Antihypertensives and Statins Flashcards
1
Q
What are the two types of hypertension?
A
- essential (>90%)
2. secondary (10%)
2
Q
What are some of the etiologies of secondary hypertension?
A
- CKD
- renovascular dz
- pregnancy
- Cushing’s (increased aldosterone)
- drug induced (cocaine)
- tumor (pituitary)
3
Q
What is total peripheral resistance?
A
Sum of peripheral resistance in the peripheral vasculature (represents diastolic BP).
4
Q
Cardiac output
A
The amount of blood pumped out by the ventricles (represent systolic BP).
5
Q
What are the mechanisms of pathogenesis?
A
- Increased peripheral resistance.
- Increased cardiac output.
6
Q
What is the pathogenesis of increased peripheral resistance?
A
Functional vascular constriction/Structural vascular hypertrophy
- over activity of sympathetic nervous system (increased epi & NE) = increased contraction and BP
- genetic components
7
Q
What is the pathogenesis of increased cardiac output?
A
- Increased preload due to:
1. increased fluid volume
2. excess sodium intake
3. renal sodium retention - venous constriction
1. excess RAAS stimulation (renin-aldosterone system). Increased aldosterone=increased fluid and constriction.
2. sympathetic nervous system overactivity
8
Q
What is the JNC BP goal for patients > 60 years old?
A
It is
9
Q
What is the JNC BP goal for patients 60 and under?
A
It is
10
Q
What is the JNC BP goal for patients with DM and CKD?
A
It is
11
Q
What are some non-pharmacological therapies for reduction of HTN?
A
- lifestyle modification
- smoking cessation
- weight loss
- DASH diet
- dietary sodium reduction
- increased physical activity
- limit alcohol intake (1 female/2 male)
12
Q
What is the most effective non-pharm therapy?
A
weight loss
13
Q
What is first line pharmacologic treatment option for HTN?
A
Thiazides, CCB, ACE-I, ARBs
ALL ARE EQUAL IN CHOICE
14
Q
Which therapies are not the best choices for treating HTN in African americans?
A
ACE-I
ARBs
15
Q
What are the best choices for HTN tx in DM or CKD patients?
A
ACE-I or ARBs
DO NOT USE TOGETHER - EITHER/OR
16
Q
What is the best choice for HTN tx in patients with cardiac hx?
A
beta blockers
17
Q
Which HTN classes are best to use in African americans?
A
thiazides, CCBs
18
Q
1st option treatment approach?
A
IN ADDITION TO NONPHARM THERAPY: Start with 1 drug and max the dose then add a 2nd agent. If still not at goal, add a 3rd agent once the 2nd agent is maxed out.
19
Q
2nd option treatment approach?
A
IN ADDITION TO NONPHARM THERAPY: Start with 1 drug and if not at goal add a 2nd drug prior to maxing out the dose on the first. Then max the dose on both drugs and if not at goal add 3rd agent. Most used in the “real world.”
20
Q
3rd option treatment approach?
A
IN ADDITION TO NONPHARM THERAPY: Start with 2 drugs from the beginning if the SBP>160 and/or the DPB>100. Max out the drug doses and add on a 3rd agent if needed.
EXAM ONLY PURPOSES.
21
Q
Thiazide Diuretics
A
HCTZ
chlorthalidone
metolzaone
22
Q
Thiazide MOA
A
Inhibits sodium reabsorption in the distal tubule.
23
Q
Metolzaone
A
Used in patients with heart failure that Lasix does not work for!
24
Q
Which drug class is first line for tx of HTN?
A
Thiazide diuretics
25
What is the typical thiazide dose?
25 mg (can start at 12.5 mg)
26
What are the adverse effects of thiazide diuretics?
- orthostatic hypotension
- decreased K, Na
- increased Ca, URIC ACID, glucose
- photosensitivity
- increased urination (typically will decrease)
- increased lithium concentrations
27
What are some precautions when using thiazide diuretics?
- use with caution in sulfa allergic patients (typically those with prior anaphylaxis)
- INEFFECTIVE IN PTS WITH SEVERE RENAL DISEASE!!! Creatinine
28
What prior conditions would you avoid giving a thiazide diuretic?
- GOUT
| - SEVERE RENAL DZ
29
Loop Diuretic drugs
- furosemide (Lasix)
- bumetanide (Bumex)
- torsemide (Demadex)
30
Hydochlorathiazide
thiazide diuretic
31
Chlorthalidone
thiazide diuretic
32
Metolzaone
thiazide diuretic
33
Loop MOA
Inhibits active transport of Na, Cl, and K in thick ascending limb of Loop of Henle, causing EXCRETION of the ions.
