Antihypertensive Drugs Munir Gharaibeh, MD, PhD, MHPE Faculty of Medicine, The University of Jordan The University of Jordan November, 2014

Antihypertensive DrugsAntihypertensive Drugs

Munir Gharaibeh, MD, PhD, MHPEMunir Gharaibeh, MD, PhD, MHPEFaculty of Medicine,Faculty of Medicine,

The University of JordanThe University of JordanNovember, 2014November, 2014

Antihypertensive Drugs Drugs

What is Hypertension:What is Hypertension:A common, incurable, persistent, but A common, incurable, persistent, but usually asymptomatic disease whose usually asymptomatic disease whose treatment provides no obvious treatment provides no obvious benefit.benefit.

IntroductionIntroduction

Thirty percent of people with high Thirty percent of people with high blood pressure don’t know they have it.blood pressure don’t know they have it.Of all people with high blood pressure, Of all people with high blood pressure, 11 percent aren’t on therapy (special 11 percent aren’t on therapy (special diet or drugs), 25 percent are on diet or drugs), 25 percent are on inadequate therapy, and 34 percent are inadequate therapy, and 34 percent are on adequate therapy.on adequate therapy.

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Average 14 readings: two per session, taken morning Average 14 readings: two per session, taken morning and evening for 7 days.and evening for 7 days.05/04/2305/04/23 44Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

BP variationsBP variationsIncreased BP variability is associated with Increased BP variability is associated with

increased organ damage and cardiovascular increased organ damage and cardiovascular morbidity.morbidity.

““White Coat” or isolated office White Coat” or isolated office hypertension.hypertension.Masked hypertension.Masked hypertension.Morning surge of BP.Morning surge of BP.During Sleep: “Non dipping’ and “extreme During Sleep: “Non dipping’ and “extreme dipping”.dipping”.





Benefits of Lowering BPBenefits of Lowering BP Antihypertensive therapy has been Antihypertensive therapy has been

associated with:associated with: 35% to 40% mean reduction in stroke 35% to 40% mean reduction in stroke incidence.incidence.20% to 25% reduction in myocardial 20% to 25% reduction in myocardial infarction. infarction. More than 50% reduction in HF. More than 50% reduction in HF.



Non-pharmacologic TreatmentNon-pharmacologic Treatment Lifestyle Modifications:Lifestyle Modifications: Weight reduction Weight reduction Diet rich in potassium and calcium and Diet rich in potassium and calcium and

sodium reduction. sodium reduction. Dietary Approaches to Stop Hypertension Dietary Approaches to Stop Hypertension

(DASH)(DASH) eating plan( 1600-mg sodium) has eating plan( 1600-mg sodium) has effects similar to single drug therapy.effects similar to single drug therapy.

Physical activity. Physical activity.


Goals of TherapyGoals of TherapyMaximal protection against Maximal protection against cardiovascular consequences with cardiovascular consequences with minimal bother to the patient.minimal bother to the patient.Stroke, coronary, and renal Stroke, coronary, and renal complications increase when BP is complications increase when BP is vigorously lowered vigorously lowered (Why?)(Why?)


Sites of action of antihypertensive drugs .


Sites of action of antihypertensive drugs.



Hemodynamic Effects of Antihypertensive DrugsHemodynamic Effects of Antihypertensive Drugs



Diuretics (Saluretics)Diuretics (Saluretics)Widely recommended as first-line therapy, Widely recommended as first-line therapy, especially in the elderly, the obese, and black especially in the elderly, the obese, and black patients.patients.Better at reducing coronary heart disease, HF, Better at reducing coronary heart disease, HF, stroke, and mortality.stroke, and mortality.Inexpensive.Inexpensive.Combine well with others.Combine well with others.Lower doses, with sodium restriction, cause fewer Lower doses, with sodium restriction, cause fewer metabolic side effects, but retain antihypertensive metabolic side effects, but retain antihypertensive activity.activity.All have same efficacy in lowering BP, although All have same efficacy in lowering BP, although not same diuretic activity. not same diuretic activity.


