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NAPLEX 2024 > 28. HTN > Flashcards

28. HTN Flashcards

1
Q

Secondary HTN can be caused by ____

A

renal disease (e.g. CKD), adrenal disease, obstructive sleep apnea, or drugs

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2
Q

Pathophysiology of HTN includes increased activity of the ____ and ____

A

sympathetic nervous system (SNS)
RAAS

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3
Q

Drugs that can increase BP

A

Amphetamines, ADHD drugs
cocaine
decongestants (e.g. pseudoephedrine, phenylephrine)
Erythropoiesis-stimulating agents
Immunousppressants (e.g. cyclosporine)
NSAIDs
systemic steroids

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4
Q

Normal BP: SBP < ___ and DBP < ____

A

<120/80

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5
Q

HTN Stage 1: SBP ____ or DBP ____

A

SBP 130-139 or DBP 80-89

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6
Q

HTN Stage 2: SBP ____ or DBP ___

A

SBP ≥140 or DBP ≥90

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7
Q

Natural products used for HTN

A

fish oil, coenzyme Q10, L-arginine, and garlic

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8
Q

When should HTN meds be started?

A

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

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9
Q

BP Goal

A

<130/80

Note: KDIGO 2021 BP in CKD recommended SBP <120 in pts with HTN and CKD

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10
Q

Initial Drug selection based on specific characteristics: non-black

A

Thiazide, DHP CCB, ACEi/ARB

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11
Q

Initial Drug selection based on specific characteristics: Black

A

Thiazide, DHP CCB

(NOT ACEi/ARB)

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12
Q

Initial Drug selection based on specific characteristics: Stage 3 CKD (eGFR <60) and/or albuminuria (albumin ≥30)

A

ACEi/ARB

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13
Q

Start 2 first-line drugs when baseline average SBP and DBP > ____ above goal

A

> 20/10 (>150/90)

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14
Q

Monitoring: Check BP every ___ and titrate med if not at goal

A

month

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15
Q

Concern with use of ACEi/ARBs and pregnancy

A

Boxed warning for fetal toxicity in pregnancy, should be stopped immediately

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16
Q

ACOG recommends ___ and ____ as first-line treatments in pregnant pts. ____ is alt but may be less effective at BP lowering.

A

labetalol and nifedipine ER
Methyldopa

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17
Q

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

A

20 weeks
daily low-dose aspirin is recommended after first trimester

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18
Q

Brand name of lisinopril/HCTZ

A

Zestoretic

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19
Q

Brand name of losartan/HCTZ

A

Hyzaar

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20
Q

Brand name of olmesartan/HCTZ

A

Benicar HCT

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21
Q

Brand name of valsartan/HCTZ

A

Diovan HCT

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22
Q

Brand name of benazepril/amlodipine

A

Lotrel

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23
Q

Brand name of valsartan/amlodipine

A

Exforge

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24
Q

Brand name of atneolol/chlorthalidone

A

Tenoretic

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25
Q

Brand name of bisoprolol/HCTZ

A

Ziac

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26
Q

Brand name of triamteren/HCTZ

A

Madxzide, Maxzide-25

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27
Q

Thiazides and thiazide-type diuretics inhibit ___ reabsorption in the ____ causing increased excretion of ____

A

inhibit sodium reabsorption
increased excretion of sodium, chloride, water, and potassium

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28
Q

Chlorthalidone dosing

A

12.5-25mg daily

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29
Q

HCTZ dosing

A

12.5-50mg daily

Max dose is 100mg daily but doses > 50mg/day have limited clinical benefit and increase risk of adverse effects

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30
Q

Contraindications of thiazide, thiazide-type diuretics

A

Hypersensitivity to sulfonamide-derived drugs (not likely to cross-react)

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31
Q

Side effects of thiazide, thiazide-type diuretics (chlorthalidone, HCTZ)

A

decrease K, Mg, Na
Increase Ca, UA, LDL, TG, BG
Photosensitivity, impotence, dizziness, rash

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32
Q

Thiazides are not effective when CrCl < ____

A

CrCl <30

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33
Q

Patient complains of waking up to use the bathroom since starting HCTZ. What do you recommend?

A

Take early in the day to avoid nocturia

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34
Q

Which thiazide, thiazide-type diuretic is the only med in this class available as IV?

A

Chlorothiazide

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35
Q

Concern with thiazide diuretics and lithium

A

Thiazide diuretics decrease lithium renal clearance and increase lithium toxicity risk

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36
Q

DHP CCBs MOA

A

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

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37
Q

Common DHP CCB options

A

Amlodipine (Norvasc)
Nicardipine (Cardene IV)
Nifedipine ER (Adalat CC, Procardia XL)

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38
Q

What is the concern of using nifedipine IR

A

Do NOT use for chronic HTN or acute BP reduction in non-pregnant adults (profound hypotension, MI and/ or death has occured)

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39
Q

Side effects of DHP CCBs

A

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

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40
Q

Which DHP CCB is considered drug of choice in pregnancy?

