1 - Hypertension Flashcards
Why are more women likely to get hypertension than males?
B/c they live longer
List some complications of HTN
- congestive heart failure
- renal failure
- peripheral vascular disease
- erectile dysfunction
- cerebrovascular disease
- stroke
- heart attack
- *more in slides
What are the 2 biggest risk factors for a CV event?
- smoking
- diabetes
Why don’t we want to start diagnosing HTN on the first clinic visit?
- could be something they did differently that day (coffee, exercise)
- could be white coat HTN
- don’t want to start someone on a life time med if they don’t actually need it
What is the BP goal for treating HTN in order to reduce complications?
140/90
Should people with mild hypertension (say 143/95) take antihypertensives?
Not really beneficial:
-antihypertensive drugs used in mild hypertension (140-159/90-99) have not been shown to reduce mortality or morbidity
What kind of Q’s do you want to ask a patient that is hypertensive?
- diet
- lifestyle (exercise)
- smoker?
- stress
- family history
- ask about other meds (both Rx and OTC)
List some types of drugs that can increase BP?
- NSAIDs
- decongestants
- alcohol
- estrogen
How long should you wait after implementing lifestyle changes to start medication?
3-6 months
List some non-pharms for lowering BP
- decrease salt intake
- exercise 30-60 mins of moderate-vig intensity 4-7 days/week
- weight reduction
- decrease alcohol
- decrease caffeine
- manage stress
- DASH diet
What are some examples of anti-hypertensives?
- diuretic
- ACEi
- ARB
- Ca channel blocker
How do you choose which antihypertensive to start a patient on? (What things are we going to be comparing)
- efficacy
- adverse drug reactions
- convenience
- cost
Is any antihypertensive more efficacious than the rest?
No - similar efficacy between the agents
If they are all the same efficacy, then we will look at adverse drug reactions:
List some side effects of thiazides
- dizziness
- increased urination (generally short lived)
- increased sun-sensitivity (minor, would only be a concern if starting thiazide and then going to a tropical location)
- hypokalemia, hyponatremia, increased lipids, increased uric acid, increased glucose
- muscle cramps
What type of patients would warrant caution when thinking about giving them a thiazide?
- Hx gout
- hypokalemic
- hyponatremic
If they are all the same efficacy, then we will look at adverse drug reactions:
List some side effects of ACEi
- DRY COUGH
- increase K+, increase serum creatinine
What type of patients would warrant caution when thinking about giving them an ACEi?
- Hx bilateral renal artery stenosis
- NSAID use
If they are all the same efficacy, then we will look at adverse drug reactions:
List some side effects of ARBs
- increase K+
- increase serum creatinine
What type of patients would warrant caution when thinking about giving them an ARB?
- Hx bilateral renal artery stenosis
- NSAID use
If they are all the same efficacy, then we will look at adverse drug reactions:
List some side effects of Beta Blockers
- cold extremities
- fatigue
- nausea
- decrease HR
- decrease exercise tolerance
- vivid dreams
- impotence
What type of patients would warrant caution when thinking about giving them beta blockers?
- Hx asthma
- severe PAD (pulmonary artery disease)
- heart block
If they are all the same efficacy, then we will look at adverse drug reactions:
List some side effects of Ca2+ channel blockers
DHP: flushing, ankle deem, headache, increased HR
non-DHP: same for DHP, plus decreased HR, heart block, worsened HF, constipation
What type of patients would warrant caution when thinking about giving them a Ca2+ channel blocker?
Hx heart failure (for non-DHP)
What are the DHP’s?
- amlodipine
- nifedipine
What are the non-DHP’s?
- verapamil
- diltiazem
What is a general rule for antiHTN meds?
Using 1/2 standard doses –> only 20% less BP reduction
*increasing dose barely increases efficacy and all it does is increase side effects
Is there any anti-HTN’s that are more convenient? (regarding dosing schedules)
Not really - either once daily or twice daily dosing
Is there any anti-HTN’s that are more cost-effective?
- thiazides are very cheap
- calcium channel blockers are the highest (about $10-30/30days)
If you started someone on a thiazide, what would you want to monitor and when?
- dizziness (esp if old and frail)
- check sodium and potassium levels
- prob do this in about 2 weeks
If you started someone on an ACEi, what do you need to monitor?
- warn them about dry cough
- check kidney fcn
- check potassium and creatinine levels
- check these in a couple of weeks
*IF OLD AND FRAIL DO THIS IN 2 WEEKS
If a patient is experiencing dizziness from a thiazide that they started 2 weeks ago, what do you tell them?
- that the dizziness should go away in 2-4 weeks
- taking them in the morning may help
What does it mean when albumin:creatinine ratio is high?
it means that the kidney is leaky bc albumin is a big ass molecule and shouldn’t be escaping into the urine
What is the BP target for anti-HTN meds?
140/90
What is the BP target for anti-HTN meds when the pt is diabetic?
140/90
*this does not change bc no RCT has ever shown a target of 130/80 to reduce complications of DM2
For a person with CV or kidney disease in addition to diabetes and hypertension, what is the first line anti-hypertensive?
ACEi/ARB
Does it matter what agent you start a pt on if they have diabetes and hypertension?
No - ALLHAT study (slide 53) showed no difference in outcomes, incidence of ESRD, or CHD between a diuretic, ACEi, and Ca channel blocker.
If a patient has kidney disease and HTN, what med should they be on?
ACEi or ARB
Diabetic patients:
Long-term CV protection is similar for traditional first line agents
True or false?
True
Diabetic patients:
For those WITHOUT kidney disease, ACEi and ARB reduce likelihood of developing _______, but not doubling of SCr or ESRD
microalbuminuria
Diabetic patients:
For those WITH kidney disease, what agent should they be on and why?
ACEi or ARB bc they both delay progression of nephropathy to ESRD
Discuss the pros and cons of either increasing the dose or adding another drug if a patient is far off from their target BP (140/90) ??
Increasing the dose:
- limits the amounts of meds they’re on
- they’re already used to the drug and it’s potential side effects
- REMEMBER THE GENERAL RULE ABOUT ANTI-HTN: won’t provide much increase in efficacy but will increase side effects
Adding another drug:
- in this case, more efficacious (additive effect, but won’t double side effects like increasing the dose would)
- con: has to add another pill to their life
Taking greater than or equal to 1 anti-HTN med at _____ may be beneficial
bedtime
If a patient is not far off target BP (140/90) would increasing a dose be appropriate or would you add another drug?
Bc he is not far off target, increasing an agent would be an ok option here bc we don’t need to reduce it that much
*if he’s farther off target, could think about adding another agent
If you start a patient on a CCB, what labs would you order?
no labs
What side effects would you expect from a CCB?
This is a vasodilator so:
- flushing
- headache
- edema
Elderly are more sensitive to sympathetic inhibition and volume depletion which can cause ???
- increased orthostatic HTN
- increased morbidity, increase risk of falls
What is the target BP for the very elderly? Why?
150/80
*don’t want it too low as this can lead to syncope and falls
