Exam #01 - HTN Flashcards
How do you calculate Pulse Pressure and Mean Arterial Pressure (MAP)
Pulse pressure = systolic BP - diastolic BP
MAP = (Pulse Pressure/3) + DBP
How do you properly use a sphygmomanometer cuff to measure BP?
- Put cuff on patient’s upper arm and make sure arm is at heart level.
- Place stethoscope over brachial artery
- Inflate cuff 30 mmHg above expected SBP and release cuff slowly
Name some potential sources of error that may affect the accuracy of auscultatory readings (sphygmomanometer)?
- cuff size
- arm position
- observer error
- rate of cuff inflation/deflation
- caffeine or nicotine in last 30 minutes
- white coat HTN
- pseudo-HTN
- talking or crossing legs while taking BP
Name (3) humoral mechanisms the body uses to naturally regulate BP? Indicate the one that is most influential contributor to BP regulation.
- Renin-Angiotensin-Aldosterone System (RAAS) MOST IMPORTANT CONTRIBUTOR
- Natriuretic hormone - lowers BP by decreasing Na+ and water retention
- Hyperinsulinemia - raises BP by increasing Na+ retention and sympathetic activity
What (3) things would stimulate the juxtaglomerular cells in the afferent arteriole of the kidney to release renin?
- increase macula densa signal
- increase sympathetic stimulation
- decrease renal artery pressure/blood flow
What (3) neural components are involved in the natural regulation of BP?
- adrenergic nervous system (alpha1 vasoconstriction, beta1 - increase HR, beta2 bronchodilation)
- central nervous system (alpha2 - inhibits NE release)
- baroreceptors
Name (3) mediators of vasodilation involved in natural regulation of BP?
- NO
- bradykinin
- prostacyclin
Name (2) mediators of vasoconstriction involved in natural regulation of BP?
- Angiotensin-II
2. Endothelin I
What (3) dietary elements are implicated in natural regulation of BP?
- Na
- Ca
- K
Name (8) major CV risk factors associated with HTN?
- cigarette smoking
- obesity
- DM
- family Hx of premature CV disease
- dyslipidemia
- physical inactivity
- microalbuminuria or estimated GFR less than 60 ml per min
- Elderly (greater than 55 years old for men and greater than 65 years old for women)
Name (11) target-organ damage associated with HTN?
- angina
- Hx of MI
- LVH (left ventricular hypertrophy)
- LVD (left ventricular dysfunction)
- HF
- stroke
- transient ischemic attack in brain
- CKD (chronic kidney disease)
- peripheral arterial disease
- retinopathy
- prior coronary revascularization
Which type of HTN has an unknown etiology in which you can’t fix one specific thing to cure it?
primary HTN
Which type of HTN has an identifiable cause, but only represents 5-10% of all HTN cases?
secondary HTN
Name the 11 drugs that can cause HTN?
- estrogens/oral contraceptives
- NSAID
- amphetamine/cocaine
- adrenal steroids (prednisone, fludrocortisones)
- pseudoephedrine
- MAO inhibitors with tyramine containing food
- venlafaxine
- erythropoietin
- transplant drugs (cyclosporine & tacrolimus)
- ethanol
- dietary supplements (ephedra, ma huang)
What are some non-pharmacologic therapies used to treat HTN?
- weight reduction
- reduce sodium intake
- exercise
- stop smoking
- alcohol restriction
- DASH diet (dietary approaches to stop HTN)
What are the BP goals for the following types of patients diagnosed with HTN?
General patient with HTN
DM patient
Chronic renal insufficiency (CrCl =160mmHg)
Elderly
General patient with HTN: < 140/90
DM patient < 140/80
Chronic renal insufficiency: <140/90
Elderly: SBP between 140-150
List the (3) goals of therapy when treating HTN
- reduce morbidity and mortality
- prevent target organ damage and CV disease
- modify other CVD risk factors (i.e. smoking)
State SBP and DBP for the 4 BP classifications (normal, pre-HTN, Stage 1 HTN, Stage 2 HTN)?
