5. Hypertension Flashcards
At what age does the incidence of HTN in women, surpass the incidence in men?
65
What gender is more likely to develop HTN?
male
As age increases, likelihood of HTN increases. (T/F)
True
What race is more likely to develop HTN?
African American
What is the cause of primary HTN?
unknown
What is the most common etiology of HTN?
primary HTN
What are the potential causes of secondary HTN? (7)
- CKD
- diabetes
- pheochromocytoma
- hyper or hypothyroidism
- Cushing’s disease
- primary aldosteronism
- sleep apnea
What tool is used to measure BP?
sphygmomanometer
What medications can cause HTN? (8)
- sympathomimetics
- excess synthroid
- NSAIDs
- glucocorticoids
- oral contraceptives
- immunosuppressants
- MAOIs
- antidepressants
What legal or illegal substances can cause HTN?
- chronic alcohol use
- nicotine
- cocaine
In what ways can HTN increase risk for damage to the brain?
- hemorrhage
- stroke
In what ways can HTN increase risk for damage to the eyes?
retinopathy
In what ways can HTN increase risk for damage to the heart?
- LV hypertrophy
- chronic heart disease
- chronic heart failure
In what ways can HTN increase risk for damage to the vasculature?
peripheral artery disease
In what ways can HTN increase risk for damage to the kidneys?
- renal failure
- proteinuria
What is the recommended BMI for patients with HTN?
18.5 – 24.9
What modification has the overall greatest reduction in BP?
weight loss
What are dietary modifications to reduce BP?
- DASH diet
- sodium restriction
In order to lower BP, what is the recommended amount of NaCl that should be consumed in a day?
< 6 g (1 tsp)
What is the exercise recommendation for lowering BP?
At least 30 minutes of aerobic activity most days of the week
In order to lower BP, what is the maximum amount of alcohol that can be consumed in one day for males?
2
In order to lower BP, what is the maximum amount of alcohol that can be consumed in one day for females?
1
What is the pharmacological treatment for prehypertension?
none
What is the JNC 8 blood pressure recommendation for patients ≥ 60 years old?
< 150/90
What is isolated systolic HTN?
systolic BP > 150
diastolic BP < 90
Treatment is recommended for patients who have a SBP > 150 and a DBP < 90. (T/F)
True
What is the highest recommended thiazide diuretic?
Chlorthalidone
What are the thiazide diuretics used to treat HTN?
- chlorthalidone
- indapamide
- HCTZ
At what CrCl are thiazides generally not effective?
< 30 ml/min
What are the electrolytes that may be decreased by thiazides?
K, Mg, Na
What is the risk of electrolyte depletion?
arrhythmias
Combining what other drug with thiazides may help prevent dangerous electrolyte depletion?
ACE-I
Why might a thiazide diuretic be combined with triamterene?
to prevent dangerous electrolyte depletion
Triamterene has little effect on BP. (T/F)
True
What class of medication does triamterene belong to?
K sparing diuretic
Thiazides can cause what condition to precipitate in patients who are already at risk?
gout
Thiazides can cause hyperglycemia and diabetes. (T/F)
True
Patients with a sulfa allergy are contraindicated for any diuretic medications that contain a sulfa group. (T/F)
False: only patients who experienced angioedema or anaphylaxis with sulfa drugs are contraindicated
What is the only diuretic that lacks a sulfa group?
ethacrynic acid
What is orthostatic hypotension?
supine-to-standing BP decrease
> 20 mmHg systolic
> 10 mmHg diastolic
If a patient is experiencing orthostatic hypotension, what medications should that patient avoid if possible?
- diuretics
- α blockers
- nitrates
When is it acceptable to increase systolic BP goal to < 160?
- low DBP
- orthostatic hypotension
What are the ACE-I agents most commonly used to treat HTN?
- lisinopril
- enalapril
- captopril
What is the only ACE-I or ARB that is IV?
enalapril
What is first line for CKD with proteinuria?
ACE-I
ACE-I should be discontinued if the BUN and/or SCr levels increase _____% baseline at 6 weeks.
> 30%
Concomitant use of what medication with ACE-I can cause increased BUN and SCr?
NSAIDs
How should ACE-Is be handled with pregnancy?
Avoid use: risk category C/D
The incidence of angioedema in __________ patients is greater due to ______ circulating ACE.
- African American
- lower
What are the most common ARBs used to treat HTN?
- Losartan
- Valsartan
- Irbesartan
When might an ARB be a more appropriate therapeutic option than an ACE-I for HTN?
In individuals who are intolerant of ACE-I, such as cough.
When would an ARB NOT be an appropriate therapeutic alternative to an ACE-I for HTN?
angioedema with ACE-I
What is the MOA of CCBs?
Block voltage-sensitive calcium channels
Which CCBs are more cardio-selective?
Non-dihydropyridines
- verapamil
- diltiazem
Which CCBs are more vascular-selective?
Dihydropyridines
- amlodipine
- felodipine
- nifedipine
CCBs are a common first line therapy option for HTN. (T/F)
False
In what patients are verapamil and diltiazem contraindicated?
heart failure
In what patients do CCBs show the most benefit it?
- atrial fibrillation/ flutter
- angina
- African Americans
What are ADRs of CCBs?
- heart block
- constipation
- rash
- gingival hyperplasia
In what populations does Amlodipine show the most benefit?
- diabetics
- African Americans
What are ADRs of Amlodipine?
