Chapter 28: Hypertension Flashcards
Stage 1 hypertension
SBP 130-139 or DBP <80
Stage 2 hypertension `
SBP >= 140 or DBP >=90
When to start treatment
- Stage 2 HTN (SBP>=140 or DBP >= 90)
- Stage 1 HTN (SBP 130-139 or DBP <80)
- Clinical CVD (stroke, HF, or coronary heart disease)
- 10 yr ASCVD risk >=20
BP goal
<130/80
Initial drug selection
- non-black: thiazide, CCB, ACE or ARB
- black: thiazide or CCB
- CKD: ACE or ARB (all races)
- Diabetes with albuminuria: ACE or ARB (all races)
- Diabetes with CAD: ACE or ARB (all races)
- Start 2 first-line drugs in stage 2 htn when average SBP and DBP >20/10 above goal
Pregnant patients with chronic hypertension
- Should receive treatment if SBP>160 or DBP >105
- Recommended 1st line drugs are labetalol and nifedipine er, methyldopa (but less effective)
- Maintain BP between SBP 120-160 and DBP 80-110
Thiazide type-diuretics MOA
Inhibit sodium reabsorption in the distal convoluted tubules causing increased excretion of sodium, chloride, water and potassium
Nephron diagram
Thiazide type-diuretics
- Chlorthalidone
- Hydrochlorothiazide
- Chlorothiazide (IV)
- Indapamide
- Metolazone
Thiazide type-diuretics side effects and CI
CI: hypersensitivity to sulfonamide-derived drugs
SE: decreased K, Mg, and Na; increased Ca, UA, LDL, TG, and BG; photosensitivity, impotence, dizziness and rash
-Can decrease lithium renal clearance and increase risk of lithium toxicity
Dihydropyridine CCBs MOA
Inhibit Ca ions from entering vascular smooth muscle and myocardial cells; this causes peripheral arterial vasodilation (decreases SVR and BP) and coronary artery vasodilation
Dihydropyridine CCBs CI and SE
CI: Nicardipine should not be used in advanced aortic stenosis
SE: peripheral edema, headache, flushing, palpitations, reflex tachycardia, gingival hyperplasia
Clevidipine CI: allergy to soybeans, soy products or eggs
Clevidipine SE: hypertriglyceridemia
Dihydropyridine CCBs CI and SE
CI: Nicardipine should not be used in advanced aortic stenosis
SE: peripheral edema, headache, flushing, palpitations, reflex tachycardia, gingival hyperplasia
Clevidipine CI: allergy to soybeans, soy products or eggs
Clevidipine SE: hypertriglyceridemia
Clevidipine kcal/ml
2kcal/ml
Non-Dihydropyridine CCBs MOA
- Primarily used to control HR
- Inhibit Ca ions rom entering vascular smooth muscle and myocardial cells but they are more selective for the myocardium that the DHP CCBs.
- Decrease in BP is due to negative inotropic (decreased force of ventricular contractions) and negative chronotropic (decrease HR) effects
Non-Dihydropyridine CCBs warnings and SE
Warnings: HF (may worsen symptoms, bradycardia
SE: edema, constipation (verapamil), gingival hyperplasia
CCBs drug interations
- ALL CCBs are major substrates of cyp450 3A4 must use caution with inducers and inhibitors. Do not use with grapefruit juice
- Dilt and verapamil are substrates and inhibitors or P-gp and inhibitors of CYP3A4. Patients who take statins should use lower doses or simvastatin or lovastatin
CCBs drug interations
- ALL CCBs are major substrates of cyp450 3A4 must use caution with inducers and inhibitors. Do not use with grapefruit juice
- Dilt and verapamil are substrates and inhibitors or P-gp and inhibitors of CYP3A4. Patients who take statins should use lower doses or simvastatin or lovastatin
Angiotensin-Converting Enzyme Inhibitors (ACEi) MOA
Block the conversion angiotensin I (Ang I) to Ang II, resulting in decreased vasoconstriction and decreased aldosterone secretion. They also block the degradation of bradykinin, which is though to contribute to vasodilatory effects
Angiotensin-Converting Enzyme Inhibitors (ACEi)
- Benazepril
- Enalapril and Enalaprilat (IV)
- Lisinopril
- Quinapril
- Ramipril
Angiotensin-Converting Enzyme Inhibitors (ACEi) Boxed warning
Can cause injury and death to developing fetus when used in 2nd and 3rd trimester. Stop use as soon as pregnancy is detected.
Angiotensin-Converting Enzyme Inhibitors (ACEi) CI and SE
CI: Do not use with history of angioedema. Do not use w/i 36hrs of sacubitril/valsartan (entresto).
