28. HTN Flashcards
Secondary HTN can be caused by ____
renal disease (e.g. CKD), adrenal disease, obstructive sleep apnea, or drugs
Pathophysiology of HTN includes increased activity of the ____ and ____
sympathetic nervous system (SNS)
RAAS
Drugs that can increase BP
Amphetamines, ADHD drugs
cocaine
decongestants (e.g. pseudoephedrine, phenylephrine)
Erythropoiesis-stimulating agents
Immunousppressants (e.g. cyclosporine)
NSAIDs
systemic steroids
Normal BP: SBP < ___ and DBP < ____
<120/80
HTN Stage 1: SBP ____ or DBP ____
SBP 130-139 or DBP 80-89
HTN Stage 2: SBP ____ or DBP ___
SBP ≥140 or DBP ≥90
Natural products used for HTN
fish oil, coenzyme Q10, L-arginine, and garlic
When should HTN meds be started?
Stage 2 HTN (SBP≥140 or DBP≥90)
Stage 1 HTN (SBP 130-139 or DBP 80-89) and any of the following:
- Clinical CVD (stroke, HF, CHD)
- 10 yr ASCVD risk ≥10%
- does not meet BP goal after 6 months of lifestyle modifications
BP Goal
<130/80
Note: KDIGO 2021 BP in CKD recommended SBP <120 in pts with HTN and CKD
Initial Drug selection based on specific characteristics: non-black
Thiazide, DHP CCB, ACEi/ARB
Initial Drug selection based on specific characteristics: Black
Thiazide, DHP CCB
(NOT ACEi/ARB)
Initial Drug selection based on specific characteristics: Stage 3 CKD (eGFR <60) and/or albuminuria (albumin ≥30)
ACEi/ARB
Start 2 first-line drugs when baseline average SBP and DBP > ____ above goal
> 20/10 (>150/90)
Monitoring: Check BP every ___ and titrate med if not at goal
month
Concern with use of ACEi/ARBs and pregnancy
Boxed warning for fetal toxicity in pregnancy, should be stopped immediately
ACOG recommends ___ and ____ as first-line treatments in pregnant pts. ____ is alt but may be less effective at BP lowering.
labetalol and nifedipine ER
Methyldopa
Preeclampsia occurs after week ___ of pregnancy and is evident by elevated BP and proteinuria. In pts high risk of preeclampsia (e.g. pre-existing HTN, renal disease, DM), ____ is recommended after first trimester
20 weeks
daily low-dose aspirin is recommended after first trimester
Brand name of lisinopril/HCTZ
Zestoretic
Brand name of losartan/HCTZ
Hyzaar
Brand name of olmesartan/HCTZ
Benicar HCT
Brand name of valsartan/HCTZ
Diovan HCT
Brand name of benazepril/amlodipine
Lotrel
Brand name of valsartan/amlodipine
Exforge
Brand name of atneolol/chlorthalidone
Tenoretic
Brand name of bisoprolol/HCTZ
Ziac
Brand name of triamteren/HCTZ
Madxzide, Maxzide-25
Thiazides and thiazide-type diuretics inhibit ___ reabsorption in the ____ causing increased excretion of ____
inhibit sodium reabsorption
increased excretion of sodium, chloride, water, and potassium
Chlorthalidone dosing
12.5-25mg daily
HCTZ dosing
12.5-50mg daily
Max dose is 100mg daily but doses > 50mg/day have limited clinical benefit and increase risk of adverse effects
Contraindications of thiazide, thiazide-type diuretics
Hypersensitivity to sulfonamide-derived drugs (not likely to cross-react)
Side effects of thiazide, thiazide-type diuretics (chlorthalidone, HCTZ)
decrease K, Mg, Na
Increase Ca, UA, LDL, TG, BG
Photosensitivity, impotence, dizziness, rash
Thiazides are not effective when CrCl < ____
CrCl <30
Patient complains of waking up to use the bathroom since starting HCTZ. What do you recommend?
