What are the 5 classification of antihypertensive drugs?

1.  Diuretics

2.  Antiadrenergic Drugs (Sympatholytics - BB', etc.)

3.  Direct-Acting Vasodilators (hydralazine, etc..)

4.  Drugs that Suppress RAAS

5.  CCB's

What constitutes HTN?

Systolic >140 and diastolic >90

What is the most common form of HTN?

Primary or essential HTN, which has no identifiable cause.

What can untreated HTN cause?

1.  Heart Disease

2.  Stroke

3.  Kidney Disease

In patient's older than 50, does elevated systolic or diastolic cause the greater CV risk?

Elevated systolic BP

What is the goal in treating HTN?

Decrease morbidity and mortality, without decreasing quality of life.

BP <140/90 or BP <130/80 in patient's with DM or kidney disease.

What are the two treatments used for HTN and in what order?

1.  Lifestyle Modifications

2.  Drug Therapy

The baroreceptor reflex, RAAS, and kidneys can oppose our attempts to lower BP with drugs.

How do we counteract these 3 things?

1.  Baroreceptor Reflex - BB

2.  Kidneys - Diuretic

3.  RAAS - ACE, ARB, DRI, or Aldosterone Antagonist

Thiazides and Loop Diuretics decrease BP in two ways.  What are they?

1.  Reduce blood volume (diuresis)

2.  Reduce AP (uinknown mechanism)

When are Loop Diuretics indicated?

1.  When the need for diuresis is greater than can be achieved with thiazides

2.  When GFR is low because thiazides don't work with low GFR.

In what ways do BB's reduce BP?

1.  Decrease PR

2.  May also decrease myocardial contractility and suppressing reflex tachycardia (beta1 in heart))

3.  Decreasing renin release (beta1 in kidneys)

What are the differences in how ACE's, ARB's & DRI's work?

1.  ACE's - block conversion of angiotensin I to II

2.  ARB's - block the action of angiotensin II

3.  DRI's - prevent formation of angiotensin I, thereby shutting down the whole system.

How do aldosterone antagonists work?

Prevent  aldosterone mediated retention of H20 and Na in the kidney

Patients with Stage I HTN are typically treated with how many drugs?

Whereas, patients with Stage II HTN are typically treated with how many drugs?

One

Two or more

What is the drug treatment of choice for uncomplicated HTN?

Thiazide Diuretics

When a combination of drugs is needed to treat HTN, it is ok to have more than one drug with the same MOA?

True or False?

False

Why is it important to start low and go slow with antihypertensive drugs?

Prevents adverse effects and permits barorecptors to reset to a lower pressure.

What is the major cause of treatment failure in treating HTN?

Lack of patient adherence

Why is adherence so difficult to achieve?

1.  No symptoms

2.  Progresses slowly, so pt's think they can put it off.

3.  tx is complex and expensive

4.  tx is lifelong

6.  tx can have adverse effects

What constitutes a hypertensive emergency?

Diastolic > 120 and ongoing end-organ damage.

What is the most common complication of pregnancy?

HTN

What constitutes Isolated Systolic Hypertension (ISH)?

Systolic > 140 and Diastolic <90

What are the common causes of death related to HTN?

Cerebral hemorrhage

RF

HF

MI

What are the treatment goals for HTN?

1.  Dec morbidity and mortality of cardiovascular events and renal failure

2.  BP systolic < 140 and diastolic < 90 or with DM and CRF Systolic < 130 and diastolic < 80

What are the determinants of BP?

CO influenced by HR, contractility, blood volume, venous return.  Change in any can result in HTN

What 3 systems regulate BP?

1.  Kidneys

2.  RAAS

3.  SNS

What happens to the baroreceptor reflex BP present level in pt's with HTN

It is set abnormally high as it gets used to higher BP

RAAS can increase BP in 5 ways and interfere with drug intervention.  What meds can hanlde these issues?

1.  BB - dec renin release

2.  ACE - block conversion of ang I to ang II

3.  DRI's - interfere with renin to angi I

4. ARB's - block angiotension II action

5.  Aldosterone Antagonist - block aldosterone receptors

What are the sites of drug actions for antihypertensives?

