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Block 9 Week 2 Meg > Earley: Antihypertensive Agents > Flashcards

Earley: Antihypertensive Agents Flashcards

1
Q

Define the following:

Normal BP
Prehypertension
HTN
Hypertension stage 1
Hypertension stage 2
A 
120/80
120-139/81-90
>140/90
Stage 1: 140-159/90-99
Stage 2: >160/100
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2
Q

What BP should you shoot for in patients less than 60 years old with hypertension?

A

<140/90

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3
Q

What BP should you shoot for in patients greater than 60 years old with hypertension?

A

<150/90

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4
Q

What BP should you shoot for in patients with diabetes?

A

<140/90

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5
Q

This form of HTN makes up 85-90% of cases

A

essential hypertension

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6
Q

What types of diseases/conditions cause secondary hypertension?

A 
sleep apnea
drug-induced
chronic kidney disease
primary aldosteronism
renovascular disease
chronic steroid therapy
pheochromocytoma
coarctation of the aorta
thyroid/parathyroid disease
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7
Q

What are some factors contributing to essential hypertension?

A 
obesity
stress
lack of exercise
diet
alcohol intake 
smoking
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8
Q

What is the prevalence of HTN in the US? What population is it most common in?

A

~30%

highest prevalence in the elderly

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9
Q

What are some complications of HTN?

A

cardiovascular disease: stroke, atherosclerosis, heart failure

renal damage

retinal damage

**starting at 115/75mmHg, risk doubles each increase of 20/10mmHg

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10
Q

What are some lifestyle modifications that can help treat hypertension?

A 
reduce weight to normal BMI (can shave off 5-10mmHg/10kg loss)
DASH eating plan (8-14mmHg)
restrict dietary sodium (2-8mmHg)
increase physical activity (4-9mmHg)
reduce alcohol consumption
stop smoking
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11
Q

Explain the DASH diet for HTN patients

A

fruits and veggies and low fat dairy
reduce sodium
whole grains, poultry, fish, nuts
reduce red meat, sugar, total saturated fat and cholesterol

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12
Q

What is mean arterial pressure?

A

dependent on CO * PVR

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13
Q

What are the three types of diuretics for HTN treatment?

A

thiazides *most commonly used
loop diaretics: furosemide, bumetanide **for severe HTN and heart failure
K+ sparing diuretics: spironolactone, amiloride, triamterene **reduce heart failure mortality

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14
Q

How do diuretics work?

A

increase Na+ and water excretion, thus decrease CO due to decreased blood volume

after 6-8 weeks, CO will return to normal but PVR will decline

typically lower BP by 10-15mmHg in most patients

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15
Q

This is the most commonly used diuretic

A

Thiazides

Ex: hydrocholorthiazide, chlorothiazide

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16
Q

What are some toxic effects of diuretics?

A 
K+ depletion (except for K+ sparing diuretics)
Mg+ depletion
impaired glucose tolerance
increased serum lipids
gout (increased uric acid)
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17
Q

What can minimize K+ depletion while taking a diuretic?

A

limiting Na+ intake

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18
Q

This is an agent that prevents adrenergic transmission

A

reserpine

**used infrequently

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19
Q

This is a selective alpha-1 adrenergic receptor blocker

A

prazosin
terazosin
doxazosin

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20
Q

This is a beta adrenergic blocking agent

A

propranolol

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21
Q

These anti-HTN agents act directly on the CNS

A

clonidine

methyldopa

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22
Q

How does reserpine work to decrease blood pressure?

A

depletes neurotransmitters in the nerve endings of the brain and periphery - depresses sympathetic nervous system centrally and peripherally and decreases HR, contractility and PVR

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23
Q

Adverse effects of reserpine?

A 
depression
insomnia
nightmares
orthostatic hypotension
impotence

**used infrequently

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24
Q

How do selective alpha 1 antagonists, like prazosin work?

A

block alpha 1, decrease vasoconstriction, decrease peripheral vascular resistance and decrease BP

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25
Q

What are some adverse effects of prazosin?

A

1st dose phenomenon (sudden severe fall in BP)
dizziness
headache

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26
Q

When are alpha 1 selective antagonists used?

A

used in stage 1 and stage 2 HTN in combo with a diuretic and a beta blocker

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27
Q

How do beta blockers work?

A

block cardiac B1 receptors to decrease CO

block renal B1 receptors to lower renin and PVR

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28
Q

Non-selective beta blocker

Main effect is to decrease HR

A

propranolol

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29
Q

What are some adverse effects of propranolol and other non-selective beta blockers?

A 
bradycardia
aggravates asthma (blocks airway - prevents smooth muscle relaxation)
30
Q

When are beta blockers used?

A

used in stage 1 or 2 HTN alone or in combo with a diuretics and/or a vasodilator

31
Q

Which drugs interact unfortunately with propranolol?

A

verapamil
diltiazem
digitalis

32
Q

List two beta blockers that are cardioselective for beta 1, and are the most widely used beta blockers for HTN

A

metoprolol

atenolol

33
Q

Combined nonselective beta and alpha-1 blocker. Beta blocking action is more prominent.
Used i.v. for hypertensive emergencies

A

labetalol

34
Q

How does alpha-methyldopa decrease BP?

A

alpha methyldopa is metabolized to alpha methyl NE, which is an alpha2 agonist, so it suppresses catecholamine release at nerve terminals; this decreases PVR and HR

35
Q

Adverse effects of alpha-methyldopa and clonidine?

A 
sedation
dry mouth
drowsiness
impotence
bradycardia
rebound HTN when you withdraw from it
36
Q

When is clonidine used?