Normal <80
Pre-HTN 120-139 or 80-89
Stage 1 HTN 140-159 or 90-99
Stage 2 HTN greater than or equal to 160 or greater than or equal to 100
At what BP classification does medication therapy begin?
Stage 1 HTN (normal and pre-HTN just rely on lifestyle modifications
List the (4) 1st line agents for Tx of Stage 1 uncomplicated HTN.
- thiazide
- ACE-i
- ARB
- CCB
True or False - One treatment option for Stage 1 HTN patients is lifestyle modifications for 6 months?
True
What medication therapy modifications would you make if a HTN patient’s BP is not at goal pressure and there seems to be no response to the medication?
substitute another drug from a different class
What medication therapy modifications would you make if a HTN patient’s BP is not at goal pressure and there seems to be an inadequate response to the medication?
add a second agent from a different class
After adjusting a HTN patient’s medications, how long until the patient should follow up with their PCP?
every 2-4 weeks until the BP goal is reached
What (2) chem-7 values are monitored 1-2 times per year in patients taking medication to control their HTN?
K+ and creatinine
Once a HTN patient’s BP is at goal BP, how often should their follow up visits be?
every 3-6 months
Based on the ALLHAT study results, which 1st line medication is recommended for uncomplicated HTN b/c of its superiority in preventing CV complications of HTN?
thiazide (chlorthalidone)
Which medication is recommended as 1st line Tx for patients with Hx of MI, angina, or HF (compelling indication) for treatment of HTN?
Beta-blockers
Which medications are the DOC for patients with HTN and LVD or systolic heart failure?
- ACE-I + loop diuretic + beta-blocker
Which medications are the DOC for patients with HTN and s/p MI? Which medication would you add to the drug regimen if patient developed systolic HF as a result of experiencing large MI?
Beta-blocker + ACE-I
Aldosterone antagonist
Which medication is first-line therapy in Tx of patients with chronic stable angina/coronary disease and HTN?
beta-blockers
Which (2) medications can be used for patients with DM and HTN?
ACE-I OR ARB
In clinical practice, usually start off with ACE-I and move to ARB if necessary
Which (2) medications can be used for patients with Chronic Kidney Disease and HTN?
ACE-I OR ARB
Which medications are used to treat patients with HTN and recurrent stroke?
ACE-I + Thiazide
Which HTN medications, when given as mono therapy, do AA respond better to than Caucasians and which HTN medications do Caucasians respond better to than AA?
AA respond better to thiazide diuretics and CCB
Caucasians respond better to ACE-I, ARBs, and beta blockers
True or False - When any HTN medications is combined with a thiazide diuretic, there is NO difference in response to medication between AA and Caucasians?
True - inter-racial differences are eliminated
Why do pre-menopausal women have a lower CV risk than post-menopausal women and men?
pre-menopausal women have more endogenous estrogen which is cardioprotective
True or False - ALL anti-HTN medications can cause ED/impotence?
True - beta-blockers and diuretics are more problematic
Thiazide diuretics are very effective in elderly patients with what disease?
Isolated Systolic Hypertension (ISH)
Which anti-HTN medication would be a good choice for post-menopausal women at risk for osteoporosis?
thiazide diuretic - thiazides can increase Ca which can increase bone density and help with treatment of osteoporosis
Which diuretic would be best for patients with HTN and CrCl of less than 25-30 ml/min?
Loop diuretics
True or False - K-sparing diuretics are often not effective for HTN and typically used for ability to decrease incidence of hypokalemia? What are (2) exceptions and why are they exception?
True
- Spironolactone
- Epleronone
Exceptions b/c they also are aldosterone antagonists so they’re very effective for HTN
The (2) K-sparing diuretics that also have aldosterone antagonism (Spironolactone and Epleronone) are useful in HTN patients with what compelling indication?
severe CHF
Name the (3) important AE associated with Thiazide diuretics?
