[28] HYPERTENSION 3.

Classification of BP
1. Types of HTN:
a. Essential HTN not known to be
caused by an identifiable factor
b. Secondary HTN linked to a
specific cause (renal/adrenal
disease, drug induced)
2. Drug induced HTN corticosteroids,
excessive alcohol (>1-2 drinks/day), NSAIDS,
ACTH, amphetamines, appetite
suppressants, caffeine,CSA, erythropoietin,
estrogen (eg: BC with higher doses), oral
decongestants (pseudoephedrine), thyroid
hormone (if too much), duloxetine &
venlafaxine (at higher doses), chemo drugs
(bevacizumab-Avastin, sorafenib-Nexavar)
DIURETICS - Diuretics Li clearance, high risk of Li toxicity- should avoid use.
Counseling: may make you feel dizzy & lightheaded when getting up from a
sitting/lying position. K+ suppl. may be needed. Will cause you to urinate more
throughout the day.
(Normal) <120/80
(Pre-HTN) 120-139 / 80-90
(Stage 1) 140-159 / 90-99 consider
thiazide. May consider ACEi/ARB, BB,
CCB, combo
(Stage 2) >160 / >100 start with 2
drug combo (usually thiazide + ACEi,
ARB, BB, or CCB
st
BB are not generally 1 line for CAD
prevention
4. Lifestyle modification:
a. DASH diet high in fruits & veg. low
fat dairy with red. Saturated and
total fat
b. Reduce Na+ - healthy adults
should be <2.4 g/day. If
hypertensive, <1.5 g.day
c. Alcohol 1 drink/day (women) 2
drinks/day (men)

Thiazides inhibit Na reabsorp at distal tubules. reduced renal fxn

Also
excretion of K and H+
Thiazides &
Chlorothiazide (Diuril)
K+ sparing
Chlorthalidone (Thalitone) diuretics
Hydrochlorothiazide (Microzide-cap, DCT
Oretic, Esidrix)
Indapamide (Lozol)
Metolazone (Zaroxolyn)
Methylchlothiazide

1. S/E: HYPO K+ , Na+, Mg, HYPER Ca+,

UA, elevated lipids, BG,
photosensitivity, rash

2. Contraindications: hypersens to
sulfonamide drugs. Sulfa Allergy may
st
not cross react, but 1 dose should be
given under supervision

3. May not be as effective if CrCL < 30,

except metolazone may work in pts with
Loop diuretics inhibit reabs of Na & Cl-
from the ascending loop of Henle & distal
rental tubule. Causes excretion of water, Na,
Cl-, Mg, Ca
Used more for edema, occasionally for BP if
renal fxn
Furosemide (Lasix) - oral loop equiv = 40
mg
Bumetanide (Bumex) - oral loop equiv = 1
mg
Torsemide (Demadex) - oral loop equiv = 20
mg
Ethacrynic Acid (Edecrin)
Loops work in ascending LH
1. S/E: HYPO K+, Na, Mg, Cl, Ca , UA,
BG, orthostatic hypotn, metabolic
alkalosis, photosensitivity, ototoxicity
(MORE with ethacrynic acid)
[loops can inc ototox potential of
aminoglycosides; Do not use ethacrynic
acid with other loops due to ototox]
2. Contraindications: caution in pts with
sulfa allergy (except ethacrynic acid)
3. Monitoring: renal fxn, fluid status, BP,
electrolytes, hearing with high doses/
rapid IV admin (IV admin is light
sensitive-use amber bottle)
K+ sparing Diuretics /Aldosterone receptor Antagonists compete w/ Aldosterone for
receptor sites in distal renal tubules. excretion of Na, Cl, water (conserves K+ and H+)
Amiloride (Midamor)
Triamterene (Dyrenium)
Triamterene + HCTZ (Maxzide, Dyazide)
Spironolactone (Aldactone) non selective aldo antag (also blocks androgen & progesterone
receptors)
Eplerenone (Inspra) selective aldo antag

