Antihypertensive Agents

PRADITA DIAH PERMATASARI

Hypertension
High blood pressure

Normal:
Systolic < 130 mm
Hg Diastolic < 85 mm Hg

Classification of Blood
Pressure
Category
BP (mm Hg)

Systemic BP (mm Hg)

Diastolic

Normal

<120

<80

prehipertensi

120-139

80-89

Hypertension
Stage 1
Stage 2

140-159
160

90-99
100

Classification of Blood
Pressure
Primary Hypertension

Specific cause unknown

90% of the cases
Also known as essential or idiopathic hypertension

Secondary Hypertension

Cause is known (such as eclampsia of pregnancy,

renal artery disease, pheochromocytoma)
10% of the cases

Blood Pressure = CO x SVR

CO = Cardiac output

SVR = Systemic vascular resistance

Antihypertensive Agents

Medications used to treat hypertension

Antihypertensive Agents:
Categories

Adrenergic agents

Angiotensin-converting enzyme inhibitors

Angiotensin II receptor blockers

Calcium channel blockers

Diuretics

Vasodilators

Antihypertensive Agents: Categories

Adrenergic Agents

Alpha1 blockers

Beta blockers (cardioselective and nonselective)

Centrally acting alpha blockers

Combined alpha-beta blockers

Peripheral-acting adrenergic agents

Antihypertensive Agents:
Mechanism of Action
Adrenergic Agents
Alpha1 Blockers (peripherally acting)

Block the alpha1-adrenergic receptors

The SNS is not stimulated

Result: DECREASED blood pressure

Stimulation of alpha1-adrenergic receptors

causes HYPERtension

Blocking alpha1-adrenergic receptors causes

decreased blood pressure

Antihypertensive Agents:
Adrenergic Agents
Alpha1 Blockers

doxazosin (Cardura)

prazosin (Minipress)

terazosin (Hytrin)

Antihypertensive Agents:
Mechanism of Action
Adrenergic Agents
Central-Acting Adrenergics

Stimulate alpha2-adrenergic receptors

Sympathetic outflow from the CNS is

decreased
Result: decreased blood pressure

Antihypertensive Agents:
Adrenergic Agents
Central-Acting Adrenergics

clonidine (Catapres)

methyldopa (Aldomet)
(drug of choice for hypertension in
pregnancy)

Antihypertensive Agents:
Mechanism of Action
Adrenergic Agents
Adrenergic Neuronal Blockers
(peripherally acting)

Inhibit release of norepinephrine

Also deplete norepinephrine stores

SNS (peripheral adrenergic nerves) is not

stimulated
Result: decreased blood pressure

Antihypertensive Agents:
Adrenergic Agents
Adrenergic Neuronal Blockers
(peripherally acting)

reserpine

guanadrel (Hylorel)

guanethidine (Ismelin)

Antihypertensive Agents:
Adrenergic Agents
Therapeutic Uses

Alpha1 blockers (peripherally acting)

Treatment of hypertension

Relief of symptoms of BPH

Management of of severe CHF when used

with cardiac glycosides and diuretics

Antihypertensive Agents:
Adrenergic Agents
Therapeutic Uses

Central-Acting Adrenergics

Treatment of hypertension, either alone or

with other agents

Usually used after other agents have failed

due to side effects

Also may be used for treatment of severe dysmenorrhea, menopausal

flushing, glaucoma

Clonidine is useful in the management of withdrawal symptoms in opioidor nicotine-dependent persons

Antihypertensive Agents:
Adrenergic Agents
Therapeutic Uses

Adrenergic neuronal blockers

(peripherally acting)

Treatment of hypertension, either alone or with other

agents

Seldom used because of frequent side effects

Antihypertensive Agents:
Adrenergic Agents
Side Effects

Most common:

dry mouth
constipation

Other:
headaches
disturbances
rash
cardiac disturbances (palpitations)

drowsiness
sedation
sleep
nausea

HIGH INCIDENCE OF ORTHOSTATIC HYPOTENSION

Antihypertensive Agents:
Categories
Angiotensin-Converting Enzyme Inhibitors
(ACE Inhibitors)