- Hypokalemia
- INCREASE Ca+2
- Hyperuricemia
- photosensitivity
Name the (2) important AE associated with Loop diuretics?
- Hypokalemia
- DECREASE Ca+2
- high IV doses can cause reversible hearing loss
What are the (2) AE seen with potassium sparing diuretics? Indicate which drug causes one AE more than the other.
- Increased K+ (Eplerenone causes this more than Spironolactone)
- Gynecomastia (Spironolactone causes this more than Epleronone)
True or False - all diuretics have the potential to increase Scr?
True
What is mild-moderate hypokalemia defined as? Severe?
mild-moderate hypokalemia 2.5-3.4 mEq/L
Severe hypokalemia less than 2.5 mEq/L
When would pharmacotherapy be appropriate to treat mild-moderate hypokalemia?
when there is underlying cardiac abnormalities (otherwise just treat with diet mods)
Name (4) common thiazide diuretics used in Tx of HTN and dosing ranges for each? Make sure to indicate generic and brand.
- Hydrochlorothiazide (Microzide) 25 mg/day
- Chlorthalidone (Hygroton) 6.25-25 mg/day
- Indapamide (Lozol) 1.25-2.5 mg/day
- Metolazone (Zaroxolyn) 2.5-10 mg/day
Name (3) loop diuretics used in Tx of HTN and dosing ranges for each? Make sure to indicate generic and brand.
- Furosemide (Lasix) 20-320 mg/day BID or TID
- Bumetanide (Bumex) 0.5-4 mg/day BID
- Torsemide (Demadex) 5-10 mg/day
Name (3) potassium-sparing diuretics used in Tx of HTN and dosing ranges for each? Make sure to indicate generic and brand.
- Triamterene (Dyrenium) 50-100 mg/day BID
- Spironolactone (Aldactone) 25-50 mg/day BID
- Epleronone (Inspra) 50-100 mg/day BID
True or False - diuretics are contraindicated in patients with anuria and dehydration?
True
Which anti-HTN is contraindicated in patients with CrCl less than 30 ml/min?
thiazide diuretics (loop diuretics are DOC in patients with low CrCl and HTN)
A patient with what (2) characteristics is Spironolactone contraindicated?
- hyperkalemia (K > 5.5)
2. CrCl < 30 ml/min
What parameters would you monitor when starting patient with HTN on diuretics (thiazide, loop, potassium-sparing)?
Baseline SCr, BUN, K+ (repeat labs 1 wk after starting meds)
Monitor BP and AE every 2-4 weeks until patient is at goal BP
Beta-2 blockade in arteriolar smooth muscle in peripheral vasculature from nonselective B-blockers can lead to __________?
unopposed alpha-induced peripheral vasoconstriction
Which beta-blockers should NOT be used in patients with HTN and s/p MI b/c they partial agonists (they have intrinsic sympathomimetic activity?
- Carteolol
- Acebutolol
- Penbutolol
- Pindolol
Name (5) beta-blockers indicated for use in HTN with starting dose?
- Atenolol (Tenormin) 25 mg/day
- Metoprolol (Lopressor) 25 mg/day BID
- Carvedilol (Coreg) 12.5 mg/day BID
- Propanolol (Inderal) 80 mg/day BID
- Nebivolol (Bystolic) 5 mg/day
Which (2) beta-blockers indicated for HTN are specifically indicated in HF?
- Metoprolol XL (Torpol-XL)
2. Carvedilol CR (Coreg CR)
Which beta-blocker produces significant vasodilation due to the release of NO?
Nebivolol (Bystolic)
Which beta-blocker has LESS fatigue and sexual dysfunction than other anti-HTN agents?
Nebivolol (Bystolic)
True or False - smoking may decrease the effectiveness of beta-blockers?
