pharm: antihypertensives

CO =

SV x HR

BP =

CO x SVR

normal bp

less than 120

\---------------

less than 80

elevated bp

120-129

\---------

less than 80

stage 1 bp

130-139

\---------

80-89

stage 2 bp

140 or higher

\---------------

90 or higher

hypertensive crisis

higher than 180

—————————

higher than 120

what affects bp?

* smoking
* obesity
* lack of exercise
* salt
* alcohol
* older age
* genetics
* CKD
* adrenal/thyroid disorders
* sleep apnea

bp classification meds

* angiotension-converting enzyme inhibitors (ACE)
* angiotensin II receptor blockers (ARBs)
* direct renin inhibitors
* calcium channel blockers
* centrally acting alpha2 agonists
* beta adrenergic blockers
* hydralazine (vasodilator)
* meds for hypertensive crisis

ACE inhibitors patho

^^stops angiotensin I from converting to angiotensin 2^^

* vasodilates
* excretion of sodium and water
* reduces damage in the blood vessels and heart from angiotensin 2 and aldosterone

ACE inhibitors uses

* HTN
* HF
* MI
* diabetic and nondiabetic nephropathy
* pt at high risk of cardiovascular event

ACE inhibitors meds

\-prils

* enalapril (vasotec)
* lisinopril (prinival)
* captopril

\
administration: PO

ACE inhibitors complications

* **orthostatic hypotension**
* stop diuretic temp. 2-3 days before starting ACE inhibitors
* assess orthostatic hypotension after meds
* **dry, persistent cough**
* if develop, switch ACE to ARBs
* **hyperkalemia**
* priority for heart dysrhythmias
* risk for renal pt.
* monitor urine output
* less potassium in diet
* monitor for muscle wkns
* **angioedema**

ACE contrindications

* cautious with pts with renal impairment
* ***DO NOT TAKE BOTH ACE AND ARBs TOGETHER***
* potassium supplements and potassium sparing diuretics inc hyperkalemia risk
* NSAIDs dec effect of ACE

angiotensin II receptor blockers (ARBs) patho

* ^^blocks the action of angiotensin II^^ in the body
* vasodilates arterioles and veins
* excretes sodium and water (by decreasing release of aldosterone)
* an alternative to ACE inhibitors if these are not tolerated by the patient

\
***DO NOT TAKE BOTH ACE AND ARBs TOGETHER***

ARBs uses

* HTN
* HF
* stroke prevention
* MI prevention
* reduces mortality following MI

ARBs meds

\-sartans

* losartan (cozaar)
* valsartan (diovan)
* irbesartan (avapro)

ARBs complications

* %%no dry cough or hyperkalemia%%

**angioedema**

* treat with subQ epinephrine
* discontinue med

**fetal injury**

* use contraceptives while on med

**hypotension**

**dizziness, lightheadedness**

what do ARBs do to bp?

decreases bp by decreasing vasocontriction, vascular resistance, afterload

direct renin inhibitors patho

* stops initiation of RAAS system
* binds with renin to inhibit production of angiotensin I

direct renin inhibitors med

aliskiren (tekturna)

direct renin inhibitors complications

* hyperkalemia
* hypotension
* angioedema
* rash
* cough
* diarrhea

direct renin inhibitors contraindications

* pts with hyperkalemia
* inc hyperkalemia w/ ACE, potassium sparing supplements, potassium sparing
* cautious with older adults
* cautious with pts w/ asthma, other resp. disorders, hx of angioedema, diabetes mellitus, kidney/hepatic disease, hypotension
* high fat foods dec absorption

calcium channel blockers (CCBs) patho

* blocks calcium, dec. contractility and blood vessels dilate
* cause contraction of heart and vessels
* blocks calcium channels in blood vessels
* vasodilation of vascular smooth muscle in the peripheries & arteries/arterioles of the heart

\
*DON’T GIVE TO HF PTS*

CCBs meds

IV or PO

* verapamil (verelan)
* diltiazem (cardizem)
* amlodipine (norvasc)

CCBs uses

* angia
* hypertension
* a-fib
* SVT (supraventricular tachycardia)

diltiazem is used for

a-fib

CCBs complications

* orthostatic hypotension
* peripheral edema
* diuretics will not help
* suppression of cardiac function

if their heart is weak, what type of med make it worse?

