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Direct ActingVenodilatorsSodiumNitroprussideMOA: releases NOin smooth muscle (muscle contraction)*some action on arterioles1stline for HTN emergency (IV)ADR: cyanide ion production (poisonous if PO)+ severe class-effect ADRsPeripheralDA-1 AgonistsFenoldopamMOA: PVR with renal blood flow, diuresis, and natriuresis (>active on renal/mesenteric vasculature than endogenous DA)Severe HTN (IV), especially renal insufficiencyComboProductsBB + DiureticMany are available and may help with compliance, generallyused afterpatient is stable on separate agentsACEI + DiureticARB + DiureticHypertension TreatmentNon-Pharmacologic (ALL HTN PATIENTS)Pharmacologic oGeneral: Monotherapyif >140/>90 or Combination Therapyif >160/100 (**but caution in elderly, DM); Consider comorbid conditions oInitial Major Treatment Options (if NO comorbidities!!!): Thiazide, ACEI/ARB, CCB or BB oACEI: 1stline in HF, Asx LV dysfunction, MI, DM, systolic dysfunction, proteinuric CKD (cardioprotective independent of BP @ risk)oARB: ADRs or intolerance to ACEI (cough, edema)oThiazide Diuretics: Chlorthalidone is preferred agent but HCTZ is used (availability, cost, combination, fewer ADRs)oCCB:long-acting DHP are most commonly used, non-DHP if rate control is needed, other (angina, COPD)oBeta Blockers: not used as initial monotherapy due to ADRs, select compelling morbidities (BB w/out ISA in MI, stable HF, Asx LV dysfunction, tachycardia+HTN, angina, migraine prophylaxis, tremor *avoid in COPD)oCombination ProductsoInitial Monotherapy Based on Age & Race ***If compelling indications exists choose that appropriate class***Young, White (22-51 y/o) ACEI/ARB, BB if compelling reasons31
Elderly, Black (baseline renin activity) DHP CCB, ThiazideTitration: Thiazides have little benefit for titrating past starting dose; Others have large dosing range & possibly additional benefit w/ dose oRisk of ADRs with titrationbetter to add drugs if neededLoss of effectiveness toward end of dosing cycle (early morning): Risk for CV events occurring in early morning due to sympathetic activityoOptions: drugs with long half-lives, sustained-release products, split daily dose (BID), patient complianceHYPERTENSIVE EMERGENCIESMalignant Hypertension: HTN (D>120)+ retinal hemorrhages, exudates, papilledema Hypertensive Urgency: severe HTN + no evidence of end-organ damageHypertensive Emergency: severe HTN + evidence of acute end-organ damageTreatment Goals:BP in a controlledfashion to prevent further damage (very rapid reduction may cause cerebral ischemia, shock)Parenteral drugs (easy to control, short half-life) vs. PO drugs (slow onset, use if parental is Nitroprusside(1stline) onset <1m, duration 1-10mPro: very controllable; Con: cyanide metabolismSpecific Hypertensive EmergenciesMalignant HTN & HTN Encephalopathy: BP no more than 25% w/in first 24hIschemic Stroke or SA/IC Hemorrhage: weigh benefit vs. possibility of worsening ischemiaAcute Pulmonary Edema: vasodilators 1stline (Nitroprusside or NTG + Loop), avoid