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Anti Hypertensive Drugs By:  Dr. Ali Osman
Definition of HTN <ul><li>Elevation of BP above the normal range, depending on the age and sex. </li></ul>
Initiation of anti HTN   ( according to BHS ) <ul><li>If sys  BP >   200 or dias BP > 120 : start treatment immediately </...
Initiation of anti HTN   ( according to BHS ) <ul><li>If sys  BP 140 – 159  or dias BP 90 -99, with CVS complications or t...
Types of Anti HTN Drugs <ul><li>DIURETICS </li></ul><ul><li>β  BLOCKERS </li></ul><ul><li>Ca Channel Blockers </li></ul><u...
DIURETICS <ul><li>MOA: </li></ul><ul><li>1- ↑ renal excretion of Na & water  </li></ul><ul><li>↓  plasma volume  ↓ C.O.  <...
1-Thiazide  <ul><li>Sulfonamide molecule </li></ul><ul><li>Prolonged action </li></ul><ul><li>Flat curve response </li></u...
2- Loop Diuretics <ul><li>Steep curve response </li></ul><ul><li>Restricted to CCF & CRF </li></ul><ul><li>Eg: Frusemide  ...
3- K+ sparing diuretics <ul><li>Not effective alone, so used in combination </li></ul><ul><li>Eg: Spironolactone, Amilorid...
Beta Blockers <ul><li>Cardioselective  (Beta1): Atenolol  </li></ul><ul><li>Noncardioselective  (Beta 1 & 2) :  Propranolo...
Beta Blockers <ul><li>MOA: </li></ul><ul><li>Block beta receptors   ↓   sympathetic drive  </li></ul><ul><li>1- ↓ H.R. & c...
Beta Blockers <ul><li>Metabolism:   </li></ul><ul><li>Hydroxylated in liver to water soluble compounds excreted in kidneys...
Beta Blockers <ul><li>SE:  bradycardia, bronchospasm, cold extremeties, hypoglycemia, insomnia, bad dreams </li></ul><ul><...
Beta Blockers <ul><li>Atenolol:  less lipid soluble  less CNS SE </li></ul><ul><li>Timolol:  lipid soluble  more CNS SE. <...
Ca Channel Blockers <ul><li>MOA: </li></ul><ul><li>1- ↓ Arteriolar tone  </li></ul><ul><li>2- ↓ Pacemaker excitability & ↓...
Ca Channel Blockers <ul><li>TYPES:- </li></ul><ul><li>Dihydropyridine:   Nefidipine, Amlodipine   </li></ul><ul><li>Mainly...
Ca Channel Blockers <ul><li>SE: Headache, sweating, palpitation, ankle swelling, flushing   (↓ by concomitant B.Blockers) ...
Ca Channel Blockers <ul><li>Nondihydropyridine:   </li></ul><ul><li>Diltiazem : (60mg) </li></ul><ul><li>50% on Heart, by ...
Ca Channel Blockers <ul><li>SE: sinus bradycardia, SAN block, L.L edema, skin rash, GIT upset (rare) </li></ul><ul><li>C.I...
Ca Channel Blockers <ul><li>Verapamil:   </li></ul><ul><li>↓  H.R. by ↓ SAN and AVN conduction </li></ul><ul><li>Minimal v...
ACE Inhibitors <ul><li>Eg: Captopril, Lisinopril </li></ul><ul><li>MOA: </li></ul><ul><li>↓  ang II  ↓ vasocostriction </l...
ACE Inhibitors <ul><li>Preferred in DM , LV dysfunction </li></ul><ul><li>Less response in Black African ( unless combined...
ACE Inhibitors <ul><li>SE: first dose hypotension, hyper K+, dry cough, angioedema (rare) </li></ul><ul><li>C.I.: severe b...
Angiotensin II receptor Antagonists <ul><li>Eg: Losartan, Valsartan </li></ul><ul><li>MOA:  block ang II receptors  vasodi...
Alpha Blockers <ul><li>Eg: Doxazocin, Prazocin </li></ul><ul><li>MOA: </li></ul><ul><li>Stimulate SM relaxation  ↓P.R </li...
VASODILATORS <ul><li>Eg: Hydralazine, Minoxidil </li></ul><ul><li>Used for pt resistant to other anti HTN </li></ul><ul><l...
Central acting agents <ul><li>Eg: Methyldopa, Reserpine </li></ul><ul><li>MOA: </li></ul><ul><li>Stimulate  α  aderenergic...
General Principles <ul><li>In younger pt avoid B.Blockers alone ( impotence, dyslipidemia) </li></ul><ul><li>In elders : 1...
Refractory HTN (Treatment failure) <ul><li>1- Noncompliance  </li></ul><ul><li>2- Inadequate treatment </li></ul><ul><li>3...
Bibliography <ul><li>Text book of Medicine: KUMAR  (5 th  edition) </li></ul><ul><li>Short Textbook of Clinical Diagnosis ...
