hypertension hypertension hypertension: a pharmacological approach robert j. didomenico, pharm.d

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  • Slide 1
  • Hypertension Hypertension Hypertension: A Pharmacological Approach Robert J. DiDomenico, Pharm.D
  • Slide 2
  • Hypertension Hypertension Hypertension
  • Slide 3
  • JNC 7 Express. NIH publication No 03-5233. http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf. May, 2003.http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
  • Slide 4
  • Hypertension Hypertension Percent Decline in Age-Adjusted Mortality Rates for Stroke by Sex and Race: U.S. 1972-1994 The decline in age-adjusted mortality for stroke in the total population is 59.0%. Age-adjusted to the 1940 U.S. census population.
  • Slide 5
  • Hypertension Hypertension Percent Decline in Age-Adjusted Mortality Rates for CHD by Sex and Race: U.S. 1972-1994 The decline in age-adjusted mortality for stroke in the total population is 59.0%. Age-adjusted to the 1940 U.S. census population.
  • Slide 6
  • Hypertension Hypertension Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995 253* *Provisional data. Adjusted for age, race, and sex.
  • Slide 7
  • Hypertension Hypertension Prevalence of Heart Failure, by Age, 1976-80 and 1988-91 1988-91 1976-80
  • Slide 8
  • Hypertension Hypertension Hypertension & Blood Pressure Hypertension is a condition in which the blood pressure is persistently higher than normal Measurement is indirect Measurement is indirect Blood pressure is silent Blood pressure is silent Hypertensive crisis: acute, life threatening rise in blood pressure associated with acute end-organ damage.
  • Slide 9
  • Hypertension Hypertension Risk Stratification Major Cardiovascular Risk Factors Hypertension Hypertension Smoking Smoking Obesity (BMI > 30) Obesity (BMI > 30) Physical inactivity Physical inactivity Dyslipidemia Dyslipidemia Diabetes mellitus Diabetes mellitus Microalbuminuria or GFR < 60ml/min Microalbuminuria or GFR < 60ml/min Advanced age Advanced age Men > 55, women > 65 Family history of premature CV disease Family history of premature CV disease Target Organ Disease Heart Heart Left ventricular hypertrophy CAD Angina and/or prior MI Prior coronary revascularization Heart failure Brain Brain Stroke or TIA Chronic renal insufficiency Chronic renal insufficiency Peripheral arterial disease Peripheral arterial disease Retinopathy Retinopathy NHBPEP Coordinating Committee. The JNC 7 Report. JAMA 2003;289:2560-72.
  • Slide 10
  • JNC 7 Treatment Recommendations Initial Drug Therapy JNC 7 Express. NIH publication No 03-5233. http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf. May, 2003.http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
  • Slide 11
  • Hypertension Hypertension Hypertension Therapeutic Treatment Options Diuretics Diuretics Beta blockers Beta blockers ACE inhibitors ACE inhibitors Angiotensin II receptor blockers Angiotensin II receptor blockers Calcium channel blockers Calcium channel blockers Alpha blockers Alpha blockers Centrally acting alpha agonists Centrally acting alpha agonists Direct vasodilators Direct vasodilators Peripheral adrenergic blockers Peripheral adrenergic blockers
  • Slide 12
  • Hypertension Hypertension Arch Inter Med 1997 Hypertension Selection of Initial Therapy Demographics Demographics Concomitant Diseases and Therapies Concomitant Diseases and Therapies Quality of Life Quality of Life Cost Cost Drug Interactions Drug Interactions
  • Slide 13
  • Hypertension Hypertension Hypertension Nervous System Somatic NS Autonomic NS Parasympathetic NS Sympathetic NS
  • Slide 14
  • Hypertension Hypertension Functional Aspects of the Sympathetic NS OrganSympathetic Response Heart Increased contractility (beta-1) Increased HR (beta-1) Arterioles Vasoconstriction (skin/viscera) (alpha-1) Vasodilation (skeletal muscle/liver) (beta-2) Lung Bronchodilation (beta-2) Kidney Increased renin (alpha-1, beta-1) Hypertension
  • Slide 15
  • Hypertension Hypertension Hypertension Therapeutic Options: Beta Blockers Inhibit sympathetic stimulation Inhibit sympathetic stimulation Beta-1 receptors heart Beta-2 receptors blood vessels, lungs Cardioselective vs. Nonselective Cardioselective vs. Nonselective Intrinsic sympathomimetic activity (ISA) Intrinsic sympathomimetic activity (ISA)
  • Slide 16
  • Hypertension Hypertension Hypertension Beta Blockers: CV Pharmacodynamics Reduced heart rate Reduced heart rate Reduced force of heart contraction Reduced force of heart contraction Reduced cardiac output Reduced cardiac output Reduced blood pressure Reduced blood pressure Decreased renin Decreased renin
