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Alex Abed

on 16 August 2015

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Transcript of Hypertension

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)
Hypertension Statistics
45 million
people in the U.S. (20% of the population) are affected by Prehypertension.

-More than
70 million
U.S. adults (one in three Americans) are diagnosed with HTN.

-The highest rate of HTN is seen in African American males.

-More than
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

-Overdosing indications

-Rebound hypotension

-Missing a dose

Classes of Antihypertensives
Primary Medications:

Primary Function

Background Information
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

Pharmacotherapy Treament
-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.

Source: http://catalog.nhlbi.nih.gov/catalog/product/Seventh-Report-of-the-Joint-National-Committee-on-Prevention-Detection-Evaluation-and-Treatment-of-High-Blood-Pressure-JNC-7-Express-/03-5233
Nonpharmacologic Treatment
-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)

Alternative Medications:

-Alpha1-adrenergic antagonists (alpha blockers)
-Alpha2-adrenergic agonists
-Direct-acting vasodilators

Source: http://www.cphospital.org/adam/In-Depth%20Reports/10/000053.php
Lowers blood pressure by decreasing the overall volume of fluid in the vasculature via urinary excretion

Subclasses of Diuretics

1. Potassium-sparing
2. Thiazide
3. Loop

Diuretics, con’t
-Most common diuretic for HTN
-Safe except for moderate K+ loss

-Mild diuretic effects
-Low risk hypokalemia
-High risk hyperkalemia

-Extreme diuresis
-High incidence hypokalemia and dehydration
-More side effects than other classes
-Only used in cases of severe HTN

ACE Inhibitors
-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
Adrenal gland
Increased sodium and water excretion

Calcium Channel Blockers
-Used in combination with other drugs
Prevents calcium from entering arterial smooth muscle
Prevents contraction
Decreased peripheral resistance
-Effect on Cardiac muscle
Nonselective CCB’s
Slows electrical conduction
Decreases heart rate

Source: http://www.cardiachealth.org/heart-disease-treatment/heart-disease-medications/blood-pressure-medications/calcium-channel-blockers
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

Alpha-Adrenergic Agonists/Antagonists
Alpha1-Adrenergic Blockers

-Prevent stimulation of receptors in arterial vasculature
Lower BP
-Second line
Reserved for patient’s unresponsive to other meds
Combination with diuretics

Alpha2-Adrenergic Agonists

-Slow transmission of signals from CNS to the heart
Decreases heart rate
Dilates vasculature
-Frequent CNS side effects

Direct Vasodilators
-Cause vasodilation immediately
Rapid drop in BP
-Serious side effects
Reflex tachycardia
Sodium and water retention
Increased BP

By Alex Abed, Jenna DeMone, Breana Falcucci and Nick Giusto
Pharmacologic class: Calcium channel blocker

-Grapefruit juice

Home Monitoring
-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!
-Lose weight
-Reduce sodium intake
-Smoking cessation
-Decrease alcohol consumption
-Stress management

Drug Examples
ACE Inhibitor
Angiotensin Receptor Blocker
Calcium Channel Blocker
Alpha1-Adrenergic Antagonists
Direct-acting vasodilators
Furosemide (Lasix)
Pharmacologic class
: Sulfonamide loop diuretic
Therapeutic class:
Diuretic, antihypertensive
Hypertension; edema caused by heart failure, hepatic cirrhosis or renal disease; actor pulmonary edema
Drug Action:
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.
Drug Metabolism:
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
30-60 minutes

Enalapril (Vasotec)
Azilsartan (Edarbi)
Nifedipine (Adalat CC, Procardia XL)
Pharmacological class:
ACE inhibitor
Therapeutic class:
hypertension, heart failure and asymptomatic left ventricular dysfunction
Drug Action:
inhibits conversion of angiotensin 1 to angiotensin 2. Also reduces aldosterone and increases plasma renin and potassium resulting in vasodilation
Drug Metabolism:
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.
2 hours

Pharmacological class:
Angiotensin II receptor blocker
Therapeutic class:
Drug Action:
Inhibits the constricting effects of angiotensin II.
Drug Metabolism:
metabolized by the liver, eliminated in feces and urine.
80 mg PO daily, patients started at 40 mg daily.
11 hours

Pharmacological class
: Calcium channel blocker
Therapeutic class
: Antianginal, anti-hypertensive
: vasospastic angina, hypertension
Drug Action
: Inhibits calcium transport to myocardium and dilates blood vessels
Drug Metabolism:
metabolized by liver
: for hypertension, 30-60 mg/day PO titrated over 7-14 days, to a maximum of 120 mg/day.
2 hours.

