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NurseReview.Org - Antihypertensives Updates (pharmacology review notes)
 

NurseReview.Org - Antihypertensives Updates (pharmacology review notes)

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    NurseReview.Org - Antihypertensives Updates (pharmacology review notes) NurseReview.Org - Antihypertensives Updates (pharmacology review notes) Presentation Transcript

    • Antihypertensive Agents
    • Hypertension
      • High blood pressure
      • Normal: Systolic < 130 mm Hg Diastolic < 85 mm Hg
    • Classification of Blood Pressure
      • Category Systemic BP (mm Hg) Diastolic BP (mm Hg)
      • Normal <130 <85
      • High normal 130-139 85-89
      • Hypertension Stage 1 140-159 90-99 Stage 2 160-169 100-109 Stage 3 180-209 110-119 Stage 4  210  120
    • Classification of Blood Pressure
      • Primary Hypertension
      • Specific cause unknown
      • 90% of the cases
      • Also known as essential or idiopathic hypertension
      • Secondary Hypertension
      • Cause is known (such as eclampsia of pregnancy, renal artery disease, pheochromocytoma)
      • 10% of the cases
    • Blood Pressure = CO x SVR
      • CO = Cardiac output
      • SVR = Systemic vascular resistance
    • Instructors may want to insert EIC Image #69: Blood Pressure: Normal Regulation
    • Antihypertensive Agents
      • Medications used to treat hypertension
    • Antihypertensive Agents: Categories
      • Adrenergic agents
      • Angiotensin-converting enzyme inhibitors
      • Angiotensin II receptor blockers
      • Calcium channel blockers
      • Diuretics
      • Vasodilators
    • Antihypertensive Agents: Categories
      • Adrenergic Agents
        • Alpha1 blockers
        • Beta blockers (cardioselective and nonselective)
        • Centrally acting alpha blockers
        • Combined alpha-beta blockers
        • Peripheral-acting adrenergic agents
    • Antihypertensive Agents: Mechanism of Action
      • Adrenergic Agents
      • Alpha1 Blockers (peripherally acting)
      • Block the alpha1-adrenergic receptors
      • The SNS is not stimulated
        • Result: DECREASED blood pressure
      • Stimulation of alpha1-adrenergic receptors causes HYPERtension
      • Blocking alpha1-adrenergic receptors causes decreased blood pressure
    • Antihypertensive Agents:
      • Adrenergic Agents
      • Alpha1 Blockers
      • doxazosin (Cardura)
      • prazosin (Minipress)
      • terazosin (Hytrin)
    • Antihypertensive Agents: Mechanism of Action
      • Adrenergic Agents
      • Central-Acting Adrenergics
      • Stimulate alpha2-adrenergic receptors
      • Sympathetic outflow from the CNS is decreased
        • Result: decreased blood pressure
    • Antihypertensive Agents:
      • Adrenergic Agents
      • Central-Acting Adrenergics
      • clonidine (Catapres)
      • methyldopa (Aldomet) (drug of choice for hypertension in pregnancy)
    • Antihypertensive Agents: Mechanism of Action
      • Adrenergic Agents
      • Adrenergic Neuronal Blockers (peripherally acting)
      • Inhibit release of norepinephrine
      • Also deplete norepinephrine stores
      • SNS (peripheral adrenergic nerves) is not stimulated
        • Result: decreased blood pressure
    • Antihypertensive Agents:
      • Adrenergic Agents
      • Adrenergic Neuronal Blockers (peripherally acting)
      • reserpine
      • guanadrel (Hylorel)
      • guanethidine (Ismelin)
    • Antihypertensive Agents: Adrenergic Agents
      • Therapeutic Uses
      • Alpha1 blockers (peripherally acting)
        • Treatment of hypertension
        • Relief of symptoms of BPH
        • Management of of severe CHF when used with cardiac glycosides and diuretics
    • Antihypertensive Agents: Adrenergic Agents
      • Therapeutic Uses
      • Central-Acting Adrenergics
        • Treatment of hypertension, either alone or with other agents
        • Usually used after other agents have failed due to side effects
        • Also may be used for treatment of severe dysmenorrhea, menopausal flushing, glaucoma
        • Clonidine is useful in the management of withdrawal symptoms in opioid- or nicotine-dependent persons
    • Antihypertensive Agents: Adrenergic Agents
      • Therapeutic Uses
      • Adrenergic neuronal blockers (peripherally acting)
        • Treatment of hypertension, either alone or with other agents
        • Seldom used because of frequent side effects
