antihypertensives Flashcards
1
Q
when therapeutic goals for hypertension are not achieved what recommended?
A
changes in medications
2
Q
the primary goal in treating pateients with HTN is to
A
reduce risk of morbidity and mortality by managing high blood pressure and other risk factors for cardiovascular disease
3
Q
what treatment is indicated for a patients with a blood pressure that is above goal
A
lifestyle modifications (non pharmacotherpy)
4
Q
what is the blood pressure threshold for patient populations with untreated hypertension and for those experiencing TIA and CVA
A
140/90
5
Q
what patient population/disease process is indicated to avoid dropping a diastolic blood pressure below 60
A
DM or over the age of 60
6
Q
since medications used to treat HTN can lower SBP and DBP with what conditions
A
Isolated systolic HTN and wide pulse pressure
7
Q
what is associated with angina being present for a low DBP (<60)
A
inadequate coronary perfusion during diastole, providers may need to treat HTN with less agressive medications to ensure diastolic function is present
8
Q
name the 6 general lifestyle modifications for managing HTN
A
- weight reduction
- dash diet
- decrease sodium intake
- physical activity
- moderate alcohol consumption
- cessation of tobacco
9
Q
In HTN, what are additional factors that patients should avoid
A
sweet, sugar containing beverage, red meats
10
Q
describe the DASH diet?
A
consume a diet rich in fruit, nuts, vegetables
high in low-fat dairy products with a reduced content of saturated and total fat
high in potassium, magnesium, and calcium
avoid processed foods
11
Q
what is the listed recomendation when considering moderate alcohol consumption for HTN lifestyle modification
A
limit consumption to NO MORE than 2 drinks/day in men and 1 drink/day in women
12
Q
list and describe the three types of physical activity for managing HTN
A
- aerobic physical activity (90-150 minutes/week)- involves CV conditioning-running, swimming, cycling
- dynamic resistance (90 to 150 minutes per week)-lifting weights/involves joint movement
- isometric resistance (exercise performed againsts an imovable object, wall sits, plank)
13
Q
according to the lifestyle modifications for a patient with elevated blood pressure or hypertension, he/she should increase their potassium intake to?
A
3500-5000 mg/day
14
Q
patients with hypertension/elevated blood pressure should take a ______ approach to physical activity to reduce the risk of injuries.
A
gradual
15
Q
beta blockers usually end in?
A
olol
16
Q
ace inhibitors usually end in?
A
pril
17
Q
name the 3 diuretics used for HTN treatment
A
loop
thiazide
potassium sparing
18
Q
another name for an antagonist drug is?
A
blocker
19
Q
name the five broad classes of antihypertensives?
A
adrenergic agents
diuretics
Renin-Angiotensin-Aldosterone Agents
Direct Arterial Vasodilators
Calcium Channel Blockers
20
Q
Name the four types of adrenergic broad categories of drugs?
A
alpha adrenergic blockers
alpha and beta adrenergic blockers
beta adrenergic blockers
central alpha 2 agonists
21
Q
what are the two classes of calcium channel blockers
A
dihydrophyridines
non-dihydropyridines
22
Q
name the three types of beta adrenergic blockers?
A
Beta 1 selective
beta 1 and beta 2 non-selective
ISA (intrinsic sympathimmetic activity)
23
Q
what are the two adrenergic receptors that are pertinenet to antihypertensive pharmacology
A
Alpha and Beta
24
Q
Adrenergic refers to the receptors in the autonomic nervous system that are actived by what two substances?
A
norepinephrine
epinephrine
25
describe alpha blockers?
drugs that are antagonist at alpha adrenergic receptors, these medication are selective antagonist at peripheral alpha 1 adrenergic receptors and do not appreciably block presynaptic alpha 2 receptors.
