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HYPERTENSION

HYPERTENSION. BY: DR. MARWA SHAALAN PHARM-D. HYPERTENSION. HTN = BP > 140/90 Assos. With: premature death vascular disease of brain, heart,kidneys. Goal of treatment. Prolong useful life by preventing cardiovascular problems by reducing BP < 140/90. Primary HTN :

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HYPERTENSION

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  1. HYPERTENSION BY: DR. MARWA SHAALAN PHARM-D

  2. HYPERTENSION • HTN = BP > 140/90 • Assos. With: premature death vascular disease of brain, heart,kidneys

  3. Goal of treatment • Prolong useful life by preventing cardiovascular problems by reducing BP < 140/90

  4. Primary HTN: also known as essential HTN. accounts for 95% cases of HTN. no universally established cause known. Secondary HTN: less common cause of HTN ( 5%). secondary to other potentially rectifiable causes. Types of Hypertension

  5. Blood Pressure • Primary Factors • Cardiac output • Peripheral resistance • Blood Volume

  6. Initial tx. of hypertension • Lifestyle modification first • No smoking • Weight control • Reduce alcohol intake • Decrease stress • Sodium control

  7. Treatment of hypertension • Lifestyle modification first • Initial tx. drug- diuretic or B-blocker • Low dose first, increase dose if necessary • 2nd med. if needed • Most respond with diuretic and one other medication (stepped care)

  8. Drugs to treat hypertension • 5 primary classes • Diuretics • Calcium channel blockers • Angiotesin converting enzyme (ACE) inhibitors • Autonomic nervous system agents • Direct acting vasodilators

  9. 1- Diuretics • Treats: mild to moderate HTN • First drug of treatment of hypertension. • Also treats heart failure or kidney disease • Few adverse side effects • Used with other anti-hypertensives to enhance effectiveness

  10. DiureticsAction • Reduce blood volume through urinary excretion of water and electrolytes • Electrolyte imbalances can occur (mainly hypokalemia) • Depends on type of diuretic

  11. Diuretics • Most efficient: Loop or High-ceiling • Reduce edema associated with CHF • Increase Urine output even if blood flow to kidney is diminished • Hypokalemia • KCL supplement given • Lasix, Demadex, Bumex

  12. Diuretics • Most widely prescribed: Thiazides • Mild to moderate HTN-primarily • Hydrodiuril – hydrochlorothiazide (HCTZ) • Hypokalemia • Potassium supplement- KCL

  13. Diuretics • Potassium-sparing:prevent hypokalemia • Mild HTN • Used in combination with other diuretics • No supplement taken • Watch for hyperkalemia

  14. Side effects • Orthostatic hypotension • Dry mouth,irritation Report: • Electrolyte imbalance- hypokalemia (potasium<3.5) • Disorientation • dehydration

  15. Implications for use • Optimal time to admin.= AM • Accurate intake and output • Daily weights • Monitor electrolyte imbalances

  16. 2-Calcium Channel Blockers • Emerged as major drug to treats HTN • Used for arrythmias also • Alternative to B-blocker ( esp.in Asthma patients)

  17. Calcium Channel Blockers Action: blocks ca+ access to muscle cells contractility + conductivity of the ______________________ demand for oxygen PVR (relaxing arterioles)[peripheral vascular resistance]

  18. Calcium Channel Blockers Examples • Verapamil Very • Procardia (nifedipine)-HTN Nice • Cardizem (diltiazem)-arrythmias Drugs

  19. Calcium Channel Blockers • SIDE EFFECTS • BP • Bradycardia • May precipitate A-V block • Headache • Abdominal discomfort • Peripheral edema

  20. 3-Angiotensin-Converting Enzyme Inhibitors • “ACE” inhibitors • Mainstay of oral vasodilator therapy • Major breakthrough in treatment of HTN • More effective when used with diuretics

  21. ACE INHIBITORS Angiotensin Converting Enzyme (ends in PRIL) captopril enalapril benzapril (Capoten) (Vasotec) (Lotensin)

  22. RENIN-ANGIOTENSIN-ALDOSTERONE AXN. • BP • excrete renin • formation of angiotensin I • angiotensin II = potent vasodilator • Aldosterone release Na and H2O

  23. ACE INHIBITORS • ACTION • peripheral vascular resistanse without Ø cardiac output Ø cardiac rate Ø cardiac contractility

  24. Advantages • Infrequent orthostatic hypotension • Lack of aggravation of pulmonary disease. • Lack of aggravation with Diabetes Mellitus • Increase renal blood flow

  25. Side effects • Headache • Orthostatic hypotension-infrequent • Cough • GI distress

  26. Drug interactions • Diuretics • Alcohol • Beta-blockers • All the above enhance the effects

  27. 4-Adrenergic ReceptorsReview of ANS • Sympathetic Nervous System • Alpha 1 = vasoconstriction • Alpha 2 = feedback/vasodilation • Beta 1 = increases heart rate • Beta 2 = bronchodilation