    • Antihypertensive Agents: Adrenergic Agents
      • Side Effects
      • Most common: dry mouth drowsiness sedation constipation
      • Other: headaches sleep disturbances nausea rash cardiac disturbances (palpitations)
        • HIGH INCIDENCE OF ORTHOSTATIC HYPOTENSION
    • Antihypertensive Agents: Categories
      • Angiotensin-Converting Enzyme Inhibitors
      • (ACE Inhibitors)
      • Large group of safe and effective drugs
      • Often used as first-line agents for CHF and hypertension
      • May be combined with a thiazide diuretic or calcium channel blocker
    • Antihypertensive Agents: Mechanism of Action
      • ACE Inhibitors
      • RAAS: Renin Angiotensin-Aldosterone System
      • When the enzyme angiotensin I is converted to angiotensin II, the result is potent vasoconstriction and stimulation of aldosterone
      • Result of vasoconstriction: increased systemic vascular resistance and increased afterload
      • Therefore, increased BP
    • Antihypertensive Agents: Mechanism of Action
      • ACE Inhibitors
      • Aldosterone stimulates water and sodium resorption.
      • Result: increased blood volume, increased preload, and increased B
    • Antihypertensive Agents: Mechanism of Action
      • ACE Inhibitors
      • ACE Inhibitors block the angiotensin-converting enzyme, thus preventing the formation of angiotensin II.
      • Also prevent the breakdown of the vasodilating substance, bradykinin
        • Result: decreased systemic vascular resistance (afterload), vasodilation, and therefore, decreased blood pressure
    • Antihypertensive Agents
      • ACE Inhibitors
      • captopril (Capoten)
      • Short half-life, must be dosed more frequently than others
      • enalapril (Vasotec)
      • The only ACE inhibitor available in oral and parenteral forms
      • lisinopril (Prinivil and Zestril) and quinapril (Accupril)
      • Newer agents, long half-lives, once-a-day dosing
      • Several other agents available
    • Antihypertensive Agents: Therapeutic Uses
      • ACE Inhibitors
      • Hypertension
      • CHF (either alone or in combination with diuretics or other agents)
      • Slows progression of left ventricular hypertrophy after an MI
      • Renal protective effects in patients with diabetes
        • Drugs of choice in hypertensive patients with CHF
    • Antihypertensive Agents: Side Effects
      • ACE Inhibitors
      • Fatigue Dizziness
      • Headache Mood changes
      • Impaired taste
        • Dry, nonproductive cough, reverses when therapy is stopped
        • NOTE: first-dose hypotensive effect may occur!!
    • Antihypertensive Agents: Categories
      • Angiotensin II Receptor Blockers (A II Blockers or ARBs)
      • Newer class
      • Well-tolerated
      • Do not cause coughing
    • Antihypertensive Agents: Mechanism of Action
      • Angiotensin II Receptor Blockers
      • Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II
      • Block vasoconstriction and release of aldosterone
    • Antihypertensive Agents:
      • Angiotensin II Receptor Blockers
      • losartan (Cozaar)
      • eposartan (Teveten)
      • valsartan (Diovan)
      • irbesartan (Avapro)
      • candesartan (Atacand)
      • telmisartan (Micardis)
    • Antihypertensive Agents: Therapeutic Uses
      • Angiotensin II Receptor Blockers
      • Hypertension
      • Adjunctive agents for the treatment of CHF
      • May be used alone or with other agents such as diuretics
    • Antihypertensive Agents: Side Effects
      • Angiotensin II Receptor Blockers
      • Upper respiratory infections
      • Headache
      • May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue
    • Antihypertensive Agents: Categories
      • Calcium Channel Blockers
      • Benzothiazepines
      • Dihydropyridines
      • Phenylalkylamines
    • Antihypertensive Agents: Mechanism of Action
      • Calcium Channel Blockers
      • Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction
      • This causes decreased peripheral smooth muscle tone, decreased systemic vascular resistance
      • Result: decreased blood pressure
    • Antihypertensive Agents
      • Calcium Channel Blockers
      • Benzothiazepines:
        • diltiazem (Cardizem, Dilacor)
      • Phenylalkamines:
        • verapamil (Calan, Isoptin)
      • Dihydropyridines:
        • amlodipine (Norvasc), bepridil (Vascor), nicardipine (Cardene)
        • nifedipine (Procardia), nimodipine (Nimotop)