Diuretics (Saluretics)Diuretics (Saluretics)Early Effects (3-4 days): Early Effects (3-4 days): – Diuresis lowers blood volume and cardiac Diuresis lowers blood volume and cardiac

output.output.– Mainly affects the systolic BP.Mainly affects the systolic BP.Late Effects (3-4 weeks):Late Effects (3-4 weeks):– Decreased Na+ & Cl-, lowers blood vessel Decreased Na+ & Cl-, lowers blood vessel

contractility. Appear even with low doses.contractility. Appear even with low doses.Increase Plasma Renin Increase Plasma Renin Side Effects:Side Effects:


Diuretics (Saluretics)Diuretics (Saluretics)Thiazide diuretics:Thiazide diuretics:Effective in mild and moderate Ht with Effective in mild and moderate Ht with normal renal and heart function.normal renal and heart function.– Hydrochlorthiazide.Hydrochlorthiazide.– Chlorthalidone: long acting.Chlorthalidone: long acting.– Bendrofluazide.Bendrofluazide.– Indapamide: vasodilating and lipid neutral. Also Indapamide: vasodilating and lipid neutral. Also

induces regression of LVHinduces regression of LVH


Diuretics (Saluretics)Diuretics (Saluretics)Loop Diuretics:Loop Diuretics:Needed in severe Ht, in renal insufficiency, Needed in severe Ht, in renal insufficiency, and in heart failure or cirrhosis.and in heart failure or cirrhosis.– Furosemide: not ideal , short acting.Furosemide: not ideal , short acting.– Torsemide: free of metabolic side effects.Torsemide: free of metabolic side effects.Potassium- sparing diureticsPotassium- sparing diuretics::Useful in heart failure.Useful in heart failure.– Spironolactone: Spironolactone: – Eplerenone.Eplerenone.– Ameloride.Ameloride.– TriamtereneTriamterene05/04/2305/04/23 2121Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

VASODILATORSVASODILATORSWork directly on arterial blood vessels, or Work directly on arterial blood vessels, or veins(organic nitrates and nitroprusside).veins(organic nitrates and nitroprusside).Actions not antagonized by known blockers.Actions not antagonized by known blockers.Reduce peripheral resistance, which will Reduce peripheral resistance, which will elicit compensatory mechanisms leading to elicit compensatory mechanisms leading to tolerance, resistance or pseudoresistance.tolerance, resistance or pseudoresistance.Usually other drugs are combined with Usually other drugs are combined with vasodilators to avoid this problem.vasodilators to avoid this problem.


Compensatory responses to vasodilatorsCompensatory responses to vasodilators



VASODILATORSVASODILATORSHydralazine:Hydralazine:

Oldest vasodilator(1950s), was withdrawn and Oldest vasodilator(1950s), was withdrawn and then came back.then came back.Arteriolar dilator, works by release of NO.Arteriolar dilator, works by release of NO.Tachyphylaxis (Tachyphylaxis (Tolerance or Tolerance or PeusdoresistancePeusdoresistance))..

Activates baroreceptor reflex.Activates baroreceptor reflex.Metabolized by acetylation.Metabolized by acetylation.Drug-induced lupus syndrome.Drug-induced lupus syndrome.Other side effects.Other side effects.Replaced by CCBs.Replaced by CCBs.Used in heart failure, combined with isosorbide Used in heart failure, combined with isosorbide dinitratedinitrate05/04/2305/04/23 2525Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

VASODILATORSVASODILATORSDiazoxide:Diazoxide:

Thiazide derivative, but not a diuretic.Thiazide derivative, but not a diuretic.Potent arterial dilator, works by opening Potent arterial dilator, works by opening potassium channels.potassium channels.Causes excessive hypotension.Causes excessive hypotension.Used in emergencies by rapid I.V. bolus injection.Used in emergencies by rapid I.V. bolus injection.Rapidly bound to albumin.Rapidly bound to albumin.Onset 10-30 seconds.Onset 10-30 seconds.Duration 2-4 hours.Duration 2-4 hours.Does not require constant monitoring.Does not require constant monitoring.


VASODILATORSVASODILATORSSodium NitroprussideSodium Nitroprusside::

Cyanide-containing molecule.Cyanide-containing molecule.Useful in emergencies, surgery and heart Useful in emergencies, surgery and heart failure.failure.Relaxes both arterial and venous smooth Relaxes both arterial and venous smooth muscle, works by release of NO.muscle, works by release of NO.No excessive reflex increase in cardiac No excessive reflex increase in cardiac output.output.Might increase C.O. if there is failure.Might increase C.O. if there is failure.


