Direct Acting Venodilators Sodium Nitroprusside MOA releases NO in smooth

Direct acting venodilators sodium nitroprusside moa

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Direct Acting Venodilators Sodium Nitroprusside MOA : releases NO in smooth muscle ( muscle contraction) *some action on arterioles 1 st line for HTN emergency (IV) ADR : cyanide ion production (poisonous if PO) + severe class-effect ADRs Peripheral DA-1 Agonists Fenoldopam MOA : PVR with renal blood flow , diuresis, and natriuresis (>active on renal/mesenteric vasculature than endogenous DA) Severe HTN (IV), especially renal insufficiency Combo Products BB + Diuretic Many are available and may help with compliance, generally used after patient is stable on separate agents ACEI + Diuretic ARB + Diuretic Hypertension Treatment Non-Pharmacologic ( ALL HTN PATIENTS ) Pharmacologic o General: Monotherapy if >140/>90 or Combination Therapy if >160/100 (**but caution in elderly, DM); Consider comorbid conditions o Initial Major Treatment Options (if NO comorbidities!!!): Thiazide, ACEI/ARB, CCB or BB o ACEI : 1 st line in HF, Asx LV dysfunction, MI, DM, systolic dysfunction, proteinuric CKD (cardioprotective independent of BP @ risk) o ARB : ADRs or intolerance to ACEI (cough, edema) o Thiazide Diuretics : Chlorthalidone is preferred agent but HCTZ is used (availability, cost, combination, fewer ADRs) o CCB: long-acting DHP are most commonly used, non-DHP if rate control is needed, other (angina, COPD) o Beta 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) o Combination Products o Initial Monotherapy Based on Age & Race ***If compelling indications exists choose that appropriate class*** Young, White (22-51 y/o) ACEI/ARB, BB if compelling reasons 31
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Elderly, Black ( baseline renin activity) DHP CCB, Thiazide Titration: Thiazides have little benefit for titrating past starting dose ; Others have large dosing range & possibly additional benefit w/ dose o Risk of ADRs with titration better to add drugs if needed Loss of effectiveness toward end of dosing cycle (early morning): Risk for CV events occurring in early morning due to sympathetic activity o Options: drugs with long half-lives , sustained-release products, split daily dose (BID), patient compliance HYPERTENSIVE EMERGENCIES Malignant Hypertension : HTN (D>120) + retinal hemorrhages, exudates, papilledema Hypertensive Urgency : severe HTN + no evidence of end-organ damage Hypertensive Emergency : severe HTN + evidence of acute end-organ damage Treatment Goals: BP in a controlled fashion 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 ( 1 st line ) onset <1m, duration 1-10m Pro: very controllable ; Con: cyanide metabolism Specific Hypertensive Emergencies Malignant HTN & HTN Encephalopathy : BP no more than 25% w/in first 24h Ischemic Stroke or SA/IC Hemorrhage : weigh benefit vs. possibility of worsening ischemia Acute Pulmonary Edema : vasodilators 1 st line (Nitroprusside or NTG + Loop), avoid
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