26
adrenergic receptors are pat of the _____ division of the ANS
sympathetic
27
what are the side effects of alpha 1 blockers
orthostatic hypotension
reflex tachycardia
**edema (remember alpha blockers cause the retention of sodium and water, may need to take a diuretic with it)**
**nasal congestion**
(rise from sitting to standing position slowly)
28
name the peripheral alpha 1 receptor blockers?
Doxazo**sin** (Cardura)
Prazo**sin** (Minipress)
Terazo**sin** (Hytrin)
Remember DPT, Don't Pissoff Tina b/c its a sin!
29
explain what first dose syncope means? and with what medication can this happen with?
oral alpha 1 blockers may cause particular potent vasodilation after the first dose is administered to a patient, possible resulting in breief unconsciousness.
30
What electrolyte will accumilate due to alpha blocker
Sodium & water which may require diuretics to manage
31
where are beta 2 receptors found at
lungs, liver, pancrease, smooth muscle
32
why does alpha 1 blockers cause nasal congestion?
b/c alpha 1 blockers prevent the receptors that normally constrict the vasculature in the nsal tissue which leads to nasal congestion.
33
why would you give a diuretic with an alpha 1 blocker?
because alpha 1 blockers may cause sodium and water retention.
34
when alpha 2 receptors are activated, sympathetic outflow from the central nervous system is \_\_\_\_\_\_\_, causing a reduction in what five actions?
sympathetic outflow from the CNS is reduced
1. decreased heart rate
2. decreased cardiac output
3. decreased total peripheral resistance
4. reduced plasma renin activity
5. reduced barorecetor reflexes
35
name the two central alpha 2 receptor agonists?
clonid**ine** (Catpres)
guanfac**ine** (Tenex)
36
Selective beta 1 blockers are also known as
cardioselective beta blockers
37
abrupt withdrawal of alpha 2 agonist may cause dangerous ______ \_\_\_\_\_\_. Why?
rebound hypertension.
because of a compensatory release of norepinephrine
38
because abrupt withdrawal of alpha 2 agonist can cause dangerous rebound hypertension, alpha 2 agonist should be avoided in which patients?
non-adherent patients
39
Beta blockers appear to cause an antihypertensive effect through their blockade of what? Explain the process.
beta 1 receptors in the heart and blockade of beta 1 receptors in the kidneys which is responsible for the release of renin, preventing the vasoconstrictive effect of angiotensin 2 resulting in a decrease in blood pressure
40
what two systems do beta blockers distribute to
central (migrane psych disorders)
peripheral
41
The biggest antihypertensive effect from selective beta 1 receptor antagonist is?
blockade of beta one receptors in the heart.
42
Beta blockers are subdivided into two groups based on their selectivity for?
beta 1 and beta 2 receptors.
43
what is a nonselective beta 1 blocker that can be used to prevent migrane headaches
propranolol
44
nonselective beta blockers affect which receptors?
beta 1 and beta 2 receptors **in nearly equal manner**.
45
Propranolol and other selective beta 1 antagonists carry the role of targeting which system
central nervous system, specifically the brain
Propranolol is not necessarily the treatment for HTN
46
How does taking a beta blocker affect a patient with diabetes
**SNS** will be blocked including**:** t**remor, tachycardia, palpitations**
**PSNS** will not be blocked: **sweating**
47
Nebivolol has additional vasodilator activity explain?
through the stimulation of endothelial nitric oxide production.
simulation of this pathway leads to decreased oxidative stress and may have additional benefits related to preserving endothelial function.
48
What is one major benefit for male patients for taking nebivolol?
this medication can treat hypertension w/o producing as severe of symptoms of erectile dysfunction, because of the release of nitric oxide which is the main mechanism for an erection.
49
what medication would your prescribe to a male patient with hypertension that is non-compliant due to side effect of erectile dysfunction from his beta blocker?
nebivolol, which is a cardioselective beta blocker that has additional vasodilator activity through the stimulation of endothelial nitric oxide production (which is the major mechanism for erection).
50
beta blockers may diminish many symptoms of hypoglycemia. Why?
Because, of blockade of sympathetic nervous system.