- ankle edema
- headache
- postural hypotension
In what patients is Nifedipine contraindicated?
heart failure
In what cases would you need to administer immediate release nifedipine?
acute BP reduction
What are the 4 main physiologic differences that are present in African Americans?
- stiffer central arteries
- impaired endothelium-dependent and independent vasodilation
- less diurnal BP variation
- salt sensitivity more common and more severe
What is the consequence of having stiffer central arteries?
Higher central and aortic pressures despite “normal” brachial BP
What is the consequence of having impaired endothelium-dependent and independent vasodilation?
impaired response to and availability of NO
What does it mean to be “salt sensitive”?
slower rates of Na excretion and more Na reabsorption
What are the 2 medications that are recommended for monotherapy in African Americans?
- thiazide
- dihydropyridine CCB
What HTN medication is not recommended in African Americans?
ACE-I
If target BP is not reached using one medication in African American patient, what is the next recommended option?
combine use of thiazide and DHP CCB
What is the recommended alternative to ACE-I in African American patients with HF?
hydrazine + isosorbide dinitrate
Thiazide diuretics increase the risk of _________ in women.
hip fracture
(Men/Women) are more likely to develop hyponatremia and hypokalemia.
women
(Men/Women) are more likely to develop cough with ACE-I.
Women
Dihydropyridines cause LESS edema in (men/women).
Men
What HTN medications are contraindicated in pregnancy?
ACE-I and ARBs
What class of diuretics should be avoided in pregnancy and why?
thiazides: decreased placental perfusion and less electrolytes for the baby
What medication should be started within first 24 hours after STEMI?
ACE-I or ARB
What is the first line recommended medication for a patient with HTN and angina?
β blocker
What are the β agents that are recommended for patients with HTN and angina?
- metoprolol
- bisoprolol
β blockers are the standard of care for what conditions?
- angina/ coronary artery disease
- migraine
- post MI
- LV dysfunction +/- HF symptoms
- essential tremor
What are the first line therapies for LVD and systolic HF?
- ACE-I or ARB
- β blocker
- aldosterone antagonist
What are the second line therapies for LVD and systolic HF?
- loop diuretics
- nitrates
- hydralazine/isosorbide dinitrate
What medications are contraindicated in LVD and systolic HF?
- verapamil/ diltiazem
- clonidine
- α blockers
To what class does Spironolactone belong?
aldosterone receptor antagonist/ K sparing diuretic
Spironolactone (does/does not) affect RAAS but (does/ does not) affect bradykinin.
Spironolactone does affect RAAS but does not affect bradykinin.
Spironolactone (is/is not) initial therapy for HTN.
is not
What are the CV indications for Spironolactone?
- Class II-IV HFrEF
- UA/NSTEMI
- resistant HTN
Spironolactone is a __ line agent for HTN.
4th
What are the ADRs for Spironolactone?
- hyperkalemia
- gynecomastia
What is strategy A for resistant HTN?
Start one drug, titrate to max dose, then add a second drug.
What is strategy B for resistant HTN?
Start one drug and then add a second drug before achieving max dose of initial drug.
What is strategy C for resistant HTN?
Begin with 2 drugs at the same time
When dealing with resistant HTN, medication adjustments should be made at __ week intervals.
4
Most patients require more than one agent to control their BP. (T/F)
True
What are the 2 preferred drug combinations for resistant HTN?
- ACE-I/ARB + NonDHP CCB
- ACE-I/ARB + diuretic
What are 2 acceptable but not preferred drug combinations for resistant HTN?
- β blocker + diuretic
- thiazide + CCB/ K sparing diuretic
What drug combination for resistant HTN is preferred in African American patients?
thiazide + CCB/ K sparing diuretic
What are the α1 blocker agents?
- prazosin
- doxazosin
α1 blockers are often used in combination with what class of drugs?
diuretics
α1 blockers are considered ____ line due to ADRs.
last
What are the ADRs of α1 blockers?
- dizziness/ postural hypotension
- edema
- worse CVA and HF
In patients with HTN and what comorbidities are α1 blockers beneficial?
- DM
- gout
- BPH
What are the direct vasodilation agents?
- hydralazine
- minoxidil
Vasodilators should ALWAYS be used in combination with what and for what reason?
diuretics: limit fluid gain
Vasodilators cause (more/less) orthostatic hypotension.
less
Vasodilators can be used in combination with what to prevent SNS and RAAS activation?
β blockers
What patient population may benefit from using direct vasodilators?
- resistant HTN
- isolated systolic HTN
- Das with HF
In what populations should direct vasodilators be used with caution?
- elderly
- recent MI
- angina with CAD
What is the MOA of clonidine?
- α2 agonist
- decreases sympathetic outflow
What are ADRs of clonidine?
- sedation
- dry mouth and eyes
- sleep disturbances
- bradycardia
- withdrawal syndrome
What are the symptoms of clonidine withdrawal syndrome?
- headache
- tremor
- sweating
- tachycardia
- rebound HTN
What patients might benefit from clonidine to treat HTN?
- resistant HTN
- pregnant women
- poor compliance (weekly patch)
Clonidine should be used with caution in what patients?
- noncompliant (except patch)
- recent MI
- stroke patients
What is the MOA of Aliskiren?
renin inhibitor
Aliskiren is recommended for initial treatment of HTN. (T/F)
False
What patients are at higher risk for hyperkalemia when taking Aliskiren?
- renal dysfunction
- DM
- concomitant use of ACE-I/ARB/NSAID/ K sparing diuretic
In what patients is Aliskiren contraindicated?
- DM
- LVSD
- post MI
- volume depletion
- pregnant women
