Antihypertensive Agents

ACEI mechanism

Target RAAS → ACE inhibition → Lower Ang II → Lower vasoconstriction and aldosterone; increase bradykinin = vasodilation

ACEI agents

Enalapril, lisinopril, ramipril, perindopril

AE of ACEI

Dry cough from high bradykinin, hyperkalemia from low aldosterone, high creatinine, angioedema; CI in pregnancy

What are ARBs

ALTERNATIVE to ACEI → block AT1 receptor instead of ACE

ARB agents

Losartan, valsartan, irbesartan, candesartan, telmisartan, Azilsartan

AE of ARB

Hyperkalemia and kidney dysfunction, cough can occur but less common than ACEI

Can you combine ARB and ACEI

Without clinical advantage DO NOT combine → Increased CKD and hyperkalemia risk

Families of CCB

Dihydropyridine and non dihydropyridine

What is dihydropyridine

BP drug → leads to peripheral vasodilation; AE = edema, flushing, headache

Dihydropyridine drugs

Amlodipine, nifedipine, nicardipine

What is Non-dihydropyridine

Lower AV conduction and contractility; AE = bradycardia, AV block, constipation; used when rate control is needed

Should CCB verapamil or diltiazem + beta blocker be used together

NO because it increase AV block and contractility effect

When would you use ACEI/ARB > CCB

Hypertension + CRK with albumin/proteinuria, Heart Failure with reduced Ejection Fraction (HFrEF), Post MI/CAD with LV dysfunction, DM + albuminuria

When would you use CCB > ACEI/ARB

HTN + elderly/isolated systolic HTN, angina, Afib rate control, Raynaud

Action of thiazide diuretics

Lower plasma volume → Lower peripheral vascular resistance

HCTZ AE

Hyponatremia, hypokalemia, hyperuricemia

What needs to be monitored if Pt was given diuretics

Serum Na, K, uric acid/gout symptoms; glucose and metabolic effect, volume and orthostatic symptoms, kidney function

When are loop diuretics used

Used in significant kidney dysfunction or fluid retention; short duration is not helpful in routine HTN treatment

What are beta blockers

Lower BP by lowering HR, CO and renin release; used when HTN coexist with angina, sinus tachycardia or HFrEF

Beta blocker examples

Metoprolol, bisoprolol, carvedilol, nebivolol.

Beta blocker AE

Bradycardia/AV block, bronchospasm, ED, hypoglycemia masking, worsening HF

What are Mineralocorticoid receptor antagonists

Spironolactone → blocks aldosterone → natriuresis + potassium retention

AE of Mineralocorticoid receptor antagonists

Hyperkalemia and metabolic acidosis risk increase in Pt with impaired kidney function and when combined with ACEI/ARB; gynecomastia in spironolactone

Why are alpha blockers NOT first line

Lower peripheral vascular resistance; causes first dose syncope and postural HTN; have LOWER cardiovascular outcomes

Central sympatholytics examples

Clonidine, methyldopa, guanfacine

Direct vasodilators examples

Hydralazine, minoxidil, general principle; causes reflex tachy + fluid retention

Stepwise combination therapy

Give ACEI/ARB first → CCB → Thiazide → Spironolactone