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Antihypertensive Lori Kenavan NUR- 304 Pharmacology Prof. Lynn McNall Fall 2012 ESC.

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1 Antihypertensive Lori Kenavan NUR- 304 Pharmacology Prof. Lynn McNall Fall 2012 ESC

2 Learning objectives Describe the role of Antihypertensives and its actions.Describe the role of Antihypertensives and its actions. Discuss whom receives Antihypertensive medications.Discuss whom receives Antihypertensive medications. List categories and subcategories of Antihypertensive Drugs.List categories and subcategories of Antihypertensive Drugs.

3 Classification Drugs used in the management of primary HTN belong to several different groups:Drugs used in the management of primary HTN belong to several different groups: Angiotensin-converting enzyme ACE inhibitorsAngiotensin-converting enzyme ACE inhibitors Angiotension II receptor blockers ARBSAngiotension II receptor blockers ARBS Calcium channel blockersCalcium channel blockers DiureticsDiuretics VasodilatorsVasodilators These drugs act to decrease blood pressure by decreasing cardiac output or peripheral vascular resistance.

4 Introduction Hypertension Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) > 140 mmHg > 90 mmHg

5 HTN Types of Hypertension EssentialSecondary A disorder of unknown origin affecting the Blood Pressure regulating mechanisms Secondary to other disease processes Environmental Factors StressNa+ IntakeObesitySmoking

6 WHY TREAT HTN? Treatment is mandatory when symptomatic:Treatment is mandatory when symptomatic: Damage to the vascular epithelium, paving the path for atherosclerosis (CVA) or nephropathy due to high intra- glomerular pressure.Damage to the vascular epithelium, paving the path for atherosclerosis (CVA) or nephropathy due to high intra- glomerular pressure. Increased load on heart due to high BP. Can cause CHF.Increased load on heart due to high BP. Can cause CHF. HTN, even asymptomatic needs interventions. HTN, even asymptomatic needs interventions.

7 Antihypertensive Drugs and Its mechanism of Action Diuretics: Diuretics: Thiazides: Hydrochlorothiazide, chlorthalidoneThiazides: Hydrochlorothiazide, chlorthalidone High ceiling: FurosemideHigh ceiling: Furosemide K+ sparing: Spironolactone, triamterene and amilorideK+ sparing: Spironolactone, triamterene and amiloride MOA: Acts on Kidneys to increase excretion of Na and H2O- decrease in blood volume = decreased BP. MOA: Acts on Kidneys to increase excretion of Na and H2O- decrease in blood volume = decreased BP. Angiotensin- converting Enzyme (ACE) inhibitors: Angiotensin- converting Enzyme (ACE) inhibitors: Captopril, lisinopril, enalapril, ramipril and fosinoprilCaptopril, lisinopril, enalapril, ramipril and fosinopril M0A: Inhibit synthesis of Angiotensin II- decrease in peripheral resistance and blood volume. Angiotensin (AT1) blockers : Losartan, candesartan, valsartan and telmisartanLosartan, candesartan, valsartan and telmisartan

8 Anti-HTN M.O.A MOA: Blocks binding of Angiotensin II to its receptors. MOA: Blocks binding of Angiotensin II to its receptors. Centrally acting:Centrally acting: -Clonidine, methyldopa -Clonidine, methyldopa MOA: Act on central receptors to decrease sympathetic outflow- fall in BPMOA: Act on central receptors to decrease sympathetic outflow- fall in BP B-adrenergic blockers: B-adrenergic blockers: Non-selective: Propranolol (nadolol, timolol, pindolol, labetolol) Non-selective: Propranolol (nadolol, timolol, pindolol, labetolol) Cardioselective: Metoprolol (atenolol, esmolol, betaxolol) Cardioselective: Metoprolol (atenolol, esmolol, betaxolol) MOA: Bind to beta adrenergic receptors and blocks the activityMOA: Bind to beta adrenergic receptors and blocks the activity B and a- adrenic blockers: B and a- adrenic blockers: Labetolol and carvedilol a-adrenergic blockers: a-adrenergic blockers: Prazosin, terazosin, doxazosin, phenoxybenzamine and phentolmine.

