Pharm

• cardiact output
• systemic vascular resistance

High blood pressure

• -Normal
• -Prehypertension
• -Stage 1 hypertension
• -Stage 2 hypertension

• Hypertension can also be defined by its cause
• -Unknown cause-Essential, idiopathic, or primary hypertension, 90% of the cases
• -Known cause- Secondary hypertension, 10% of the cases

• -Post-MI
• -High cardiovascular risk
• -Heart failure
• -Diabetes mellitus
• -Chronic kidney disease
• -cerebrovascular disease

• -High diastolic BP (DBP) is no longer considered to be more dangerous than high systolic BP (SBP)
• -Studies have shown that elevated SBP is strongly associated with heart failure, stroke, and renal failure.
• -For those older than age 50, SBP is a more important risk factor for cardiovascular disease (CVD) than DBP
• -"Prehypertensive" BPs are no longer considered "high normal" and require lifestyle modifications to prevent CVD.
• -Thiazide-type diuretics should be the initial drug therapy for most patients with hypertension (alone or with other drug classes)
• -The previous labels of "mild", "moderate", and "severe" have been dropped.

• -Beta-blockers and ACE inhibitors have been found to be more effective in Caucasians patients than African American patients.
• -CCBs and diuretics have been shown to be more effective in geriatric and African American patients than in Caucasian patients.

• -Diet and Exercise
• -Limit alcohol consumption
• -Reduce sodium intake
• -Smoking cessation

• -Adrenergic agents
• -Angiotensin converting enzyme (ACE) inhibitors
• -Angiotensin II receptor blockers (ARBs)
• -Calcium channel blockers (CCBs)
• -Diuretics
• -Vasodilators

• -Centrally and peripherally acting adrenergic neuron blockers
• -Centrally acting alpha2-receptor agonists
• -Peripherally acting alpha1-receptor antagonists
• -Peripherally acting beta-receptor blockers (beta blockers)-both cardioselective (beta1-receptors) and nonselective (noth beta1 and beta2-receptors)
• -Peripherally acting dual alpha1-and beta receptor blockers

• -Centrally and peripherally stores in neurotransmitters storage vesicles
• -SNS is not stimulated (beta-receptors in the heart and alpha1-receptors in blood vessels)
• -Result: decreased blood pressure.

• -Resperine
• -The only centrally and peripherally acting neuron blocker still available in the U.S.

• -Centraly acting alpha2-receptor agonists
• -stimulate alpha2-adrenergic receptors in the brain
• -Sympathetic outflow from the CNS is decreased
• -Norepinephrine production is decreased
• -Result: decreased blood pressure

• -clonidine (catapres)
• clonidine patch (catapres-TTS)
• -guanfacine (Tenex)
• -methyldopa (aldomet) -drug of choice for hypertension in pregnancy

• -Preipherally acting alpha1-receptor antagonists.
• -Block the alpha1-adrenergic receptors
• -The SNS is not stimulated
• -Result: decreased blood pressure
• -stimulation of alpha1-adrenergic receptors cause hypertension
• -Blocking alpha1-adrenergic receptors causes decreased blood pressure

• -Doxazosin (cardura)
• -Prazosin (minipress)
• -Terazosin (hytrin)

• -Adrenergic neuronal blockers (centrally and peripherally acting neuron blocker)
• -Treatment of hypertension, either alone or with other agents.
• -seldom used because of frequent side effects
• -Centrally acting alpha2-receptor agonists
• -Treatment of hypertension, either alone or with other agents
• -Usually used after other agents have failed due to side effects.
• -Centally acting alpha2-receptor agonists
• -Also may be used for treatment of severe dysmenorrhea, menopausal flushing, glaucoma
• -Clonidine is useful in the management of withdrawal symptoms in opioid- or nicotine- dependent persons.
• -Peripherally acting alpha1-receptor antagonists
• -Treatment of hypertension
• -Relief of symptoms of BPH
• -Management of severe HF when used with cardiac glycosides and diuretics

• Most common: dry mouth, drowsiness, sedation, constipation
• Other: Headaches, sleep disturbances, nausea, rash, cardiac disturbances (palpations)
• HIGH INCIDENCE OF ORTHOSTATIC HYPOTENSION

• -Act in the periphery
• -Reduce heart rate due to beta1-blockade
• -Examples: Propranolol (inderal), atenolol (tenormin), metoprolol (Lopressor), metoprolol-extended release (Toprol XL)

• -Act in the periphery at heart and blood vessels
• -Reduce heart rate (beta1-receptor blockade)
• -Cause vasodilation (alpha1-receptor blockade)
• -Excamples: labetalol (Normodyne,Tandate),carvdilol(Coreg)

• -Large group of safe and effective drugs
• -Often used as first-line agents for HF and hypertension
• -May be combined with a thiazide diuretic or calcium channel blocker

• RAAS: renin angiotensin-aldosterone system
• -When the enzyme angiotensin I is converted to angiotensin II, the result is potent vasconstriction and stimulation of aldosteron.
• -Result of vasoconstriction: increased systemic vascular resistance and increased afterload
• result: increased BP
• -Aldosteron stimulates water and sodium resorption
• -Result: increased blood volume, increased preload, and increased BP
• -ACE inhibitors block the angiotensin converting enzyme, thus preventing the formation of angiotensin II
• -Also prevent the breakdown of the vasodilating substance, bradykinin
• -Result: decreased systemis vascular resistance (afterload), vasodilation, and therefore decreased blood pressure.

