Hypertension What is it? Chronic disorder that remains asymptomatic until after injury has begun.

Results in heart and kidney disease, CVA. No cure, treat symptoms Normal BP (120/80) *Can be either the systolic or diastolic #. Pre-HTN (120s-130s/80s) Stage 1 HTN (140s-150s/90s) Stage 2 HTN (>160/>100) Types: Primary (essential) -no cause; genetic Secondary - identifiable cause, treat cause *Table 62-4 Diagnostics EKG Urinalysis H&H Chem 7 (all involved in conduction of heart) Na+ K+ Ca2+ (1000-1200mg daily) Creatinine (0.7-1.2) Glucose (makes blood thicker; causes turbulent blood flow which hurts intima) Uric Acid (4.4-7.4) Triglycerides Total Cholersterol (<170) LDL (>130) HDL (35-60; we want it closer to 60 though) Stepped Care Management Step 1 Lifestyle modifications (reduce Na, alcohol, smoking & increase physical activity) Step 2 Continue lifestyle modifications Initial drug selection (Diuretic or Beta blocker) Step 3 Inadequate response addressed with increased dose of drug, substitute, or additional drug class. Step 4 Add a 2nd, 3rd, or diuretic if not already prescribed. Risk Factors Older (>55 men; >women)* AA & Hispanic Family history of premature CV disease* Post-menopause Obese* Smoking* Inadequate exercise* Dyslipidemia (hyper)* Diabetes* Microalbuminuria (ARBS treat this)* *are MAJOR risk factors.

Lifestyle Modifications Weight loss Sodium restriction (up to 6g daily) DASH http://dashdiet.org/ Alcohol restriction (men: 1 oz (2 drinks); women: 0.5 oz daily) Aerobic exercise (Brisk walk 20-45 min daily) K and Ca intake (they are needed for heart function) Drugs for HTN Diuretics serum Na and blood volume Beta-blockers HR and strength of contraction; vasodilates ACE Inhibitors Blocks AI to AII; AII receptor blocker; blocks effects of Angiotensin on blood vessels. (Not effective in AA so use BiDil instead.) Ca Channel blockers Relaxes muscle contractions

Sympatholytic Drug Interactions: Clonidine & CNS depresssants (exacerbate depression) Carvedilol & antidiabetics (increases hypoglycemic effects)

Sympatholytics (used for HTN) Assess: BP, P, R, adverse rxns, weight, F&E status Diagnoses: Risk for injury r/t orthostatic hypotension Risk for injury r/t HTN Deficient knowledge r/t drug therapy Alpha 1 Blockers -ZOSIN Decrease vascular tone; promote vasodilation (prevents vasoconstriction) Ex. doxazosin, prazosin, terasozin Adverse Effect: Orthostatic Hypotension -Take first dose at night Centrally acting Alpha 2 Agonists Suppress sympathetic outflow to heart and blood vessels; vasodilation and reduced CO. Ex. Clonidine, Methyldopa Adverse Effects: Dry mouth Sedation Rebound HTN (if stopped suddenly *especially Clonidine -decrease over 2-3 days)

Carvedilol & Ca Channel blockers & Digoxin (increases dig levels which can cause dig toxicity) Beta Blockers -OLOL Suppress SNS (influences heart, blood vessels...etc) Ex.Propanolol, metoprolol, aternolol Block vasoconstriction HR, and muscle contraction reflex tachycardia cased by vasodilators Can mask hypoglycemia Adverse Effects: Bradycardia (hold if <60bpm) Use Atropine and isoproterenol to restore HR. Mask tachycardia (early sign of low BG in diabetics) AV Block (3 degrees) 1st impulse is delayed through AV node 2nd if some blood moves through 3rd if no blood moves through Orthostatic hypotension (dangle feet) Rebound myocardium excitation (can occur from abrupt withdrawal) NAIDS can HTN drug effects Alpha & Beta Blockers Powerful at blocking receptors in SNS (If Beta then bronchoconstriction occurs) Ex. Carvedilol, Labetalol Adverse Effects: Fatigue Loss of libido (teaching point) Inability to sleep GI & GU complications Exacerbate bradycardia & asthma

Adrenergic Neuron Blockers Decreases BP by acting on post ganglionic sympathetic neurons (this sympathetic stimulation of heart and blood vessels). Ex. Guanadrel, Guandethidine, Reserpine Adverse Effects: Severe orthostatic hypotension and depression Watch suicidal people closely *Last choice for chronic HTN (due to adverse effects)

Renin Angiotensin Aldosterone Suppressants Goal: prevent AI converting to AII, arterioles dilate, and vascular volume reduced (Treats HTN) Aldosterone: hormone made by cortex of adrenal gland that regulates balance of Na and H2O. It is secreted in response to low salt levels. Diagnoses: Same as sympatholytics

ACE Inhibitors
Inhibits enzyme that converts AI to AII Potent Vasoconstrictor aldosterone release (prevents Na & H20 retention) Disrupt the RAAS Ex. Benazepril, Captopril, Enlapril Adverse Effects: HA, fatigue Dry, nonproductive, persistent cough Angioedema (swelling in skin occurs from histamine release treated with...listen to lecture!) Hyperkalemia (avoid supplements)

Used after acute MI and left ventricular dysfxn or failure Combined with beta blockers and diuretics Interventions: Monitor adverse rxns Monitor weight and F&E status Food decreases absorption (give prior to meals) Prevent orthostatic hypotension by dangling feet. Captopril -spills protein into urine, reduced neutrophils and granulocytes Used to treat HTN, HF, and used with other meds. Ex. Losartan, Valsartan Interventions: Administer at bedtime/with food. Prevent orthostatic hypotension. Monitor for adverse rxn, weight, F&E status, and therapeutic effects

Angiotensin II Receptor Blockers (ARBS)

Lowers BP by blocking vasoconstrictive effects of angiotensin II. Blocks binding of AII to AII receptors (prevents vasoconstriction and aldosterone effects) Adverse Effects: HA, fatigue Angioedema (not as severe as ACE inhibitors) Fetal Harm** Do not give to pregnant women! NSAIDS reduces hypotension effects

Direct Renin Inhibitors Aldosterone Antagonists (K sparing diuretics)

Direct Acting Vasodilators

BP, acts on arteries AND veins Relaxes vascular smooth muscles causing vessels to dilate Total peripheral resistance is reduced Adverse Effects: Vasoconstriction (SNS compensating) Tachycardia (SNS compensating) Edema (bc vessels are wide open; watch for clotting bc blood is pooling) HA, fatigue Angina (bc tissues are not getting O2 as quickly r/t slower blood flow through dilated vessels) Pericardial effusion Nitroprusside (IV) -Can cause iotrogenic thoicyanate toxicity, especially from rapid infusion (should be 15mcg/kg/min) -Check thiocyanate levels q 72 hours (>100mcg/mL may cause toxicity) -Watch for HTN, dyspnea, HA, LOC -Sensitive to light (wrap in foil or cover)

Ex. Hydralazine, Minoxidil Nitroprusside (Nitropress)* only used in HTN emergencies -See below for more on Nitropress. Interventions: Watch for Orthostatic (postural) Hypotension Monitor BP, P

-Discard after 24 hours -Infusion pump & piggyback peripheral with no other meds. -Check BP q 5 min after start and q 15 min thereafter. -Titrate as ordered -Stop immediately if severe hypotension or cyanide toxicity.