/ r i . s s n a i s r e p . p i v / / : p t t h http://vip.persianss.ir/ SECTION ONE B O A R D R E V I E W Cardiology / r i 2 Hypertension . s 3 Lipid Disorderss n 4 Coronary Artery Disease a 5 Arirhythmias s r 6 Heart Failure e p 7 Valvular Heart Disease . p 8 Pericardial Disease i v 9 Electrocardiogram Review / / : p t t h CHAPTER 2 B O A R D R E V I E W Hypertension GREGORY P. PROKOPOWICZ, MD, MPH Hypertension is present in nearly 30% of the general popu- ■ Hypertension is more prevalent among African lation, and with the aging of the population and the increase Americans, who also experience more end-organ in obesity, its prevalence is expected to increase. Hyperten- damage / sion is an important risk factor for many common diseases ■ There is a graded relationship rbetween BP level and including stroke, end-stage renal disease, heart failure, and the incidence of stroke, endi-stage renal disease, heart myocardial infarction, and is the most common modifiable failure, and ischemic hear.t disease cardiovascular disease risk factor. Aggressive control of ■ Younger than age 5s0, diastolic BP is the most elevated blood pressure (BP) results in a significant decline important predictor of adverse cardiovascular s in morbidity and mortality. outcomes; older than age 50, systolic BP is the most imporntant predictor Basic Information ■ The prevalence of hypertension rises with age ■ Hypertension definition (Fig. 2-1)a. ■ BP 140/90 mm Hg or higher (i.e., a systolic BP ■ Systolic BP rises continuously; diastolic BP i ≥140 mm Hg, a diastolic BP ≥90 mm Hg, or both) rsises until approximately age 50 years and then (Table 2-1). declines ■ The classification of BP applies to patients not r■ Isolated systolic hypertension (i.e., systolic BP taking antihypertensives and without acute illness e >140 mm Hg and diastolic BP <90 mm Hg) is (which may raise or lower BP); patients taking common among the elderly and is an important antihypertensive medication are considered to p cardiovascular risk factor have hypertension ■ Patients with prehypertension have an increased . ■ BP of 140 to 159/90 to 99 mm Hg is designated as risk of progression to hypertension p Stage 1 hypertension, and BP 160/100 mm Hg or ■ Pathophysiology higher as Stage 2 hypertension i ■ Most patients (>90%) do not have an identifiable ■ If the systolic and diastolic BPs fall inv different cause of hypertension; this is commonly referred stages, the higher stage is used (e.g., a BP of to as essential hypertension / 182/95 mm Hg is categorized as Stage 2) ■ BP is the product of cardiac output and peripheral / ■ BP of 120 to 139/80 to 89 m:m Hg is designated vascular resistance; increased cardiac output can play as prehypertension p a role in the initiation of hypertension; however, ■ Prehypertension is a risk category, not a disease; most patients with long-standing hypertension have patients with prehypetrtension are at high risk of increased peripheral resistance with normal or progressing to actutal hypertension and should be diminished cardiac output targeted for lifesthyle modification ■ In some “salt sensitive” patients, BP responds ■ Hypertensive urgency refers to severe strongly to changes in sodium intake and hypertension without acute end-organ extracellular fluid; salt sensitivity occurs more dysfunction commonly among African Americans and the ■ There is no agreed-upon BP that defines elderly hypertensive urgency, although some sources use ■ End-organ damage from hypertension can affect the 180/120 mm Hg kidneys, heart, vasculature, brain, and eyes (Table 2-3) ■ Headache, anxiety, or medication nonadherence Clinical Presentation often contribute to elevated BP in patients with hypertensive urgency ■ Most patients are asymptomatic ■ Hypertensive emergency implies elevated BP ■ Some have evidence of target organ damage at first with acute end-organ dysfunction (Table 2-2) presentation (see Table 2-3) ■ Although hypertensive emergency is not defined ■ Occasionally, patients may present with hypertensive by any specific level of BP, most patients have BPs urgencies or emergencies (see Table 2-2) 180/120 mm Hg or higher Diagnosis and Evaluation ■ Epidemiology ■ Hypertension affects more than 60 million ■ Measurement of BP Americans and is the most common modifiable ■ Allow patient to relax and sit quietly for more than 5 cardiovascular disease risk factor minutes 6 http://vip.persianss.ir/ HYPERTENSION 7 TABLE 2-1 Classification of Blood Pressure Systolic BP Diastolic BP Systolic Category (mm Hg) (mm Hg) Pulse e pressure Normal <120 and <80 ur s Prehypertension 120 to 139 or 80 to 89 es 2 pr Hypertension d o Stage 1 140 to 159 or 90 to 99 Blo Diastolic 50s Stage 2 ≥160 or >100 BP, Blood pressure. Age Modified from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood FIGURE 2-1 Blood pressure and age. Pressure. JAMA. 2003;289:2560–2572. / r Clinical Manifestations of Chronic i TABLE 2-3 Target Org.an Damage in Manifestations of Acute End-Organ Hypertenssion TABLE 2-2 Damage in Hypertensive Emergency Heart Left sventricular hypertrophy Hypertensive Headache 1) Enlarged PMI or S4 gallop encephalopathy Altered mental status n2) Evidence of LVH on ECG or ECHO Seizures Left ventricular dysfunction Nausea, vomiting a 1) Signs/symptoms of CHF Papilledema (see Fig. 2-2) 2) Enlarged PMI or S3 gallop Abnormalities on brain imaging 3) Systolic or diastolic dysfunction on ECHO i Coronary artery disease Intracranial hemorrhage Headache s 1) Angina Altered mental status 2) History of MI, PCI, or CABG Focal neurologic abnormalities r Hemorrhage on brain imaging e Brain Cerebrovascular disease 1) History of stroke Unstable angina Chest pain 2) Carotid bruit p ECG abnormalities Eyes Retinovascular disease Acute myocardial Chest pain . 1) Arteriolar narrowing infarction ECG abnormalities p 2) Arteriovenous nicking Cardiac enzyme elevation 3) Hemorrhage LV failure with Dyspnea i 4) Exudates pulmonary edema Hypoxia v Vasculature Atherosclerosis Pulmonary congestion on chest 1) Claudication / imaging 2) Diminished or absent pulses / 3) Renal or femoral bruits Acute aortic dissection Chest :pain Syncpope Kidneys Hypertensive nephrosclerosis, ESRD End-organ ischemia 1) Proteinuria or microalbuminuria Eclampsia tProteinuria 2) Elevated serum creatinine tSeizures CABG, Coronary artery bypass graft; CHF, congestive heart failure; h ECG, electrocardiography; ECHO, echocardiography; ECG, Electrocardiographic; LV, left ventricular. ESRD, end-stage renal disease; LVH, left ventricular hypertrophy; MI, myocardial infarction; PMI, point of maximum impulse; PCI, percutaneous coronary intervention. ■ The patient should also refrain from smoking or consuming caffeine for more than 30 minutes ■ Two methods to assess BP: before BP measurement ■ Auscultatory method: Systolic BP is defined as the ■ Use an appropriate sphygmomanometer cuff first appearance of Korotkoff sounds, and diastolic size; the bladder of the cuff should encircle 80% pressure is defined as the disappearance of or more of the arm without overlapping; using a Korotkoff sounds smaller cuff may yield falsely elevated readings ■ Oscillometric method: used by electronic BP ■ The arm in which BP is being measured should be measuring devices, which detect pressure supported and relaxed at the level of the heart fluctuations in the cuff. This method is often ■ BP should be measured in both arms, and the higher preferred over the auscultatory method because it of the two readings used is not subject to human bias or error. ■ At each clinical visit, the BP preferably should be ■ Elevated BP readings on two separate clinical visits taken at least twice in the arm with the higher BP should be obtained before classifying a patient as measurement hypertensive; however, if BP is very high (systolic ■ The average BP should guide management BP >180 mm Hg) on multiple readings at the initial 8 CARDIOLOGY visit, it is reasonable to start antihypertensive ■ Identify comorbidities medications at that time ■ Diabetes mellitus (DM) ■ In elderly patients, or when orthostatic hypotension ■ Chronic kidney disease (CKD) is suggested, standing BP measurements should be ■ Ischemic heart disease and