Download File - Erin Ropelewski

Chapter 44
ANTIHYPERTENSIVE DRUGS
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Hypertension
Selected regulators of blood
pressure
Kidneys via reninangiotensin system (RAS)
Vasodilation = hypotension
(dec. BP)
Vasoconstriction =
hypertension (inc. BP)
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Hypertension (cont’d)
Baroreceptors in the aorta and
carotid sinus
Vasomotor center in the
medulla
Hormones: antidiuretic
hormone (ADH) atrial
natriuretic peptide (ANP), and
brain natriuretic peptide (BNP)
Hypertension
Physiologic risk factors
Excess fat and carbohydrate intake
Alcohol increases renin secretions
Obesity affects cardiovascular system
Cultural responses
Asian Americans twice as sensitive as whites to beta
blockers & other hypertensives
American Indians reduced/lower response to beta
blockers
African Americans decreased response to beta blockers
and ACE inhibitors (use calcium channel blockers)
Hypertension
Nonpharmacologic control of
hypertension
Stress reduction techniques
Exercise
Salt restriction
Decreased ETOH
Weight reduction
Guidelines for Determining
Hypertension
Category
Systolic Pressure
Diastolic Pressure
Normal
<120 mm Hg
<80 mm Hg
Prehypertension
120-139 mm Hg
80-89 mm Hg
Stage 1
hypertension
140-159 mm H g
90-99 mm Hg
Stage 2
hypertension
>160 mm Hg
>100 mm Hg
Antihypertensive Drugs
Diuretics
Thiazides: hydrochlorothiazide (HydroDiuril)
Loop (high-ceiling) diuretics (Lasix)
Combinations of hydrochlorothiazide with
potassium-sparing diuretics and other
antihypertensive drugs, i.e., ACE inhibitors, etc.
Side effects
Potassium loss/hypokalemia, electrolyte imbalances,
hypovolemia/dehydration, hypotension (orthostatic)
Sympatholytics
(Sympathetic Depressants)
Beta-adrenergic blockers
Centrally acting alpha2 agonists
Alpha-adrenergic blockers
Adrenergic neuron blockers (peripherally
acting sympatholytics)
Alpha1- and beta1-adrenergic blockers
Beta-Adrenergic Blockers
Noncardioselective beta blockers (beta 1 and
beta 2)
Action: Slows HR thereby reducing BP
Caution: may cause bronchoconstriction
Contraindications: chronic obstructive
pulmonary disease (COPD)
propanolol (Inderal)
Beta-Adrenergic Blockers
Cardioselective beta blockers (beta 1)
Action: works mainly on the heart and not
the lungs (Preferred over non-selective)
Caution: clients with diabetes mellitus,
pulmonary disease
Examples:
metoprolol (Lopressor)
Atenolol (Tenormin)
May be given as a combo drug with a thiazide
diuretic
Beta-Adrenergic Blockers
Nursing Considerations
Monitor VS-especially HR and BP
Teach patient to stand slowly
Teach patient non-pharmacological methods
to reduce BP
Teach patient about long term effects of HTN
Side/adverse effects
Decreased pulse rate markedly decreased BP
Rebound hypertension with abrupt
discontinuation
Insomnia, depression, nightmares, sexual
dysfunction
Centrally Acting Alpha2 Agonists
Multiple actions results in reduced peripheral
vascular resistance and increased vasodilation
Contraindications: impaired liver function
Side effects: sodium and water retention, dry
mouth, bradycardia
Diuretics are frequently prescribed to avoid
fluid retention
Avoid abruptly stopping drug, rebound
hypertension may result
Alpha-adrenergic blockers
Prototype: prazosin (Minipress)
Function
Vasodilation  decreased BP
Also helps with lipid abnormalities (decrease VLDL)
Does not affect glucose or respiratory function
Side effects: orthostatic hypotension, nausea,
drowsiness, nasal congestion, impotence, urinary
frequency, edema
Alpha-adrenergic blockers
Nursing considerations
Client needs to report edema that is present
in the morning.
Daily BP record should be kept
Do not take OTC cough and cold meds
without contacting MD
Other Antihypertensive Drugs
Direct-acting arteriolar vasodilators
VERY potent!
Nitroprusside and Diazoxide only used
for acute HTN emergency!
