• Cerebrovascular disease

Compelling indications for specific drug therapies are summarized in Table

5-5.1,8 In patients with hypertension and angina, B-blockers and long-acting CCBAs

1 26

are indicated due to their antihypertensive and antianginal effects. In addition, patients may benefit from the potential atherosclerotic plaque stabilizing effects of am-lodipine. In patients at high-risk of ischemic heart disease, such as diabetic patients with additional cardiovascular risk factors or chronic coronary artery or vascular disease, ACE inhibitors are particularly useful in reducing the risk of cardiovascular events regardless of whether the patient carries a concurrent diagnosis of hyperten-sion.1,50 8 In patients intolerant to an ACE inhibitor, an ARB may be substituted given the findings of the recently completed ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET).89

B-Blockers and ACE inhibitors are indicated for post-MI patients due to their proven reduction of cardiovascular morbidity and mortality in this population. Al-dosterone antagonists are also indicated for the post-MI patient with reduced left ventricular systolic function and diabetes or signs and symptoms of heart failure.1,76

Patients with asymptomatic left ventricular systolic dysfunction and hypertension should be treated with B-blockers and ACE inhibitors. Those with heart failure secondary to left ventricular dysfunction and hypertension should be treated with drugs proven to also reduce the morbidity and mortality of heart failure, including B-blockers, ACE inhibitors, ARBs, aldosterone antagonists, and diuretics for symptom control as well as antihypertensive effect. In African Americans with heart failure and left ventricular systolic dysfunction, combination therapy with nitrates and hy-dralazine not only affords a morbidity and mortality benefit, but may also be useful as antihypertensive therapy if needed. The dihydropyridine CCBAs amlodipine or felodipine may also be used in patients with heart failure and left ventricular systolic dysfunction for uncontrolled BP, although they have no effect on heart failure morbid-

ity and mortality in these patients. For patients with heart failure and preserved ejection fraction, antihypertensive therapies that should be considered include diuretics, P-blockers, ACE inhibitors, ARBs, CCBAs (including nondihydropyridine agents),

1 77

and others as needed to control BP.

Patients with diabetes and hypertension should initially be treated with either ACE inhibitors, ARBs, P-blockers, diuretics, or CCBAs. There is a general consensus that therapy focused on RAAS inhibition by ACE inhibitors or ARBs may be optimal if the patient has additional cardiovascular risk factors such as left ventricular hypertrophy or CKD.1,78,79,52

In patients with CKD and hypertension, ACE inhibitors and ARBs are preferred,

usually in combination with a diuretic. ACE inhibitors in combination with a thiazide diuretic are also preferred in patients with a history of prior stroke or transient ischemic attack. This therapy reduces the risk of recurrent stroke, making it particu-

larly attractive in these patients for BP control.

There are several situations in the management of hypertension requiring special considerations including, but not limited to:

• Hypertensive crisis

• Elderly populations

• Isolated systolic hypertension

• Minority populations

• Pediatrics

Hypertensive crisis can be divided into hypertensive emergencies and hypertensive urgencies. A hypertensive emergency occurs when severe elevations in BP are accompanied by acute or life-threatening target organ damage such as AMI, unstable angina, encephalopathy, intracerebral hemorrhage, acute left ventricular failure with pulmonary edema, dissecting aortic aneurysm, rapidly progressive renal failure, accelerated malignant hypertension with papilledema, and eclampsia, among others. BP is generally greater than 220/140 mm Hg, although a hypertensive emergency can occur at lower levels, particularly in individ-uals without previous hypertension. The goal in a hypertensive emergency is to reduce mean arterial pressure by up to 25% to the range of 160/100 to 110 mm Hg in minutes to hours.1,90 IV therapy is generally

required and may consist of the agents listed in Table 5-6. A hypertensive urgency is manifested as a severe elevation in BP without evidence of acute or life-threatening target organ damage. In these individuals, BP can usually be managed with orally administered short-acting medications (i.e., captopril, clonidine, or labetalol) and observation in the emergency department over several hours, with subsequent discharge

1 87

on oral medications and follow-up in the outpatient setting within 24 hours. '

The treatment of elderly patients with hypertension, as well as those with isolated systolic hypertension, should follow the same approach as with other populations with the exception that lower starting doses may be warranted to avoid symptoms. Special attention should be paid to postural hypotension. This should include a careful assessment of orthostatic symptoms, measurement of BP in the upright position, and caution to avoid volume depletion and rapid titration of antihypertensive therapy.1 In individuals with isolated systolic hypertension, the optimal level of diastolic pressure is not known, and although treated patients who achieve diastolic pressures less than 60 to 70 mm Hg had poorer outcomes in a landmark trial, their cardiovascular event rate was still lower than those receiving placebo.90 In addition, a recently completed trial (HYVET) documented the benefits of antihypertensive therapy in patients over the age of 80 as they experienced a significant reduction in all-cause mortality, fatal stroke and heart failure when treated with a diuretic (indapamide) with or without an ACE inhibitor (Perindopril).36

