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Questions and Answers
What is the primary concern for patients who abruptly withdraw from their medication?
What is the primary concern for patients who abruptly withdraw from their medication?
Which of the following is a potential complication of beta1 blocker therapy?
Which of the following is a potential complication of beta1 blocker therapy?
What is the recommended target for systolic blood pressure in patients over 60 years of age?
What is the recommended target for systolic blood pressure in patients over 60 years of age?
What is the primary consideration when evaluating a patient's response to antihypertensive therapy?
What is the primary consideration when evaluating a patient's response to antihypertensive therapy?
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What is the recommended target for diastolic blood pressure in patients with chronic kidney disease?
What is the recommended target for diastolic blood pressure in patients with chronic kidney disease?
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Which of the following medications is associated with a contraindication of liver dysfunction?
Which of the following medications is associated with a contraindication of liver dysfunction?
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What is the primary consideration when using vasodilators as antihypertensive therapy?
What is the primary consideration when using vasodilators as antihypertensive therapy?
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What is the recommended approach when discontinuing antihypertensive therapy?
What is the recommended approach when discontinuing antihypertensive therapy?
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Which of the following is a recommended strategy for patients taking alpha-adrenergic agonists?
Which of the following is a recommended strategy for patients taking alpha-adrenergic agonists?
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What is the importance of monitoring patients for evidence of controlled blood pressure?
What is the importance of monitoring patients for evidence of controlled blood pressure?
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Study Notes
Hypertension Definition and Prevalence
- Hypertension is defined as a persistent systolic blood pressure (SBP) of >150 mm Hg and/or a diastolic blood pressure (DBP) of >90 mm Hg for patients 60 years or older, and SBP >140 mm Hg and DBP >90 mm Hg for patients younger than 60 and those with chronic kidney disease or diabetes.
- Hypertension affects approximately 70 million people in the United States and approximately 1 billion people worldwide.
Risks and Complications
- Hypertension is a major risk factor for coronary artery disease, cardiovascular disease, and death resulting from cardiovascular causes.
- It is the most important risk factor for stroke and heart failure, and a major risk factor for renal failure and peripheral vascular disease.
Blood Pressure Regulation
- Blood pressure is determined by the product of cardiac output and systemic vascular resistance (SVR).
- All antihypertensives affect cardiac output in some way.
Classification and Treatment
- The JNC 8 guidelines categorize individual cases of hypertension into four stages based on blood pressure measurements: normal, prehypertension, stage 1 hypertension, and stage 2 hypertension.
- Therapy should be started if blood pressure is at or greater than 150/90 for patients over 60 years and 140/90 for patients younger than 60 and those with chronic kidney disease or diabetes.
Drug Therapy
- Drug therapy for hypertension needs to be individualized, considering demographic factors, cultural implications, and cost.
- The main categories of pharmacologic drugs used to treat hypertension include:
- Adrenergic drugs
- Vasodilators
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin receptor blockers (ARBs)
- Calcium channel blockers (CCBs)
- Direct renin inhibitors
Adrenergic Drugs
- Adrenergic drugs have central action (in the brain) or peripheral action (at the heart and blood vessels).
- Five subcategories of adrenergic drugs:
- Adrenergic neuron blockers
- Alpha2-receptor agonists
- Alpha1-receptor blockers
- Beta-receptor blockers
- Combination alpha1- and beta-receptor blockers
- Adverse effects of adrenergic drugs:
- Bradycardia with reflex tachycardia
- Postural and post-exercise hypotension
- Dry mouth
- Drowsiness
- Dizziness
- Depression
- Edema
- Constipation
- Sexual dysfunction
ACE Inhibitors
- ACE inhibitors work by blocking the production of angiotensin II (AII), a potent vasoconstrictor.
- ACE inhibitors are very safe and efficacious, and are often used as first-line drugs in the treatment of both heart failure and hypertension.
- Therapeutic effects of ACE inhibitors:
- Prevent vasoconstriction caused by AII
- Prevent aldosterone secretion and sodium and water resorption
- Prevent the breakdown of bradykinin, a potent vasodilator
- Adverse effects of ACE inhibitors:
- Fatigue
- Dizziness
- Mood changes
- Headaches
- Cough
Angiotensin II Receptor Blockers (ARBs)
- ARBs are similar to ACE inhibitors, but they affect primarily vascular smooth muscle and the adrenal gland.
- ARBs block the binding of AII to the type 1 AII receptors in vascular smooth muscle and the adrenal gland.
- Therapeutic effects of ARBs:
- Decrease blood pressure
- Decrease SVR
- Adverse effects of ARBs:
- Upper respiratory tract infections
- Headache
- Dizziness
- Inability to sleep
- Diarrhea
- Dyspnea
- Heartburn
- Nasal congestion
- Back pain
- Fatigue
Calcium Channel Blockers
- Calcium channel blockers may be used to treat angina, dysrhythmias, and hypertension.
- CCBs help to reduce blood pressure by causing smooth muscle relaxation and dilatation of blood vessels.
- Adverse effects of CCBs:
- Headache
- Dizziness
- Flushing
- Edema
- Nausea
- Vomiting
Diuretics
- Diuretics are a highly effective class of antihypertensive drugs.
- Diuretics decrease plasma and extracellular fluid volumes, resulting in decreased preload, cardiac output, and total peripheral resistance.
- Adverse effects of diuretics:
- Hypokalemia
- Dehydration
- Electrolyte imbalance
- Increased uric acid levels
- Gout
- Impotence
Vasodilators
-
Vasodilators act directly to relax arteriolar and/or venous smooth muscle.
-
Vasodilators are useful for their ability to directly cause peripheral vasodilation, resulting in a reduction in SVR.
-
Adverse effects of vasodilators:
-
Headache
-
Dizziness
-
Tachycardia
-
Palpitations
-
Flushing
-
Hypotension### Blood Pressure Monitoring
-
For patients 60 years of age or older, systolic blood pressure (SBP) must be less than 150 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg.
-
For patients younger than 60 years old, or those with chronic kidney disease or diabetes, SBP must be less than 140 mm Hg and DBP less than 90 mm Hg.
Contraindications and Adverse Effects
- Epleronone (Inspra) is contraindicated in patients with elevated serum potassium levels (> 5.5 mEq/L) or severe renal impairment.
- Epleronone (Inspra) should be avoided with concurrent use of drugs that inhibit cytochrome P-450 enzyme 3A4, such as antifungals, antivirals, and some antibiotic drugs.
- Bosentan (Tracleer) is contraindicated in patients with liver dysfunction and should not be given concurrently with cyclosporine or glyburide.
Evaluation and Monitoring
- Baseline blood pressure readings should be assessed.
- Monitoring patients for evidence of controlled blood pressure is crucial.
- Changes in the fundus are a more reliable indicator of long-term treatment effectiveness than blood pressure readings.
Therapeutic Effects of Antihypertensives
- Antihypertensives improve blood pressure and the disease process.
- Effects include improved energy levels, decreased signs and symptoms of hypertension, such as:
- Less edema
- Improved breath sounds
- No abnormal heart sounds
- Capillary refill in less than 5 seconds
- Less shortness of breath (dyspnea)
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Description
This quiz covers the definition and prevalence of hypertension, including its effects on different age groups and individuals with chronic kidney disease or diabetes. It's a vital topic for anyone interested in healthcare and medicine.