Take early in the day to avoid nocturia
Which thiazide, thiazide-type diuretic is the only med in this class available as IV?
Chlorothiazide
Concern with thiazide diuretics and lithium
Thiazide diuretics decrease lithium renal clearance and increase lithium toxicity risk
DHP CCBs MOA
inhibit Ca ions from entering vascular smooth muscle and myocardial cells, causes peripheral arterial vasodilation (decrease SVR and BP) and coronary artery vasodilation
Peripheral vasodilation leads to common side effects of reflex tachycardia/palpitations, HA, flushing, peripheral edema
Common DHP CCB options
Amlodipine (Norvasc)
Nicardipine (Cardene IV)
Nifedipine ER (Adalat CC, Procardia XL)
What is the concern of using nifedipine IR
Do NOT use for chronic HTN or acute BP reduction in non-pregnant adults (profound hypotension, MI and/ or death has occured)
Side effects of DHP CCBs
generally well tolerated
can cause peripheral edema, HA, flushing, palpitations, reflex tachycardia, fatigue (worse with nifedipine IR), gingival hyperplasia (more common with non-DHP CCBs), nausea
Which DHP CCB is considered drug of choice in pregnancy?
Nifedipine ER
___ is considered the safest if a CCB must be used to lower BP in HFrEF
Amlodipine
What antihypertensives are used to prevent peripheral vasoconstriction in Raynaud’s (i.e. cold/blue fingers)
DHP CCBs (e.g. nifedipine ER)
Which DHP CCBs has a contraindication with allergy to soybeans, soy products, or eggs?
Clevidipine
Warnings for clevidipine
Hypotension, reflex tachycardia, infections
Side effects of clevidipine
Hypertriglyceridemia
Clevidipine is a milky-white lipid emulsion (provides ___ kcal/mL)
Use strict aseptic technique d/t infection risk, max time of use after vial puncture is ____
2 kcal/ml
12 hrs
T/F: Non-DHP CCBs are more selective for the myocardium than DHP CCBs
True
The decrease in BP produced by non-DHP CCBs is d/t ___
negative inotropic (decrease force of ventricular contraction)
Negative chronotropic (decrease HR) effects
Warnings for non-DHP CCBs (diltiazem, verapamil)
HF (may worsen symptoms), bradycardia
Others: hypotension, acute liver injury, increase LFTs, cardiac conduction abnormalities (diltiazem), hypertrophic cardiomyopathy (verapamil)
Side effects of non-DHP CCBs
edema, constipation (more with verapamil), gingival hyperplasia, HA, dizziness
When using CCBs, use caution with other drugs that decrease HR including ___
beta-blockers, digoxin, clonidine, amiodarone, and dexmedetomidine (Precedex)
All CCBs (except clevidipine) are major substrates of ___
CYP3A4
do not use with grapefruit juice and check for DDIs
Non-DHP CCBs (diltiazem, verapamil) are substrates and inhibitors of ___ and moderate inhibitors of ___
P-gp
CYP3A4
Lower doses of simvastatin or lovastatin
ACEi and ARBs have shown to slow the progression of ____
CKD
In ___, ACEi/ARBs protect the myocardium from remodeling affects of Angiotensin II
Heart failure
Why should RAAS inhibitors (ACEi and ARBs) not be used in combination?