Side effects: reflex tachycardia,
palpitations, restlessness, agitation,
confusion, hyperglycemia (diazoxideinhibits insulin release from the
pancreas)
Angiotensin-Converting Enzyme (ACE)
Inhibitors
Function
Inhibits formation of
angiotensin II
Lack of aldosterone 
sodium excretion,
potassium retained
Little change in CO, HR
Cultural effects: not for
African Americans, older
adults
Angiotensin-Converting Enzyme
(ACE) Inhibitors
Side effects: irritating cough, insomnia,
hyperkalemia , GI distress, first dose
hypotension
lisinopril (Prinivil) pg 665
Remember the “pril”
Angiotensin II Receptor Blockers (ARBs)
Function
Block angiotensin II at receptor
Cause vasodilation and decreased peripheral
resistance
Cultural effects: Do not use with African
Americans
losartan potassium (Cozaar) pg 666
Remember “sartan”
Calcium Channel Blockers
for Hypertension
Block calcium channel promoting vasodilation
Coronary and peripheral vessels sensitive 
peripheral edema
Use this class for African Americans
amlopidine (Norvasc)
Remember “pidine”
Calcium Channel Blockers
for Hypertension
Herbal Interactions with all hypertensives
Ephedra: counteracts antihypertensives
Black cohosh: increase hypotensive effect
Licorice: antagonize antihypertensives
Parsley: increase hypotensive effect
Practice Question #1
CB’s diuretic was changed to an angiotensin II
receptor blocker (ARB). An example of an ARB is:
A.
B.
C.
D.
losartan (Cozaar).
amlodipine (Norvasc).
captopril (Capoten).
metoprolol (Lopressor).
Practice Question #2
CB’s diuretic was changed to an angiotensin II
receptor blocker (ARB). An example of an ARB is:
A.
B.
C.
D.
losartan (Cozaar).
amlodipine (Norvasc).
captopril (Capoten).
metoprolol (Lopressor).
Practice Question #3
A common side effect of ACE is:
A.
B.
C.
D.
irritating cough.
nervousness (tremors).
asthmatic attacks.
dizziness.
Practice Question #3
A common side effect of ACE is:
A.
B.
C.
D.
irritating cough.
nervousness (tremors).
asthmatic attacks.
dizziness.
Chapter 45
ANTICOAGULANTS,
ANTIPLATELETS, AND
THROMBOLYTICS
Anticoagulants
Heparin
Purposes: DVT, PE, open heart surgery, DIC
Contraindications: stroke, peptic ulcer, blood
anomalies
Administration of heparins: SubQ, IV
Monitoring heparin doses: PTT, aPTT
Side effects: bleeding
Antidote: protamine sulfate (only when heparin
present)
Low Molecular Weight
Heparin
Prevent venous
thrombus with decreased
bleeding risk
enoxaparin sodium (Lovenox)
Monitor platelet count: must be >100 (PTT
not monitored)
Oral Anticoagulants
Monitoring warfarin (Coumadin) doses:
therapeutic INR (2-4) depending on diagnosis or
PT
Drug interaction (highly protein-bound)
Herbal interaction
Increased effect: dong quai, feverfew, garlic,
ginger, gingko, bilberry
Decreased: ginseng, alfalfa, golden seal
Side effects: bleeding
warfarin (Coumadin) pg 675
Oral antidote: Vitamin K (IM)
Anticoagulants
New drug: daabigatran etexilate (Pradaxa)
Use for atrial fibrillation only
No labs required
New research found increased
bleeding risk
Antiplatelets
Prophylactic use only!!!
Functions: inhibits platelet aggregation
Antiplatelet drugs
clopidogrel (Plavix), ticlopidine (Ticlid),
dipyridamole (Persantine), and others
Side effects: flu-like symptoms, dizzness, headaches,
fatigue
Herbal products: dong quai, feverfew, garlic, gingko
Thrombolytics “Clot Busters”
Purposes: MI, thrombolic stroke, PE
Contraindications: hemorrhagic stroke,
contusion
Thrombolytic drugs:
altepase(tPA/Activase), streptokinase, and
others
Adverse effects: hemorrhage, vascular
collapse
Should be administered within 3 hrs of
Practice Question #1
PQ had a major stroke. Following his stroke he was
prescribed aspirin 81 mg and clopidogrel (Plavix).
Classification of clopidogrel is:
A. anticoagulant.
B. intravenous anticoagulant.
C. antiplatelet.
D. thrombolytic.
Practice Question #1
PQ had a major stroke. Following his stroke he was
prescribed aspirin 81 mg and clopidogrel (Plavix).
Classification of clopidogrel is:
A. anticoagulant.
B. intravenous anticoagulant.
C. antiplatelet.
D. thrombolytic.
Practice Question #2
PQ arrived in the emergency department 2 hours following his
stroke. He was given an intravenous (IV) injection of tPA.