cardiomyopathy taken ■ Identify other cardiovascular disease risk factors: ■ Some patients may have a marked discrepancy cigarette smoking, dyslipidemia, older age, obesity, between BP measurements obtained at home and in physical inactivity, family history the clinic ■ Assess for identifiable (secondary) causes of ■ Elevated BP in clinic with normal out-of-office hypertension (see later discussion) readings is referred to as white-coat ■ Recommended laboratory tests for initial evaluation hypertension ■ Serum creatinine, sodium, potassium, fasting glucose ■ Elevated out-of-office BP with normal clinic ■ Urinalysis with microscopic examination readings is referred to as masked ■ Electrocardiogram (or echocardiogram) hypertension ■ Fasting lipid profile ■ In either case, home BP readings and/or 24-hour ■ Optional: serum calcium, thyroid/-stimulating ambulatory BP monitoring should be obtained and hormone r used to guide management. ■ Screen for identifiable (secoindary) causes of ■ For daytime home BP monitoring, hypertension is hypertension (Table 2-4). defined as an average BP greater than 135/85 mm Hg ■ Consider secondary hypsertension in the following ■ For 24-hour BP monitoring (which includes readings scenarios: s taken during sleep), an average BP greater ■ Sudden onset of hypertension in a previously than130/80 mm Hg is considered hypertensive normotensiven patient ■ Goals in initial evaluation of the hypertensive patient: ■ Age, history, physical examination, severity of ■ Assess for target organ damage (Fig. 2-2; see also hypertenasion, or initial laboratory findings Table 2-3) suggestive of a specific cause (see Table 2-4) i ■ Requires comprehensive physical examination, ■ Recsurrence of hypertension in a previously including assessing vital signs, body mass index, well-controlled patient (nonadherence should and cardiopulmonary systems, and auscultation of ralso be considered) the major blood vessels to identify bruits in the e■ Hypertension resistant to three or more drugs, eyes, neurologic system, and limbs including a diuretic p ■ Substances that may cause or worsen hypertension ■ Alcohol (use or withdrawal) . ■ Amphetamines, cocaine p ■ Over-the-counter medications (decongestants, diet pills, nonsteroidal antiinflammatory drugs i v [NSAIDs]) ■ Prescription medications (NSAIDs, oral / contraceptives, cyclosporine, erythropoietin) / ■ Supplements (ephedra) : p ■ Licorice (inhibits metabolism of endogenous cortisol to cortisone) t ■ Other correctable causes of hypertension t ■ Acute pain or stress in hospitalized or h institutionalized patients ■ Obstructive sleep apnea ■ Hyperthyroidism or hypothyroidism ■ CKD (caused by renin oversecretion and impaired sodium excretion) ■ Co-arctation of the aorta (very uncommon in adults) ■ Delayed femoral pulses, diminished leg BP, and rib notching on chest radiograph suggest this diagnosis, which is confirmed with computed tomography or magnetic resonance imaging ■ Treatment is either surgery or angioplasty Treatment (Essential Hypertension): ■ Management requires close BP follow-up: ■ Table 2-5 suggests follow-up intervals, depending on the degree of elevation ■ Suggested follow-up intervals should be shorter if important risk factors (e.g., DM) or target organ FIGURE 2-2 Papilledema in hypertension. (From Yanoff M. Ophthalmology. 2nd ed. Philadelphia: Mosby; 2004, Fig. 113-7.) damage is present http://vip.persianss.ir/ HYPERTENSION 9 TABLE 2-4 Major Causes of Secondary Hypertension Pathophysiology Clinical Presentation Diagnosis Treatment Renal Artery Stenosis Underperfused kidney Sudden onset of significant Magnetic resonance Goal is to improve HTN 2 produces excess renin, hypertension at older (>55 angiography: highly control and measures to which increases angiotensin years) or younger (<30 sensitive, no contrast preserve renal function II (vasoconstriction) and years) age required Revascularized patients aldosterone (sodium Abdominal bruits CT angiography: highly usually still require retention and volume Patient with peripheral sensitive, contrast required medication for BP control