CCBs

for HF pts with inc bp, do not give

CCBs

CCBs interactions

* verapamil can increase digoxin levels
* concurrent use of beta blockers
* %%**NO GRAPEFRUIT!!!**%%

CCBs nursing interventions

* verapamil: administer inj. slowly over 2-3 mins
* monitor BP & HR
* pulse

centrally acting alpha2 agonists patho

* dec sympathetic outflow, thus dec stimulation of adrenergic receptors of both the heart and peripheries
* dec HR and CO
* vasodilates

centrally acting alpha2 agonists uses

* migraine headache
* anxiety management
* management of ADHD

centrally acting alpha2 agonists complications

* dry mouth
* drowsiness

centrally acting alpha2 agonists contraindications

* avoid using during lactation
* pts w/ bleeding disorder or are on anticoags
* cautious in pts w/ stroke, asthma, COPD, MI, diabetes, depressive disorder, CKD

centrally acting alpha2 agonists meds

* clonidine (catapres)
* patch or PO
* methyldopa (aldomet)

centrally acting alpha2 agonists nursing interventions

* 2x/day
* larger dose at bedtime to dec daytime sleepiness

beta adrenergic blockers patho

aka beta blockers

* sympatholytic
* dec. sympathetic stimulation
* dec HR
* dec myocardial contractility
* dec cardiac output
* dec rate of conduction thru AV node

cardioselective

* affects beta1
* only the heart
* does not affect lungs
* choose beta1 to block

non-cardioselective

* blocks beta1 & beta2
* affects heart and lungs
* don’t give to COPD, asthma pt b/c bronchospasms

BB uses

* hypertension
* angina
* tachy-dysrhythmias
* HF
* MI
* treatment of hyperthyroidism, migraines
* cardio-protective

BB complications

* bradycardia
* dec CO
* orthostatic hypotension
* can cause an AV block

what to check when taking BB?

apical pulse for 1 min

* do not give if less than 60 bpm

BB meds

\-lol

* **metoprolol (lopressor)**
* cardioselective
* **atenolol (tenormin)**
* cardioselective
* **propanolol (inderal)**
* non-cardioselective
* contraindicated for patients w/ asthma
* **carvedilol (coreg)**
* **labetalol**

BB contraindications

* diabetes
* produces glycogenolysis: breakdown glycogen
* lung diseases
* pts with hypotension, renal, angina, older adults

BB cannot increase

blood sugar

→

can mask tachycardia and signs of hypoglycemia

BB nursing interventions

* PO
* 1 or 2x/day
* take with food to inc absorption

How and when is hydralazine given?

given for hypertensive crisis thru ^^IV^^

hydralazine

* vasodilator → dec PVR
* direct acting smooth muscle relaxant
* ^^dec peripheral resistance^^
* PO or IV
* can elicit a reflex sympathetic stimulation of the heart, so it is not a primary drug for hypertension
* has a rebound effect
* not for 1st line of HTN

hypertensive crisis meds

* nitroprusside (centrally acting vasodilator)
* nitroglycerin (vasodilator)
* nicardipine (CC blocker)
* esmolol (BB)

nitroprusside effect on bp

dec bp to prevent sudden spike in bp

* commonly IV

action of emergency drugs for a hypertensive crisis

* direct and immediate vasodilation
* rapid reduction in BP
* monitor for hypotension
* lightheadedness
* dizzy
* n&v
* dec LOC
* chest pain \*\*\*
* monitor ECG and BP cont.
* keep pt supine
* must have its own dedicated IV line if it is an IV drip
* **nitroprusside**: protect IV container from light
* sensitive to light b/c deactivates drug

