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138 Cards in this Set
- Front
- Back
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What is the definition of hypertension?
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A sustained systolic BP of over 140mmHg or a sustained diastolic BP of over 90mmHg
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What is the most common cause of hypertension.
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Idiopathic (unknown)
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What is the name used for hypertension without known cause?
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Essential hypertension
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How many percent of hypertensive patients have essential hypertension?
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90%
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How many percent of the population have hypertension?
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15%
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That means that out of 150 people, X nr of people should be hypertensive in a population.
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22,5
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What is the most common symptom of hypertension?
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It is most often asymptomatic.
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What are the complications of long-standing hypertension?
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Strokes, CHF, MI, and renal damage.
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What are the results of early diagnosis and treatment of hypertension?
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Significant reduction in morbidity and mortality.
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Is hypertension progressive?
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Yes
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Describe the categories of progression of hypetension
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Normal <120/80
Prehypertension 120-139/80-89 Stage 1 hypertension 140-159/90-99 Stage 2 hypertension >160/100 |
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What are contributing factors to likelihood of hypertension?
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Family history
African heritage 4:1 Male gender (at middle age) Age Obesity Smoking Stress Lack of exercise Diet (sodium, saturated fat) |
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Arterial blood pressure is directly proportional to the product of...
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Peripheral vascular resistance and cardiac output.
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Cardiac output and peripheral vascular resistance are controlled mainly by two overlapping control mechanisms, the...
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baroreflexes which activate the sympathetic nervous system and the renin-angiotensin-aldosterone system.
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Where are the baroreceptors located?
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In the carotid sinuses and in the aortic arch.
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What organ besides the heart is responsible for the long-term regulation of blood pressure?
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The kidney
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How does the kidney regulate blood pressure?
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By secreting renin in response to decreased blood pressure which leads to changes such as increased fluid volume, increased vasocontriction etc.
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What is the goal in the treatment of hypertension?
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To reduce morbidity and mortality of cardiovascular and renal disease.
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What type of hypertension may be controlled with a single drug?
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Mild hypertension.
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What is true however of most hypertensive patients?
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Most hypertensive patients require more than one drug.
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What do current guidelines recommend in regard to initiation of antihypertensive therapy?
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That therapy be initiated with a thiazide diuretic unless there are compelling evidence to initiate therapy with another class of drug.
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What to do if blood pressure is inadequately controlled on a thiazide diuretic?
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Then another agent is added with the selection based on minimizing the side effects of the combined regimen.
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What is the drug which is often added to the thiazide diuretic?
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A beta blocker if the initial drug was a diuretic or vice versa.
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Which is usually the third step in these patients who fail to respond to the dual regimen therapy?
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Then usually a vasodilator is added.
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What are the other types of agents that may be used to initiate therapy?
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ACE inhibitors, ARBs and calcium channel blockers.
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Why is it important to individualize therapy in hypertension?
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Because certain individuals may respond better to one agent over another and there are large variations in reponse to therapy among different populations. For example blacks respond poorly to beta blockers or ace inhibitors but well to diuretics and calcium channel blockers.
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Which agents are favored in the elderly?
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Calcium channel blockers, ace inhibitors, and diuretics.
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Which are the agents used for hypertension in patients with concomitant angina pectoris in order of efficacy?
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Calcium channel blockers, Beta blockers, Diuretics and ACE inhibitors.
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Which are the agents used for hypertension in patients with concomitant diabetes in order of efficacy?
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Diuretics, ARBs, ACE inhibitors, Calcium channel blockers and beta blockers.
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Which are the agents used for hypertension in patients with concomitant recurrent strokes in order of efficacy?
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ACE inhibitors and diuretics.
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Which are the agents used for hypertension in patients with concomitant heart failure in order of efficacy?
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ACE inhibitors, Diuretics, ARBs and beta blockers. Not calcium channel blockers!!!!
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Which are the agents used for hypertension in patients with concomitant previous MI in order of efficacy?
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Beta blockers and ACE inhibitors
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Which are the agents used for hypertension in patients with concomitant chronic renal disease in order of efficacy?
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ACE inhibitors, ARBs, beta blockers and Calcium channel blockers.
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What is the most common reason for failure of antihypertensive therapy?
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Lack of patient compliance.
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Why is the patient often noncompliant?
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Because the hypertension is often asymptomatic and the antihypertensives have side effects.
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What has recent data suggested in comparing beta blockers and diuretics in the treatment of hypertension?
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That diuretics are superior to beta blockers in the treatment of hypertension in older adults (the main group of patients for hypertension).
