• Those with only elevated systolic pressure have ISOLATED SYSTOLIC HYPERTENSION (ISH).  The systolic is 140 or higher, but diastolic is less than 90.  When systolic high, vessels become less flexible and stiffen, leading to CV disease and kidney damage.  When these pts are treated (same way), caution is needed to not lower the diastolic under 70. 
• If TLC not effective, then drug therapy initiated; goal is 140/90 or 130/80 for diabetics or pts with chronic kidney disease
• Without compelling indications (no diabetes/renal disease, goal is 140/90)
• Prehypertension TLC only (no drugs)
• Stage 1 hypertension 140-159 sys. Or 90-99 dias.
• Thiazide-type diuretics for most. 
• State 2 hypertension 160+ sys or 100+ dias
• Thiazide type AND
• Another antihypertensive
• With compelling indications (diabetes or renal disease, goal is 130/80)
• Prehypertension
• Treat with “drug(s) for compelling indication”
• Stage 1 HT
• Treat with “drug(s) for compelling indication”
• Stage 2 HT
• Treat with both
• “drug(s) for compelling indication” and
• other antihypertensive as needed
• If goals are not met, may consider changing doses or adding other antihypertensives
• Another drug of first choice are beta-adrenergic blockers bc are very effective
• There is no best single drug for hypertension; may require tweeking, changing doses, adding drugs.  Also continue with stress reduction, dietary changes etc

• one of the common used herbs for CV problems. Should not be used in pregnant, breastfeeding or allergic to it.  Can cause hyptension, arrythmias, sedation, nausea and anorexia.  Can interact with drugs cuasing hypotension, increases effet of inotropic drugs and increases sedative effet with CNS depressants.  Must inform PCP when using.

• Diuretics – ch 48
• B-adrenergic blocking drugs – ch 25
• acebutolol
• atenolol
• betaxolol
• bisoprolol
• carteolol
• metoprolol
• nadolol
• nebivolol
• penbutolol
• pindolol
• propranolol
• timolol
• A/B-Adrenergic Blocking drugs
• carvedilol
• labetalol
• Antiadrenergic drugs (centrally acting) – ch 25
• clonidine
• guanabenz
• guanfacine
• methyldopa or methyldopate
• Antiadrenergic drugs (peripherally acting) – ch 25
• doxazosin
• mecamylamine
• prazosin
• reserpine
• Calcium channel blockers
• amlodipine
• diltiazam
• felodipine
• isradipine
• nicardipine
• nifedipine
• nisoldipine
• verapamil
• Angiotensin-converting enzyme inhibitors (ACEIs)
• beazepril
• captopril DO NOT TAKE WITH FOD
• enalpril
• fosinopril
• lisinopril
• moexipril
• perindopril
• quinapril
• ramipril
• trandolapril
• Angiotensin II receptor antagonists
• candesartan
• eprosartan
• irbesartan
• losartan
• olmesartan
• telisartan
• valsartan
• Vasodilors – ch 37
• hydralazine
• minoxidil
• nitroprusside
• Direct renin inhibitors
• aliskiren – inhibits rennin preventing angiotensin conversion
• Selective aldosterone receptor antagonists (SARAs)
• eplerenone – blocks angiotensin process by binding with aldosterone
• Combinations
• ARE VERY MANY but most combine an antihypertensive with a diuretic and often hydrochlorothiazide

                                                               i.      Suppress the renin-angiotensin-aldosterone system.  Prevent activity of ACE = angiotensin-converting-enzyme which converts angiotensin I to angiotensin II, a powerful casoconstrictor. 

1.        ACE and angiotensin I created endogenously (are endogenous substances)

2.        angiotensin II stimulates secretion of aldosterone by adrenal cortex, which promotes retention of sodium and water

3.        So, ultimately, the drug result is a decrease in sodium and water retention, lowering blood pressure.

•  Calcium movement across membranes of vascular smooth muscle affect arteries.  The cal chan blockers inhibit movement of calcium across cardiac and arterial muscle cells resuling in less calcium available for transmission of nerve impulses, resulting in a relazation of blood vessels, increasing supply of o2 to heart, reducing the workload of the heart.