RESULT= collecting duct excretes more H2O in response.
34
Furosemide
Lasix (brand name)
The most potent loop diuretic.
1st choice tx in CHF.
35
Bumetanide
Bumex (brand name)
| Loop diuretic. Not as potent as furosemide.
36
Torsemide
Demadex (brand name)
| Least potent loop diuretic
37
Loop diuretics are typically 1st choice for what pathology?
- CHF
- Peripheral and pulmonary edema
- HTN
38
Adverse effects of loop diuretics
```
Decreased K, Na, Ca, Mg
Increased uric acid
Increased serum creatinine
Dehydration
Ototoxicity (if combined with another aminoglycoside abx)
```
39
Loop diuretics - precautions
Use with caution in pts with sulfa allergies
- nephrotoxicity
- Do not use in patients with GOUT!
40
If you were to give a second dose of Lasix, what would the frequency be?
After first dose, can give another dose 6 hours later. Don't give the dose later than 4pm!
41
What are two types of potassium sparing diuretics?
- Aldosterone receptor blockers
| - Potassium sparing
42
What are the aldosterone receptor blockers?
- spironolactone (Aldactone)
| - eplerenone (Inspra)
43
MOA of Aldosterone Receptor Blockers
| (ARBs)
Competes with aldosterone, prevents sodium reabsorption and potassium excretion.
44
MOA of Potassium Sparing Drugs?
Blocks sodium reabsorption and potassium excretion, effect independent of aldosterone.
45
Aldosterone Receptor blocker drugs
- spironolactone
| - eplerenone
46
Potassium sparing drugs
-triamterene
-amiloride
These are not used by themselves. Usually paired with a thiazide.
47
In what area do potassium sparing drugs work?
In the collecting duct. Very distal.
48
What are potassium sparing drugs used to treat?
HTN.
| Class IV heart failure. Has mortality benefit!
49
Adverse effects of loop diuretics
Hyperkalemia - use with caution in RENAL PTs
- Spironolactone may cause gynecomastia, menstrual irregularities.
- Eplerenone is less selective = Less side effects!
50
Which loop diuretic has potential mortality benefit?
spironolactone
51
ACE inhibitors MOA
- Inhibits ACE to block production of angiotensin II
- Inhibits breakdown of vasodilator bradykinin
- Dilates efferent arteriole of the kidney
52
Inhibition of bradykinin is bad because?
Increased levels of bradykinin cause cough in about 20% of patients taking ACE inhibitors.
53
Common ACE inhibitor drugs?
All end in -pril!
- lisinopril (Zestril, Prinivil) GO TO CHOICE
- captopril (Capoten)
- enalapril (Vasotec)
- quinapril (Accupril)
54
Why are ACE inhibitors good for kidneys?
The increase blood flow through the kidney by dilating the efferent arteriole.
e=exit (efferent)
55
ACE inhibitors are used to treat?
HTN - one of the first line choices in CKD and DM patients!
| -CHF
56
What is the "usual" dosing for ACE inhibitors?
Once daily (90%), sometimes BID.
57
What labs must be monitored with ACE inhibitors?
-serum potassium and creatinine 4 WEEKS of initiation or dose increase.
58
What lab value(s) might you see an increase in after beginning ACE tx or increasing dose?
Serum K+ and creatinine.
| 40% is not normal.
59
What should you advise the patient to watch in their diet when taking ACE inhibitors?
Dietary potassium intake.
60
Adverse effects of ACE inhibitors?
- COUGH!!!!
- angioedema
- hyperkalemia, especially in CKD and DM patients.
- acute renal failure
- neutropenia
61
ACE inhibitors contraindications
- Pregnancy category C/D
- Angioedema when taken with other ACE inhibitors
- RENAL ARTERY STENOSIS
62
What drug class is contraindicated in renal artery stenosis?
ACE inhibitors
63
ACE inhibitor drug interactions
- potassium supplements
- potassium sparing diuretics
- NSAIDS (can increase BP) and are harmful to the kidney due to prostaglandin dilation of afferent tubules. Blood pools in kidney.
64
ACE inhibitors + NSAIDS
Bad drug interaction! Harms the kidney!
65
All of the ACE inhibitors can be dosed once EXCEPT for
Captopril. Dosed BID to TID. Because of this, is used infrequently. Also needs to be taken on an empty stomach?
66
Which ACE inhibitor is a prodrug of enalaprilat?
Enalapril. Only available IV
67
Which is the most commonly used ACE-I?
