Exam 2 Flashcards
1
Q
Why do we treat cholesterol?
A
Cholesterol = precursor to hormones LDL = leads to atherosclerosis; low density VLDL = very low density Apo B = linked to HDL Apo A = linked to LDL Non-HDL = inc number → inc risk of ASCVD
2
Q
Describe the CTT landmark lipid trial (purpose, result of cycle 1, and result of cycle 2)
A
-CTT = Cholesterol Tx Trialist
-Purpose = address uncertainties by developing meta-analyses to inc power of lipid trials
-Result of Cycle 1 = statins safe and improved CV outcomes; linear relationship b/w LDL lowering and CV outcome reduction
-Result of Cycle 2 = more intensive LDL lowering → better CV outcomes
-Each 39mg/dL dec ASCVD risk by 21%
-Each 1% dec in LDL results in about 1% dec in risk of ASCVD
—Moderate intensity = 30% dec ASCVD risk
—High intensity = 50% dec ASCVD risk
3
Q
SAMS abbreviation and assess symptoms (timeline, nature)
A
Statin associated muscle symptoms
Usually bilateral, proximal muscles
Onset weeks to months after starting therapy
Resolves with discontinuation
4
Q
Possible non-statin etiologies for muscle pain (5)
A
- Hypothyroidism
- Dec renal/hepatic fx
- Rheumatologic disorders
- Vitamin D deficiency (some studies show adding vitamin D makes pt more able to tolerate statin)
- Primary muscle disease
5
Q
If suspect myopathy/rhabdomyolysis
A
-Stop statin
-Check CK if severe SAMS and muscle weakness
-Assess for rhabdomyolysis
—CK >/= 10x ULN (men: 900; women: 700)
-Renal: inc SCr and/or inc UACR
-Can restart statin if rhabdomyolysis is reversible cause (drug interaction)
-Stop statin immediately if rhabdomyolysis is not reversible or can’t ID cause
If no reversible or identifiable cause, may need to stop statin indefinitely
6
Q
What to do if pt has pain with a statin?
A
If pain with one statin, try lower dose with same statin. If still in pain, try a different statin. If still in pain, switch off statin therapy
7
Q
SAMS management (what to do if you DON’T suspect myopathy or rhabdomyolysis)
A
-Stop statin
-Wait for SAMS to resolve
-Re-challenge with (select all that apply Q)
—Reduced dose of same statin
—Different statin
—Alternate dosing (intermittent)
-Monitor for re-emergence of SAMS
-Use max statin dose indicated and/or tolerated
-Moderate intensity statin + zetia may be alternative if high intensity statin isn’t tolerated
—And PCSK9 inh benefits those with familial Hyperlipidemia and ASCVD
8
Q
Statins hepatotoxicity measurements/symptoms
A
LFTs at baseline
Measure again if hepatotoxicity symptoms arise with statin use
- Unusual fatigue/weakness
- Loss of appetite
- Abdominal pain
- Dark colored urine
- Yellowing of skin/sclera
9
Q
Statin blood glucose effects
A
- Potent statins sometimes elevate BG
- Possible to get diabetes with statin use
- Several studies showed association —> led to FDA warning on statin label and generated discussion of risk vs benefit of statins in primary prevention
- JUPITER study (elaborate on different card)
10
Q
Elaborate on JUPITER study for statins/BG
A
-JUPITER study re-evaluated to say pts with at least 1 DM risk factor have a 28% inc risk of developing DM
—But benefit 39% dec in composite of MI, stroke, and hospital admin for unstable angina; and 17% dec in total mortality
—Equates to 134 vascular deaths avoided for 54 new cases of DM
11
Q
Diabetes risk factors
A
- African Americans, Hispanic, native Americans, Asian, Pacific Islander
- Family history
- Gestational DM
- Baby > 9 lbs
- PCOS
- HDL < 35 and/or TG > 250
12
Q
Statins/blood glucose: pts with no risk factors
A
- No inc risk of developing DM
- Statins produced 52% dec in MI, stroke, hospital admin for unstable angina; 22% dec in total mortality
- Equates to 86 vascular deaths avoided with no new DM cases
13
Q
What is considered ASCVD (select all that apply q)
A
Acute coronary syndrome (ACS) [recent = < 1 yr ago]
History of Myocardial infarction (MI, STEMI, NSTEMI)
Stable or unstable angina (SA or UA)
Stroke (CVA)
Peripheral Artery Disease (PAD)
Coronary/Arterial revascularization (stents)
Percutaneous transluminal coronary angioplasty (PTCA)
Coronary artery bypass graft (CABG)
Stroke or transient ischemia attack (TIA)
Peripheral arterial disease (PAD)
14
Q
ASCVD = leading cause of
A
morbidity and mortality globally
15
Q
Heart Dz in US
A
Leading cause of death in men and women
1 in every 4 deaths
Leading cause of death for most ethnicities (including AA, Hispanics, and whites)
Second to cancer in American Indians or Alaska Natives and Asians or Pacific Islanders
16
Q
Stroke in US
A
1 out of 20 deaths
Happens every 40 seconds, & someone dies from it every 4 mins
87% are ischemic
Leading cause of long-term disabilities
17
Q
ASCVD risk score calculator
A
Risk calculator developed by the NHLBI work group
Est the 10 year hard ASCVD risk of 1st event
Non-fatal MI, coronary heart disease death, fatal or non-fatal stroke
18
Q
who to use risk calculator in
A
Developed using data from large, racially and geographically diverse, NHLBI-sponsored studies
Best used in
Non-Hispanic caucasians and African Americans
Aged 40-79
Pts with LDL 70-189mg/dL
Overestimates risk in Hispanics and Asians
Underestimates risk in American Indians (puerto ricans and south Asians)
19
Q
what info is required to use ASCVD risk calc?
A
Age Sex Race Blood pressure Cholesterol panel DM: yes/no Smoker: yes/no On BP meds: y/n On statin: y/n On aspirin: y/n
20
Q
screening pts
A
Adults 20+ years old, measure either fasting or non-fasting
If non-fasting results show TG >/=400, repeat with fasting panel
If LDL <70, measure direct rather than using Friedewald equation
21
Q
Lifestyle management in hyperlipidemia
A
Try first and then with cholesterol-lowering drugs Adhere to a heart healthy diet Regular exercise (2.5 hours/week) Avoid ALL tobacco products Maintain healthy weight
22
Q
Heart healthy diet in hyperlipidemia
A
Emphasize fruits, veggies, and whole grains
Include low-fat dairy products, poultry, fish, legumes, non-tropical oils, and nuts
Limit intake of sweets, sugar-sweetened beverages, and red meats
Reduce % of calories from saturated (keep at 5-6%) and trans fat
Lower sodium intake (1500-2400 mg/day)
Follow DASH, USDA, or AHA dietary patterns & Mediterranean diet
23
Q
DASH
A
dietary approaches to stop HTN
24
Q
Exercise for dyslipidemia
A
2.5 hours/week or aerobic activity with moderate to vigorous intensity
Pt can build up this regimen if needed and exercise can be in 10 min increments
Examples
Brisk walking, swimming laps, raking leaves, dancing, heavy home cleaning
25
Approach to treatment
Guidelines say “if on max statin and LDL still > 100, adding Zetia may be reasonable”
26
Primary prevention
haven’t had an ASCVD event yet and trying to prevent it
LDL >/= 190
Diabetes
ASCVD risk elevation
27
secondary prevention
already had a heart attack/stroke and trying to prevent a second one
Clinical ASCVD
28
what are the 4 statin benefit groups?
