Drugs Used to Treat Hypertension Chapter 23 Drugs Used to Treat Hypertension Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 23 Lesson 23.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Discuss blood pressure and its measurement Define hypertension Differentiate between primary and secondary hypertension Summarize nursing assessments and interventions used for the treatment of hypertension State recommended lifestyle modifications for a diagnosis of hypertension Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypertension Characterized by an elevation of systolic blood pressure (sbp), diastolic blood pressure (dbp) or both Primary hypertension: 90% of cases, unknown cause Secondary hypertension: occurs after another disorder Normal BP: less than 120 sbp, less than 80 dbp Prehypertension: 120 to 139 sbp, or 80 to 89 dbp Stage I: 140 to 159 sbp or 90 to 99 dbp Stage 2: greater than or equal to160 sbp or greater than or equal to 100 dbp National High Blood Pressure Committee encourages practitioners to use systolic pressure as the determinant for diagnosis. Treatment is important because control of hypertension reduces the frequency of cardiovascular disease. More than 50 million people in the United States are affected. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Major Risk Factors of Hypertension Smoking Obesity Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated glomerular filtration rate (GRF) less than 60 mL/min Age (older than 55 for men, older than 65 for women) Family history of premature cardiovascular disease Increased circulation of cholesterol causes plaque formation within blood vessel walls, resulting in a narrowed lumen which increases vascular resistance. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Major Risk Factors of Hypertension (cont’d) Target organ damage Heart Brain Kidneys Blood vessels Eyes Slide 6 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessments for Patients with Hypertension Blood pressure sitting for 5 minutes quietly; no recent caffeine products Family history and risk factors present Laboratory data for lipids, triglycerides, cholesterol, renal function studies BMI Peripheral pulses Patient education focuses on lifestyle modifications Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education and Health Promotion Lifestyle modifications Smoking cessation Weight reduction DASH diet Physical activity Restriction in alcohol intake Stress reduction Regular sleep pattern of at least 7 hours each night Sodium control Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 23 Lesson 23.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Identify specific factors the hypertensive patient can use to assist in managing the disease Identify 10 classes of drugs used to treat hypertension Review Figure 23-2 to identify options and progression of treatment for hypertension Develop patient education objectives for individuals with hypertension Summarize the action of each drug class used to treat hypertension Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Options and Progression of Treatment for Hypertension Long-term success depends on patients understanding the characteristics and diseases that contribute to the issue Demographic characteristics – age, gender, race Coexisting diseases and risk factors – migraine headaches, dysrhythmias, angina, diabetes mellitus, previous therapy used, concurrent therapy, cost of treatment The nurse must be willing to explore with the patient all aspects of therapy and the need for continual control of hypertension while avoiding potential adverse effects. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Management of Hypertension Lifestyle modifications are initial therapy If no significant effect, drug therapy is introduced Start with diuretics for stage 1 hypertension Add beta blockers(lol), ACE inhibitors(pril), calcium channel blockers(dipine), and angiotensin receptor blockers(ARBs) as tolerated Start with two-drug combination for stage 2 hypertension Goal of blood pressure less than 140/90 mm Hg, or less than 130/80 mm Hg for patients with diabetes or chronic kidney disease. Additional drugs are added until goal blood pressure is achieved. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Classes Used for Hypertension Management Diuretics; beta-adrenergic blocking (lol) agents ACE inhibitors (pril); angiotensin II receptor blockers (ARBs) Direct renin inhibitors; aldosterone receptor antagonist Calcium channel blockers (dipine); alpha-1 adrenergic blocking agents Central-acting alpha-2 agonists; peripheral-acting adrenergic antagonists; direct vasodilators Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Diuretics Actions Uses Cause volume depletion, sodium excretion, vasodilation of peripheral arterioles Uses Most commonly prescribed antihypertensives In combination with other antihypertensive agents Discussed further in Chapter 29 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Beta-Adrenergic Blocking Agents Actions Inhibit cardiac response to sympathetic nerve stimulation Inhibit renin release from kidneys Uses Initial therapy for stage 1 and 2 hypertension Common adverse effects Bradycardia, peripheral vasoconstriction (purple mottled skin); heart failure; bronchospasm, wheezing; masks hypoglycemia in diabetic patients Not effective for African Americans. Sudden discontinuation of therapy results in exacerbation of anginal symptoms. