hello and welcome to this third video in a series of three on uh hypertension my name is Dr Bill Deal Jones and in this video we're going to focus on common anti-hypertensive medications so I like to think of uh there being really two main categories of treatment first always beginning with lifestyle modification so we look at things like Diet low sodium of the DASH diet exercise eating certain foods uh as being sort of primary prevention measures uh at some point of course we get into the need for using pharmacotherapies your choice of pharmacotherapy is based on diagnosis and other comorbidities and uh some of these scenarios are laid out in the hypertension canid guidelines so certainly have a look at those and whenever you're thinking about these phic Therapies always think about potential side effects and today what we're really going to focus on is filling in some of the tools in the tool box so the actual management piece will not be uh the focus here but really what are some of the tools and how to those tools work all right I like to think of the ABCDs of anti-hypertensive medications a stands for ACE inhibitors and uh otens and receptor blockers so ACE inhibitors and arbs B for beta blockers C for calcium channel blockers and D for the diuretics I'll also talk briefly about some of the other types of anti-hypertensive medications that you may not commonly be seeing in primary care so we'll begin first with ACE inhibitors and uh uh angitis receptor blockers and both of which Target different components of the renin and gensin aldosterone system so what are some commonly used ACE inhibitors what lyso captopril ramar and Alo if you're noticing a trend here of course it should be that PRS at the end of these names it's your clue it's probably an Ace inhibitor and they are first line agents uh in treating hypertension and ACE inhibitors are known to have improved C cardiovascular outcomes including reduced hospitalizations for heart failure cardiovascular uh mortality and they're also helpful in reducing micro aluria or albumin showing up in urine and slowing the progression of kidney disease even and especially with patients with type 2 diabetes so some of the common arbs that we use or angens and receptor blockers are Valsartan candesartan herb sartan and so on and they too are firstline agents for the management of hypertension and they've also been uh shown in various studies to improve certain cardiovascular outcomes now it's important to appreciate that both Aces and ACE inhibitors and arbs uh do have side effects more commonly we see angioedema as a a a side effect of a Inhibitors but it's also been shown in arbs as well cough fairly common with ACE inhibitors also cough is uh common in some of the first line uh uh beta blockers that we'll talk about later uh hyperemia and hyperia are also two possible side effects so what you see in this little picture out side here is a drawing of a component of the renan andot tensin alos system and we'll show you the targets of these uh as a little uh study Aid so ACE inhibitors Target the Angiotensin converting enzyme so that we get less Angiotensin 2 remember Angiotensin 2 is that very vasoactive factor which also has uh effects on salt and water retention and of course angot tensin receptor blockers block the receptor of angiotensin 2 uh in various Target organs on to the beta blockers so beta blockers uh in some Studies have shown to improve survival postm and patients with congestive heart failure again newer studies are always coming up and and our understanding may change um the drugs uh used beta blockers used congestive heart failure have been used includes include carbol and metalol and these are the only two that seem to so far increase survival there's a couple clinical pearls about beta blockers they they decrease heart rate uh they may increase depression uh cause asthma uh Elevate lipids and uh Elevate potassium levels in serum so again little schematic to show you where they work beta blockers competitively l block uh receptors for norepinephrine uh and we find both beta2 receptors and Alpha 1 receptors uh as potential targets for beta blockers uh so they're not always just totally beta selective so uh beta 2 receptors in the heart also alpha 1 receptors to a lesser extent on uh vascular smooth muscle cells calcium channel blockers uh include two main varieties the so-called dhps to hydrop Pines and the non dhps uh the non de hydrop paradin and they vary in terms of uh how they work so examples of the dhps include neopine mpene fotene and they can cause some peripheral vasil dilation and a slight reduction in myocardial contractility and typically with uh uh most dhps the heart rate stays the same or goes up the sort of the black sheep or the different one of the family is a mapine it it does it can cause decreased heart rate and it seems to be slightly better calcium blocker for ES schic Hearts the non dhps include deltm which decrease heart rate whereas most HPS don't uh reduce inotropy or decrease contractility and can cause edema or constipation and even heart failure so you have to watch which uh calcium blocker use uh patients with heart failure they seem to be pretty good for a fib uh clinical Pearl is that calcium channel blockers don't really improve survival at least in the studies I've seen so far so how do they work well again uh calcium channel blockers block predominantly lype calcium channels and here you see the dhps having a major effect on calcium channels on except for my head here but underneath is the calcium channel on a a vascular smooth muscle cell and a slight effect on contractility uh for dhps and non dhps uh you see here uh primarily cardiac effect okay diuretics uh there's a lot of diuretics that uh are are used of course to uh decrease blood volume but the two common groups that we use for