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Anti Hypertensive Drugs

  1. 1. Anti Hypertensive Drugs By: Dr. Ali Osman
  2. 2. Definition of HTN <ul><li>Elevation of BP above the normal range, depending on the age and sex. </li></ul>
  3. 3. Initiation of anti HTN ( according to BHS ) <ul><li>If sys BP > 200 or dias BP > 120 : start treatment immediately </li></ul><ul><li>If sys BP > 160 or dias BP > 100 : should be confirmed over 1-2 wks, then start treatment. </li></ul>
  4. 4. Initiation of anti HTN ( according to BHS ) <ul><li>If sys BP 140 – 159 or dias BP 90 -99, with CVS complications or target organ damage or DM: should be confirmed over 3-4 wks , then start treatment. If the above associations are absent , remeasure weekly over 4-12 wk, if still sustained start treatment. </li></ul>
  5. 5. Types of Anti HTN Drugs <ul><li>DIURETICS </li></ul><ul><li>β BLOCKERS </li></ul><ul><li>Ca Channel Blockers </li></ul><ul><li>ACE inhibitors </li></ul><ul><li>Ang II antagonists </li></ul><ul><li>Vasodilators </li></ul><ul><li>α Blockers </li></ul><ul><li>Central acting agents </li></ul>
  6. 6. DIURETICS <ul><li>MOA: </li></ul><ul><li>1- ↑ renal excretion of Na & water </li></ul><ul><li>↓ plasma volume ↓ C.O. </li></ul><ul><li>2- ↓ peripheral resistance ( desensitize smooth muscles to action of catecholamines ) </li></ul>
  7. 7. 1-Thiazide <ul><li>Sulfonamide molecule </li></ul><ul><li>Prolonged action </li></ul><ul><li>Flat curve response </li></ul><ul><li>Potentiates action of other anti HTN </li></ul><ul><li>Eg: Hydrochlorothiazide ( Ezidrex ) , Bendrofluazide </li></ul><ul><li>SE: hypo K+ , hypo Na+, hyperuricemia, hyperglycemia, lipid profile disturb. </li></ul>
  8. 8. 2- Loop Diuretics <ul><li>Steep curve response </li></ul><ul><li>Restricted to CCF & CRF </li></ul><ul><li>Eg: Frusemide </li></ul><ul><li>SE: ↓ K+ , ↓ Na+ , hypotension, ototoxic in v.high doses </li></ul>
  9. 9. 3- K+ sparing diuretics <ul><li>Not effective alone, so used in combination </li></ul><ul><li>Eg: Spironolactone, Amiloride , </li></ul><ul><li>Uniretic ( HCT + Amiloride) </li></ul><ul><li>SE: ↑ K+, gynecomastia </li></ul>
  10. 10. Beta Blockers <ul><li>Cardioselective (Beta1): Atenolol </li></ul><ul><li>Noncardioselective (Beta 1 & 2) : Propranolol </li></ul>
  11. 11. Beta Blockers <ul><li>MOA: </li></ul><ul><li>Block beta receptors ↓ sympathetic drive </li></ul><ul><li>1- ↓ H.R. & contractility, ↑ P.R. ↓ C.O. </li></ul><ul><li>2- ↓ Renin release & activity ↓ Ang II </li></ul><ul><li>↓ BP </li></ul><ul><li>Act as anti HTN within 3-7 days </li></ul>
  12. 12. Beta Blockers <ul><li>Metabolism: </li></ul><ul><li>Hydroxylated in liver to water soluble compounds excreted in kidneys </li></ul><ul><li>Preferred in HTN with angina, SVT, HOCM, Thyrotoxicosis, Pheochromocytoma, Migraine and L.cirrhosis. </li></ul>
  13. 13. Beta Blockers <ul><li>SE: bradycardia, bronchospasm, cold extremeties, hypoglycemia, insomnia, bad dreams </li></ul><ul><li>Overdose: hypotension, bradycardia, bronchospasm, coma ( treated with Atropine, Isoprenaline, glucagon ) </li></ul><ul><li>C.I: HF, Asthma, DM, H.Block, Periph.vascular diseases , Hyperlipidemia </li></ul>
  14. 14. Beta Blockers <ul><li>Atenolol: less lipid soluble less CNS SE </li></ul><ul><li>Timolol: lipid soluble more CNS SE. </li></ul>
  15. 15. Ca Channel Blockers <ul><li>MOA: </li></ul><ul><li>1- ↓ Arteriolar tone </li></ul><ul><li>2- ↓ Pacemaker excitability & ↓ contractility ↓CO </li></ul><ul><li>3- ↓ conduction in C.S. </li></ul>
  16. 16. Ca Channel Blockers <ul><li>TYPES:- </li></ul><ul><li>Dihydropyridine: Nefidipine, Amlodipine </li></ul><ul><li>Mainly vasodilators ( so combined with B.Blockers) </li></ul><ul><li>Preferable in black old pts & Angina </li></ul><ul><li>Effective in isolated sys HTN </li></ul><ul><li>Used cautiously in HF </li></ul>