SE: Cough, hyperkalemia, increased SCr, hypotension
Angiotensin Receptor Blockers (ARBs)
- Irbesartan
- Losartan
- Olmesartan
- Valsartan
Angiotensin Receptor Blockers (ARBs)
- Irbesartan
- Losartan
- Olmesartan
- Valsartan
Angiotensin Receptor Blockers (ARBs) CI and SE
Same as ACEi except:
- less cough
- less angioedema
- no washout period required for entresto
Direct Renin inhibitor
Directly inhibits renin, which is responsible for the conversion of angiotensinogen to Ang I. A decrease in the formation of Ang I results in a decrease in the formation of Ang II
ACEi/ARB and lithium
Can decrease lithium renal clearance and can increase lithium toxicity
ACEi/ARB and lithium
Can decrease lithium renal clearance and can increase lithium toxicity
Potassium Sparing diuretics MOA
Compete with aldosterone at receptor sites in the distal convoluted tubule and collecting ducts of the nephron, increasing Na and H2O excretion and conserving K
Potassium Sparing diuretics boxed warning, CI, and SE
Boxed warning: amiloride and triamterene hyperkalemia (k>5.5)
CI: Do not use if hyperkalemia, severe renal impairment, Addison’s disease
SE: hyperkalemia, increased SCr, dizziness; Spironolactone: gynecomastia, breast tenderness, impotence
K sparing diuretics and lithium
Can decrease lithium renal clearance and can increase lithium toxicity
K sparing diuretics and lithium
Can decrease lithium renal clearance and can increase lithium toxicity
Beta-Blockers MOA
Decrease BP by competitively blocking beta-1 and/or beta-2 adrenergic receptors, resulting in decreases in HR and myocardial contractility
BBs role
- No longer recommened 1st line therapy for HTN unless the patient has a comorbid condition (post-MI, stable ischemic heart disease, HF)
- Bisoprolol, carvedilol, and metoprolol succinate should be used for HF
BBs with beta-1 selectivity
- Atenolol
- Esmolol (IV)
- Metoprolol tartrate
- Metoprolol succinate
BBs with beta-1 selectivity boxed warning, warnings and SE
Boxed warning: do not d/c abruptly, taper dose over 1-2 weeks
Warnings: can worsen hyperglycemia or hypoglycemia and can mask hypoglycemic symptoms
SE: bradycardia, fatigue, hypotension, dizziness, depression, impotence
BBs with beta-1 and beta-2 activity (non selective)
- Propranolol (has high lipid solubility and crosses blood brain barrier and associated with more CNS SEs [migraine prophylaxis]
- Nadolol
BBs with beta-1 and beta-2 activity (non selective)
- Propranolol (has high lipid solubility and crosses blood brain barrier and associated with more CNS SEs [migraine prophylaxis]
- Nadolol
BBs with non-selective BB and alpha-1 blockers
- Carvedilol (take w/food, CR versions have less bioavailability [coreg 3.125 bid= coreg CR 10mg qd]
- Labetalol (drug of choice in pregnancy) (SE: dizziness)
Centrally-Acting Alpha-2 adrenergic agonists MOA
Decrease BP by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow of NE which decreases SVR and HR
Centrally-Acting Alpha-2 adrenergic agonists CI, warnings, SE
CI: Do not use methyldopa with MAOi
Warnings: Do not d/c abruptly (rebound HTN) taper over 2-4 days. Methyldopa; hemolytic anemia
SE: dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, impotence. methyldopa; drug-induced lupus erythematosus (DILE)
Centrally-Acting Alpha-2 adrenergic agonists CI, warnings, SE
CI: Do not use methyldopa with MAOi
Warnings: Do not d/c abruptly (rebound HTN) taper over 2-4 days. Methyldopa; hemolytic anemia
SE: dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, impotence. methyldopa; drug-induced lupus erythematosus
Direct Vasodilators MOA
Cause direct vasodilation of arterioles, with little effect on veins. Results in decreases in SVR and reduction in BP
Direct Vasodilators Warnings and SE
Hydralazine: DILE, peripheral edema, headache, flushing, palpitations, reflex tachycardia
Minoxidil: potent antihypertensive, fluid retention, tachycardia, hair growth
Direct Vasodilators Warnings and SE
Hydralazine: DILE, peripheral edema, headache, flushing, palpitations, reflex tachycardia
Minoxidil: potent antihypertensive, fluid retention, tachycardia, hair growth
Alpha-blockers
- Doxazosin, prazosin, terazosin
- Bind to alpha-1 adrenergic receptors, which results in peripheral vasodilation of arterioles and veins
- NOT recommended for HTN, may be used in the who have HTN and BPH
Hypertensive Crisis BP
BP >= 180/120
Hypertensive emergency
emergency: pt has acute target organ damage (encephalopathy, stroke, AKI, ACS), treat with IV meds, decrease BP by no more than 25% within the 1st hr, then, if stable, decrease to about 160/100 in the next 2-6 hours
Hypertensive urgency
- no evidence of acute target organ damage
- treat with any oral medication that has a short onset of actions (15-30 mins)
- decrease BP gradually over 24-48hr
IV hypertension meds
- Chlorothiazide
- Clevidipine
- Diltiazem
- Enalaprilat
- Esmolol
- Hydralazine
- Labetolol
- Metoprolol tart
- Nicardipine
- Nitroglycerin
- Nitroprusside
- Propranolol
- Verapamil
Drugs that can increase BP
- amphetamines and ADHD drugs
- cocaine
- decongestants (sudafed)
- erythropoiesis-stimulating agents
- immunosuppressants (cyclosporine)
- NSAIDs
- Systemic steroids