This drug is a(n):
A. anticoagulant.
B.
C.
D.
intravenous anticoagulant.
antiplatelet.
thrombolytic.
Practice Question #2
PQ arrived in the emergency department 2 hours following his
stroke. He was given an intravenous (IV) injection of t-PA.
This drug is a(n):
A. anticoagulant.
B.
C.
D.
intravenous anticoagulant.
antiplatelet.
thrombolytic.
ANTIHYPERLIPIDEMICS
AND PERIPHERAL
VASODILATORS
Antihyperlipidemics
HDL – Highly desired lipoproteins
LDL – Least desired lipoproteins
Nonpharmacologic methods for cholesterol
reduction
Decrease saturate fats and cholesterol
75% to 85% cholesterol endogenous
Exercise program (increases HDL)
Stop smoking (increases LDL, decreases
HDL)
Antihyperlipidemics
Lipoprotein classification: VLDL, LDL,
HDL
Serum lipids values
Cholesterol: 150-200 mg/dl
Triglycerides: 40-150 mg/dl
LDL: less than 100 mg/dl
HDL: 45-60 mg/dl
Antihyperlipidemics (cont’d)
Types of antilipidemics
Bile-acid sequestrants: cholestyramine
(Questran)
Fibrates (fibric acid): gemfibrozil (Lopid)
Nicotinic acid (niacin) – watch for flushing
Cholesterol absorption inhibitors: ezetimibe
(Zetia)
Hepatic 3-hydroxy-3-methyglutaryl-coenzyme
A (HMG-CoA) - statins
HMG-CoA / Statins
Function
inhibit cholesterol synthesis in liver
Decrease serum cholesterol, LDL, VLDL,
triglyceride
Slightly increase HDL
atorvastatin calcium (Lipitor) pg 689
Side/adverse effects
Very rare
Rhabdomyolysis: muscle tenderness/weakness,
fever, malaise
Peripheral Vasodilators
Function: increase blood flow to extremities
Uses: Raynaud’s (vasospasm), arteriosclerosis
Classifications
Beta-adrenergic antagonists
isoxsuprine HCl (Vasodilan)
Side/adverse effects: lightheadedness, dizziness,
orthostatic hypotension, tachycardia, palpitations,
flush, GI distress
Peripheral Vasodilators
Hemorrheologic : pentoxifylline (Trental)
Works by increasing the microcirulation and
enhances tissue oxygenation
Others: i.e., antiplatelets, certain
antihypertensives
Practice Question #1
AL’s serum lipids were as follows: cholesterol 197 mg/dL,
low-density lipoprotein (LDL) 110 mg/dL, and highdensity lipoprotein (HDL) 35 mg/dL. Which of the
following is a correct statement?
A. Serum lipids are within desirable values.
B. Cholesterol is within desirable value, but not LDL and
HDL.
C. Cholesterol is not within desirable value, though LDL and
HDL are.
D. Cholesterol, LDL, and HDL are not within desirable values.
Practice Question #1
AL’s serum lipids were as follows: cholesterol 197 mg/dL,
low-density lipoprotein (LDL) 110 mg/dL, and highdensity lipoprotein (HDL) 35 mg/dL. Which of the
following is a correct statement?
A. Serum lipids are within desirable values.
B. Cholesterol is within desirable value, but not LDL and
HDL.
C. Cholesterol is not within desirable value, though LDL and
HDL are.
D. Cholesterol, LDL, and HDL are not within desirable values.
Practice Question #2
AL was prescribed atorvastatin (Lipitor) 10 mg to prevent
coronary artery disease (CAD). The drug classification
of atorvastatin is a:
A. fibrate.
B. bile-acid sequestrant.
C. combination of anticholesterol drugs.
D. statin.
Practice Question #2
AL was prescribed atorvastatin (Lipitor) 10 mg to prevent
coronary artery disease (CAD). The drug classification
of atorvastatin is a:
A. fibrate.
B. bile-acid sequestrant.
C. combination of anticholesterol drugs.
D. statin.
Practice Question #3
A serious adverse reaction of atorvastatin (Lipitor) is:
A.
B.
C.
D.
pharyngitis.
rash/pruritus.
rhabdomyolysis.
agranulocytosis.
Practice Question #3
A serious adverse reaction of Lipitor is:
A.
B.
C.
D.
pharyngitis.
rash/pruritus.
rhabdomyolysis.
agranulocytosis.