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Hypertension (HTN) is considered one of the leading causes of increased cardiovascular disease. Lowering blood pressure does reduce cardiovascular risks; maintaining systolic blood pressure of less than 130 mm Hg demonstrably prevents complications in patients with heart failure, diabetes, coronary artery disease, stroke, and other cardiovascular diseases. This activity discusses the guidelines for selecting the appropriate antihypertensive medications. It presents the different classes for first, second, and third-line treatments for hypertension and highlights the indications and side effects. It highlights the studies done to compare different classes of antihypertensive medications and indications for each class. Objectives: Describe the guidelines for using antihypertensive medications and guide the treatment choices for first-line treatment. Review the different anti-hypertensive medication classes, summarizing the guidelines for the indication to use combination treatment when mono-therapy fails. Outline the significant side effects of each class of antihypertensive medications. Identify the approach of the interprofessional team to identify an appropriate care plan for a hypertension patient. Access free multiple choice questions on this topic.

Thiazides and loop diuretics toxicity can cause electrolyte abnormalities ( mainly hypokalemia and hyponatremia) and metabolic acidosis (hypochloremic). Severe dehydration can occur. No antidotes are available for these diuretics; treatment is primarily volume and electrolyte replacement.[24] Potassium-sparing diuretics toxicity presents as severe hyperkalemia; the main treatment is to stop all medications that cause elevated potassium levels, IV hydration, IV calcium gluconate, IV insulin with glucose, sodium bicarbonate, and potassium binding resins.[46] Non-dihydropyridine CCB toxicity occurs due to the decreased ionotropy effect on the cardiac muscle, leading to bradycardia and hypotension. A complete heart block and idioventricular rhythm can occur.[30] Dihydropyridine CCBs cause peripheral vasodilation and severe hypotension but have less effect on the heart rate. IV hydration is recommended for hypotension, IV atropine, and an external pacemaker for bradycardia. Calcium chloride or calcium gluconate intravenously can help hypotension if IV hydration does not improve blood pressure. IV vasopressors can be an option if blood pressure does not improve.[30] Toxicity from ACE inhibitors and ARBs can cause severe hypotension, hyperkalemia, and hyponatremia. No antidotes are available, and IV hydration and management for hyperkalemia are recommended.[31] Like CCBs, beta-blockers cause hypotension and bradycardia and may lead to second or third-degree AV blocks. IV glucagon is the initial antidote; IV hydration and an external pacemaker may be required if there is no response.[32] Hydralazine toxicity can cause severe hypotension, tachycardia, and skin flushing; in severe cases, patients may develop cardiac shock or myocardial ischemia. No antidote is available; IV hydration and IV vasopressors are interventions for severe cases. Beta-blockers can be used for severe tachycardia.[33] Clonidine toxicity can present as lethargy, hypotension, bradycardia, and miosis. In severe cases, respiratory depression may develop. Treatment is supportive care with hydration and vasopressors. Dopamine and norepinephrine are common choices in this scenario. IV atropine is an option for severe bradycardia, and the use of an external pacemaker is reserved for cases resistant to atropine treatment.[49]

Clonidine toxicity can present as lethargy, hypotension, bradycardia, and miosis. In severe cases, respiratory depression may develop. Treatment is supportive care with hydration and vasopressors. Dopamine and norepinephrine are common choices in this scenario. IV atropine is an option for severe bradycardia, and the use of an external pacemaker is reserved for cases resistant to atropine treatment.[49] Minoxidil toxicity can cause tachycardia and hypotension. Treatment is supportive with IV hydration and vasopressors.[44] Alpha-blockers toxicity can cause severe hypotension, and IV hydration and vasopressors are the primary treatment options.[50]

Antihypertensives are a broad group of medications, and healthcare workers are recommended to have special caution in monitoring adherence and possible adverse reactions to these medications. Treatment of HTN is essential in preventing cardiovascular disease, and choosing the precise class of drugs is critical to achieving the appropriate control with fewer side effects. An interprofessional team of clinicians, nurses, and pharmacists is required to monitor patients on these medications. The clinician starts the antihypertensive regimen; this should be followed by special attention from the pharmacies to check on the drug-drug interactions, patient adherence to treatment, and medication reconciliation. The nurse plays a vital role in monitoring the patient's adherence and determining barriers to good response to the treatment, including monitoring diet and activity levels and evaluating the home environment. Home visiting nurses will monitor blood pressure and heart rate response to the treatment and identify early adverse reactions. Both pharmacists and nurses should inform the clinician of any possible concerns of adherence, adverse reactions, or home environmental changes. This comprehensive interprofessional team effort helps achieve the maximal benefits of the regimen and the best care delivery to the patient and family. [Level 5]