A

Nifedipine ER

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40
Q

___ is considered the safest if a CCB must be used to lower BP in HFrEF

A

Amlodipine

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41
Q

What antihypertensives are used to prevent peripheral vasoconstriction in Raynaud’s (i.e. cold/blue fingers)

A

DHP CCBs (e.g. nifedipine ER)

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42
Q

Which DHP CCBs has a contraindication with allergy to soybeans, soy products, or eggs?

A

Clevidipine

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43
Q

Warnings for clevidipine

A

Hypotension, reflex tachycardia, infections

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44
Q

Side effects of clevidipine

A

Hypertriglyceridemia

45
Q

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 ____

A

2 kcal/ml
12 hrs

46
Q

T/F: Non-DHP CCBs are more selective for the myocardium than DHP CCBs

47
Q

The decrease in BP produced by non-DHP CCBs is d/t ___

A

negative inotropic (decrease force of ventricular contraction)
Negative chronotropic (decrease HR) effects

48
Q

Warnings for non-DHP CCBs (diltiazem, verapamil)

A

HF (may worsen symptoms), bradycardia
Others: hypotension, acute liver injury, increase LFTs, cardiac conduction abnormalities (diltiazem), hypertrophic cardiomyopathy (verapamil)

49
Q

Side effects of non-DHP CCBs

A

edema, constipation (more with verapamil), gingival hyperplasia, HA, dizziness

50
Q

When using CCBs, use caution with other drugs that decrease HR including ___

A

beta-blockers, digoxin, clonidine, amiodarone, and dexmedetomidine (Precedex)

51
Q

All CCBs (except clevidipine) are major substrates of ___

A

CYP3A4
do not use with grapefruit juice and check for DDIs

52
Q

Non-DHP CCBs (diltiazem, verapamil) are substrates and inhibitors of ___ and moderate inhibitors of ___

A

P-gp
CYP3A4
Lower doses of simvastatin or lovastatin

53
Q

ACEi and ARBs have shown to slow the progression of ____

54
Q

In ___, ACEi/ARBs protect the myocardium from remodeling affects of Angiotensin II

A

Heart failure

55
Q

Why should RAAS inhibitors (ACEi and ARBs) not be used in combination?

A

Increased risk for adverse effects

56
Q

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

A

ACEi than ARBs or aliskiren
Black

57
Q

T/F: if angioedema occurs with any RAAS inhibitor, other RAAS inhibitors should be avoided

58
Q

ACEi MOA

A

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

59
Q

Boxed warnings for ACEi

A

injury and death to developing fetus in 2nd and 3rd trimesters, d/c as soon as pregnancy is detected

60
Q

Contraindications with ACEi

A

Do not use with hx of angioedema
do not use with in 36hr of sacubitril/valsartan (Entresto)
Do not use with aliskiren in diabetes

61
Q

Side effects with ACEi

A

cough, hyperkalemia, increase SCr, hypotesnion/dizziness

62
Q

ARBs MOA

A

block angiotensin II from binding to angiotensin II type-1 (AT1) receptor on vascular smooth muscle, preventing vasoconstriction

63
Q

Safety and side effects of ARBs is similar to ACEi except ____

A

less cough, less angioedema
No wash out period needed with sacubitril/valsartan (Entresto)

64
Q

Warnings with Olmesartan (Benicar)

A

Sprue-like enteropathy – severe, chronic diarrhea with substantial weight loss; can occur months to years after drug initiation

65
Q

___ is a direct renin inhibitor (decreases conversion of angiotensinogen to angiotensin I)

A

Aliskiren (Tekturna)

66
Q

Concern with ACEi and ARBs and lithium

A

ACEi and ARBs can decrease lithium renal clearance and increase lithium toxicity

67
Q

What effect do all RAAS inhibitors have on electrolyte imbalance?

A

Increase risk of hyperkalemia

68
Q

K-sparing diuretics are often used with _____ to counteract the mild potassium losses seen with thiazide diuretics

A

HCTZ (e.g. Triamteren+HCTZ = Maxzide)

69
Q

Which aldosterone receptor antagonist is non-selective vs selective?

A

Spironolactone = non-selective
Eplerenone = selective

70
Q

Boxed warning with amiloride and triamterene

A

Hyperkalemia (K>5.5) more likely in pts with DM, renal impairment, or elderly pts

70
Q

Contraindications with K-sparing diuretics

A

Do not use if hyperkalemia, severe renal impairment, Addison’s disease (spironolactone), or taking strong CYP3A4 inhibitors (eplerenone)

71
Q

Which K-sparing diuretics are preferred add-on drugs in resistant HTN and used commonly in HF?

