Taming the Devil Inside:Pharmacologic Management

of Hypertension

Christopher Roe, MSN, ACNP-BC

Lead Nurse Practitioner

Christiana Care Cardiology Consultants

Why Bother?

• 78 million adults have HTN

• Directly linked to myocardial infarction, stroke, heart failure, and kidney disease

• Estimated cost $51 billion in 2009

Statistics from:http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf

Who is the Devil?

Who is the Devil?

• Hormonal Mechanisms

• Neural Mechanisms

• Vascular Mechanisms

• Renal Mechanisms

Hormonal Mechanisms

Neural Mechanisms

Vascular Mechanisms

Renal/Salt Mechanisms

Guidelines for Management of HTNJNC-7 or ESH/ESC

What is the definition?

EHA/ESC Guidelines JNC-7 Guidelines

Treatment of Stage or Grade 1 HTN (without compelling indications)

• JNC-7– Thiazide Diuretic–May consider ACEi, ARB, BB, CCB, or combo

• ESH/ESC– Your choice: no agent is superior– Thiazide Diuretic, BB, CCB, ACEi, or ARB

Thiazide Diuretics• Hydrochlorothiazide• Chlorthalidone• Indapamide (“thiazide-like”)

• Mechanism of Action—diuresis & vasodilation

• Side Effects• Disease related issues

Angiotensin Converting Enzyme Inhibitors (ACEi)

captopril, lisinopril, ramipril, enalapril, trandopril, benazepril

Mechanism of Action

Angiotensin Converting Enzyme Inhibitors (ACEi)

• Side Effects– Cough– Angioedema– Hyperkalemia– Elevated BUN/Cr

• Disease Related issues

Angiotensin Receptor Blockers

• valsartan, losartan, telmisartan, candesartan

• Mechanism of Action

• Side Effects

• Disease related issues

Calcium Channel Blockers

Dihydropyridine Non-dihydropyridine

Calcium Channel BlockersDihydropyridine

• amlodipine, felodipine, nicardipine, nifedipine

• Mechanism of Action

• Side Effects

• Disease related issues

Calcium Channel BlockersNon-dihydropyridine

• diltiazem and verapamil

• Mechanism of Action

• Side Effects

• Disease Related Issues

Beta Blocker

• atenolol, propranolol, metoprolol, nadolol• Subtypes of Beta Recptors– β-1– β-2

• Mechanism of Action• Subgroupings of Beta Blockers– Nonselective– Selective– Nonselective with alpha-1 blocking

Beta Blocker

• Side Effects

• Disease Related Issues

Other Antihypertensives

• Aldosterone Antagonists• Central Acting Alpha-2 Agonists (presynaptic)• Alpha-1 Adrenergic Antagonists (postsynaptic)• Direct Vasodilators• Renin Inhibitors• Others

Novel Pharmacologic Therapies

• Vitamin D

• Fish Oil

• Statins

• Aspirin

Not So Novel Non-Pharmacologic Agents

Reduce Salt Intake

Reduce Alcohol Intake

Increase Aerobic Activity

Novel Interventional Techniques

Renal Nerve Denervation

Questions?

Thank you and Goodbye!