Large group of safe and effective drugs

Often used as first-line agents for CHF

and hypertension

May be combined with a thiazide diuretic

or calcium channel blocker

Antihypertensive Agents:
Mechanism of Action
ACE Inhibitors
RAAS: Renin Angiotensin-Aldosterone System

When the enzyme angiotensin I is converted to

angiotensin II, the result is potent vasoconstriction
and stimulation of aldosterone

Result of vasoconstriction: increased systemic

vascular resistance and increased afterload

Therefore, increased BP

Antihypertensive Agents:
Mechanism of Action
ACE Inhibitors

Aldosterone stimulates water and sodium

resorption.

Result: increased blood volume, increased

preload, and increased B

Antihypertensive Agents:
Mechanism of Action
ACE Inhibitors

ACE Inhibitors block the angiotensinconverting enzyme, thus preventing the

formation of angiotensin II.

Also prevent the breakdown of the

vasodilating substance, bradykinin
Result: decreased systemic vascular resistance
(afterload), vasodilation, and therefore,
decreased blood pressure

Antihypertensive Agents
ACE Inhibitors

captopril (Capoten)

Short half-life, must be dosed more frequently

than others

enalapril (Vasotec)

The only ACE inhibitor available in oral and

parenteral forms

lisinopril (Prinivil and Zestril) and quinapril

(Accupril)

Newer agents, long half-lives, once-a-day dosing

Several other agents available

Antihypertensive Agents:
Therapeutic Uses
ACE Inhibitors

Hypertension

CHF (either alone or in combination with

diuretics
or other agents)

Slows progression of left ventricular

hypertrophy after an MI

Renal protective effects in patients with

diabetes
Drugs of choice in hypertensive patients with CHF

Antihypertensive Agents:
Side Effects
ACE Inhibitors

Fatigue

Dizziness

Headache

Mood changes

Impaired taste
Dry, nonproductive cough, reverses when therapy
is stopped
NOTE: first-dose hypotensive effect may occur!!

Antihypertensive Agents:
Categories
Angiotensin II Receptor Blockers (A II Blockers or ARBs)

Newer class

Well-tolerated

Do not cause coughing

Antihypertensive Agents:
Mechanism of Action
Angiotensin II Receptor Blockers

Allow angiotensin I to be converted to

angiotensin II, but block the receptors
that receive angiotensin II

Block vasoconstriction and release of

aldosterone

Antihypertensive Agents:
Angiotensin II Receptor Blockers

losartan

(Cozaar)

eposartan
valsartan

(Teveten)

(Diovan)

irbesartan

(Avapro)

candesartan
telmisartan

(Atacand)

(Micardis)

Antihypertensive Agents:
Therapeutic Uses
Angiotensin II Receptor Blockers

Hypertension

Adjunctive agents for the treatment of

CHF

May be used alone or with other agents

such
as diuretics

Antihypertensive Agents:
Side Effects
Angiotensin II Receptor Blockers

Upper respiratory infections

Headache

May cause occasional dizziness, inability

to sleep, diarrhea, dyspnea, heartburn,
nasal congestion, back pain, fatigue

Antihypertensive Agents:
Categories
Calcium Channel Blockers

Benzothiazepines

Dihydropyridines

Phenylalkylamines

Antihypertensive Agents:
Mechanism of Action
Calcium Channel Blockers

Cause smooth muscle relaxation by

blocking the binding of calcium to its
receptors, preventing muscle contraction

This causes decreased peripheral smooth

muscle tone, decreased systemic vascular
resistance

Result: decreased blood pressure

Antihypertensive Agents
Calcium Channel Blockers

Benzothiazepines:

Phenylalkamines:

diltiazem (Cardizem, Dilacor)

verapamil (Calan, Isoptin)

Dihydropyridines:

amlodipine (Norvasc), bepridil (Vascor),

nicardipine (Cardene)

nifedipine (Procardia), nimodipine (Nimotop)

