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High Blood Pressure (Hypertensive) Medication There are a variety of medications used to treat high blood pressure.

These drugs are called antihypertensive agents. Which agent a patient is started on depends on numerous factors, including ease of use, side effects, and coexisting medical conditions that might dictate preferential use of one agent over another. Generally, an antihypertensive agent is started at a relatively low dose, and the response to it is assessed over the course of several weeks. If the blood pressure remains elevated, the dose of the medication is gradually increased. When treatment with relatively high doses of an antihypertensive medication fails to lower blood pressure to target levels, two options are possible: (1) that particular medication may be discontinued and a different class of antihypertensive medication begun, or (2) a second class of medication may be added to the first agent. The second approach is often used because different classes of antihypertensive agents work in different ways to lower blood pressure, and the actions of one agent may complement the actions of the second agent. In some patients, it may be necessary to add a third agent. Most of the newer blood pressure medications are taken once or twice a day. They all have side effects, but most are well tolerated by patients. Diuretics ("water pills") increase the kidneys' excretion of salt (sodium) and water, decreasing the volume of fluid in the bloodstream and the pressure in the arteries. Diuretics are the oldest and most studied antihypertensive agents. One of the most commonly used diuretic agents is hydrochlorothiazide (HydroDiuril, Microzide). Other diuretics used to treat hypertension include the following: Acetazolamide (Diamox) Furosemide (Lasix) Indapamide (Lozol) Metolazone (Zaroxolyn) Spirnolactone (Aldactone) Torsemide (Demadex) Triamterene (Dyrenium)

Combination medications that contain both a diuretic and a different class of antihypertensive agent are being produced. The main side effect of these agents is increased frequency of urination. Another side effect is increased urinary excretion of potassium. Because of this, doctors monitor blood potassium levels when initiating therapy and periodically thereafter. Patients who have low potassium levels are encouraged to eat foods rich in potassium, such as bananas, or may be prescribed a potassium supplement. Aliskiren (Tekturna) is a medication that can be used alone or in combination with other antihypertensive agents to treat high blood pressure. It is often used with diuretics and an angiotensin-receptor blocker (ARB). This medication should not be used during pregnancy. Beta blockers decrease the vigor of the heart's contractions. By decreasing the force used to pump blood into the arteries, the medications decrease blood pressure. In addition to lowering blood pressure, beta blockers have multiple beneficial effects (including prolonged life) in patients with coronary artery disease, patients who have had myocardial infarction (heart attack), and many patients with congestive heart failure (CHF). Commonly used beta blockers include the following:

Atenolol (Tenormin) Bisoprolol (Zebeta) Carvedilol (Coreg) Metoprolol (iLopressor, Toprol SL) Timolol (Blockadren)

Another beta blocker, labetolol (Normodyne, Trandate) has alpha blocker properties that dilate the arteries and lower blood pressure. Potential side effects of the beta blockers are slowing the heart rate excessively, worsening heart failure (careful long-term use has been shown to frequently provide beneficial effects in patients with CHF), and, rarely, contributing to confusion, depression, and impotence (erectile dysfunction) Calcium channel blockers. This class of agents lowers blood pressure in several ways. Two of these agents, diltiazem (Cardizem) and verapamil (Calan, Covera HS, Isoptin, Veralan) act in part like the beta blockers, decreasing the vigor of the heart's contractions. They decrease blood pressure by decreasing the force with which blood is pumped into the arteries. These agents also dilate (open up) arteries, decreasing resistance to blood flow, thereby decreasing blood pressure. The newer calcium channel blockers primarily dilate the arteries and have little effect on the forcefulness of the heart's contractions. These include: Amlodipine (Norvasc) Felodipine (Plendil) Idradipine (DynaCirc) Nicardipine (Cardene) Nisoldipine (Sular)

Norvasc has been combined with the cholesterol-lowering drug Lipitor to treat patients with high blood pressure and high cholesterol. This combination drug, which is called Caduet, offers the convenience of taking only one medication to control both conditions. Calcium channel blockers may have serious side effects and should be used with caution in patients with pulmonary arterial hypertension (PAH). PAH, which is lifethreatening, is high blood pressure in the arteries that supply blood to the lungs (the pulmonary arteries). In some cases, diltiazem and verapamil, which decrease the force of the heart's contractions, worsen congestive heart failure symptoms. Verapamil may occasionally cause constipation, especially in elderly patients. Many of the calcium channel blockers cause headache and edema (swelling) in the ankles and feet. ACE inhibitors. These medications help dilate the arteries, thereby decreasing resistance to blood flow and consequently decreasing blood pressure. They have many other beneficial effects and are used to treat patients with congestive heart failure. Many studies have shown that treatment of heart failure patients with ACE inhibitors improves heart failure symptoms, decreases the chance of future hospitalizations, decreases the risk for future heart attack, and decreases the risk of death from heart failure. There are many ACE inhibitors available, including the following: Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Quinapril (Accupril)

