NR565/NR 565 Pharm Week 3| Questions and Answers
Latest Updated (Graded A+)- Chamberlain
Welcome to Week 3
This week, your exploration into pharmaceutical agents will focus on cardiovascular drugs which
are among the most widely used in healthcare. A variety of medications are used to treat heart
conditions such as hypertension, angina, heart failure, and arrhythmias. The cardiovascular
system is complex with many influencing factors; these factors impact not only the function of
the system but also the drugs used to affect the system. From lifestyle and environmental
influences to race and ethnicity, a range of factors must be considered in the management of
cardiovascular disorders. Associated clinical practice guidelines will be examined to help guide
decisions about management and treatment plans to maximize outcomes. The nurse
practitioner plays a significant role in reducing the risk of cardiovascular disease and improving
cardiovascular health through evidence-based interventions.
HYPERTENSION
Hypertension
Hypertension (HTN) is a complex cardiovascular condition with underlying vascular dysfunction
that leads to end-organ damage (primarily in the brain, eyes, heart, and kidneys). End organ
damage can be detected early, reflects the patient's overall cardiovascular risk, and is prevented
and treated with antihypertensive treatment (Chisholm-Burns et al., 2019). It is estimated that
46% of American adults have hypertension or are taking medication for hypertension (Muntner
et al., 2018). Learn more about hypertension in 3D interactive technology.
Increased blood flow exerts greater pressure on artery walls. Tunica media cannot effectively
contract.
Video Lecture Review:
- Factors Affecting BP:
o Cardiac Output (CO=HR x SV)
o Regulation of arterial pressure (AP=PR x CO)
▪ Peripheral resistance
▪ Volume fluid balance – RAAS
- Drug Classes Used to treat:
o Thiazide or thiazide-type diuretics
▪ Ex. Chlorthalidone (preferred), or hydrochlorothiazide
▪ MOA: Increase renal excretion of sodium, chloride, potassium and water
(addressing volume of blood)
▪ Need baseline info: weight, vital signs, electrolytes
▪ Monitor: hyponatremia, hypokalemia, uric acid (gout), and calcium levels
, ▪ Use in caution in patients with cardiovascular disease, renal impairment,
DM, or history of gout and in patients taking digoxin, lithium, or
antihypertensive drugs.
▪ Initiate therapy with low doses, adjust doses carefully, monitor weight
loss daily, and use an intermittent dosing schedule
▪ No black box warning
o ACE Inhibitors:
▪ Ex. Lisinopril, Enalapril, Captopril
▪ MOA: through RAAS system (considered renal protective, but need to
monitor anyway)
• Reducing levels of angiotensin II (through inhibition of ACE)
• Increasing levels of bradykinin (through inhibition of kinase II)
▪ Need baseline info: determine blood pressure and renal function
▪ Monitor:
• Hyperkalemia, especially in patients with CKD or in those on K+
supplements or K+ sparing drugs
• Consider checking creatinine 2-4 weeks after starting
• In patients with diabetic nephropathy, monitor proteinuria and
GFR
▪ Do not use in combination with ARBs or direct renin inhibitors. May cause
acute renal failure in patients with severe bilateral renal artery stenosis.
Do not use with history of angioedema with ACE inhibitors. Avoid in
pregnancy.
▪ Instruct patients to consult the prescriber if experiencing cough or facial
swelling. Use caution in combinations with drugs that elevate K levels
▪ BBW: use during 2nd and 3rd trimesters of pregnancy can injure the
developing fetus
o ARBs
▪ Ex. Losartan, Valsartan
▪ MOA: Block angiotensin II receptors on the blood vessels in the heart and
in the adrenals. Increases renal excretion of sodium and water.
▪ Need baseline info: determine blood pressure and renal function
▪ Monitor:
• Hyperkalemia, especially in patients with CKD or in those on K+
supplements or K+ sparing drugs
• Consider checking creatinine 2-4 weeks after starting
• In patients with diabetic nephropathy, monitor proteinuria and
GFR
▪ May cause ARF in patient with severe bilateral renal artery stenosis. Do
not use with history of angioedema with ARBS. Patients with a history of
angioedema with an ACEI can receive an ARB 6 weeks after ACEI is
discontinued. Avoid in pregnancy (contraindicated during the second and
third trimesters of pregnancy)
, ▪Instruct patients to consult the prescriber if experiencing cough or facial
swelling. Use caution in combination with drugs that elevate K levels.
▪ BBW: use during 2nd and 3rd trimesters of pregnancy can injure the
developing fetus
o CCBs (Calcium Channel Blockers)—dihydropyridines
▪ Ex. amiodipine, nifedipine
▪ MOA: dihydropyridines act primarily on arterioles
▪ Need baseline info: determine blood pressure and pulse rate and obtain
laboratory evaluations of liver and kidney function
▪ No routine monitoring of blood work required
▪ Avoid use in patients with HFrEF. Use with caution in patients with
hypotension, sick sinus syndrome, HF, and second- or third- degree
atrioventricular block.
