 2 THERAPY
SIDE EFFECTS
SODIUM AND WATER RETENTION
POSTURAL HYPOTENSION
CONSTIPATION
DRY MOUTH
IMPOTENCY
SYMPATHOLYTICS
CLONIDINE
REBOUND HYPERTENSION IF NOT COMPLIANT
PATCH ALTERNATIVE
MAY BE USED FOR ACUTE HIGH BP
METHYLDOPA
RESERPINE - noted to cause breast CA
GUANETHIDINE - 4th step due to diarrhea
BETA BLOCKERS
BLOCKS RENIN RELEASE
DIABETICS
ASTHMATICS
ALPHA ADRENERGIC BLOCKERS
DUAL MECHANISM - Blocks alpha receptor and directly causes vascular smooth muscle vasodilation
No rebound tachycardia
First Dose Effect - caution for syncope
USES
Hypertension
Prostate hypertrophy
VASODILATOR
DIRECT RELAXATION OF VASCULAR SMOOTH MUSCLE
REBOUND TACHYCARDIA
SODIUM AND WATER RETENTION
VASODILATOR
HYDRALAZINE
Side effect - lupus like syndrome
MINOXIDIL
Side effect - hair growth
NITROPRUSSIDE
dilates arterioles and venules
therapy cannot exceed 3 days or leads to thiocyanate poisoning (muscle spasm,stupor)
VASODILATOR
DIAZOXIDE
side effect - hyperglycemia
very poor control of the lowering of blood pressure
ANGIOTENSIN CONVERTING ENZYME INHIBITOR
BLOCKS CONVERSION OF ANGIOTENSIN 1 TO ANGIOTENSIN 2
SIDE EFFECT - Non-productive cough
USE
HYPERTENSION
CONGESTIVE HEART FAILURE
DIABETIC RENAL SPARING
ANGIOTENSIN RECEPTOR BLOCKER
Utilized for patients that cannot tolerate side effects of ACE inhibitors
Examples: losartan, irbesartan
CALCIUM CHANNEL BLOCKER
Blocks entry of calcium into cells
Prevents contraction of vascular smooth muscle
Use
Hypertension
Angina
Arrhythmia