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What is the antihypertensive effects of the thiazide diuretics?
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Thiazide diuretics such as hydrochorothiazide, lower blood pressure initially by reducing fluid volume. With long term treatment, plasma volume reaches a normal value but peripheral resistance decreases. So the antihypertensive effects of the thiazides is not due to a reduced plasma volume but a form of vasodilation.
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Why are the thiazide diuretics so useful in combination with other antihypertensives?
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Because thiazides do not cause the sodium and water retention which is often observed with other agents, and therefore the combination is optimal.
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In what patients are thiazides particularly useful in treating hypertension?
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In blacks and elderly.
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In what patients are the thiazides inefficient?
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In patients with inadequate kidney function.
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What type of diuretic do we use in patients with decreased renal function?
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Loop diuretics
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How are thiazide diuretics administrered?
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Orally
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How are thiazides excreted?
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The thiazides are ligands for the organic acid secretory system of the nephron and as such they may compete with uric acid for excretion.
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What are the side effects of the thiazide diuretics?
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Thiazide diuretics induce hypokalemia and hyperuricemia in 70% of patients! Hyperglycemia occurs in 10% of patients. Hypomagnesemia may also occur. Potassium levels should be closely monitored in patients predisposed to arrhythmias.
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Which are the potassium sparing diuretics used in hypertension?
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Amiloride and triamterene as well as spironolactone and eplerenone.
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When are beta blockers used as first line agents?
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When concomitant disease is present, with the exception maybe of diabetes, copd and ashtma
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By what mechanism is the blood pressure reduced with the beta blockers?
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The beta blockers reduce the blood pressure mainly by decreasing cardiac output.
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What are other mechanisms by which beta blockers reduce blood pressure?
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By reducing sympathetic outflow from the CNS, and by inhibiting the release of renin from the kidneys.
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To which patients should beta blockers be administered very cautiously?
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Asthmatics and COPD patients shouldn't receive beta blockers. Patients with acute heart failure, diabetes and peripheral disease should only be cautiously treated with beta blockers.
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What are traits in a person that allows for success of beta blocker treatment of hypertension?
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White patients respond better to black. Young patients respond better than the elderly.
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Do the beta blockers show antihypertensive properties immediately after administration?
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No, beta blockers may require several weeks in order to become fully active.
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What are the common adverse effects of beta blockers?
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Bradycardia and CNS side effects such as fatigue, lethargy, insomnia, and hallucinations, and they may also lead to hypotension. The beta blockers often lead to decreased sexual functioning with decreased libido and impotence.
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What are side effects of the beta blockers on the parameters of the blood?
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Beta blockers may disturb lipid metabolism, decreasing HDL and increasing TAG.
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What is important to do when deciding to quit beta blocker therapy?
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That there is no abrupt withdrawal, but that the dose is tapered off for some time to avoid withdrawal reactions.
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Why does beta blocker withdrawal occur?
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Because over time there is upregulation in the number of adrenergic receptors and their responsiveness with the use of adrenergic blockers, and then when no blocker suddenly is present, the body is hyperreactive to sympathetic stimuli.
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What are the effects of beta blocker withdrawal?
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Beta blocker withdrawal can produce angina (due to excessive sympathetic constriction of both coronary and peripheral vessels and increased adrenergic stimulation of heart contraction), myocardial infarction, or even sudden death in patients with ischemic heart disease.
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What is the amount of time needed to taper of the beta blockers?
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2 to 3 weeks.
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When are the ACE inhibitors indicated in the treatment of hypertension?
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The ace inhibitors are indicated in the treatment of hypertension when the first line agents (beta blockers or diuretics) are contraindicated or ineffective.
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By what mechanisms do the ACE inhibitors decrease blood pressure?
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The ACE inhibitors reduce the peripheral vascular resistance by reducing the amount of circulating angiotensin II and increasing the levels of bradykinin. Additionally the ACE inhibitors reduce the plasma fluid volume thereby reducing pre and afterload.
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What patients benefit most from the ACE inhibitors?
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Like the beta blockers, the ACE inhibitors are benefited mostly by white and young people.
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When are the ACE inhibitors as effective in blacks as in whites?
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When combined with a diuretic.
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What are the adverse effects of the ACE inhibitors?
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Cough, rash, fever, altered taste, hypotension, and hyperkalemia.
Angioedema is rare but life-threatening. ACE inhibitors are fetotoxic. |
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What must be monitored in patients on ACE inhibitors?
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Potassium levels.
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Which is the prototypic ARB?