▪ Reflex tachycardia can be suppressed with a B-blocker. Peripheral edema
can be reduced with a diuretic.
▪ No BBW
o CCB’s—non-dihydropyridines (wont be asked about this class)
▪ Ex. Diltiazem ER, Verapamil (IR, SR, ER)
▪ Avoid routine use with beta blockers due to increased risk of bradycardia
and heart block. Do not use in patients with HRrEF. Drug interactions with
diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)
How do we know what to give?
Non-black/African American patients: thiazide diuretics ACEI ARB
Black/African American patients: thiazide diuretics CCB
**Black/AA patients process renin differently—do not give ACE or ARB
Hypertension Treatment Goals
The American College of Cardiology (ACC) and American Heart Association (AHA) provides
evidence-based clinical practice guidelines to manage hypertension and improve cardiovascular
health in adults. The Eighth Joint National Committee (JNC 8) also provides evidence-based
guidelines to assist in the prevention and treatment of hypertension. The ACC/AHA guidelines
focus on stricter treatment thresholds, while the JNC 8 guidelines allow more permissive
(higher) blood pressure goals, as seen in the table below.
, Thiazide Diuretics
Thiazide diuretics are the preferred agent for treating stage 1 hypertension, and the preferred
initial therapy for treating African Americans with hypertension. All diuretics decrease blood
volume, venous pressure, and preload. More specifically, thiazide diuretics block the sodium-
chloride channel in the kidney, decreasing the cross of sodium over the luminal membrane,
which in turn decreases the action of the sodium-potassium pump and sodium and water
passage to the renal interstitium. These changes increase urinary output and require the
monitoring of potassium and other electrolytes to prevent adverse effects. All thiazides contain
sulfa compounds; therefore, these medications should be avoided in patients allergic to sulfa.
Thiazide diuretics are also used to manage osteopenia or osteoporosis, as they slow calcium loss
in bones.
Examine side effects and contraindications associated with common thiazide diuretics. Thiazide
diuretics include:
• HCTZ (hydrocholorothiazide) 12. to 25 mg PO daily
• Hygroton (chlorthalidone) 12.5 to 25mg PO daily
• Lozol (indapamide) PO daily
Side effects and contraindications include:
Latest Updated (Graded A+)- Chamberlain
Welcome to Week 3
This week, your exploration into pharmaceutical agents will focus on cardiovascular drugs which
are among the most widely used in healthcare. A variety of medications are used to treat heart
conditions such as hypertension, angina, heart failure, and arrhythmias. The cardiovascular
system is complex with many influencing factors; these factors impact not only the function of
the system but also the drugs used to affect the system. From lifestyle and environmental
influences to race and ethnicity, a range of factors must be considered in the management of
cardiovascular disorders. Associated clinical practice guidelines will be examined to help guide
decisions about management and treatment plans to maximize outcomes. The nurse
practitioner plays a significant role in reducing the risk of cardiovascular disease and improving
cardiovascular health through evidence-based interventions.
HYPERTENSION
Hypertension
Hypertension (HTN) is a complex cardiovascular condition with underlying vascular dysfunction
that leads to end-organ damage (primarily in the brain, eyes, heart, and kidneys). End organ
damage can be detected early, reflects the patient's overall cardiovascular risk, and is prevented
and treated with antihypertensive treatment (Chisholm-Burns et al., 2019). It is estimated that
46% of American adults have hypertension or are taking medication for hypertension (Muntner
et al., 2018). Learn more about hypertension in 3D interactive technology.
Increased blood flow exerts greater pressure on artery walls. Tunica media cannot effectively
contract.
Video Lecture Review:
- Factors Affecting BP:
o Cardiac Output (CO=HR x SV)
o Regulation of arterial pressure (AP=PR x CO)
▪ Peripheral resistance
▪ Volume fluid balance – RAAS
- Drug Classes Used to treat:
o Thiazide or thiazide-type diuretics
▪ Ex. Chlorthalidone (preferred), or hydrochlorothiazide
▪ MOA: Increase renal excretion of sodium, chloride, potassium and water
(addressing volume of blood)
▪ Need baseline info: weight, vital signs, electrolytes
▪ Monitor: hyponatremia, hypokalemia, uric acid (gout), and calcium levels
, ▪ Use in caution in patients with cardiovascular disease, renal impairment,
DM, or history of gout and in patients taking digoxin, lithium, or
antihypertensive drugs.
