Cardiology Review: HTN: Julia Akaah M.D

Cardiology Review: HTN
Julia Akaah M.D.

 Of the estimated 50 million Americans that
have HTN (average BP>140/90):
 90% have essential HTN
 Remainder have secondary HTN
 Renal parenchymal disease
 Renovascular disease
 Pheochromocytoma
 Cushing’s syndrome
 Primary hyperaldosteronism
 Coarctation of the aorta
 Autosomal dominant or recessive diseases of the

adrenal-renal axis that result in salt retention
Laboratory Evaluation
 Help identify patient’s baseline and any
evidence of organ damage
 Urinalysis
 Hematocrit
 Electrolytes, BUN, Cr, glucose, Ca
 Uric acid
 Fasting lipid profile
 CXR
 ECG
 echocardiogram
Initial Management
 Goal of treatment is to prevent long term

sequelae
 Most patients should be given a 3-6 month
opportunity to reduce BP by
nonpharmacologic means
Pharmacologic therapy
 Diuretics
 Beta Blockers
 Alpha1-receptor blockers
 Centrally acting Adrenergic Antagonists
 Calcium channel blockers
 ACE-I/ARBs
 Vasodilators
Diuretics: Mechanism of Action
 Initiate natriuresis and decrease
intravascular volume
 May initially increase peripheral

resistance and decrease cardiac output
 May produce mild vasodilation by

inhibiting Na entry into vascular smooth
muscle cells
Thiazide diuretics
HCTZ, chlorthalidone, metolazone
 Block sodium reabsorption in distal
convoluted tubule by inhibition of the
thiazide sensitive Na/Cl co transporter
 Usually ineffective when creatinine

>2.0mg/dl
 Side effects:
 Weakness  Hypercalcemia
 ms. Cramps  Hyperglycemia
 Impotence  Hyperuricemia
 Hypokalemia  Hyponatremia
 Hypomagnesemia  thiazide induced
 increased LDL and
pancreatitis
TG
Loop diuretics
furosemide, torsemide, bumetanide
 Block Na reabsorption in the thick ascending
loop of Henle by inhibiting the Na/K/2Cl
cotransporter
 Most effective in patients with associated renal
insufficiency
 Can cause hypomagnesemia, hypocalcemia,
hypokalemia, increase fasting glucose, postural
hypotension and reversible ototoxicity (dose
related)
Potassium sparing diuretics
spironolactone, amiloride,
triamterene
 Spironolactone competitively inhibits the
action of aldosterone
 Triamterene and amiloride inhibit the
reabsorption of Na and secretion of K
 Weak agents when used alone therefore
combined with thiazide for added potency
 Hyperkalemia, gynecomastia, renal tubular
damage and renal calculi with combination
of triamterene and HCTZ
Beta Blockers
 Competitive inhibition of catecholamines
at B- adrenergic receptors which
decreases heart rate, cardiac output, and
decreases plasma renin
 Advantageous in patients with increased
adrenergic drive, LVH and previous MI and
stable HF
 Cardioselective beta blockers have primarily
beta-1 blocking effects (atenolol, metoprolol,
bisoprolol, etc.)
 therefore can be given at low doses, with caution in

mild COPD, DM and peripheral vascular disease
 At higher doses, selectivity is lost
 Nonselective (nadolol, propranolol, timolol)
 Alpha and beta antagonists (labetolol, carvedilol)

 As lipid solubility increases, the liver metabolizes
more of the drug and more enters the brain, and
therefore duration of action is shorter
 Very lipid soluble: propranolol, metoprolol, timolol
 As lipid solubility decreases the drug is renally

eliminated and less drug enters the brain and
therefore duration of action is longer
 Least-lipid soluble: atenolol, betaxolol, nadolol
 Side effects: high degree AV block, HF,

Raynauds, impotence, insomnia, depression,
contraindicated in asthma, severe COPD, and
DM
Alpha1-receptor blockers
prazosin, terazosin, doxazosin
 Block alpha receptors, producing arterial
and venous vasodilation
 Side effects
 First dose effect
 Hypotension
 Syncope
 May decrease total cholesterol and TG levels
and increase HDL
Centrally acting Adrenergic Antagonists
methyldopa, clonidine
 Stimulate presynaptic alpha 2-adrenergic
receptors leading to decrease in peripheral
sympathetic tone and systemic vascular
resistance
 Side effects: bradycardia, drowsiness, dry

mouth, orthostatic hypotension, galactorrhea
and sexual dysfunction
 acute withdrawal of clonidine can cause rebound HTN
Calcium channel antagonists
 Effective in both blacks and whites
 Dihydropyridines (nifedipine, felodipine,

amlodipine etc.)
 Nondihydropyridines (verapamil, diltiazem)