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Losartan
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How many additional ARBs are there?
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six
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What is the main difference in the action of the ARBs and the ACE inhibitors?
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The ARBs cause a more potent inhibition of angiotensin receptors and also do not raise the bradykinin levels.
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Why are ARBs an attractive option in diabetic hypertensives?
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Because the ARBs reduce the nephrotoxicity associated with diabetes.
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What is the name of a selective renin inhibitors?
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Aliskiren
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When was aliskiren released?
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Recently
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For what indication was aliskiren released?
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For the treatment of hypertension.
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What is the effectiveness of aliskiren in treatment of hypertension?
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It is as effective as the ace inhibitors, arbs and thiazides.
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What are the side effects of Aliskiren?
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It can cause diarrhea, especially at high doses. It may also cause cough and angioedema but probably less so than ace inhibitors.
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When is aliskiren contraindicated?
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During pregnancy.
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When are calcium channel blockers indicated in treating hypertension?
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The calcium channel blockers are indicated when the first line agent in contraindicated or ineffective.
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In what patients are the calcium channel blockers especially good?
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In patients with angina or diabetes.
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Which are the three chemical classes to which the calcium channel blockers are divided?
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The diphenylalkylamines (verapamil), benzothiazepines (diltiazem) and the dihydropyridines (nifedipine)
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What are the indications for Verapamil?
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Supraventricular tachyarrhythmias, angina and migraine headache.
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So verapamil has no use in hypertension?
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No
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How many generations of dihydropyridines are there?
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2 generations
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Which are the members of the first generation of the dihydropyridines?
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Nifedipine
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Which are the members of the second generation of the dihydropyridines?
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Amlodipine, Felodipine, Isradipine, Nicardipine and Nisoldipine
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Do all the dihydropyridines have the same indications?
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No they differ in their indications.
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What is the difference between the dihydropyridines and verapamil?
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The dihydropyridines have a much higher selectivity for the vascular smooth muscle in comparison to affecting calcium channels of the heart.
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So which agents then, would be preferred in the treatment of hypertension, verapamil or dihydropyridines?
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Dihydropyridines due to their vasodilatory effect.
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Why does usage of a calcium channel blocker usually not require the addition of a diuretic?
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Because the calcium channel blockers have an innate natriuretic effect.
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What type of patients respond especially well to the calcium channel blockers?
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Blacks
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What are the half lifes of the calcium channel blockers?
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Usually rather short, of 3 to 8 hours.
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What are the side effects of the calcium channels blockers?
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Constipation occurs in 10% of patients treated with Verapamil. Dizziness, headache, and a feeling of fatigue caused by a decrease in blood pressure are more frequent with dihydropyridines. Verapamil should be avoided in patients with CHF or AV nodal block due to its negative inotropic and dromotropic effects.
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Which are the alpha adrenergic blockers which may be used in hypertension?
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Prazosin, doxazosin and terazosin, the alpha1 selective blockers.
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What is their mechanism of action in hypertension?
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They decrease blood pressure by inhibiting vasoconstriction due to norepinephrine. This occurs in arterioles as well as veins.
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Do the alpha adrenergic blockers produce an effect on the heart?
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No they only minimally affect the cardiac output, renal blood flow and glomerual filtration rate.
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When are the alpha1 adrenergic drugs indicated in hypertension?
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They are used to treat mild to moderate hypertension in combination with a beta blocker or a diuretic.
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What happens when starting alpha1 adrenergic blockers?
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First dose hypotension and reflex tachycardia leading to syncope.
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Are the alpha1 blockers readily used in hypertension?
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No because of their side effects, long term unsafety and due to the development of safer drugs.
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Are there any other types of adrenergic blockers used in hypertension?
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Yes occasionally carvedilol or labetalol which block not only beta 1 and beta 2 but also alpha1 receptors.
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What drugs that act centrally may be used to treat hypertension?
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The centrally acting adrenergic drugs Clonnidine and alpha-methyldopa.
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By what mechanisms does Clonidine lower blood pressure?
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Clonidine acts centrally to activate alpha2 receptors which then inhibit the release of catecholamines and reduce the outflow of sympathetic stimulation from the CNS. This leads to less vasoconstriction and cardiac stimulation.
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When is Clonidine useful in hypertension and why?
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Clonidine is useful in hypertension complicated by renal disease because it doesn't reduce renal blood flow.
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How is Clonidine administered?
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Orally
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How is Clonidine excreted?
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Renally
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How may Clonidine affect the function of the kidney?
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Clonidine may cause sodium and water retention.