expansion) vascular disease Doppler ultrasound: sensitivity Statin therapy decreases Usually caused by Unexplained deterioration in dependent on operator progression atherosclerosis, especially in renal function skill, no contrast required The longer stenosis has been older patients Consider FMD in young Captopril radionuclide scan: present, the less likely May also be caused by FMD, females less sensitive, requires intervention will help which usually occurs in Unusually large drop in BP discontinuation of (kidney becomes atrophic) young female patients with ACEI or ARB treatment antihypertensive Interve/ntional options: medications before test (1) rAngioplasty ± stent Renal artery angiography: i(lesions at ostia of renal gold standard, invasive, .arteries are often not may be performed with s amenable to angioplasty) CO to avoid use of (2) Surgical bypass 2 iodinated contrast s (3) Surgical excision of kidney if size <8 cm n Medical therapy usually best if recovery of renal a function is unlikely Pheochromocytoma i Tumors that originate in the Headache Screen swith plasma free- Surgical resection adrenal medulla or Sweating metanephrines, confirm Preoperatively, patients sympathetic ganglia and Palpitations rwith 24-hour urine should receive release catecholamines Pallor e collection for phentolamine or periodically Anxiety catecholamines, VMA, phenoxybenzamine to Most are sporadic Weight loss metanephrines prevent crisis p Familial forms (20% to 35%) Orthostatic hypotension Certain drugs may cause are associated with: HTN may be episodic or false-positive or false- . (1) Multiple endocrine sustained negative screens p neoplasia IIA and IIB If screen is positive, localize (2) Neurofibromatosis with MRI (or MIBG scan if (3) von Hippel-Lindau i MRI negative) disease (with retinal v angiomas, cerebellar / hemangioblastomas, and renal cell carcinoma) / : Hyperaldosteronism (see Chappter 42) Most common cause of Spontaneous hypokalemia in Screen with plasma Surgical resection of secondary hypertension t a hypertensive patient (may aldosterone and renin adenoma Can be caused by an t cause cramps and muscle serum: ratio of aldosterone Treat with spironolactone for adenoma that produhces weakness) to renin >20 suggests patients with hyperplasia aldosterone (Conn Severe hypokalemia induced disease syndrome) or bilateral by diuretics Confirm by measuring 24-h adrenal hyperplasia (zona Mild metabolic alkalosis urine aldosterone after 3 granulosae) days of salt loading: >12 µg Rarely can be caused by an confirms disease aldosterone-producing If screen positive, localize carcinoma with CT or MRI; adrenal vein sampling Hypercortisolism (see Chapter 42) Several possible causes: Truncal obesity Screen with 24-h urinary free Surgical resection of tumor (1) ACTH-secreting pituitary Moon facies cortisol, salivary cortisol, or or discontinuation of tumor (Cushing disease) Purple striae 1 mg overnight steroid therapy (2) Adrenal adenomas Proximal weakness dexamethasone suppression (3) Ectopic ACTH secretion Hirsutism test (4) Iatrogenic steroid Hyperglycemia If positive, perform high-dose administration Osteoporosis dexamethasone suppression test and measure plasma ACTH Localize with imaging of adrenals or pituitary ACTH, Adrenocorticotropic hormone; ACEIs, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blocker; BP, blood pressure; CO carbon dioxide; CT, computed tomography; HTN, hypertension; FMD, fibromuscular dysplasia; MIBG, iodine-131 metaiodobenzylguanidine; 2, MRI, magnetic resonance imaging; VMA, vanillylmandelic acid. 10 CARDIOLOGY ■ Target BP goal is 140/90 mm Hg for all patients ■ Counsel moderate alcohol intake (1 ounce or less (including those with DM or CKD), except patients per day in men, 12 ounce in women) aged 60 or older without DM or CKD, who should ■ Recommend diet modifications: be treated to a goal BP of 150/90 mm Hg ■ Advise low sodium intake (100 mmol/day, i.e., ■ Therapy choice depends on hypertension stage and 6 g NaCl or 2.4 g Na+, or less) the presence of risk factors or target organ damage ■ Recommend a diet high in