Antihypertensive Agents:
Therapeutic Uses
Calcium Channel Blockers

Angina

Hypertension

Dysrhythmias

Migraine headaches

Antihypertensive Agents:
Side Effects
Calcium Channel Blockers

Cardiovascular

Gastrointestinal

hypotension, palpitations, tachycardia

constipation, nausea

Other

rash, flushing, peripheral edema, dermatitis

Antihypertensive Agents:
Diuretics
Decrease

the plasma and extracellular fluid volumes

Results:

decreased preload
decreased cardiac output
decreased total
peripheral resistance

Overall

effect: decreased workload of the heart,

and decreased blood pressure

Antihypertensive Agents:
Mechanism of Action
Vasodilators

Directly relaxes arteriolar smooth muscle

Result:

decreased systemic vascular response,

decreased afterload, and

VASODILATION

PERIPHERAL

Antihypertensive Agents
Vasodilators

diazoxide (Hyperstat)

hydralazine HCl (Apresoline)

minoxidil (Loniten, Rogaine)

sodium nitroprusside (Nipride, Nitropress)

Antihypertensive Agents:
Therapeutic Uses
Vasodilators

Treatment of hypertension

May be used in combination with other

agents

Sodium nitroprusside and diazoxide IV are

reserved for the management of
hypertensive emergencies

Antihypertensive Agents:
Side Effects
Vasodilators

Hydralazine:

dizziness, headache, anxiety, tachycardia, nausea and

vomiting, diarrhea, anemia,
dyspnea, edema, nasal congestion

Sodium nitroprusside:

bradycardia, hypotension, possible

cyanide toxicity

Antihypertensive Agents:
Nursing Implications

Before beginning therapy, obtain a thorough health

history and head-to-toe physical examination.

Assess for contraindications to specific antihypertensive

agents.

Assess for conditions that require cautious use of these

agents.

Antihypertensive Agents:
Nursing Implications

Educate patients about the importance of not

missing a dose and taking the medications
exactly as prescribed.

Patients should never double up on doses if a

dose is missed; check with physician for
instructions on what to do if a dose is missed.

Monitor BP during therapy. Instruct patients

to
keep a journal of regular BP checks.

Antihypertensive Agents:
Nursing Implications

Instruct patients that these drugs should not

be stopped abruptly, as this may cause a
rebound hypertensive crisis, and perhaps lead
to CVA.

Oral forms should be given with meals so that

absorption is more gradual and effective.

Administer IV forms with extreme caution and

use an IV pump.

Antihypertensive Agents:
Nursing Implications

Remind patients that medications is only

part of therapy. Encourage patients to
watch their diet, stress level, weight, and
alcohol intake.

Patients should avoid smoking and eating

foods high in sodium.

Encourage supervised exercise.

Antihypertensive Agents:
Nursing Implications

Instruct patients to change positions

slowly to avoid syncope from postural
hypotension.

Patients should report unusual shortness

of breath; difficulty breathing; swelling of
the feet, ankles, face, or around the
eyes; weight gain or loss; chest pain;
palpitations; or excessive fatigue.

Antihypertensive Agents:
Nursing Implications

Men taking these agents may not be

aware that impotence is an expected
effect. This may influence compliance
with drug therapy.

If patients are experiencing serious side

effects,
or believe that the dose or medication
needs to
be changed, they should contact their
physician immediately.

Antihypertensive Agents:
Nursing Implications

Hot tubs, showers, or baths; hot weather;

prolonged sitting or standing; physical
exercise; and alcohol ingestion may
aggravate low blood pressure, leading to
fainting and injury. Patients should
sit or lie down until symptoms subside.

Patients should not take any other

medications, including OTC drugs, without
first getting the approval of their
physician.

Antihypertensive Agents:
Nursing Implications

Monitor for side/adverse effects

(dizziness, orthostatic hypotension,
fatigue)
and for toxic effects.

Monitor for therapeutic effects

Blood pressure should be maintained at

less
than 140/90 mm Hg

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