E1: anti-HyperTensioN Flashcards
HTN: Most common cardiovascular disease…Prevalence increases with age…Higher among the sex of _____ than _____…Higher among _______ populations….Individuals at age 55 with normal BP have a ____% lifetime risk for developing hypertension..WOAH
Higher among women than men..Higher among MINORITY populations: non-Hispanic blacks, non- Hispanics and Mexican Americans…90%
Did you know? Only ___% of patients with KNOWN
hypertension are treated!!!
50%. yes HALF that freaking know they have it!!!
What is the official name for idiopathic or primary HTN and it represents 85-90% of cases..?
Essential HTN
What type of HTN is associated with disease process of endocrine or renal system? Drugs: NSAIDS, birth control pills, decongestants, tricyclic antidepressants
Secondary HTN
What type of HTN develops in 5% of patients with primary or secondary HTN? BP very high or RAPIDLY rises; evidence of RETINAL and renal damage.
Malignant HTN
If a patient is showing signs of RETINAL Damage c/o HTN, what type of HTN are they most likely experiencing?
Malignant HTN
What is the first line of Tx for a Pt with HTN?
Life Style Changes!
What are the BP values used to determine need for intervention? ___/___ ˂ 60 years…____/____ ˃ 60 years
140/90 if younger than 60yrs…150/90 if older than 60
What are the 3 basic methods we can lower BP?
- Reduce Peripheral Resisitance (block the SympNS) 2.Reduce CO 3.Decrease blood Volume
What are the 3 classes of Diuretics?
1.Thiazides 2.Loop 3.Potassium Sparing
How do most diuretics work?
They block the REABSORPTION of Na+ (so its filtered and secreted, but not reabsorbed)
What is the typical FIRST line defense for treating HTN in America?
DIURETICS!
What 3 places in the nephron do MOST of the diuretics work?
Ascending Loop, D conv tubule, collecting duct…(there are some that work on the proximal, so really everywhere!
Mech of action for Mercury Diuretics: Block Na+ reabsorption by releasing mercury ions to interact with the _______ group of the Na+ transport receptors in tubules
sulfhydryl group
What was the first class of diuretics that are no longer on the market? (for good reason!)
mercurials
What is the helpful tool for naming mercurial diuretics?
they begin with “mer”..mercaptomerin (Thiomerin); meralluride (Mercuhydrun)
First choice agents for hypertension and congestive heart failure**
Thiszides (BenzoThiaZides)…(most commonly Rx’d diuretics)
Thiazides (benzothiazides) Inhibition of active Na+ reabsorption in which two areas of the nephron??
proximal and distal tubules
Mech of action-Thiazides: inhibition of _________ = decreased availability for H+ exchange with Na+
carbonic anhydrase (breaks up bicarb in lumen, puts bicarb back together in tubule)
Desired Effects of Thiazide Diuretics: Lower blood pressure: Decreased _______ volume…Decreased _______ fluid
plasma… extracellular
Desired Effects of Thiazide Diuretics: Decreased _______- thanks to STARLINGS law (if decrease amount of blood returning to the heart (preload), heart doesn’t have to work as hard to eject blood back into the systemic circulation)
cardiac output
Desired Effects of Thiazide Diuretics: Normalization of cardiac output after how long???
several days
What are the two main oral complications from HCTZ?
Xerostomia & lichenOID reaction
What is the main adverse affect of thiazide diuretics?
HYPOKALEMIA (K+ follows Na+ out in the urine) (more Na+ eaten, more K+ loss!)
What are 5 of the main adverse effects of thiazide diuretics? (10 total)
1.HypoKalemia 2.HYPERglycemia 3.Elevated cholesterol 4.Weakness/Fatigue 5.Sexual Dysfxn…(others: loss of bicarb, low Mg+,low Na+, HyperUricemia, elevated TAGs)
Since were talkin bout adverse effects of thiazides, they are not good for _____ patients and patients with high ______.
diabetes (hyperglycemia a side effect) and high lipid/cholesterol(another side effect)
What are the drugs that cause a MAJOR loss of plasma volume and are the go to for serious edema?
Loop Diuretics
Loop diuretics result in a major loss of ____ and ____ = serious electrolyte imbalances may result
Na+ and K+
How do Loop Diuretics work?? Potent inhibition of active Na+ reabsorption in the _________ by blocking reabsorption of ___….Inhibits the _____ “symporter”
ascending Loop of Henle..Cl-..Na+K+Cl-
Which class of drugs are notorious for OTOTOXIC effects( hearing loss/deafness)????
LOOP DIURETICS
What are the two most common preparations for thiazide diuretics?
1.HydroChloroThiaZide (HCTZ) 2.chlorothiazide (Diuril)
What is the most common Loop Diuretic preparation? What is the second loop diuretic she emphasized?
furo-sem-ide (Lasix)…eth-ac-ryn-ic acid (Edecrin)
A lot of the adverse effects of Loop diuretics are similar to thiazide diuretics, but these 2 are a bit different…
1.Nephrotoxicity (when used with cephalexin (keflex)) 2.OTOTOXICITY
What is a good way to see that a thiazide or loop diuretic has caused a lichenOID reaction and NOT lichen planus???
lichenOID will be on the lips! REAL lichen planus is not.