  • Slide 17
  • Hypertension Hypertension Hypertension Beta Blockers: Potential Adverse Effects Glucose intolerance, masked hypoglycemia Glucose intolerance, masked hypoglycemia Bradycardia, dizziness Bradycardia, dizziness Bronchospasm Bronchospasm Increased triglycerides and decreased HDL Increased triglycerides and decreased HDL CNS: Depression, fatigue, sleep disturbances CNS: Depression, fatigue, sleep disturbances Reduced C.O., exacerbation of heart failure Reduced C.O., exacerbation of heart failure Impotence Impotence Exercise intolerance Exercise intolerance
  • Slide 18
  • Hypertension Hypertension Hypertension Beta Blockers: Precautions Bronchospastic disease Bronchospastic disease Heart Block Heart Block Sick sinus syndrome Sick sinus syndrome Diabetes Diabetes Dyslipidemia Dyslipidemia Depression Depression
  • Slide 19
  • Hypertension Hypertension Hypertension Beta Blockers: Specific Indications Myocardial Infarction Myocardial Infarction Congestive Heart Failure Congestive Heart Failure Essential Tremors Essential Tremors Hyperthyroidism Hyperthyroidism Angina Angina Supraventricular tachycardias Supraventricular tachycardias Perioperative Hypertension Perioperative Hypertension Migraine Headaches Migraine Headaches Beta blockers are underused!!! Compelling indications
  • Slide 20
  • Hypertension Hypertension Hypertension Therapeutic Options: Alpha-Beta Blockers Work by binding to both alpha-1 and beta-1 and/or beta-2 adrenergic receptors consequently preventing their activation by sympathetic neurotransmitters. Work by binding to both alpha-1 and beta-1 and/or beta-2 adrenergic receptors consequently preventing their activation by sympathetic neurotransmitters. Carvedilol: alpha-1 + beta-1+ beta-2 blockade Labetalol: alpha-1 + beta-1 + beta-2 blockade
  • Slide 21
  • Hypertension Hypertension Hypertension
  • Slide 22
  • Hypertension Therapeutic Options: Diuretics Promote sodium and water excretion at various sites of the nephron Promote sodium and water excretion at various sites of the nephron Loop diuretics Thiazide/Thiazide-like diuretics diuretics Potassium-sparing diuretics Carbonic Anhydrase Inhibitors
  • Slide 23
  • Hypertension Hypertension Hypertension
  • Slide 24
  • Hypertension
  • Slide 25
  • Hypertension Loop diuretics Thiazide diuretics Potassium-sparing diuretics Carbonic anhydrase inhibitors
  • Slide 26
  • Hypertension Hypertension Hypertension Diuretics: Pharmacodynamics Decreased intravascular (blood) fluid volume Decreased intravascular (blood) fluid volume Decreased extravascular (edema) fluid volume Decreased extravascular (edema) fluid volume Decreased blood pressure Decreased blood pressure
  • Slide 27
  • Hypertension Hypertension Hypertension Diuretics: Potential Adverse Effects Electrolyte disturbances Electrolyte disturbances potassium, magnesium, sodium, calcium Hyperglycemia Hyperglycemia Hypotension, orthostasis Hypotension, orthostasis Lipid abnormalities Lipid abnormalities Photosensitivity Photosensitivity Ototoxicity Ototoxicity Hyperuricemia, gout flare Hyperuricemia, gout flare
  • Slide 28
  • Hypertension Hypertension Unless contraindicated Hypertension Diuretics: Compelling Indications* Isolated Systolic Hypertension Isolated Systolic Hypertension Congestive Heart Failure Congestive Heart Failure Diuretics: Possible Favorable Effects Osteoporosis (thiazides) Osteoporosis (thiazides) Diuretics: Possible Unfavorable Effects Diabetes Diabetes Gout Gout Renal Insufficiency Renal Insufficiency
  • Slide 29
  • Hypertension Hypertension Hypertension Diuretics: Considerations Useful for patients with ISH, African Americans, CHF Useful for patients with ISH, African Americans, CHF Different diuretic classes can be combined for additive, or possible synergistic effects Different diuretic classes can be combined for additive, or possible synergistic effects Work well in combination with other antihypertensives Work well in combination with other antihypertensives Efficacy drops when renal function becomes seriously impaired Efficacy drops when renal function becomes seriously impaired
  • Slide 30
  • Hypertension Hypertension Hypertension Therapeutic Options: ACE Inhibitors ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor Therapeutic Options: Angiotensin II Receptor Blockers (ARBs) ARBs block the effects of angiotensin II by competing for binding sites at the receptor ARBs block the effects of angiotens

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