1. BBW: spironolactone tumor risk. Amiloride & triamterene hyperkalemia, potentially fatal.

2. S/E: HYPER K+, Cr . For Spironolactone = gynecomastia, breast tenderness,

impotence, hypercloremic met. acidosis
3. Contraindications: Anuria, K > 5.5, SCr >2.5 CrCl <30

RAAS Inhibitors
All RAAS inhibitors vasoconstriction, aldosterone release & benefit renal protection & HF.
Angioedema is more common in black pts. It is more likely caused by ACEi/ARBs & if a pt had
angioedema with either class of agents, all others are contraindicated. Report s/s of : swelling
of lips, mouth, tongue, or neck

ARBS block Ang II from binding to AT1 4. CI: angioedema & bilateral artery
receptor on vascular smooth muscle stenosis
Valsartan (Diovan) 5. DI: aliskiren is a 3A4 substrate.
Losartan (Cozaar) Atorvastatin
Irbesartan (Avapro) aliskiren levels. Aliskiren furosemide
Candesartan (Atacand) levels
Olmesartann (Benicar)
Telmisartan (Micardis)
Eprosartan (Teveten)
Azilsartan (Edarbi)
1. BBW: can cause injury & death to
developing fetus. d/c when preg is
st rd
detected. Preg Cat C (1 trim), D (2,3
trim) . Valsartan is Preg D.

2. S/E: HyperK+, angioedema, hypotn,

headache, dizziness
3. CI: angioedema & bilateral artery
stenosis

Renin Inhibitor directly inhibits renin (resp

for conversion of angiotensinogen to ang I)
Aliskiren (Tekturna)

1. Avoid high fat foods. +/- food

2. BBW: can cause injury & death to
developing fetus. d/c when preg is
st rd
detected. Preg Cat C (1 trim), D (2,3
trim) [28]
3. S/E: HyperK+, angioedema, hypotn.
ACEi inhibits ACE from converting Perindopril (Aceon)
Ang I to Ang II (a potent VC) Trandolapril (Mavik)
Preload Afterload
Benazepril (Lotensin)
1. BBW: can cause injury & death to
Captopril (Capoten) take 1 hr before developing fetus. d/c when preg is
meals, TID st
detected. Preg Cat C (1 trim), D (2,3
rd

Enalapril, Enalaprilat IV inj (Vasotec) trim)