Clinical ASCVD
LDL >/= 190mg/dL (Age >/= 20)
Diabetes (Age 40-75, LDL b/w 70-189 mg/dL)
ASCVD Risk Score elevation (age 40-75, LDL b/w 70-189 mg/dL)
29
Secondary ASCVD Prevention (for pts who already had ASCVD event) (3 broad groups w/n)
ASCVD + Not high risk Age = 75
ASCVD + Not high risk Age > 75
ASCVD + Very High Risk
30
ASCVD + Not high risk Age = 75
High-intensity statin
Goal: dec LDL by at least 50%
Threshold: LDL >/= 70; non-HDL >/= 100
If on max statin and not reaching threshold → initiate Zetia
If on statin + zetia and not reaching threshold → PCSK9-I
31
ASCVD + Not high risk Age > 75
Moderate-intensity statin or high-intensity statin
Goal: dec LDL by at least 30% (or 50%)
Threshold: LDL >/= 70; non-HDL >/= 100
32
ASCVD + Very High Risk
History of multiple (>/= 2) ASCVD events OR 1 major ASCVD + at least 2 high-risk conditions
High-intensity statin
Goal: dec LDL by at least 50%
Threshold: LDL >/= 70; non-HDL >/= 100
If on max statin and not reaching threshold → initiate Zetia
If on statin + zetia and not reaching threshold → PCSK9-I
33
Primary Severe Hypercholesterolemia (group)
LDL >/= 190
34
Risk Enhancing Factors
| REF
Premature family history of ASCVD
---= 55 male relative; = 65 female relative
Primary hypercholesterolemia
---LDL 160-189; Non HDL 190-219
Race/Ethnicity (ex: south asian)
Persistently High LDL (>/= 160)
Chronic Inflammatory conditions
---Lupus, HIV, RA, Psoriasis
Premature menopause and preg-associated condn that inc ASCVD risk
CKD
---eGFR < 60 ml/min, not on dialysis or kidney transplant
Metabolic syndrome (must have at least 3)
Persistent TG > 175 mg/dL
35
DM In adults (w/ LDL 70-189)
| 2 broad groups
DM 20-39yo
DM 40-75yo
36
DM 40-75yo w/ low ASCVD risk, and only 2 REF
Minimum of moderate intensity statin
37
DM 40-75yo
| ASCVD risk >/= 20% OR >/= 2 DM specific risk enhancing factors
high intensity statin (goal of 50% dec in LDL and Non-HDL >/=130)
If goal not met → Zetia if ASCVD risk at least 20%
Multi risk factors alone is not enough to initiate high-intensity statin in DM pts; must meet threshold of LDL at least 70.
38
DM 20-39yo
>/= 2 DM specific risk enhancing factors & LDL >/=70
| Moderate intensity statin
39
```
Primary Prevention (40-75yo w/o DM and with LDL >/= 70)
(4 broad groups)
```
ASCVD Risk <5% “low risk”
ASCVD Risk >/=5% but < 7.5% “borderline risk”
ASCVD Risk >/= 7.5% but < 20% “intermediate risk”
ASCVD Risk >/= 20% “high-risk”
40
ASCVD Risk <5% “low risk”
Lifestyle modifications
41
ASCVD Risk >/=5% but < 7.5% “borderline risk”
>/= 2 ASCVD risk enhancing factors
Consider moderate intensity statin
Borderline pts with <2 REF or pts opposed to statin tx → use CAC to guide decision and convince the pt
42
ASCVD Risk >/= 7.5% but < 20% “intermediate risk”
>/= 2 ASCVD risk enhancing factors
| Moderate-intensity statin
43
ASCVD Risk >/= 20% “high-risk”
High-intensity statin
44
Risk Factors for ASCVD
```
Age
>/= 45 men; >/= 55 women
Current Smoking
HTN
BP > 130/80 or use of antihypertensives
Diabetes
Sex (male > female)
```
45
Risk Enhancing Factors
| REF
Premature family history of ASCVD
= 55 male relative; = 65 female relative
Primary hypercholesterolemia
LDL 160-189
Non HDL 190-219
Race/Ethnicity (ex: south asian)
Persistently High LDL (>/= 160)
Chronic Inflammatory conditions
Lupus, HIV, RA, Psoriasis
Premature menopause and preg-associated condn that inc ASCVD risk
CKD
eGFR < 60 ml/min, not on dialysis or kidney transplant
Metabolic syndrome (must have at least 3)
46
Metabolic syndrome (must have at least 3 of the following)
Inc waist (men >/= 40inches; women >/= 35 inches)
TG >/= 150 mg/dL
Elevated BP >/= 130/85 or antiHTN therapy
Elevated blood glucose >/= 100mg/dL fasting or on tax
Low HDL = 40 mg/dL in men; = 50 mg/dL in women
---Can inc HDL with exercise
47
Lipid/biomarkers
| REF
```
Persistent TG > 175 mg/dL
hsCRP >/= 2mg/dL
Highly sensitive C reactive protein
Inflammatory marker
Lp(a) >/= 50mg/dL
ApoB >/=130mg/dL
Ankle brachial index (ABI) < 0.9
Compares BP between upper and lower limbs
```
48
Diabetes-Specific Risk Enhancing Factors
```
Long duration (>/= 10 yr for T2DM or >/= 20 yr for T1DM
eGFR < 60 ml/min
Albuminuria (>/= 30 mcg/mg)
ABI < 0.9
Retinopathy
Neuropathy
```
49
High-Risk Conditions
```
Age >/= 65
Heterozygous familial hypercholesterolemia
Hx of CABG or PCI
DM
HTN
CKD
Current smoking
Hx of HF
Persistently elevated LDL >/= 100mg/dL even with max statin & Zetia
```
50
Low-Intensity Statins
```
Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg
Pitavastatin 1mg
```
51
Moderate-Intensity Statins
```
Atorva 10-20mg
Rosuva 5-10mg
Simva 20-40mg
Prava 40-80mg
Lova 40mg
Fluva XL 80mg
Pitava 2-4mg
```
52
High-Intensity Statins
Atorva 40-80mg
| Rosuva 20-40mg
53
Atorva
Lipitor; 10,20,40,80mg
54
Rosuva
Crestor; 5, 10, 20, 40mg
55
Simva
Zocor; 5,10,20,40,80mg
56
Prava
Pravachol; 10,20,40,80mg
57
Fluva
