HTN Flashcards by Jerrina Gusler

JNC Joint National Committee

sets standards of treatment

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Diuretics

Ions drive the action
Increase osmolality of filtrate
Requires good blood flow to Kidney
GFR> 30

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Thiazide Diuretics

African American Male (good response)

Works at Distal convuluted tubule
Blocks Na+ channels–no reabsorption of Na+/ Cl.-filtrate stays in kidney for excretion.
Contraindicated with Gout DX’
NO Na+ in and NO uric acid out—> risk
Gout.

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Thiazide Diuretics

Contraindicated in DX
Gout, Renal Insuffiency

Chlorothiazide 250 mg -1gm/day
Hydrochlorothiazide ** most common
  12.5-100mg/day
Metolazone 2.5-5mg/day
Chlorthalidone -more potent/ longer half life

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Loop Diuretics

Blocks Na+ at loop of Henle
Blocks Cl binding at NA+/K+/Cl transporter
increased risk of K+ loss
increased effectiveness due to increased Na+ absorption in loop of Henle.

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Loop Diuretics

Standard of treatment in Renal Disease

Furosemide 20-80 mg/day
Bumetidine (Bumex) 0.5-2mg/day

Monitor K+, NaCl, Ca+, and renal fx
K+ supplementation

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K+ Sparing Diruetics

Monitor for hypercalemia
esp with combinations of K= sparing meds (prils and birth contorl Yaz/yasman)
Blocks Na+/K+ pump–blocks Na+ reabsorption to body–increases Na+ in filtrate–K+ reabsorbs into body- no loss of K+.

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K+ sparing Diuretics

Spironolactone 25-100mg/day
Amiloride 5-20mf/day
Triamterene 100-200mg/day

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K+ sparing Diuretics

Aldosterone Receptor Antagonist

Used with liver failure/heart failure
Used in PCOS (block of androgen effect)

Spironolactone.
Blocks action of aldosterone at the collecting duct. Na= stays out/K= stays in
caution K+ levels with other K+ sparing meds.

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MI compelling indication for

Beta Blocker

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Beta blockers

Categories
Non selective with alpha blocking
Non selective Beta - blocks Beta1/Beta2
Selective blocks only Beta1

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Non selective Beta Blocker

Beta 1 & Beta 2 antagonist

***Contraindicated with DX lung Disease

Propranolol (Inderal)
Nadolol
Timolol

Uses hyperthyroidism, tremor, migraine prevention

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Non selective Beta Blocker

Effects

decreased HR (-chronotrope)
decreased contraction (-inotrope)
decreased Renin secretion
Bronchoconstriction
increased GI distress

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Selective Beta Blocker

Beta 1 Antagonist

Atenolol (Tenormin)
Metroprolol
   tartate -regular
   succinate-ER  (Toprol XL)
Uses Cardiac

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Selective Beta blocker
Effects

**Can lose selectivity at higher doses (MAX DOSE)

decreased HR (-chronotrope)
decreased contraction (-inotrope)
decreased Renin secretion

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Nebivolol- Bystolic

Selective Beta blocker Beta 1

Very cardio selective
good safety record in RAD (reactive Airway Disease)
increases release of NO (Nitrous Oxide)= vasodilation=decrease BP

Labetolol
Carvedilol (coreg)

Non selective Beta blocker +
Beta 1, Beta 2, Alpha 1
1st line drug for HF
carefully watch lung fx. (trial low dose )

Alpha 1 antagonist effects---
  Vasodilation=decreased vascular resistance.
Beta 1 antagonist effects--
  decreased HR (-chronotrope)
  decreased contraction (-inotrope)
  decreased Renin secretion
Beta 2 antagonist effects---

Beta blockers & Prescribing indications HTN

Compelling indications
S/P MI, HF, DM2 combined DM/HF
other uses HF migraine prevention

Start low-titrate slowely
Hold if HR <60
Consider dx lung disease

**note blunting SNS response masks s/s of hypoglycemia

Beta Blocker SE

<HR                           Dizziness
depression                  GI upset
sexual dysfunction       **fatigue
malaise
Rebound HTN with sudden withdrawl

Beta Blocker Contraindications

> 1st degree heart block
Bradycardia
RAD (Reactive Airway Disease)

Common interaction– Separate dosing time
Antacids
Anti-cholinergics-increase absorption

