Hypertension

2/6/2011 1:00:00 PM

Basic Science CO = SV x HR Things that increase stroke volume o end diastolic volume results in preload causes more forceful contractions of the heart muscle o Positive Inotropic agents Results in Contractility Examples: Increased sympathetic stimulation Catecholamines Serum glucagon Serum thyroid Increased Ca2+ in extracellular fluid o arteriole BP during diastole results in afterload semilunar valves open sooner Things that increase heart rate o CNS Medulla oblongata receives input from cerebral cortex, limbic system, proprioceptors, baroreceptors, and chemoreceptors sympathetic stimulation and parasympathetic stimulation o Chemicals Catecholamines Serum thyroid Increased Ca2+ in extracellular fluid o Other factors Infants Elderly Low physical fitness Increased body temperature Blood pressure o Hydrostatic pressure excerted by blood on walls of a blood vessel

2 o Systolic blood pressure Highest pressure in arteries during systole o Diastolic blood pressure Lowest pressure in arteries during diastole o Mean arteriole pressure MAP = diastolic BP + 1/3 (systolic BP diastolic BP) o MAP=COxR Resistance o Size of the lumen o Blood viscosity o Total blood vessel length Control of blood pressure and flow o The cardiovascular center in the Medulla oblongota Regulates HR, contractility of ventricals, and blood vessel diameter Receives input from the cerebral cortex, limbic system, and hypothalamus Proprioceptors In muscles and joints Cause initial rise in HR at beginning of exercise Baroreceptors Monitor stretch in vessels Chemoreceptors Monitor concentration of chemicals in blood Hormones and Blood Pressure o Epinephrine and Norepinephrine BP via HR and contractility affecting CO also causes vasoconstriction in -1 receptors of abdomen and skin affecting SVR o Angiotensin II, ADH BP via vasoconstriction affecting SVR o Atrial Natriuretic peptid, nitric oxide BP via vasodialation o Epinepherine BP via vasodiation of 2 receptors in arterioles of cardiac and skeletal muscle

3 o ADH, aldosterone BP via Blood volume o Atrial Natriuretic peptid BP via blood volume

Hypertension Medications

2/6/2011 1:00:00 PM

Loop Diuretics (Lasix furosemide) inhibit sodium, chloride and calcium reabsorption in the thick ascending loop of henle BV CO BP Adverse affects: hypokalemia Thiazide Diuretics (HCTZ) Inhibits sodium reabsorption in distal convoluted tubule, inhibits chloride BV CO BP Adverse affects: hypokalemia

Potassium Sparing Diuretics (spironolactone) Inhibits Na+ reabsorption and K+ excretion in the collecting ducts of the nephron Often used with thiazide or loop-sparing diuretic H2O excretion BV CO BP Adverse affects: hyperkalemia Amiloride (Midamor) Clinical: prevention and treatment of hypokalemia Spironolactone (Aldactone) Clinical: hyperaldosteronism, hypokalemia, hypertension, severe heart failure Enalapril (vasotec)

Beta Blockers (propranolol) Competitively binds to 2 receptors where catecholamines would bind in the heart causing decreased contractility and HR CO BP Adverse affects: bradycardia, dizziness

Calcium Channel Blockers (verapamil) Blocks calcium channels during depolarization decreasing contractility SV CO BP

5 Adverse affects: bradycardia

Angiotensin Receptor Blockers (candesartan) Blocks angiotensin II receptors, reduces vasoconstriction and sodium reabsorption in the proximal convoluted tubule H2O reabsorption BV CO BP Adverse affects: bilateral renal artery stenosis ACE-Inhibitors (lisinopril) Prevents conversion of Angiostensin I to Angiotensin II Na+ reabsorption, K+ excretion, H2O reabsorption, vasodialation TPR, BV CO BP Adverse affects: dry cough

Direct renin inhibitor Aliskiren (Teckturna) Binds to active site of renin and prevents cleavage of angiotensinogen and formation of angiotensin I, lowers plasma renin activity and levels of angiotensin I and angiotensin II

HTN workup
Stage I

2/6/2011 1:00:00 PM

hypertension Systolic 140-159 Diastolic 90-99 Treat w lifestyle modification, Thiazide diuretic or ACE, ARB, CCB, Beta blocker or combination hypertension Systolic 160 Diastolic 100 Lifestyle modification and 2-drug combination (usually a thiazide diuretic and ACE, ARB, CCB, or Beta blocker

Stage II

Major Cardiovascular risk factors HTN Tobacco BMI 30 Physical inactivity Dyslipidemia DM Microalbuminuria or est. GFR < 60 Age > 55 males, > 65 females FmHx of premature cardiovascular disease

Target organ damage Heart o Left Ventricular hypertrophy o Angina or MI o Heart failure Brain o TIA o CVA CKD Peripheral arterial disease Retinopathy

Identifiable causes of HTN

7 Sleep apnea Drug induced/related Primary aldosteronism Renovascular disease Chronic Steroid therapy Cushing syndrome Pheochromocytoma Coarctation of the aorta Thyroid desease Parathyroid disease

Causes of resistant HTN Improper BP measurement Volume overload and pseudotolerance o Excessive sodium intake o Volume retention from kidney disease o Inadequate diuretic therapy Drug-induced or other causes o Non-adherent to medications o o o o o o o o o Inadequate doses Inappropriate combinations NSAIDS, COX-2 inhibitors Sympathomimics (decongestants, anoretics) Cocaine, amphetamines, other illicit drugs Oral Contraception Adrenal Steroids Cyclosporine and tacrolimus EPO

o Licorice o Ephedra, ma haung, bitter orange Associated conditions o ETOH use o Obesity Identifiable causes

Labs, Routine:

8 CBC Electrolytes Serum Creatinine Serum Glucose Uric Acid Urinalysis Lipid Profile

Special labs aldosterone /plasma renin activity ratio to detect primary hyperaldosteronism urinary catecholamines and fractionated metanephrines for pheochromocytoma TSH for hypothyroidism, hyperthyroidism Microalbuminuria in the pt with DM

Imaging Echo for LVH CT or MRA for renal vascular stenosis Other tests ECG Home

Hypertension Medications/Brands

2/6/2011 1:00:00 PM

Potassium Sparing Diuretics Amiloride (Midamor) Clinical: prevention and treatment of hypokalemia Spironolactone (Aldactone) Clinical: hyperaldosteronism, hypokalemia, hypertension, severe heart failure Side effects: gynecomastia and impotence (males), hyperkalemia ACE-Inhibitors Enalapril (Vasotec) o Clinical: HTN, HF, post-MI, decrease progression of diabetic neuropathy o Adverse affects: taste disturbances, hypotension, dry cough Loop Diarectics Furosemide (Lasix) o