Hypertension medications

What is the most common primary diagnosis in America?

HTN

What causes primary HTN?

It 1s unknown, but thought to be coorelated with genetics, poor diet, lack of exercise, and obesity.

Risk factors of HTN

Obesity, stress and anxiety, excessive alcohol, excessive salt, family history, diabetes, tobacco, African American

Causes of secondary HTN

Chronic kidney disease, renal artery stenosis, disease of adrenal glands, pregnancy, medications or elicit drug usage

Non pharm HTN treatment

Dietary modification, weight reduction, physical activity

Ace inhibitor MOA

Block conversion of angiotensin I to angiotensin II

Less angiotensin II = less vasoconstriction

Increases bradykinins = more vasodilation

Ace inhibitors metabolized by

Cleared by kidneys

Ace inhibitor examples

• Lisinopril ( primeval/ zestril)

• Benazepril ( lotensin)

• Quinapril (accupril)

ACEI indications

Hypertension

First line for HTN in CHF and a diabetic patient

MI

Contraindication of ACEI

Pregnancy

Renal artery stenosis

Use with caution of renal insufficient patients

ACEI side effect

Persistent dry cough

Hyperkalemia ( ↑ risk with potassium sparing diuretics)

Hypotension

Renal dysfunction

Angioedema ( can occur years after usage)

What blood work should be done through the coarse of an ACEI?

Potassium and creatinine levels

ACEI increase levels of

Digoxin and lithium

What should not be taken w/an ACEI?

Antacid → I ↓ absorption

ARB act by

Preventing the binding of angiotensin II to the receptor.

How do ARB differ from ACEI?

ARB have no effect on bradykins, so not as much vasodilation.

ARBs examples

• Losartan ( cozaar)

• Valsartan ( Diovan)

• Irbesartan ( avapro)

ARBs indications

• Hypertension

• First line anti hypertensive for CHF

• Patients who can not tolerate ACEI due to cough

• Tx for pts with hypertension and diabetes with nephropathy

• Cardiac protection in high risk cardiac patients

Contraindication of ARBs

Pregnancy

ARBs side effects

Fairly well tolerated but can cause dizziness,hypotension, hyperkalemia, angioedema, renal failure

ARBs half life

12 - 24 hours, so a once daily dosing

African descent have a smaller average BP response to ARBs

Beta 1 Vs beta 2

Beta 1 is cardio selective and has receptors on the myocardial tissue

Beta 2 receptors are on uterine, vascular, and pulmonary tissue

Cardioselective b-blockers

Atenolol ( tenormin)

Metoprolol ( lopressor/ toprol)

Non cardloselective b-blocker examples

Propranolol (inderal)

Mixed alpha and beta blocker example

Carvedilol ((coreg))

B-blocker indications cardiac use

Hypertension

Stable CHF

Tachyarrhythmias → sinus tachycardia, hyperthyroidism cocaine

Atrial fibrillation / flutter

Angina

Decreased mortality in patients with recent MI

Non cardiac indications for B- blocker

Migraine prevention

Anxiety

Glaucoma

Tremor

B-blocker contraindications

Asthmatics/copd → could have bronchoconstriction

Second degree heart block → could lead to 3rd degree

Bradycardia, severe hypotension, acute heart failure

B-blocker SE

Hypotension, CHF, asthma, bradycardia, raynauds, fatigue, hypoglycemia, ins effect, lipid effect depression

B-blocker have what effect on hypertension

Reduces HR and stroke volume leading to decreased cardiac output which is how BP decreases.

B-blockers effect for tachycardia / arrhythmia

Slow the SA pacemaker rate ( only in tachycardia )

Depression of AV nodes to prolong refractory time

What is important to remember when prescribing a b-blocker?

Do not abruptly discontinue b-blockers due to rebound effect

Ca channel blockers effect what?

The l-type calcium channels which are located on the heart, skeletal muscle, neurons, vascular smooth muscle, uterus.

What can a Ca channel blockers do for the heart?

Relax coronary vascular smooth muscle, coronary vasodilation, increase myocardial oxygen delivery.

Ca channel blocker examples

Dihydropyridines: nifedipine ( pericardia) or amlodipino ( norvasc)

Nondihydropyridine: distrazem ( cardizem) or verapamil ( calan )

Dihydropyridines

Are largely vasodilators and can have increase permability of neural or vasculature tissue

Non-di hydropyridines

Reduce vascular permability and effect cardiac contractility

Indication for non DHP

Stable angina, afib/flutter, paroxysmal SVT, hypertension

Indications for DHP

Hypertension, prevent or treat coronary spasm invariant agitadiastolic HF

Contraindication of non -DHP

Wolff parkinson white, hypotension, , acute CHF AV blocks

Contraindications of DHP

Pregnancy, condition where tachycardia is harmful, CAD, aortic stenosis, mitral stenosis

Ca channel Non DHP SE

Bradycardia, HF, hypotension constipation

Ca channel DHP SE

Vasocialation (flushing ), dizziness, headache, tachycardia, constipation

What DHP Ca channel blocker has an slow onset, but longer half life

Amlodipine

CYP3A4 is important for metabolizing what Ca channel blocker group?

Dinydropyradines

The bioflavonoids in grapefruit inhibit metabolism of DHPs

Thiazide diuretic

Enhances secretion of sodium and chloride in the urine so water is excreted with.

Potassium sparing diuretic

Blocks the exchange of sodium for potassium, resulting in excretion of sodium and potassium but little loss of potassium.

Loop diuretic

Inhibits kidneys ability to reabsorb sodium so more sodium and water are in urine.

Carbonic anhydrase inhibitors

Work by ↑ excretion of sodium, potassium, bicarbonate, and water from renal tubules.

Osmotic diuretics

Prevent reabsorption of water sodium, or chloride.

Thiazide examples

Hydrochlorothiazide /hctz 12.5 - 50 mg

Potassium sparing diuretic example

Triamterere 50 -100 mg

Thiazide/ potassium sparing drug

HCTZ + triamterene 25mg/37.5mg or 50 mg/ 75mg

Adverse effects of diuretics

Dry mouth, thirst, weakness, lethargy, drowsy, restlessness, muscle cramps or pain, confusion, secures, hypotension, oligouria

Mixed alpha + b-blocker example

Carvedilol ( coreg) 12.5-50mg

Aldosterone receptor blockers example

Spironolactone/ aldactone 25-50 mg