hypertensive crisis med complications

* excessive hypotension
* rapid administration can dec BP rapidly
* monitor BP and ECG
* supine during administration
* bradycardia, tachycardia, ECG changes

hypertensive crisis med contraindications

* pts w/ HF, dec PVR, AV shunt
* cautious w/ pt w/ liver & kidney disease, hypothyroidism, hypovolemia, fluid and electrolyte imbalances, older adults
* %%do not administer nitroprusside in the same infusion as any other medications%%

hypertensive crisis med nursing interactions

* dilute for IV infusion
* protect IV container from light
* discard after 24 hrs
* monitor vitals and ECG cont.

meds affecting urinary output

* loop diuretics
* thiazide diuretics
* potassium sparing diuretics
* osmotic diuretics

meds affecting urinary output uses

* manage blood pressure
* excrete fluid causing edema for HF, kidney and liver disease
* prevention of kidney failure
* dec SV, CO, preload

loop diuretics

PO, IV, IM

* used for ^^hypertensive crisis^^ too
* work in the ascending limb of loop of henle
* blocks reabsorption of sodium, chloride and water
* K, Ca wasting
* causes extensive diuresis
* used in ==emergent situations== and ==daily maintenance==
* %%furosemide is not used for daily maintenance if pt only has HTN%%
* daily use for renal & HF pts

loop diuretic meds

PO, IV, IM

* furosemide (lasix)
* bumetanide (bumex)
* torsemide (demedex)

loop diuretic complications

* dehydration
* hypotension
* ototoxicity
* **hypokalemia**
* monitor K
* T wave depression
* muscle wkns
* hypomagnesemia
* hypoglycemia
* hyperuricemia
* hypocalcemia
* dec HDL, inc LDL

furosemide

* monitor for ototoxicity
* esp. if giving thru rapid IV push
* give over 2 mins
* if given fast will experience tinnitus and damage ears

loop diuretic contraindications

* avoid during pregnancy
* pt w/ anuria
* cautious in pts w/ diabetes, dehyration, CV disease, gout electrolyte depletion
* cautious w/ pts taking digoxin, lithium, ototoxic meds, NSAIDs, antihypertensives

loop diuretic interactions

* digoxin toxicity can occur in presence of hypokalemia
* concurrent use of antihypertensives
* NSAIDs reduce diuretic effect

loop diuretic nursing considerations

* BP
* K (3.5-5.1)
* hypokalemia
* monitor I/O’s
* 30mL/hr OR 0.5mL/kg/day
* furosemide: expect urine output in 15 mins
* give in the morning
* avoid late in the day to prevent nocturia
* advise pt about orthostatic hypotension
* no sudden changes in movement
* sit, dangle before getting up

foods high in potassium

* avocado
* banana
* potatoes
* spinach
* beans
* citrus juices
* fish

thiazide diuretics patho

* K wasting


* con be given with ARBs or others
* works in the early distal convoluted tubule
* blocks reabsorption of sodium, chloride and water at this site
* promotes diuresis
* less compared to loop diuretics
* less reabsorption on kidneys
* may be used with other antihypertensive agents for BP control

thiazide diuretics meds

* hydrochlorathiazide (HCTZ)
* metolazone

thiazide diuretic uses

FIRST LINE FOR ANTIHYPERTENSIVE MANAGEMENT

* edema
* may be used with other antihypertensive agents for BP control
* reduce urine production in diabetics
* Ca wasting

thiazide diuretic complications

* dehydration
* hyponatermia
* hypokalemia
* hyperglycemia
* hyperuricemia
* hypomagnesemia
* inc lipids

thiazide diuretic contraindications

* void during preg
* if taken during lactation, do not breastfeed
* renal impairment
* cautious in pts w/ diabetes, dehyration, CV disease, gout electrolyte depletion
* cautious w/ pts taking digoxin, lithium, ototoxic meds, NSAIDs, antihypertensives