treating hypertension include the thighside and thide like uh diuretics which include drugs like hydrochloride and and damid and the the way they work is to decrease sodium reabsorption primarily at the distal convolu tubal they can increase calcium uric acid lipus and glucose and can cause hypon nutria then the other class are the Loop Diuretics and the Loop Diuretics well the classic one is Lasix uh and Lasix inhibits sodium chloride and pottassium reabsorption so if this is a nefron you see normally we shut those salts out into the interstitium around the nefron makes it very salty and therefore water tries to get in in there uh and uh if we inhibit those then we tend to dires those ions and water chases it so we get rid of water volume uh both these classes generally decrease serum potassium but Loop Diuretics more so so you have to watch for hypokalemia it doesn't seem to be a big Improvement in survival overall some clinical pearls include the fact that thides and thide like d u di can trigger go uh if you're predisposed to it and what's the difference between thide and thide like well they're fairly even in terms of their efficacy although seems like thide like diuretics like indapamide have longer elimination halflife and other pharmacologic effects among the other blood pressure medications which you don't typically see used very much in Primary Care are the alpha 1 antagonists Alpha 1 receptors are found all over the peripheral vasculature and normally when an alpha one Agonist like norrine binds you get Vaso constriction however vasod dilation occurs when you have alpha 1 blockade and an example of an alpha 1 antag Agonist is prosen so basically if it's got OS i n at the end of the name it's probably an alpha 1 antagonist uh it's not been shown to reduce mortality and myocardial infraction or congestive heart failure but it can prevent nightmares in cases of PTSD so to show you how it works here's prosen comes along binds to its receptor and voila phaso dilation uh so there can be a side effect of serious one uh called first dose hypotension so the first time patient sees an alpha1 antagonist uh blood pressure can really drop so uh usually that's given uh at night and a little uh pharmacologic Pearl here is that uh you'll see this drug used not so much in treating hypertension but it is a common uh drug used in the treatment of benign prostatic hyperplasia uh Alpha 2 agonists are primarily found in the brain stem and what they're good at doing is uh decreasing peripheral resistance and they do that uh primarily by decreasing calcium in the synaptic cfts of neurons uh in the sympathetic nervous system you'll see also uh sometimes Alpha 2 agus use in treatment of opioid withdrawal because of their CNS effects so here's a picture of clonidine binding to its receptor and it decreases neopine phrine both centrally and peripherally um so there can be some withdrawal effects and they can have sedative effects other blood pressure meds well nitrates are pretty common you recall we talked about nitric oxide is a potent phaso dilator uh so n nitrates convert to nitric oxide and they um and Vascular smooth muscle cells cause the same Cascade of events resulting in cell diate we talked about before they also relax coronary arteries so they tend to improve myocardial profusion uh there's some pre-load reduction as well as after load reduction so it reduces the work of the heart some of the indications for nitrates of course commonly angina but also sometimes you see the news post uh myocardial infarction and sometimes with conges AI failure uh if nitrates are not tolerated often will'll go to beta blockers uh and sometimes nitrates and hydroline may be used together but that again is an exceptional circumstance of what's the pharmacological Pearl well somebody using nitrates needs to often have a nitrate free interval and it's really contraindicated in right ventricular fa failure okay hydrazine uh is a direct arteriolar dilator uh we don't really know how it works um at least we're not sure but it does decrease pressure and it's not a primary drug for treating hypertension uh because it does elicit uh sympathetic stimulation of the heart that can increase heart rate and cardiac output which is kind of not um the object of the exercise uh and cases of coronary AR disease may even cause anina or so Hydra hydrazine is used advisedly uh uh if it's used too long you can get a lupuslike condition which does go away when you stop it uh it can cause ready to go up and there may be some fluid retention with hydrazine not a drug you'll typically use in Primary Care another medication which really could be placed under the diuretics because this is diuretic is spironolactone um so it it's a diuretic it um Works uh really by blocking aldosterone and uh uh inhibiting the sodium pump along the collecting duct so it stops sodium e flux uh out of the duct and potassium in so um it can raise potassium levels it's good for congestive heart failure in some cases uh but usually only if injection fractions 35% or less so some clinical pearls you need to watch creatinine uh can also lead to U uh acute renal failure in gomasa so uh there's a newer drug out there called a plone which doesn't cause gynocomastia and there's a a trial a few years ago called the emphasis trial which show showed some uh help with postm CHF all right so in conclusion we've introduced some of the major anti-hypertensive tools if not talked about specific management choices most of these Target the renin ens and aldosterone or vascular system and some several of these medications are also used in treatment of congestive heart failure as parting words I would say always follow Clin Uh current clinical practice guidelines be aware of side effects and contraindications and always look for new developments okay thanks very much signing off