Antihypertensives

Recommendedreading:
Katzung,9thEd.;Chap.11(pg.160183)
GoodmanandGilman,11thEd.;
Chap.30Reninandangiotensin;pp.789822
Chap.33TherapyforHypertension;pp.871900
Online;www.AccessMedicine.com

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ACE,angiotensinconvertingenzyme
HDL,highdensitylipoprotein
ADH,antidiuretichormone

HT,hypertension
AngII,angiotensinII
\
LDL,lowdensitylipoprotein
BP,bloodpressure
NE,norepinephrine

CHF,congestiveheartfailure
SV,strokevolume
CO,cardiacoutput
SymNS,sympatheticnervoussystem
CNS,centralnervoussystem
TPR,totalperipheralresistance
GFR,glomerularfiltrationrate
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VSM,vascularsmoothmuscle

Objectives:
1.
2.
3.
4.
5.
6.

Knowmechanismsofbloodpressureregulationand
cardiovascularpathophysiologywhichchronicallyincrease
bloodpressure(Review).
Understandtypesandetiologiesofmajorformsofclinical
hypertension.
Generaltreatmentstrategyforhypertension.
Knowmajorclassesofantihypertensiveagents,theirgeneral
sitesandmechanismsofaction.
Identifyspecific,widelyused,antihypertensiveagents,sitesof
action,mechanismsofaction,indicationsandcontraindications.
Understandstrategiesforhypertensionmanagementassociated
withotherpathologies.

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Hypertension:TheSilentKiller

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HeartAttack

Stroke

KidneyFailure

CRITICALPOINT!
Hypertensionasymptomatic
Morbidityandmortalityduetoendorgandamage
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DeterminantsofArterialPressure
Blood
Volume

MeanArterial
Pressure =

Stroke
Volume

Arteriolar
Diameter

Heart
Rate

CRITICALPOINT!
Changeanyphysical
factorscontrollingCO
Contractility FillingPressure
and/orTPRandMAPcan
bealtered.
BloodVolume VenousTone COheartfunction
TPRvascularfunction

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MechanismsControllingCOandTPR
1.Neural
SymNS
PSNS

2.Hormonal
Renal
AngII
Adrenal
Catecholamines
Aldosterone

Artery Vein

3.LocalFactors

CRITICALPOINTS!
1.TheseorgansystemsandmechanismscontrolphysicalfactorsofCOandTPR
2.Therefore,theyarethetargetsofantihypertensivetherapy.
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ChangesinBPopposedbyreflexes
Servonullcontrolsystem(setpoint),
sensor,processor,compensation
1. Arterialbaroreflexesshortterm(secmin)
2. Renalpressure/natriuresisresponselongterm
Bothmajorreflexesactascompensatormechanism
tomaintainBPatasetlevel
Changesinpressureopposedbycompensationin
bothCO/TPR
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SummaryTypesandEtiologyofHypertension
1.Whitecoathypertension(duetostressassociatedwith
office/hospitalvisit/environmental)
2.Secondaryhypertensionduetospecificorganpathology
1.renalarterystenosis
2.pheochromocytoma
3.aorticcoarctation
4.adrenaltumor
3.EssentialHypertension
95%>Noknowncause.
CRITICALPOINT!
PharmacologicalTherapyused
primarilyforessentialhypertension.
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Summary

GeneralTreatmentStrategyofHypertension
1.Diagnosis36independentmeasurements.
2.Determinationofprimaryvs.secondaryhypertension.
3.Ifsecondary,treatunderlyingpathology.
4.Ifprimary,initiatelifestylechanges
smokingcessation
weightloss
diet
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lessalcohol
etc.
5.Pharmacologicaltreatment.
CRITICALPOINTS!
GoalnormalizepressuredecreaseCOand/orTPR
Strategyaltervolume,cardiacand/orVSMfunction
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PharmacologicalTreatment
ClassesofAntihypertensiveAgents
1.Diuretics
2.PeripheralAdrenergicAntagonists
3.CentralSympatholytics(agonists)
4.AdrenergicAntagonists
5.AntiangiotensinIIDrugs
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7.Vasodilators
CRITICALPOINTS!
1. Eachdesignedforspecificcontrolsystem
2. Oftenusedincombination
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1.Diuretics
1.Thiazides
hydrochlorothiazide(HydroDIURIL,Esidrix);
chlorthalidone(Hygroton)
2.Loopdiuretics
furosemide(Lasix);bumetadine(Burmex);
ethacrynicacid(Edecrin)
3.K+Sparing
amiloride(Midamor);spironolactone(Aldactone);
triamterene(Dyrenium)
4.Osmotic
mannitol(Osmitrol);urea(Ureaphil)
5.Other
CombinationHCTH+triamterene(Dyazide)
acetazolamide(Diamox)