Propranolol hydrochloride (Inderal)
Beta-adrenergic antagonist (beta-blocker)
Pharmacological class:
beta-adrenergic blocker
Therapeutic class:
Antianginal, antihypertensive, anti-arrhythmic, vascular headache suppresant
Angina, hypertension, arrhythmias, essential tremor, vascular headache, prophylaxis after MI
Drug Action:
Blocks beta1 and beta2 receptor sites which decreases cardiac output, reduces blood pressure and slows heart rate
Drug Metabolism:
metabolized by liver
40 mg PO b.i.d. or 80 mg extended release Po daily. Maximum dosage is 240 mg.
3-6 hours

Terazosin hydrochloride (Apo-Terazosin)
Pharmacological class:
Therapeutic class:
hypertension, benign prostatic hyperplasia
Drug Action:
Blocks alpha1 receptors causing vasodilation
Drug Metabolism:
metabolized by the liver
1 mg PO increased to up to 5 mg/day
12 hours

Alpha 2- adrenergic agonist
Clonidine (Catapres)
Pharmacological class:
centrally acting sympatholytic
Therapeutic class:
hypertension, pain
Drug Action:
stimulates alpha 2 receptors in CNS inhibiting vasoconstriction and lowering blood pressure
Drug Metabolism
: 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)
Pharmacological class:
peripheral vasodilator
Therapeutic class:
Drug Action:
relaxes smooth muscle of blood vessels causing vasodilation and decreased blood pressure
Drug Metabolism:
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.
2-8 hours.

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.
Adverse effects:
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.
Drug-diagnostic tests:
BUN transient increase; calcium, potassium, sodium, magnesium and platelets decreased; cholesterol, glucose, creatinine, nitrogen increased.
: dandelion, ginseng, licorice.
acute alcohol ingestion, sun exposure.
Nursing Considerations:
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
Adverse effects:
cerebrovascular accident, arrhythmias, cardia arrest, pancreatitis, oliguria, agranulocytosis, bone marrow, hepatitis, hyperkalemia, eosinophilic pneumonitis

Interactions: Drug-Drug:
antacids, digoxin, lithium, allopurinol, diuretics, NSADS, rifampin.
Drug-diagnositc tests:
BUN, bilirubin increased levels; sodium decreased levels.
salt-substitutes with potassium.
acute alcohol ingestion and sun exposure

Nursing Considerations:
monitor for rapid hypotension and worsening renal function (for patients with renal disease); monitor vital signs; monitor for liver function tests
Adverse effects:
hypotension, orthostatic hypotension oliguria diarrhea, rarely progressive azotemia with acute renal failure and death

Interactions: Drug-drug:
Drug-diagnostic tests:
serum creatinine
Adverse effects:
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.
Drug-diagnostic tests:
antinuclear antibody, direct Coombs test.
ephedra, ginkgo, ginseng; St. John's wort.
alcohol use
Nursing Considerations:
monitor for vital signs, chest pain and rash.
Adverse effects:
arrhythmias, heart failure, MI and sudden death with abrupt withdrawal, thrombocytopenic purpura, hypoglycemia, thyrotoxicosis, bronchospasm, pulmonary edema, erectile dysfunction, decreased libido.

Interactions: Drug-drug:
antacids, anticholinergics, antidepressants, digoxin, diuretics, glucagon, insulin, neuromuscular blockers, NSAIDs, thioridazine.
Drug-diagnostic tests:
BUN, eosinophils, alkaline phosphate, glucose, platelets.
acute alcohol use.
Nursing Considerations:
monitor for hypotension; monitor for oliguria; watch for increasing serum creatinine levels; monitor vital signs; monitor for inflammation and edema
Nursing Considerations:
monitor vital signs; monitor fluid balance; monitor CBC and liver function; assess for blood glucose levels and hypoglycemia
Adverse effects:
arrhythmias, tachycardia, hypotension, chest pain, palpitations, edema, dizziness, headache, nervousness, vertigo, nausea, vomiting, abdominal pain, urinary frequency, joint pain, dyspnea, fever

Interactions: Drug-Drug:
estrogens, NSAIDs,nitrates, midodrine.
alcohol use.
Nursing Considerations:
monitor vital signs; monitor for hypotensions; monitor cardiovascular status
Adverse effects:
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.
Alcohol use.
Nursing Considerations:
monitor vital signs; monitor for drug tolerance monitor for cardiovascular changes
Adverse effects
: arrhythmias, dizziness, drowsiness, headache, tachycardia, sodium retention, flushing, pruritus, urticaria


antihypertensives, MAOIs, propranolol, epinephrine.
Drug-diagnostic tests:
Coombs test, CBC.
alcohol use.
Nursing Considerations:
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.
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