                                                               i.      Block binding of angiotensin II (again, is a potent vasoconstrictor) in vascular smooth muscle and adrenal gland, blocking release of aldosterone, thus limiting sodium and water retention lowering BP

a.        Orthostatic hypotension for all, esp. early in therapy

b.       CNS

                                                               i.      Fatigue, depression, dizziness, headache and syncope

c.        Respiratory

                                                               i.      Upper resp infections and cough

d.       GI

                                                               i.      Ab pain, nausea, D/C, gastric irritation and anorexia

e.        Other

                                                               i.      Rash pruritus, dry mouth, tachycardia, hypotension, proteinuria and neutropenia (what is this again?)

f.         ARE MORE LISTED IN DRUG TABLE

a.        ACEIs and angiotensin II receptor blockers contra in pts with impaired reanl fnx, HF, salt or volume depletion, bilateral stenosis or angioedema.  Also during pregnancy (cat C furing first tri and cat D during 2^nd and 3d trimesters) and lactation.  May cause fetal/neonatal injury or death.

b.       Calcium channel blockers conta in pts with sick sinus sundrome, second or third degree atrioventricular block (except with functioning pace maker), hypotension (systolic pressure less than 90 mm Hg), ventricular dysfunction, or cardiogenic shock.

a.        Used cautiously in pts with renal/hep impairment, electrolyte imbalances, during lactation and pregnancy (except as noted above) and in older pts.

b.       Calcium channel blockers with caution in pts with HF, during preg (cat C) and lactation.

c.        ACEIs used with caution in pts with sodium depletion, hypovolemia, coronary/cerebrovascular insufficiency, pts on diuretics or on dialysis.

d.       Angiotensis II receptor agonists used cautiously hypovolemia, volume/salt depletion and pts on high dose of diuretics

a.        Most antihypertensives when given with diuretics or other antihypertensives cause greater hypotension (duh)

b.       Many drugsinteract with antihypertensives and decrease their effectiveness

                                                               i.      MAOIs

                                                              ii.      Antihistamines

                                                            iii.      Sympathomimetic bronchodilators

c.        Calcium channel blockers with

                                                               i.      Cimetidine or ranitidine increases effect of calcium channel blockers

                                                              ii.      With therophylline increases pharm and toxic effect of theophylline

                                                            iii.      With digoxin for HF increased risk of digitalis toxicity

                                                            iv.      With refampin (TB) decreases effects of calsium channel blocker

d.       Ask about alternative treatments

                                                               i.      There is a possible interaction with St. John’s wort decreaseing levels of calcium channel blockers

e.        ACEIs with

                                                               i.      NSAIDS reduce effect of ACEIs

                                                              ii.      Rifampin decreases ACEI effect

                                                            iii.      Allopurinol (gout) higher risk for hypersensitivity reaction (to which agent?)

                                                            iv.      Digoxin changes digoxin levels (both ways)

                                                             v.      Loop diuretics, decreases diuretic effects

                                                            vi.      Lithium, increases serum lithium to possible toxicity

                                                          vii.      Hypoglycemic agents and insulin, increases risk of hypoglycemia

                                                         viii.      Potassium-sparing diuretics, elevates serum potassium (heart implications)

f.         Angiotensin II receptor antagonists with

                                                               i.      Fluconazole (antifungal) increases adv rxns of antihypertensive esp. losartan

                                                              ii.      Indomethacin for pain decreases hypotensive effect esp. with losartan

a.        Preadmin

                                                               i.      Assess BP, pulse on both arms with pt standing, sitting and lying. 

                                                              ii.      Obtain weight, esp. if diuretic part of therapy or if PCP says to lose weight

b.       Ongoing

                                                               i.      Monitor BP very important (duh) esp. early in therap to determine effectiveness.  PCP may adjust or change.

                                                              ii.      Q time take BP, do in same arm in same position.  Someimtes PCP orders BP in various positions

                                                            iii.      If severe HT, monitor BP closely at 15-30 minutes or is critically ill

                                                            iv.      NURSING ALERT – BP and pulse must be obtained immeditaly before each admin of antihypertensive and compared with previous readings.  If significantly decreased from baseline, withhold drug and notify PCP.  Also notify if there is a significant increase in BP

                                                             v.      Take daily weights during initial period

                                                            vi.      Pts sometimes retain sodium and water when on antihypertensive, so look for edema and take wirght. Reprot gain of 2lb or more per day and any edem

                                                          vii.      If weight reduce tion diet, weigh regularly, or if on diuretic

                                                         viii.      If outpt, help pt self monitor weight and BP and instruct to bring records to each appointment

                                                               i.      Administering antiadrenergics

1.        if clonidine transdermal, apply to heairless intact skin on upper arm or torso, leave for 7 days.  Apply adhesive overlay to keep in place.  Rotate.  If loosens before  days, reinforce with nonallergenic tape; write date of patch placed and date it is to be removed

                                                              ii.      Admin of calcium channel blockers

1.        can give without regard to meals

2.        if GI upset occurs, give with meals

3.        Verapamil best with meal because tends to GI upset

4.        If verapamil capsules (not sustained realeas) can open and put in liquid or soft foods

5.        diltiazem can be crushed and mixed with food or dluids if difficulty swallowing

                                                            iii.      Admin of ACEIs

1.        admin captopril and moexipril 1 hour before or 2 hours after meals to enhance absorption

2.        Some pts will get dry cough that won’t subside until drug stopped, if too bothersome, PCP may dc

3.        Endure pt not pregnant before ACEI – can cause fetal death – use birth control (reliable).  Notify immediately PCP if preg suspected

4.        May cause sugnigicant BP drop after first dose,so monitor after first dose 15-30min for at least 2 hours and afterward until stable for 1 hour.

