Drugs Affecting Blood Pressure

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Blood Pressure Control
‡ Elements
± Heart Rate ± Stroke Volume ± Peripheral Vascular Resistance

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Blood Pressure Control
‡ Baroreceptors ‡ Renin-Angiotensin System Renin-

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Hypertension
High blood pressure
‡ Normal: Systolic < 130 mmHg » Diastolic < 85 mm Hg

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Classification of Blood Pressure
Category Normal High normal Hypertension Stage 1 Stage 2 Stage 3 Stage 4 Systemic BP (mm Hg) <130 130-139 130140-159 140160-169 160180-209 180u 210 Diastolic BP (mm Hg) <85 85-89 8590-99 90100-109 100110-119 110u 120

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Classification of Blood Pressure
Primary Hypertension
‡ Specific cause unknown ‡ 90% of the cases ‡ Also known as essential or idiopathic hypertension

Secondary Hypertension
‡ Cause is known (such as eclampsia of pregnancy, renal artery disease, pheochromocytoma) ‡ 10% of the cases
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SteppedStepped-Care Management of HPN by JNC 7
Step 1: Lifestyle modification weight reduction reduction moderation of alcohol intake smoking cessation physical activity increase

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SteppedStepped-Care Management of HPN by JNC 7
Step 2 : Inadequate Response continue lifestyle modification initial drug selection 1. Diuretic or Beta blocker 2. ACE inhibitor, calcium channel blocker, ARB

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SteppedStepped-Care Management of HPN by JNC 7
Step 3 : Inadequate Response increase drug dose, or substitute another drug, or add a 2nd drug from another class

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SteppedStepped-Care Management of HPN by JNC 7
Step 4 : Inadequate Response add a 2nd or 3rd agent or diuretic if not already prescribed

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Hypotension
‡ Hypotensive states:
± Heart muscle is damaged

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Blood Pressure = CO x SVR
‡ CO = Cardiac output ‡ SVR = Systemic vascular resistance

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Instructors may want to insert EIC Image #69: Blood Pressure: Normal Regulation

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Antihypertensive Agents
‡ Medications used to treat hypertension

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Antihypertensive Agents: Categories
‡ Sympathetic Nervous System Blockers/Adrenergic agents ‡ Angiotensin-converting enzyme inhibitors Angiotensin‡ Angiotensin II receptor blockers ‡ Calcium channel blockers ‡ Diuretics ‡ Vasodilators
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Antihypertensive Agents: Categories
‡ Sympathetic Nervous System Blockers/ Adrenergic agents
± Alpha1 blockers ± Beta blockers (cardioselective and nonselective) ± Centrally acting alpha blockers ± Combined alpha-beta blockers alpha± Peripheral-acting adrenergic agents PeripheralCopyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antihypertensive Agents: Mechanism of Action
Adrenergic Agents Alpha1 Blockers (peripherally acting)
‡ ‡ Block the alpha1-adrenergic receptors alpha1The SNS is not stimulated
Result: DECREASED blood pressure

‡
‡

Stimulation of alpha1-adrenergic receptors alpha1causes HYPERtension
Blocking alpha1-adrenergic receptors causes decreased alpha1blood pressure

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Antihypertensive Agents:
Adrenergic Agents Alpha1 Blockers
‡ doxazosin (Cardura) ‡ prazosin (Minipress) ‡ terazosin (Hytrin)

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Antihypertensive Agents: Mechanism of Action
Adrenergic Agents CentralCentral-Acting Adrenergics
‡ Stimulate alpha2-adrenergic receptors alpha2‡ Sympathetic outflow from the CNS is decreased Result: decreased blood pressure

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Antihypertensive Agents:
Adrenergic Agents CentralCentral-Acting Adrenergics
‡ clonidine (Catapres) ‡ methyldopa (Aldomet) (drug of choice for hypertension in pregnancy)

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Antihypertensive Agents: Mechanism of Action
Adrenergic Agents Adrenergic Neuronal Blockers (peripherally acting)
‡ Inhibit release of norepinephrine ‡ Also deplete norepinephrine stores ‡ SNS (peripheral adrenergic nerves) is not stimulated Result: decreased blood pressure
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Antihypertensive Agents:
Adrenergic Agents Adrenergic Neuronal Blockers (peripherally acting)
‡ reserpine ‡ guanadrel (Hylorel) ‡ guanethidine (Ismelin)