Potassium-SPARING diuretics: Competes with _______ for receptor sites in the ____ renal tubules, increasing Na+, Cl- and water excretion while CONSERVING K+ and ____.
adosterone…distal…conserving K+ AND H+
Potassium-SPARING diuretics: Blocks the effect of _________
aldosterone
Interesting! 5 Adverse effects of Potassium-SPARING diuretics:
1.HyperKalemia 2.Gynecomastia 3.Tenderness of breasts in young women 4.Menstrual irregularities 5.decreased libido in males
Mechanism: Carbonic Anhydrase Inhibitors. Also what is the strength of this diuretic? Where does it act on the nephron?
CA usually allows for Na+ reabsorption, when we inhibit it we excrete more Na+ and hold onto H+. It is a MILD diuretic. Proximal & distal convoluted tubules.
What is the main indication for a Carbonic Anhydrase Inhibitor?
Glaucoma!
When do we use OSMOTIC diuretics? Where do they work? What is the preparation name?
EMERGENCY renal failure….bowman’s capsule/proximal tubule (drug is filtered and NOT reabsorbed..water follows)…prep: urea(Ureaphil)
What is the situation for Acidifying Diurectics? How does it work? What is the preparation?
EMERGENCY tx of metabolic alkalosis…increases Cl- and Na+ into urine (keeps H+ in blood)…Ammonium Chloride
THE 3 WAYS Xanthines Work!!! 1. stimulate cardiac function to increase renal blood flow and ______. 2. They also inhibit tubular reabsorption of ___. 3.THEY ALSO inhibit the hormone ___.
1.GFR…interesting! coffee is AWESOME…2. Na+…3. ADH
Rank the potency of the 4 most regularly used diuretics.
Most potent: 1.Loop 2.Thiazide 3.Carbonic Anhydrase 4.Potassium-SPARING
DENTAL considerations for Diuretics: MAJOR ONE due to water loss.
Xerostomia
DENTAL considerations for Diuretics: another term for mouth ulcers
Aphthous stomatitis
DENTAL considerations for Diuretics: delayed drug hypersensitivity that looks like something else. Caused by WHICH two diuretics???
LichenOID….loop and thiazide
DENTAL considerations for Diuretics: the use of _____ for more than 3 weeks can decrease the effectiveness of diuretics!!
NSAIDS!!! REMEMBER THIS!!!!
What do a lot of patients take to counteract the loss of K+ with diuretics? What do they all start with? What is a major adverse affect?
Potassium supplements…K in the name (K-Tab, Klor-Con)…adverse-GI distress
Think REAL hard…which HTN family is K+ supplements contraindicated with?
ACE Inhibitors
What affect does Blocking Beta1’s have on vessels?
reduce peripheral resistance (a normal symp NS response)
What are the two classes of Beta Blockers and what is the MAGICAL way to distinguish them by name? WHAT IS THE ONLY EXEPTION (damn new drug!)
CardioSelective (A-M) and Non-CardioSelective (N-Z)…ALPHABETICALLY!…exception: NEB-iv-o-LOL
What are the main reasons for side effects when using beta blockers? What is Dr. S’ nickname for these people with sideffects?
over-activity of the ParasymNS (we are blocking the Sym!)..FAINTERS & FALLERS
What is the counterintuitive side effect of beta blockers?
xerostomia! although we are getting MORE parasym stimulation, Pt’s get a ‘sticky’ mucus.
What are the 4 contraindications for Rxing Beta Blockers?
1.Congestive Heart Failure 2.Asthma (can use selective blocker) 3.Heart Block 4.Diabetes
Which blockers produce peripheral vasodilation in arterioles and venules, decreasing peripheral vascular resistance? Who are they usually Rx’d to? What are they usually paired with to make them more effective?(2)
Alpha 1!!…OLD MEN (they help BPH!!!)..usually paired with diuretics and/or beta blockers
Whats the numero uno adverse effect of alpha blockers?
othrostatic hypOtension
What are the 3 Alpha1 blockers that “everyone should know”?
1.dox-az-OSIN 2.pr-az-OSIN 3.tam-sul-OSIN (flowmax)
What do ACE inhibitors all end in?
“-pril”
ACE inhibitors prevent conversion of angiotensin I to angiotensin II, “______ing” vasoconstriction
angiotensin I to angiotensin II…inhibiting vasoconstriction
ACE inhibitor results in lower levels of angiotensin II, which causes an increase in plasma _____ activity and a reduction in ________ secretion.(among MANY other effects! A-II is POWERful!)