Leschol/Leschol XL; 20,40mg (80mg XL)
58
Pitava
Livalo; 1,2,4mg
59
Lova
Mevacor; 10,20,40mg
60
CAC
(Coronary Artery Calcium)
Useful with pts reluctant to start tx and want more information to make informed choice
Concerned abt reinitiation of tx after dc due to ADE
Who are older with little risk burden (M 55-80; F 60-80)
With borderline risk and RF and REF to better inform tx decisions
61
CAC interpretation
0: withhold statin and reassess in 5-10yr
1-99: initiate statin in pts >/= 55yo
>/= 100 or 75th percentile: start statin
62
Pt with CI to high intensity statin or do not tolerate ADE
Go to moderate intensity statin or to whatever intensity is tolerated
If no statin is tolerated → add non-statin tx
63
Triglycerides classification
Normal <150
Moderate 150-499
Severe >/= 500
Don’t solely tx TG unless “severe”
64
Moderately elevated TG treatment (20+ years old)
Lifestyle (obesity; metabolic syndrome)
---Waist circumference: men > 40, women > 35
TG > 150; high BP, high BG, low HDL: men < 40, women < 50
Rule out secondary factors
65
secondary factors to rule out for elevated TG tx
DM
Chronic liver disease or CKD (ckd is GFR <60)
Hypothyroidism
Meds that inc TG
66
Moderately elevated TG treatment (40-75 yo)
All steps for >20 yo
If persistently elevated TG level and ASCVD risk >/= 7.5% when tested on 2 separate occasions (different appointments)
Then consider statin therapy
May intensify if TG stays elevated
67
Severely elevated TG treatment (40-75 yo)
All steps for moderate
**TG >/= 500 mg/dL, consider statin therapy (moderate) and can add fibrate but NOT bile acid sequestrant (bc they inc TG levels)**
68
TG >/=1000
really need to change diet (do all of the following)
```
Moderate statin
Very low fat diet
Avoid refined carbs and alcohol
Inc omega 3 FAs
*can initiate fenofibrate if needed to prevent pancreatitis (a risk when TG >/= 500)
```
69
Meds that can inc TG (13)
```
Oral estrogen
Tamoxifen
Raloxifene
Retinoids
Immunosuppressives
***Beta blockers (at high doses)***
Atypical antipsychotics
Protease inhibitors
***Glucocorticoids***
***BAS***
Cyclophosphamide
Interferons
***High dose thiazides***
```
70
Hyperlipidemia TX (list the 4 main points)
Monitor response
Safety
Monitoring for adverse
Patient education
71
Monitoring response of hyperlipidemia tx
Recheck lipid panel in 4-12 weeks after initiation or dose adjustments
How is adherence? Are they meeting goal? Are they achieving thresholds?
Then recheck lipid panel every 3-12 months if at/reaching goal
72
Statins Pt and provider discussion points (4)
Indications
Benefits
Risk of SAMS
Pt concerns and preferences
* *check CK at baseline in case of muscle complaints
* future appts: discuss adherence, statin response, reaffirm benefit, address any SAMS
73
SAMS (statin associated muscle symptoms?)
| 4
Myalgia (most common; subjective)
Myopathy
Myositis (rare)
Rhabdomyolysis (rare)
74
Rhabdomyolysis
Suspect if CK > 10 x ULN + signs of renal injury (inc SCr and inc UACR)
UACR: urine albumin to creatinine ratio
Pt complaints of severe muscle pain; usually in large muscle groups like thighs
75
other reasons CK gets elevated
Muscle cramps, injury, exercise
Baseline levels can be as high as 10x the ULN
NORMAL RANGE
Men: 25-90 IU/L
Women: 10-70 IU/L
76
Safety: statins and diabetes
-Evaluate for new-onset diabetes
-*Risk of diabetes not a contraindication to statin therapy; benefit outweighs the risk
-For people at risk for diabetes, recommend lifestyle modifications to prevent DM
Exercise
Healthy diet
Moderate weight loss*
77
Statins drug interactions
- Multiple CYP P450 interactions
- Most can be managed with mitigation strategy
- Be aware of what statin uses what P450 pathway
- DO NOT USE GEMFIBROZIL
78
Atorvastatin. List brand name, CYP and pt education
Lipitor; 3A4 (not as much as lova and simva); can take any time of day, avoid grapefruit juice; high intensity statin
79
Rosuvastatin. List brand name, CYP, and pt edu
Crestor; high intensity statin; 2C9; can take any time of day
80
Pitavastatin. List brand name, CYP, and pt edu
Livalo; 2C9 (minor 2C8); can take any time of day
81
Simvastatin. List brand name, CYP, and pt edu
- Zocor; 3A4; take at bedtime, avoid grapefruit juice
- Don’t use 80mg dose unless pt is already stable on it and not having ADEs (no new rxs for it bc so many ADEs)
- Max dose if giving with amiodarone or amlodipine or ranolazine is 20mg
No more than 10mg simva daily with verapamil and diltiazem
82
Lovastatin. List brand name, CYP, and pt edu
- Mevacor; 3A4; take at bedtime, avoid grapefruit juice
- Max dose with diltiazem, verapamil, Danazol, or amlodipine is 20mg lova
- max dose with amiodarone is 40mg lova
83
Pravastatin. List brand name, CYP, and pt edu
Pravachol; no CYP; take at bedtime
84
Fluvastatin. List brand name, CYP, and pt edu
Lescol; 2C9 (minor 2C8 & 3A4); take with evening meal
85
Niacin. What ya know about it?