9 Anti-htn m.o.a MOA: Blocking of alpha adrenergic receptors in smooth muscles- vasodilation.MOA: Blocking of alpha adrenergic receptors in smooth muscles- vasodilation. Calcium Channel Blockers (CCB): Calcium Channel Blockers (CCB): Verapamil, diltiazem, nifedipine, felodipine, amlodipine, nimodipine etc.Verapamil, diltiazem, nifedipine, felodipine, amlodipine, nimodipine etc. MOA: Blocks influx of Ca++ in smooth muscle cells- relaxation of SMCs = decrease BP MOA: Blocks influx of Ca++ in smooth muscle cells- relaxation of SMCs = decrease BP K+ Chanel activators: K+ Chanel activators: Diazoxide, minoxidil, pinacidil and nicorandilDiazoxide, minoxidil, pinacidil and nicorandil

10 Anti-Htn M.O.a MOA: Leaking of K+ due to opening- hyper polarization of SMCs = relaxation of SMCsMOA: Leaking of K+ due to opening- hyper polarization of SMCs = relaxation of SMCs Vasodilators: Vasodilators: Arteriolar- Hydralazine (also CCB and K+ channel activators)Arteriolar- Hydralazine (also CCB and K+ channel activators) Arterio- venular: Sodium Nitroprusside.Arterio- venular: Sodium Nitroprusside.

11 antihypertensives

12 Indications for use 1.Significant hypertension Infants >80 mm Hg DBPInfants >80 mm Hg DBP Children >86 mm Hg DBPChildren >86 mm Hg DBP Adolescents >90 mm Hg DBPAdolescents >90 mm Hg DBP 2.Evidence of target organ damage 3.Symptoms or signs related to elevated blood pressure

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14 Allergic and adverse effects Common side effects:Common side effects: slight dizziness, fatigue, cough and headache.slight dizziness, fatigue, cough and headache. Serious side effects:Serious side effects: insomnia, decreased sex drive, shortness of breath and depressed mood.insomnia, decreased sex drive, shortness of breath and depressed mood. Contact physician and stop medication. Severe side effects:Severe side effects: chest pain, difficulty breathing, fainting, irregular heartbeat and rash. Swelling of the face, lips, tongue or extremities may be the sign of an allergic reaction to the medication. For these symptoms, treatment should not be delayed and seek medical help.chest pain, difficulty breathing, fainting, irregular heartbeat and rash. Swelling of the face, lips, tongue or extremities may be the sign of an allergic reaction to the medication. For these symptoms, treatment should not be delayed and seek medical help.

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16 Choice of drug Choice of drugs in treating hypertension: Choice of drugs in treating hypertension: Patients with diabetes – ACEIPatients with diabetes – ACEI Patients with congestive heart failure or left ventricular dysfunction- ACEIPatients with congestive heart failure or left ventricular dysfunction- ACEI Patients with angina pectoris – a beta adrenoceptor blockerPatients with angina pectoris – a beta adrenoceptor blocker Patients with migraine - a beta adrenoceptor blockerPatients with migraine - a beta adrenoceptor blocker Patients with myocardial infarction – a beta adrenoceptor blocker, ACEIPatients with myocardial infarction – a beta adrenoceptor blocker, ACEI Patients with hyperlipidemia – ACEIs,  -adrenoceptor antagonists, andPatients with hyperlipidemia – ACEIs,  -adrenoceptor antagonists, and Ca channel blockers Ca channel blockers Black patients – diuretics and Ca channel blockers are more effective Black patients – diuretics and Ca channel blockers are more effective Older patients with isolated systolic hypertension – diuretics, Older patients with isolated systolic hypertension – diuretics, dihydropyridine Ca channel blockers. dihydropyridine Ca channel blockers.

