Symptomatic hypotension

Apart from possible clinical differences between the P-block-ers approved for HF, selection of a p-blocker may also be affected by pharmacologic differences. Carvedilol exhibits a more pronounced blood pressure lowering effect and thus causes more frequent dizziness and hypotension as a consequence of its ar receptor blocking activity. Therefore, in patients predisposed to symptomatic hypotension, such as those with advanced LV dysfunction (LVEF less than 20%) who normally exhibit low systolic blood pressures, metoprolol succinate may be the most desirable first-line P-blocker. In patients with uncontrolled hypertension, carvedilol may provide additional antihypertensive efficacy. 

Blockers Monitor patients for bradycardia (heart rate less than 60 bpm), symptomatic hypotension (blood pressure less than 90/60 mm Hg), and easy fatigability. 

Because diuretics can cause excessive preload reduction, they must be used judiciously to obtain the desired improvement in congestive symptoms while avoiding a reduction in cardiac output, symptomatic hypotension, or worsening renal function. 

SBP <90 mm Hg Symptomatic hypotension Worsening renal function Unresponsive/i nto lerant IV vasodilators... 

Blood pressure should be monitored to ensure that symptomatic hypotension does not develop as a result of drug therapy. 

Use in concomitant diuretics - If BP is not adequately controlled with perindopril alone, a diuretic may be added. In patients currently being treated with a diuretic, symptomatic hypotension occasionally can occur following the initial dose of perindopril. To reduce likelihood of such reaction, the diuretic should, if possible, be discontinued 2 to 3 days prior to beginning perindopril therapy. Then, if BP is not controlled with perindopril alone, resume the diuretic. If the diuretic cannot be discontinued, use an initial dose of 2 to 4 mg daily in 1 or 2 divided doses with careful medical supervision for several hours and until BP has stabilized. Titrate the dosage as described above. 

Hypotension/Votume- or salt-depleted patients In patients who are intravascularly volume-depleted (eg, those treated with diuretics), symptomatic hypotension may occur. Correct these conditions prior to administration. 

Symptomatic hypotension Patients require careful monitoring for signs and symptoms of orthostatic hypotension while being treated with dopaminergic... 

Systemic administration of rIL-2 causes fever, nausea, vomiting, fatigue, and malaise. Other adverse affects include flushing, diarrhea, chills, rash, edema, symptomatic hypotension, and certain renal abnormalities. These tend to occur at increased dosage levels and are attenuated by reducing the dosage. 

Baseline electrolytes, urinalysis, BUN and creatinine with recheck at 2-4 wk after initiation (sooner in volume-depleted patients) monitor sitting BP watch for symptomatic hypotension, particularly in volume-depleted patients... 

Cardiovascular effects. Given aj-adrenergic receptor antagonism, quetiapine may induce orthostatic hypotension and concomitant symptoms of dizziness, tachycardia, and syncope. The risk of symptomatic hypotension is particularly pronounced during initial dose titration. Quetiapine should be used with caution in patients with cardiovascular disease, cerebrovascular disease, or other illnesses predisposing to hypotension. 

French J, White H. Transient symptomatic hypotension in patients on simvastatin. Lancet 1989 2(8666) 807-8. 

Adverse effects These include postural hypotension, renal insufficiency, hyperkalemia, and a persistent dry cough. The potential of symptomatic hypotension with ACE inhibitor therapy requires careful monitoring. ACE inhibitors should not be used in pregnant women. 

Symptomatic hypotension due to the withdrawal of angiotensin 11-mediated vasoconstrictor tone can occur, especially after the first dose of an ACE-inhibitor, and particularly in patients with high plasma renin activity (e.g., patients with salt depletion due to high doses of diuretics, or with CHF). 

Symptomatic hypotension has occasionally been reported in patients with myocardial infarction who have been given adenosine (SEDA-20,174). 

The SPICE was a smaller trial (270 patients, 12 weeks follow-up) which evaluated the use of candesartan versus placebo in patients with heart failure and a history of intolerance of ACE inhibitors (most commonly because of cough, symptomatic hypotension, or renal insufficiency). Titration to the highest dose of candesartan 16 mg was possible in 69% of the patients (84% in the placebo group). Death and cardiovascular events tended to be lower with candesartan (7). 

Wachter RM. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med 1987 147(3) 556-8. 

The pressure-lowering effect of a step-wise intravenous infusion of glyceryl trinitrate was significantly increased in 12 healthy volunteers treated for 4 days with sildenafil 25 mg tds episodes of symptomatic hypotension were also more frequent with sildenafil (52). When sublingual glyceryl trinitrate was used, the reduction in systolic blood pressure was fourfold greater in association with sildenafil. 

Captopril was well tolerated by most patients but rash and fever occurred in some patients. Patients with very high initial PRA may be extremely sensitive to blockade of the RAS and at least one episode of symptomatic hypotension has occurred after captopril in a 0 volume-depleted patient. These clinical studies, as... 

Timolol is contraindicated in patients with nnstabilized cardiac failure or bronchial obstruction, AV condnction disturbances of the second and third grade, nnstable insnlin-dependent diabetes, and severe peripheral arterial obstruction. The most common side effects are mnscnlar fatigne, cold hands and feet, symptomatic hypotension, and bradycardia. 

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