51
What symptoms for hypoglycemia will be blocked with a beta blocker?
tremor
tachycardia
palpitation
52
what is the cause of Raynauds phenomenon in correlation to beta 2 antagaonists
a blockade of beta 2 receptors will cause an increase in constriction leading to vasospastic attacks
53
Sweating is mediated by the ______ nervous system and serves as a reliable symptom of hypoglycemia in patients with diabetes who are taking beta blockers.
parasympathetic
54
What should you educate diabetic patients on beta blockers?
know beta blockers mask sympathetic nervous system signs and symptoms of hypoglycemias except sweating which is caused by the parasympathetic nervous system.
55
list adverse effects of beta blockers?
cardiovascular toxicity
dyslipidemia
cold extremities (d/t blockade of beta 2 receptors in smooth muscle)
Raynauds phenomenon
56
Raynauds phenomenon can be an adverse effect from which drugs?
beta blocker (non selective)
57
what is the drug of choice for Raynauds phenomenon
Dihydropyridine (CCB)
58
What is the sequence of events that takes place in digits due to Rayneauds
White due to lack of blood flow
Blue due to lack of oxygen
Red when blood flow returns
59
describe raynaud's phenomenon?
vasospastic attack in blood vessels in the fingers and toes to constrict, resulting in cold and numb digits. When arterioles dilate and blood returns, the digits become red as the attack ends causing throbbing and tingling.
60
name the type of beta blocker?
nadolol
non selective beta blocker
61
name the type of beta blocker?
carvedilol
alpha 1 and beta blockers
62
name the type of beta blocker?
labetalol
alpha 1 and beta blocker
63
list the two Alpha 1 and Beta receptors
Carvedilol
Labetalol
64
In regards to alpha1 and beta blockers, what receptor have a higher affinity
the affinity is stronger for blockade of beta receptors
65
describe how you know non-selective beta blockers?(tricks)
O-Z
and end in olol
66
describe how you know alpha 1 and beta blockers?
have "lol" ending but another letter beside "o" before the "lol", such as "alol" or "ilol"
67
When Alpha 1/ Beta blockers reach their therapeutic dose, while they may have a higher affinity for beta blockers initial, then they will exhibit what an affinity for what as well?
clinical important Alpha 1 blockade effect
68
Labetaolol taken with food ____ absorption and may _____ orthostatic hypotension.
enhances
increase
69
What Alpha 1 and Beta blocker should be taken with food and why
Carvedilol- it will delay its oral absorption and decrease the risk of developing orthostatic hypotension
70
List the pathway of the RAAS system in regards to HTN
1. RENIN
2. ACE (ANGIOTENSIN CONVERTING ENZYME)
3. ANGIOTENSIN I-------------ANGIOTENSIN II
71
Activation of AT2 leads to a ______ in blood pressure because ______ occurs.
decrease
vasodilation
72
ARBs stands for?
angiotension 2 receptor blockers
73
What are the three main medication groups countering the RAAS system
* Renin inhibitors
* ACE inhibitors
* angiotensin 2 receptor blockers (ARBS)
74
ARBs are specifically able to block what receptor \_\_\_\_\_? thus they are effective antihypertensive medications.
AT1
because remember AT1 increases blood pressure through vasoconstriction
75
Renin inhibitors target the _____ enzyme, leading to lack of ______ production
renin
angiotension 2
76
what are the main side effects provoked by ACE inhibitors
persistent cough
angioedema
rash (rare)
77
ACE inhibitors are able to specifically block ? which leads to a reduction of ?
the angiotensin converting enzyme
angiotensin 2
78
ACE inhibitor medications end in?
pril
79
ACE plays an important role in HTN as it catalyzes the formation of the _______ from \_\_\_\_\_\_.
angiotensin 2
angiotensin 1
80
Angiotensin 2 is a potent \_\_\_\_\_\_\_, therefore the inhibition of angiotensin 2 production by ACE-inhibitors decreases \_\_\_\_\_\_.
vasoconstrictor
vasoconstriction
thus ACE-Inhibitors result in the reduction of blood pressure in patients who suffer from hypertension
81
The degradation of ______ is normally catalyzed by ACE.
bradykinin
82
Thus, ACE-inhibitors prevents the breakdown of?
bradykinin
83
what is the hypothesized reason for the hallmark cough with ace inhibitors?
the buildup of bradykinin due to the inhibitory process of ACEs which normally breakdown bradykinins.
