Updated: 7/19/2020

Antihypertensives

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
6 6
0
0
0%
0%
Evidence
10 10
0
0
Snapshot
  • A 54-year-old man presents to his primary care physician for an annual examination. In his previous visit, he was diagnosed with hypertension. In today's visit, his blood pressure has not improved given his difficulty to adhere to a diet with more fruits and vegetables and exercise. His medical history is significant for type II diabetes mellitus and he is currently taking metformin. Physical examination is remarkable for a blood pressure of 152/99 mmHg and mildly decreased vibration and proprioception sense in his lower extremities. He is started on lisinopril.
Introduction
  • Antihypertensive medications are used to manage hypertension in patients where conservative measures are ineffective
    •  there are four commonly used antihypertensive medications
      • diuretics
        • thiazides
        • potassium-sparing diuretics
      • sympatholytics
        • β-blockers
        • α-blockers
      • vasodilators
        • calcium channel blockers
        • hydralazine
        • minoxidil
      • renin-angiotensin-aldosterone inhibitors
        • angiotensin-converting enzyme (ACE) inhibitors
        • angiotensin receptor blockers (ARBs)
        • direct renin inhibitors
Diuretics
  • Medications
    • thiazides
      • mechanism of action
        • inhibits the NaCl transporter in the distal tubule
        • vasodilation (mechanism is unclear)
    • potassium-sparing diuretics
      • mechanism of action
        • promotes Na+ excretion in the distal nephron
  • Note that loop diuretic abuse can result in an increased sodium and potassium level in the urine 
Sympatholytics
  • Medications
    • β-blockers
      • mechanism
        • decreases heart rate, which decreases cardiac output
        • decreases renin release, which decreases total peripheral resistance
      • notes
        • can result in bronchospasm, impotence, and hypoglycemia 
      • e.g., metoprolol
    • α-blockers
      • mechanism
        • central α
          2
          -agonists
          • decreases the sympathetic outflow to blood vessels, heart, and kidneys
            • e.g., methyldopa and clonidine
        • α
          1
          -blockers
          • blood vessel smooth muscle relaxation
            • e.g., prazosin and terazosin
Vasodilators
  • Medications
    • hydralazine
      • mechanism
        • increases cGMP to cause direct vascular smooth muscle relaxation
      • note
        • this causes a reflex tachycardia; therefore, β-blockers are often given together
    • minoxidil
      • mechanism
        • direct arteriolar smooth muscle relaxation
    • calcium channel blockers
      • mechanism
        • decreases cardiac and vascular calcium influx, resulting in a decreased cardiac output and total vascular resistance
      • can result in peripheral edema   
        • treat with ACE inhibitors, changing the CCB, or changing the dose 
Renin-Angiotensin-Aldosterone Inhibitors
  • Medications
    • angiotensin-converting enzyme (ACE) inhibitors
      • mechanism
        • inhibits ACE, which decreases circulating angiotensin II (ATII)
          • recall that ATII causes
            • vascular vasoconstriction
            • increased aldosterone secretion from the adrenal gland (zona glomerulosa)
      • notes
        • decreases mortality in patients with
          • acute myocardial infarction
          • heart failure with decreased ejection fraction
        • can result in a cough 
        • beneficial for patients with diabetes
    • angiotensin receptor blockers (ARBs)
      • mechanism
        • directly blocks the AG-II receptor
      • notes
        • beneficial for patients with diabetes
Antihypertensives in Pregnancy
  • Medication options used to manage hypertension in pregnancy include
    • hydralazine
    • labetalol
    • methyldopa
    • nifedipine
Antihypertensives in Hypertensive Emergencies
  • Nitroprusside
    • mechanism
      • arteriolar and venous dilation via cGMP
    • notes
      • is metabolized into cyanide, which can potentially lead to cyanide poisoning
  • Fenoldopam
    • mechanism
      • a peripheral dopamine-1 receptor agonist
    • notes
      • maintains renal perfusion while the blood pressure is being decreased
        • therefore, it is beneficial in patients with renal impairment
  • Nicardipine and clevidipine
    • mechanism
      • decreases cardiac and vascular calcium influx
  • Labetalol
    • mechanism
      • α- and β-blocker
 
Antihypertensive Medications That Address Comorbid Conditions
 
Individualizing Antihypertensive Therapy
Condition Antihypertensive Medication
Benign prostatic hyperplasia
  • α-blockers
Essential tremor
  • β-blocker
Hyperthyroidism
  • β-blocker
Migraine
  • β-blocker
  • Calcium channel blocker
Osteoporosis
  • Thiazide diuretics
Raynaud phenomenon
  • Dihydropyridine calcium channel blocker
 
  • renin-angiotensin-aldosterone inhibitors
 

Please rate topic.

Average 4.2 of 5 Ratings

Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.CV.16.29) A 26-year-old male is brought into the emergency room because he collapsed after working out. The patient is a jockey, and he states that he feels dehydrated and has an upcoming meet for which he needs to lose some weight. On exam, the patient has dry mucosa with cracked lips. His temperature is 98.9 deg F (37.2 deg C), blood pressure is 115/70 mmHg, pulse is 105/min, and respirations are 18/min. The patient's blood pressure upon standing up is 94/65 mmHg. His serum Na+ is 125 mEq/L and K+ is 3.0 mEq/L. His urinalysis reveals Na+ of 35 mEq/L and K+ of 32 mEq/L. The abuse of which of the following is most likely responsible for the patient's presentation? Review Topic | Tested Concept

QID: 104303
1

Furosemide

0%

(0/0)

2

Metoprolol

0%

(0/0)

3

Polyethylene glycol

0%

(0/0)

4

Spironolactone

0%

(0/0)

5

Amiloride

0%

(0/0)

L 2 E

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidences (10)
Topic COMMENTS (8)
Private Note