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Treatment of Essential Hypertension

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Treatment of Essential Hypertension 2020 edition by Mark A. Simmons, PhD Department of Pharmaceutical Sciences School of Pharmacy University of Maryland Eastern Shore Originally developed by Hugh J. Burford, PhD, FCP Department of Pharmacology Schools of Medicine and Pharmacy University of North Carolina Chapel Hill and Patricia B. Williams, PhD, FCP Department of Pharmacology Eastern Virginia Medical School Norfolk Note to Instructors The POPS exercises are divided into seven sections: A. Introduction to the POPS System, introduction to and objectives of the clinical simulations, a pretest, and review topics B-E. Four different color-coded sections with pretest answers and the clinical problem F. Posttest G. Posttest answers For information on conducting the exercise, see the Instructor's Manual: Patient-Oriented Problem-Solving (POPS) System in Pharmacology. © 2020 Association of Medical School Pharmacology Chairs Treatment of Essential Hypertension Introduction to the Patient-Oriented Problem-Solving (POPS) System This is a patient-oriented problem-solving activity. The purposes are: 1. to help you learn how to apply your basic science knowledge to the solution of clinical problems; 2. to encourage you to better locate information necessary for solving problems by using sources (e.g., literature sources and peers) that will be available to you throughout your career; and 3. to encourage you to work with your fellow students and thus: a. increase your ability to evaluate your colleagues' opinions, thought processes, and clinical decisions; b. increase your communications skills; and c. increase your skills in interpersonal and interprofessional relations. This activity consists of five phases: First, you will review the attached set of objectives and complete the pretest on your own. In the second phase, you will use the pretest and the recommended review topics for further individual study before you meet with your group. In the third phase, you will join three other students and review the pretest answers in an "open-book" discussion. In the fourth phase, the group will solve patient-oriented problems. Information exchange and group interaction are keys to the success of this phase, which will allow you to teach your fellow students and, at the same time, learn from them. Finally, you will take a posttest, individually, which will enable you to assess your progress. Treatment of Essential Hypertension Introduction High blood pressure (hypertension) occurs in 25% to 35% of adults and children in the United States. Over half of the population over age 65 have hypertension. The prevalence and severity of hypertension increase with age. Hypertension occurs at younger ages in blacks than in whites. If untreated, patients with hypertension eventually become ill and may die of the effects of the disease. There are now ample data to show that lowering of blood pressure, even in patients with mild to moderate hypertension, reduces morbidity and mortality. In about 10% of cases, hypertension is secondary to another disease. In these cases treatment of the cause should be addressed. In most patients hypertension is of unknown etiology (essential or primary hypertension), and, therefore, specific therapy to correct causative factors is not possible. This has led to the development of drugs that lower blood pressure by various mechanisms: (1) diuretics, (2) drugs that affect the renin-angiotensin system, (3) calcium-channel blockers, (4) vasodilators, and (5) drugs that act through the sympathetic nervous system. Also, nonpharmacologic therapies, including weight loss, exercise, changes in diet, limiting alcohol consumption and smoking cessation, are effective in the treatment of mild hypertension and enhance the efficacy of pharmacologic therapy. One of the greatest problems with mild to moderate hypertension is that patients usually feel well (asymptomatic) and, therefore, are not motivated to undertake or continue treatment, especially since most antihypertensive drugs may have undesirable side effects. The availability of a wide variety of antihypertensive drugs with different sites of action makes it possible to develop an effective drug regimen that produces minimal side effects. Different populations respond differently to some drug classes. With pharmacologic and nonpharmacologic approaches, implementing the best therapy for an individual patient is a significant factor for promoting patient adherence. The authors designed this POPS unit to give you practice in applying your knowledge of the pharmacology of many drug classes that can be used for the reduction of elevated blood pressure. Treatment of Essential Hypertension Learning Objectives When you have completed this exercise, you should be able to: 1. list the major complications and diseases that result from untreated hypertension; 2. describe the physiologic factors involved in the regulation of blood pressure; 3. define hypertension and understand how to evaluate the hypertensive patient appropriately; 4. establish a therapeutic goal for blood pressure for individual