A

Aldosterone receptor antagonists - spironolactone and eplerenone

72
Q

Side effects of K-sparing diuretics

A

Hyperkalemia, increase SCr, dizziness, hypochloremic metabolic acidosis

Spironolactone: Gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea

Eplerenone: increase TGs

73
Q

Concern with K-sparing diuretics and lithium use

A

Diuretics decrease lithium renal clearance and increase lithium toxicity

74
Q

Beta-blockers are no longer recommended first-line for treating HTN unless ____

A

pt has comorbid condition for which beta-blockers are indicated (e.g. post-MI, stable ischemic heart disease, HF)

75
Q

Which beta-blockers should be used if treating chronic HF?

A

Bisoprolol, carvedilol, metoprolol succinate

76
Q

___ and ___ are beta-blockers with alpha-1 blocking properties

A

Carvedilol and labetalol

77
Q

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.

A

Acebutolol
Others: penbutolol, pindolol

78
Q

Boxed warnings for beta-blockers

A

do not d/c abruptly, taper dose over 1-2 weeks to avoid acute tachycardia, HTN, and/or ischemia

79
Q

Examples of beta-1 selective beta blockers

A

Atenolol (Tenormin)
Esmolol (Brevibloc) - injection
Metoprolol tartrate (Lopressor) - tablet, injection
Metoprolol succinate ER (Toprol XL) - tab, capsule sprinkle

80
Q

Warnings for beta-blockers

A

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

81
Q

Side effects for beta-blockers

A

Bradycardia, fatigue, hypotension, dizziness, depression, impotence (less than thiazides), cold extremities (can exacerbate Raynaud’s)

82
Q

Most PO beta-blockers can be taken without regard to meals except ____

A

Metoprolol - Lopressor and Toprol XL
Carvedilol - Coreg, Coreg CR (to decrease rate of absorption and risk of orthostatic hypotension)

83
Q

Metoprolol tartrate IV to PO ratio

84
Q

Beta-1 selective drugs mnemonic AMEBBA

A

Atenolol, metoprolol, esmolol, bisoprolol, betaxolol, acebutolol

85
Q

___ is a beta-1 selective blocker with nitric oxide-dependent vasodilation

A

Nebivolol (Bystolic)

86
Q

Examples of non-selective beta-blockers

A

Propranolol (Inderal LA, XL)
Nadolol (Corgard)

Others: pindolol, timolol)

87
Q

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)

A

Propranolol

88
Q

What type of beta-blockers are used in portal HTN?

A

Non-selective - propranolol, nadolol, pindolol, timolol

89
Q

Examples of non-selective beta-blocker and alpha-1 blockers

A

Carvedilol (Coreg, Coreg CR)
Lbaetalol

90
Q

Why should all forms of carvedilol be taken with food?

A

to decrease rate of absorption and risk of orthostatic hypotension

91
Q

T/F: dosing conversion from carvedilol IR to CR is 1 to 1

92
Q

Which beta blocker is drug of choice in pregnancy?

93
Q

Beta-blockers can mask s/sx of hypoglycemia except ____

A

sweating and hunger

94
Q

Beta-blockers can cause hyperglycemia by ___

A

decreasing insulin secretion

95
Q

When using beta-blockers, use caution when administering other drugs that decrease HR such as ___

A

diltiazem, verapamil, digoxin, clonidine, amiodarone, and dexmedetomidine (Precedex)

96
Q

Which antihypertensive is commonly used for resistant HTN and in pts who cannot swallow since it is available in patch formulation?

97
Q

Examples of centrally-acting alpha-2 adrenergic agonists

A

Clonidine (Catapres, Catapres-TTS patch)
Guanfacine IR
Methyldopa

98
Q

Contraindications for methyldopa

A

Concurrent use with MOAi and active liver disease

99
Q

Warnings for centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa)

A

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

100
Q

Side effects for centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa)

A

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

101
Q

Clonidine patch administration instructions

A

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

102
Q

Which centrally-acting alpha-2 adrenergic agonists (clonidine, guanfacine, methyldopa) can be used in pregnancy?

A

Methyldopa

103
Q

Examples of direct vasodilators

A

Hydralazine
Minoxidil

104
Q

Warnings with hydralazine

A

DILE -dose and duration related, peripheral neuritis, blood dyscrasias, hypotension

105
Q

Boxed warning for minodixil

A

potent antihypertensive - can cause pericardial effusion and angina exacerbations; administer with BB and loop diuretic

106
Q

Side effects of minoxidil

A

Fluid retention, tachycardia, hair growth (used as OTC topical for hair growth)

107
Q

T/F: Alpha blockers are not recommended for HTN but may be used in men who have HTN and BPH

108
Q

Compare hypertensive urgency vs emergency

A

Emergency = includes organ damage (e.g. encephalopathy, stroke, AKI, acute coronary syndrome, aortic dissection, acute pulmonary edema)

Urgency = no organ damage

109
Q

Compare treatment of hypertensive urgency vs emergency

A

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

NAPLEX 2024 (74 decks)

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