17 Some Herbal Solutions Garlic - Garlic is beneficial for those with hypertension. By thinning the blood garlic can lower blood pressure by 5 to 10 percent. It can also lower cholesterol and discourage clot formation. Unfortunately, garlic has a reputation for being an "anti-social" food, but with all of the health benefits that garlic provides, bad breath should be the least of your worries. Garlic - Garlic is beneficial for those with hypertension. By thinning the blood garlic can lower blood pressure by 5 to 10 percent. It can also lower cholesterol and discourage clot formation. Unfortunately, garlic has a reputation for being an "anti-social" food, but with all of the health benefits that garlic provides, bad breath should be the least of your worries. Fish oil – Fish oil may have a modest effect on high blood pressure. Although fish oil supplements often contain both DHA (docohexaenoic acid) and EPA (eicosapentaenoice acid), there is some evidence that DHA is the ingredient that lowers high blood pressure. Fish oil – Fish oil may have a modest effect on high blood pressure. Although fish oil supplements often contain both DHA (docohexaenoic acid) and EPA (eicosapentaenoice acid), there is some evidence that DHA is the ingredient that lowers high blood pressure. Folic acid - Folate is a B vitamin necessary for formation of red blood cells. It may help to lower high blood pressure in some people, possibly by reducing elevated homocysteine levels. One small study of 24 cigarette smokers found that four weeks of folic acid supplementation significantly lowered blood pressure. Folic acid - Folate is a B vitamin necessary for formation of red blood cells. It may help to lower high blood pressure in some people, possibly by reducing elevated homocysteine levels. One small study of 24 cigarette smokers found that four weeks of folic acid supplementation significantly lowered blood pressure.

18 Herbal cont. There are many more such as: Vit C, Celery, Cayenne, Ayurveda, Black Cumin Seeds, Rauwolfia serpentina, Ca Mg K, high fiber foods, seaweeds.There are many more such as: Vit C, Celery, Cayenne, Ayurveda, Black Cumin Seeds, Rauwolfia serpentina, Ca Mg K, high fiber foods, seaweeds. Avoid natural licorice products.Avoid natural licorice products.

19 Yoga and meditation Yoga can fight off the causes of the abnormal blood pressure. It helps both type of blood pressure and stabilizes blood pressure.Yoga can fight off the causes of the abnormal blood pressure. It helps both type of blood pressure and stabilizes blood pressure. Some yoga poses for high blood pressure include- Easy Pose (Sukhasana), Shoulder Stretches, Stand spread leg forward fold, Cat Pose (Bidalasana) and many more.Some yoga poses for high blood pressure include- Easy Pose (Sukhasana), Shoulder Stretches, Stand spread leg forward fold, Cat Pose (Bidalasana) and many more. If you do transcendental meditation, it reduces your blood pressure as it decreases the constriction of the blood vessels. If you do transcendental meditation, it reduces your blood pressure as it decreases the constriction of the blood vessels. By doing meditation daily, you not only keep your blood pressure under control but also avoid the complications that you might develop because of hypertension. So, meditation is one of the best ways to prevent and treat your abnormal BP!By doing meditation daily, you not only keep your blood pressure under control but also avoid the complications that you might develop because of hypertension. So, meditation is one of the best ways to prevent and treat your abnormal BP!

20 Dietary Solutions A low sodium low calorie diet.A low sodium low calorie diet. Hydration is key. Adequate fluid intake is necessary.Hydration is key. Adequate fluid intake is necessary. Limit alcohol use.Limit alcohol use. Watch intake of Grapefruit: can potentiate antihypertensives- Calcium channel blockers.Watch intake of Grapefruit: can potentiate antihypertensives- Calcium channel blockers.

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22 O.T.C Many over-the-counter painkillers can push blood pressure higher.Many over-the-counter painkillers can push blood pressure higher. Some types of nonsteroidal anti-inflammatory drugs (NSAIDs) can be risky.Some types of nonsteroidal anti-inflammatory drugs (NSAIDs) can be risky. ibuprofen., naproxen sodium, and ketoprofen, the active ingredients in meds like Advil and Aleve.ibuprofen., naproxen sodium, and ketoprofen, the active ingredients in meds like Advil and Aleve. Some of these NSAIDs reduce the blood flow to the kidneys. The kidneys -- which filter your blood -- work more slowly, and so fluid builds up in your body. The increased fluid drives up your blood pressure.Some of these NSAIDs reduce the blood flow to the kidneys. The kidneys -- which filter your blood -- work more slowly, and so fluid builds up in your body. The increased fluid drives up your blood pressure. Other options: Ice packs, heat, physical activity, relaxation, acupuncture.Other options: Ice packs, heat, physical activity, relaxation, acupuncture.