Fosinopril (Monopril)
2. S/E: Cough, HyperK+, angioedema,
Lisinopril (Prinivil, Zestril)
hypotn. Captopril has more SEs
Quinapril (Accupril)
(taste perversion, rash)
Ramipril (Altace)
Moexipril (Univasc)
3. CI: angioedema & bilateral artery stenosis
 Beta Blockers
BB can cover up symptoms of hypoglycemia (shakiness, anxiety) but not sweating/hunger
mainly occurs in non- selective agents
BB can enhance the effects of insulin & oral hypoglycemic (sulfonylureas)
Use with caution with other drugs that slow HR (digoxin)
-1 selective blockers (AMEBBA atenolol,
metoprolol, esmolol, bisoprolol, betaxolol,
acebutolol)
Acebutolol (Sectral) ISA (B1 selec, B2 at
high doses)
Atenolol (Tenormin)
Betaxolol (Kerlone)
Bisoprolol (Zebeta)
Metoprolol tartrate (Lopressor)
Metoprolol succinate (Lopressor XL,
Toprol XL)
1. S/E : HR, hypotn, fatigue, dizziness.
Less common
depression, libido (1 for propranolol
but any can cause it
2. CI: severe bradycardia, 2
nd rd
or 3 degree
heart block
3. Caution in those with DM who have
recurrent hypoglycemia, asthma,
COPD
CCB
Covera HS, Adalat CC, Sular have
capsular shells that can be seen in feces
Clevidipine (for inpt DPH CCB) CI in
soy/egg allergy
Dihydropyridines (amlodipine,
nifedipine)
1. 1 used for HTN, angina
2. Cause VD, which can lead to reflex
tachy, HA, flushing, periph edema
DHP CCB inhibits Ca from entering the
slow channels (voltage sensitive areas of
vascular SM), resulting in peripheral VD and
periph vascular resistance
Amlodipine (Norvasc)
Felodipine (Plendil)
Nifedipine IR (Procardia) , ER
-1 selective blocker & Nitric Oxide
Nebivolol (Bystolic)
1. S/E: HA, fatigue, dizziness, diarrhea,
nausea ; Nitric oxide causes peripheral
VD
-1, -2 blockers ; ISA =(CAPP acebutolol,
carteolol, penbutolol, pindolol)- these do not
HR as much as others
Propranolol (Inderal LA, InnoPran XL)
Carteolol (Cartrol)
Nadolol (Levatol)
Penbutolol (Levatol)
Pinodolol (Visken)
Timolol (Blocadren)
Non selective & blockers
Carvedilol (Coreg, Coreg CR) take with
food
Labetalol (Trandat, Normodyne) 200
2400 mg/d
1. S/E: same as above. Preg Cat C
Non dihydropyridines (diltiazem, verapamil)
1. 1 used for arrhythmias to
control/slow HR, sometimes HTN,
angina
2. Negative inotropes (contraction force)
3. Negative chronotropes (HR)
4. Diltiazem & verapamil are 3A4
Inhibitors & substrates
5. S/E: HR, constipation (esp
verapamil), gingival hyperplasia
(Adalact CC, Procardia XL, Afeditab CR)
Nisoldipine ER (Sular)
Nicardipine IR (Cardene- TID), ER (Cardene
SR)
1. S/E: Peripheral edema, reflex tachy, HA,
flushing
2. Do not use SL nifedipine, may inc risk
of MI
Non DHP CCB inhibits Ca from entering
the slow channels (voltage sensitive areas of
vascular SM) & myocardium, result in coronary
VD
Diltiazem (Cardizem, Dilacor, Dilt-CD,
Cartia, Tiazac, Taztia)
Verapamil (Calan and SR, Isoptin SR,
Verelan PM, Covera HS)
1. S/E: edema, AV block, bradycardia,
hypotn, arrhythmias, HF, HA,
constipation (more with verapamil),
gingival hyperplasia
[28]
 Centrally Acting 2 Adrenergic Agonists
Clonidine is commonly used for resistant HTN & in pts who cannot swallow (dysphagia,
dementia) since it comes as a patch. ed Qweek, so good for adherence
o Sometimes its used off label to treat opioid withdrawal to block nervousness, anxiety, help
with sleep
o Do not stop abruptly, it will cause withdrawal syndrome (high BP, anxiety, H, tremors)
taper over 2-5d

Centrally acting 2 Agonists stimulates 2 Direct vasodilators VD of arterioles w/ little effect

in brain which results in reduced sympathetic
outflow from CNS
Clonidine (Catapres, Catapres TTS
patch, Duraclon Inj, Clonidine ER susp)
Guanfacine (Tenex)
Methyldopa (Aldomet)
1. S/E: bradycardia, dry mouth, drowsiness,
fatigue, lethargy, depression, psychotic
rxns, nasal stuffiness, impotence, &
exacerbation of Parkinsons. skin irritation
with patch
2. Methyldopa above s/e +
hypersensitivity rxns, hepatitis,
myocarditis, hemolytic anemia, post
coombs test, lupus like syndrome.
3. Rebound HTN if stopped abruptly.
on veins
Hydralazine (Apresoline) Afterload
1. S/E: Lupus like syndrome (report fever,
joint/muscle ache, fatigue), reflex tachy
Minoxidil
1. S/E: fluid retention, tachycardia,
aggravation of angina, pericaridla effusion,
hirsutism (used for hair growth - Rogaine)
Blockers binds to 1 which results in VD of
st
arterioles & veins. Used mostly for BPH. Not 1
line for HTN
Prazosin (Minipress)
Terazosin (Hytrin)
Doxazosin (Cardura)
1. S/E: orthostatic hypotn, syncope with
st
1 dose, dizziness, fatigue
2. Caution w. concurrent use with PDE5 inh
(additive effect on BP, dizziness)