  17. 17. Ca Channel Blockers <ul><li>SE: Headache, sweating, palpitation, ankle swelling, flushing (↓ by concomitant B.Blockers) </li></ul>
  18. 18. Ca Channel Blockers <ul><li>Nondihydropyridine: </li></ul><ul><li>Diltiazem : (60mg) </li></ul><ul><li>50% on Heart, by inhibition of AVN conduction </li></ul><ul><li>50% on Vessels </li></ul><ul><li>Prophylaxis and treatment of angina </li></ul><ul><li>Mild & moderate HTN </li></ul>
  19. 19. Ca Channel Blockers <ul><li>SE: sinus bradycardia, SAN block, L.L edema, skin rash, GIT upset (rare) </li></ul><ul><li>C.I: Hypersensitivity , sys BP < 90, CCF, SAN syndrome, H.Block. </li></ul><ul><li>Should not be combined with B.Blockers, Antiarrhythmic and digoxin. </li></ul>
  20. 20. Ca Channel Blockers <ul><li>Verapamil: </li></ul><ul><li>↓ H.R. by ↓ SAN and AVN conduction </li></ul><ul><li>Minimal vasodilator effect </li></ul><ul><li>Used mainly as anti arrhythmic </li></ul><ul><li>SE: bradycardia, H.Block, constipation, C.I. with B.Blockers and Digoxin </li></ul>
  21. 21. ACE Inhibitors <ul><li>Eg: Captopril, Lisinopril </li></ul><ul><li>MOA: </li></ul><ul><li>↓ ang II ↓ vasocostriction </li></ul><ul><li>↓ degradation of Bradykinin ( vasodilator) </li></ul>
  22. 22. ACE Inhibitors <ul><li>Preferred in DM , LV dysfunction </li></ul><ul><li>Less response in Black African ( unless combined with diuretics) </li></ul><ul><li>Less effective in elders & Predominant sys HTN </li></ul>
  23. 23. ACE Inhibitors <ul><li>SE: first dose hypotension, hyper K+, dry cough, angioedema (rare) </li></ul><ul><li>C.I.: severe bilat. RA stenosis </li></ul><ul><li>Relative C.I.: periph. Vascular disease </li></ul><ul><li>Monopril has dual route of excretion (Liver & kidney) better in Renal insufficiency. </li></ul>
  24. 24. Angiotensin II receptor Antagonists <ul><li>Eg: Losartan, Valsartan </li></ul><ul><li>MOA: block ang II receptors vasodilitation & block Aldestrone secretion </li></ul><ul><li>Advantage: No cough </li></ul>
  25. 25. Alpha Blockers <ul><li>Eg: Doxazocin, Prazocin </li></ul><ul><li>MOA: </li></ul><ul><li>Stimulate SM relaxation ↓P.R </li></ul><ul><li>Preferred in pt with prostatism </li></ul><ul><li>SE: postural Hypotension, 1 st dose syncope </li></ul>
  26. 26. VASODILATORS <ul><li>Eg: Hydralazine, Minoxidil </li></ul><ul><li>Used for pt resistant to other anti HTN </li></ul><ul><li>Usually combined with B. BLOCKERS </li></ul><ul><li>SE: </li></ul><ul><li>Hydralazine: Reflex tachycardia, SLE-like syn, fluid retention </li></ul><ul><li>Minoxidil: severe edema , Hirsitism </li></ul>
  27. 27. Central acting agents <ul><li>Eg: Methyldopa, Reserpine </li></ul><ul><li>MOA: </li></ul><ul><li>Stimulate α aderenergic receptors in CNS ↓ vasomotor tone </li></ul><ul><li>SE: Sedation, Dry Mouth, Postural hypotesion, Impotence </li></ul>
  28. 28. General Principles <ul><li>In younger pt avoid B.Blockers alone ( impotence, dyslipidemia) </li></ul><ul><li>In elders : 1 st diuretics, then B.Blockers, ACE inhibitors. </li></ul><ul><li>In CCF: ACE inh, Nitrate </li></ul><ul><li>Ischemic HD: B.Blockers, Ca blockers </li></ul><ul><li>DM: ACE inh </li></ul><ul><li>CRF: Diureics </li></ul>
  29. 29. Refractory HTN (Treatment failure) <ul><li>1- Noncompliance </li></ul><ul><li>2- Inadequate treatment </li></ul><ul><li>3- 2° HTN ( RA stenosis, Pheochromocytoma ) </li></ul><ul><li>4- Using of anagonists ( eg: steroids, NSAID) </li></ul>
  30. 30. Bibliography <ul><li>Text book of Medicine: KUMAR (5 th edition) </li></ul><ul><li>Short Textbook of Clinical Diagnosis and Management: M. I. Danish (5 th edition) </li></ul>
  31. 31. THANK YOU….
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