23 Nursing considerations: Diuretics Diuretics can increase serum glucose and cholesterol levels, monitor for hyperglycemia and hypercholesterolemia.Diuretics can increase serum glucose and cholesterol levels, monitor for hyperglycemia and hypercholesterolemia. Teach patients to take diuretics in the morning to avoid nocturnal diuresis and urination.Teach patients to take diuretics in the morning to avoid nocturnal diuresis and urination. Caution patients to stand up slowly to minimize the risk of dizziness from orthostatic hypotension.Caution patients to stand up slowly to minimize the risk of dizziness from orthostatic hypotension. Monitor for signs of hypo­kalemia, such as muscle weakness and changes in mental status, including confusion and irritability.Monitor for signs of hypo­kalemia, such as muscle weakness and changes in mental status, including confusion and irritability.

24 NC: Diuretics con’t. Patients taking a potassium-sparing diuretic are at risk for hyperkalemia. The risk is especially high in patients also taking an angiotensin-converting enzyme (ACE) inhibitor.Patients taking a potassium-sparing diuretic are at risk for hyperkalemia. The risk is especially high in patients also taking an angiotensin-converting enzyme (ACE) inhibitor. Weigh patients daily at the same time using the same scale. Report a significant weight gain, 3 pounds in 3 days.Weigh patients daily at the same time using the same scale. Report a significant weight gain, 3 pounds in 3 days. Remind your patient that even if he feels fine, he should keep appointments with the healthcare provider because renal function must be monitored.Remind your patient that even if he feels fine, he should keep appointments with the healthcare provider because renal function must be monitored.

25 Nursing Considerations Beta-Blockers Teach patients that they shouldn’t suddenly stop therapy because of the risk of rebound tachycardia and hypertension.Teach patients that they shouldn’t suddenly stop therapy because of the risk of rebound tachycardia and hypertension. Beta blockers can cause transient increases in serum lipid and glucose levels.Beta blockers can cause transient increases in serum lipid and glucose levels. Monitor for symptoms of hypoglycemia in patients with diabetes who use insulin.Monitor for symptoms of hypoglycemia in patients with diabetes who use insulin. Some older beta blockers such as propranolol can cause broncho­constriction and asthma symptoms.Some older beta blockers such as propranolol can cause broncho­constriction and asthma symptoms. Check for common adverse effects of beta blockers, such as dizziness, slowing of the pulse, fatigue, and hypotension.Check for common adverse effects of beta blockers, such as dizziness, slowing of the pulse, fatigue, and hypotension.

26 Nursing Considerations alpha-blockers Warn patients about the risk of orthostatic hypotension, which can cause falls.Warn patients about the risk of orthostatic hypotension, which can cause falls. Teach patients to take their first dose at bedtime and to move slowly from a sitting to a standing position.Teach patients to take their first dose at bedtime and to move slowly from a sitting to a standing position.

27 Nursing Considerations calcium channel blockers Tell patients to report dizziness and symptoms of an irregular heart rate.Tell patients to report dizziness and symptoms of an irregular heart rate. Teach your patients to avoid grapefruit juice because it inhibits the hepatic metabolism of calcium channel blockers and may lead to increased blood drug levels and increased pharmacologic effects.Teach your patients to avoid grapefruit juice because it inhibits the hepatic metabolism of calcium channel blockers and may lead to increased blood drug levels and increased pharmacologic effects. All calcium channel blockers should be used cautiously in patients with heart failure.All calcium channel blockers should be used cautiously in patients with heart failure.

28 Nursing Considerations ACE-Inhibitors and angiotensions Assess patient for hyperkalemia.Assess patient for hyperkalemia. Rare adverse effects include: agranulocytosis, proteinuria, glomerulonephritis, acute kidney failure, and angioedema.Rare adverse effects include: agranulocytosis, proteinuria, glomerulonephritis, acute kidney failure, and angioedema. Assess for angioedema, which can lead to airway swelling and requires emergent treatment.Assess for angioedema, which can lead to airway swelling and requires emergent treatment. A history of angioedema contraindicates the use of ACE inhibitors.A history of angioedema contraindicates the use of ACE inhibitors.