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Diuretics(cont)
1.SiteofAction
RenalNephron
2.MechanismofAction
UrinaryNa+excretion
Urinarywaterexcretion
ExtracellularFluid
and/orPlasmaVolume
3.EffectonCardiovascularSystem
AcutedecreaseinCO
ChronicdecreaseinTPR,normalCO
Mechanism(s)unknown
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Diuretics(cont)
4.AdverseReactions
dizziness,
electrolyteimbalance/depletion,
hypokalemia,
hyperlipidemia,
hyperglycemia(Thiazides)
gout

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5.Contraindications
hypersensitivity,
compromisedkidneyfunction
cardiacglycosides(K+effects)
hypovolemia,
hyponatremia
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Diuretics(cont)
6.TherapeuticConsiderations
Thiazides(mostcommondiureticsforHTN)
Generallystartwithlowerpotencydiuretics
GenerallyusedtotreatmildtomoderateHTN
UsewithlowerdietaryNa+intake,
andK+supplementorhighK+food
K+Sparing(combinationwithotheragent)

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Loopdiuretics(severeHTN,orwithCHF)
Osmotic(HTNemergencies)
Maximumantihypertensiveeffectreached
beforemaximumdiuresis2ndagentindicated
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PeripheralAdrenergicAntagonists
Drugs:prazosin(Minipres);terazosin(Hytrin)
1.SiteofActionperipheralarterioles,smoothmuscle

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CRITICALPOINT!
Majormechanism/siteofSymNScontrolofbloodpressure.
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PeripheralAdrenergicAntagonists,cont.
2.MechanismofAction
Competitiveantagonistatreceptorsonvascular
smoothmuscle.

3.EffectsonCardiovascularSystem
Vasodilation,reducesperipheralresistance
CRITICALPOINT!
Blockingreceptorsonvascularsmoothmuscleallows
musclerelaxation,dilationofvessel,andreducedresistance.
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PeripheralAdrenergicAntagonists,cont.
4.Adverseeffects
nausea;drowsiness;posturalhypotenstion;
1stdosesyncope
5.Contraindications
Hypersensitivity
6.TherapeuticConsiderations
noreflextachycardia;small1stdose;
doesnotimpairexercisetolerance
usefulwithdiabetes,asthma,and/or
hypercholesterolemia
useinmildtomoderatehypertension
oftenusedwithdiuretic,antagonist
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CentralSympatholytics(2Agonists)
Drugs:clonidine(Catapres),methyldopa(Aldomet)
1.SiteofAction
CNSmedullary
cardiovascularcenters
clonidine;direct2agonist
methyldopa:falseneurotrans.
2.MechanismofAction
CNSadrenergicstimulation
Peripheralsympathoinhibition
Decreasednorepinephrinerelease
3.EffectsonCardiovascularSystem
DecreasedNE>vasodilation>DecreasedTPR
CRITICALPOINT!
Stimulationofreceptorsinthemedulladecreasesperipheral
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sympatheticactivity,reducestone,vasodilationanddecreasesTPR. 18

CentralSympatholytics(2Agonists);cont.
4.AdverseEffects
drymouth;sedation;impotence;

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5.Contraindications
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6.TherapeuticConsiderations
generallynot1stlinedrugs;
methyldopadrugofchoiceforpregnancy
prolongedusesalt/waterretention,adddiuretic
Reboundincreaseinbloodpressure
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drenergicAntagonists
Drugs:propranolol(Inderal);metoprolol(Lopressor)
atenolol(Tenormin);nadolol(Corgard);
pindolol(Visken)
1.SitesofAction

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2.MechanismofAction
competitiveantagonistatadrenergicreceptors
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drenergicAntagonists,cont.
3.EffectsonCardiovascularSystem
a.CardiacHR,SVCO
b.RenalReninAngiotensinIITPR
4.AdverseEffects
impotence;bradycardia;
fatigue;exerciseintolerance;
5.Contraindications
asthma;diabetes;bradycardia;
hypersensitivity
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drenergicAntagonists,cont.
6.TherapeuticConsiderations
Selectivity
nadolol(Corgard)nonselective,but20hr1/2life
metoprol(Lopresor)selective,34hr1/2life
Riskyinpulmonarydiseaseevenselective,
Availableasmixedblockeravailablelabetalol

(Trandate,Normodyne)
Usepostmyocardialinfarctionprotective
Usewithdiureticpreventreflextachycardia

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AntiAngiotensinIIDrugs
AngiotensinIIFormation
1. AngiotensinConvertingEnzyme
Inhibitors
enalopril(Vasotec);
quinapril(Accupril);
fosinopril(Monopril);
moexipril(Univasc);
lisinopril(Zestril,Prinivil);
benazepril(Lotensin);
captopril(Capoten)

Angiotensinogen

ACE

AngI

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Renin

2.AngIIReceptorAntagonists
losartan(Cozaar);
candesartan(Atacand);
valsartan(Diovan)