Combo Drugs
Lotrel Amlodipine + benazepril Micardis HCT Telmisartan + HCTZ
Exforge Amlodipine + valsartan Diovan HCT Valsartan + HCTZ
Azor Amlodipine + olmesartan Benicar HCT Olmesartan + HCTZ
Lotensin HCT Benazepril + HCTZ Tenorectic Atenolol + chlorthalidone
Prinzide, Lisinopril + HCTZ Ziac Bisoprolol + HCTZ
Zestorectic
Avalide Irbesartan + HCTZ Dyazide, Triamterene + HCTZ
Hyzaar Losartan + HCTZ maxzide

Hypertensive Urgency o Do not use nifedipine SL!

BP > 185/ 110 w.o acute organ damage
Txt: PO meds
o Captopril (Capoten) hypotn, K,
angioedema (shortest T acei)
o Clonidine (Catapres) hypotn,
drowsiness, sedation, dry mouth
o Labetolol (Normodyne, Trandate)
hypotn, heart block,
bronchoconstriction
Hypertensive Emergency Nicardipine
BP > 185 / 110 with organ damage (Cardene) o
(encephalopathy, MI, unstable angina, Fenolopam
PE, eclampsia, stroke, aortic (Corlopam)
dissection) o NTG IV will absorb into plastic,
Txt: IV meds keep in glass bottles and do not use
o Clevidipine tubing.
(Cleviprex) o o Enalaprilat (Vasotec IV)
o Hydralazine
Nitroprusside
o Labetalol, Esmolol
(Nipride) o
 [28]
Chapter 28: HTN
Mainly asymptomatic - symptoms not usually seen until BP is very high
1 in 4 pts d/c HTN meds within 6 months - the major cause is lack of understanding of
the necessity of treatment and the cost
Most cases are essential HTN - no known cause - poor lifestyle and genetics are contributory
Secondary HTN - renal disease, adrenal dz, or drug induced
Drug Induced HTN - CS, excessive EtOH, NSAIDs, ACTH, amphetamines, stimulants,
appetite suppressants, caffeine, cyclosporine, tacrolimus, erythropoietin, estrogen
(OPCs), decongestants, thyroid meds, duloxetine and venlafaxine if HD, oncology drugs,
herbals, etc
BP Classification
Normal - Less than 120/80
Pre-HTN - 120-139/80-89
Stage 1 - 140-159/90-99
Stage 2 - greater than 160/100
Compelling Indications and Treatment per JNC VII
HF - ACE, ARB, BB, diuretic, aldosterone antagonist
Post MI - ACE, BB, aldosterone antagonist
High risk of CAD - ACE, BB, diuretic, CCB
DM - ACE, ARB, BB, CCB, diuretic
CKD - ACE, ARB
Recurrent Stroke Prevention - ACE, diuretic
JNC VII Treatment Goals - < 140/90, unless pt has DM or CKD < 130/80
Treatment Based on AHA Guidelines
General CAD Prevention - < 140/90 - use any drug or combo
High CAD Risk - < 130/80 - ACE, ARB, thiazide, CCB, or combo
Stable Angina < 130/80 - BB and ACE or ARB
Unstable Angina/NSTEMI/STEMI < 130/80 - BB and ACE or ARB
LVD < 120/80 - ACE or ARB + BB + aldo antagonist + diuretic + hydralazine/isosorbide (if AA)
Diuretics
Thiazides inhibit Na reabsorption in the distal convoluted tubule causing increased
excretion of Na, H2O, and K. The long term BP effect is from vasodilation and decr
resistance
HCTZ (Microzide), Indapamide, Chlorthalidone, Metolazone
SE - hypokalemia, hyperuricemia, elevated lipids, hyperglycemia,
hypercalcemia, hyponatremia, hypomag, photosenstivity, rash
Sulfa Allergy - not much cross reactivity, but give first dose under supervision
Thiazides loose effectiveness in CrCl < 30, except metolazone still works in these pts
Loops work on the ascending loop by blocking Na reabsorption and causing volume depletion
They interact with the chloride co-transport system causing increased excretion
of water, Na, Cl, Mg, and Ca
Furosemide (oral loop dose equivalency = 40 mg), Bumetanide (1mg), Torsemide (20
mg), Ethacrynic Acid
SE - hypokalemia, orthostatic hypotension, decreased Na Mg Cl Ca (while thiazides
