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Chapter 47

Chapter 47. Drugs for Hypertension. Classification of Blood Pressure (BP). Four BP categories (defined by JNC 7): Normal Systolic BP below 120 mm Hg and diastolic BP below 80 mm Hg Prehypertension Systolic BP 120–139 mm Hg or diastolic BP 80–89 mm Hg Hypertension

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Chapter 47

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  1. Chapter 47 Drugs for Hypertension

  2. Classification of Blood Pressure (BP) • Four BP categories (defined by JNC 7): • Normal • Systolic BP below 120 mm Hg and diastolic BP below 80 mm Hg • Prehypertension • Systolic BP 120–139 mm Hg or diastolic BP 80–89 mm Hg • Hypertension • Systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg • Stage 2 hypertension: systolic BP and diastolic BP in different categories (eg, 160/92 mm Hg)

  3. Types of Hypertension • Two broad categories of hypertension • Primary (essential) hypertension • No identifiable cause • Chronic, progressive disorder • Population: older adults, African Americans, Mexican Americans, postmenopausal women • Treated but not cured (lifelong condition) • Referred to as “essential hypertension” • Secondary hypertension • Identifiable primary cause • Possible to treat the cause directly • Some individuals can actually be cured

  4. Consequences of Hypertension • Heart disease • Myocardial infarction (MI) • Heart failure • Angina pectoris • Kidney disease • Stroke

  5. Basic Considerations • Benefits of lowering blood pressure • Patient evaluation • Hypertension with a treatable cause • Factors that increase cardiovascular risk • Diagnostic tests • Treatment goals • Therapeutic interventions

  6. Lifestyle Modifications • Sodium restriction • DASH (Dietary Approaches to Stop Hypertension) eating plan • Alcohol restriction • Aerobic exercise • Smoking cessation • Maintenance of potassium and calcium intake

  7. Pharmacologic Therapy • Review of blood pressure control • Principal determinants of blood pressure • Arterial pressure = Cardiac output × Peripheral resistance • Cardiac output • Heart rate • Myocardial contractility • Blood volume • Venous return • Systems that help regulate blood pressure • Sympathetic baroreceptor reflex • Renin-angiotensin-aldosterone system • Renal regulation of blood pressure

  8. Pharmacologic Therapy • Antihypertensive mechanisms: sites of drug action • Brainstem • Sympathetic ganglia • Terminals of adrenergic nerves • Beta1-adrenergic receptors on the heart • Alpha1-adrenergic receptors on blood vessels • Vascular smooth muscle • Renal tubules • Beta1 receptors on juxtaglomerular cells • Angiotensin-converting enzyme • Angiotensin II receptors • Aldosterone receptors

  9. Pharmacologic Therapy • Classes of antihypertensive drugs • Diuretics • Thiazide diuretics • High-ceiling (loop) diuretics • Potassium-sparing diuretics • Sympatholytics (antiadrenergic drugs) • Beta-adrenergic blockers • Alpha1 blockers • Alpha/beta blockers: carvedilol and labetalol • Centrally acting alpha1 agonists • Adrenergic neuron blockers

  10. Pharmacologic Therapy • Sympatholytics (antiadrenergic drugs) (cont’d) • Direct-acting vasodilators: hydralazine and minoxidil • Calcium channel blockers • Drugs that suppress RAAS • ACE inhibitors • Angiotensin II receptor blockers • Aldosterone antagonists • Direct renin inhibitors ACE = angiotensin-converting enzyme; RAAS = renin-angiotensin-aldosterone system.

  11. Pharmacologic Therapy • Fundamentals of hypertension drug therapy • Treatment algorithm • Initial drug selection • Patients WITHOUT compelling indications • Patients WITH compelling indications • Adding drugs to the regimen • Rationale for drug selection • Benefits of multidrug therapy • Dosing • Step-down therapy

  12. Pharmacologic Therapy • Individualizing therapy • Patients with comorbid conditions • Renal disease • Diabetes • Patients in special populations • African Americans • Children and adolescents • The elderly

  13. Pharmacologic Therapy • Minimizing adverse effects • Promoting adherence • Why adherence can be difficult to achieve • Ways to promote adherence • Educate the patient • Teach self-monitoring • Minimize side effects • Establish a collaborative relationship • Simplify the regimen • Other measures

  14. Drugs for Hypertensive Emergencies • Sodium nitroprusside • Fenoldopam • Labetalol • Diazoxide • Clevidipine

  15. Drugs for Hypertensive Disorders of Pregnancy • Chronic hypertension and pregnancy • ACE inhibitors, ARBs, and DRIs are contraindicated during pregnancy • Most other antihypertensives can be continued during pregnancy • Preeclampsia and eclampsia • Hydralazine • Magnesium sulfate (anticonvulsant) ARB = angiotensin receptor blocker; DRI = direct renin inhibitor.

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