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IP1 > E3: HTN Therapeutics > Flashcards

E3: HTN Therapeutics Flashcards

1
Q

Define hypertension and what two things are increased with it

A

Hypertension: persistently elevated arterial blood pressure
-Increase cardiac output (CO)
-increased peripheral vascular resistance (PVR)

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2
Q

Define primary hypertension

A

Unknown cause but thought to be genetics, poor diet, lack of exercise & obesity

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3
Q

What are 4 causes of secondary hypertension

A
  1. Obstructive sleep apnea (OSA)
  2. Hyperaldosteronism
  3. Medications
  4. Alcohol
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4
Q

Short and long term complications of HTN (3)

A
  1. myocardial infarction
  2. heart failure
  3. stroke
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5
Q

Long term complications of HTN (5)

A
  1. peripheral artery disease (PAD)
  2. chronic kidney disease (CKD)
  3. Retinopathy
  4. Sexual dysfunction
  5. Atrial fibrillation (Afib)
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6
Q

What is the goal of HTN therapy and what is the target BP for most patients per ACC?AHA

A

Reduce morbidity and mortality from CV events
BP Target: 130/80

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7
Q

What was the trial that established the target BP for most patients w/HTN and what was its findings

A

SPRINT trial, found that patients that had their BP brought down to 120 with medications experienced more side effects. Ultimately, it is better to be below 130 than 120 because the additional SE do not outweigh the benefits

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8
Q

Classification of BP (Normal to Stage 2)

A

Normal: <120/80
Elevated: 120-129/<80
Stage 1: 130-139/80-89
Stage 2: >140/90

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9
Q

Intervention and follow for various BP readings (Normal to Stage 2)

A

Normal: <120/80
Intervention: Lifestyle and follow up in 1 year

Elevated: 120-129/<80
Intervention: Lifestyle and follow up in 3-6 months

Stage 1: 130-139/80-89
Primary prevention & ASCVD 10 yr risk < 10%
Intervention: Lifestyle and follow up in 3-6 months

Stage 1: 130-139/80-89
Secondary prevention OR ASCVD 10-year risk >10%
Intervention: Lifestyle + 1 med and follow up in 2-4 weeks

Stage 2: >140/90
Intervention: Lifestyle + 2 med and follow up in 2-4 weeks

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10
Q

Define primary prevention
Define secondary prevention

A

Primary prevention: NO heart-attack, stroke, or heart failure
Secondary prevention: History of heart-attack, stroke, or heart failure

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11
Q

What is ASCVD

A

Atherosclerotic Cardiovascular disease risk
Pooled Cohort Equations preferred by guidelines to estimate 10-year risk of ASCVD

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12
Q

Who is ASCVD valid for? What about those outside of the age range?

A

US adults age 40 to 79 in absence of concurrent statin therapy
Those >79 years old, the 10-year ASCVD risk is generally >10%
Uncertain utility in other racial groups

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13
Q

Define established HTN

A

Anyone who is currently treated for hypertension or has failed lifestyle modifications

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14
Q

For those with established HTN, if their SBP is <110, what should you do

A

consider decreasing BP meds, especially if polypharmacy or symptomatic hypotension

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15
Q

For those with established HTN, if their BP is 110-130/80, what should you do

A

Continue treatment plan, their BP is controlled

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16
Q

For those with established HTN, if their BP is >130/80, what should you do? How to do you select which option is the best

A

1) Need to make a change to improve BP control
2) Verify adherence to current plan
3) Increase non-pharmacologic modifications
4) Increase medication dose
5) Add additional medication

Selection depends on patient factors
-current BP (>140/90 need med change)
-patient wishes, adherence, PMH, etc

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17
Q

What are the 7 life-style changes

A
  1. weight loss
  2. physical activity
  3. DASH diet
  4. reduced salt intake
  5. increase potassium
  6. alcohol intake
  7. tobacco cessation
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18
Q