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Antihypertensive Agents: Adrenergic Agents
Therapeutic Uses
‡ Alpha1 blockers (peripherally acting) ± Treatment of hypertension ± Relief of symptoms of BPH ± Management of of severe CHF when used with cardiac glycosides and diuretics

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Antihypertensive Agents: Adrenergic Agents
Therapeutic Uses
‡ Central-Acting Adrenergics Central± Treatment of hypertension, either alone or with other agents ± Usually used after other agents have failed due to side effects ± Also may be used for treatment of severe dysmenorrhea, menopausal flushing, glaucoma ± Clonidine is useful in the management of withdrawal symptoms in opioid- or nicotineopioid- nicotinedependent persons
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Antihypertensive Agents: Adrenergic Agents
Therapeutic Uses
‡ Adrenergic neuronal blockers (peripherally acting) ± Treatment of hypertension, either alone or with other agents ± Seldom used because of frequent side effects

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Antihypertensive Agents: Adrenergic Agents
Side Effects
Most common: Other: dry mouth sedation drowsiness constipation

headaches sleep disturbances nausea rash cardiac disturbances (palpitations)

HIGH INCIDENCE OF ORTHOSTATIC HYPOTENSION

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Antihypertensive Agents: Categories
AngiotensinAngiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)
‡ Large group of safe and effective drugs ‡ Often used as first-line agents for CHF firstand hypertension ‡ May be combined with a thiazide diuretic or calcium channel blocker

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Antihypertensive Agents: Mechanism of Action
ACE Inhibitors RAAS: Renin Angiotensin-Aldosterone System Angiotensin‡ When the enzyme angiotensin I is converted to angiotensin II, the result is potent vasoconstriction and stimulation of aldosterone ‡ Result of vasoconstriction: increased systemic vascular resistance and increased afterload ‡ Therefore, increased BP
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Antihypertensive Agents: Mechanism of Action
ACE Inhibitors
‡ Aldosterone stimulates water and sodium resorption. ‡ Result: increased blood volume, increased preload, and increased B

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Antihypertensive Agents: Mechanism of Action
ACE Inhibitors
‡ ACE Inhibitors block the angiotensin-converting angiotensinenzyme, thus preventing the formation of angiotensin II. ‡ Also prevent the breakdown of the vasodilating substance, bradykinin
Result: decreased systemic vascular resistance (afterload), vasodilation, and therefore, decreased blood pressure

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Antihypertensive Agents
ACE Inhibitors
‡ captopril (Capoten) ‡ Short half-life, must be dosed more frequently halfthan others ‡ enalapril (Vasotec) ‡ The only ACE inhibitor available in oral and parenteral forms ‡ lisinopril (Prinivil and Zestril) and quinapril (Accupril) ‡ Newer agents, long half-lives, once-a-day dosing halfonce‡ Several other agents available
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Antihypertensive Agents: Therapeutic Uses
ACE Inhibitors
‡ Hypertension ‡ CHF (either alone or in combination with 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 CHF
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Antihypertensive Agents: Side Effects
ACE Inhibitors
‡ Fatigue ‡ Headache ‡ Impaired taste
Dry, nonproductive cough, reverses when therapy is stopped NOTE: first-dose hypotensive effect may occur!! first-

Dizziness Mood changes

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Antihypertensive Agents: Categories
Angiotensin II Receptor Blockers (A II Blockers or ARBs)
‡ Newer class ‡ Well-tolerated Well‡ Do not cause coughing

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Antihypertensive Agents: Mechanism of Action
Angiotensin II Receptor Blockers
‡ Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II ‡ Block vasoconstriction and release of aldosterone

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Antihypertensive Agents:
Angiotensin II Receptor Blockers
‡ losartan (Cozaar) ‡ eposartan (Teveten) ‡ valsartan (Diovan) ‡ irbesartan (Avapro) ‡ candesartan (Atacand) ‡ telmisartan (Micardis)
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Antihypertensive Agents: Therapeutic Uses
Angiotensin II Receptor Blockers
‡ Hypertension ‡ Adjunctive agents for the treatment of CHF ‡ May be used alone or with other agents such as diuretics

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Antihypertensive Agents: Side Effects
Angiotensin II Receptor Blockers
‡ Upper respiratory infections ‡ Headache ‡ May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue

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Antihypertensive Agents: Categories
Calcium Channel Blockers
‡ Benzothiazepines ‡ Dihydropyridines ‡ Phenylalkylamines

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Antihypertensive Agents: Mechanism of Action
Calcium Channel Blockers
‡ Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction ‡ This causes decreased peripheral smooth muscle tone, decreased systemic vascular resistance ‡ Result: decreased blood pressure

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Antihypertensive Agents
Calcium Channel Blockers
‡ Benzothiazepines:
± diltiazem (Cardizem, Dilacor)

‡ Phenylalkamines:
± verapamil (Calan, Isoptin)

‡ Dihydropyridines:
± amlodipine (Norvasc), bepridil (Vascor), nicardipine (Cardene) ± nifedipine (Procardia), nimodipine (Nimotop)
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Antihypertensive Agents: Therapeutic Uses
Calcium Channel Blockers
‡ Angina ‡ Hypertension ‡ Dysrhythmias ‡ Migraine headaches

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Antihypertensive Agents: Side Effects
Calcium Channel Blockers
‡ Cardiovascular ± hypotension, palpitations, tachycardia ‡ Gastrointestinal ± constipation, nausea ‡ Other ± rash, flushing, peripheral edema, dermatitis
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Antihypertensive Agents: Diuretics
‡ Decrease the plasma and extracellular fluid volumes ‡ Results: decreased preload decreased cardiac output decreased total peripheral resistance

‡ Overall effect: decreased workload of the heart, and decreased blood pressure

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Antihypertensive Agents: Mechanism of Action
Vasodilators
‡ Directly relaxes arteriolar smooth muscle ‡ Result: decreased systemic vascular response, decreased afterload, and PERIPHERAL VASODILATION

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Antihypertensive Agents
Vasodilators
‡ diazoxide (Hyperstat) ‡ hydralazine HCl (Apresoline) ‡ minoxidil (Loniten, Rogaine) ‡ sodium nitroprusside (Nipride, Nitropress)

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Antihypertensive Agents: Therapeutic Uses
Vasodilators
‡ Treatment of hypertension ‡ May be used in combination with other agents ‡ Sodium nitroprusside and diazoxide IV are reserved for the management of hypertensive emergencies

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Antihypertensive Agents: Side Effects
Vasodilators ‡ Hydralazine:
± dizziness, headache, anxiety, tachycardia, nausea and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion

‡ Sodium nitroprusside:
± bradycardia, hypotension, possible cyanide toxicity
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Antihypertensive Agents: Nursing Implications
‡ Before beginning therapy, obtain a thorough health history and head-to-toe physical head-toexamination. ‡ Assess for contraindications to specific antihypertensive agents. ‡ Assess for conditions that require cautious use of these agents.
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Antihypertensive Agents: Nursing Implications
‡ 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 physician for instructions on what to do if a dose is missed. ‡ Monitor BP during therapy. Instruct patients to keep a journal of regular BP checks.

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Antihypertensive Agents: Nursing Implications
‡ Instruct patients that these drugs should not be stopped abruptly, as this may cause a rebound hypertensive crisis, and perhaps lead to CVA. ‡ 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.

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Antihypertensive Agents: Nursing Implications
‡ Remind patients that medications is only part of therapy. Encourage patients to watch their diet, stress level, weight, and alcohol intake. ‡ Patients should avoid smoking and eating foods high in sodium. ‡ Encourage supervised exercise.

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Antihypertensive Agents: Nursing Implications
‡ Instruct patients to change positions slowly to avoid syncope from postural hypotension. ‡ Patients should report unusual 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.

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Antihypertensive Agents: Nursing Implications
‡ Men taking these agents may not be aware that impotence is an expected effect. This may influence compliance with drug therapy. ‡ If patients are experiencing serious side effects, or believe that the dose or medication needs to be changed, they should contact their physician immediately.

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Antihypertensive Agents: Nursing Implications
‡ 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 first getting the approval of their physician.

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Antihypertensive Agents: Nursing Implications
‡ Monitor for side/adverse effects (dizziness, orthostatic hypotension, fatigue) and for toxic effects. ‡ Monitor for therapeutic effects ‡ Blood pressure should be maintained at less than 140/90 mm Hg

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