-Nicotinic acid inc HDL and dec TG
-*Flushing from highest to lowest chance
IR > SR > ER*
-Titrate niacin doses slowly
-*Take 325mg enteric coated aspirin 30 min before taking niacin to minimize flushing*
-Tolerance to flushing will inc over time
-Take with food
-If miss a dose, just skip it
86
Niacin safety and monitoring
-Associated with hepatotoxicity (usually w/SR)
-Inc BG (watch in DM pts)
-Gout (esp big toe; too much uric acid)
-Monitor at baseline, up-titration, q6months
—LFTs
—Fasting BG or A1c
—Uric acid
-Don’t use if LFTs > 2-3x ULN (she will provide this info) or if persistent severe cutaneous symptoms, hyperglycemia, acute gout, unexplained ab pain/GI symptoms or if new onset of A-fib or weight loss
87
BAS basic info and dosing
-Can inc TGs
-Bind in GIT, trap cholesterol, and excrete it
-Colestipol (Colestid)
—5-20g (max 30g) [powder and tab]
-cholestyramine (Questran, Prevalite)
—4-16g (max 24g) [powder]
-colesevelam (Welchol)
—2.6-3.8g (max 4.4g) [powder and tab]
88
BAS pt edu
-Mix with non-carbonated beverages (juice, milk, water)
-Add drink to powder and drink immediately
-Drink before meals BID
-Drink a large glass of water with tablets
-Titrate dose to minimize side effects (should lessen over time)
-*Dose must be separated from other meds
—Take other meds 1 hr before or 4 hrs after (select all that apply Q)*
89
BAS ADEs and associated conditions
Associated with
- Pancreatitis
- GI upset
- Multiple drug interactions (absorption)
ADEs
-Constipation, abdominal pain, bloating, fullness, nausea, gas (less so with colesevelam)
90
BAS monitoring
-before starting, 4-6 weeks after starting, at 3 months, then every 6-12 months
—Fasting lipid panel
—*Don’t use if baseline TG >/= 300 mg/dL*
—Use with caution if TG 250-299
—Discontinue if TG > 400
91
CAI general comments, usual dose, and available preparations
- Zetia (add on therapy. Not first line)
- Generally well tolerated
- Usual daily dose: 10mg
- Available preparations: Zetia or Vytorin (combo with simva)
92
CAI monitoring, drug interactions, and ADEs
Monitor before starting and when clinically needed
- LFTs
- Discontinue if persistent ALT elevations >3x ULN
Drug interactions
-Gemfibrozil, cyclosporine, cholestyramine
Safety/ADEs
-No serious ADEs; arthralgia, diarrhea, possible gallstones (cholelithiasis)
93
Fibrates (meds, pt edu)
- Gemfibrozil (Lopid)
- Fenofibrate (Tricor)
- Generally well tolerated
-Pt education
-Not all fenofibrate formulations are bioequivalent
-LoFibra, original Tricor (54 or 160mg) and Lipofen
—Take with food
-New tricor (48 or 145mg), Antara, or gemfibrozil
—Without regard to food
-Triglide
—Without regard to food; no chipped/broken tabs
-Trilipix
—Without regard to food; indicated with statins
94
Fibrates monitoring
-Before starting, within 3 months, then q6months
-*MUST MAKE RENAL ADJUSTMENTS
SCr and eGFR
—Don’t use if eGFR < 30 mL/min
—Discontinue if eGFR dec persistently to = 30 mL/min
—If eGFR 30-59 mL/min, dose of fenofibrate shouldn’t exceed 54 mg/day*
95
Omega 3 FAs
-Lovaza (rx)
-Fish oil supplements
—*Dose: 2-4g EPA + DHA daily can dec TG by 35%
—Make sure dose is reached if taking OTC*
Associated with
- Fishy taste (refrigerate to minimize taste)
- GI disturbances
- Inc bleeding risk (minor)
Monitoring
-No labs required, confer with pts on side effects
96
Utilizing the Friedewald equation, calculate a patient’s LDL
Most cases, LDL is calculated not directly measured
* LDL = TC - [HDL + (TG/5)]*
- Equation is invalidated if TG >/= 400
*Non HDL = TC - HDL*
97
BP
amt of tension exerted by blood against the arterial walls measured in mmHg
Amt of force req for the heart to circulate the blood through the body
98
SBP
systolic; max blood pressure during ventricular systole (cardiac contraction)
99
DBP
minimal blood pressure in the vasculature at the end of diastole (cardiac relaxation)
100
Primary/Essential HTN
```
Unknown cause
No secondary cause IDed
Abt 90% of htn pts
Multifactorial
Genetics may play a role
```
101
Secondary HTN
```
Consequence of another disorder
Could be result of…
CKD**
Primary aldosteronism**
Obstructive sleep apnea**
Cushing’s syndrome
Aortic dissection
Pheochromocytoma
Pregnancy
Thyroid disease
drugs/substances
Sudafed, amphetamines, BC bills, NSAID, Sodium, alcohol, cyclosporine
```
102
White coat HTN
Ambulatory blood pressure monitoring (ABPM)
Records bp at preset intervals over 24-48 hr
Used to confirm/exclude white coat htn
103
types of HTN
```
Isolated systolic HTN (ISH)
Isolated diastolic HTN
Pulmonary htn
Pseudohypertension
Masked htn
white coat HTN
primary/secondary HTN
```
104
HTN Prevalence & Epidemiology
~33% of americans dx
Only about 54.4% of HTN pts at goal
Most common among AA, elderly, low socioeconomic classes
Normotensive adults >55 have 90% chance of developing htn in their lifetime
105
Normal BP & Tx options
<120 & <80
| Lifestyle modifications for prevention
106
Elevated BP & Tx options
120-129 & <80
| Lifestyle modifications
107
Stage 1 HTN & Tx options
130-139 or 80-89
| Antihypertensive + lifestyle if ASCVD risk >/= 10%
108
Stage 2 HTN & Tx options
>/= 140 or >/= 90
| Antihypertensives + lifestyle regardless of ASCVD risk
109
urgency/emergency BP
>/= 180 or >/= 120
110
Risk Factors for HTN
```
Race
Family history
Increased sodium or alcohol intake
Obesity & wt gain
Sedentary lifestyle
Diabetes
Dyslipidemia
Personality traits
Vit D deficiency
Smoking
Secondary factors: drugs
```
111
Complications of HTN
Major modifiable risk factor for premature CVD
Starting at 115/75 mmHg, CVD risk doubles with every 20 mmHg inc of SBP or every 10 mmHg inc in DBP
Strokes, headache, convulsion, elevated sugar lvl, hpertensive retinopathy, MI, HF, chronic renal failure
112
Dx of HTN
Not based on single elevated measurement; Avg of two or more properly measured readings taken at two or more visits used
113
Evaluation of HTN
```
Physical exam
Lab testing (Urinalysis, Lipid panel, TSH, EKG)
```
114
Goals of Tx for HTN
Reduce HTN associated morbidity & mortality
Dec: CVD, renal dz, MI/Stroke, HF
BP goal
<130/80
115
Lifestyle modifications HTN
Lower BP in ALL HTN/elevated BP pts
w/ normal bp: encourage following lifestyle modifications for prevention
Wt reduction, DASH, dec sodium intake, inc potassium, physical activity, moderation of alcohol consumption (1.5 oz liquor, 5 oz wine, 12 oz beer)
DASH: dietary approaches to stop HTN diet
