W9, RAAS Drugs, Vasodilators, & Anti-hypertensives

What are long term effects of hypertension?

Heart failure, weakening vessels, risk of cardiovascular disease (CVD) and stroke

What are lifestyle modifications to help manage hypertension?

Switch to low-sodium diet or DASH diet, increase exercise, quit smoking

True/False: There is a cure, atropine, to hypertension

False; there is no cure to hypertension, just lifelong treatment

What are 5 ways to promote patient adherence to treatment of hypertension?

Education, self-monitoring, minimizing side effects, have collaborative relationship, simplify regimen

What is education about hypertension nurse could provide to patient to promote adherence to treatment?

Hypertension could lead to stroke, heart disease or kidney disease, and by treating it patient could live a longer healthier life

What is self-monitoring nurse could teach patient to promote adherence to treatment of hypertension?

Track BP daily to help with monitoring

What are ways nurse could help patient minimize side effects of hypertension to promote adherence to treatment?

Encourage patient to report side effects, start patient on lower doses and increase dosage as needed

In addition to collaborating with patient, who else should nurse collaborate with to promote adherence to treatment of hypertension?

Collaborate with patient’s family too

How could nurse simply regimen for patient to promote adherence to treatment of hypertension?

Give patient pill to take once or twice a day (instead of 3 or 4 times a day or multiple pills for example)

Why might it be difficult for patients to adhere to treatment of hypertension?

Treatment is life-long and there are no manifestations (signs or symptoms) of hypertension

Why might patient not believe they need to treat their hypertension?

There are no manifestations (signs or symptoms) of hypertension

What is hypertension also known as?

The silent killer

Why is hypertension also known as the silent killer?

There are no manifestations (signs or symptoms) of hypertension, so people might not even know they have hypertension or they might not believe they need treatment

What are manifestations (signs and symptoms) of hypertension?

Typically none until it has caused significant damage to the body or becomes severely elevated (usually in severe or crisis cases)

What are 5 drugs classified as ACE inhibitors?

Lisinopril, captopril, enalapril, benazepril, ramipril

What does “ACE” in ACE inhibitors stand for?

Angiotensin-Converting Enzyme (inhibitors)

What is classification of lisinopril, captopril, enalapril, benazepril, and ramipril?

ACE inhibitors

What is suffix in name of all ACE inhibitors?

-pril

True/False: Lisinopril, captopril, enalapril, benazepril, and ramipril are Angiotensin-Converting Enzyme inhibitors

True (Angiotensin-Converting Enzyme is full name of ACE inhibitors)

What are therapeutic uses of ACE inhibitors (lisinopril, captopril, enalapril, benazepril, ramipril)?

Hypertension, MI, HF, LV dysfunction, diabetic and non-diabetic nephropathy, prevention of MI, stroke, and death

What is mechanism of action of ACE inhibitors?

To suppress formation of Angiotensin II which will cause dilation of blood vessels, reduction in blood volume, and prevention of pathologic changes in heart and blood vessels, and to increase bradykinin to cause vasodilation

What are 2 mechanisms of action of ACE inhibitors?

To suppress formation of Angiotensin II (from Angiotensin I), to increase bradykinin

When ACE inhibitors suppress formation of Angiotensin II (mechanism of action), what does that cause?

Causes dilation of blood vessels, reduction in blood volume, and prevention of pathologic changes in heart and blood vessels

When ACE inhibitors increase bradykinin (mechanism of action), what does that cause?

Causes vasodilation

What is bradykinin?

Peptide that causes vasodilation

What is typical function of Angiotensin II?

Potent vasoconstrictor that stimulates release of aldosterone (which typically reabsorbs water and sodium)

True/False: The mechanism of action of ACE inhibitors is (1) to suppress formation of Angiotensin II which will cause dilation of blood vessels, reduction in blood volume, and prevention of pathologic changes in heart and blood vessels, and (2) to increase bradykinin to cause vasodilation

True

Which number (#1, #2, or #3) represents the mechanism of action of ACE inhibitors?

#2 because ACE inhibitors prevent conversion of angiotensin I to angiotensin II, which also prevents aldosterone release (causing vasodilation and reduction in blood volume overall)

Which part of mechanism of action of ACE inhibitors (suppression of formation of Angiotensin II or increase of bradykinin) causes adverse effect of cough?

Increase of bradykinin because ACE inhibitors cause vasodilation in lungs too

When taking ACE inhibitors, how does increase of bradykinin (mechanism of action of ACE inhibitors) cause adverse effect of cough?

Bradykinin accumulates in lungs, causes vasodilation, and irritates airway receptors, which can lead to dry, persistent cough

True/False: Due to mechanism of action of ACE inhibitors that increases bradykinin, this increase causes bradykinin to accumulate in lungs and cause vasodilation, which irritates airway receptors and can lead to dry, persistent cough (adverse effect)

True

What are adverse effects of ACE inhibitors?

Cough, angioedema, first-dose hypotension, hyperkalemia, renal failure, fetal injury

Why might hyperkalemia occur as adverse effect when taking ACE inhibitors?