Lifestyle change: weight loss
Goal BMI, SBP reduction = x

A

Goal weight is BMI 18.5 to 24.9
1mmHg/1kg weight loss

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19
Q

Lifestyle change: physical activity
Goal time, SBP reduction = x

A

90-150/wk
-4-8 mmHg

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20
Q

Lifestyle change: DASH diet

A

Increase consumption in fruits, vegetables, and low-fat dairy
-10mmHg

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21
Q

Lifestyle change: reduced salt intake

A

at least 1 g reduction, ideally consume less than 1.5 g daily
-6mmHg

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22
Q

Lifestyle change: increase potassium
Excluded population

A

3.5 to 5 g daily preferred in diet
NOT for patients w/CKD or hyperkalemia
-4mmHg

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23
Q

Lifestyle change: alcohol intake

A

<2 drink for men daily
<1 drink for women daily
-4mmHg

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24
Q

Lifestyle change: tobacco cessation

A

Recommend tobacco cessation at every visit
No reduction but is a risk factor for CVD

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25
Q

First line HTN agents (4)
What is the benefit of them

A
  1. ACE inhibitors
  2. ARB
  3. CCB
  4. Thiazide diuretics

Additional mortality benefit in HTN

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26
Q

Second line HTN agents (2)
What is the benefit of them

A
  1. Aldosterone antagonists
  2. Beta Blockers (BB)

Mortality benefit in other diseases

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27
Q

Third line HTN agents (3)

A
  1. α-1 blockers
  2. Central α-2 agonists
  3. Direct vasodilators
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28
Q

What is the ACE inhibitor we specifically mentioned and its max dose

A

Lisinopril 40mg

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29
Q

When is it best to use ACEi
When should you avoid them

A

Best: first line in HTN especially if patients have signs or risks of chronic kidney dysfunction
AVOID:
1. acute kidney injury
2. hyperkalemia (K>5.5 mEq/mL)
3. pregnancy
4. severe bilateral renal artery stenosis

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30
Q

Key monitoring for ACE inhibitors and response

A
  1. Angioedema: D/C & document as allergy
  2. Cough: D/C & document as allergy
  3. BMP ran 1-2 weeks after start or dose increase to monitor for ↑SCr or ↑K
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31
Q

-pril

A

ACE inhibitors

32
Q

After labs are ran 1-2 weeks after starting an ACEi or dose is increased what do you do for the following results in SCr and K
↑ <30%:
↑ 30-50%:
↑50%:

A

↑ <30%: continue therapy w/labs PRN
↑ 30-50%: continue therapy BUT redraw labs 1-2 weeks
↑50%: put therapy on hold, redraw labs, can retrial lower dose once labs normalize

33
Q

-artan

A

ARB

34
Q

When is it best to use ARBs
When should you avoid ARBS

A

Best: first line HTN especially if patients have signs or risks of chronic kidney dysfunction (same as ACEi)

AVOID:
1. acute kidney injury
2. hyperkalemia (K >5 mEq/mL)
3. pregnancy
4. severe bilateral renal artery stenosis
(same as ACEi except K >5.5 mEq/mL)

35
Q

Key monitoring for ARBs and response

A
  1. Angioedema: D/C, document as allergy (same as ACEi)
  2. BMP 1-2 weeks after start or dose increase to monitor for ↑SCr or ↑K
36
Q

After labs are ran 1-2 weeks after starting an ARB or dose is increased what do you do for the following results in SCr and K
↑ <30%:
↑ 30-50%:
↑50%:

A

↑ <30%: continue therapy w/labs PRN
↑ 30-50%: continue therapy BUT redraw labs 1-2 weeks
↑50%: put therapy on hold, redraw labs, can retrial lower dose once labs normalize