VASODILATORSVASODILATORSSodium Nitroprusside:Sodium Nitroprusside:

Short half life.Short half life.Action is immediate, requires constant Action is immediate, requires constant monitoring in ICU. monitoring in ICU. Drug is light sensitive.Drug is light sensitive.Thiocyanate levels and acid-base balance: Thiocyanate levels and acid-base balance: weakness, nausea, tinnitus, flushing, lactic weakness, nausea, tinnitus, flushing, lactic acidosis and anoxia.acidosis and anoxia.



VASODILATORSVASODILATORSMinoxidil:Minoxidil:

K+ channel-opener: increases efflux leading K+ channel-opener: increases efflux leading to hyperpolarization.to hyperpolarization.Prolonged arterial relaxation.Prolonged arterial relaxation.Superior to hydralazine.Superior to hydralazine.For severe intractable hypertension, or renal For severe intractable hypertension, or renal insufficiency, usually in combination with a insufficiency, usually in combination with a diuretic and diuretic and ββ blocker. blocker.Hypertrichosis, so useful for baldness.Hypertrichosis, so useful for baldness.Pericarditis.Pericarditis.05/04/2305/04/23 3030Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

VASODILATORSVASODILATORSFenoldopam:Fenoldopam:

Dopamine DDopamine D1 1 agonist, which results in agonist, which results in vasodilation, renal vessel dilation, and vasodilation, renal vessel dilation, and natriuresis.natriuresis.Rapidly metabolized, short acting.Rapidly metabolized, short acting.Used by continuous infusion in Used by continuous infusion in emergencies or postoperatively.emergencies or postoperatively.


Calcium Channel BlockersCalcium Channel Blockers More effective than others in protection More effective than others in protection

against stroke.against stroke.Primarily act to reduce PVR, aided by at least Primarily act to reduce PVR, aided by at least

an initial diuretic effect, especially with the an initial diuretic effect, especially with the short-acting DHPs.short-acting DHPs.

Effective in the elderly.Effective in the elderly.Equally effective in blacks and nonblacks.Equally effective in blacks and nonblacks.Cause no metabolic disturbances Cause no metabolic disturbances



Calcium Channel BlockersCalcium Channel Blockers PVR PVR HRHR COCO

NifedipineNifedipine - - -- - - +++ ++ +++ ++ (Reflexly)(Reflexly)

DiltiazemDiltiazem - -- - - - - -

VerapamilVerapamil - -- - - - -- - - --


Angiotensin - Converting Enzyme InhibitorsAngiotensin - Converting Enzyme Inhibitors(ACEI)(ACEI)

Angiotensin II:Angiotensin II: Potent vasoconstrictor by itself.Potent vasoconstrictor by itself.Facilitates release of NE.Facilitates release of NE.Central actions to increase BP.Central actions to increase BP.Promotes release of aldosterone.Promotes release of aldosterone.Regulates tubular function.Regulates tubular function.Regulates intra-renal blood flow.Regulates intra-renal blood flow.



Inhibit ACE in the lungs.Inhibit ACE in the lungs.Also inhibit kinin metabolism. Also inhibit kinin metabolism.


Sites of action of drugs that interfere with the Sites of action of drugs that interfere with the renin-angiotensin-aldosterone system.renin-angiotensin-aldosterone system.



Captopril --------------Prototype.Captopril --------------Prototype.Enalapril Enalapril QuinaprilQuinaprilLisinopril.Lisinopril.BenazeprilBenazeprilFosonoprilFosonopril

All are similarly effective All are similarly effective Might differ in toxicityMight differ in toxicity



Therapeutic BenefitsTherapeutic Benefits::Effective in high-rennin hypertension (20%), HF and Effective in high-rennin hypertension (20%), HF and

Ischemic Heart Disease.Ischemic Heart Disease.Do not increase HR.Do not increase HR.Useful in diabetic nephropathy by dilating efferent Useful in diabetic nephropathy by dilating efferent

arterioles thus reducing intraglomerular pressure arterioles thus reducing intraglomerular pressure and and consequently protects against progressive consequently protects against progressive glomerulosclerosis.glomerulosclerosis.