fruits, vegetables, (Table 2-6) and low-fat dairy products: Dietary Approaches ■ Management recommendations: to Stop Hypertension (DASH) eating plan ■ Always start with lifestyle modification even if ■ Recommend smoking cessation, although not drug therapy is also needed demonstrated to cause chronic hypertension ■ Recommend weight reduction of 10 pounds or ■ No strong recommendations for altering caffeine more intake; chronic caffeine intake not shown to ■ Encourage 30 minutes or more of moderately correlate with elevated BP intense physical activity (e.g., brisk walking) four ■ Relaxation therapy and stress management are of or more times a week uncertain benefit / ■ Drug therapy: r ■ See Figure 2-3 for suggestedi therapeutic algorithm and Table 2-7 for a list of. medications ■ General principles: insitial therapy TABLE 2-5 Initial Management of Blood ■ In the general psopulation, including those with Pressure DM, start either a thiazide-type diuretic, calcium channnel blocker (CCB), angiotensin- INITIAL BLOOD PRESSURE (mm Hg) Recommended converting enzyme inhibitor (ACEI), or Systolic Diastolic Follow-up a angiotensin receptor blocker (ARB), either <120 <80 Recheck in 2 years alone or in combination (exception: do not use i 120 to 139 80 to 89 Recheck in 1 year* AsCEIs and ARBs in combination) ■ In the general black population, including 140 to 159 90 to 99 Confirm within 2 rpatients with DM, start either a thiazide-type months* e diuretic or CCB 160 to 179 100 to 109 Evaluate or refer ■ In patients with CKD, start either an ACEI within 1 month p or ARB ≥180 ≥110 Evaluate and treat ■ In most cases, choose agents with 24-hour duration . immediately or of action and once-daily dosing p within 1 week, ■ General principles: subsequent therapy depending on clinical isituation ■ Monotherapy is successful in approximately 40% v of patients; in approximately 60%, consider using and complications two or more drugs to attain goal BP, especially in / *Provide advice about lifestyle modification. patients with a BP higher than 160/100 mm Hg Modified from Chobanian AV, Bakris GL, Black /HR, et al. The seventh ■ If there is a partial but inadequate response to the report of the Joint National Committee o:n Prevention, Detection, first antihypertensive drug, either increase the dose Evaluation, and Treatment of High Blopod Pressure. JAMA. 2003;289:2560-2571. or add a second agent from a different class t t h TABLE 2-6 Treatment Recommendations by Risk Group INITIAL DRUG THERAPY Blood Pressure (BP) Lifestyle Classification Modification No Compelling Indication Compelling Indication(s) Present Normal (<120/80 mm Hg) Encourage None None Prehypertension (120 to Yes None Appropriate drug(s) for DM, CKD, or 139/80 to 89 mm Hg) CAD if BP >130/80 mm Hg, for HF if BP >120/80 mm Hg Stage 1 (140 to 159/90 to Yes Thiazide diuretic for most; Appropriate drug(s) for compelling 99 mm Hg) may consider other drug indication classes Stage 2 (≥160/>100 mm Hg) Yes Two-drug combination for Two-drug combination for most, most, including thiazide usually including appropriate diuretic drug(s) for compelling indication CAD, Coronary artery disease; HF, heart failure; CKD, chronic kidney disease; DM, diabetes mellitus. Modified from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA. 2003;289:2561. http://vip.persianss.ir/ HYPERTENSION 11 Does the ■ Heart failure: ACEI or ARB, β-blocker, patient have Yes aldosterone antagonist, diuretics diabetes ■ Myocardial infarction: β-blocker, ACEI, or CKD? BP goal is aldosterone antagonist No >140/90 ■ Migraines: β-blockers, CCBs Is the patient Yes ■ Benign prostatic hypertrophy: α-blockers 2 younger than 60? Does the patient Yes Include ACEI ■ Essential tremor: β-blockers or ARB in ■ Hyperthyroidism: β-blockers (nonselective) No have CKD? regimen ■ Contraindications to certain antihypertensives with BP goal is conditions/disease states: >150/90 No ■ Pregnancy: ACEIs and ARBs are absolutely contraindicated Is the patient Yes Start with ■ Asthma, chronic obstructive pulmonary disease, diuretic peripheral vascular disease: use caution