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WIDESPREAD PROBLEM...
CANADIAN STATISTICS:More than 1 in 5 adults have hypertension
(22%)46% of Canadians age 55-65
42% - No diagnosisOnly 16% are controlled9% of those with diabetes (more stringent
targets)
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IMPORTANCE OF NURSES’ ROLE
Nurses have:Frequent patient contactPatient trustFavourable financial model
Educational role
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...PART OF THE PICTUREMETABOLIC SYNDROME:
HypertensionInsulin resistanceHypercholesterolemia Abdominal weight gainProthrombic statePro-Inflammatory state
All are risk factors for cardiovascular disease#1 cause of death
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CAUSES OF METABOLIC SYNDROME
Obesity InactivityPoor dietUnknown genetic factorsStress?
Cortisol Increases BP, heart rate, lipids, blood glucose Weight gain around waist
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KEY CHEP MESSAGES...Need to assess overall CVD riskCombination of drug therapy and lifestyle
changes are most effectiveMonitor regularly when above target
Regular screening for all adultsFocus on adherence
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ADHERENCEAssess regularly
Encourage patients to bring bottles Check date filled and amount remaining
Fit to daily scheduleStrive for once daily dosing
Long-acting formulasFixed-dose combinations
Fewer pills per dayOften more expensive, not covered
Use unit-of-dose packagingImprove patient educationEncourage patient involvement in monitoring
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TYPES OF HYPERTENSION MEDICATIONSThose that affect hormone systems
Beta-blockersACE Inhibitors (angiotensin converting enzyme
inhibitors)ARBs (angiotensin receptor blockers
Those that affect electrolytesFluid balance
Diuretics Vasodilation
Calcium channel blockers
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ABCs OF HYPERTENSION MEDS
A. Angiotensin Converting Enzyme Inhibitors (ACE-I), Angiotensin Receptor Blockers (ARB)
B. Beta-BlockersC. Calcium channel blockers (CCBs)D. DiureticsE. “Everything else”... Alpha-Blockers
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ACE-InhibitorsEnd with “-pril”Block the enzyme that converts Angiotensin I to
Angiotensin IIAlso reduce morbidity/mortality of
HF, angina, stroke, DM neuropathyGenerally well tolerated
25% can develop dry cough ACE enzyme also block breakdown of bradykinin (xs
causes cough)
Teratogenic – caution in pre-menopausal women
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ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)End with “-sartan”Block the effect of Angiotensin II instead of
blocking productionActions similar to ACE-I
But does not affect bradykininNo cough side effect
Better toleratedMore expensive
Also teratogenic
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BETA-BLOCKERSEnd with “-olol”“Beta adrenergic receptor blockade”
Block beta receptors for adrenalinBeta-1, Beta-2 receptors
Beta-1 - heart, blood vessels Beta-1 selective BB’s (e.g. Atenolol, Metoprolol)
Beta-2 - lungs, brain Non-selective BB’s (e.g. Propranolol, Nadolol)
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BETA-BLOCKERSBETA-2:Lungs
Bronchodilation Site of action of Salbutamol (beta-agonist)
BrainDreamingMigraine
Beta-blockers can decrease frequency
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BETA-BLOCKERSBlock action of adrenalin and beta(adrenalin)
agonists on lungs:Can worsen bronchospasm, asthmaBlock action of inhaled Salbutamol
Can be useful for blocking essential tremor
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BETA-BLOCKERSDisadvantages:
Slow heart rate, lower blood pressure (fatigue)Reduce blood flow to extremities (cold hands, feet,
impotence)Less heart-selective can increase dreamingIncrease risk of diabetes (especially with diuretics)Not recommended over 65 years
Advantages:Reduce mortality post-MIAlso useful for HF, anginaNon-cardio selective can prevent migraineInexpensive
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CALCIUM CHANNEL BLOCKERS
Calcium is necessary for smooth muscle contraction
Calcium enters cells via tiny channelsBlocking calcium channel inhibit muscle
contraction Vasodilation Reduced force of heart muscle contraction
Affect heart, blood vessels – not skeletal muscle
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CALCIUM CHANNEL BLOCKERSThree types:Dihydropyridines (DRPs) - end with “-dipine”
Amlodipine, Felodipine, NifedipinePhenylalkylamines
VerapamilBenzothiazepines
Diltiazem
Last 2 have similar characteristics Often referred to as “non-dihydropyridines” (non-DRPs)
Essentially 2 classes now: DRPs and non-DRPs
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CALCIUM CHANNEL BLOCKERSDIFFERENT SITES OF ACTION:DRPs (-dipines) act mainly on blood vessels
“vasodilating” Excess relaxation -> peripheral edema Adversely affect renal function in diabetes
Non-DRPs (verapamil, diltiazem) also act on heart “modulating”
Verapamil has the strongest effect on heart Diltiazem is “middle of the road” Both slow conduction of impulse through AV node
Caution with 2nd and 3rd degree heart block Avoid in heart failure Renal protective
Preferable if risk of diabetes or kidney damage
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CALCIUM CHANNEL BLOCKERSNo effect on:
Insulin secretion or actionBlood glucosePlasma protein levelsPotassium balanceMagnesium balance
Grapefruit interactionAmlodipine, felodipine
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CALCIUM CHANNEL BLOCKERSShort-acting nifedipine
Spike in norepinephrine, transient rise in plasma renin Reflex tachycardia, BP rise No longer used for emergency hypertension
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DIURETICSEnd with “-ide”
Hydrochlorothiazide, indapamide, furosemideAct on kidney to increase fluid excretion
Reduced blood volume -> reduced pressure Thiazides – act on tubules Furosemide - “Loop” diuretic, more potent
Most cause loss of potassium Increased risk of electrolyte imbalances Exceptions “potassium sparing”:
Spironolactone (Aldactone) Amiloride (in Moduret, Apo-Amilzide), Triamterene (in Dyazide, Apo-Triazide, Nov0-
Triamzide )21
DIURETICSMany side effects:
Lethargy, reduced exercise tolerance, polyuriaHypokalemia
Skeletal muscle weakness, GI hypomotility (ileus, constipation)
Leg cramps, arrhythmiaCan precipitate gouty arthritis (increased uric
acid)Adverse effect on glucose and lipids (especially
with B-Blockers) Poorer compliance noted than with other classes
Very inexpensive, effective22
“EVERYTHING ELSE”ALPHA BLOCKERSEnd with “-azosin”
Prazosin, terazosinAlso used for enlarged prostate
Block alpha adrenalin receptorsStrong rapid blood pressure reduction
Dose must be started low and raised slowlySide effect:
Postural hypotension (may be severe)
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CONCLUSION...HTN is most important cause of stroke,
angina and renal and heart failureMost important key for successful treatment
is patient education
Important to focus on multiple CV risk factors:10% in BP + 10% in TC = 45% in CVD!
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