No need for a diuretic but can be added.No need for a diuretic but can be added. Can be combined with CCBs.Can be combined with CCBs. Should not be combined with Beta blockers. Should not be combined with Beta blockers.

No metabolic effects.No metabolic effects.** Contraindicated in pregnancy and bilateral renal Contraindicated in pregnancy and bilateral renal artery artery stenosis.stenosis. 05/04/2305/04/23 3939Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE


Side Effects:Side Effects:Captopril is SH containing drug, so very toxic( Captopril is SH containing drug, so very toxic(

bone marrow suppression, disguesia, bone marrow suppression, disguesia, proteinuria, allergic skin rash, fever) proteinuria, allergic skin rash, fever) Hypotension( Hypotension( First Dose PhenomenaFirst Dose Phenomena) especially ) especially with renovascular hypertension.with renovascular hypertension.K+ retention, especially in the presence of K+ retention, especially in the presence of renal dysfunction or when combined with renal dysfunction or when combined with K+ sparing diuretics or ARBs. K+ sparing diuretics or ARBs. Cough(10% of patients).Cough(10% of patients).Angioedema.Angioedema.


Angiotensin II Receptor Blockers (AT-1)Angiotensin II Receptor Blockers (AT-1)Result in more complete inhibition of Result in more complete inhibition of angiotensin actions (angiotensin actions (Chymase ?Chymase ?) with no ) with no effects on bradykinins.effects on bradykinins.May be only indicated when ACEI are May be only indicated when ACEI are intolerable.intolerable.Most expensive, but fastest growing class of Most expensive, but fastest growing class of antihypertensive drugs.antihypertensive drugs.Free of side effects, especially cough.Free of side effects, especially cough.May be better than ACEI in protection against May be better than ACEI in protection against stroke (activation of AT-2 receptor facilitates stroke (activation of AT-2 receptor facilitates collateral vessels and neuronal resistance).collateral vessels and neuronal resistance).


Angiotensin II Receptor Blockers Angiotensin II Receptor Blockers (AT-1) (AT-1)

Losartan.Losartan.Valsartan.Valsartan.Candesartan.Candesartan.Irbesartan.Irbesartan.Telmisartan ( Telmisartan ( additionaladditional peroxisome peroxisome proliferator- activated receptor-proliferator- activated receptor-g g agonist activity).agonist activity).Eprosartan.Eprosartan.


Renin Enzyme InhibitorsRenin Enzyme Inhibitors

Aliskiren.Aliskiren.


Sympatholytics or Adrenergic Sympatholytics or Adrenergic BlockersBlockers

Alpha Adrenergic AntagonistAlpha Adrenergic Antagonist– Non selective AntagonistsNon selective Antagonists 1 -Selective Antagonists.1 -Selective Antagonists.Beta Adrenergic BlockersBeta Adrenergic BlockersAdrenergic Neurone Blockers.Adrenergic Neurone Blockers.Ganglionic BlockersGanglionic Blockers

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Non selective Alpha Adrenergic AntagonistNon selective Alpha Adrenergic Antagonist

Phentolamine Phentolamine PhenoxybenzaminePhenoxybenzamine– Block both Block both 1 and 1 and 2 receptors, so cause reflex 2 receptors, so cause reflex

tachycardia and increased contractility. tachycardia and increased contractility. – Used only for pheochromocytoma.Used only for pheochromocytoma.


1 -selective Alpha Adrenergic Antagonists1 -selective Alpha Adrenergic AntagonistsPrazosinPrazosinTerazocinTerazocinDoxazosinDoxazosin

First - Dose Phenomenon.First - Dose Phenomenon.All are free of metabolic effects, but can All are free of metabolic effects, but can cause drowsiness, diarrhea, postural cause drowsiness, diarrhea, postural hypotension, tachycardia, and tolerance due hypotension, tachycardia, and tolerance due to fluid retention.to fluid retention.

Effective in moderate hypertension as well Effective in moderate hypertension as well as benign prostatic hypertrophy.as benign prostatic hypertrophy.