True
What AE can beta-blockers have in diabetic patients?
beta-blockers can mask the symptoms of hypoglycemia (hunger, tremor, palpitations)
Exception is sweating, DM patients still sweat when hypoglycemic
In what (2) conditions are beta-blockers contraindicated?
- patients with 2nd/3rd degree heart block (HR <40, respectively
- patients with acute HF (unstable)
What parameters would you monitor when starting a patient with HTN on beta-blockers?
- HR
- BP
- AE
Which (2) beta-blockers should be avoided in patients with severe renal disease (CrCl ~15 ml/min)?
- Atenolol
2. Nadolol
What important drug interaction do beta-blockers have?
verapamil/diltiazem decreases HR and puts patient at risk of significant bradycardia, AV block
Which beta-blocker is indicated in pregnancy?
Labetolol
Which (2) beta-blockers are non-selective alpha-beta blockers with similar properties as other beta-blockers, but also has alpha-blockade which can produce orthostatic hypotension. They also may be safer in patients with peripheral vascular disease b/c unopposed alpha constriction does not occur?
- Labetolol (Trandate)
2. Carvedilol (Coreg)
True or False - in long standing HTN, damage to glomerular basement capillaries causes renal insufficiency (decreased GFR)?
True
Why would you expect a slight increase in SCr in a patient given an ACE-I/ARB?
ACE/ARB dilate the postglomerular efferent arteriole more than afferent resulting in reduction in glomerular capillary hydrostatic pressure and GFR, thus less SCr is filtered and more will be in blood
Name (3) ways ACE-I/ARB prevents remodeling of the heart?
- improves endothelial function
- promotes LVH regression
- collateral vessel development
True or False - ACE-I block the RAAS system?
True - that’s why they’re good in combination with a thiazide. Thiaizide may cause reflex response of increased renin from decrease in pressure, but ACE-I block this
What is the most common AE seen with ACE-I?
Cough - non-productive, dry, persistent cough (switch to ARB)
Name all monitoring parameters when giving patients ACE-I/ARB?
Baseline SCr, BUN, K+ (repeat labs within 1 wk of starting/adjusting meds)
angioedema, cough, BP every 2-4 weeks
What Tx should be given to patient with mild hyperkalemia (K+ 5.1-5.9)?
no specific therapy, just dietary education and D/C K+ supplement. monitor K+ weekly (or daily in inpatient)
Name the (3) contraindications associated with ACE-I/ARB?
- bilateral renal artery stenosis or renal artery stenosis to solitary kidney
- pregnancy
- Hx of angioedema
Name (5) ACE-I and starting doses. Be sure to include generic and brand
- Captopril (Capoten) 12.5mg/d BID
- Enalapril (Vasotec) 2.5mg/d daily
- Fosinopril (Monopril) 10mg/d
- Lisinopril (Prinivil) 5mg/d
- Ramipril (Altace) 2.5mg/d
Name (5) ARBs and starting dose. Be sure to include generic and brand
- Losartan (Cozzar) 50mg/d
- Candesartan (Atacand) 8mg/d
- Irbesartan (Avapro) 150mg/d
- Telmisartan (Micardis) 20mg/d
- Valsartan (Diovan) 80mg/d
True or False - you want to avoid K-sparing diuretics and NSAIDs/COX-2 b/c of hyperkalemia risk and inhibition of antihypertensive effects, respectively when giving patients ACE-I/ARB?
True
Name (1) renin inhibitor (generic and brand).
Aliskiren (Tekturna) - has similar SE profile as ACE-I/ARBs
Name (2) non-DHP CCBs with starting dose?
- Diltiazem SR 180 mg/d
2. Verapamil SR 120 mg/d
Name (3) DHP CCBs with starting dose?