Lisinopril (Zestril, Prinivil)
| Dose 10-40 mg daily
68
Which ACE-I needs to be taken on an empty stomach?
Captopril. Absorption is decreased by 30-40% when given with food. Also needs multiple dosing.
69
Angiotensin II Receptor Blockers
All end in -sartan
- Irbesartan (Avapro)
- Losartan (Cozaar)
- Olmesartan (Benicar)
- Valsartan (Diovan)
70
Which ARB causes diarrhea?
Olmesartan (Benicar)
71
ARBs MOA
Inhibits angiotensin II at its receptor sites.
| -Does not inhibit breakdown of bradykinin!
72
ARBs are used to treat
FIRST LINE OPTION FOR CKD!!
| -CHF
73
How often are ARBs dosed?
Often once daily
74
Increased potassium and angioedema may be seen in
ARBs
75
```
Hypotension/orthostatic hypertension
-angioedema
-hyperkalemia
-dizziness
are all adverse effects of what drug class?
```
ARBs
76
ARB contraindications
- Pregnancy category C/D
- Caution in patients with RENAL ARTERY STENOSIS
- possible use in patients that have had prior angioedema with ACE. Use with caution.
77
ARBs contraindications
- potassium supplements
- potassium sparing diuretics
- NSAIDS
78
What is a direct inhibitor of renin?
Aliskiren
79
What are the two categories of Calcium Channel Blockers?
1. Non-dihydropyridines
| 2. Dihydropyridines
80
What drug classes are best choices for African Americans with HTN?
CCA
| Thiazides
81
What are the non-dihydropyridine drugs?
- verapamil (Calan)
- diltiazem (Cardizem, Cartia, Dilacor, Taztia)
All of the above ARE NOT INTERCHANGABLE! Once patient is started on one kind, do not change!
82
What are the dihydropyridine drugs?
- amlodipine (Norvasc) most common
- felodipine (Plendil)
- isradipine (Dynacirc)
- nifedipine (Adalat, Procardia)
83
Role of Calcium Channels?
When channels are opened, calcium influx into smooth muscle, specifically:
1. cardiac smooth muscle
2. vascular smooth muscle
- results in activation of intracellular Ca+ and ultimately leads to MUSCLE CONTRACTION (activates myosin and actin).
84
CCB MOA
- inhibits Ca+ influx into cells to PREVENT MUSCLE CONTRACTION
- inhibition at cardiac smooth muscle
**decreases inotropy (force) and
chronotropy (rate) of contraction**
- inhibition at vascular smooth muscle, which causes VASODILATION
85
Why are CCBs not indicated in patients with CHF?
CCBs lower BP, and since CHF pts already have decreased contractile force, CCBs might increase CHF. **especially nondihydropyridines!
86
Dihydropyridines MOA
- inhibits Ca+ influx into VASCULAR SMOOTH MUSCLE
As a result, EVERYTHING DILATES!!
**Watch for possible pedal or tibial edema.
87
Non-dihydropyridines MOA
- inhibits Ca+ influx into CARDIAC SMOOTH MUSCLE. Result: decreased rate and force of contraction.
CI in CHF!!
88
Uses of CCB?
HTN. To induce smooth muscle dilation. Vascular and cardiac. Do not use in CHF.
89
What drug can be used to treat SVT and afib?
Diltiazem and verapamil.
| CCBs
90
What drug(s) can be used for migrane prophylaxis?
Verapamil - CCB (can cross BBB)
| Propranolol - beta blocker
91
What CCB causes constipation?
Verapamil
92
Hypotension is an adverse effect of?
All CCBs
93
Constipation, bradycardia, exacerbation of COPD, heart block, and gingival hyperplasia are adverse reactions of what drug(s)?
Non-dihydropyridines
94
What are some adverse effects of dihydropyridines?
- peripheral edema (because it dilates vascular smooth muscle).
- reflex tachycardia
- flushing
- headache
- BP and pulse
95
What CCB causes the worst peripheral edema?
Nifedipine
96
Which dihyropyridines are ok to use in patients with CHF?
- amlodipine
- felodipine
- isradipine
97
Which CCB should you never use sublingually?
nifedipine (dihydropyridine). Causes severe hypotension, and increased risk for MI and death.
98
Patients with isolated systolic HTN might benefit from what CCB?
Dihyropyridines (amlodipine, felodipine, isradipine, nifedipine)
99
Soy and egg allergy are CI in this drug
Clevidipine (IV only)
100
Verapimil DI
- P450 inhibitor
| - metabolized by CYP450
101
Which is not a potential adverse effect associated with furosemide therapy?
