Anti hypertensives
-
Upload
aman-hassan -
Category
Health & Medicine
-
view
61 -
download
0
Transcript of Anti hypertensives
![Page 1: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/1.jpg)
ANTI-HYPERTENSIVES
Dr. AMANULLA ABUL HASSANCHENNAI
![Page 2: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/2.jpg)
BLOOD PRESSURE
• Measure of pressure exerted on the lateral wall of the blood vessels by a flowing column of blood
• Has two components – Systolic– Diastolic
• Normal- 120/80 mm of Hg
![Page 3: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/3.jpg)
FACTORS INFLUENCING BP
• Blood pressure = Cardiac output (CO)* Total peripheral resistance(TPR)
• Cardiac output = Heart rate * Stroke volume• Stroke volume in turn depends upon the
venous return and blood volume• TPR depends upon the size of the blood
vessels mainly under the control of ANS• RAAS System
![Page 4: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/4.jpg)
![Page 5: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/5.jpg)
JNC – 8 ClassificationCategory Systolic Diastolic
Normal <120 <80
Prehypertensive 120-139 80-89
Stage 1 Hypertensive 140-159 90-99
Stage 2 Hypertensive >160 >100
Isolated Systolic Hypertension
>/=140 <80
![Page 6: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/6.jpg)
How Anti Hypertensives work?
• By reducing blood volume and sodium concentration
• By abolition of the sympathetic activity• By dilating the blood vessels• By inhibiting the RAAS system
![Page 7: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/7.jpg)
ANTIHYPERTENSIVES
DIURETICS SYMPATHOPLEGICS
VASODILATORS
RAAS INHIBITOR
![Page 8: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/8.jpg)
DIURETICS• THIAZIDE-1st line drug in Management.
– Hydrochlorthiazide- 12.5 to 50 mg– Chlorthaidone- 12.5 to 25mg– Indapamide- 1.25 to 5 mg . Longer acting
• LOOP DIURETICS– Furosemide: 20 to 80 mg twice daily– Torsemide: 10 to 40 mg
• POTASSIUM SPARING– Amiloride: 5 to 10 mg– Spiranolactone: 25 to 50 mg– Triamterene : 100 mg
![Page 9: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/9.jpg)
• Initial and prolonged effect?– Initailly: Both CO and TPR reduces– Later: CO comes to normal and TPR remains low
• ADR:– Hypokalemia* – Hyperglycemia* (What to do in diabetics?)– Hyperuricemia *(What to do in GOUT?)
![Page 10: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/10.jpg)
ANTIHYPERTENSIVES
DIURETICS SYMPATHOPLEGICS
VASODILATORS
RAAS INHIBITOR
![Page 11: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/11.jpg)
SYMPATHOPLEGICS
DRUGS DECREASING CENTRAL
SYMPATHETIC OUTFLOW
GANGLION BLOCKER
NEURON BLOCKERS
ALPHA BLOCKERS
BETA BLOCKERS
![Page 12: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/12.jpg)
CENTRAL SYMPATHETIC OUTFLOW INHIBITORS
• CLONIDINE (0.1 to 0.2 mg twice daily) and ALPHA METHYL DOPA (250 to 500 mg twice daily)
• Alpha 2 receptor agonists in brain• ADR:
– Clonidine- Rebound Hypertension– Alpha Methyl Dopa- Hemolytic anemia
• Moxonidine and Rilmenidine- Imidazoline receptors that modulate the activity of alpha 2 recpetors in brain
• Better to add diuretics in prolonged use due to their sodium and water retention activity on prolonged use.
![Page 13: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/13.jpg)
SYMPATHOPLEGICS
DRUGS DECREASING CENTRAL
SYMPATHETIC OUTFLOW
GANGLION BLOCKER
NEURON BLOCKERS
ALPHA BLOCKERS
BETA BLOCKERS
![Page 14: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/14.jpg)
Ganglion Blockers
• Nn type receptor blockers in Ganglion• Both sympathetic and parasympathetic system
is blocked• Hence the side effects like Urinary retention
and dry mouth• Hexamethonium and Trimethopan• Not used nowadays except in Aortic dissection
![Page 15: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/15.jpg)
SYMPATHOPLEGICS
DRUGS DECREASING CENTRAL
SYMPATHETIC OUTFLOW
GANGLION BLOCKER
NEURON BLOCKERS
ALPHA BLOCKERS
BETA BLOCKERS
![Page 16: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/16.jpg)
ADRENERGIC NEURON BLOCKERS
• Reserpine, Guanethidine and Bretylium• Reserpine– Inhibits vesicular uptake of Adrenaline, Serotonin and
Dopamine.– Serotonin- Depression and Suicidal tendencies
• Guanethidine and Bretylium– Enters vesicles and displaces the Noradrenaline which in
turn is metabolised– Active orally– Orthostatic hypotension – Not a first dose phenomenon.
