39 - Hypertension

Question 1

What are the HTN targets?

Answer 1

General population: < 140/90
Diabetes: < 130/80
High risk of CV events: SBP < 120
Isolated systolic HTN: SBP < 140
Home setting: < 135/85

Question 2

non-pharms

Answer 2

• healthy lifestyle
• weight loss of > 4 kg if overweight
• waist circumference < 102 cm in men
• waist circumference < 88 cm in women
• sodium < 2g/day
• increase K+ intake if patient not at risk for hyperkalemia
• exercise
• reduce alcohol
• stop smoking

Question 3

If BP > ______ start meds and non-pharms at the same time

Answer 3

160/100

Question 4

If BP is _______ start meds if patient has organ damage or other risk factors for CV disease

Answer 4

140-159/90-99

Question 5

Dose increase every ____ weeks

Answer 5

2-4

Question 6

What is 1st line for uncomplicated HTN?

Answer 6

low-dose thiazide or related diuretics

Question 7

Diuretics can cause _____

Answer 7

hypokalemia

Question 8

Consider alternate agent to thiazide diuretic if patient is strongly predisposed to _____ _____

Answer 8

serious arrhythmia

Question 9

Use a _____ diuretic for those with renal impairment

Answer 9

loop

Question 10

Diuretics can worsen _____

Answer 10

dysglycemia

Question 11

Who are selective B1 blockers 1st line in?

Answer 11

< 60 yo, or who have stable angina, heart failure or a Hx of MI

also useful for those with migraines, tachycardia or essential tremor

Question 12

BBs are not as effective as ARBs, CCBs or diuretics as initial Tx for primary prevention of ___ events in patients > 60 yo.

Answer 12

CV

Question 13

What are examples of RAAS drugs?

Answer 13

• ACEis
• ARBs
• direct renin inhibitors
• spironolactone

Question 14

Who are ACEis first line in?

Answer 14

non-black patients with uncomplicated HTN and for patients with DM, recent MI, HF or CKD

Question 15

Who are ARBs 1st line in?

Answer 15

uncomplicated HTN, DM or ischemic heart disease

*they are a good alternative to ACEis

Question 16

How do direct renin inhibitors work?

Answer 16

prevent renin from converting angiotensin to angiotensin I

Question 17

Give an example of direct renin inhibitor

Answer 17

aliskiren

Question 18

Place in therapy for direct renin inhibitors?

Answer 18

should be used as add-on agent after all 1st line therapies have been tried

Question 19

Why don’t you use short acting DHP CCBs?

Answer 19

bc they can increase CV events so you need to use long-acting DHP CCBs

Question 20

What type of patients are particularly responsive to CCBs

Answer 20

• elderly patients with isolated systolic HTN

- black patients

Question 21

When is it reasonable to start with 2 first line agents at the same time?

Answer 21

if SBP > 20 or DBP > 10 above the recommended target

Question 22

What defines resistant HTN?

Answer 22

HTN despite being on 3 dose-optimized drugs, 1 of which is a diuretic

Question 23

BB not recommended as initial therapy in patients over ____ yo

Answer 23

60

Question 24

Pregnancy:

Women at high risk of preeclampsia (all women with HTN included) should be offered what?

Answer 24

• ASA 81 mg daily

- should get 1 g calcium supplement regardless of dietary intake

Question 25

Pregnancy:

What options can we use?

Answer 25

methyldopa, labetalol and nifedipine XL for HTN that is not severe

can use clonidine or acebutolol, pindolol, propranolol or metoprolol

Question 26

Pregnancy:

What can we use for severe HTN ?

Answer 26

IR oral nifedipine, parenteral labetaolol or parenteral hydralazine

Question 27

Pregnancy:

What drugs do you want to avoid?

Answer 27

atenolol - associated with IUGR (intrauterine growth restriction)

avoid thiazide and loop diuretics, ACEi, and ARBs, and spironolactone

Question 28

Breastfeeding:

What drugs do you want to avoid?

Answer 28

• diuretics suppress lactation
• avoid atenolol and other BBs with low serum protein-binding (which concentrate in breast milk)
• avoid long acting ACEi (ramipril, lisinopril, cilazapril, perindopril)