thiazide diuretic interactions

* digoxin toxicity can occur in presence of hypokalemia
* concurrent use of antihypertensives
* NSAIDs reduce diuretic effect

thiazide diuretic nursing considerations

* BP
* K (3.5-5.1)
* hypokalemia
* monitor I/O’s
* 30mL/hr OR 0.5mL/kg/day
* give in the morning
* avoid late in the day to prevent nocturia
* advise pt about orthostatic hypotension
* no sudden changes in movement
* sit, dangle before getting up
* %%don’t give to pt with high calcium%%
* %%monitor Ca levels (hyperparathyroidism, cancer)%%

thiazide diuretic effectiveness

* dec BP
* dec edema
* inc urine output

potassium sparing diuretics patho

* blocks aldosterone action resulting in K retention and excretion of Na and H2O
* often combined w/ other diuretics
* useful in HF
* therapeutic effect can take up to 12-48 hrs

potassium sparing diuretics meds

PO

* spironolactone (aldactone)
* triamterene
* HCTZ/triam
* combo drug

potassium sparing diuretics uses

* hypertension
* edema
* HF

potassium sparing diuretics complications

* caution with ACE, ARBs, and renin inhibitors
* all causes changes in K+ levels
* hyperkalemia
* elevated T waves
* wkns
* fatigue
* dyspnea
* dysrhythmias
* endocrine effects
* deep voice
* hirsutism
* drowsiness, metabolic acidosis

potassium sparing diuretics contraindications

* don’t give to pts w/ hyperkalemia, potassium supplements, or other potassium sparing diuretic


* don’t give pts w/ severe kidney failure and anuria
* cautious w/ pts that have kidney or liver disease, electrolyte imbalances, metabolic acidosis

potassium sparing diuretics interactions

* concurrent use of ACE inhibitor, ARBs, direct renin inhibitors inc risk for hyperkalemia
* concurrent use of potassium supplements, salt substitutes, another potassium sparing diuretic inc risk for hyperkalemia

potassium sparing diuretics nursing administration

* daily weight


* monitor BP & I/O’s
* ECG periodically
* monitor K levels
* avoid salt substitutes that contain potassium
* dec potassium foods
* %%triamterene turns urine bluish color%%

osmotic diuretic

* reduces ICP and intraocular pressure (IOP)
* draws fluid back into the vascular and extravascular space
* initially will inc blood volume
* not used for HTN crisis
* affects heart diseases and kidney
* %%IV infusion only%%
* ==filter needle used==
* monitor dehydration and edema
* monitor serum osmolarity q6h = >300 then stop mannitol b/c dehydrated
* monitor for inc ICP
* seen mostly in ICU and neuro ICU

osmotic diuretic med

mannitol (osmitrol)

mannitol is a

potent diuretic

mannitol uses

* prevents kidney failure in hypovolemic shock and severe hypotension
* decreases ICP caused by cerebral edema
* draws fluid from brain into the blood stream
* dec IOP by drawing ocular fluid into the bloodstream
* for hyponatremia and fluid volume excess
* promotes sodium retention and water excretion
* administered for the oliguria phase of acute kidney injury
* ensuring pt has adeq. renal perfusion

mannitol complications

* HF
* pulmonary edema
* rebound inc intracranial pressure
* fluid and electrolyte imbalances, metabolic acidosis

mannitol interactions

* lithium excretion thru kidneys inc
* inc risk for hypokalemia w/ cardiac glycosides

mannitol nursing administration

* cont. IV infusion
* use a filter needle
* daily weight
* I/O’s
* blood electrolytes
* monitor K levels

mannitol effectiveness

* normotensive BP
* absence of cardiac dysrhythmias
* absence of chest pain
* control of heart failure manifestations
* normal kidney function AEB normal lab values
* dec in IOC or IOP
* dec in pulmonary or peripheral edema
* weight loss
* inc in urine output