Ramipril (Altace) Trandolapril (Mavik)

ACE inhibitors are usually tolerated well, but there are potential side effects. Approximately 10% of patients develop a chronic nonproductive cough. Rarely, ACE inhibitors produce a sudden swelling of the lips, face, and cheek areas in an allergic reaction that can occur at any time during therapy. If an allergic reaction occurs, medical attention should be sought immediately. Because ACE inhibitors can affect kidney function and raise the potassium level, doctors monitor these during the first several weeks of therapy and periodically thereafter. Angiotensin-receptor blockers (ARBs). This class of medications are similar in some respects to ACE inhibitors. Like ACE inhibitors, they help dilate arteries, lowering blood pressure and making it easier for the heart to pump blood throughout the body. Also, like ACE inhibitors, they can improve congestive heart failure symptoms, decrease the chances of future hospitalizations for heart failure, and prolong life. Ongoing studies are comparing the effects of ARBs with the ACE inhibitors and are investigating the use of both in patients with heart failure. Currently available ARBs include: Azilsartan medoxomil (Edarbi) Candesartan (Atacand) Irbesartan (Avapro) Losartan (Cozaar) Telmisartan (Micardis) Valsartan (Diovan)

ARBs are generally taken once a day and do not commonly produce significant side effects. Rarely, they interfere with or worsen kidney function. In September 2009, the U.S. Food and Drug Administration (FDA) approved a combination of aliskiren and valsartan (called Valturna) to treat high blood pressure in patients when monotherapy (treatment with one medication) is not effective or when hypertension is likely to require more than one drug. Side effects of Valturna include fatigue, flu-like symptoms, diarrhea, and dizziness. This medication should not be used in women who are pregnant because it can cause serious harm or death in unborn fetuses. Severe side effects include swelling (edema) and extremely low blood pressure (hypotension). Direct-acting vasodilators. The medication hydralazine more or less directly dilates the arteries in the body, lowering blood pressure. Hydralazine is sometimes used in combination with isosorbide dinitrate to treat patients with congestive heart failure. Centrally acting agents. These antihypertensive agents affect the central nervous system (brain) to decrease blood pressure. Such medications include clonidine (Catapres) and methyldopa (Aldomet). Because these drugs act directly on the brain, they occasionally cause drowsiness, depression, and other symptoms.

Insights For me Ive learned in this article that one of the causes of Buergers Disease of that woman is diabetes and hypertension. So as a student nurse, I should have a healthy lifestyle. Like eating balance and the right kinds of foods. Avoid eating sweets, rich in

fats and cholesterol foods to avoid diabetes and hypertension. And most of all, avoid smoking because it is one of the most cause of Buergers Disease.

Article Buergers Disease

A 69-year-old man presented with a 10-day history of discoloration of the left foot and pain in the left foot while at rest. He reported a 1-year history of intermittent claudication in his left leg. His medical history was notable for type 2 diabetes mellitus and hypertension. On examination, his left foot was erythematous, cold to the touch, and pulseless in the dorsalis pedis and posterior tibial arteries while hanging down (Panel A). However, the foot became pale when elevated (Panel B) and became red again while hanging down, which is Buerger's symptom, suggesting the presence of peripheral artery disease. Both feet had some signs of vascular insufficiency, such as loss of hair and thin and dry skin, but there was no pallor or cyanosis. Subsequent angiography showed severe arteriosclerosis involving the right and left external iliac arteries, with stenosis of 67% and 82%, respectively, and total thrombotic occlusion of the left superficial femoral artery. Percutaneous transluminal angioplasty, with stent insertion in both external iliac arteries and in the left superficial femoral artery, restored the distal blood flow. After the procedure, both the redness of the left foot and the ischemic symptoms resolved. Paradoxical redness in patients with peripheral artery disease occurs with very restricted arterial inflow and chronic dilatation of the peripheral vascular bed. The patient was well during the 3-year follow-up period, without recurrent symptoms of arterial insufficiency.

Leroy Carlo C. Baares BSN3B