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Transcript of Hypertension
people in the U.S. (20% of the population) are affected by Prehypertension.
U.S. adults (one in three Americans) are diagnosed with HTN.
-The highest rate of HTN is seen in African American males.
of patients with HTN are unaware of their condition.
-In America, approximately
people die each year due to HTN
What is Hypertension?
Therapeutic class: Antihypertensive and antianginal
Pregnancy Category C
-The effects on the fetus have only been studied in animals, not humans
-Potential benefit of the drug may outweigh the risk
-The drug’s effect on breastfeeding
-Must be administered whole
-Missing a dose
Classes of Antihypertensives
Patient Teaching: Nifedipine
Drug Classes for Hypertension
Defined as: the consistent elevation of systemic arterial pressure.
-Also known as high blood pressure
-Most common type of cardiovascular disease
-Mild hypertension is often treated with lifestyle modification
-Moderate to severe hypertension usually requires pharmacotherapy
A patient is diagnosed with hypertension (or HTN) if the individual presents with a systolic blood pressure of greater than 140 mmHg or diastolic pressure of greater than 90 to 99 mmHg on 3 or more separate clinical visits.
Categories and Recommendations for Treating Hypertension:
Normal Blood pressure
= 119/79 mmHg or less
= 120-139/80-89 mmHg
Stage 1 Hypertension
= 140-159/90-99 mmHg
Recommended initial antihypertensive therapy usually includes Thiazide diuretics
-Stage 2 Hypertension
= 160 mmHg or higher
Recommended initial antihypertensive therapy usually includes a two-drug combination antihypertensive
-Goal is to reduce the morbidity and mortality associated with chronic HTN.
-Maintaining blood pressure within normal limits.
-Individualized to the patient’s risk factors, comorbid medical conditions, and degree of blood pressure elevation.
-Limit alcohol intake to no more than 2 alcoholic drinks/day for men and 1 for women.
-Restrict sodium consumption to less than 2.4g/day
-Reduce intake of saturated fat and cholesterol.
-Increase daily consumption of fresh fruits and vegetables.
-Increase aerobic physical activity to at least 30 minutes 4 times/week
-Discontinue use of tobacco products.
-Reduce sources of stress and learn to implement coping strategies, including yoga and meditation
-Attempt incorporation of daily deep breathing/meditation for stress reduction
-Maintain optimum weight.
The Harvard Alumni Health Study
-A cohort study of 18,881 male university students.
-Researchers measured the participant’s blood pressure at university entry between the years 1914 to 1952 (average age 18 years old).
-Participants responded to a questionnaire mailed in either 1962 or 1966 (average age 45 years old) where physician-diagnosed hypertension status was reported.
-Participants were followed for mortality until the end of 1998.
-Higher blood pressure in early adulthood was associated with elevated risk of all-cause mortality, CVD, and CHD.
-Blood pressure lowering in early adulthood yields long-term benefits.
-Angiotensin-converting enzyme (ACE) inhibitors
-Angiotensin II Receptor Blockers
-Calcium channel blockers
-Beta-adrenergic antagonists (Beta blockers)
-Alpha1-adrenergic antagonists (alpha blockers)
Lowers blood pressure by decreasing the overall volume of fluid in the vasculature via urinary excretion
Subclasses of Diuretics
-Most common diuretic for HTN
-Safe except for moderate K+ loss
-Mild diuretic effects
-Low risk hypokalemia
-High risk hyperkalemia
-High incidence hypokalemia and dehydration
-More side effects than other classes
-Only used in cases of severe HTN
-Inhibit the angiotensin-converting enzyme of the renin-angiotensisn-aldosterone system
Prevents formation of Angiotensin II
-Decreases BP by:
Lowering vascular resistance
Decreasing fluid retention
Angiotensin Receptor Blockers
-Block receptors for Angiotensin II
Arteriolar smooth muscle
Causes vessel dilation
Increased sodium and water excretion
Calcium Channel Blockers
-Used in combination with other drugs
Prevents calcium from entering arterial smooth muscle
Decreased peripheral resistance
-Effect on Cardiac muscle
Slows electrical conduction
Decreases heart rate
Beta Adrenergic Antagonists (Beta-blockers)
Block beta1-adrenergic receptors in the heart
Decrease heart rate and contractility
Decreases cardiac output and lowers BP
-Can be used to Tx angina, myocardial infarctions, heart failure and dysrhythmias
-Prevent stimulation of receptors in arterial vasculature
Reserved for patient’s unresponsive to other meds
Combination with diuretics
-Slow transmission of signals from CNS to the heart
Decreases heart rate
-Frequent CNS side effects
-Cause vasodilation immediately
Rapid drop in BP
-Serious side effects
Sodium and water retention
By Alex Abed, Jenna DeMone, Breana Falcucci and Nick Giusto
Pharmacologic class: Calcium channel blocker
-How to take a radial pulse
-How to take your blood pressure
-What to report to your PCP
It’s Not Just About the Medication!
