ANTIHYPERTENSIVES, DIURETICS, ANTICOAGULANTS .ppt
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1、ANTIHYPERTENSIVES, DIURETICS, ANTICOAGULANTS AND DYSLIPIDEMICS,PHARMACOLOGY NUR 3703 BY LINDA SELF,Hypertension,Hypertension common in US, up to 60 million afflicted Leads to MI, heart failure, stroke and renal disease Strong correlation with metabolic syndrome,Blood Pressure Classification accordin
2、g to the JNC 7,Normal SBP or equal to 160 or DBP or equal to 100,Types of Hypertension,Essential or primaryetiology ?. Contributors include: salt sensitivity, insulin resistance, genetics, sleep apnea, environmental factors,others Secondaryrenal, adrenal, coarctation of the aorta, steroids, pregnanc
3、y,BP review,Any condition that affects heart rate, stroke volume or peripheral vascular resistance affects arterial blood pressure Compensatory mechanisms to maintain balance between hypotension and hypertension,BP review,BP regulation operates in a negative feedback system Baroreceptors and chemore
4、ceptors in the carotid arteries and aortic arch detect changes in arterial blood pressure and in pO2, pCO2 and H+. Increased BP results in increased stretch of vessels; activation of vagus and stimulation of medulla via sympathetic or parasympathetic pathways.,BP review,Normally, when the arterial b
5、lood pressure is elevated Kidneys will excrete more fluid Fluid loss will result in decreased ECF volume and blood volume Decreased blood flow to the heart will reduce cardiac output Decreased CO reduces arterial blood pressure,BP review cont.,5. Vascular endothelium produces vasodilating substances
6、 (nitric oxide, prostacyclin) which reduce blood pressure,Essential Hypertension,Activation of sympathetic nervous system causing prolonged vasoconstriction Activation of RAAS plays integral part as well In combination, mechanisms cause prolonged increased vascular resistance; this in turn results i
7、n a thickening of vessel walls, less production of nitric oxide (vasodilator) and increased endothelin (increased vascular tone),Essential Hypertension,Also felt that hyperinsulinemia and insulin resistance cause endothelial dysfunction by enhanced oxygen free radical-mediated damage and decreased n
8、itric oxide bioavailability. Also is an increased sympathetic response; results in increased vascular tone and constriction,Nonpharmacologic Management of Hypertension,Weight reduction Exercise Salt restriction in diet Stress reduction DASH eating plan Moderation in alcohol intake If systolic BP can
9、not be maintained 140 systolic, tx.,Antihypertensive Drugs,Classes: Angiotensin converting enzyme inhibitors (ACEI) Angiotensin II Receptor Blockers Antiadrenergics Calcium channel blockers Diuretics Direct vasodilators Renin inhibitors,ACEIs,Block the enzymes that convert angiotensin I to angiotens
10、in II (potent vasoconstrictor) Have action of vasodilation and decrease aldosterone production Inhibit breakdown of bradykinins (vasodilator) prolonging effect,ACEIs,Reverse remodeling of heart muscle and blood vessels Reno-protective Excellent for heart failure and hypertension Improve post-myocard
11、ial infarction survival Used alone or in combination,ACEIs,Useful in heart failure as decrease peripheral vascular resistance, cardiac workload and ventricular remodeling Captopril is the prototype Low incidence of side effects Can cause cough or hypotension when first started,ACEIs,Can cause hyperk
12、alemia Should never be used during pregnancy May not be as effective in African Americansmay add diuretic in this population to increase efficacy,ACEIs,Lotensin (benazepril) Capoten (captopril) Vasotec (enalapril) Zestril (lisinopril) Altace (ramipril) Aceon (perindopril),Angiotensin II Receptor Blo