A

stage 1 and 2 HTN

37
Q

When is methyldopa used?

A

for HTN during pregnancy

38
Q

List three drug classes that work as vasodilators

A

calcium channel blockers (nifedipine)
direct acting vasodilators (sodium nitroprusside)
K+ channel openers (minoxidil)

39
Q

How do calcium channel blockers work?

A

inhibit Ca++ entry through L-type voltage gated Ca++ channels

40
Q

This Ca++ channel blocker is a phenylalkylamine

A

verapamil

41
Q

This Ca++ channel blocker is a benzothiazepine

A

diltiazem

42
Q

This Ca++ channel blocker is a dihydropyridine

A

amlodipine

43
Q

Selective blockade of vascular Ca2+ channels

Main effect: vasodilation–>lower PVR–>lower BP

A

amlodipine

44
Q

Adverse effects of amlodipine:

A

flushing
ankle edema
reflex tachycardia

45
Q

When is amlodipine used?

A 
in HTN (esp for African Americans)
angina
46
Q

Mechanism: Blockade of Ca2+ channels in the vasculature, heart muscle and AV node

Main effects: same as amlodipine group

Adverse effects: Similar to amlodipine except that they do not cause reflex tachycardia

A

verapamil

diltiazem

47
Q

You should be cautious when prescribing verapamil and diltiazem with what drugs?

A

when used with beta blockers or digitalis, can cause AV block

**this is not the case for amlodipine

48
Q

This is a direct acting vasodilator, which increased NO and increases cGMP

A

Sodium nitroprusside

49
Q

How does sodium nitroprusside work?

A

generates NO which is a rapid acting venous and arteriolar vasodilator

50
Q

Adverse effects of Na-nitroprusside?

A

reflex tachycardia
severe hypotension
possible cyanide poisoning

51
Q

When is Na-nitroprusside used?

A

in hypertensive emergencies

52
Q

This is a potassium channel opener which causes decreased BP

A

Minoxidil

53
Q

How does Minoxidil, a K+ channel opener, decrease BP?

A

opens K+ channels –> smooth muscle hyperpolarization –> smooth muscle relaxation –> arterial dilation –> decreased PVR –> decreased BP

54
Q

List some general drug classes that affect the renin-angiotensin-aldosterone system

A

ACE inhibitors: captopril, lisinopril
Ang II receptor blockers: losartan, valsartan, irbesartan
renin inhibitors

55
Q

How do ACE inhibitors decrease BP?

A

decrease circulating levels of Ang II –> decrease PVR –> decrease BP

56
Q

Adverse effects of ACE inhibitors?

A

skin rash
dry cough
hyperkalemia **when you activate the RAAS, you increase sodium retention and increase K+ excretion

57
Q

When are ACE inhibitors used?

A

stage 1 and 2 HTN

CHF

58
Q

Drug of choice in HTN patients with diabetes, because it does not have effects on plasma lipid levels

A

captopril

**and other ACE inhibitors

59
Q

When should ACE inhibitors not be used?

A

during pregnancy!!

**also not very affective in African Americans

60
Q

How do Ang II receptor inhibitors decrease BP?

A

selective block the Ang II receptor –> decrease PVR –> decrease BP

61
Q

Adverse effects of Ang II receptor inhibitors?

A

no cough!! **could be an alternative to ACE inhibitors if not well tolerated
otherwise similar to ACE inhibitors
**also toxic to fetus

62
Q

This is a renin inhibitor, which inhibits the conversion of angiotensinogen to Ang I; equally as effective as ACE inhibitors and ARBs

A

Aliskiren

63
Q

Side effects of Aliskiren, a renin inhibitor?

A 
diarrhea
stomach pain
heartburn
cough
rash
dizziness
fetal toxicity

**don’t use in patients with diabetes or CKD

64
Q

Describe how you might approach the treatment plan for a patient with HTN

A
  1. implement lifestyle interventions
  2. set blood pressure goal and initiate BP lowering meds based on age, diabetes, and chronic kidney disease
  3. for people less than 60 yo, aim for a BP <140/90
  4. if non-black, try thiazide-type diuretics, ACEI or ARB or CCB alone or in combo; if black, try thiazide-type diuretics or CCB
65
Q

What should you do if your patient is not reaching your goal blood pressure?

A 
reinforce medication and lifestyle adherence
add additional medication class not previously prescribed
66
Q

What are 3 different strategies when starting a medication regimen for patients with HTN?

A
  1. start one drug, titrate to max dose, then add second drug
  2. start one drug, add second drug before achieving max dose on first drug
  3. begin with both drugs at the same time, as separate pills or a combo
67
Q

Definition (AHA): BP > 140/90 mmHg (130/80 with diabetes and CKD) for patients prescribed 3 or more antihypertensive medications at optimal doses
or
BP controlled with 4 or more antihypertensive drugs

A

resistant hypertension

68
Q

What percentage of HTN patients have resistant HTN?

A

up to 40% !!!

69
Q

Adherence to HTN meds is higher for (blank) and/or lower number of doses per day

Adherence may be higher for (blank) and (blank) vs. diuretics and β-blockers.

Adherence to (blank) changes are even worse, ~10-20% for Na+ reduction.

A

single drug;
RAS and Ca++ channel blockers;
dietary

70
Q

Review: which blood pressure meds should be used first for black patients?

A

thiazide type diuretic
Ca++ channel blocker

**ACE inhibitors & ARBs not particularly effective

Block 9 Week 2 Meg (8 decks)

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