= 2300 mg sodium to lower; = 1500 mg lowers further
=1500 mg sodium recommended for…
Pt with HTN, DM, CKD, AA, age 51+
116
Volume depleters (Diuretics) HTN
Thiazide & Thiazide-like
Loops
K+ sparing
Ald Antag
117
Thiazide & Thiazide-like HTN ADE
HCTZ, Chlorthalidone
Doses > 50 don’t show much more dec in BP but inc ADE
```
Electrolyte disturbances
Hyperuricemia (may precipitate gout)
Hyperglycemia, glucose intolerance
Sexual dysfx
Rare cross-reactivity with sulfa allergies
May inc lipids at higher doses
```
118
HTN: Thiazide and Thiazide-Like Monitoring & Pt Edu
```
Uric acid level (usually <6)
BG
Electrolytes
Lipids
GFR
```
EDU: Take in morning; Watch for cramps/muscle weakness
119
HCTZ (HTN)
(Microzide, Hydrodiuril) -- 12.5-25 mg / day
Does not work as well at eGFR < 30
120
Chlorthalidone
(Thalitone) -- 12.5-25 mg / day
Preferred over HCTZ
Works okay for eGFR > 10 (no adj req)
Longer t1/2
Proven dec in CVD risk
121
HTN: Thiazide and Thiazide-Like MOA
Inhib Na reabs in DCT → inc excretion of Na, H2O, and K
Dec SBP by 15-20 mmhg
Dec DBP by 5-10 mmhg
122
(HTN) Loops MOA
Block Na/K/Cl cotransport in thick ascending limb of loop of henle
Reserved for pts with co-existing renal insufficiency or HF (fluid overload)
Can push a loop until you get the diuresis you need BUT unlike thiazides, people don’t get used to loop diuresis
123
(HTN) loops ADE
Electrolyte disturbances (hypokalemia most often)
Watch for cramps/muscle weakness as sign
Only need to supplement K if pt is actually low
Hyperuricemia: may precipitate gout
124
Furosemide (loop, HTN)
(Lasix) 20-80 mg/day (divided doses)
125
Bumetanide (loop, HTN)
(Bumex) 0.5-4mg/day (divided doses) *40x more potent than furosemide*
126
Torsemide (loop, HTN)
(Demadex) 5-10mg/day
127
Loop (HTN) monitoring
Sulfa allergy
Electrolytes, esp K
Dehydration
128
Loop pt edu (HTN)
Take qam and early afternoon to avoid nocturnal diuresis (don’t recommend taking after 6pm)
Watch for cramps/muscle weakness
129
Potassium sparing diuretics (HTN) MOA
Block Na channels from late distal convoluted tubule to collecting duct
Dec intracellular Na —> K retention and dec Ca, Mg, and H excretion
Directly inh K secretion
130
When to use K sparing in HTN
If previous diuretic tx caused hypokalemia (counteracts K wasting with thiazides)
Triamterene/HCTZ (Maxzide/Dyazide) 37.5/25mg (both)
Maxzide 75/50mg
Dyazide 50/25mg
AVOID in pts with eGFR <45
131
Triamterene (k sparing, HTN)
(Dyrenium) 50-100mg/day
132
Amiloride (k sparing, HTN)
(Midamor) 5-10 mg/day
133
(HTN) K sparing ADEs
Electrolyte disturbances
Gynecomastia
Come back within 1 month to see if working/ADEs
134
K sparing monitoring parameters & pt edu (HTN)
```
Electrolytes
Renal function (eGFR <45)
```
edu:
Take in morning; avoid excessive K intake
135
Aldosterone antagonists MOA & ADE (HTN)
In distal renal tubules; inc NaCl and water excretion while conserving K and H ions
ADE: Electrolyte disturbances (hyperkalemia)
Gynecomastia (spironolactone)
136
Ald antag monitoring (HTN)
K, Na, renal fx
K should be <5 when starting therapy**
Bc K levels will inc so don’t want too high even before therapy starts
Not recommended with CrCL <30 mL/min in general population. Why?
Not going to work as well. If not clearing quicker, hold onto drug, inc risk of arrhythmias (get baseline K)
137
Ald antag pt edu (HTN)
Take qam; watch for cramps/muscle weakness
138
Spironolactone (ald antag, HTN)
(Aldactone) 50-200mg/day
139
Eplerenone (ald antag, HTN)
(Inspra) 25-100mg/day
140
Adrenergic inhibitors (HTN)
(Peripheral, central, alpha/beta receptors)
141
Betaxolol (HTN)
(Kerlone)
| cardioselective b-blocker
142
Bisoprolol(HTN)
(Zebeta) 2.5-10mg/day
| cardioselective b-blocker
143
Esmolol(HTN)
iv only
| cardioselective b-blocker
144
Acebutolol(HTN)
Sectral
| cardioselective b-blocker
145
Metoprolol(HTN)
(Lopressor, Toprol XL) 50-400mg/day
| cardioselective b-blocker
146
Atenolol(HTN)
(Tenormin) 25-100 mg/day
| cardioselective b-blocker
147
Nebivolol(HTN)
(Bystolic) 5-40 mg/day
| cardioselective b-blocker
148
B-blockers
-olol
149
Cardioselective B-blockers
MANBABE or BBEAMAN
betaxolol, bisoprolol, esmolol, acebutolol, metoprolol, atenolol, nebivolol
150
non-selective b blockers
nadolol, propranolol, timolol
151
Nadolol (HTN)
Corgard
152
Propranolol (HTN)
Inderal) 40-480 mg/day
153
Timolol (HTN)
(Blocadren)
154
beta & alpha 1 blockers
carvedilol & labetolol
155
Carvedilol (HTN)
(Coreg) 12.5-50mg/day
156
Labetalol (HTN)
(Trandate) 200-2400 mg/day
157
Beta blocker MOA HTN
Inh beta-adrenergic receptors —> dec CO and dec renin release —> dec peripheral vascular resistance
Dec HR/FOC/AV conduction rate
Not usually first line unless co-morbid conditions
Taper to discontinue
Bc up regulation —> reflex tachycardia
May mask signs of hypoglycemia (EXCEPT sweaty palms)
158
Beta blocker ADEs
| HTN
Bradycardia
Bronchial constriction (at high dose, even cardio selective do this bc lose selectivity)
Discontinuation syndromes (rebound tachycardia)
CNS fatigue/insomnia/depression/bizarre dreams
Sexual dysfunction (Not in Bystolic bc inc NO production)
Worsening depression
Weight gain
Exercise intolerance
159
Beta blocker cautions (HTN)
Bradycardia
Diabetics (tight glycemic control)
Asthma/COPD
Noncompliance
160
Beta blocker contraindications
| HTN
```
HR < 60bpm
SBP <90 mmHg
Severe asthma
Heart block
Acute decompensated HF
```
161
Beta blocker monitoring
| HTN
HR (want slower but not too much slower to where clots form and then it gets pumped somewhere and causes heart attack or stroke)
162
Beta blocker counseling points
| HTN
Pts with diabetes- monitor BG
| Compliance to avoid rebound HTN
163
Antihypertensive agents are almost equally _______, producing good antihypertensive response in ___ to ___ % of pts
Efficacious; 30-50%
164
Selection criteria for Tx for HTN
- Indication & Contraindications
| - Allergies, past medical history, comorbidities, pt preference, etc
165
If monotherapy is warranted in HTN in the absence of comorbidities, what are the preferred drugs to start with due to improved CV endpts?
- Thiazide-like diuretics, or DHP CCB (FIRST LINE)
| - ACEI/ARB are also acceptable for monotherapy
166
When is combo tx initially preferred? HTN
Stage 2 HTN
| ASCVD risk >/= 10%
167
What do you typically start with to treat HTN?
Thiazide or ACEI/ARB or DHP CCB (or a combo of these)
168
What do you typically start with to treat HTN in AAs?
