Updated: 10/10/2018

Antihypertensive Therapy

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Snapshot
  • A 44-year-old man presents to his primary care physician for an annual examination. He currently does not have any acute complaints. He has been attempting to increase the number of fruits and vegetables in his diet and has lost approximately 15 pounds over 6 months. 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 155/103 mmHg and mildly decreased vibration and proprioception sense in his lower extremities. He returns to the clinic for two consecutive days to measure his blood pressure, which is 152/100 mmHg and 158/107 mmHg. 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)
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
Sympatholytics
  • Medications
    • β-blockers 
      • mechanism
        • decreases heart rate, which in turn, decreases cardiac output
        • decreases renin release, which in turn, decreases total peripheral resistance
      • notes
        • can result in bronchospasm, impotence, and hyperglycemia
      • e.g., metoprolol
    • α-agonists
      • mechanism
        • central α2-agonist
          • decreases the sympathetic outflow to blood vessels, heart, and kidneys by activating presynaptic
            α2-adrenoreceptors
            • e.g., methyldopa and clonidine
    • α-blockers
      • mechanism
        • α
          1
          -blockers
          • blood vessel smooth muscle relaxation
            • e.g., prazosin
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
Renin-Angiotensin-Aldosterone Inhibitors
  • Medications 
    • angiotensin-converting enzyme (ACE) inhibitors 
      • mechanism
        • inhibits ACE, which in turn, decreases circulating angiotensin II (AT-II)
          • recall that AT-II 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
      • arteriole 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
 

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Questions (9)
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

(M1.CV.84) A 60-year-old woman presents to her primary care physician for a wellness checkup. She has a past medical history of hypertension and was discharged from the hospital yesterday after management of a myocardial infarction. She states that sometimes she experiences exertional angina. Her temperature is 99.5°F (37.5°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is within normal limits. Which of the following is the best next step in management? Review Topic

QID: 100600
1

Atenolol

11%

(16/141)

2

Furosemide

15%

(21/141)

3

Hydrochlorothiazide

42%

(59/141)

4

Nifedipine

8%

(11/141)

5

Nitroglycerin

23%

(33/141)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(M1.CV.90) A 67-year-old gentleman with a history of poorly controlled diabetes presents to his primary care physician for a routine examination. He is found to be hypertensive on physical exam and is started on a medication that is considered first-line therapy for his condition. What should the physician warn the patient about before the patient takes his first dose of the medication? Review Topic

QID: 100606
1

Hypertensive episodes

0%

(0/16)

2

Hypotensive episodes

81%

(13/16)

3

Hyperthermic episodes

6%

(1/16)

4

Hypothermic episodes

0%

(0/16)

5

Anuric episodes

12%

(2/16)

M1

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PREFERRED RESPONSE 2

(M1.CV.4753) A 45-year-old male with a history of diabetes and poorly controlled hypertension presents to his primary care physician for an annual check-up. He reports that he feels well and has no complaints. He takes enalapril and metformin. His temperature is 98.8°F (37.1°C), blood pressure is 155/90 mmHg, pulse is 80/min, and respirations are 16/min. His physician adds another anti-hypertensive medication to the patient’s regimen. One month later, the patient returns to the physician complaining of new onset lower extremity swelling. Which of the following medications was likely prescribed to this patient? Review Topic

QID: 108864
1

Metoprolol

8%

(7/92)

2

Verapamil

13%

(12/92)

3

Nifedipine

59%

(54/92)

4

Hydrochlorthiazide

12%

(11/92)

5

Spironolactone

8%

(7/92)

M1

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PREFERRED RESPONSE 3
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(M1.CV.139) A 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram. His vitals signs are stable, with blood pressure 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable. If this patient's cough is due to one of the medications he is taking, what would be the next step in management? Review Topic

QID: 100655
1

Change citalopram to escitalopram

0%

(0/23)

2

Change lisinopril to metoprolol

9%

(2/23)

3

Change lisinopril to amlodipine

4%

(1/23)

4

Change atorvastatin to to lovastatin

0%

(0/23)

5

Change lisinopril to losartan

87%

(20/23)

M1

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PREFERRED RESPONSE 5

(M1.CV.85) A 72-year-old anthropologist with long-standing hypertension visits your office for a routine exam. You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene. What abnormality did you most likely find?
Review Topic

QID: 100601
1

Hypercalcemia

17%

(4/23)

2

Hyperkalemia

70%

(16/23)

3

Hypernatremia

4%

(1/23)

4

Thrombocytopenia

4%

(1/23)

5

Anemia

0%

(0/23)

M1

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PREFERRED RESPONSE 2
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(M1.CV.93) A 67-year-old man with a history of diabetes mellitus type II and a previous myocardial infarction presents to your office for a routine examination. His blood pressure is found to be 180/100 mmHg. Which drug is the first-line choice of treatment for this patient's hypertension? Review Topic

QID: 100609
1

Amlodipine

0%

(0/8)

2

Hydrochlorothiazide

25%

(2/8)

3

Lisinopril

75%

(6/8)

4

Prazosin

0%

(0/8)

5

Isoproterenol

0%

(0/8)

M1

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PREFERRED RESPONSE 3
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