Alpha Blockers for HTN

Never 1st line tx

3rd or 4th line drug

Good to treat stress component of HTN etiology.
Vasodilation

Selective alpha 1 blocker
***do not combine with Nitrates= unsafe drop in BP
Use in conjunction with a diuretic.
Commonly used for prostate

Doxazosin mesylate (Cardura)
Prazosin HCl (minipress)
Terazosin HCl (hytrin)

alpha blockers SE

***Severe orthostatic hypotension (biggest)
fatigue
Na+/H2O retension=edema
HA, N/V
educate prostate pts--get up slowly

alpha 1 blockers contraindications

hepatic dysfunction

drug interactions NSAIDS attenuate antihypertensive effect

Alpha 2 agonist Labs decrease urine catecholamines and vanillylmandelic acid (+for DX of phenochromacytoma- tumor causing very high BP)

Alpha 2 receptors put breaks on SNS. decrease SNS activity in peripheral vessels increases vagus activity para SNS vasodilation decreased CO cardiac output decreased catecholamine& renin release

Alpha 2 agonist Uses drug withdrawl, tourettes,anger management and menopause (calming)

Methyldpoa (Aldomet) oldest BP med pregnancy approved Clonidine weekly patch or po.

alpha 2 agonist effects Caution in recent MI& depression drug reaction with TCA Tricyclic antidepressants

CNS depression/sedation in addition of alpha 1 responses Severe orthostatic hypotension, fatigue Na+/H2O retension=edema, HA, N/V

CCB Calcium Channel Blockers

``` 3 channels for calcium to enter cells. l type, N type and T type. focus on L type long lasting--contractile muscle Heart and smooth muscle T type - found only in pace making cells ```

CCB Calcium Channel Blockers | Non-dihydropyridines

Diltiazem (Cardizem) A FIB Verapamil (calan SR) A FIB Greater effect on T-type channels Pacing cells but modest impact on HTN

CCB Calcium Channel Blockers Dihydropyridines 1st pril then ipine Used for HTN other uses HF and esophageal spasm

``` Nifidipine (Procardia XL) Amlodipine (Norvasc) Cleridipine emergency use drugs ending in IPINE Greater effect on L type channels decreased contractility heart and arterial smooth muscle---HTN tx ```

CCB- Adverse reactions CCB contraindications 2nd/3rd degree heart block SBP< 90 Sick Sinus Syndrome Aortic stenosis Severe CHF

***Flushing Dizziness/HA/Dry mouth/nausea and constipation (decreased in smooth muscle contraction). Peripheral edema (give in combo with ACE/pril to decrease edema) heart dysrhythmias photosensitivity

Direct acting Vasodilators

``` Cause direct relaxation and dilation of arteriolar smooth muscle-decrease vascular resistance Hydralazine (Apresoline) slow IV admin + reflex tachycardia& HTN Minoxidil (Loniten) Used primarily for side effect of hair growth--not used much for HTN Nitroprusside (Nitropress) *****Emergency only keep away from light ```

Endothelial Dysfunction | Players

Nitric Oxide--Vasodilation RAAS-- Angiotension II (called AT1 receptor)--vasoconstriction Thromboxane A2

``` ACE Inhibitors Pregnancy class D ``` Decreased BP, stroke, and MI

ACE blocks angiotension I from changing to angiotension II by blocking angiotension converting enzyme---vascular changes (AT1) & decreased aldosterone activity (AT2)--increased Na+ & H2O excretion, increased K+ retension PO/IV administration .

ACE SE Dry cough--AT2 breaks down Bradykinin in lungs. Blocking AT2=increased Bradykinin in lungs

r/t antihypertensive effects (HA,dizziness, tachycardia, cough, Maculopapular rash, neutropenia/agranulocytosis, angioedema (swelling lips and rash, incidence increasing)

ARBS Angiotension II receptor blockers End in sartan

Blocks angiotension II at receptor site in tissue--decreased vascular resistance Benicar Diovan

ARBS SE

FEW No cough K+ sparing -careful in combo with other K= sparing meds >K+ ? same Benefits as ACE ?use in renal impairment

Renin Inhibitors Newest class of antihypertensives Aliskiren

Direct Renin inhibitor--, conversion of angiotensinogen to angiotension I. effects RAAS without increasing the plasma renin activity Dosage 150-300mg daily

ReninInhibitors Adverse Effects Drug interactions

Angioedema, diarrhea, cough Substrate of P450 3A4 reduced loop diuretic activity Do not combine with ACE/ARB ?safety/efficacy in renal disease