with African American? and/or CCB β-blockers / No ■ Gout: avoid or minimize drose of diuretics Use diuretic, ACEI/ ■ First- or second-degree iheart block: avoid ARB,* or CCB, β-blockers, verapamil., and diltiazem caolmonbein oart iionn *Use either ACE or ARB, ■ Uncomplicated hypsertension: but not both ■ β-Blockers: Unless there is a specific indication, s If not at goal such as coronary artery disease or heart failure, Increase dose(s) or Note: consider white coat effect avoid β-nblockers unless diuretic, CCB, and add from above and reinforce medication and ACEI or ARB therapy have all been tried drugs lifestyle adherence at all visits ■ Looap diuretics: Should be used only when If still not at goal thiazide diuretics are likely to be inadequate i Add (cid:31)-blocker, s (i.e., congestive heart failure or Stage 4 CKD). aldosterone Short-acting loop diuretics (furosemide, antagonist, r bumetanide) should be taken twice daily, or (cid:30)-blocker, or others e replaced with a long-acting diuretic (e.g., If still not at goal torsemide). p Refer to hypertension specialist . Treatment (Hypertensive Urgency p and Emergency) FIGURE 2-3 Hypertension treatment algorithm. ACEI, Angiotensin-converting enzyme inhibitor; ARB, angiiotensin ■ Hypertensive urgency (severely elevated BP without receptor blocker; BP, blood pressure; CCB, calciumv channel acutely progressive end-organ damage): blocker; CKD, chronic kidney disease. (Modified from James PA, ■ Need prompt but gradual control of BP using oral Oparil S, Carter BL, et al. 2014 evidence-bas/ed guideline for the agents management of high blood pressure in ad/ults: report from the panel members appointed to the Eight:h Joint National Committee ■ Outpatient follow-up is appropriate, but needs BP [JNC 8]. JAMA. 2014;311:507-520.)p assessment at least weekly ■ Rapidly acting oral agents, such as clonidine, are not t usually needed ■ If there is no resptonse to the first drug or if the ■ Hypertensive emergency (severely elevated BP with drug is not tolehrated, substitute a drug from a acutely progressive end-organ damage): different class ■ BP must be brought down rapidly but in a controlled ■ Always consider a diuretic in any patient fashion in an intensive care unit by administering needing three or more drugs intravenous antihypertensive medications, which ■ Consider using low-dose combination therapy have a rapid effect and are easily titratable instead of higher doses of a single agent, to (Table 2-8) minimize dose-dependent side effects ■ Initial goal is to lower mean arterial BP by ■ Formulations combining two or more drugs may approximately 25%, but not more, within offer improved convenience or lower cost, 2 hours examples include: ■ Subsequent goal is to lower BP to approximately ■ Low-dose diuretics and ACEIs, ARBs, or 160/100 mm Hg over the next 2 to 24 hours (if β-blockers aortic dissection is also present, reduce BP further as ■ Thiazides with potassium-sparing diuretics tolerated) ■ CCBs with ACEIs or ARBs Prevention ■ Three-drug combinations containing a CCB, an ACEI or ARB, and a diuretic ■ Provide counseling to patients with prehypertension ■ Comorbidities can help guide choice of (BP <140/90 mm Hg and >120/80 mm Hg) on lifestyle antihypertensive medication: modifications to decrease their risk of progression to ■ CKD: ACEI or ARB hypertension 12 CARDIOLOGY TABLE 2-7 Antihypertensive Agents Class Examples Side Effects Comments Thiazide diuretics Hydrochlorothiazide Hypokalemia Thiazides not effective if GFR <30 mL/min Chlorthalidone Hyponatremia Side effects rarely a problem at low doses Indapamide Alkalosis Hyperuricemia Dehydration Hypercalcemia Loop diuretics Furosemide As for thiazide diuretics, Furosemide and bumetanide have short Torsemide except for hypercalcemia half-lives; dose twice a day for HTN Bumetanide Sodium restriction should accompany diuretics Potassium-sparing Distal tubule sodium Hyperkalemia Often given in combination with thiazides (to diuretics channel blockers: Hyponatremia prevent hypokalemia) triamterene, amiloride Dehydration Avoid or use with caution