Might occur due to inhibition of aldosterone release (which typically makes kidneys excrete potassium and retain sodium and water)

What is angioedema?

Allergic reaction where face, lips, and airway swells up

True/False: If patient experiences angioedema while taking ACE inhibitors, patient will not continue to take this drug (drug will be stopped immediately)

True

True/False: ACE inhibitors should be used with caution in patients with kidney failure

True, ACE inhibitors can be beneficial to these patients but require close monitoring

What are drug interactions to watch out for when taking ACE inhibitors?

Diuretics, antihypertensive agents, drugs that raise potassium, lithium, NSAIDs

Why should diuretics and ACE inhibitors not be taken together?

Diuretics will intensify first-dose hypotension

Why should antihypertensive agents and ACE inhibitors not be taken together?

Together will cause increased hypotension (most likely too much)

Why should drugs that raise potassium and ACE inhibitors not be taken together?

Together can cause increased hyperkalemia

Why should lithium and ACE inhibitors not be taken together?

Will lead to lithium toxicity

Why should NSAIDs and ACE inhibitors not be taken together?

NSAIDs will reduce antihypertensive effect of ACE inhibitors

What should nurse educate patient taking ACE inhibitors to check everyday?

To check BP everyday

What is mnemonic of side effects of ACE inhibitors?

CAPTOPRIL

What does mnemonic CAPTOPRIL stand for (tells side effects of ACE inhibitors)?

Cough, Angioneurotic edema, Proteinuria, Taste disturbance and Teratogenic, Other (Fatigue), Potassium increased, Renal impairment, Itch, Low BP

Which drug’s side effects are displayed here?

ACE inhibitors

True/False: ACE inhibitors decrease peripheral vascular resistance without affecting cardiac output, cardiac rate, and cardiac contractility

True

What is fun way to remember ACE inhibitors drug names all end with -pril?

Think ACE inhibitors as April (A for ACE inhibitors and -pril for the ending!)

True/False: Some side effects of ACE inhibitors include dizziness, orthostatic hypotension, nonproductive cough, GI distress, and headache

True

What do ARBs stand for?

Angiotensin II receptor blockers

What are 2 drugs classified as ARBs?

Losartan, Valsartan

What is suffix of all drugs classified as ARBs?

-sartan

What is classification of losartan and valsartan?

ARBs

What are therapeutic uses of ARBs (losartan and valsartan)?

Hypertension, HF, diabetic nephropathy, MI, prevention of MI, stroke, and death in high risk patients, patients who cannot tolerate ACEs

True/False: ARBs are typically started if patient cannot tolerate ACE inhibitors due to cough or angioedema for example

True

Why do ARBs not present with adverse effect of cough like ACE inhibitors?

Mechanism of action of ARBs doesn’t increase bradykinin like ACE inhibitors do, and increased bradykinin is what causes adverse effect of cough

True/False: Both ARBs and ACE inhibitors cause adverse effect of cough

False; only ACE inhibitors cause adverse effect of cough because mechanism of action of ARBs doesn’t increase bradykinin like ACE inhibitors do, and increased bradykinin is what causes adverse effect of cough

What is mechanism of action of ARBs?

To block actions of angiotensin II by blocking access of angiotensin II to its receptors in blood vessels, adrenal glands, and all other tissues, which causes dilation of arterioles and veins, prevention of angiotensin II from inducing pathologic changes in cardiac structure, and increase in renal excretion of sodium and water (because aldosterone is blocked too)

True/False: Mechanism of action of ARBs is to block actions of angiotensin II by blocking access of angiotensin II to its receptors in blood vessels, adrenal glands, and all other tissues, which causes dilation of arterioles and veins, prevention of angiotensin II from inducing pathologic changes in cardiac structure, and increase in renal excretion of sodium and water (because aldosterone is blocked too)

True

Why is effect of mechanism of action of ARBs increase in renal excretion of sodium and water?

By blocking actions of angiotensin II, aldosterone is prevented from being released, and aldosterone typically reabsorbs sodium and water, so without aldosterone being released, sodium and water will be excreted instead of reabsorbed

Which number (#1, #2, or #3) represents the mechanism of action of ARBs?

#3 because ARBs block actions of angiotensin II by blocking access of angiotensin II to its receptors in blood vessels, adrenal glands, and all other tissues (which causes dilation of arterioles and veins, prevention of angiotensin II from inducing pathologic changes in cardiac structure, and increase in renal excretion of sodium and water because aldosterone is blocked too)

What are adverse effects of ARBs?

Angioedema, fetal harm, renal failure

What is a drug interaction to watch out for when taking ARBs?

Other antihypertensives

Why should other antihypertensives and ARBs not be taken together?

Together will cause increased hypotension

True/False: ARBs have decreased risk of hyperkalemia as adverse effect

True

Which drug’s mechanism of action and adverse effects are being described here?

Angiotensin II receptor blockers (ARBs)

True/False: Losartan and valsartan are classified as angiotensin II receptor blockers

True (angiotensin II receptor blockers is full name of ARBs)

What is prototype of direct renin inhibitors?