37
Q

CCB
NonDHP: (2)
DHP: (3 we care about)
Drug w/dose we MUST know

A

NonDHP: verapamil & diltiazem
DHP: amlodipine, nifedipine, nicardipine

MUST KNOW: Amlodipine max dose = 10mg

38
Q

When to use CCB
When to avoid CCB

A

Best:
1. Suitable first line HTN for most patients
2. Preferred in Black patients and isolated systolic HTN

AVOID:
1. NonDHP in heart failure patients

39
Q

Key monitoring for CCB and the proper response

A
  1. hypotension, dizziness, flushing, nausea
    –dose reduce, slower titration as tolerated
  2. NonDHP: bradycardia
    –dose reduce to maintain HR >60
  3. DHP: Dose related pedal edema
    –dose reduce or D/C and list as intolerance
40
Q

Thiazide diuretics (3)
Doses for 2 of them

A

Hydrochlorothiazide: 25 mg
Chlorthalidone: 25 mg
Indapamide

41
Q

When to use thiazide diuretics
When to avoid thiazide diuretics

A

Best
-First line for HTN, best to take in AM
-Take w/ACEi, ARB, or aldosterone antagonist to reduce potassium levels

AVOID
-CrCl less than 30mL/min (less effective
-patients w/gout

42
Q

Key monitoring and response for thiazide diuretics

A

BMP 1 to 2 weeks after starting or dose increase to monitor for ↓Na+, ↑Scr, or ↓K+
Response: if one of the following, put therapy on hold, redraw labs, and may retrial at lower dose once labs normalize
Na <135
Scr-50% ↑
K < 3.5

43
Q

When to use beta blockers
When to AVOID beta blockers

A

Second line agent used for many cardiac conditions such as myocardial infarctions, heart failure, atrial fibrillation

Avoid in DM and those at high risk for hypoglycemia, because it can mask symptoms; avoid in uncontrolled asthma and COPD because you want to avoid ß2 selectivity

44
Q

Key monitoring for beta blockers and response

A
  1. BRADYCARDIA: dose reduce to maintain HR >60
  2. Beta blocker blues (fatigue, tiredness): continue dose if able, should improve w/time
  3. Adherence for rebound HTN if stopped; titration off if stopping medication
45
Q

Aldosterone antagonist agents

A

Spironolactone, Eplerenone

46
Q

When to use aldosterone antagonists
When to AVOID aldosterone antagonists

A

Use for resistant HTN or HTN from primary aldosteronism; can also use in myocardial infarctions, heart failure

AVOID in hyperkalemia (K>5mEq/mL) and POOR kidney function (CrCl <30 mL/min)

47
Q

Key monitoring for Aldosterone antagonists
Key monitoring for spironolactone specifically

A

BMP 3 to 7 days after starting or increased dose then additional testing in 1 to 2 weeks to monitor for ↑Scr and ↑K+

Gynecomastia and impotence for men, switch to eplerenone

48
Q

After labs are ran 3 to7 days and 1-2 weeks after starting an aldosterone antagonist or dose is increased what do you do for the following results in SCr and K
↑ <30%:
↑ 30-50%:
↑50%:

A

↑ <30%: continue therapy w/labs PRN
↑ 30-50%: continue therapy BUT redraw labs 1-2 weeks
↑50%: put therapy on hold, redraw labs, can retrial lower dose once labs normalize
* same as ACEi and ARB *

49
Q

Third line agents (3)

A

Alpha-1 antagonist
Alpha-2 agonist
Vasodilator

50
Q

Alpha-1 antagonists suffix and examples

A

zosin
doxazosin, terazosin, prazosin

51
Q

Alpha-1 antagonist counseling and SE

A

Doxazosin, terazosin, prazosin

take at nighttime d/t orthostatic hypotension

S/E: dizziness and headaches

52
Q

Alpha-2 agonist agent and counseling

A

Clonidine
S/E sedation, drowsiness, headache

53
Q

Vasodilator agent, dose frequency/disadvantage, S/E

A

Hydralazine
Dosed TID or BID difficult for adherence

S/E: orthostatic hypotension, edema, reflex tachycardia

54
Q

4 key points in the hypertension algorithm

A
  1. adults 18 yro or older w/NO compelling indications
  2. TZ diuretic, ACEi/ARB, or CCB
  3. Follow up in 2 to 4 weeks after adding or increasing medication
  4. If uncontrolled, check adherence and continue to increase dose or add first line agents as appropriate
55
Q