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So what should be done to avoid this sodium and water retention of Clonidine?
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A diuretic can be added.
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What are the side effects of Clonidine treatment?
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They are generally mild and consist of sedation and drying of the nasal mucosa. Rebound hypertension occurs following abrupt withdrawal of Clonidine.
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What is the mechanism of alpha-methyldopa?
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alpha-methyldopa acts by the same mechanism as Clonidine, by stimulating presynaptic alpha2 receptors to inhibit the release of catecholamines.
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What are the indications for alph-methyldopa in hypertensives?
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The same as those for Clonidine (renal disease)
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What is the most common side effect of alpha-methyldopa?
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Sedation and drowsiness.
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Which are the direct acting vasoodilatos used to treat hypertension?
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Hydralazine and Minoxidil
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What is the response of the heart to the decrease blood pressure of the direct vasodilators?
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Reflex tachycardia
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What are the effects of the direct vasodilators on fluid levels in the body?
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Due to the decreased BP, the kidney secretes renin and fluid retention occurs.
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So what needs to be done in order to avoid the fluid retention that accompanies use of hydralazine or minoxidil?
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They can be given with a diuretic, or a beta blocker (blocks both the fluid retention and tachycardia)
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On what type of vessels does hydralazine act?
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Mainly on arteries and arterioles.
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In what type of hypertension may we use hydralazine?
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In moderately severe hypertension.
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Is hydralazine administered as single therapy?
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No, hydralazine is almost always administered in combiination with a diuretic and beta blocker.
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When is hydralazine monotherapy an accepted practise?
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In preganacy-induced hypertension.
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What are the adverse effects of hydralazine treatment?
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Headache, tachycardia, nausea, sweating, arrhythmia, and precipitation of angina. Hydralazine may also cause a lupus-like syndrome in high doses.
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What type of vessels are dilated by minoxidil?
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Resistance type vessels, arterioles, but not capacitance vessels such as venules.
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When is minoxidil administered?
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In malignant hypertension which is refractory to other treatment modalities.
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Does reflex tachycardia occur with minoxidil like with hydralazine?
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Yes and reflex tachycardia may be severe.
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What about the fluid retention seen with hydralazine, is it seen with minoxidil?
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Yes, and it may also be severe.
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What is done to reduce the reflex tachycardia and fluid retention?
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Concomitant administration of a beta blocker and a diuretic.
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What happens if a diuretic is not administered together with minoxidil?
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Then minoxidil causes a severe fluid overload, causing edema, and congestive heart failure.
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What is another strange side effect of minoxidil?
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Hypertrichosis (the growth of body hair)
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So what is another indication for minoxidil?
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Male baldness
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What is the name of Minoxidil commercially?
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Regaine
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What is hypertensive emergency?
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Hypertensive emergency is a rare but life threatening situation in which the DBP is either above 150mmHg in an otherwise heathy individual or above 130mmHg in an individual with preexisting complications, such as encephalopathy, cerebral hemorrhage, LVF, or aortic stenosis.
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What is the therapeutic goal in hypertensive emergency?
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To reduce blood pressure.
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What are agents employed in hypertensive emergency?
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Sodium nitroprusside, Labetalol, Fenoldopam and Nicardipine.
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How is sodium nitroprusside administered?
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Intravenously
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What are the effects of intravenous sodium nitroprusside administration?
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Prompt vasodilation and reflex tachycardia.
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What type of vessels does sodium nitroprusside act on?
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Arterioles as well as venules.
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What is the halflife of sodium nitroprusside?
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Minutes, so continuous administration is necessary to maintain hypotensive effect.
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What are the adverse effects of sodium nitroprusside?
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Few adverse effects except the potential hypotension. Nitroprusside metabolism leads to the formation of cyanide ions, but this cyanide can be eliminated by adminstering sodium thiosulphate which foorms thiocyanate which can be excreted.
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How is Labetalol used in Hypertensive emergencies?
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It is injected as a bolus.
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Does labetalol cause reflex tachycardia?
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No
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What is the mechanism of action of Fenoldopam?
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Fenoldopam is a peripheral dopamine type 1 receptor agonist that is given by intravenous infusion.
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What is the main difference between fenoldopam and other antihypertensives used in hypertensive emergency?
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Fenoldopam doesnt reduce the blood flow to the kidney while reducing bp.
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In what patients is fenoldopam contraindicated?
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In patients with glaucoma.
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What is the use of Nifedipine in hypertensive emergency?
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Being a calcium channel blocker vasodilator, nifedipine can be given intravenously in case of hypertensive emergency.
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