| 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 diureticsthiazidespotassium-sparing diureticssympatholyticsβ-blockersα-blockersvasodilatorscalcium channel blockers hydralazineminoxidilrenin-angiotensin-aldosterone inhibitorsangiotensin-converting enzyme (ACE) inhibitorsangiotensin receptor blockers (ARBs) |
| Diuretics |
| Medicationsthiazidesmechanism of actioninhibits the NaCl transporter in the distal tubulevasodilation (mechanism is unclear)potassium-sparing diureticsmechanism of actionpromotes Na+ excretion in the distal nephron |
| Sympatholytics |
| Medicationsβ-blockers mechanismdecreases heart rate, which in turn, decreases cardiac outputdecreases renin release, which in turn, decreases total peripheral resistancenotescan result in bronchospasm, impotence, and hyperglycemiae.g., metoprololα-agonistsmechanismcentral α2-agonistdecreases the sympathetic outflow to blood vessels, heart, and kidneys by activating presynaptic α2-adrenoreceptorse.g., methyldopa and clonidineα-blockersmechanismα 1-blockersblood vessel smooth muscle relaxatione.g., prazosin |
| Vasodilators |
| Medicationshydralazinemechanismincreases cGMP to cause direct vascular smooth muscle relaxationnotethis causes a reflex tachycardia; therefore, β-blockers are often given togetherminoxidilmechanismdirect arteriolar smooth muscle relaxationcalcium channel blockersmechanismdecreases 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 mechanisminhibits ACE, which in turn, decreases circulating angiotensin II (AT-II)recall that AT-II causesvascular vasoconstrictionincreased aldosterone secretion from the adrenal gland (zona glomerulosa)notesdecreases mortality in patients withacute myocardial infarction heart failure with decreased ejection fractioncan result in a cough beneficial for patients with diabetes angiotensin receptor blockers (ARBs) mechanismdirectly blocks the AG-II receptornotesbeneficial for patients with diabetes |
| Antihypertensives in Pregnancy |
| Medication options used to manage hypertension in pregnancy includehydralazine labetalolmethyldopanifedipine |
| Antihypertensives in Hypertensive Emergencies |
| Nitroprussidemechanismarteriole and venous dilation via cGMPnotesis metabolized into cyanide, which can potentially lead to cyanide poisoningFenoldopammechanisma peripheral dopamine-1 receptor agonistnotesmaintains renal perfusion while the blood pressure is being decreasedtherefore, it is beneficial in patients with renal impairmentNicardipine and clevidipinemechanismdecreases cardiac and vascular calcium influxLabetalolmechanismα- and β-blocker |
Antihypertensive Medications That Address Comorbid Conditions