    • Antihypertensive Agents: Therapeutic Uses
      • Calcium Channel Blockers
      • Angina
      • Hypertension
      • Dysrhythmias
      • Migraine headaches
    • Antihypertensive Agents: Side Effects
      • Calcium Channel Blockers
      • Cardiovascular
        • hypotension, palpitations, tachycardia
      • Gastrointestinal
        • constipation, nausea
      • Other
        • rash, flushing, peripheral edema, dermatitis
    • Antihypertensive Agents: Diuretics
      • Decrease the plasma and extracellular fluid volumes
      • Results: decreased preload decreased cardiac output decreased total peripheral resistance
      • Overall effect: decreased workload of the heart, and decreased blood pressure
    • Antihypertensive Agents: Mechanism of Action
      • Vasodilators
      • Directly relaxes arteriolar smooth muscle
      • Result: decreased systemic vascular response, decreased afterload, and PERIPHERAL VASODILATION
    • Antihypertensive Agents
      • Vasodilators
      • diazoxide (Hyperstat)
      • hydralazine HCl (Apresoline)
      • minoxidil (Loniten, Rogaine)
      • sodium nitroprusside (Nipride, Nitropress)
    • Antihypertensive Agents: Therapeutic Uses
      • Vasodilators
      • Treatment of hypertension
      • May be used in combination with other agents
      • Sodium nitroprusside and diazoxide IV are reserved for the management of hypertensive emergencies
    • Antihypertensive Agents: Side Effects
      • Vasodilators
      • Hydralazine:
        • dizziness, headache, anxiety, tachycardia, nausea and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion
      • Sodium nitroprusside:
        • bradycardia, hypotension, possible cyanide toxicity
    • Antihypertensive Agents: Nursing Implications
      • Before beginning therapy, obtain a thorough health history and head-to-toe physical examination.
      • Assess for contraindications to specific antihypertensive agents.
      • Assess for conditions that require cautious use of these agents.
    • Antihypertensive Agents: Nursing Implications
      • Educate patients about the importance of not missing a dose and taking the medications exactly as prescribed.
      • Patients should never double up on doses if a dose is missed; check with physician for instructions on what to do if a dose is missed.
      • Monitor BP during therapy. Instruct patients to keep a journal of regular BP checks.
    • Antihypertensive Agents: Nursing Implications
      • Instruct patients that these drugs should not be stopped abruptly, as this may cause a rebound hypertensive crisis, and perhaps lead to CVA.
      • Oral forms should be given with meals so that absorption is more gradual and effective.
      • Administer IV forms with extreme caution and use an IV pump.
    • Antihypertensive Agents: Nursing Implications
      • Remind patients that medications is only part of therapy. Encourage patients to watch their diet, stress level, weight, and alcohol intake.
      • Patients should avoid smoking and eating foods high in sodium.
      • Encourage supervised exercise.
    • Antihypertensive Agents: Nursing Implications
      • Instruct patients to change positions slowly to avoid syncope from postural hypotension.
      • Patients should report unusual shortness of breath; difficulty breathing; swelling of the feet, ankles, face, or around the eyes; weight gain or loss; chest pain; palpitations; or excessive fatigue.
    • Antihypertensive Agents: Nursing Implications
      • Men taking these agents may not be aware that impotence is an expected effect. This may influence compliance with drug therapy.
      • If patients are experiencing serious side effects, or believe that the dose or medication needs to be changed, they should contact their physician immediately.
    • Antihypertensive Agents: Nursing Implications
      • Hot tubs, showers, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low blood pressure, leading to fainting and injury. Patients should sit or lie down until symptoms subside.
      • Patients should not take any other medications, including OTC drugs, without first getting the approval of their physician.
    • Antihypertensive Agents: Nursing Implications
      • Monitor for side/adverse effects (dizziness, orthostatic hypotension, fatigue) and for toxic effects.
      • Monitor for therapeutic effects
      • Blood pressure should be maintained at less than 140/90 mm Hg