michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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1- Fludrocortisone : a mineralocorticoid that helps retain sodium and water, thereby partially<br />
compensating for vascular tone that inappropriately high for normal intravascular volumes<br />
2- Midodrine : an α-adrenergic agonist that causes vasoconstriction and increases peripheral<br />
vascular resistance. This medication is particularly effective in patients with noradrenergic<br />
denervation, and should probably be avoided in the evening to avoid further worsening <strong>of</strong><br />
supine <strong>hypertension</strong>. Other alpha-adrenergic agonists that have been used include ephedrine,<br />
pseudoephedrine, and phenylephrine.<br />
3- Yohimbine, a centrally and peripherally acting α-2 adrenoceptor antagonist, increases<br />
sympathetic nervous system efferent output by antagonizing central or presynaptic a2-<br />
adrenoreceptors. Side effects <strong>of</strong> yohimbine include anxiety, tremor, palpitations, diarrhea and<br />
supine <strong>hypertension</strong><br />
4- Clonidine, predominantly a presynaptic α-2 adrenoceptor agonist, has a sympatholytic effect<br />
in normal individuals by decreasing catecholamine release. Clonidine has lesser affinity for<br />
postsynaptic α-1 adrenoceptors, but this effect can normally be seen only at high doses (> 1 mg<br />
per day). However, in patients with neurogenic OH and markedly diminished central efferent<br />
sympathetic activity, the postsynaptic affects may predominate. The drug needs to be used with<br />
caution since it can exacerbate hypotension in some patients.<br />
5- Droxidopa (L-threo-3,4-dihydroxyphenlyserine or L-DOPS) has been reported to improve OH.<br />
It has been suggested that droxidopa may be less likely to exacerbate supine <strong>hypertension</strong><br />
than standard pressor drugs such as midodrine. The drug appears to replete postganglionic<br />
adrenergic axons, thereby restoring physiologic control <strong>of</strong> supine BP. It also seems to improve<br />
OH even where there is a severe loss <strong>of</strong> postganglionic fibers (as in pure autonomic failure)<br />
thereby suggesting an extraneuronal mode <strong>of</strong> action as well.<br />
6- Non-selective beta blockers, such as propranolol, result in unopposed stimulation <strong>of</strong> peripheral<br />
α-1 receptors.<br />
7- Desmopressin, a vasopressor that helps constrict peripheral vessels and may increase cerebral<br />
and coronary blood flow<br />
8- Pyridostigmine, a cholinesterase inhibitor that increases ganglionic trafficking in proportional<br />
response to orthostatic stress<br />
9- SSRI antidepressants<br />
220 Hypertension Core Curriculum