84
why does ACE inhibitiors cause a persistent cough?
due to the inhibition of bradykine breakdown leading to an increase in bradykinin
85
All ACE inhibitors can cause what dermitological symptom?
rash although although uncommon
86
what patient population that has a contraindicaition to administering ACE inhibitors
pregnant patients
87
Inhibition of angiotension 2 fromation leads to a decrease in _________ secretion.
aldosterone
88
Decreased in aldosterone secretion by decreased angiotensin 2, subsequently decrease in renal excretion of \_\_\_\_\_\_\_\_.
potassium
89
While hyperkalemia does not usually occur with hypertension patients taking ACE inhibitors with normal renal function. You should worry about hyperkalemia when prescribing ACE inhibitors to which patients?
if combined with other drugs that promote potassium retention (potassium sparing diuretics)
patient with compromised renal function
90
Adverse effects are not dependent on the dose of the ACE inhibitor , with the exception of?
hyperkalemia
91
ARBs stands for?
angiotension II receptor blockers
92
in comparison to HTN medications, what is a medication class now used which is new to the treatment of this condition
ARBS (angiotensin II **receptor** **blocker**)
93
ARBs end in?
sartan
94
ARBS have competitive binding with angiotensin II for which receptor site?
**AT1** only because it prevents vasoconstriction
ARBs allow angiotension 2 to bind to AT2 which allows for vasodilation by increasing nitric oxide production
95
Compare the difference between AT1 adn AT2
AT1: vasoconstrictor
AT2: vasodialator
96
ACE-inhibitors are non selective because why?
because they block the formation of angiotension 2. Thus, preventing the stimulation of AT1 and AT2
97
what are the adverse effects of ARBS
the same as ACE
cough (lower insidence)
hyperkalemia
angioedema
98
what is the only drug type for renin inhibition
Aliskiren
99
ARBs should not be used in pregnant patients. Why?
mutagenic findings in animal studies
100
Aliskiren is a potent and selective inhibitor of plasma renin with one single dose lasting \_\_\_\_\_
24 hours
101
what patient population is Aliskiren contraindicated for?
**diabetics** that are taking **ACE** and **ARBS** d/t an increase in the risk of renal impairment, hyperkalemia, and hypotension
102
Renin inhibitors degrease thr production of what two things?
angiotension 2
aldosterone
103
the most significant adverse effects of renin inhibitors are? (3 things)
hyperkalemia
increased serum creatinine
diarrhea
REMEMBER CKD B/C diabetic patients should not take renin inhibitors d/t worrying about renal impairment which could lead to CKD
104
what potassium sparing diuretics are more effective at lowering blood pressure compared to other potassium sparing diuretics? Why?
Eplerenone and Spirinolactone b/c they also act as aldosterone antagonists
105
Aliskiren should no be used in which population?
pregnant patients due mutagenic effects
106
aldosterone antagonist end in?
**"one"**
epleron**one**
Spironolact**one**
107
\_\_\_\_\_\_\_\_\_ may need twice daily dosing for adequate blood pressure lowering?
eplerenone
108
to have the maximum effect of aldosterone antagonists, combination therapy with which drugs may bettter resistant hypertension
ACE's and ARBs and diuretics
109
Eplerenone is contraindicated in which three groups of patients?
renal impairment
type 2 diabetes
or patients with reduced levels of albumin, because albumin is excreted in their urine (b/c this an indication of potential renal impairment)
110
A baseline level of potassium of ____ should not recieve aldosterone antagonists
5
111
muscle contraction is dependent on and influx of ______ ions into the cell.
calcium
112
what are the names of dihydropyramide CCBs, meaning they end in what?