13、ckers (ARBs),Block effects of angiotensin II, compete with angiotensin II for tissue binding sites Block the receptors in brain, kidneys, heart, vessels and adrenal tissue,ARBs,Similar end results as seen with ACEIs Less likely to cause hyperkalemia Persistence of cough is rare Prototype is Cozaar (
14、losartan),Examples of ARBs,Atacand (candesartan) Cozaar (losartan) Diovan (valsartan) Micardia (telmisartan) Benicar (olmesartan),Antiadrenergics,Inhibit activity of the sympathetic nervous system Effective in decreasing heart rate, force of myocardial contraction, cardiac output, and blood pressure
15、,Antiadrenergics,Alpha 1 adrenergics receptor blocking agents dilate vessels and decrease peripheral vascular resistance Can experience first dose phenomenon with orthostatic hypotension, dizziness, syncope, possible sodium and fluid retention,Antiadrenergics-Alpha 1,Cardura (doxazosin) Minipress (p
16、razosin) Hytrin (terazosin),Antiadrenergics,Centrally acting sympatholytics stimulate presynaptic alpha 2 receptors in the brain Less norepinephrine is released and sympathetic outflow is reduced Results in decreased cardiac output, heart rate, peripheral vascular resistance and blood pressure,Antia
17、drenergicsAlpha 2 agonists,Centrally acting agents also can result in fluid and sodium retention Catapres (clonidine)orally or by patch Tenex (guanfacine) Aldomet (methyldopa),Beta Adrenergic Blockers,Decrease heart rate, force of myocardial contraction, cardiac output, and renin release from the ki
18、dneys Drugs of choice with patients with tachycardia, angina, MI, left ventricular hypertrophy and high renin hypertension Most are pregnancy category C and D,Beta Blockers,Inderal (propranolol) Corgard (nadolol) Lopressor (metoprolol) Tenormin (atenolol) Kerlone (betaxolol) for glaucoma (ophthalmic
19、), hypertension (orally),Calcium Channel Blocking Agents,Useful in hypertension as dilate peripheral arteries and decrease peripheral vascular resistance by relaxing vascular smooth muscle Monotherapy or in combination Tolerated well in renal failure,Calcium Channel Blocking Agents,Norvasc (amlodipi
20、ne) Cardizem (diltiazem) Plendil (felodipine) Procardia (nifedipine) Calan (verapamil)may cause gingival hyperplasia Note these are also Pregnancy category C,Diuretics,Useful in hypertension due to their sodium and water depletion May be used as monotherapy Preferred in the elderly and in African-Am
21、ericans Should be included in any multi-drug regimen Thiazide diuretics are most commonly used diuretics for hypertension,Diuretics,Hydrodiuril (HCTZ),Vasodilators,Relax smooth muscle in blood vessels resulting in dilation and decreased peripheral vascular resistance Reduce afterload so helpful in h
22、eart failure May cause sodium and water retention,Vasodilators,Limited effect when used alone. Vasodilating action that lowers BP also stimulates SNS. This, in turn, triggers reflexive compensatory mechanisms that raise BP,Vasodilators,Corlopam (felodapam)IV infusion, in hypertensive emergencies, av
23、oid in patients with allergies to sulfites Apresoline (hydralazine)IV, IM or PO. Can cause orthostatic hypotension. Rogaine (Minoxidil) po or topical,Ethnic Considerations,Use calcium channel blockers, diuretics and alpha blockers most effective in African Americans; beta blockers, ACEIs and some AR
24、Bs are not as effective as in Caucasians Beta blockers have greater effects on Asians than in Caucasians,Hypertensive Emergencies,Is defined as having end organ damage or diastolic BP of 120 torr or higher With oral medications, use captopril 25-50mg po every 1 to 2 hours or clonidine , 0.2mg initia
25、lly then 0.1mg every hour until diastolic blood pressure falls below 110 torr or 0.7mg has been given,Hypertensive Emergencies,Nitroglycerinetolerance develops over 24-48 hours Nitroprussideintraarterial bood pressure should be monitored; metabolized to thiocyanate (precursor to cyanide), a toxic me
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