Aliskiren

What is classification of aliskiren?

Direct renin inhibitor

What decreases absorption of direct renin inhibitors (aliskiren)?

High fat meals

Since high fat meals decrease absorption of direct renin inhibitors (aliskiren), when should aliskiren be taken if patient wants to consume high fat meal?

Aliskiren should be taken at same time, so about an hour before meals

True/False: High carb meals decrease absorption of aliskiren

False; high fat meals decrease absorption of aliskiren

What is mechanism of action of direct renin inhibitors (aliskiren)?

Acts on renin to inhibit conversion of angiotensinogen into angiotensin I which then suppresses entire RAAS, and thus will cause vasodilation, decreased blood volume, and no aldosterone release

What is therapeutic use of direct renin inhibitors (aliskiren)?

Hypertension

Which drug’s mechanism of action is being described: Acts on renin to inhibit conversion of angiotensinogen into angiotensin I which then suppresses entire RAAS, and thus will cause vasodilation, decreased blood volume, and no aldosterone release?

Direct renin inhibitors (aliskiren)

True/False: Direct renin inhibitors (aliskiren) mechanism of action is to act on renin to inhibit conversion of angiotensinogen into angiotensin I which then suppresses entire RAAS, and thus will cause vasodilation, decreased blood volume, and no aldosterone release

True

Which number (#1, #2, or #3) represents the mechanism of action of direct renin inhibitors (renin)?

#1 because direct renin inhibitors (aliskiren) act on renin to inhibit conversion of angiotensinogen into angiotensin I which then suppresses entire RAAS, and thus will cause vasodilation, decreased blood volume, and no aldosterone release

True/False: ACE inhibitors stop entire RAAS

False; direct renin inhibitors stop entire RAAS

What are adverse effects of direct renin inhibitors (aliskiren)?

GI effects, diarrhea, abdominal pain, indigestion, fetal harm

True/False: Direct renin inhibitors (aliskiren) have lower incidence of angioedema and hyperkalemia

True

What are drug interactions to watch out for when taking direct renin inhibitors?

Atorvastatin and Ketoconazole, Irbesartan, Furosemide

Why should Atorvastatin and Ketoconazole not be taken with direct renin inhibitors?

Atorvastatin and Ketoconazole can significantly increase levels of direct renin inhibitors, which can cause toxicity

Why should Irbesartan not be taken with direct renin inhibitors?

Irbesartan can significantly decrease direct renin inhibitors, so effect won’t be as helpful

Why should Furosemide not be taken with direct renin inhibitors?

Direct renin inhibitors will decrease effect of furosemide

What is drug classified aldosterone antagonist (potassium-sparing diuretic)?

Spironolactone

What is classification of spironolactone?

Aldosterone antagonist (potassium-sparing diuretic)

When is spironolactone (aldosterone antagonist potassium-sparing diuretic) used?

If patient does not respond well to ACE inhibitors or ARBs, or could be used in conjunction with either ACE inhibitors or ARBs

True/False: Spironolactone, an aldosterone antagonist potassium-sparing diuretic, is used if patient does not respond well to ACE inhibitors or ARBs, or could be used in conjunction with either ACE inhibitors or ARBs

True

If patient doesn’t respond well to treatment from ACE inhibitors or ARBs, what drug is taken then (either taken alone, or in conjunction with ACE inhibitors or ARBs)?

Spironolactone (aldosterone antagonist potassium-sparing diuretic)

What is mechanism of action of spironolactone?

Blocks aldosterone which will cause retention of potassium as well as increased excretion of sodium and water, to ultimately reduce blood volume and reduce blood pressure

True/False: Mechanism of action of spironolactone is to increase reabsorption of sodium and water, to ultimately increase blood volume and blood pressure

False; mechanism of action of spironolactone is to block aldosterone which will cause retention of potassium as well as increased excretion of sodium and water, to ultimately reduce blood volume and reduce blood pressure

What are therapeutic uses of spironolactone?

Hypertension, heart failure

What are adverse effects of spironolactone?

Hyperkalemia, endocrine effects, fetal harm

What should nurse educate patient about when taking spironolactone?

Educate patient to use salt substitutes and to watch diet so potassium levels don’t go up too high and cause adverse effect of hyperkalemia

What are endocrine effects that could appear as adverse effect to spironolactone?

Deepening of voice, hirsutism (excessive facial hair growth in women), menstrual irregularities

What is biggest adverse effect of spironolactone?

Hyperkalemia

What are drug interactions to watch out for when taking spironolactone?

Drugs that raise K+ levels, ACE inhibitors, ARBs, direct renin inhibitors

Why should spironolactone be used with caution when taken with ACE inhibitors, ARBs, or direct renin inhibitors?

ACE inhibitors, ARBs, and direct renin inhibitors are other antihypertensive drugs, so watch out for too much hypotension

Why should spironolactone and drugs that raise K+ levels not be taken together?

Could cause too much potassium in bloodstream (hyperkalemia) together

What are 2 drugs classified as vasodilators?

Hydralazine, minoxidil