increase calcium), metabolic alkalosis, hyperuricemia, hyperglycemia,
photosensitivity, and ototoxicity (more with ethacrynic acid, high doses, and IV
administration)
AVOID use w/ AMGs - increased risk for ototoxicity
Caution in pts w/ sulfa allergy - except with ethacrynic acid
Potassium Sparing are not as effective on BP and are not used as monotherapy
MOA - compete with aldosterone for receptor sites in distal renal tubule -
increasing excretion of Na, Cl, and water, while conserving K and H
Triamterene, Spironolactone, Amiloride, Epleronone
 BBW - tumor risk w/ spironolactone (seen in rats)
Contraindications - CrCL < 30
SE - hyperkalemia, increased SCr, and w/ spironolactone - gynecomastia and breast
tend
DO not give lithium and diuretics together - may reduce clearance of the lithium
RAAS Inhibitors - vasoconstriction and decrease aldosterone release - renal and heart failure
protection
Angioedema is more common in AA, and more likely w/ ACEs than ARBs. If a person
gets it with any of these agents, all others are contraindicated.
Do not bother using Captopril - dosed 2-3x/day 1hr before meal, and more SE - taste disturb, rash
ARBs - block AngII from binding to the AT1 receptor on vascular smooth muscle
BBW - serious injury/death to fetus, d/c in pregnancy
Contraindications - angioedema, bilateral renal artery stenosis, coadministration
w/ aliskiren in DM patients
ACE-I - prevent conversion of AngI to AngII, which is a potent vasoconstrictor
All warnings the same as ARBs, except chance for ACE Cough and acute renal failure
Renin Inhibitor - Aliskiren (Tekturna) - renin is responsible for the conversion of Ang to AngI
Same warnings as ARBs/ACE - but also do not use in combo with CrCl < 60
Can cause angioedema as well and if occurs it is contraindication to use
Metabolized by CYP3A4 - do not use with cyclosporine, and levels increased by atorvastatin
BBs - for HTN, post-MI, angina, HF, and migraine ppx
Different Types/Actions
Beta+Alpha Blocking - for heart failure and HTN (different dosages/titrations)
Carvedilol (Coreg), Labetaolol (Trandate)
BB+NO - Nebivolol (bystolic) - indicated for HTN, used off label for HF - benefit of NO
unclear
BB+ISA - CAPP = Carteolol, acebutolol, penbutolol, pindolol - they act as antagonist and
partial agonist at the Beta receptor (less HR lowering) - good in those who need BB but
have excessive bradycardia
B1 Selective - AMEBBA - Atenolol, metoprolol, esmolol, bisoprolol, betaxolol, acebutolol
B1+B2 Nonselective - Propranolol, timolol, pindolol, penbutolol, nadolol, carteolol
Lipid Solubility - Propranolol has highest lipid solubility = more sedation and depression
BBs can cover up symptoms of hypoG (mainly non-selective) - but dont mask sweating and
hunger
Caution in pts with asthma - use B1 selective, and keep to lower dose to maintain selectivity
Do not initiate any if active asthma bronchospasm
Caution in those w/ DM and recurrent hypoG, asthma, severe COPD, and resting limb ischemia
Metoprolol IR should be taken w/ food, while the ER can be taken without regard to meals
Carvediolol - take all forms with food - CR is less bioavailable than IR - dose conversion 10:3.125
Substrate for CYPs, cation DDI (rifampin)
Pregnancy - Labetaolol is used first line, may also use nifedipine. Used to use methyldopa but many
SE
CCBs
DHPs - end in pine - used primarily for HTN and angina - cause peripheral vasodilation - can
