Page 836 - Cardiac Nursing

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812 PA R T V / Health Promotion and Disease Prevention
Table 35-6 ■ ORAL ANTIHYPERTENSIVE DRUGS* (continued)
Usual Dose Range,
Total mg/day*
Drug Trade Name (frequency per day) Selected Side Effects and Comments*
Moexipril Univasc 7.5–30 (1)
Perindopril Aceon 4–8 (1–2)
Quinapril hydrochloride Accupril 10–40 (1)
Ramipril Altace 2.5–20 (1)
Trandolapril Mavik 1–4 (1)
Angiotensin II Receptor Blockers Angioedema (very rare), hyperkalemia
Candesartan Atacand 8–32 (1)
Eprosartan Teveten 400–800 (1–2)
Irbesartan Avapro 150–300 (1)
Losartan potassium Cozaar 25–100 (1–2)
Olmesartan Benicar 20–40 (1)
Telmisartan Micardis 20–80 (1)
Valsartan Diovan 80–320 (1)
Direct Renin Inhibitors
Tekturna Aliskiren 150–300 (1)
Aldosterone Receptor Blockers
Eplerenone Inspra 50–100 (1–2) Hyperkalemia
Spironolactone Aldactone 25–50 (1–2) Hyperkalemia, gynecomastia
*These dosages may vary from those listed in the Physicians’ Desk Reference (51st edition), which may be consulted for additional information. The listing of side effects is not all-
inclusive and side effects are for the class of drugs except where noted for individual drugs (in parentheses); clinicians are urged to refer to the package insert for a more detailed listing.
†
(G) indicates generic available.
‡
Has intrinsic sympathomimetic activity.
§
Cardioselective.
and selected side effects of most of the common antihypertensive Should -blockers be used as first-line agents is another issue
agents. Some of the most commonly used combinations are that has surfaced since the JNC 7. Many of the European Guide-
shown in Table 35-7. Combinations are often useful in simplify- line Committees have indicated that -blockers should be used as
ing therapy to increase adherence once the dose of medicines have second-line or even third-line agents due to their inability to re-
been titrated appropriately and in Stage 2 HTN initially. Once an duce stroke as effectively as other medicines and reserved only for
initial drug has been chosen, it is recommended that the patient post-MI patients or those with angina. 187,188 The controversy
begin with a low dose, which is titrated, or a new drug is added if continues as many of the studies were conducted in the older
7
BP goals are not achieved after a period of 1 to 2 months. This be- adults where it is known that -blockers are not as effective in
comes critically important as one of the failures of achieving better lowering BP as other agents. Moreover, in some studies, small
BP control is failure of health care professionals to titrate antihy- doses of -blockers were given once per day, which did not reduce
pertensive medications. 35 BP to the same degree as newer agents. 189 Finally, newer vasodi-
lating -blockers have not been tested in outcome studies. In gen-
A Few Issues Beyond JNC 7 eral, many experts now believe that nonvasodilating -blockers
Numerous studies have been undertaken since the release of the should not be used as first-line agents unless one has a history of
JNC 7 guidelines, which may add some relevance to changes that coronary heart disease. 189
may occur with new guidelines. For example, there have been The relevant issues about medications and their use in special
questions about whether to treat individuals with high-normal populations are discussed in more detail in the next section.
BP or prehypertensive individuals if they do not respond well to BP Management in Special Populations
lifestyle changes. The Trial of Preventing Hypertension Study
(TROPHY) was undertaken to determine if an ARB compared Management of HTN is modified on the basis of individual char-
with a placebo in groups who had received lifestyle therapy acteristics as well as knowledge of HTN care for specific groups.
would slow the progression of prehypertension to HTN defined The following section outlines additional information that guides
as a BP of 140/90 mm Hg. 186 In this trial, the use of an an- the management of HTN in several special populations.
giotensin receptor blocker slowed the progression of prehyperten- HTN in Older Adults. Individuals older than 60 years rep-
sion to HTN in the 2 years of the trial and the 2 years following resent the most rapidly growing segment of the U.S. population.
the study when the drug was withheld. However, the authors SBP increases almost linearly with age in industrialized societies as
stated very clearly that until this trial is confirmed with other does the overall prevalence of HTN and the proportion of hyper-
7
studies, treatment should not be given to those individuals with tensives with isolated systolic HTN. Isolated systolic HTN is de-
pre-HTN unless there are other risk factors such as diabetes, fined as SBP greater than 140 mm Hg with DBP less than 90 mm
CHD, or renal disease. Hg. The incidence of isolated systolic HTN increases with age,