"pine"
113
with CCB, muscle contraction is dependent on
influx of CA into the cell
114
the influx of Calcium from L-type Ca channels will cause
muscle contraction
115
What is the main function of Dihydropyridine (PINE) CCB
They are selective for L type CA channels in the vasculature causing conformational change that limits the influx of CA ions---resulting in vasodialation and decreased BP
116
Non-Dihydropyridine calcium channel blockers also block the influx of _______ through L-type channesl, but not by ________ of the calcium channel, but by a ______ change of the calcium channel.
calcium
occlusion of the calcium channel (closes the channel)
cause a confirmational change in the calcium change
117
what are the side effects of Dihydropyridine
gastrointestinal upset
headache
tachycardia
flushing
peripheral edema
\*\*GINGIVAL HYPERPLASIA\*\*
118
in use of Dihydropyridine CCB, what happens in ginival hyperplsia
gum tissue has significant overgrowth
119
Do CCB affect serum electrolytes?
NO!
120
Dihydropyridine is also used to treat what medical condition
Raynauds which frequently occurs with beta blockers
121
non-dihydropyridine calcium channel blockers block the influx of calcium through L-type channels, by?
binding sites in the channel and altering the confirmation.
122
what are the adverse effects of non-dihydropyrididine CCB
bradycardia
GI upset
peripheral edema
gingival hyperplasia
headache
123
what factor would limit the titration of non-dihydropyridine CCB?
bradycardia (may limit titration)
124
Do non-dihydropyridine CCB affect serum electrolytes
NO
125
what are three categories of diuretics
thiazide
loop
potassium sparing
126
The Non-dihydropyridine cause negative inotropic effects due to?
decreased cardiac muscle cell firing, reducing the force of cardiac contraction.
127
Compare the advantages of using loop vs. thiazide diuretic
LOOP: most potent diuretic producing diuresis
THIAZIDE: most potent agent in reducing HTN
128
what type of diuretic is the most effective at controlling HTN
Thiazide
129
what additional disease can thiazide diuretics be used for
osteoporosis
130
Thiazide diuretics are thought to exert blood pressure lowering effect how?
mobilizing sodium and water from the arterial walls, which will lessen the amount of physical encroachment on the lumen of the vessel created by excessive accumulation of intracellular fluid in the smooth muscle vasculature as the diameter of the lumen increases there is less resistance to the flow of blood through the vessel and PVR decreases
131
Thiazide diuretics are equally effective, well tolerated, and relatively _____ compared to other antihypertensive medications.
inexpensive
132
What antihypertensive are typically used as the initial therapy in most patients, either alone or in combination with another antihypertensive medications?
thiazide diuretics
133
High dietary sodium intake will reverse the effects of \_\_\_\_sodium intake and blood pressure lowering effects of diuretics
low
134
As a provider you should worry about a decrease in which electrolytes that could cause muscle fatigue and cramps when prescribing a thiazides diuretic to a patient?
potassium and magnesium
135
How do thiazide diuretics affect calcium
hypercalcemia (useful for slowing bone demineralization)
136
Why should providers use caution in hypertensive patients with gout before prescribing thiazides diuretics?
because thiazide diuretics can increase uric acid levels
137
What are the most highly efficacious diuretics?
loop diuretics
138
Loop diuretics exert their blood pressure lowering effects how?
by reducing blood volume
139
what are the adverse effects of loop diuretics
GI upset
dizziness
headache
hypernatremia (dehydrated & NA/Kpump)
hypokalemia
dehydration
140
Loop diuretics are useful in patients with ______ \_\_\_\_\_\_\_,
volume overload
141
Higher doses of loop diuretics may bre needed for patients with what two disease processes?