lead to reflex tachycardia, HA, flushing, and peripheral edema (amlodopine has lower freq of
SE)
MOA - Inhibit Ca ions from entering the slow channels of vascular SM
resulting in peripheral arterial vasodilation and decreased PVR
Amlodopine, nifedipine, felodipine, nicardipine, etc
Do not use sublingual nifedipine, may increase risk of MI
Non-DHPs - used primarily for arrhythmias and rate control, but also can be for HTN and angina
MOA - inhibit Ca ions from entering slow channels of vascular SM and myocardium
causing coronary vasodilation - Diltiazem, Verapamil
Negative inotropes (decrease contraction force) and negative chronotropes (decrease HR)
 3A4 Inhibitors and substrates - many significant DDIs
Have more SE - constipation (esp w/ verap) and may cause gingival hyperplasia,
edema, AV block, bradycardia, arrhythmias, HF, HA
Central Acting Alpha Agonists - Clonidine - stimulate alpha-2-adrenergic receptors in the brain to
reduce sympathetic outflow from the CNS - used for resistant HTN and those who cannot swallow
(patch)
Many SE - sedation, dizziness, lethargy, dry mouth, can aggravate depression and cause sex dysf
Off label for opioid withdrawal - for nervousness, anxiety, and sleep
Must taper over 2-5 days, abrupt cessation very dangerous - very high BP, HA, ANX, tremor
Others include - Guanfacine (Tenex/Intuniv) for ADHD, Guanabenz, and Methyldopa
Methyldopa also causes hypersenstivity rxn, hepatitis, myocarditis, hemolytic anemia, etc
Clonidine Patch is applied weekly
Direct Vasodilators - direct effect on arterioles with little effect on veins
Hydralazine - SE include lupus like syndrome (dose and duration related), reflex
tachycardia
Minoxidil - SE include fluid retention, tachycardia, aggravating angina, pericardial effusion,
hirsutism
Alpha Blockers - bind to a-1 receptor causing vasodilation of arterioles and veins - mostly for BPH
Doxazosin (Cardura), Terazosin (Hytrin), Prazosin (Minipress)
Caution chance of orthostasis and syncope with first dose - enhanced by PDE5 inhibitors
Hypertensive Urgency - BP > 185/110 without acute target organ damage
Treatment - oral meds w/ fast onset of action (15-30mins) and reduce BP gradually over 24-48h
Drugs for HTN Urgency - labetalol, clonidine, captoprol - do not use nifedipine sublingual
Hypertensive Emergency - BP > 185/110 with acute target organ damage (enecphalopathy,
MI, unstable angina, pulmonary edema, eclampsia, stroke, aortic dissection)
Treatment - reduce SBP or MBP by 10-15% in first 30-60mins, and continue to lower gradually
over 24h - use IV med
Drugs for HTN Emerg - Clevidipine (lipid emulsion), sodium nitroprusside, nicardipine,
fenoldapam, NTG (keep in glass bottles, avoid PVC tubing), enalaprilat, hydralazine, labetolol,
esmolol
Diuretics:
Thiazides: Work on the distal convoluted tubule to inhibit Na+. Sulfa Allergy. Can
cause
hypokalemia, HYPERcalcemia, elevated lipids, hyperuricemia (gout),
hyperglycemia,
photosensititivity, rash.
Chlorthalidone (Thalitone)
Hydrochlorothiazide
Metolazone (Zaroxolyn): may work in reduced renal function more than others.
Loops: work in the ascending loop of Henle to inhibit Na+. Sulfa Allergy except
ethacrynic
acid. Ototoxic. Can cause hypokalemia, HYPOcalcemia, hyperuricemia (gout),
elevated lipids,
hyperglycemia, photosensititivity.
furosemide (Lasix): Oral Loop Dose
Equivalency = 40mg
bumetanide = 1mg
Torsemide (Demadex) = 20mg
ethacrynic acid (Edecrin) = 50mg