When selecting a first line agent, what 3 things must be considered

A
  1. Safety
  2. Efficacy
  3. Patient preference
56
Q

What are the home blood pressure monitoring guidelines for those actively adjusting medications (3)

A
  1. Test 3-7 days before appointment
  2. Test 2 times 1 minute apart
  3. Test before taking medications in morning and in the evening
57
Q

What are the home blood pressure monitoring guidelines for those with long-term follow ups

A
  1. Test 1-2 measurements/week
58
Q

What are the 3/4 compelling indications

A
  1. CKD
  2. DM + proteinuria
  3. Pregnancy
59
Q

First line agents and alternative agents for CKD

A

First line: ACEi/ARB
Alternative: CCB or TZ diuretic

60
Q

First line agent and alternative agent for DM + proteinuria

A

First line: ACEi/ARB
Alternative: CCB or TZ diuretic

61
Q

First line agent and alternative agent for pregnancy

A

First line: Nifedipine or labetalol
Alternative: Methyldopa

62
Q

Define CKD and its treatment goal

A

Chronic Kidney Disease: eGFR <60ml/min w/proteinuria >300mg/g
Goal: <130/80

63
Q

Those w/CKD are at high risk for ______ and ______, so we must be cautious and have _____ dose adjustments

A

high risk for hyperkalemia and hypotension

slow dose adjustments

64
Q

Those w/CKD must avoid ______ or ______ _______ if CrCl is <30ml/min

A

Avoid TZ diuretics or aldosterone antagonists

65
Q

Diabetes + HTN BP goal and treatment
Preferred treatment if microalbuminuria (>30mg/g)

A

Goal: 130/80
Treatment: All are appropriate
Microalbuminuria: ACEi/ARB

66
Q

What class of agents are to be used w/caution in diabetics because they can mask hypoglycemia

A

beta-blockers

67
Q

HTN in pregnancy: Pre-eclampsia

A

medical emergency, HTN crisis that can be deadly to mother and baby

68
Q

What agents can NOT be used in pregnancy (3)

A

ACEi
ARB
Renin inhibitors

69
Q

Are anti-HTN medications excreted into the breastmilk

A

YES, consider withholding antihypertensive for a few months

70
Q

What agents (4) are recommended for lactation and which agents (3) are to be avoided

A

Recommended: Methyldopa, hydralazine, beta blockers (Propranolol or labetalol)

AVOID: ACEi, ARBs, diuretics

71
Q

Given the current guidelines, what agents are recommend in black patients w/HTN and no other compelling indications

A

Thiazide diuretics or CCB

72
Q

Define resistant HTN

A

patient is optimized on 3 HTN medications (at least 1 diuretic, all different classes) but not able to achieve goal

73
Q

Risk factors of resistant HTN (5)

A

elderly
obesity
CKD
Black
DM

74
Q

What agents should be added if a patient has resistant HTN

A

aldosterone antagonist

75
Q

Medication induced HTN: volume retention
Causes:
Treatment:

A

Causes: NSAIDs, oral contraceptives, corticosteroids
Treatment: ACEi/ARB or diuretic

76
Q

Medication induced HTN: sympathomimetic activation
Causes:
Treatment:

A

Causes: decongestants, caffeine/nicotine, psychostimulants, SNRI (venlafaxine), bupropion
Treatment: reduce exposure

77
Q

Medication induced HTN: abrupt withdrawal
Causes:
Treatment:

A

Causes: B-blockers, alpha2 agonist
Treatment: consistent adherence

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