  28. A-Beta Adrenergic Blocking Agents • Known as Beta-blockers • Anti-adrenergic: Inhibit cardiac response to sympathetic nerve stimulation by blocking Beta receptors • Decreases heart rate and Cardiac output • Decreases blood pressure

  29. Beta Adrenergic Blocking Agents • Examples – “olol” names • Beta 1: Atenolol • Beta 1 and 2: Propranolol

  30. Implications • Can not be abruptly discontinued • Check baseline b.p. • Check patients of resp. condition-aggravates broncho-constriction

  31. Side effects • Bradycardia • Bronchospasm, wheezing • Diabetic: hypoglycemia • Heart failure: edema,dyspnea,rhales

  32. Interactions • Antihypertensives- additive effect • Anti-adrenergic effects. • Enzyme inducing agents-enhance metabolism • Indomethacin and salicylates:< controll

  33. B-Alpha-1 adrenergic blockers • Alternative if B-blockers and diuretics do not work • Also used to treat mild to mod. urinary obstructive disease. (BPH)

  34. Alpha-1 Adrenergic Blocking Agents Action: • Block postsynaptic alpha-1 adrenergic receptors to produce arteriolar and venous vasodilation • Reduces peripheral-vascular resistance

  35. Side effects • Drowsiness • Headache • Dizziness,tachycardia,fainting • Weakness,lethargy • Interactions: other antihypertensives (enhance effects)

  36. Clinical Implications • Side effects most prevalent with first dose • Warn patient that this is normal • Instruct pt. to lie down if dizzy ,weak ….,etc.

  37. Examples of Apha-1 blockers • Cardura (doxazosin) • Minipress (prazosin)

  38. C-Centrally Acting Alpha-2 Agonists • Stimulate Alpha-2 receptors in brainstem • Decreases HR, SBP and DBP • More frequent side effects – drowsiness, dry mouth, dizziness • Never suddenly Discontinued = rebound HTN • Clonidine [ Catapress] • Methyldopa [Aldomet]

  39. 5-Direct Acting Vasodilators • Action: direct arteriolar smooth muscle relaxation, decreasing PVR • Uses: HTN, renal disease, toxemia of pregnancy • Ex: Apresoline, Minoxedil • SE: tachycardia, orthostatic hypotension , dizziness, palpitations, nausea, nasal congestion

  40. Patient Teaching forAntihypertensive drugs • Take medication as prescribed • Never discontinue without approval of healthcare provider • Incorporate lifestyle changes, even if medication brings BP within normal Limits • Check BP on regular basis and report significant variations (and pulse) • Get out of bed slowly

  41. Patient Teaching forAntihypertensive drugs • Increase intake of potassium-rich foods, unless taking potassium sparing diuretics • Weigh regularly and report abnormal weight gains or losses • Do not take OTC drugs without checking with healthcare provider

  42. Special notes on Treatment of Hypertension. • Never combine: • 1-Alpha or beta blocker and clonidine - antagonism • 2-Nifedepine and diuretic synergism • 3-Hydralazine with DHP or prazosin – same type of action • 4-Diltiazem and verapamil with beta blocker – bradycardia • 5-Methyldopa and clonidine • Hypertension and pregnancy: • No drug is safe in pregnancy • Avoid diuretics, propranolol, ACE inhibitors, Sodium nitroprusside ..etc • Safer drugs: Hydralazine, Methyldopa, cardioselective beta blockers and prazosin

  43. Hypertensive Crisis • Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated Hypertension) • Hypertensive Emergencies: Progressive end-organ dysfunction. (Malignant Hypertension)

  44. Hypertensive Urgencies • Severe elevated BP in the upper range of stage II hypertension. • Without progressive end-organ dysfunction. • Examples: Highly elevated BP without severe headache, shortness of breath or chest pain. • Usually due to under-controlled HTN.

  45. Hypertensive Emergencies • Severely elevated BP (>180/120mmHg). • With progressive target organ dysfunction. • Require emergent lowering of BP. • Examples: Severely elevated BP with: - Hypertensive encephalopathy -Acute left ventricular failure with pulmonary edema -Acute MI or unstable angina pectoris -Dissecting aortic aneurysm

  46. Hypertensive Emergencies • 1-Cerebrovascular accident or head injury with high BP • 2-Hypertensive encephalopathy • 3-Angina or MI with raised BP • 4-Acute renal failure with high BP • 5-Eclampsia[ pregnancy hypertension ] • Drugs: • Sodium Nitroprusside (20-300 mcg/min) – dose titration and monitoring • GTN (5-20 mcg/min) – cardiac surgery, LVF, MI and angina • Esmolol (0.5 mg/kg bolus) and 50-200mcg/kg/min - useful in reducing cardiac work

  47. The End

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