hypertensive patients and be able to periodically reassess whether or not the goal is being met without undue discomfort for the patient; 5. for each of the major classes of antihypertensive drugs: a. identify the principal site of action and describe the mechanism(s) by which the drugs lower blood pressure, b. describe their main hemodynamic effects, and c. identify the primary advantages, disadvantages, and complications associated with these drugs and relate these to contraindications for their use; 6. apply the current therapeutic guidelines to treatment of a patient with progressive essential hypertension; 7. identify factors that promote patient adherence; 8. list major nonpharmacologic adjuncts to drug therapy that help decrease blood pressure in patients with mild to moderate hypertension; and 9. identify the first-choice drug for emergency use in a specific patient in hypertensive crisis. When you have become familiar with the objectives, complete the pretest on the next page. Treatment of Essential Hypertension Pretest Instructions: To facilitate later discussion and review, please mark these pretest pages with your answers to the following questions. If your instructor has provided a separate form, mark your answers both on that form (being sure to fill in the identification section) and on these pages. Choose the one correct or most appropriate answer. If you do not know an answer leave the space blank. Do not guess. Health professionals who think they know something, but do not, can do real harm. Those who know they don't know something can get help. Don't be upset if you don't know all the answers. The purpose of the pretest and the objectives are to alert you to important concepts. The posttest will be similar in content to the pretest. 1. Nitroprusside is the preferred drug in a patient with hypertensive crisis because A. it has a rapid predictable antihypertensive effect B. it promotes fluid and sodium retention C. it decreases venous return and cardiac work D. A and C E. A, B, and C 2. Which of the following inhibits angiotensin-converting enzyme and delays the progression of chronic kidney disease? A. hydrochlorothiazide B. losartan C. clonidine D. lisinopril 3. Which of the following antihypertensive sympathetic drug acts by blocking peripheral α1-adrenergic receptors? A. methyldopa B. propranolol C. reserpine D. prazosin 4. Which of the following may be associated with untreated hypertension? A. decreased life span B. renal damage C. congestive heart failure D. cerebrovascular accident (stroke) E. all of the above Treatment of Essential Hypertension 5. Which of the following antihypertensive drugs acts as a competitive antagonist at the angiotensin-II type 1 receptor? A. hydrochlorothiazide B. losartan C. clonidine D. captopril E. nifedipine 6. Which of the following has/have been associated with reflex tachycardia? A. amlodipine B. enalopril C. hydralazine D. propranolol E. A and C 7. The sympathetic nervous system plays an important role in blood pressure regulation. Which of the following drugs produces a decrease in blood pressure by blocking both beta-adrenergic receptors and α1-adrenergic receptors? A. carvedilol B. metoprolol C. propranolol D. terazosin E. verapamil 8. Drug X is given together with a thiazide diuretic for the control of hypertension. The dosage of drug X is increased to maintain control of blood pressure. Which of the following findings would lead you to conclude that the therapeutic effectiveness limit for drug X had been reached? Increasing the dosage of drug X causes A. no further decrease in blood pressure. B. deterioration of hepatic function. C. an increased incidence and severity of side effects. D. prolongation of its half-life. E. A and C Treatment of Essential Hypertension 9. All of the drugs listed below are appropriate for initial management of hypertension in nonblack patients, because in usual dosages they will lower blood pressure, with few side effects, except: A. thiazide diuretics B. centrally acting α2-agonists C. ACE inhibitors D. calcium-channel blockers E. angiotensin receptor blockers 10. Your search of the literature reveals the following data for the blood pressure (BP) lowering effects of hydrochlorothiazide (HCTZ): Daily oral dosage Diastolic BP lowering (standing) 12 mg 9 mm Hg 25 mg 8 mm Hg 50 mg 10 mm Hg 100 mg 12 mm Hg 200 mg 6 mm Hg A logical therapeutic strategy to lower diastolic BP more than 12 mm Hg in your patient who is receiving 25 mg of HCTZ daily would be to A. increase the HCTZ dose above 200 mg per day. B. add a second thiazide diuretic and observe the patient for signs of synergism. C. discontinue HCTZ and substitute a vasodilator. D. add a non-diuretic-antihypertensive drug to the HCTZ regimen. E. add a potassium-sparing diuretic and observe the patient for signs of synergism. Treatment of Essential Hypertension When you have completed the pretest, consult your study materials. Try to identify the correct answers and understand the concepts that make them correct. As a guideline for your studies, you may use the Learning Objectives. When your group meets, you will be responsible for explaining some of the answers.
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