pharm: blood pressure

what is hypertension classified as?

>130/80

what is hypertensive crisis classified as?

>180/120

what is hypotension classified as?

<90/60

what is bradycardia classified as?

<60

below which blood pressure parameter should you hold or not give a blood pressure lowering medication?

below 90/60 or if the patient presents with symptomatic hypertension

what are signs of symptomatic hypertension?

dizziness, syncope, altered mental status

below which heart rate parameter should you hold or not give a heart rate reducing medication?

<60 bpm (re-assess vitals, document reason for hold)

HTN is a…

silent killer

uncontrolled BP causes ______ _______ and _______ _______

vascular remodeling; organ ischemia

uncontrolled BP can lead to..

stroke, MI, chronic kidney disease, blindness / retinopathy, heart failure

why must antihypertensives be tapered down?

if stopped abruptly, causes rebound hypertensive crisis and sympathetic hyperactivity (tachycardia, angina, or acute MI)

which beta receptor is specific for the heart?

Beta 1

Beta 1 increases ____, _____, and ____ _______

HR, contractility, AV conduction

Beta 2 is specific to the ____

lungs

Beta 2 causes _______ and ______ _______

bronchodilation; peripheral vasodilation

chronotropic refers to….

heart rate

Inotropic refers to….

myocardial contractility

dromotropic refers to…

conduction velocity through the AV node

reflex tachycardia occurs when potent vasodilation rapidly lowers BP and…

baroreceptors signal the brainstem to activate sympathetic drive, increasing heart rate to compensate

reflex tachycardia is caused by…

Dihydropyridine CCBs (-ipines),

Direct vasodilators (Hydralazine),

and Alpha 1 Blockers (-osins)

first dose phenomenon occurs when severe, sudden…

orthostatic hypotension and syncope occurs within 30-90 minutes of the very first dose (or dose escalation)

what class of drug is most notorious for the first dose phenomenon?

alpha 1 blockers (-osins)

what is done to prevent the first dose phenomenon?

taking initial dose at bedtime

orthostatic hypotension is classified as a drop in..

SBP >20, DBP >10

manage orthostatic hypotension by…

changing positions slowly (dangling feet), taking meds at bedtime, avoiding hot showers, staying hydrated, and wearing compression hose

what pharmacological class does clonidine belong to?

Alpha 2 agonist

clonidine decreases _______ ______ _____

central sympathetic outflow

the side effects of clonidine are…

sleepiness, dry mouth, severe rebound hypertension if stopped abruptly, bradycardia, hypotension

epidural clonidine is contradicted in patients with…

bleeding disorders or on anti coagulation therapy due to high risk of hematoma and nerve impairment

what suffix defines beta blockers?

-lol

what are the cardioselective beta blockers?

metaprolol, atenolol, esmolol, bisoprolol, acebutolol

cardioselective beta blockers selectively block…

B1 in the heart

when is cardioselectivity lost for Beta 1 blockers?

in extremely high doses, in which it targets B2 in the lungs and causes bronchospasms

what are the non-selective beta blockers?

propanolol, nadolol, timolol, sotalol

what do non selective beta blockers block?

B1 and B2

what are non selective beta blockers contraindicated in?

asthma, COPD. B2 blockade prevents bronchodilation, causing bronchoconstriction

which beta blockers block A1, B1, and B2?

carvedilol and labetalol

combining B1/B2 blockade with A1 blockage produces…

arterial vasodilation without reflex tachycardia

carvedilol is ideal for..

heart failure

labetalol is ideal for….

pregnancy / hypertensive crisis

beta blockers mask sympathetic signs of ______

hypoglycemia

what are the masked signs of hypoglycemia while on a beta blocker?

tremors, anxiety, tachycardia

what is the only sign of hypoglycemia that is not masked when on a beta blocker?

diaphoresis because it is mediated by cholinergic pathways

teach diabetics that _____ is their primary hypoglycemia warning sign while on a beta blocker

sweating

why are non selective beta blockers contraindicated in raynaud’s disease

blocking B2-mediated vasodilation leaves A1 vasoconstriction unopposed, causing severe peripheral vascular constriction, digital vasospasms, cold extremities, and ischemic tissue pain

metaprolol succinate is extended release, taken..

once daily for long term heart failure and hypertension management

metaprolol tartrate is…

immediate release, taken BID or IV, for acute MI, post MI protection, and acute arrhythmia control

what are the signs of beta blocker toxicity?

severe bradycardia, profound hypotension, heart blood, cardiogenic shock, bronchospasm, hypoglycemia

what is the specific antidote for beta blocker toxicity?

IV Glucagon (bypasses beta receptors to increase intracellular cAMP)

what suffix identifies alpha 1 antagonists?

-osin

what are some A1 antagonists?

prazosin, terazosin, doxazosin, tamsulosin

which A1 antagonist is prospective for BPH?

tamsulosin selectively blocks A1 receptors in prostate, relieving BPH symptoms without altering BP

what are the primarily indications for A1 blockers besides HTN?