Potassium-Sparing: Work in the DCT and collecting ducts. CI in CrCl <30 ml/min
and
hyperkalemia.
triamterene (Dyrenium)
triamterene + HCTZ (Maxzide, Dyazide)
amiloride(Midamor)
spironolactone (Aldactone): Can cause gynecomastia and breast tenderness.
BBW for tumor risk.
epleronone (Inspra): for Heart Failure and
HTN
RAAS Inhibitors:
***All have a BBW to discontinue if pregnant. CI in renal artery stenosis,
angioedema, and
pregnancy.
All can cause hyperkalemia too.
Angioedema-swelling of lips, mouth, tongue, face, neck) more common in blacks.
If they

get angioedema, all others in the class including ARBs and Aliskiren are CI. It can
be fatal.

ACE Inhibitors:
***Can cause dry cough. If so, switch to
ARB.
benazepril (Lotensin)
enalapril (Vasotec)
lisinopril (Prinvil, Zestril)
quinapril (Accupril)
 ramipril (Altace)
ARBs:
valsartan (Diovan)
losartan (Cozaar)
olmesartan (Benicar): ***Can cause Sprue-
like enteropathy (severe diarrhea)
telmesartan (Micardis)
irbesartan (Avapro)
Direct Renin Inhibitor:
aliskiren (Tekturna)
Do not use with with ACEi or ARB in patients with diabetes

Beta Blockers:
***NOT FIRST LINE FOR HYPERTENSION ANYMORE
Can alter blood glucose levels
propranolol (Inderal): Non-selective
atenolol (Tenormin)
metoprolol tartrate (Lopressor): Take with food
metoprolol succinate (Toprol XL): Used in heart
failure too. Max in HF is titrating to 200mg/day.
nebivolol (Bystolic): Also releases Nitric Oxide
carvedilol (Coreg): Used in heart failure too.
Alpha and Beta Blocker. Take with food.
Dosing conversions between Coreg and Coreg CR:
3.125 BID Coreg10mg Coreg CR Daily, 6.25BID20mg, 12.5mg BID 40mg, 25mg
BID80mg

labetalol (Trandate): Alpha and Beta Blocker. 1st line often in HTN in
pregnancy.

Side note: Beta Blockers with ISA: (acebutolol, carteolol, penbutolol, pindolol)- They
dont decrease HR as much.

Calcium Channel Blockers:

***Can cause peripheral edema and gingival hyperplasia.
Non-DHP: (Work in the heart, mainly for arrhythmias)
3A4 substrates and inhibitors
diltiazem (Cardizem)
verapamil (Calan, Verelan): Can be constipating

DHP: (For HTN and Angina)

amlodipine (Norvasc)
nifedipine (Adalat CC, Procardia XL, Procardia)
nicardipine (Cardene): Comes IV also
clevidipine (Cleviprex): Do no use with soy or egg allergy

Centrally acting alpha 2 agonists:

clonidine (Catapres, Catapres-TTS patch): Patch is applied weekly.
 Do not stop abruptly or it can cause severe hypertension. Has many
off-label uses (opioid withdrawal, anxiety, sleep etc.) Has many side effects
(bradycardia, drowsiness, sexual dysfunction, depression, nasal stuffiness)
gaunfacine (Tenex): Intuniv is for ADHD

Direct Vasodilators:
Hydralazine
directly vasodilates arteries, litte effect on veins
Hydralazine: can cause a rare lupus-like syndrome

Alpha Blockers: (Used mostly for BPH, not first line for HTN)
terazosin (Hytrin)
doxazosin (Cardura, Cardura XL) Combo Products:
amlodipine + benazepril (Lotrel)
amlodipine + valsartan (Exforge)
lisinopril + HCTZ (Prinzide, Zestoretic)
losartan + HCTZ (Hyzaar)
valsartan + HCTZ (Diovan HCT)
olmesartan + HCTZ (Benicar HCT)
bisoprolol + HCTZ (Ziac)
triamterene + HCTZ (Dyazide, Maxide)

JNC 8 (Joint National Committee):

> 60 yrs. old (<150/90)
< 60 yrs. old (<140/90)
>18 yrs. old with CKD or Diabetes (<140/90)
Non-Blacks Initial Tx (including Diabetes): ACEi, ARB, CCB, or Thiazide
Blacks Initial Tx (including Diabetes): CCB or
Thiazide
If CKD, must have ACEi or ARB regardless of race
Dyslipidemia:
LDL = TC HDL (TG/5)
Non-statin therapies are not recommended unless statins are not tolerated
Statins, fibrate, and niacin require LFT check at
baseline. For statins, recheck in 4-12 weeks after initiation or titration then every 3-
12 months
thereafter.
fibrates (when TG are high) and fish oil can

bile acid sequestrant can increase TGs

4 groups should be initiated on statin therapy:
Clinical ASCVD including coronary heart disease (ACS, S/P MI, stable or unstable
angina,
coronary or arterial revascularization), stroke, TIA, or PAD.
LDL > 190
Diabetes and 40-75 yrs. old with LDL between 70-189
40-75 yrs. old with LDL between 70-189
with estimated 10-year ASCVD risk > 7.5%
The appropriate statin intensity is based on the patients level of risk:
High Intensity Statins: (decreases LDL > 50%)
o Atorvastatin 40-80mg/day
o Rosuvastatin 20-40mg/day
Moderate Intensity: (decreases LDL 30-49%)
o Atorvastatin 10-20mg/day o Rosuvastatin 5-10mg/day o Simvastatin 20-
40mg/day o Pravastatin
40-80mg/day o Lovastatin 40mg/day
o Pitavastatin 2-4mg/day
Low Intensity: (Decreases LDL <30%)
o Simvastatin 10 mg/day o Pravastatin 10-20mg/day o Lovastatin 20mg/day
o Pitavastatin 1mg/day
Statins:
HMG-CoA reductase inhibitors
**Liver enzymes need to be monitored. Stop drug if ALT or AST > 3 times upper
limit of normal
Obviously they can cause rhabdomyolysis .
Increased risk with Niacin or gemfibrozil (Lopid) use
CI in Pregnancy

SAL are 3A4 substrates

simvastatin (Zocor), simvastatin + ezetimibe (Vytorin) 20mg, **take in the
evening.
Do not exceed 10mg/day with verapamil, diltiazem, or
dronedarone
Do not exceed 20mg/day with amiodarone,
amlodipine, or ranolazine
atorvastatin (Lipitor): equivalent dose: 10mg
Do not use with cyclosporine
Do not exceed 20mg/day with clarithromycin or lopinavir/ritonavir
Do not exceed 40mg/day with nelfinavir and boceprevir
(Hep C)
lovastatin (Mevacor, Altoprev) 40mg,
**Mevacor with evening meal, Altoprev bedtime.
Do not exceed 20mg/day with verapamil,
diltiazem, or dronedarone
Do not exceed 40mg/day with amiodarone
rosuvastatin(Crestor) 5mg
pravastatin (Pravachol) 40mg
pitavastatin (Livalo): most potent, 2mg

Cholesterol absorption inhibitor:

ezetimibe (Zetia)
simvastatin + ezetimibe (Vytorin) Bile Acid sequestrant:
colesevelam (Welchol): also approved for Type 2 DM
to decrease A1C. Take with meals and liquid. Can cause constipation, bloating, gas,
cramping,
increased triglycerides or neutral, sipping or holding in mouth can lead to tooth
decay.
 Many meds need to be taken 4 hours before or 4-
6 hours after or it can bind them.

ex. Oral Contraceptives, phenytoin, levothyroxine, olmesartan,

sulfonylureas, tetracyclines and many others.

Fibrates: PPARa Activators

Niacin: (nicotinic acid or Vit B3)

ER Niacin (Niaspan 500, 750, or 1,000 mg):*** Less flushing and
Less Hepatotoxic
Hepatotoxic (monitor LFTs) and causes
Flushing/Itching. Can cause hyperuricemia (gout) and orthostatic
hypotension.
Slo-Niacin: Highest risk of hepatotoxicity
IR Max: 6 gm/day ER/CR Max: 2gm/day
Flush-free doesnt work for cholesterol
Fish Oils:
Not completely understood
Omega-3 acid (Lovaza) or Vascepa
Indicated as an adjunct in patients with TGs >500
Can increase LDL up to 44% (Only Lovaza).
Vascepa can cause joint pain (arthralgia)
Can prolong bleeding time