- Nifedipine XL 30mg/d
- Amlodipine 2.5 mg/d
- Felodipine 5mg/d
True or False - Verapamil, Amlodipine, and Felodipine use in HF patients is ok for further control of BP after recommended 1st agents (ACE-I)
False - Verapamil causes a large decrease in cardiac contractility. Amlodipine and felodipine are ok for use in HF patients
Do non-DHP (verapamil and diltiazem) or the DHP (amlodipine, nefedipine, felodipine) cause more vasodilation?
DHP cause more vasodilation (may cause reflex tachycardia from too much vasodilation)
Which CCB is useful in ISH, angina, or stable coronary disease?
Nifedipine XL
Which CCBs are useful in diastolic dysfunction, a-fib, angina, atrial tachycardia?
Non-DHP (verapamil and diltiazem)
Which parameters would you monitor in patients taking CCBs? What would you want to counsel patient on?
- HR
- BP
- peripheral edema
Counsel on notifying PCP if they experience irregular heart beat, SOB, swelling of hands and feet, dizziness, constipation, and to swallow medicine whole, do not chew
Name (2) contraindications associated with CCBs?
- heart block
2. systolic heart failure (verapamil/diltiazem)
What (2) AE are associated with non-DHP CCBs (verapamil and diltiazem)?
- bradycardia
2. constipation
What (6) AE are associated with DHP CCBs?
flushing, HA, hypotension, dizziness, palpitations, peripheral edema
What medications can you give to treat peripheral edema AE seen in CCBs?
ACE-I/ARBs NOT DIURETICS b/c this edema is not associated with sodium and water retention
What course of action would you take if patient develops peripheral edema from CCBs?
decrease dose or D/C CCB OR add ACE-I/ARB
True or False - Nifedipine IR is not indicated for Tx of HTN and is associated with MI?
True - Nifedipine XL is used to Tx HTN
True or False - betablockers can increase the risk of bradycardia seen in non-DHP (verapamil and diltiazem)?
True
Which second line HTN agents are associated with post-traumatic stress disorder related nightmares and sleep disruption?
alpha-blockers
What is the main AE associated with alpha-blockers?
orthostatic hypotension
Name (3) alpha blockers and starting dose?
- Doxazosin (Cardura) 1mg at night
- Terazosin (Hytrin) 1mg at night
- Prazosin 2mg/d BID
What parameters would you monitor patients on alpha blockers? What would you want to counsel patients on?
BP and AE
Counsel on using caution when rising from sitting or lying, avoid driving for 12-24 hours after first dose, first dose syncope (fainting)
Name (3) central alpha-2 agonists that can be used as monotherapy for Tx of HTN? What is the most common complaint AE?
- Clonidine (Catapres)
- Methyldopa (used in pregnancy)
- Guanfacine
dry mouth
True or False - Clonidine can be used in HTN urgencies b/c of its rapid onset of action
True
What (2) major counseling points would you discuss with patient with HTN taking central alpha-2 agonists?
- dry mouth may occur
2. do not stop taking meds abruptly (rebound HTN)
Which (2) direct arterial vasodilators are very useful for resistant HTN?
- Hydralazine 20mg/d
2. Minoxidil 2.5mg/d
Which direct arterial vasodilator is good for patients with systolic HF intolerant of ACE-I/ARB in combination with nitrates?
Hydralazine
What is the chief AE is associated with Hydralazine? Minoxidil?
Hydralazine - SLE/Lupus
Minoxidil - hair growth
Why is it important to add beta blocker to patient taking direct arteriole vasodilators?
to manage reflex tachycardia caused by arteriole vasodilators (hydralazine/minoxidil)
What is the Tx for pre-clampsia (HTN with complications that can be life threatening for mother and fetus)?
Deliver baby immediately, treat mother with IV hydralazine and IV labetolol
This term is defined as BP that remains higher than goal value despite the use of 3 anti-HTN meds at doses that provide optimal benefit OR patients whose BP is CONTROLLED but need 4 meds to control?
Resistant HTN
What is the pharmacologic treatment for resistant HTN?
maximize diuretic therapy (maybe add spironolactone)