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: ACE Inhibitors Actions Inhibit angiotensin I converting enzyme (ACE), disrupting the conversion of angiotensin I to angiotensin II Uses Single therapy for stage 1 or 2 hypertension Common adverse effects Nausea, fatigue, headache, diarrhea; orthostatic hypotension Serious adverse effects Angioedema; neutropenia; hyperkalemia; chronic cough; birth defects For specific drugs, see Table 23-5. Understanding the renin-angiotensin-aldosterone system (RAAS) is critical to understanding the actions of most antihypertensives. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: ARBs Actions Uses Common adverse effects Bind to angiotensin II receptor sites and block the vasoconstrictor from binding to receptor sites in target organs Uses Alone or in combination with other antihypertensives to reduce blood pressure Common adverse effects Dyspepsia, cramps, diarrhea; headache; orthostatic hypotension Serious adverse effects Birth defects; hyperkalemia For specific drugs, see Table 23-6. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Direct Renin Inhibitors Drug: aliskiren (Tekturna) Actions Block the first step in the RAAS cascade preventing release of aldosterone Uses Alone or in combination with other antihypertensives to reduce blood pressure Common adverse effects Dyspepsia, cramps, diarrhea; headache; orthostatic hypotension Serious adverse effects Altered fluid and electrolytes, birth defects Reserved for patients who do not respond to ACE inhibitors or ARBs. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Aldosterone Receptor Antagonist Drug: eplerenone (Inspra) Actions Block stimulation of aldosterone at receptor sites, preventing sodium reabsorption Uses Alone or in combination with other antihypertensives to reduce blood pressure Common adverse effects Nausea, diarrhea; fatigue, headache; orthostatic hypotension Serious adverse effects: hyperkalemia, hyperlipidemia, nephrotoxicity, hepatotoxicity, vaginal bleeding, gynecomastia. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Calcium Channel Blockers Actions Inhibit movement of calcium ions across cell membranes Uses Ideal for first- or second-line drug therapy for hypertension Serious adverse effects Hypotension and syncope For specific drugs, see Table 23-7. Also used for heart rhythm disturbances and angina. Effective for African Americans and elderly patients. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Alpha-1 Adrenergic Blocking Agents Actions Block postsynaptic alpha-1 adrenergic receptors to produce vasodilation, decrease peripheral vascular resistance Uses Alone or in combination with other antihypertensives to reduce blood pressure Reduce mild to moderate urinary obstruction Common adverse effects Drowsiness, headache, weakness, lethargy; dizziness, tachycardia, fainting For specific drugs, see Table 23-8. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Central-Acting Alpha-2 Agonists Actions Stimulate alpha-adrenergic receptors in the brainstem, reducing sympathetic outflow from CNS Uses Considered adjunctive therapy; used only in combination with other antihypertensives Common adverse effects Drowsiness, dry mouth, dizziness, altered urine color, altered rest results Serious adverse effects Depression; rash For specific drugs, see Table 23-9. Adverse effects such as dry mouth and dizziness are self-limiting. Urine will darken on exposure to air and is not harmful. False-positive urine glucose tests may occur. Rash occurs with transdermal patch application of clonidine. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Direct Vasodilators Actions Relax arterial smooth muscle, reducing peripheral vascular resistance Uses Treatment of stage 2 hypertension, renal disease hypertension, toxemia of pregnancy Common adverse effects Dizziness, numbness, tingling in legs; orthostatic hypotension, palpitations, tachycardia; nasal congestion; hair growth Serious adverse effects Fever, chills, joint and muscle pain, skin eruptions; gynecomastia Drugs: hydralazine (Apresoline), minoxidil (Loniten), and nitroprusside sodium (Nitropress) Nitroprusside is used in severe hypertensive crisis and refractory heart failure. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.