Thiazide or DHP CCB
169
HTN Treatment initiation therapy dependent factors
```
CVD risk
Safety
Efficacy
Tolerability
Cost
Pt centered concerns
Degree of HTN lowering needed
```
170
HTN Tx initiation: general non-black population
Thiazide or DHP CCB or ACEI/ARB
171
HTN Tx initiation: general black population
Thiazide or DHP CCB
172
HTN Tx initiation: if BP >20/10 above goal
- Use combo therapy
- ACEI/ARB + DHP CCB (ACCOMPLISH trial)
- Thiazide + ACEI/ARB or DHP CCB
173
HTN w/o Compelling indications
Tx based on the degree of elevated BP
174
Stage 1 HTN (without compelling indications)
-Monotherapy
-Thiazide, ACEI/ARB, CCB (thiazide = most common)
—CCB and thiazide are equally best… use before ACEI/ARB
-IF AA → THIAZIDE OR CCB
175
Stage 2 HTN (without compelling indications)
-2-drug combo including a thiazide (Thiazide + ACEI/ARB/CCB)
-Doses should be titrated & addn drugs added until goal BP achieved
-Combo pdts used to dec pill burden & improve compliance
Ex: lisinopril/HCTZ, losartan/hctz, olmesartan/amlodipine
176
General HTN Tx Approach
- Initiate tx if BP > goal
- If monotherapy → thiazide or DHP CCB
- If two drugs → Thiazide & ACEI/ARB or Thiazide & CCB or CCB & ACEI/ARB
- If AA with combo tx → one needs to be DHP CCB or Thiazide → doesn’t have to be both though
177
HTN w/ Compelling Indications
-Amend initial tx in presence of underlying condn requiring specific antihypertensive agents independent of BP control
-Require certain antiHTN drug classes for high risk cond
—Drug selection for compelling indications is based on favorable outcomes from clinical trials
—Combination of agents may be required
178
HF (compelling indication w HTN ) (ACEI/ARB)
ACEI/ARB to inhibit cardiac remodeling → ACEI preferred over ARB
-If using ARB: valsartan, losartan, candesartan have best evidence for dec preload/afterload
179
HF (compelling indication w HTN ) (BB)
B-Blocker: monitor HR (<60bpm = too low)
| -Use CASH MONEY BILLIONAIRES only: metoprolol succinate (Toprol XL), Carvedilol, Bisprolol
180
HF (compelling indication w HTN ) (Other drugs besides ACE/ARB/BB)
-ALD antagonist: eplerenone or spironolactone
-Loops: for fluid overload → good with dec GFR; keep inc dose until fluid overload is dec, then dec dose while still in hosp
—Improves symptoms & exercise tolerance
—DOES NOT IMPROVE MORBIDITY AND MORTALITY
-Thiazides: not useful for monotx, but useful add-on for diuretic resistance
—Metolazone (good w/ low GFR for combo tx)
181
IN AA PT WITH HF (w HTN)
Bidil (isosorbide dinitrate/hydralazine) recommended
- Added to standard tx with b-blocker and ACEI in AA pt that is persistently symptomatic
- Also for pts who cannot tolerate ACEI/ARB
- Reduces mortality but to a lesser extent than ACEI
182
Stable Ischemic Heart Dz (compelling indications w HTN)
- B-blocker, ACEI/ARB, and thiazide have evidence for prevention of CV complications of HTN
- Choice of agent depends on… compelling indications, dz states, tolerability
- Can substitute long-acting non-DHP CCB (verapamil XR/diltiazem XR) for B-blocker to dec contractility & HR
- May add on DHP CCB in chronic stable angina → but not if on non-DHP already
183
Post MI therapy (Stable Ischemic Heart Dz; compelling indication)
-B-blockers → reduce reinfarction & sudden death
—Dec recurrence of CV events, improve O2 supply/demand ratio, most beneficial in first 3 yr
-ACEI → reduce risk of death, hospitalization, recurrent MI, progression to HF, inhib cardiac remodeling
-Can add DHP-CCB or ald antag
—Eplerenone if MI + HF
-Most common tx: B-Blocker, ACEI, + Statin post-MI
184
Diabetes (compelling indication w HTN) (what it causes)
- Most common cause of ESRD
- HTN is second most common cause of ESRD
- Intensive BP control in DM pt significantly reduces complications
185
TX of DM w/ HTN
-All first-line agents
-Usually start with ACEI/ARB → ACEI = some renal protection
—Decrease progression of diabetic nephropathy and reduce albuminuria
—MUST USE IF PT ALREADY HAS ALBUMINURIA
-RAAS Drugs & CCBS → improve and/or do not worsen insulin sensitivity
-B-Blocker → may worsen insulin sensitivity; can mask hypoglycemia symp
-Diuretics → hypokalemia & worsening glucose tolerance
186
CKD (compelling indication w HTN)
-CKD → eGFR <60; presence of albuminuria
-ACEI/ARBs (CKD w HTN)
—Limited rise in SCr
—Used in CKD pt with stable renal Fx
187
Secondary Stroke Prevention (compelling indication w HTN)
-Pt with stroke usually only med compliant for ~3mo
-AntiHTN tx reduce risk of stroke by 30-40%
-Ischemic stroke
—Considered form of HTN associated target-organ damage
188
First line monotherapy for Secondary Stroke Prevention (compelling indication w HTN)
ACEI/ARB or Thiazide
189
Combo tx for Secondary Stroke Prevention (compelling indication w HTN)
ACEI + thiazide preferred
Also okay → ACEI + CCB
190
When to treat HTN in pts with prior stroke but previously untreated for HTN
Do not start tx unless BP > 140/90
191
HF (compelling indication w HTN Tx summary)
ACEI/ARB + BBlocker
| If fluid overload → Loop → thiazide for resistance
192
Stable Ischemic Heart Dz (compelling indication w HTN Tx summary)
ACEI/ARB + BBlocker
193
DM (compelling indication w HTN Tx summary)
ACEI/ARB if albuminuria
| CCB, thiazide
194
CKD (compelling indication w HTN Tx summary)
ACEI/ARB
195
Secondary Stroke Prevention (compelling indication w HTN Tx summary)
ACEI/ARB and/or Thiazide
| Tx HTN if BP > 140/90
196
Pregnancy (in HTN)
| Define and list drugs
-Chronic HTN: high BP prior to pregnancy or diagnosed before 20th week gestation
-*If antiHTN taken prior to pregnancy, transition to methyldopa (DAVD), long acting nifedipine, hydralazine (DAVD), and/or labetalol
—All shown safe in pregnancy
—Do NOT use ACEI/ARB or direct renin inh*
197
Pregnancy in HTN recommendations (not specific drugs)
-*Recommend HTN tx if severe (SBP >/=160; diastolic >/= 110)
—Should dec risk of maternal stroke/pre-eclampsia
-Goal BP during pregnancy not clearly est
-Overall goal: minimize short term HTN risks to mother while avoiding potentially harmful therapy to fetus*
198
Older adults (in HTN) prevalence and drugs
-HTN prevalence inc with age
—65+ pt more likely to have CVD and renal insufficiency
—80+ significantly inc risk of isolated systolic hypertension
-ISH: thiazides or long acting DHP-CCB is first line
—Nifedipine preferred but most use amlodipine
—May also use ACEI/ARBs
—BB less efficacious as initial agents in elderly
199
Older adults (in HTN) ADEs and dosing
-Predisposed to orthostatic hypotension from volume depletion and sympathetic inhibition