![Page 17: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/17.jpg)
SYMPATHOPLEGICS
DRUGS DECREASING CENTRAL
SYMPATHETIC OUTFLOW
GANGLION BLOCKER
NEURON BLOCKERS
ALPHA BLOCKERS
BETA BLOCKERS
![Page 18: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/18.jpg)
Alpha Blockers
• NON SELECTIVE:– Phenoxybenzamine: Pheochromocytoma– Phentolamine: Clonidine withdrawal– Tolazoline: Clonidine Withdrawal– Greater Tachycardia than selective
• SELECTIVE:– DOC in Hypertension with BPH– First dose hypotension– Do not impair metabolism: Can be used in Diabetics, CAD and Gout– Prazosin : 0.5 to 20 mg– Terazosin: 1 to 5 mg– Doxazosin: 1 to 4 mg– Usually bed time doses
![Page 19: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/19.jpg)
SYMPATHOPLEGICS
DRUGS DECREASING CENTRAL
SYMPATHETIC OUTFLOW
GANGLION BLOCKER
NEURON BLOCKERS
ALPHA BLOCKERS
BETA BLOCKERS
![Page 20: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/20.jpg)
BETA BLOCKERS
• Inhibition of Beta-1 receptors– Heart– JG apparatus– Brain
• Usually Cardioselective drugs are used• Celiprolol, Oxeprenalol, Pindolol, Alprenolol and
acebutalol• Esmolol, Atenolol, Nevibolol, Betaxolol and
bisoprolol.
![Page 21: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/21.jpg)
• Metoprolol succinate 50-100mg and tartrate 50-100mg twice daily
• Nebivolol 5-10mg• Propranolol 40-120mg twice daily• Carvedilol 6.25-25mg twice daily• Bisoprolol 5-10mg• Labetalol 100-300mg twice daily• Carvedilol and Labetalol is both alpha and beta
blockers
![Page 22: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/22.jpg)
• Not first line agents – reserve for post-MI/CHF• Cause fatigue and decreased heart rate • Adversely affect glucose metabolism• Mask hypoglycemic awareness• Non selective Beta blocker is contra-indiated
in Asthmatics
![Page 23: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/23.jpg)
ANTIHYPERTENSIVES
DIURETICS SYMPATHOPLEGICS
VASODILATORS
RAAS INHIBITOR
![Page 24: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/24.jpg)
Vasodilators
• May be – Arteriolar: Potassium Channel openers, CCB,
Dopamine agonist– Venodilator: Nitrates– Both arteriolar and Venous: Sodium
nitroprussides, ARB, ACE-i, Alpha blockers.
![Page 25: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/25.jpg)
Vasodilators
Calcium Channel Blockers
Potassium Channel Openers
NO Releasers
Dopamine Agonist
![Page 26: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/26.jpg)
Calcium Channel Blockers
Calcium Channel Blockers
Phenylalkylamines
Verapamil 80 to 120 mg thrice. ER-240 to 480 mg stat
Norverapamil
Benzothiazipines
Diltiazem180 to 360 mg
Dihydropyridines
Nifedipine, 30 to 90mg,Nicardipine,
Amlodipine 5-10mg etc
![Page 27: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/27.jpg)
• Blocks L- type calcium Channels• Reducing the frequency of opening of the calcium channels and that
results in Smooth muscle relaxation and depression of heart.• Dihydropyridines are also called as peripheral CCBs- Reflex tachycardia
more common– Nifedipine– Amlodipine- Maximum Half life– Nicardipine- Longest acting
• Parentral• DOC of hypertensive emergency
– Nimodipine: Cerebroselective– Clevidipine: Ultrashort acting recently approved for Emergencies
• Verapamil> Diltiazem
![Page 28: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/28.jpg)
VERAPAMIL-WHERE AND WHERE NOT?WHERE? WHERE NOT?