 Cause arteriolar vasodilation by selective
blockade of the slow inward calcium
channels in vascular smooth muscle cells.
May cause initial natriureses
 Side effects: constipation, nausea, HA,

orthostatic hypotension, lower extremity
edema
Inhibitors of the renin-angiotensin
system: ACE-I
 Inhibition of ACE leads to arteriolar and
venous vasodilation and to natriuresis
 beneficial in pts. with associated heart
failure or kidney disease
 Retard progression of nephropathy and
proteinuria
 ACE-I prevent recurrent MI and the
development of CHF in persons who have
had an MI complicated by reduced LV
function
 Dose reduction in renal insufficiency and
contraindicated in pregnancy
 Side effects: orthostatic hypotension,
hyperkalemia, cough, angioedema, and
loss of renal function
Angiotensin II receptor blockers
losartan, valsartan, candesartan
 Cause decreased peripheral resistance by
by inhibiting the actions of angiotensin II
at its cell surface receptor
 Side effect profile similar to ACE-I but

decreased likelihood of cough
 Avoid in pregnancy
Vasodilators
hydralazine, minoxidil
 Direct dilatation of arterioles
 Dose should not exceed 200mg/d because
of the increased risk of lupus like
syndrome
 Side effects: headache, palpitations,
tachycardia, fluid retention, lupus like
syndrome, and peripheral neuropathy with
hydralazine
 Side effects: weight gain, hirsutism and
pericardial effusions with minoxidil
 Don’t use in ischemic heart disease,

dissecting aneurysm, or cerebral
hemorrhage because it can increase
cardiac output and cerebral blood flow
 Drugs for monotherapy: diuretics, B
blockers, CCBs, ACEI, alpha-beta blockers,
and ARBs
 Diuretics and calcium antagonists are more
effective in blacks and elderly
 Centrally acting alpha agonists are not
used as monotherapy but are appropriate
in combination with diuretics
 Vasodilators are best used as third drug in
combination with diuretics and adrenergic
inhibitors
Hypertensive crisis
 Hypertensive Urgency
 DBP >120-130mmHg
 BP reduction within several hours
 Hypertensive Emergency
 SBP >210, DBP >130
 Manifestations of acute organ disease
 Immediate BP reduction by 20-25%
Inservice topics related to HTN:
 Antihypertensive monotherapy for elderly

black patient
 Rebound hypertension with clonidine
 Identify drugs that can unmask
hyporeninemic hypoaldosteronism
 Hypertension in DM with proteinuria
 Hypertensive crisis
 In several office visits, a 33 yr old woman has an
average BP of 150/105 mmHg. She has a strong
family history of HTN. She is asymptomatic. Except
for mild obesity, the physical examination is normal.
The results of routine laboratory studies are also
normal. She is a nonsmoker. She states that she
recently married and is trying to get pregnant. In
addition to lifestyle recommendations, what is the
most appropriate drug to consider for BP reduction?
a. Atenolol
b. Methyldopa
c. Lisinopril
d. HCTZ
e. Losartan

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Cardiology Review: HTN

Julia Akaah M.D.

 Coarctation of the aorta

 Autosomal dominant or recessive diseases of the

 Goal of treatment is to prevent long term

 May initially increase peripheral

 May produce mild vasodilation by

 Usually ineffective when creatinine

 therefore can be given at low doses, with caution in

 Nonselective (nadolol, propranolol, timolol)

 Alpha and beta antagonists (labetolol, carvedilol)

 As lipid solubility decreases the drug is renally

 Side effects: high degree AV block, HF,

 Side effects: bradycardia, drowsiness, dry

 Dihydropyridines (nifedipine, felodipine,

 Nondihydropyridines (verapamil, diltiazem)

 Side effects: constipation, nausea, HA,

 Side effect profile similar to ACE-I but

 Don’t use in ischemic heart disease,

 Antihypertensive monotherapy for elderly

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