Hypertension

By Ankur

Rathore

What is Hypertension (HTN)?

High blood Pressure (BP) Systolic pressure > 140 mm Hg Diastolic pressure > 90 mm Hg Classification of Hypertension

Primary Secondary

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Pathophysiology of High BP
Blood pressure is the force of blood

exerted on arteries as it flows through them

Classification of BP Systolic Diastolic

(mm Hg)

(mm Hg)
<80 80-89 90-99 >100

Normal <120 Prehypertension 120-139 Stage 1 Hypertension 140-159 Stage 2 Hypertension >160

Blood Pressure Control Mechanism

Blood Pressure
Depends on: -Cardiac Output -Contractility -Fluid Volume -Peripheral vascular resistance Is affected by: -Nervous system -Kidney function -Hormonal changes -Capillary fluid shift

Causes of Hypertension
Aging
Smoking Obesity
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High sodium (salt) diet

High cholesterol Lack of exercise
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Drinking
Being insulin resistant

Risk Factors of HTN

Smoking Age Women older than 65 years of age Men older than 55 years of age Obesity Diabetes Lack of Physical activity Chronic alcohol consumption Family history of cardiovascular disease Sex men and postmenopausal women African American 2x more likely than Whites

Facts About Hypertension

According to American Society of HTN

50 millions of Americans are affected More than 90% of cases have no cause Children whos parents have HTN will more likely be affected HTN is called a SILENT KILER due to having no warning signs or symptoms but increases ones risk of cardiovascular collapse

Due to not being aware of having HTN, only of people are being treated

What are the Symptoms?

Prehypertension and Stage 1 HTN

Usually none

Stage 2 HTN

If occurs rapidly symptoms of Hypertensive Crisis

Headache

(pulsating behind eyes more in the

AM) Visual disturbances Nausea & vomiting

How is HTN Diagnosed?

Usually by routine doctors visit
One high BP reading does not mean you

have HTN Repeated BP reading will be done at different positions Complete physical, medical and family history will be performed Risk factors identified

Treatment of HTN
There are following steps in treating HTN 1. Lifestyle modification 2. First line treatment 3. Second line treatment 4. Third line treatment

Lifestyle Modification
Weight reduction
Reduction of sodium intake Decrease of alcohol intake

Smoking cessation
Increase in physical activity If inadequate, continue to first line

treatment

First Line Treatment

Continue with lifestyle modification
Initial drug selection:

Diuretic Beta-blocker If inadequate, continue to second line treatment

Second Line Treatment

Adding drugs from the folloving

categories

Angiotensine Converting Enzyme (ACE) Inhibitor Calcium Channel Blocker Angiotensine II Receptor Blocker (ARB) - blocker, - and -blocker If inadequate, continue to third line treatment

Third Line Treatment

Increase drug dose, or
Substitute another drug, or Add a second drug from another class

If inadequate, may need to do further

studies Serious organ damage may be present

Possible Outcomes of Delayed Treatment of HTN

Stroke
Myocardial infarction Congestive heart failure

Renal failure

www.nlm.nih.gov

Hypertension Treatment

Drugs Used to Treat HTN

Diuretics Furosemide (Lasix); Hydrochlorothizide (HydroDIURIL)
Beta blockers Atenolol (Tenormin); Propranolol (Inderal) ACE inhibitors Captopril (Capoten); Enalapril (Vasotec) ARBs Irbesartan (Avapro); Losartan (Cozaar) Calcium channel blockers Amlodipine (Norvasc); Diltiazem (Cardizem)

Site Of Action of Antihypertensive Drugs

Action of Beta-Blockers

Block vasoconstriction Decrease heart rate Decrease cardiac muscle contraction Tend to increase blood flow to the kidneys -> leading to a decrease in the release of renin

What Are Beta-Blockers?