-Reduce sodium intake
-Decrease alcohol consumption
Angiotensin Receptor Blocker
Calcium Channel Blocker
: Sulfonamide loop diuretic
Hypertension; edema caused by heart failure, hepatic cirrhosis or renal disease; actor pulmonary edema
Unclear, but thought to inhibit sodium and chloride reabsorption in the loop of Henle, increasing potassium excretion and plasma volume and promoting renal excretion of water.
Minimally metabolized by liver, some renal excretion
For hypertension, 40 mg PO b.i.d. may be titrated upward if needed to a maximum of 240 mg PO daily in two or three divided doses
Nifedipine (Adalat CC, Procardia XL)
hypertension, heart failure and asymptomatic left ventricular dysfunction
inhibits conversion of angiotensin 1 to angiotensin 2. Also reduces aldosterone and increases plasma renin and potassium resulting in vasodilation
converted by liver to enalaprilat, eliminated by kidneys
For hypertension, adults initially take 5 mg PO once daily (if not on other diuretics) which is increased after 1-2 weeks to up to 10-40 mg PO daily given either once or in two divided doses. If the patient is taking other diuretics, initial does is 2.5 mg PO. For children, 0.08 mg/kg PO daily can be increased to a max dose of 5 mg daily.
Angiotensin II receptor blocker
Inhibits the constricting effects of angiotensin II.
metabolized by the liver, eliminated in feces and urine.
80 mg PO daily, patients started at 40 mg daily.
: Calcium channel blocker
: Antianginal, anti-hypertensive
: vasospastic angina, hypertension
: Inhibits calcium transport to myocardium and dilates blood vessels
metabolized by liver
: for hypertension, 30-60 mg/day PO titrated over 7-14 days, to a maximum of 120 mg/day.
Propranolol hydrochloride (Inderal)
Beta-adrenergic antagonist (beta-blocker)
Antianginal, antihypertensive, anti-arrhythmic, vascular headache suppresant
Angina, hypertension, arrhythmias, essential tremor, vascular headache, prophylaxis after MI
Blocks beta1 and beta2 receptor sites which decreases cardiac output, reduces blood pressure and slows heart rate
metabolized by liver
40 mg PO b.i.d. or 80 mg extended release Po daily. Maximum dosage is 240 mg.
Terazosin hydrochloride (Apo-Terazosin)
hypertension, benign prostatic hyperplasia
Blocks alpha1 receptors causing vasodilation
metabolized by the liver
1 mg PO increased to up to 5 mg/day
Alpha 2- adrenergic agonist
centrally acting sympatholytic
stimulates alpha 2 receptors in CNS inhibiting vasoconstriction and lowering blood pressure
: metabolized in liver, eliminated in urine
for hypertension, 0.1 mg PO b.i.d. increased in 0.1 increments until desired response
44-72 hours (neonates), 8-12 hours (children), 12-16 hours (plasma, adults), 1.3 hours (adults, CNS)
Hydralazine hydrocloride (Apresoline)
relaxes smooth muscle of blood vessels causing vasodilation and decreased blood pressure
metabolized by GI mucosa and liver
For adults, initialld, 10 mg PO q.i.d., within 2-4 days dosage can be increased to 25 mg PO q.i.d. and then up to 50mg PO q.i.d. by the seventh day. For children, initially 0.75 mg/kg/day which can be increased to up to 7.5 mg/kg within 3-4 weeks.
1. Adams, M., Holland, N., & Urban, C. (2014). Pharmacology for nurses: A pathophysiologic approach. (4th ed.). Upper Saddle River, NJ: Pearson.
5. Gray, L., Lee, L.M., Sesso, H.D., Batty, G.D. (2011). Blood pressure in early adulthood, hypertension in middle age, and future cardiovascular disease mortality: HAHS (Harvard Alumni Health Study). Journal of the American College of Cardiology. 58(23):2396-2403.
necrotizing angiitis, thrombophlebitis, arrhythmias, acute pancreatits, oliguria, interstitial nephritis, leukopenia, thrombocytopenia, hemolytic anemia, hypocalcemia, alkalosis, erythema multiforme, fever, anemia
ototoxic drugs like aminoglycosides, antihypertensives and diurectics, cardiac glycosides, lithium, potassium- wasting diuretics, salicylates, propranolol, insulin.
BUN transient increase; calcium, potassium, sodium, magnesium and platelets decreased; cholesterol, glucose, creatinine, nitrogen increased.