Hypercalcemia
102
Perindopril is from what class?
ACE inhibitor
103
Eprosartan belongs to what class?
ARBs
104
Most common beta blockers
- atenolol
- metropolol succinate
- metropolol tartate
105
Drugs ending in -olol are most likely
Beta blockers
106
Beta blockers are reserved for patients that have
significant cardiac Hx.
- Heart failure
- post MI
- CAD
- CKD
107
Beta blocker MOA
block beta-1 receptors thus decreasing the effects of epinephrine and NE. Result is decreased BP and HR.
108
Where are beta 1 receptors?
Think beta "ONE"
| ONE heart. Receptors located in the heart.
109
Beta 2 receptors are found where?
Think beta "TWO"
TWO lungs. Receptors located in the lungs.
Remember your beta 2 agonists, like albuterol.
110
What are the four "groups" of beta blockers?
- cardioselective
- mixed a + b
- ISA (intrinsic sympathomimetic activity)
- non-specific
111
Which drugs belong to the cardio selective group of beta blockers?
```
- AMEBBA!!
A tenolol
M etropolol
E smolol
B ioprolol
B etaxaolol
A cebutolol
```
112
Which beta blockers are beta -1 specific?
the AMEBBA drugs!
| Cardio selective!
113
Carvedilol and labetaolol belong to what class of b-blockers?
mixed alpha & beta
114
This medication prevents sodium reabsorption in the distal tubule
Thiazide diuretics
115
This medication class inhibits active transport of sodium, chloride and potassium in thick ascending limb of Loop of Henle, causing excretion of these ions
Loop diuretics
116
This medication class competes with aldosterone, prevents sodium reabsorption and potassium excretion
Aldosterone receptor blockers
117
This drug class inhibits the conversion of angiotensin I to angiotensin II
ACE-I
118
Propanolol acts via this specific MOA
blocks beta 1 and beta 2 receptors
119
This drug class is typically dosed at night
Alpha-1 blockers. Due to orthostatic hypotension
120
Clonidine patch is changed this often
every 7 days
121
Most ACE-I are dosed this way
Once daily
122
Metropolol succinate is dosed how often
Once daily
123
Name 3 drug classes that should be dosed in the morning
- loops
- thiazides
- potassium sparing diuretics
124
Name at least one drug class that you should not use during pregnancy
ACE-I and ARBs
125
Which drug class do you NOT want to use in a patient with CHF
Nondihyropyridines
126
Use precaution with these 2 drugs classes in patients with sulfa allergies
Loops
| Thiazides
127
Which drug classes would you want to avoid in patients with high potassium
- potassium sparing diuretics
- aldosterone antagonists
- ACE-I
- ARBs
128
Which drug class do you NOT want to use in a patient with renal artery stenosis
ACE-I
129
Describe how the electolytes are affected by HCTZ
K+ and Na+ decrease
Ca+ and uric acid increase
130
This is the number one side effect of verapamil
Constipation
131
This is the most common side effect of captopril
Dry cough
132
Rebound HTN will occur with these 2 classes of medication if suddenly discontinued
Beta-blockers and clonidine
133
Terazosin causes this side effect which is why it must be taken at bedtime
First dose hypertension
134
Do not take salt substitutes with the 4 following drug classes
What are ACE-I, ARBs, and potassium sparing diuretics and aldosterone antagonists
135
Report any angioedema with the following two drug classes
ACE-I
| ARBs
136
Counsel patients about peripheral edema with this class of medication
Dihydropyridines
137
This class of medication does not inhibit the breakdown of bradykinin thus is much less likely to cause cough
ARBs
138
Beta blockers will cause these symptoms when the drug is started but will subside within a few weeks
"beta blocker blues"
| Fatigue, tired, depression, funny heart beat
139
These are the first line drug classes to treat HTN in African American patients
CCBs and thiazides
140
This beta blocker can be used to prevent migranes
propranolol
141
If a patient needs HTN medication, what are the 3 options for starting therapy?
1. start 1 drug and max the dose
2. start 2 drugs and add on another prior
to maxing the dose on the first drug
3. start 2 drugs
142
These are 2 good agents to use in pregnancy
Methyldopa
| Labetalol
143
Which 2 agents should NOT be combined with aliskiren and describe the reason why
ACE-I and ARBs
| - Increased risk of renal dysfunction
144
MOA of cholesterol absorption inhibitors
Selectively inhibits dietary and biliary cholesterol absorption in the intestine
- decreases delivery of dietary cholesterol to the liver
- depletes hepatic cholesterol stores
- increases clearance from the blood
- increases expression of LDL receptors