4646Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

Beta Adrenergic BlockersBeta Adrenergic BlockersAntihypertensive Mechanisms:Antihypertensive Mechanisms:

1. Decrease HR, SV, and consequently C.O.1. Decrease HR, SV, and consequently C.O. 2. Decrease Rennin Release2. Decrease Rennin Release 3. Central Action3. Central Action 4. Inhibit NE release4. Inhibit NE release


Beta Adrenergic BlockersBeta Adrenergic BlockersPreparations:Preparations: 3030

Propranolol:Propranolol: Prototype,1957 Prototype,1957 Timolol LipophilicTimolol LipophilicNadolol Long actingNadolol Long actingPindolol ISAPindolol ISAAcebutelol ISAAcebutelol ISAEsmolol Short half lifeEsmolol Short half lifeMetoprolol Metoprolol ββ1 selective1 selectiveAtenololAtenolol ββ1 selective.1 selective.Betaxolol Betaxolol ββ1 selective.1 selective.Bisoprolol Bisoprolol ββ1 selective.1 selective.05/04/2305/04/23 4848Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

Beta Adrenergic BlockersBeta Adrenergic BlockersTherapeutic Effectiveness:Therapeutic Effectiveness:

Effect not immediate.Effect not immediate.High - rennin hypertensionHigh - rennin hypertensionCombination or monotherapyCombination or monotherapyHyperkinetic heartsHyperkinetic hearts

Used in other cardiovascular conditionsUsed in other cardiovascular conditionsIneffective in blacksIneffective in blacksNo postural hypotensionNo postural hypotension


Beta Adrenergic BlockersBeta Adrenergic BlockersSide Effects:Side Effects:

Bronchospasm , especially with the non selectiveBronchospasm , especially with the non selectiveHeart Failure?Heart Failure?CNS: fatigue, depression, impotence ..etcCNS: fatigue, depression, impotence ..etcImpair lipid and glucose metabolism Impair lipid and glucose metabolism Masked hypoglycemia !!!Masked hypoglycemia !!!ClaudicationClaudicationWithdrawal SyndromeWithdrawal Syndrome


Vasodilating Beta Adrenergic BlockersVasodilating Beta Adrenergic BlockersLabetalol: Labetalol: – , , 1 (20% of 1 (20% of ) antagonist & ) antagonist & 2 partial agonist.2 partial agonist.– Useful for pheochromocytoma and Useful for pheochromocytoma and

emergencies. emergencies.

Carvedilol:Carvedilol: , , 1 (10% of 1 (10% of ) antagonist.) antagonist.

Esmolol:Esmolol: 1 selective, rapidly metabolized.1 selective, rapidly metabolized.– Used by continuous IV infusion.Used by continuous IV infusion.

NebivololNebivolol


Adrenergic Neurone BlockersAdrenergic Neurone BlockersGuanethidineGuanethidineBethanedineBethanedineDebrisoquinDebrisoquinGuanadrelGuanadrel

Hydrophilic.Hydrophilic.Uptake 1.Uptake 1.Block NE release. Block NE release. Displace NE from vesicles ------- MAO.Displace NE from vesicles ------- MAO.Cause depletionCause depletion of NE.of NE.


Life Cycle of NorepinephrineLife Cycle of Norepinephrine


Adrenergic Neurone BlockersAdrenergic Neurone BlockersReserpine (Rauwolfia Alkaloids):Reserpine (Rauwolfia Alkaloids):

LipophilicLipophilicBinds to the sympathetic vesicles.Binds to the sympathetic vesicles.Prevents DA uptake into vesicles.Prevents DA uptake into vesicles.Amines are metabolized by MAO.Amines are metabolized by MAO.Depletes: NE, 5HT, ACTH, DA.Depletes: NE, 5HT, ACTH, DA.

Old fashioned, slow onset and offset, Old fashioned, slow onset and offset, very cheap.very cheap.