RENIN…aldosterone
What is the drug of choice for HTN in diabetes patients? (you think this IMPORTANT?!?!?!? :)
ACE inhibitor- LISIN-O-PRIL
What is a very common side effect of ACE inhibitors? What is causing it? Why should we watch it as oral physicians?
Chronic Dry Chough…so annoying!….bradykinin in lungs….CARIES c/o lozenges/cough syrups
What is a secondary side effect with ACE inhibitors?
AngioNeurotic Edema (with the FIRST dose!) (eye and lip swelling)
Which ACE inhibitor is the ORIGINAL GANGSTER in its class? Which ACE Inhibitor is the biggest market seller in the US?
O.g: EN-AL-a-pril….biggest market seller: LI-SIN-o-pril
What are the 3 mechanisms of Action for Angiotensin Receptor Blockers? (if you get the first one wrong I will kill you)
1.Blocks Vasoconstrictor and 2. Aldosterone-secreting effects of Angiotensin II….3.increases RENIN (which causes vasodilation, decreased sodium and water retention.
Which is more preferred: ACE inhibitor OR Angiotensin Receptor Blockers?? WHYYYY? (2)
ARBs!!! 1.specific site of action 2.less side effects!
What are the two most common Angiotensin Receptor Blockers? What do these drugs usually end in?
end in “-artan”……1. Lo-sar-tan 2.val-sar-tan
NEW DRUGS!!! What name and mech of action for the NEW RENIN inhibitors??
ALI-SKI-REN……binds to Renin and therefore decreases levels of angiotensin I, II, and aldosterone
Ca2+ Channel Blockers…Drop some knowledge! Inhibits calcium ion from entering the “slow channels” or select voltage-sensitive areas of ________ and ________ during depolarization.
vascular smooth muscle…myocardium
Ca2+ Channel Blockers…Drop some knowledge! Produces _______ of coronary vascular smooth muscle and coronary ________.
relaxation…vasodilation
Ca2+ Channel Blockers…Drop some knowledge! Increases myocardial _______ delivery (good for angina too)
oxygen
What are the 3 indications for the use of Ca2+ blockers?
1.HTN 2.Angina 3.Arrhythmias
What are the 3 main Ca2+ channel blockers? YOU BETTER NOT GET at least one of these!!! ALSO…which one is the NEWEST? Oldest?
1.Ni-fed-ipine!! (gingival hyperplasia) 2.verapamil (original gangster 8% chance of gong overgrowth) 3.Aml-od-ipine (newest #1 in sales)
Speaking of Ca2+ channel blockers and gingival hyperplasia…how long until we know the extent of this side effect? DOES oral hygiene have an effect?
3 months will tell you a lot..YEP, Dr. Spolarich did the research!
What are the 2 names of the Alpha2 agonists acting on the CNS?
clon-id-ine(catapres)…guan-fac-ine
Clonidine activates alpha2 receptors on the brainstem which activates an inhibitory neuron…sooooo WHAT is the overall effect on the Sympathetic NS??
Decreases sympathetic outflow from CNS
What are the three main side effects of clonidine?
1.Xerostomia 2.Parotid Gland Swelling 3. Dysgeusia
What are the ‘not really used any more’ drugs that block granular uptake and storage (depletion) of norepinephrine = decrease sympathetic activity due to lack of neurotransmitter supply
Catecholamine Release Blockers
What are the two catecholamine release blockers? Which one crosses the BBB for schizophrenia? Which one blocks APs?
Res-er-pine (BBB) & Guanethidine (blocks AP)
Catecholamine Release Blockers are CONTRAINDICATED in patients with _________.
PEPTIC ULCERS
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! Enhanced hypotension with general anesthetics and ________.
CNS depressants (clonidine, reserpine)
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! Prolonged action of _________, sedatives and tranquilizers (think central acting drugs)
analgesics
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! Use EPINEPHRINE with caution– Remember safe cardiac dose of epinephrine = _____ mg – Always take ____ prior to injection of local anesthetics
0.04 mg…BP
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! OTC sympathomimetics (_____ capsules and _____ tablets) may counteract antihypertensive therapy.
cold…asthma
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! Use of NSAIDS for longer than ________ may decrease effectiveness of some diuretics, beta blockers and ACE inhibitors
– Worst offender: indomethacin
3 weeks…in-do-meth-acin (an NSAID)
You think this is important???Dental Drug Interactions with Antihypertensive Medications!!! What are the 2 actions of Nicotine in cigars and cigarettes?
constricts blood vessels and increases blood pressure
Dental Considerations with Antihypertensive Medications: Prevent sudden changes in _______
posture
Dental Considerations with Antihypertensive Medications: Tissue retraction with vasopressors (e.g. impregnanted gingival retraction cord) is ____________!!!!!
CONTRAINDICATED!!!!
Dental Considerations with Antihypertensive Medications: ________ hypertension may develop if antihypertensive agents are abruptly withdrawn
Rebound
REMEMBER!!! Diuretics make you ______ potassium
LOSE
REMEMBER!!! ACEI and ARBs _________ potassium
INCREASE