1.  Brainstem - suppress symp outflow

2.  Sympathetic Ganglia - profound dec BP - rarely used

3.  Terminal Adrenergic Nerves - rarely used

4.  Beta1 Adrenergic - heart

5.  Alpha1 Adrenergic - blood vessels

6.  VSM - Nitroprusside

7.  Renal Tubules - Na & H20 excretion

What is the initial drug selection for HTN w/o compelling indication?

Stage 1:  Thiazide; Then any of the others

except Alpha1 Blockers

Stage 2:  2 drug combo = thiazide + ?

What is the initial drug selection for HTN w/compelling indications?

DM - all but aldosterone antagonists

CKD - ACE and ARB's

HF - all but BB's

What are the benefits of multidrug therapy for HTN?

1.  Lower dosages

2.  Offset SE's of one another

What is the treatment approach for pt with RD and HTN?

1.  Most important - BP <130/80

2.  ACE &/or ARB's + diuretic are best

3.  Avoid K+ sparing diuretics

What is the best treatment approach for pt with DM and HTN?

1.  Most important - Bp <130/80

2.  ACE, ARB's, CCB's and diuretics in low doses

(diabetic nephropathy)

What are the two SE's of BB's that pose problems for DM?

1. Suppress glycogenolysis

2.  Mask hypoglycemia

What is a SE of Thiazides and Loop Diuretics that are of particular concern for pt's with DM?

Causes hyperglycemia

African Americans have high risk of HTN and what other diseases?

1.  HD

2. ESRD

3. Stroke

How do you best treat the Afrian-American

1.  BP < 135/85 or 130/80 if CVD

2.  Diuretics drug of choice as others don't work as well in this population

Children tend to have secondary htn so we treat the cause.  What if they have primary HTN.  How do we treat that?

Just like an adult.

The elderly have an increased risk of ISH.  What is the BP goal here?

65-79 = systolic 140

>80 = systolic 145

Have a significant risk of hypotension due to age.

What are the 3 most common SE's of antihypertensives?

1.  Hypotension

2.  Sedation

3.  Sexual Dysfunction

What are some ways to promote adherence?

1.  Pt Ed

2.  Teach Self-Monitoring

3. Minimize SE's

4. Collaborative RElationship

5.  Simplify regimen

What is the risk of prolonged treatment with Nitroprusside?

Thiocyanate poisoning - cyanide

What is the most important thing to do in HTN in pregnancy?

Distinguish between chronic HTN and preeclampsia

What constitutes chronic HTN in pregnancy?

present prior to pregnancy or within first 20 weeks.

Recommendation is to treat severe HTN in pregnancy and not treat mild HTN in pregnancy.  What constitutes each?

Severe - systolic >180 and diastolic > 110

Mild - Systolic 140-179 and diastolic 90-109

What are the two primary symptoms of preeclampsia?

1.  HTN

2.  Proteinuria

both after 20th week

What constitutes eclampsia and what is the only cure?

Seizures

Delivery

If given prior to 16 weeks, what can help prevent preeclampsia?

Low dose ASA

What are the classifications of HTN?

Normal  systolic <120 and diastolic <80

Prehypertension systolic 120-139  OR diastolic 81-89

Hypertension Stage I: 140-159 OR 90-99

Hypertension Stage 2:  >160 OR >100

HTN is a risk factor for what target organ damage?

1.  CVD - MI, HF

2. Kidney Disease

3. Stroke and TIA's

4. Retinopathies

5. PAD

AP = CO X TPR

True or False?

True

What are the 2 thermostats that govern BP?

1.  RAAS

2.  SNS

AP = CO X TPR

What drugs effect CO?

What drugs effect TPR?

CO - beta blockers, CCB's, diuretics

TPR - ACE, ARB, Renin Inhib, Alpha blockers, alpha2 agonists, CCB's, diuretics, sympatholytics, vasodilators

What are the 6 major antihypertensive drug categories?

1.  Diuretics

2.  CCB's

3.  Sympatholytic Agents (alpha and beta)

4.  Renin-Angiotensin Blockers/Antagonists

5. Direct Renin Inhibitors

6. Vasodilators