Increased risk for adverse effects
Angioedema is a potentially fatal adverse effect that can occur with the use of any drug. It is more common with ____ than ____, and___ patients have higher risk
ACEi than ARBs or aliskiren
Black
T/F: if angioedema occurs with any RAAS inhibitor, other RAAS inhibitors should be avoided
True
ACEi MOA
block conversion of angiotensin I to angiotensin II, resulting to decrease vasoconstriction and decrease aldosterone secretion
Block degradation of bradykinin, which is thought to contribute to vasodilatory effects and side effects such as dry, hacking cough and angioedema
Boxed warnings for ACEi
injury and death to developing fetus in 2nd and 3rd trimesters, d/c as soon as pregnancy is detected
Contraindications with ACEi
Do not use with hx of angioedema
do not use with in 36hr of sacubitril/valsartan (Entresto)
Do not use with aliskiren in diabetes
Side effects with ACEi
cough, hyperkalemia, increase SCr, hypotesnion/dizziness
ARBs MOA
block angiotensin II from binding to angiotensin II type-1 (AT1) receptor on vascular smooth muscle, preventing vasoconstriction
Safety and side effects of ARBs is similar to ACEi except ____
less cough, less angioedema
No wash out period needed with sacubitril/valsartan (Entresto)
Warnings with Olmesartan (Benicar)
Sprue-like enteropathy – severe, chronic diarrhea with substantial weight loss; can occur months to years after drug initiation
___ is a direct renin inhibitor (decreases conversion of angiotensinogen to angiotensin I)
Aliskiren (Tekturna)
Concern with ACEi and ARBs and lithium
ACEi and ARBs can decrease lithium renal clearance and increase lithium toxicity
What effect do all RAAS inhibitors have on electrolyte imbalance?
Increase risk of hyperkalemia
K-sparing diuretics are often used with _____ to counteract the mild potassium losses seen with thiazide diuretics
HCTZ (e.g. Triamteren+HCTZ = Maxzide)
Which aldosterone receptor antagonist is non-selective vs selective?
Spironolactone = non-selective
Eplerenone = selective
Boxed warning with amiloride and triamterene
Hyperkalemia (K>5.5) more likely in pts with DM, renal impairment, or elderly pts
Contraindications with K-sparing diuretics
Do not use if hyperkalemia, severe renal impairment, Addison’s disease (spironolactone), or taking strong CYP3A4 inhibitors (eplerenone)
Which K-sparing diuretics are preferred add-on drugs in resistant HTN and used commonly in HF?
Aldosterone receptor antagonists - spironolactone and eplerenone
Side effects of K-sparing diuretics
Hyperkalemia, increase SCr, dizziness, hypochloremic metabolic acidosis
Spironolactone: Gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
Eplerenone: increase TGs
Concern with K-sparing diuretics and lithium use
Diuretics decrease lithium renal clearance and increase lithium toxicity
Beta-blockers are no longer recommended first-line for treating HTN unless ____
pt has comorbid condition for which beta-blockers are indicated (e.g. post-MI, stable ischemic heart disease, HF)
Which beta-blockers should be used if treating chronic HF?
Bisoprolol, carvedilol, metoprolol succinate
___ and ___ are beta-blockers with alpha-1 blocking properties
Carvedilol and labetalol
Beta-blockers with intrinsic sympathomimetic activity (ISA) (_____) partially stimulate beta receptors while blocking effects of catecholamines (e.g. NE). They do not decrease HR to the same degree as beta-blockers without ISA and are NOT recommended in post-MI pts.
Acebutolol
Others: penbutolol, pindolol
Boxed warnings for beta-blockers
do not d/c abruptly, taper dose over 1-2 weeks to avoid acute tachycardia, HTN, and/or ischemia
Examples of beta-1 selective beta blockers
Atenolol (Tenormin)
Esmolol (Brevibloc) - injection
Metoprolol tartrate (Lopressor) - tablet, injection
Metoprolol succinate ER (Toprol XL) - tab, capsule sprinkle
Warnings for beta-blockers
use caution in use caution in pts with DM - can worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms
Use caution with bronchospastic diseasses (e.g. asthma, COPD); beta-1 selective preferred
Use caution with Raynaud’s
Side effects for beta-blockers
Bradycardia, fatigue, hypotension, dizziness, depression, impotence (less than thiazides), cold extremities (can exacerbate Raynaud’s)
Most PO beta-blockers can be taken without regard to meals except ____
Metoprolol - Lopressor and Toprol XL
Carvedilol - Coreg, Coreg CR (to decrease rate of absorption and risk of orthostatic hypotension)
Metoprolol tartrate IV to PO ratio
1 : 2.5
Beta-1 selective drugs mnemonic AMEBBA
Atenolol, metoprolol, esmolol, bisoprolol, betaxolol, acebutolol
___ is a beta-1 selective blocker with nitric oxide-dependent vasodilation
Nebivolol (Bystolic)
Examples of non-selective beta-blockers
Propranolol (Inderal LA, XL)
Nadolol (Corgard)
Others: pindolol, timolol)
Which beta-blocker is a/w with more CNS side effects d/t high lipid solubility and crosses BBB? (but useful in other conditions like migraine ppx, essential tremor)
Propranolol
What type of beta-blockers are used in portal HTN?