BPH (eases urine outflow) and PTSD nightmares (Parozosin crosses BBB to reduce central sympathetic tone)

what are examples of dihydropyridine CCBs?

amlodipine and nifedipine (ipines)

what do dihydropyridines target?

vascular smooth muscle (arterial vasodilation)

what do non-dihydropyridines target?

heart myocardium and AV node, blood vessels

what are examples of non-dihydropyridines?

verapamil, diltiazem

verapamil and diltiazem (non dihydropyridines) are negative…

chronotropes, inotropes, and dromotropes (reduces HR, force, AV velocity)

amlodipine and nifedipine are neutral on HR / contractually but..

potent arterial vasodilation causes reflex tachycardia

what is a unique adverse effect for verapamil?

severe constipation, gingival hyperplasia

severe constipation caused by verapamil is caused by…

blockade of calcium channels in GI smooth muscle

what should be advised for a patient on verapamil?

fluid intake and high fiber diet

non dihydropyridine CCBs are contraindicated in patients with…

severe heart failure or AV block

non dihydropyridine CCBs are contraindicated in patients with heart failure or AV block due to their…

negative inotropic and dromotropic effects depressing cardiac contractility and slow AV conduction

negative inotropic and dromotropic effects of non dihydropyridine CCBs worsens..

fluid overload in HF and causes complete heart block

dihydropyridine CCBs cause vasodilation of precapillary arterioles and increase capillary hydrostatic pressure, pushing…

fluid into ankle/foot interstitial spaces and causing peripheral edema

how is peripheral edema in dihydropyridine CCB therapy managed?

elevation, compression, adding an ACE/ARB to dilate post capillary venules

what drink is contraindicated in CCB therapy?

grapefruit juice

grapefruit juice is contraindicated in CCB therapy due to irreversibly..

inhibiting intestinal CYP3A4 enzymes, preventing CCB metabolism

grapefruit juice and CCB interaction causes…

massive drug absorption

lead level toxicity

profound hypotension

severe reflex tachycardia

_____ doses of CCB with drinking grapefruit juice does not prevent the catastrophic interaction

spacing

nimodipine treats the non cardiovascular condition of…

subaracnoid hemorrhage

nimodipine selectively dilates cerebral arteries to prevent ______ _____ and neurological deficits following a ruptured brain aneurysm

ischemic vasospasm

what is the step of RAAS?

renin from kidneys concerts angiotensinogen from liver into angiotensin 1

what is the second step of RAAS?

ACE (in pulmonary capillary endothelium) converts angiotensin 1 into angiotensin 2

angiotensin 2 is a potent…

vasoconstrictor that stimulates aldosterone secretion from adrenal cortex to retain Na/H2O and excrete K

what suffix identifies ACE inhibitors?

-pril

what are examples of ACE inhibitors?

lisinopril, enalapril, captopril, ramipril

ACE inhibitors prevent the conversion of…

angiotensin 1 to angiotensin 2

ACE inhibitors stops the breakdown of…

inflammatory bradykinin

ACE inhibitors cause…

dry cough and angioedema

inhibition of ACE prevents bradykinin breakdown, causing bradykinin accumulation in lungs, causing…

a persistent cough

bradykinin accumulation in skin and submucosa causes…

vasodilation and vascular permeability, triggering fatal angioedema

what suffix identifies angiotensin receptor blockers (ARBs)?

-sartan

what are some examples of ARBs?

losartan, valsartan, olmesartan

ARBs selectively block which receptors directly?

angiotensin 2 AT1

by ARBs selectively blocking angiotensin 2 receptors directly, ACE is uninhibited and ______ levels remain normal, eliminating ______ _____

bradykinin; dry cough

what electrolyte abnormality is caused by ACEIs, ARBs, DRIs, and aldosterone antagonists?

hyperkalemia (> 5.0)

why do ACEIs, ARBs, DRIs, and aldosterone antagonists cause hyperkalemia?

by suppressing aldosterone, they decrease renal potassium excretion

for patients on ACEIs, ARBs, DRIs, and aldosterone antagonists, monitor..

serum K

for patients on ACEIs, ARBs, DRIs, and aldosterone antagonists, teach patients to avoid…

potassium-containing salt substitutes

what is the direct renin inhibitor?

aliskiren

a boxed warning with the DRI aliskiren is…

fetal toxicity / tertaogenicity (causes fetal death and renal damage, DC if pregnant)

a boxed warning for the DRI aliskiren is do not combine with ACEIs and ARBs due to…

renal impairment risk

aldosterone antagonists block aldosterone in distant renal tubule do…

excrete Na/H2O and certain K

spironolactone causes endocrine side effects because it is non-selective, blocking…

androgen/progesterone receptors causing gyencomastia and menstrual irregularities

eplerenone doesn’t cause endocrine side effects like spironolactone because it is ___ _____

highly selective

what patients are ACEIs and ARBs contraindicated in?

renal artery stenosis

ACEIs and ARBs are contraindicated in renal artery stenosis patients bc GFR is maintained entirely by…

angiotensin II-mediated vasoconstriction of the efferent arteriole

blocking angiotensin II in renal artery stenosis patients dilated efferent arterioles, causing…

rapid drop in intaglomerular pressure and acute renal failure