• -Hypertension
• -HF (either alone or in cobination of diuretics or other agents)
• -Slows progression of left ventricular hypertrophy after an MI
• -Renal protective effects in patients with diabetes
• -Drugs of choice in hypertensive patients with HF
• -captopril (Capoten)- very short half life
• -enalapril (Vasotec)- Available in oral and parenteral forms
• -lisinopril (Prinivil and Zestril) and quinapril (Accupril)- Newer agents, long half-lives, once a day dosing
• -Several other agents available

• -Fatigue, headache, impaired taste, dizziness, mood changes, possible hyperkalemia, dry, nonproductive cough, which reverses when therapy is stopped
• NOTE: First-dose hypotensive effect may occur!!

• -( A II blockers, or ARBs)
• -Newer class
• -Well tolerated
• -Do not cause a dry cough

• -Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II
• -Block vasconstriction and release of aldosterone

• -Isartan (Cozaar, Hyzaar)
• -valsartan, (Diovan)
• -candesartan (Atacand)

• -Hypertension
• -Adjunctive agents for the treatment of HF
• -May be used alone or with other agents such as diuretics
• -Used primarily in patients who cannot tolerate ACE inhibitors

• -Upper respiratory infections
• -Headache
• -May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue
• -Hyperkalemia much less likely to occur

• -Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction
• -This causes decreased peripheral smooth muscle tone and decreased systemic vascular resistance
• -Result: decreased blood pressure

-Benzothiazepines - diltiazem (Cardizem, Dilacor)

-Phenylalkamines- verapamil (Calan, Isoptin)

-Dihydropyridines- amlodipine (Norvasc), nicardipine (Cardene) nifedipine (Procardia), nimodipine (Nimotop)

• -Angina
• -Hypertension
• -Dysrhythmias
• -Migraine headaches
• -Raynaud's disease

• -Cardiovascular- Hypotension, palpitations, tachycardia
• -Gastrointestinal- Constipation, nausea
• -Other- Rash, flushing, peripheral edema, dermatitis

• -Decrease the plasma and extracellular fluid volumes
• -Results: Decreased preload, decreased cardiac output, decreased total peripheral resistance
• -Overall effect: Decreased worload of the heart, and decreased blood pressure.

• -Directly relax arteriolar smooth muscle
• -Result: decreased systemic vascular response, decreased afterload, and peripheral vasodilation

• -diazoxide (Hyperstat)
• -hydralazine HCl (Apresoline)
• -minoxidil (Loniten,Rogaine)
• -sodium nitroprusside (Nipride, Nitropress)

• -Treatment of hypertension
• -May be used in combination with other agents
• -Intravenous sodium nitroprusside and diazoxide are reserved for the management of hypertensive emergencies.

-Hydralazine-Dizziness, headache, anxiety, tachycardia, nausea, and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion

-Sodium nitroprusside- Bradycardia, hypotension, possible cyanide toxicity.

• -Before beginning therapy, obtain a thorough health history and head to toe physical examination
• -Assess for contraindications to specific antihypertensive agents
• -Assess for conditions that require cautious use of these agents
• -Educate patients about the importance of not missing a dose and taking the medications exactly as prescribed
• -Patients should never double up on doses if a dose is missed; check with the physician for instruction on what to do if a dose is missed
• -Monitor BP during therapy; instruct patients to keep a journal of regular BP checks
• -Instruct patients that these drugs should be stopped abruptly because this may cause a rebound hypertensive crisis, and perhaps lead to a stroke
• -Oral forms should be given with meals so that absorption is more gradual and effective.
• -Administer IV forms with extreme caution and use an IV pump
• -Remind patients that medication is only part of therapy. Encourage patients to watch their diet, stress level, weight, and alcohol intake.
• -Patients should avoid smoking and eating food high in sodium
• -Encourage supervised exercise
• -Instruct patients to change positions slowly to avoid syncope from postural hypotension
• -Patients should report unsual shortness of breath; difficulty breathing; swelling of the feet, ankles, face, or around the eyes; weight gain or loss; chest pain; palpitations; or excessive fatigue
• -Men takign theses agents may not be aware that impotence is an expected effect. This may influence compliance with the drug therapy
• -If patients are experincing serious side effects, or believe that t he dose or medication needs to be changed, they should contact their physician immediately
• -Hot tubs, showers, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low blood pressure, leading to fainting and injury. Patients should sit or lie down until symptoms subside.
• -Patients should not take any other medications, including OTC drugs, without frist getting the approval of their physician.
• -Educate about lifestyle change that may be needed
• -Weight loss
• -Stress management
• -supervised exercise
• -Monitor for side/adverse effects (dizziness,orthostatic hypotension, fatigue) and for toxic effects
• -Monitor for therapeutic effects - BP should be maintained at less than 140/90mm hg
• -If a patient with hypertension also has diabetes or renal disease, the BP goal is <130/80 mm hg