▪ Initiate therapy with low doses, adjust doses carefully, monitor weight
loss daily, and use an intermittent dosing schedule
▪ No black box warning
o ACE Inhibitors:
▪ Ex. Lisinopril, Enalapril, Captopril
▪ MOA: through RAAS system (considered renal protective, but need to
monitor anyway)
• Reducing levels of angiotensin II (through inhibition of ACE)
• Increasing levels of bradykinin (through inhibition of kinase II)
▪ Need baseline info: determine blood pressure and renal function
▪ Monitor:
• Hyperkalemia, especially in patients with CKD or in those on K+
supplements or K+ sparing drugs
• Consider checking creatinine 2-4 weeks after starting
• In patients with diabetic nephropathy, monitor proteinuria and
GFR
▪ Do not use in combination with ARBs or direct renin inhibitors. May cause
acute renal failure in patients with severe bilateral renal artery stenosis.
Do not use with history of angioedema with ACE inhibitors. Avoid in
pregnancy.
▪ Instruct patients to consult the prescriber if experiencing cough or facial
swelling. Use caution in combinations with drugs that elevate K levels
▪ BBW: use during 2nd and 3rd trimesters of pregnancy can injure the
developing fetus
o ARBs
▪ Ex. Losartan, Valsartan
▪ MOA: Block angiotensin II receptors on the blood vessels in the heart and
in the adrenals. Increases renal excretion of sodium and water.
▪ Need baseline info: determine blood pressure and renal function
▪ Monitor:
• Hyperkalemia, especially in patients with CKD or in those on K+
supplements or K+ sparing drugs
• Consider checking creatinine 2-4 weeks after starting
• In patients with diabetic nephropathy, monitor proteinuria and
GFR
▪ May cause ARF in patient with severe bilateral renal artery stenosis. Do
not use with history of angioedema with ARBS. Patients with a history of
angioedema with an ACEI can receive an ARB 6 weeks after ACEI is
discontinued. Avoid in pregnancy (contraindicated during the second and
third trimesters of pregnancy)
, ▪Instruct patients to consult the prescriber if experiencing cough or facial
swelling. Use caution in combination with drugs that elevate K levels.
▪ BBW: use during 2nd and 3rd trimesters of pregnancy can injure the
developing fetus
o CCBs (Calcium Channel Blockers)—dihydropyridines
▪ Ex. amiodipine, nifedipine
▪ MOA: dihydropyridines act primarily on arterioles
▪ Need baseline info: determine blood pressure and pulse rate and obtain
laboratory evaluations of liver and kidney function
▪ No routine monitoring of blood work required
▪ Avoid use in patients with HFrEF. Use with caution in patients with
hypotension, sick sinus syndrome, HF, and second- or third- degree
atrioventricular block.
▪ Reflex tachycardia can be suppressed with a B-blocker. Peripheral edema
can be reduced with a diuretic.
▪ No BBW
o CCB’s—non-dihydropyridines (wont be asked about this class)
▪ Ex. Diltiazem ER, Verapamil (IR, SR, ER)
▪ Avoid routine use with beta blockers due to increased risk of bradycardia
and heart block. Do not use in patients with HRrEF. Drug interactions with
diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)
How do we know what to give?
Non-black/African American patients: thiazide diuretics ACEI ARB
Black/African American patients: thiazide diuretics CCB
**Black/AA patients process renin differently—do not give ACE or ARB
Hypertension Treatment Goals
The American College of Cardiology (ACC) and American Heart Association (AHA) provides
evidence-based clinical practice guidelines to manage hypertension and improve cardiovascular
health in adults. The Eighth Joint National Committee (JNC 8) also provides evidence-based
guidelines to assist in the prevention and treatment of hypertension. The ACC/AHA guidelines
focus on stricter treatment thresholds, while the JNC 8 guidelines allow more permissive
(higher) blood pressure goals, as seen in the table below.
, Thiazide Diuretics
Thiazide diuretics are the preferred agent for treating stage 1 hypertension, and the preferred
initial therapy for treating African Americans with hypertension. All diuretics decrease blood
volume, venous pressure, and preload. More specifically, thiazide diuretics block the sodium-
chloride channel in the kidney, decreasing the cross of sodium over the luminal membrane,
which in turn decreases the action of the sodium-potassium pump and sodium and water
passage to the renal interstitium. These changes increase urinary output and require the
monitoring of potassium and other electrolytes to prevent adverse effects. All thiazides contain
sulfa compounds; therefore, these medications should be avoided in patients allergic to sulfa.
Thiazide diuretics are also used to manage osteopenia or osteoporosis, as they slow calcium loss
in bones.
Examine side effects and contraindications associated with common thiazide diuretics. Thiazide
diuretics include:
• HCTZ (hydrocholorothiazide) 12. to 25 mg PO daily
• Hygroton (chlorthalidone) 12.5 to 25mg PO daily
• Lozol (indapamide) PO daily
Side effects and contraindications include:
