Chapter 43

ANTIHYPERTENSIVES

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Cardiovascular Circulation
Systemic Circulation Pulmonary Circulation

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Hypertension

Selected regulators of blood pressure

Kidneys via reninangiotensin system

Renin-angiotensin system.
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Hypertension

Renin-angiotensin system.
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Regulators of Blood Pressure

Baroreceptors in the aorta and carotid sinus Vasomotor center in the medulla Hormones: antidiuretic hormone (ADH), atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP)

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Physiologic Risk Factors

Excess fat and carbohydrate intake Alcohol increases renin secretions Obesity affects cardiovascular system Nonpharmacologic control of hypertension

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Guidelines for Determining Hypertension

Category Systolic Pressure Diastolic Pressure

Normal

Less than120 mm Hg 120-139 mm Hg

Less than 80 mm Hg 80-89 mm Hg

Prehypertension

Stage 1 hypertension Stage 2 hypertension

140-159 mm Hg

90-99 mm Hg

Greater than160 mm Hg

Greater than 100 mm Hg

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Antihypertensive Drugs

Diuretics

Thiazides: hydrochlorothiazide (HydroDiuril) Loop (high-ceiling) diuretics Combinations of hydrochlorothiazide with potassium-sparing diuretics and other antihypertensive drugs (i.e., ACE inhibitors) Potassium loss or hypokalemia and others

Side effects

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Antihypertensive Drugs

ACE (Angiotensin Converting Enzyme) Inhibitors

Captopril (Capoten), Enalapril (Vasotec), Ramipril (Altace), Lisinopril (Prinivil) ACE inhibitors block the conversion of angiotensin I to angiotensin II. They, therefore, lower arteriolar resistance and increase venous capacity; increase cardiac output, cardiac index, stroke work, and volume; lower renovascular resistance; and lead to increased natriuresis (excretion of sodium in the urine)
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Antihypertensive Drugs

ACE (Angiotensin Converting Enzyme) Inhibitors

Expected Side effects nausea, fatigue, headache, diarrhea, orthostatic hypotension, dizziness, weakness, faintness Side effects to report swelling of the face, eyes, lips, tongue, difficulty in breathing, neutropenia & agranulocytosis, nephrotoxicity, hyperkalemia, chronic cough (bradykinin) Contraindicated to pregnant women
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Antihypertensive Drugs

ACE (Angiotensin Converting Enzyme) Inhibitors

Drugs that enhance therapeutic/toxic effects diuretics, alcohol, B-blockers, anti-HPNs Drugs that reduce therapeutic effects antacids, indomethacin, rifampin

ACE inhibitors may increase serum levels of Digoxin and Lithium

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Angiotensin II Receptor Blockers (ARBs) (Angiotensin II Blockers)

Acts by binding to Angiotensin II receptor sites, blocking the very potent vasoconstrictor from binding to the receptor sites in the vascular smooth muscle, brain, heart, kidneys, & adrenals Losartan (Cozaar), Telmisartan (Micardis) Candesartan (Atacand), Olmesartan (Benicar), Irbesartan (Avapro)

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Angiotensin II Receptor Blockers (ARBs) (Angiotensin II Blockers)

Expected Side effects headache, dyspepsia, cramps, diarrhea, orthostatic hypotension, dizziness, weakness, faintness Side effects to report hyperkalemia Contraindicated to pregnant women

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Sympatholytics (Sympathetic Depressants)

Beta-adrenergic blockers Centrally acting alpha2 agonists Alpha-adrenergic blockers Adrenergic neuron blockers (peripherally acting sympatholytics) Alpha1- and beta1-adrenergic blockers

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Beta-Adrenergic Blockers

Metoprolol (Lopressor), Propanolol (Inderal), Atenolol (Tenormin), Noncardioselective beta blockers

Contraindications: chronic obstructive plumonary disease (COPD) Contraindications: clients with diabetes mellitus when taking beta blockers Antihypertensive drugs, lidocaine, digoxin Beta Adrenergics, enzyme-inducing agents eg cimetidine, phenytoin, NSAIDS
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Cardioselective beta blockers

Interactions:

Beta-Adrenergic Blockers

Side effects: marked decrease in blood pressure, bradycardia, peripheral vasoconstriction (purple mottled skin), bronchospasm, wheezing, hypoglycemia, insomnia, depression, nightmares, sexual dysfunction Do not abruptly stop taking beta blockers: rebound hypertension, exacerbation of anginal symptoms, MI may result

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Calcium Channel Blockers

Amlodipine (Norvasc), Felodipine (Plendil), Diltiazem (Cardizem), Nifedipine (Procardia), Verapamil (Calan), Nicardipine (Cardene)
Decrease calcium levels and movement of Ca through calcium channels to the heart, and promote vasodilation Calcium channel blockers are also frequently used to alter heart rate, to prevent cerebral vasospasm, and to reduce chest pain caused by angina pectoris items 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Elsevier items and derived

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Calcium Channel Blockers

Side effects may include hypotension and syncope, may cause peripheral vasodilation (edema) Avoid ingestion of grapefruit juice; could intensify drug effect Interactions

Drugs that enhance therapeutic/toxic effects are diuretics, phenothiazines, alcohol, B-blockers, histamine antagonists, anti-HPNs Digoxin-Ca blockers may increase serum digoxin levels (WOF N/V, blurred/colored vision, bradycardia, headaches, anorexia) Antidiabetics assess for signs of hyperglycemia
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Centrally Acting Alpha2 Agonists

Clonidine (Catapres), Methyldopa (Aldomet), Guanabenz (Wytensin) Contraindications: impaired liver function Side effects: drowsiness, dizziness, sodium and water retention, dry mouth, bradycardia, altered urine color, false (+) urine glucose test, depression and rashes Diuretics are frequently prescribed to avoid fluid retention Avoid abruptly stopping drug; rebound hypertension may result
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Apha-Adrenergic Blockers (Alpha Blockers)

Blocks the alpha-adrenergic receptors, to produce arteriolar and venous vasodilation, reducing peripheral vascular resistance w/o reducing cardiac output or inducing a reflex tachycardia, resulting in decreased blood pressure Drugs: Doxazosin mesylate (Cardura), prazosin HCl (Minipress), terazosin HCL (Hytrin)

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Apha-Adrenergic Blockers (Alpha Blockers)

Side effects drowsiness, headache, dizziness, weakness, lethargy, tachycardia, fainting Diuretics, tranquilizers, alcohol, barbiturates, antihistamines, betaadrenergic blocking agents and other antiHPN drugs can enhance therapeutic/toxic effects

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Other Antihypertensive Drugs

Direct-acting arteriolar vasodilators

Hydralazine (Apresoline) causes direct arteriolar smooth muscle relaxation Nitroprusside (Nitropress) potent vasodilator on the smooth muscle of blood vessels Minoxidil (Loniten) direct relaxation of smooth muscle of arterioles, reducing peripheral vasoresistance. Side effects: reflex tachycardia and Na/H2O retention, palpitations, numbness & tingling of legs, nasal congestion, restlessness, agitation, confusion, light-headedness, dizziness, nausea hair growth (Minoxidil)
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Angiotensin-Converting Enzyme (ACE) Inhibitors

Function Examples of ACE inihibitors (10 drugs) African American and older adult effect with monotherapy Combination with ACE inhibitors and calcium blockers Side effects: irritating cough, insomnia, hyperkalemia

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Practice Question #1
CBs blood pressure (BP) is 142/82. The health care provider prescribed a diuretic to lower his BP. CB asks, Why the diuretic? Your answer could be:
A.

B.
C. D.

Your blood pressure is within the prehypertensive range. Your systolic blood pressure indicates you have stage 1 hypertension. You have stage 1 hypertension according to your diastolic pressure. According to the new guidelines for hypertension, your blood pressure indicates stage 2 hypertension.

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Practice Question #1 (contd)

Answer: B

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Practice Question #2
CBs diuretic was changed to an angiotensin II receptor blocker (ARB). An example of an ARB is:
A. B. C. D.

valsartan (Diovan). amlodipine (Norvasc). captopril (Capoten). metoprolol (Lopressor).

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Practice Question #2 (contd)

Answer: A

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Practice Question #3
A common side effect of an ARB is:
irritating cough. B. nervousness (tremors). C. asthmatic attacks. D. dizziness.
A.

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Practice Question #3 (contd)

Answer: D

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