: dandelion, ginseng, licorice.
acute alcohol ingestion, sun exposure.
monitor for signs of ototoxicity and drug toxicity (including abdominal pain, arrhythmias and renal dysfunction); assess blood glucose; monitor for signs of hypokalemia; monitor vital signs; maintain adequate hydration; monitor for orthostatic hypotension by having patients go from laying to sitting to standing
cerebrovascular accident, arrhythmias, cardia arrest, pancreatitis, oliguria, agranulocytosis, bone marrow, hepatitis, hyperkalemia, eosinophilic pneumonitis
antacids, digoxin, lithium, allopurinol, diuretics, NSADS, rifampin.
BUN, bilirubin increased levels; sodium decreased levels.
salt-substitutes with potassium.
acute alcohol ingestion and sun exposure
monitor for rapid hypotension and worsening renal function (for patients with renal disease); monitor vital signs; monitor for liver function tests
hypotension, orthostatic hypotension oliguria diarrhea, rarely progressive azotemia with acute renal failure and death
headache, dizziness, fatigue, asthenia, paresthesia, vertigo, peripheral edema, chest pain, hypotension, epistaxis, rhinitis, nausea, constipation, urinary frequency, erectile dysfunction, leg cramps, flushing.
beta-adrenergic blockers, cimetidine, coumarin, digoxin, quinidine.
antinuclear antibody, direct Coombs test.
ephedra, ginkgo, ginseng; St. John's wort.
monitor for vital signs, chest pain and rash.
arrhythmias, heart failure, MI and sudden death with abrupt withdrawal, thrombocytopenic purpura, hypoglycemia, thyrotoxicosis, bronchospasm, pulmonary edema, erectile dysfunction, decreased libido.
antacids, anticholinergics, antidepressants, digoxin, diuretics, glucagon, insulin, neuromuscular blockers, NSAIDs, thioridazine.
BUN, eosinophils, alkaline phosphate, glucose, platelets.
acute alcohol use.
monitor for hypotension; monitor for oliguria; watch for increasing serum creatinine levels; monitor vital signs; monitor for inflammation and edema
monitor vital signs; monitor fluid balance; monitor CBC and liver function; assess for blood glucose levels and hypoglycemia
arrhythmias, tachycardia, hypotension, chest pain, palpitations, edema, dizziness, headache, nervousness, vertigo, nausea, vomiting, abdominal pain, urinary frequency, joint pain, dyspnea, fever
estrogens, NSAIDs,nitrates, midodrine.
monitor vital signs; monitor for hypotensions; monitor cardiovascular status
drowsiness, depression, dizziness, hypotension, bradycardia, palpitation, nausea, vomiting, constipation, urinary retention, sodium retention, rash, sweating, weight gain
amphetamines, beta-blockers ,MAOIs, tricyclic antidepressants, levodopa, CNS depressants, epidural local anesthetics, antihypertensives, myocardial depressants.
monitor vital signs; monitor for drug tolerance monitor for cardiovascular changes
: arrhythmias, dizziness, drowsiness, headache, tachycardia, sodium retention, flushing, pruritus, urticaria
antihypertensives, MAOIs, propranolol, epinephrine.
Coombs test, CBC.
monitor CBC; monitor vital signs; assess for joint pain, fever and peripheral neuritis
2. Deglin, J., & Vallerand, A. (2009). Davis's drug guide for nurses (11th ed.). Philadelphia, Penn.: F.A. Davis.
4. Gorman, J. M. (2015). A plausible mechanism for a non-pharmacological therapy for hypertension. Clinical Autonomic Research, 25(2), 85-86.
7. Wexler, R., & Aukerman, G. (2006, June 1). Nonpharmacologic Strategies for Managing Hypertension. American Family Physician Journal. 73(11):1953-1956. Retrieved August 7, 2015.
6. Okonta, N. R. (2012). Does yoga therapy reduce blood pressure in patients with hypertension?: an integrative review. Holistic nursing practice, 26(3), 137-141.
"Key Points for Practice"
•" In the general population, pharmacologic treatment should be initiated when blood pressure is 150/90 mm Hg or higher in adults 60 years and older, or 140/90 mm Hg or higher in adults younger than 60 years.
• In patients with hypertension and diabetes, pharmacologic treatment should be initiated when blood pressure is 140/90 mm Hg or higher, regardless of age.
• Initial antihypertensive treatment should include a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB in the general nonblack population or a thiazide diuretic or calcium channel blocker in the general black population.
• If the target blood pressure is not reached within one month after initiating therapy, the dosage of the initial medication should be increased, or a second medication should be added."
Some of the guidelines established in the JNC-7 were changed slightly in the JNC-8. The American Academy of Family Physicians summarizes some of these new guidelines below:
3. Gauer, R., & Laocque, J. (2014). JNC 8: Relaxing the Standards. American Family Physician, 90(7), 449-452.