severe chronic kidney disease
severe heart failure
142
when potassium sparing diuretics are combigned with a loop or thiazide, what electrolyte levels are affected
hypokalemia and hypomagnesium
143
What diuretic could you give with a loop diuretic to prevent hypokalemia and hypomagnesemia?
potassium sparing diuretics
144
what are the side effects of potassium sparing diuretics
GI upset
headache
(unlike other diuretics, hypokalemia will not be present)
145
While potassium sparing diuretics are not classified as aldosterone antagonists as a monotherapy for hypertension b/c they are weak antihypertensives they can be used as?
additive therapy agents when used in combination with thiazide or loop diuretic therapy for additive blood pressure lowering effect
146
what other effects do direct arterial vasodilatators cause in the cardiac system
increase HR, cardiac output, renin release (leading to an increase in NA fluid retention due to compensator effect of the vasodialation)
147
Name the two potassium sparing diuretics that are not aldosterone antagonists?
amiloride
triamterene
148
what are the side effects of direct arterial vasodialators
Lupus like symptoms (arthralgia, myalgia, fever, and serositis)
peripheral neuropathy
tachycardia
149
Why would you give a patient receiving a direct arterial vasodilator a pretreatment regimen of beta blocker and diuretic?
to minimize the reflex tacycardia and fluid retention (increased renin release causing sodium and water retention) which are compensatory mechanisms to vasodilation effects
150
Hydralazine is useful in patients with what two disease processes?
resistant hypertention
severe chronic kidney disease
151
What does it mean if a combination drug therapy has synergy?
A greater effect than expected from the combination of the individual blood pressure lowering effects of each drug alone.
152
what type of effect is desired for combination therapy of antihypertensive medications
combinations with synergistic effects
153
Combination effect: Diuretics + ACEI, ARB or Renin inhibitor
synergestic
154
Give an example of an additive effect in hypertension combination therapy versus synergistic effect?
Drug A lowers blood pressure 5 mmHg
Drug B lowers blood pressure by 8 mmHg
Additive effect: if drug A and drug B are used together expect a reduction in blood pressure by 13 mmHg
synergistic effect: blood pressure will be lowered more than 13 mmHg with drug A and Drug B are used together
155
Synergism is extremely beneficial because it allows the use of _____ doseages of both drugs and _____ the risk of adverse effects while maintaining an appropriate level of blood pressure control.
Lower
reduces
156
Combination effect: Dihydropyridine CCB + ACEI, ARB, or Renin inhibitor
Synergistic
157
Beta blocker plus ACEI, ARB or Renin inhibitor has what effect?
no additional benefits
158
Diuretic plus Dihydropyridine CCB has what effect?
no additional benefits
159
Beta blocker plus dihydropyridine CCB has what effect?
additive
160
Combination effect: Nondihydropyridine CCB + ACEI, ARB, or renin inhibitor
additive
161
Resistant hypertension is the failure to achieve BP goal for patients adhereing to what treatment regimens
3 drug treatment regimens including (CCB, diuretic, ACEI, and ARB)
162
Resistant hypertension is also defined as patients who achieve their blood pressure goal with _____ or more antihypertensives medications.
4
163
Before diagnosing a patient with resistant hypertension it is important to ensure they are what?
adhering to the antihypertensive medication regimen and that poor blood pressure measurement has been ruled out
164
when diagnosing a patient with resistant hypertension, what other factors need to be considered
white coat hypertension
masked hypertension
165
what are causes of resistant hypertension
nonadherence (multiple comorbidities, complex drug regimens)
Secondary HTN
obesity
excessive NA intake
volume retention from kidney disease
excessive alcohol intake
poor choices in medications
inadequate diuretic therapy
poor BP measurement technique
166
alpha adrenergic receptor antagonist are _____ antagonists at peripheral alpha ____ adrenergic receptors and do not block alpha ____ receptors.
selective
1
2
167
what is one side effect that is unique to verapamil?
constipation (20-42% of patients)
168