Non-selective - propranolol, nadolol, pindolol, timolol
Examples of non-selective beta-blocker and alpha-1 blockers
Carvedilol (Coreg, Coreg CR)
Lbaetalol
Why should all forms of carvedilol be taken with food?
to decrease rate of absorption and risk of orthostatic hypotension
T/F: dosing conversion from carvedilol IR to CR is 1 to 1
False
Which beta blocker is drug of choice in pregnancy?
Labetalol
Beta-blockers can mask s/sx of hypoglycemia except ____
sweating and hunger
Beta-blockers can cause hyperglycemia by ___
decreasing insulin secretion
When using beta-blockers, use caution when administering other drugs that decrease HR such as ___
diltiazem, verapamil, digoxin, clonidine, amiodarone, and dexmedetomidine (Precedex)
Which antihypertensive is commonly used for resistant HTN and in pts who cannot swallow since it is available in patch formulation?
Clonidine
Examples of centrally-acting alpha-2 adrenergic agonists
Clonidine (Catapres, Catapres-TTS patch)
Guanfacine IR
Methyldopa
Contraindications for methyldopa
Concurrent use with MOAi and active liver disease
Warnings for centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa)
Do not d/c abruptly (can cause rebound HTN), sweating, anxiety, tremors)
Taper over 2-4 days
Methyldopa: risk for hemolytic anemia (detected by + Coombs test), hepatic necrosis
Side effects for centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa)
Dry mouth, somnolence, fatigue, dizziness, constipation, decrease HR, hypotension, impotence, HA, depression, behavioral changes (irritability, confusion, anxiety, nightmares)
Clonidine patch - skin rash, pruritus, erythema
Methyldopa - hypersensitivity reactions (DILE), edema or weight gain (control with diuretics), increase prolactin levels
Clonidine patch administration instructions
apply weekly to clean dry and hairless area on upper outer arm or upper chest
Remove before MRI
Can apply adhesive cover over patch if it loosens
Which centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa) can be used in pregnancy?
Methyldopa
Examples of direct vasodilators
Hydralazine
Minoxidil
Warnings with hydralazine
DILE -dose and duration related, peripheral neuritis, blood dyscrasias, hypotension
Boxed warning for minodixil
potent antihypertensive - can cause pericardial effusion and angina exacerbations; administer with BB and loop diuretic
Side effects of minoxidil
Fluid retention, tachycardia, hair growth (used as OTC topical for hair growth)
T/F: Alpha blockers are not recommended for HTN but may be used in men who have HTN and BPH
True
Compare hypertensive urgency vs emergency
Emergency = includes organ damage (e.g. encephalopathy, stroke, AKI, acute coronary syndrome, aortic dissection, acute pulmonary edema)
Urgency = no organ damage
Compare treatment of hypertensive urgency vs emergency
Emergency = IV meds, decrease BP by no more than 25% within the first hr), then if stable, decrease to ~160/100 in the next 2-6hrs
Urgency = short acting PO meds or restart chronic HTN treatment in nonadherent pts , decrease BP gradually over 24-48hrs