ANGINA SICK SINUS SYNDROME
PSVT CHF
HYPERTENSION ALONG WITH BETA BLOCKERS
HOCM
![Page 29: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/29.jpg)
Vasodilators
Calcium Channel Blockers
Potassium Channel Openers
NO Releasers
Dopamine Agonist
![Page 30: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/30.jpg)
POTASSIUM CHANNEL OPENERS• Releases potassium from smooth muscle leading to
hyperpolarisation and relaxation• Mainly Arteriolar• Hydralazine 25-100mg twice daily
– Drug induced lupus erythamatosis– Metabolised by acetylation*– Also a nitrate releaser- Needs intact endothelium
• Minoxidil 5-10mg– Prodrug activated to minoxidil sulphate by Phase 2 reaction– Safe in CKD– Hirsuitism
![Page 31: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/31.jpg)
Vasodilators
Calcium Channel Blockers
Potassium Channel Openers
NO Releasers
Dopamine Agonist
![Page 32: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/32.jpg)
NO releasers
Releases NO
Stimulate Guanalyl Cyclase
Increases cGMP
![Page 33: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/33.jpg)
• Sodium nitroprusside– Short acting– Continous i.v infusion in hypertensive emergency– Accumulation of cyanide and produce toxicity– Lead to hypothyroidism due to accumulation of
Thiocyanate.
![Page 34: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/34.jpg)
Vasodilators
Calcium Channel Blockers
Potassium Channel Openers
NO Releasers
Dopamine Agonist
![Page 35: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/35.jpg)
DOPAMINE AGONIST
• FENOLDOPAM• D1 receptor agonist• Peripheral vasodilation• Suited for Patients with Renal diseases due to
improved renal perfusion• ADR:– Hypokalemia– Increased intraocular pressure
![Page 36: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/36.jpg)
ANTIHYPERTENSIVES
DIURETICS SYMPATHOPLEGICS
VASODILATORS
RAAS INHIBITOR
![Page 37: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/37.jpg)
![Page 38: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/38.jpg)
RENIN INHIBITOR
• Aliskiren• Remikiren• Enalkiren• Can be used orally for Chronic hypertension• Not in protocol provided by JNC
![Page 39: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/39.jpg)
ACE INHIBITORS
• Captopril• Lisinopril• Benazapril• Enalapril- 5 to 20mg• Fosinopril and quinapril 10-40mg• Ramipril 5-10mg• Trandolapril 2-8mg
![Page 40: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/40.jpg)
Side effects
• Dry cough• Angioedema• Taste Disturbance• Orthostatic Hypotension• Renal Failure*• Contraindicated:– Pregnancy– Hyperkalemia– Renal artery Stenosis
![Page 41: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/41.jpg)
Angiotensin Receptor Blockers.
• Candesartan 8-32mg• Valsartan 80-320mg• Losartan 50-100mg – Competetive antagonist of TXA2
• Olmesartan 20-40mg • Telmisartan 20-80mg• Side effects are all same as ACE-i Other than
Cough and Angioedema.
![Page 42: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/42.jpg)
Initial Drugs of Choice for Hypertension
• ACE inhibitor (ACEI) • Angiotensin receptor blocker (ARB) • Thiazide diuretic • Calcium channel blocker (CCB)
![Page 43: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/43.jpg)
• CKD irrespective of age and Race – ACEi and ARB
• Black people without CKD- Thiazide and CCB
![Page 44: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/44.jpg)
JNC 8 Strategies
![Page 45: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/45.jpg)
Goal BP
![Page 46: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/46.jpg)
Lifestyle changes
• Smoking Cessation • Control blood glucose and lipids • Diet
Eat healthy (i.e., DASH diet) Moderate alcohol consumption Reduce sodium intake to no more than 2,400 mg/day
• Physical activity Moderate-to-vigorous activity 3-4 days a week averaging 40 min per session
![Page 47: Anti hypertensives](https://reader035.fdocuments.us/reader035/viewer/2022070510/58ac20f91a28abf03a8b508b/html5/thumbnails/47.jpg)