Table 5-6 Parenteral Antihypertensive Agents for Hypertensive Emergency"


Dose flange

□nier of Action

Duration uf Action

Adve rse Effects*

Special Indications

Vijudiliicir iotfwm Û/S-IU Immediate l-i minutes nitropuHKfe min as IV infusion'

Nicardipine 5-15mgytilV

î-lômipuies 15-3) marnies, may exceed 1 hoois

Fenoldopam CL1-CL J mcg/kgvlmln tesithan 3} minutes mesylate as UV infusion' 5 minutes

Nitroglycerin 5-I0Û mog/tog/Tnln 2-£ minules 5-10 minutes y, tV infusion

hours IV nmnutai l-tydraEartne 10-70 mg IV

hyidiatiiloride mg im

Ckrvklifmc- 1-21 «Hi/lHV

DUïOsiife 1-3 mg/kg or iß-IÖO nig ewiy 5-15 iTiirtut« Furosemide I0-+D mg/Mii miMrinnimSO 160 mg/h IV Adrenergic Inhibitors Lüsetalol 2(1-80 img IV toluS

hytffLxhlorlde every 10 immUei



1-4 hours IV houis IM

2 J niïnjli", 5~15 Irtfcltei i mkwKi

5 minulei

J-12 hotirs

2 hours minutes î-6 hours

ESIKVjkjl hytfiocfiloride


7V>- 500 ffK^rtg/ min Cv bolus, 1 hen 50 I00 mc-gAg/ rnln hy iniusicn may leptiat bolus l/Idi 5 minutes et InoHK Inhuion (o 500 mog/min 5-1S nrvg IVholui i ; miimm io 30n*nutft^u vomiting, mndt Ivyitdhing, tiwJlingL.

eyande intoxication Tachycardie headache. 1lu-,l iiiiii, Itcal phlebitis lactyicardla headache, reused, flushing

Headache, vomiting, metheniiiigkifcfiwiai tolerance with pfotonged use

Pjfr piicuilji in presSUI» in high-renin states varia Uli rt; ipen» î-,>vji i Ii,i. flushing teddache, ramitingi, j!.]r,LV:irinn ul on: |iri,l

AfriJIfibfilUlion. fCVK^. insomnia, nausea headache, vorrnling poftpnctdunl hennoi rhage,. acute renal failure, respiratory f»4jre

HyperglyrennL* »(tiMm and wjler retention

Hvpoicnsion, eleclrolyle immtTujitks htariiiy knpak ment

Vsntfuinc), stilft Umging, diriine«, biiXiihoiOiiHriaiun. ftsusei Iwrhkx*,

□rlhoslatic hypotension

Mypownijoa namwM. asthma. firstdegiee hturl bloch. heart fiikire

LiLÎi/.:,11 rti,! I!.j\hiir ■ -headache n/iosi liypertensitfe emeigencies: use-wilh cduiir.m wü.h high ¡nriiitr.inLiil pressure tu anolernia Moil hypertensive emergencies escepi acute Ivan failure; ui,' wjth caution with coronary ischemia ft/iosi hypertensive emeigertie^; use-wilh «tniofiivirh gfaucoma Goionary ischemia

Acute Hi vend irular fa*irft jh'üHj in acute myocardial iniaiction Éclanifteia

5wrc Jta I k. vieiioy', Ji+i-v li'/f ipirl nvcaboliuri

Priet^nrfKia, « lannosia, impaired renal function

Heart lükjie, Iluid mçrload, adjunct therapy to vasodilate«:

rAjiT liypefteosi^ emerijefvries ewcepl acute hear! failure

A<1| tic diiWMIion. pCrktHTJl rrt-


IM, inlrynuKular.

■Hnypoienstijn nmifoccrf «Ith all asefltt. 'Het^ires sceci^ dsliwyijartm,

Adj(/rd lrc)m .'JlJAif laugh in [J.Hyp(r1pn>iC<1.li1:0iPiiü IT, TjHUtI SI, ÖC, i I MiJ FliOrrtUiaihn-.irr AP,i0i0fiir>'d^gi< Afflioifh. Jrhfd.

tirwUferfciMf&jft HJt lf^wilh prm-^aii

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