Lung
VSM
Brain
Kidney
AdrGland

AngI

AT1

Ang II

ACE

AT2

AngII
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AntiAngiotensinIIDrugs,cont
3.EffectonCardiovascularSystem

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Volume

Aldosterone
Vasopressin

CO
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HR/SV

AngiotensinII
Norepinephrine
SymNS

CO

AngiotensinII

Vasoconstriction
SymNS

TPR
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AntiAngiotensinIIDrugs,cont
4.AdverseEffects
hyperkalemia
angiogenicedema(ACEinhib);cough(ACEinhib);
rash;itching;
5.Contraindications
pregnancy;hypersensitivity;bilateralrenalstenosis
6.TherapeuticConsiderations:
usewithdiabetesorrenalinsufficiency;
adjunctivetherapyinheartfailure;
oftenusedwithdiuretic;
Enalapril,ivforhypertensiveemergency
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Ca++ChannelBlockers
Drugs:verapamil(Calan);nifedipine(Procardia);
diltiazem(Cardizem);amlodipine(Norvasc)
1.SiteofAction
Vascularsmoothmuscle
2.MechanismofAction
BlocksCa++channel
decreases/preventscontraction
3.EffectonCardiovascularsystem
Vascularrelaxation
DecreasedTPR
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Na+ Ca++

K+

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Ca++ChannelBlockers,cont.
4.AdverseEffects
nifedipineIncreaseSymNSactivity;
headache;dizziness;peripheraledema
5.Contraindications
Congestiveheartfailure;pregnancyandlactation;
Postmyocardialinfarction
6.TherapeuticConsiderations
verapamilmainlycardiac;interactionsw/cardiac
glycosides
nifedipinemainlyarterioles
diltiazembothcardiacandarterioles
athighdoses,AVnodeblockmayoccur;
nifedipinemayincreaseheartrate(reflex)
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Vasodilators
Drugs:hydralazine(Apresoline);minoxidil(Loniten);
nitroprusside(Nipride);diazoxide(HyperstatI.V.);
fenoldopam(Corlopam)
1.SiteofActionvascularsmoothmuscle
2.Mechanismofaction
nitroprusside

fenoldopam

NO
DA

Na+

hydralazine
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Ca++

Ca++

K+

minoxidil
diazoxide
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Vasodilators,Cont

3.Effectoncardiovascularsystem
vasodilation,decreaseTPR

4.AdverseEffects
reflextachycardia
IncreaseSymNSactivity(hydralazine,minoxidil,diazoxide)
lupus(hydralazine)
hypertrichosis(minoxidil)
cyanidetoxicity(nitroprusside)
5.Contraindications
6.TherapeuticConsiderations
nitroprussideivonly
hydralazinesafeforpregnancy
diazoxideemergencyuseforseverehypertension
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Summary
SitesandMechanismsofAction

3.2agonists

blockers

Other5.ACEinhibitors
Lung,VSM,Kidney,CNS
CRITICALPOINTS!

Receptorantag.
2.antag.
5.angIIantag.
7.Vasodilators
6.Ca++antag.

1.Diuretics
blockers

1.CanalterCO/TPRatnumberofsitesand/ormechanisms.
2.Antihypertensivesmechanisticallyspecific,andalterblood
pressurethroughphysiologicallydiverseeffectsonCO/TPR .
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3.Allorgansystemsand/oreffectormechanismsarepcoltargets.

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Hypertensiontreatmentwith

somecommoncoexistingconditions
HeartFailure
ACEinhibitors
Diuretics
MyocardialInfarction
blockers
ACEinhibitors
Diabetes
ACEInhibitors
AVOIDblockers
Isolatedsystolichypertension(Olderpersons)
Diureticspreferred
calciumchannelantagonist
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TreatmentStrategywith
SomeCommoncoexistingConditions,cont
RenalInsufficiency
ACEInhibitors
Angina
blocker
Calciumchannelantagonists
Asthma
Ca++channelblockers
AVOIDblockers

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SummaryImportantPoints
HypertensiveAgents
Eachclassofantihypertensiveagent:

1.hasasspecificmechanismofaction,
2.actsatoneormoremajororgansystems,
3.onamajorphysiologicalregulatorofbloodpressure,
4.reducesCOand/orTPRtolowerbloodpressure,
5.hasspecificindications,contraindications,and
therapeuticadvantagesanddisadvantagesassociated
withthemechanismofaction.

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Baroreflexes
1) MAP=setpoint
2) Reflexesdefendsetpoint
1) ArterialBaroreflexes
2) Pressure/Natriuresis
3) ChangeinMAPopposedby
reflexresponsetomaintain
setpressure.
4) Hypertensionpressureresets
tohigherleveldefendedby
reflexsystems.
CRITICALPOINT!
**Multipletherapiesoften
neededtoblockreflex
compensation.
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COXSVR=
MAP
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