5.        LIFESPANB ALERT – for start of menopause periods are irregular and may no think they need birth control.  But since it can occur, stress this and birth control measures.

                                                            iv.      Admin of Angiotensin II Receptor Antagonists

1.        no regard to meals. 

2.        Make sure not pregnant and recommend birth control – can cause fetal death- notify PCP if preg suspected

                                                             v.      Andmin of Direct Renin Inhiobitors or SARAs

1.        no regard to food, wlthough aliskiren absorption limited with high fat diet

2.        Direct rennin inhibitors can cause fetal death in 2^nd or third trimester, so if preg suspected, tell PCP immediately

3.        Increased serum potassium can occir with both, therefore, teach to refrain from using pot based salt substitutes

4.        NURSING ALERT – advise that angioedema can occur at any time on aliskirn.  If so, hold next dose and call PCP immediately

                                                            vi.      Admin of vasodilators

1.        carefully monitor pt on minoxidil bc increases heart rate and notify PCP if

a.        heart rate of 20bpm or more above normal (for pt?)

b.       rapid weight gain of 5lb or more

c.        unusual swelling anywhere

d.       dypnea, angina, severe indigestion or fainting

                                                          vii.      Admin of drugs for Hypertensive Emergencies

1.        nitroprusside given, requires hemodynamic monitoring of pts BP and CV status over entire course

2.        LIFESPAN ALERT – older adults esp. sensitive to hypotensive effects of nitroprusside.  To minimize risk, is given at lower dose and require more frequent monitoring

                                                               i.      General

1.        monitor for adv reactions bc may req change in drug.  Notify PCP of adv rxns

2.        Sometimes pt may have to tolerate mild reactions like dry mouth and mild anorexia

3.        NURSING ALERT – if antihypertensive is dced, never done abruptly.  The PCP will prescribe how, usually gradually over 2 to 4 days to avoid rebound hypertension

                                                              ii.      “Risk for Deficient Fluid Volume rt excessive diuresis secondary to admin of diuretic”

1.        pt on diuretic watched for dehydration and electrolyte imbalances

2.        morelikely to have fluid deficit if pt doesn’t drink enough, esp. elderly  or confused; encourage fluid up to 20000mL/day unless contraindicated, esp. if has been vomiting or diarrhea

3.        Electrolyte imbalances with diuretic (see ch 55)

4.        Aliskiren or eplerenon can cause hyperklemia, so watch; notify if signs or sx of elec imbalance

                                                            iii.      “Risk for Injury rt to dizziness or light-headedness secondary to postural or orthostatic hypotensive episodes”

1.        dizziness, weakness and orthostartic BP can happen.  Advise to rise slowly, after lying sit for a while.  May assist pt also.

                                                            iv.      “Risk for Ineffective Sexuality Patterns rt impotence secondary to effects of antihypertensive”

1.        ranges from impotence to inhibiting ejaculation.  Provide open and understanding atmosphere. Explain that these things can happen. Suggest other methods of intimacy. Are drugs for ED and many are safe with antihypertensives.

                                                             v.      “Risk  for activity intolerance rt fatigue and weakness”

1.        some pts have less exercise tolerance and fell fatigued, week and lethargic.  Encourage ambulation as much as possible, may need assistive device.  Gradually increase.  Fatigue often diminished after a month or so.

                                                            vi.      “Pain (acute headache) rt to antihypertensive drugs

1.        esp. antiadrenergics or angiotensin II receptor blockers.  If acute, take measures like relaxing, back rub, guided imagery.  If ineffective, contact PCP may give analgesic.

• These drugs not a cure so skipping dose can cause severere rebound
• Avoid alcohol unless PCP says ok
• Teach about orthostatic side effects and how to change position; If have orthostatic BP problems, drink a lot of fluids
• If drowsy, avoid hazardous tasks, may go away after time
•  If unexplained weakness or fatigue contact PCP
•  Do not use salt substitutes until approved
•  Notify PCP if DBP suddenly increases to 130 or higher, may be hypertensive emergency