in renal insufficiency Aldosterone antagonists: / spironolactone, r eplerenone i . β-Adrenergic β-selective: atenolol, Bradycardia May mask hypoglycemic symptoms in antagonists 1metoprolol Fatigue diabetics s (β-blockers) Non–β-selective: Insomnia Do not use alone in cases of catecholamine prop1ranolol, nadolol Erectile dysfunction excess (scocaine intoxication, α and β blockade: Bronchospasm in asthma and pheochromocytoma) as unopposed α 1carved1ilol, labetalol COPD patients vasnoconstriction without β vasodilatio1n may 2 increase BP precipitously a ACEIs Benazepril Cough Inhibit the renin-angiotensin-aldosterone Captopril Angioedema system by blocking conversion of i Enalapril Hyperkalemia s angiotensin I to angiotensin II Fosinopril Use cautiously if CKD, Dilate renal efferent arterioles Lisinopril renovascular diseaser, CHF, Also inhibit degradation of bradykinin, which Moexipril or dehydration is present may lead to cough e Perindopril Do not use in pregnant patients; teratogenic Quinapril Ramipril p Trandolapril . ARBs Azilsartan Hypeprkalemia Inhibit the renin-angiotensin-aldosterone Candesartan system by blocking the angiotensin II Eprosartan receptor i Irbesartan Do not use in pregnant patients; teratogenic v Losartan Olmesartan / Telmisartan / Valsartan : α-Adrenergic Doxazosin p Orthostatic hypotension Block postsynaptic α receptors, causing 1 antagonists Prazosin vasodilation Terazostin Favorable effect on lipid profile and glucose t level h May increase CHD mortality if used as a single agent Nondihydropyri- Verapamil Bradycardia, heart block Verapamil may increase cyclosporine and dine CCBs Diltiazem Decreased cardiac contractility digoxin levels Constipation Dihydropyridine Amlodipine Headache Dilate arterioles CCBs Felodipine Flushing Possibly increase heart rate Isradipine Tachycardia Short-acting nifedipine and nicardipine cause Nicardipine Pedal edema marked reflex tachycardia and are not Nifedipine recommended for HTN Nisoldipine Nifedipine increases cyclosporine levels Direct Minoxidil Headache Considered third-line agents vasodilators Hydralazine Tachycardia Fluid retention Minoxidil: hirsutism, pericardial effusion Hydralazine: drug-induced lupus http://vip.persianss.ir/ HYPERTENSION 13 TABLE 2-7 Antihypertensive Agents (Continued) Class Examples Side Effects Comments Central Clonidine Clonidine, guanfacine: Inhibit sympathetic outflow from CNS adrenergic Guanfacine Sedation, dry mouth, Clonidine also available in patch inhibitors Methyldopa Withdrawal hypertension Methyldopa safe in pregnancy 2 Reserpine Methyldopa: Coombs-positive hemolytic anemia Liver toxicity ACEIs, Angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; BP, blood pressure; CCBs, calcium channel blockers; CHD, coronary heart disease; CHF, congestive heart failure; CKD, chronic kidney disease; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; GFR, glomerular filtration rate; HTN, hypertension. / Review Questions Drugs Used in Treatment of r TABLE 2-8 Hypertensive Emergency i For review questions, please go. to ExpertConsult.com. Drug Indication Precaution s Nitroprusside Most emergencies Thiocyanate toxicity SUGGESTED READINGS s Nitroglycerin Angina, MI Headache, tolerance James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of nhigh blood pressure in adults: report from the Nicardipine Most emergencies Tachycardia panel members appointed to the Eighth Joint National Committee (JNC 8). JAMaA. 2014;311:507-520. Labetalol Most emergencies CHF, bradycardia Kaplan NM. Clinical Hypertension. 11th ed. Baltimore: Lippincott Fenoldopam Most emergencies Tachycardia Williamis & Wilkins; 2014. Weber MsA, Schiffrin EL, White WB, et al. Clinical practice guidelines Enalaprilat CHF Rapid, unpredictable for the management of hypertension in the community: a statement BP drop rby the American Society of Hypertension and the International Esmolol Perioperative, Nausea e Society of Hypertension. J Clin Hypertension. 2014;16:14-26. aortic dissection p BP, Blood pressure; CHF, congestive heart failure; MI, myocardial infarction. . p i v / / : p t t h