Ganglionic BlockersGanglionic Blockers

TrimethaphanTrimethaphanPentoliniumPentoliniumMecamylamineMecamylamineBlock transmission in both symp & Block transmission in both symp & parasypathetic systems.parasypathetic systems.Act immediately and are very efficacious.Act immediately and are very efficacious.Effect rapidly reversed, so used for short Effect rapidly reversed, so used for short term control of BP, e.g. intraoperatively or term control of BP, e.g. intraoperatively or emergency.emergency.Many side effects.Many side effects.05/04/2305/04/23 5555Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE


Centrally Acting Antihypertensive DrugsCentrally Acting Antihypertensive DrugsVasomotor Center:Vasomotor Center:

Receptor activation decreases BPReceptor activation decreases BP Receptor activation increases BPReceptor activation increases BP

Nucleus Tractus Solitarius Nucleus Tractus Solitarius Nucleus Ambiguus Nucleus Ambiguus Rostral Ventral Medulla Rostral Ventral Medulla


Autonomic and hormonal control of cardiovascular functionAutonomic and hormonal control of cardiovascular function


Centrally Acting Antihypertensive DrugsCentrally Acting Antihypertensive DrugsCommon Properties:Common Properties:

Cross BBB.Cross BBB.Reduce preganglionic sympathetic activity. Reduce preganglionic sympathetic activity. Orthostasis is unusual, due to preservation Orthostasis is unusual, due to preservation of peripheral sympathetic activity.of peripheral sympathetic activity.CNS side effects.CNS side effects.


Centrally Acting Antihypertensive DrugsCentrally Acting Antihypertensive Drugs1.1. PropranololPropranolol2. 2. Reserpine.Reserpine.3. 3. - Methyl Dopa:- Methyl Dopa:

Old drug, thought to work by forming a pseudo Old drug, thought to work by forming a pseudo transmitter which works peripherally.transmitter which works peripherally.

Central Central agonist. agonist. MD-------- MD-------- MDA MDA -------- -------- MNE. MNE.Lowers BP but not CO or renal blood flow.Lowers BP but not CO or renal blood flow.Can cause lactation and positive Coomb’s test.Can cause lactation and positive Coomb’s test.Safe in pregnancy.Safe in pregnancy.


Centrally Acting Antihypertensive DrugsCentrally Acting Antihypertensive Drugs 4. 4. Clonidine:Clonidine:

Imidazoline derivative, tried initially as a Imidazoline derivative, tried initially as a nasal decongestant.nasal decongestant.Central Central agonist. agonist.I.V: Biphasic Effect: peripheral then central I.V: Biphasic Effect: peripheral then central actions. actions. Oral. Oral. Transdermal Patch(7 days).Transdermal Patch(7 days).


Step Therapy of HypertensionStep Therapy of Hypertension


Causes of Resistant HypertensionCauses of Resistant Hypertension Improper blood pressure Improper blood pressure measurement, “White Coat measurement, “White Coat Hypertension”.Hypertension”.Noncompliance.Noncompliance.Psychological stresses, secondary Psychological stresses, secondary hypertension, sleep disordershypertension, sleep disordersVolume overload and pseudotolerance. Volume overload and pseudotolerance. Excess sodium intake Excess sodium intake Volume retention from kidney disease.Volume retention from kidney disease.Inadequate diuretic therapy. Inadequate diuretic therapy. 05/04/2305/04/23 6363Munir Gharaibeh MD, PhD, MHPEMunir Gharaibeh MD, PhD, MHPE

Causes of Resistant HypertensionCauses of Resistant Hypertension

Inadequate doses. Inadequate doses. Inappropriate combinations .Inappropriate combinations .NSAID; cyclooxygenase 2 NSAID; cyclooxygenase 2 inhibitors. inhibitors. Cocaine, amphetamines, other Cocaine, amphetamines, other illicit drugs. illicit drugs. Sympathomimetics, e.g. Sympathomimetics, e.g. decongestants, anorecticsdecongestants, anorectics


Causes of Resistant HypertensionCauses of Resistant Hypertension

Oral contraceptives Oral contraceptives Adrenal steroids Adrenal steroids Cyclosporine Cyclosporine Erythropoietin Erythropoietin Licorice (including some chewing Licorice (including some chewing tobacco). tobacco). Excess alcohol intake. Excess alcohol intake.



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Antihypertensive Drugs Munir Gharaibeh, MD, PhD, MHPE Faculty of Medicine, The University of Jordan The University of Jordan November, 2014