—Usually initiate with DHP-CCB, with addition of ACEI/ARB or diuretic if needed
-*Lower starting doses and slower titrations to prevent ortho hypo*
200
Children and adolescents in HTN (facts)
-CANT USE INDAPAMIDE IN CHILDREN (18+ only)
-HTN defined as BP >95 percentile according to gender, age, and height on at least 3 occasions
—Secondary HTN (most commonly renal disease) is most common cause
—Essential HTN is second most common cause in children 11+ yo
201
Children and adolescents in HTN (tx)
-Start with lifestyle changes then drug therapy in essential HTN
-*drug therapy usually required for chronic secondary HTN
—Thiazide, ACEI/ARB, CCB are acceptable choices
—Avoid ACEI/ARBs in sexually active females
—Counsel on sexual side effects in younger male pts*
202
AA in HTN (basic facts and tx)
- Affected at higher rate and target-organ damage is more prevalent
- Inc need for combo therapy to reach BP goals
- *most effective: thiazides and DHP-CCBs as mono therapy (-ipines)*
- Combo of thiazide or CCB with ACEI/ARB/BB has significant inc antiHTN response
- Inc risk of angioedema and cough from ACEI
203
AntiHTN compliance
```
HTN is chronic asymptomatic disease
Monitor BP response
Question pts about how they take meds
Pill counts
Monitor freq of refills
```
204
How to improve HTN med compliance
Maintain pt contact
Keep med regimens simple and inexpensive
Dec BP slowly to dec adverse symptoms
205
AntiHTN pt edu
-Benefits and ADEs
-Awareness of normal and abnormal BP
-Consequences of uncontrolled BP
-Need for chronic therapy
—Meds control BP without curing disease
-Benefits of lifestyle modifications and setting realistic goals
206
PCP of HTN: collect
- Pt characteristics (age, race, sex, pregnant)
- Pt history (personal medical, family, social like eating habits/drinking/tobacco use)
- Home BP readings
- Current meds/any history of antiHTN use
- BP, HR, height, weight, BMI
- Electrolytes, SCr, BUN, lipid panel, glucose, ECG
207
PCP of HTN: assess
Compelling indications
HTN related complications
10 yr ASCVD risk if indicated
Current meds that may cause/worsen HTN
BP goal and if it’s been achieved
Is current antiHTN regimen appropriate and effective
For resistant HTN if taking 3 or more antiHTN meds
208
PCP of HTN: plan
-Tailored lifestyle modifications and weight mgmt
—Heart healthy diet; 150 min/wk of moderate to vigorous exercise
-Drug therapy regimen including specific antiHTN, dose, route, frequency, and duration; specify if need to continue/stop
-Monitor parameters including efficacy (BP, CV events, kidney health), safety (ADEs), timeframe
-Pt edu
-Self-monitoring BP, HR, weight- where and how to record
-Referrals to other providers if needed
209
PCP of HTN: Implement
- Provide pt edu regarding all elements of tx plan
- Use motivational interviewing and coaching to inc adherence
- Schedule follow up
210
PCP of HTN: monitor and evaluate
- Determine if reaching BP goal
- Presence of ADEs
- Occurrence of CV events and development/progression of kidney impairment
- Pt adherence to tx plan using multiple sources of info
211
Treatment of HTN crises (Define HTN crises)
- HTN crises: clinical syndromes when severe HTN results in irreversible end-organ damage or death over a short period of time if untreated
- Diagnosis of HTN crises: absolute BP measurement, rate of BP rise, and presence of coexisting complications
212
HTN urgency and emergency characterized by…
Very elevated BP (usually >180-120) with or without end-organ damage
213
HTN urgency
-Asymptomatic and no signs of target organ damage
-Give clonidine (or labetalol, captopril, furosemide) in office, then they can return to normal regimen; out-pt
—Adjust maintenance therapy or add therapy
-If BP >180/120 without evidence of progressive end-organ damage
-BP needs to be lowered in hours to days, but not immediately
—Initial goal: BP <160/100 over a few hours-days
—MAP shouldn’t be lowered by more than 25-30% over this time period
-Re-evaluate within 1-3 days; no longer than a week
214
List HTN urgency drug tx and ADEs (4 drugs)
Clonidine (go-to choice)
ADE: hypotension, drowsiness, dry mouth
Labetalol
ADE: bronchoconstriction; heart block, orthostatic hypotension
Captopril
ADE: hypotension, bilateral renal artery stenosis
Furosemide
ADE: hypokalemia
215
HTN emergency
-Has target organ damage; give IV drugs
-If BP >180/120 with end organ damage that’s either progressive or present at initial evaluation
—Requires immediate treatment in ICU
-Goal to dec and maintain diastolic BP 100-110 for 1-2 days
-Usually systolic BP should be dec gradually by no more than 25% within first hour
-If pt is stable, dec BP to <160/100 over 2-6 hours then gradually dec to goal over 24-48 hours
-Start oral therapy once goal is met
216
List HTN emergency drug tx and comments
Nicardipine; contraindicated in advanced aortic stenosis; no dose adj needed for elderly
Clevidipine; contraindicated in pts with soybean, soy product, EGG/egg products allergies and in pts with defective lipid metabolism. Use low end dose range for elderly
-Defective lipid metabolism: pathological Hyperlipidemia, lipoid nephrosis or acute pancreatitis
Esmolol; contraindicated in pts on BBs, have bradycardia, and/or decompensated HF (monitor for bradycardia; may worsen HF); higher doses may block B2 receptors and impact lung function in reactive airway disease
Labetalol; contraindicated in reactive airway disease or COPD; especially useful in hyper-adrenergic syndromes; may worsen HF and shouldn’t be given in pts with 2nd or 3rd degree heart block or bradycardia
217
Signs of end-organ damage
CV findings: left ventricular hypertrophy (LVH), possible acute HF, pulmonary edema
-Increased O2 consumption, detrimental to pts with coronary artery disease
GI findings: N/V
218
HTN crises goals of therapy
Lower BP at a safe rate
219
What are effects of overly aggressive dec in BP? (3)
Dec cerebral blood flow
-May lead to cerebral ischemia (leading to seizures, coma, stroke)
Dec in coronary perfusion
-Possibly leading to MIs or arrhythmias
Dec in renal blood flow
-May lead to renal impairment/failure
220
ARBs “sartans” Drugs and dosing (4)
Candesartan (Atacand) -- 8-32 mg/day -- daily
Olmesartan (Benicar) -- 20-40 mg/day -- daily
Valsartan (Diovan) -- 80-320 mg/day -- daily
Losartan (Cozaar) -- 50-100 mg/day -- daily BID
221
ARB MOA and ACEI indications for switching
-Inhib AT1R & venous dilation
- Alt tx for pts with ACEI cough or if they are not tolerated
- Cross-reactivity in ACEI angioedema is < 10% so still an option