Beta blockers are Beta-adrenergic

receptor blockers they block action of Adrenalin and Noradrenaline (SNS stimulants), which are involved in Fightor-flight response There are two types of Beta receptors

1 found mostly in the heart 2 found mostly in the lungs

Classification of Beta Blockers

1 receptors blockers

Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (Zabeta) Metoprolol (Lopressor, Toprol-XL) Nadolol (Corgard) Propranolol (Inderal, Inderal LA) Labetolol (Normodyne, Trandate)

1, 2 receptor blockers

1, 2, receptor blockers

Beta Blockers
Commonalities: -One chiral center -Aromatic ring -Side alkyl chain -Secondary hydroxyl group -Amine

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Discovery of Beta Blockers

Started in 1950s when Heart disease had become a

serious epidemic By Sir James Black, an English physician and a basic scientist who started research in Glasgow Veterinary School laboratory His goal was to find a drug that would decrease the oxygen demand in the heart He developed the first Beta-blocker Propranolol (Inderal) in 1964 It successfully blocked the hearts adrenaline-responsive beta-receptors Hence the name Beta-Blockers He was awarded the Nobel Prize in 1988 for this and other discoveries

Beta Blockers Side Effects

Fatigue

Orthostatic hypotension
Weakness Blurred vision Stuffy nose Impotence Rash CHF

Bradycardia
Pulmonary edema

Treatment of Side Effects

Changing position slowly
Sit at the edge of bed or chair for a few

minutes before standing up Drink adequate amount of fluids Contact physician in more serious case to adjust the dose or change the medication

How Much the Drug Cost?

Drug Name Dosage of PO drug Frequency of Use Monthly Cost of Generic Monthly Cost of Brand

Atenolol (Tenormin)
Betaxolol (Kerlone) Bisoprolol (Zabeta)

25mg 50mg
10mg 10mg

2x/day
1x/day 1x/day

$10 $10
$30 $38

$47 $47
$41 $55

Labetolol (Normodyne)
Metoprolol tartrate (Lopressor) Nadolol (Korgard) Propranolol (Inderal)

100mg
25mg 50mg 20mg 20mg 40mg

2x/day
1x/day 1x/day 1x/day 2x/day 2x/day

$26
$9 $9 $18 $13 $15

$38
$35 $35 $59 $44 $56

Propranolol
Initial Dose in treating HTN - 80mg PO 2x/day - 80mg extended release form 1x/day Increase at 3-7 day intervals to max daily dose of 640mg
Maintanance dose -120-240mg daily -120-160mg extended release form

Nursing2007 Drug Handbook

Propranolol Metabolism
Part of my future research

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Further Research
Development of propranolol from the lead

compound Pharmacokinetics and pharmacodynamics of propranolol in our body Interview with heart specialists at Atlanta Medical Center about current treatment of HTN Interview with my family members and clients with HTN how is their life affected by this condition

QUESTIONS?

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References

Beta Blockers common dosage guidelines (2008). The clinicians Ultimate Reference Retrieved March 15, 2008 from http://www.globalrph.com/beta.htm Karch, A. (2006). Focus on Nursing Pharmacology. (3rd. Ed.). Philadelphia: Lippincott Williams &Wilkins Pharmacokinetics and Pharmacodynamics Mehvar, R.; Brocks, D. R. (2001). Stereospecific of Beta-Adrenergic Blockers in Humans. J Pharm Pharmaceut Sci 4(2), 185-200. Retrieved march 15, 2008 from http://images.google.com/imgres?imgurl=http://www.ualberta.ca/~csps/JPPS4(2)/ R.Mehvar/Fig2.gif&imgrefurl=http://www.ualberta.ca/~csps/JPPS4(2)/R.Mehvar/be tablockers.htm&h=629&w=490&sz=9&hl=en&start=7&tbnid=br7jKXMxHZijM:&tbnh=137&tbnw=107&prev=/images%3Fq%3Dpropranolol%26g bv%3D2%26hl%3Den%26sa%3DG Popple, I. (2004, October 14). How Beta-Blockers came To Be. McGill Reporter, 37(3), 2004-2005. Retrieved March 15, 2008 from http://www.mcgill.ca/reporter/37/03/black/ Propranolol tablets Retrieved March 15, 2008 from psyweb.com Treating the High Blood Pressure and Heart Disease: Beta-blockers. (2008). Consumer Reports:Best Buy Drugs Retrieved March 13, 2008 from http://www.consumerreports.org/health/resources/pdf/best-buydrugs/2pager_BetaBlockers.pdf