Week 8 (HTN, HF, CAD-Angina Medications)

Cause of essential/primary HTN?

Idiopathic (cause is unknown)

Cause of secondary HTN?

Can be specified (renal, endocrine, etc)

How to determine the history of HTN symptoms?

Onset, duration, frequency, aggravating factors

• Often doesn’t come with any symptoms, which can be deadly

Elderly response to antihypertensive agents

• Orthostatic hypotension

• Increased fall risks

POC response to antihypertensive agents

• HTN at younger age and higher mortality

• Low renin levels (increases BP and regulates blood volume)

• Liddle syndrome: low aldosterone levels (minimize BB and ACEI use)

Asian

• Sensitive to BBs; lower doses and monitor closely

Native Americans

• Lower response to BBs; lower doses and monitor closely

Consequences of HTN

• Stroke (facial weakness, arm weakness, slurred speech)

• Kidney disease

• Chest pain

• Pitting edema from heart failure

Contributing factors to HTN

Overweight, excessive salt intake, smoking, sedentary lifestyle, increased alcohol intake, excessive stress

HTN risk factor reduction by lifestyle modifications

• Aerobic exercise

• DASH (dietary approaches to stop hypertension)

• Sodium restriction/discuss salt substitutes

• Smoking cessation

• Alcohol restriction

• Stress reduction techniques

BP control/guidelines

Normal BP: 120/80

Adults with confirmed hypertension should aim for a systolic blood pressure of <130/80 mmHg

• Further reduction to <120 mmHg is encouraged to lower CVD events and mortality, with therapy initiation based on confirmed hypertension

ACC/AHA and ESH guidelines recommend initial treatment with antihypertensive agents from at least 1 of what 4 major classes?

Angiotensin-converting enzyme inhibitors (ACEIs)

Angiotensin-receptor blockers (ARBs)

Thiazide or thiazide-like diuretics

Calcium channel blockers (CCBs)

HTN treatment guideline

Use a treatment algorithm and choose ONE drug therapy to lower BP (monotherapy)

• Start at lower doses and gradually increase to desired effects

  • Decreases risk of side effects

  • Allows baroreceptors to gradually reset to lower BP

• Add additional drugs to regimen as needed

  • Each should come from a different class

  • Increases effectiveness with different mechanisms of action

Blood pressure is controlled by which 3 factors?

Peripheral/systemic vascular resistance (SVR)

Kidneys

Cardiac output

Vasodilators (example, mechanism, route, SEs, interventions)

hydralazine (Apresoline)

Direct acting peripheral vasodilators

PO/IV

• Overexpression of effect → drastic drop in BP, monitor closely

• IV hydralazine works fast and drastically; use in hypertensive criss

• Take at the same time everyday

How does the RAAS regulate BP?

• Constriction of arterioles and veins (angiotensin II)

• Retention of sodium → retention of water by the kidney (aldosterone)

• When there’s an increase in angiotensin II and aldosterone in the body → hypertension

• Treatment aimed at decreasing these elements AKA decrease BP

Angiotensin Converting Enzyme Inhibitors (ACEIs) (example, mechanism, route, SEs, interventions)

(-pril)

Inhibits ACE, which stops the conversion of angiotensin I to angiotensin II → less constriction of arterioles/veins → decreased BP

Delays the onset or slow progression of nephropathy

Used for HTN and HF

PO

• Dry cough, hyperkalemia, angioedema

• Monitor for S/S of hyperkalemia and other drugs that can cause hyperkalemia

• Can cause renal impairment

• Caution with NSAIDs (decrease ACEI effect and acute kidney failure)

• Avoid foods with K+

Angiotensin Receptor Blockers (ARBs) (example, mechanism, route, SEs, interventions)

(-sartan)

Blocks the action of angiotensin II → decreased aldosterone → decreased BP

Used for HTN and HF if ACEI is not working/causing SEs

PO

• Dry cough, hyperkalemia, angioedema

  • Not as prominent as ACEIs but can still occur

What are the 3 types of diuretics that can be used to treat HTN?

Thiazide diuretics (HTN, HF): HCTZ

Loop diuretics (HTN, HF): furosemide

K+ sparing diuretics (adjunct for HTN, HF): spironolactone

Calcium channel blockers (CCBs) (example, mechanisms, SEs, interventions)

Amlodipine

Blocks Ca → decrease in heart contraction and relaxes blood vessels

PO

• Peripheral edema, headache

• Monitor for edema and the drug’s long ½ life

Beta blockers (selective, non-selective)

Selective

• Beta-adrenergic blockers

• Metoprolol

• Main use: HF, MI, arrhythmias

• SE: decreased HR

Nonselective

• Alpha/beta blockers

• Carvedilol

• Main use: HF, MI, arrhythmias

• SE: asthma related symptoms

Check apical HR before giving BBs; if <60, then hold

What IVs must be administered during a HTN crisis?

• Alpha/beta blocker (nonselective): labetalol IVP

• Vasodilator/NTG: nitroprusside IV infusion

• CCB: nicardipine IV infusion

• Norepinephrine: levophed

Titrate based on response; IV must be on a pump

Orthostatic hypotension (symptoms, causes)

Dizzy, lightheaded

Causes:

• Dehydration

• Certain medications

  • Meds causing drowziness (antiemetics, opioids, HTN meds)

Nursing and patient education for all BP meds (hypotension)

• Lie flat and lift legs

• Fluid bolus isotonic

• Turn off any IV HTN medications infusing

• PRN IV medications (norepinephrine, phenylephrine)

• When first trialing a BP medication, patient should stay in bed bc of fall risk; caution with driving

• ACEI/ARB: monitor kidney function, K+ levels, two meds taken together that could cause hyperkalemia

• Increase fluids on hot days

• Adhere to regimen; lifelong, requires self-monitoring

• Lifestyle changes: risk factor reduction, decrease stress

• Taper off BP meds to decrease rebound HTN