29 Nursing Considerations Tell patients not to stop taking these drugs on their own because an abrupt withdrawal can result in rebound hypertension.Tell patients not to stop taking these drugs on their own because an abrupt withdrawal can result in rebound hypertension. Teach to take own blood pressure daily and record it, bringing the record to scheduled clinic visits.Teach to take own blood pressure daily and record it, bringing the record to scheduled clinic visits. Teach name, dose, action, and side effects of antihypertensive medication.Teach name, dose, action, and side effects of antihypertensive medication. Instruct patient to develop a daily exercise routine. Instruct patient to develop a daily exercise routine. Discuss strategies for maintaining a healthy weight. Discuss strategies for maintaining a healthy weight. Refer for a dietary consultation for further teaching about the DASH diet.Refer for a dietary consultation for further teaching about the DASH diet. Discuss stress-reducing techniques, helping identify possible choices.Discuss stress-reducing techniques, helping identify possible choices.

30 Video’s (Understanding HTN) (Antihypertensive Meds) (Guide to lowering HTN) PLEASE CLICK ON LINK’S FOR SHORT VIDEOS

31 Questions 1. When giving antihypertensive drugs, the nurse must consider giving the first dose at bedtime for which of the fallowing classes of drugs?1. When giving antihypertensive drugs, the nurse must consider giving the first dose at bedtime for which of the fallowing classes of drugs? A.a-Blockers such as prazosin (Minipress) B.Diuretics such as furosemide (Lasix) C.ACE inhibitors such as captopril (Capoten) D.Vasodilators such as hydralazine (Apresoline)

32 Questions 2. A 56 yr. old man started anti-hypertensive drug therapy 3 months earlier and is in the office for a follow- up visit. While the nurse is taking his blood pressure, he informs the nurse that he has had some problems with sexual intercourse. Which of the following would be the most appropriate response by the nurse?2. A 56 yr. old man started anti-hypertensive drug therapy 3 months earlier and is in the office for a follow- up visit. While the nurse is taking his blood pressure, he informs the nurse that he has had some problems with sexual intercourse. Which of the following would be the most appropriate response by the nurse? A.“Not to worry. Tolerance will develop” B.“The physician can work with you on changing the dose and/or drugs” C.“Sexual dysfunction happens with this therapy, and you must learn to accept it.” D.“This is an unusual occurance, but it is important to stay on your medications.”

33 Questions 3. Which of the following adverse effects is most concern for the older adult patient taking antihypertensive drugs?3. Which of the following adverse effects is most concern for the older adult patient taking antihypertensive drugs? A.Dry mouth B.Hypotension C.Restlessness D.Constipation

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35 References Abrams, A.C., Pennington, S.S., & Lammon, C.B. (2009). Clinical Drug Therapy; Rationales for Nursing Practice. (9th ed). Philadelphia, PA: Wolters Kluwer. Lippincott Williams & Wilkins. Frohlich E.D., Apstein C., Chobanian A.V., et al. (1992) The heart in hypertension. New Engl J Med 327:998–1008. Ganau A., Devereux R.B., Roman M.J., et al. (1992). Patterns of left ventricular hypertrophy and geometric remodelling in essential hypertension. J Am Coll Cardiol 19:1550–1558. Koffland M.J.M., van der Lee C., ten Cate F.J., Roelandt J.R.T.C. (1998). Hypertrophic cardiomyopathy: update and new perspectives. Cardiologie 5:511–524.

36 References Pegram B.L., Ishise S., Frohlich E.D. (1982). Effect of methyldopa, clonidine and hydralazine on cardiac mass and haemodynamics in Wistar Kyoto and spontaneously hypertensive rats. Cardiovasc Res 16:40–46. Pluim B.M., Vliegen H.W., van der Laarse A., van der Wall E.E. (1998). Pathological left ventricular hypertrophy. Cardiologie 5:574–582. Savage D.D., Garrison R.J., Kannel W.B., et al. (1987). The spectrum of left ventricular hypertrophy in a general population sample: the Framingham study. Circulation 75(suppl.I):I26–I33. Spirito P., Pelliccia A., Proschan M.A., et al. (1994). Morphology of the ‘athlete's heart’ assessed by echocardiography in 947 elite athletes representing 27 sports. Am J Cardiol 74:802–806.


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