- Cut starting dose in half if given with diuretic
222
ARB ADEs
Angioedema, hyperkalemia, <3% cough, renal dysfx
223
ARB contraindications
-Same as ACEI
-Absolute CI
—Pregnancy (2nd & 3rd trimesters)
—Angioedema
—Bilateral renal artery stenosis
-Relative CI
—Cough, hyperkalemia, volume depletion, unstable renal fx
224
ARB monitoring
```
Same as ACEI
BP
Electrolytes
SCr
HR
BUN
Baseline LFT
```
225
Alpha-1 blockers (HTN)
-zosins
226
Doxazosin (HTN)
(Cardura) 1-16 mg/day
| Alpha-1 blockers
227
Prazosin (HTN)
(Minipress) 2-30 mg/day
Also used to treat PTSD nightmares
Can cause unwanted erections
Alpha-1 blockers
228
Terazosin (HTN)
(Hytrin) 1-20 mg/day
| Alpha-1 blockers
229
Alpha1 blockers MOA
| HTN
Block activation of postsynaptic a1 receptors by circulating catecholamines —> vasodilation
Usually for pts with HTN and BPH (benign prostatic hyperplasia)
230
Alpha1 blockers ADEs
| HTN
****First dose syncope
Temporary loss of consciousness from fall in BP
Tell pt to stand slowly to dec risk of orthostatic hypotension
Caution: fall risk in elderly****
Headache
Drowsiness
Fatigue
Weakness
231
Alpha-2 agonists MOA
| HTN
Stimulate a2 receptors in brain —> inh release of NE centrally —> dec sympathetic outflow and inc vagal tone —> vasodilation —> dec HR, CO, systemic vascular resistance, and plasma renin activity
Most effective w/diuretic to dec fluid retention
**use with caution in elderly
232
Clonidine (Alpha-2 agonists HTN)
Catapres, 0.1-2.4 mg/day
233
Methyldopa (Alpha-2 agonists HTN)
(Aldomet) 250-3000 mg/day
234
Clonidine: DOA, uses
| HTN
```
DOA: 6-8 hrs (relatively short)
Dosed BID or TID
Should NOT be given once daily at night
Potentially would rebound HTN in the morning
Good at lowering BP and doing it quickly
Also given for ADHD
Good for refractory HTN
Not recommended in pregnancy
```
235
Clonidine ADE HTN
Sedation
Dry mouth
Rebound HTN
Patch: skin irritation
236
Methyldopa: ADEs
| in HTN
```
One of safest drugs in pregnancy
Side effects usually make clonidine better choice unless pregnant
Somnolence (drowsiness)
Postural hypotension
Hemolytic anemia
Positive antinuclear antibodies
Fever
Liver dysfunction
```
237
Vasodilators in HTN
direct vasodilators, CCB, ACEI, ARBs, Direct Renin Inhibitors
238
Direct vasodilators MOA HTN
Smooth muscle relaxation for vasodilation
Saved for special conditions
Particularly pts with CKD who need additional BP control
239
DAVD ADEs HTN
```
Headache
Tachycardia
Lupus-like syndrome (hydralazine)
Fluid retention (Minoxidil black box warning: max out a diuretic and 2 other antiHTN first)
Hirsutism (minoxidil)
```
240
Hydralazine
(Apresoline) 10-300 mg/day
| DAVD
241
Minoxidil
(Loniten) 5-100 mg/day
| DAVD
242
CCB for HTN classes
DHPs (ipines) & Non-DHPs
243
DHP CCB for HTN monitoring
Less effect on HR than non-DHPs
Monitoring
HR, Edema, LFTs (since hepatic elim)
244
Amlodipine
(Norvasc) -- 2.5-10 mg/day
| DHP CCB
245
Nifedipine LA
(Procardia XL, Adalat CC) -- 60-120 mg/day
| DHP CCB
246
Clevidipine
IV only
| DHP CCB
247
Which DHPs are first gen, second gen, and third gen?
1st gen: nifedipine
2nd gen: isradipine, nicardipine, felodipine
3rd gen: amlodipine
248
Non-DHPs MOA for HTN
Less peripheral and coronary arteriolar vasodilation, mostly neg inotropic and chronotropic effects (prefer XR in HTN tx)
Given more for arrhythmia and angina than in DHPs
Verapamil > diltiazem
Not first line therapy for HTN
May reduce proteinuria in pts with CKD
249
Which non-DHP is a phenylalkylamine? A benzothiazepine?
Phenylalkylamine: verapamil
Benzothiazepine: diltiazem
250
What are the cardiac and vascular effects of non-DHPs?
Cardiac: dec contractility, dec HR, dec conduction velocity
Vascular: relax smooth muscle
251
Verapamil
nonDHP CCB
| (Verelan, Calandras): 120-480 mg/day
252
Diltiazem
(Cardizem, Cartia, Taztia): 180-360 mg/day
| NonDHP CCB
253
Non-DHP contraindications
2nd and 3rd degree heart block
Cardiogenic shock
Acute MI (diltiazem)
Systolic heart failure
254
CCB ADEs htn
```
Bradycardia
Tachycardia (nifedipine)
Heart failure exacerbation
Constipation (mainly in verapamil)
Peripheral edema (esp Amlodipine 10)
Gingival hyperplasia (swollen gums)
AV node block
Hypotension (postural; get up slow)
Reflex tachycardia (mostly nifedipine)
Headache & Flushing (esp nifedipine from inc vasodilation)
GERD
Fatigue
```
255
CCB monitoring in HTN
HR
BP
EKG
LFTs
256
What is not a counseling point for pt recently started on chlorthalidone?
May dec BG in diabetes (wrong bc CAN impact BG)
257
Which condition is NOT a common side effect of nifedipine?
Constipation (more common in verapamil)
258
ACEI useful in what comorbid conditions w HTN
HF
High CVD risk
Diabetic pts
259
how to change start dose of ACEI in pt with HTN and taking diuretic
cut starting dose in ½
| Start low and titrate up
260
ACEI MOA (HTN)
Inhib ACE from converting ang I to ang II → vasodilation
261
Benazepril
(Lotensin) -- 10-40mg/day -- daily BID
| ACEI
262
Captopril
(Capoten) -- 12.5-150 mg/day -- daily BID
| ACEI
263
Enalapril
(Vasotec) -- 5-40mg/day -- daily BID
| ACEI
264
Lisinopril
Prinivil, Zestril) -- 10-40mg/day -- daily
| ACEI
265
Contraindications for ACEI use in HTN
Absolute CI
Pregnancy (2nd & 3rd trimesters)
Angioedema
Bilateral renal artery stenosis
Relative CI
Cough, hyperkalemia, volume depletion, unstable renal fx
266
ACEI monitoring in HTN
```
BP
Electrolytes
SCr
HR
BUN
Baseline LFT
```
267
Direct renin inh drug and MOA
Aliskiren (Tekturna) 150-300mg/day
Inh conversion of Ang I to Ang II by directly inh plasma renin activity
*CYP3A4 substrate so watch for drug interactions*
268
Direct Renin inh ADEs
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Cough
Hyperkalemia
Elevated CK (muscle pain)
Dizziness
Diarrhea
Angioedema (switch pt off of all drugs that affect RAAS pathway)
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269
Direct Renin inh contraindications
Pregnancy
| Taking other ACE-I or ARBs in diabetics
270
Direct renin inh monitoring
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K
Renal function (BUN, SCr)
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271
Direct renin inh pt edu
Admin at same time every day consistent with regards to meals
High fat meal reduces abs
Renin inh have been reported to cause bradycardia but don’t know MOA
272
What is a more common side effect of aliskiren?
Diarrhea
273
What are effects of blocking the response to beta-adrenergic stimulation?
Inc central sympathetic output
274
Hypokalemia is NOT a possible ADE in which diuretic?
Eplerenone
