Exam 6 lecture 3 Flashcards
direct vasodilator agents
Minoxidil, hydralazine
Direct vasodilators are reserved for pts with
Severe CKD/hemodialysis
Which is more potent direct vasodilator
Minoxidil
Can vasodilators be a monotherapy?
NO, concomitant use with BB or diuretic needed
frequency of minoxidil
1-3f
requency of hydralazine
2-4
adverse effects of direct vasodilators
Palpitations, tachycardia, chest pain, headache, GI side effects, fluid retention
Specific hydralazine adverse effects
Lupus (joint pain and generalized weakness)
Boxed warning for minoxidil
May cause pericarditis and pericardial effusion that may progress to tamponate
May increase )2 demand and exacerbate angina
A-1 blocker drugs
Doxasozin, Prazosin, Terazosin
all end with sin
side effects for a-1 blockers
Orthostatic HTN
Central a-2 agonist drugs
Clonidine, methyldopa, Guanfacine
last line due to adverse ffects
side effects of central a-2 agonist
CNS, depression, dizzinessm fatugue
which a-2 drug is the most preferred in pregnancy
Methyldopa
Which form of clonidine is preferred and why
Patch is preferred due to reduced risk of rebound HTN
How many times a day is methyldopa dosed
BID
How many times a day is guanfacine dosed
QD
what to monitor for BB
HR
monitoring parameters for ACE/ARB, Aldosterone antagonist
BUN/Scr/K+
What to do if patient is not at HTN goal
Consider switching to night time dosing for ACE/ARB/CCB
assess adherence
Educate on diet, exercise and smoking
Rule out white coat HTN
What is resistant HTN
Failure to attain BP goal while adherent to regimen that include atleast 3 agents at MAX doses or when 4 or more agents are needed to control it
STepwise treatment for tx reistant HTN
- Maximize LSM
Optimize 3 drug (ACE/ARB, CCB, thiazide) at max dose - if uncontrolled substitute optimized thiazide-like diuretics (chlorthalidone, indapamide) (stop hydrochlorothiazide and switch to these.
- Add mineralcorticoid receptor antagonist (spironolactone, eplerenone)
- Add BB if HR>70
Guanfacine at bedtime or clonidine patch if BB contraindicated (HR<70)
- Hydralazine
- minoxidil substitue for hydralizine
Goals for hypertensive emergency
Hour 1- reduce BP by a max of 25%
Hour 2- Reduce BP<160/100-110
hours 6-48- reduce BP to goal
What are the two types of hypertensive crisis
Urgency vs emergency
difference between hypertensive urgency vs emergency
urgency- Systolic BP>180 and or diastolic BP>120
no evidence of target organ damage.
Emergency- Systolic BP>180 and or diastolic >120
evidence of target organ damage
symptoms patients report with target organ damage
H/a
chest pain
SOB
back pain
nummbness/weakness
change in vision
speaking difficulty
do more people have hypertensive crisis or emergency?
60-75% crisis
Most common causes of hypertensive emergency
Non-adherence
others- Chronic HTN
MEdication/substance
pregnancy
renal disease
Is there a need for the ER for urgency? what about emergency?
Urgency- no need for ER
HTN emergency- send to ER
why should BP be lowered gradually
Risk for cerebral edema
WHat are some medications used in hypertensive emergencies
DHP CCBs
Vasodilators
BB
others
What is the gold standard for hypertensive emergencies
Nicardipine IV
CI of nicardipine IV
reflex tachycardia
aortic stenosis
What are the two DHP CCBs used in hypertensive emergencies
Nicardipine
Clevdipine
Clevdipine CI
Soy/egg allergies
Severe aortic stenosis
Vasodilators used in hypertensive emergenices
Nitroglycerin
SNP
Hydralazine
What type of hypertensive crisis patients have benefits for nitroglycerin
Coronary ischemia
What is something to note about nitroglycerin and SNP
Both cause tolerance in 24-48 hours
WHat B blockers should be used in hypertensive emergencies
Labetalol IV push
Esmolol
What are other drugs that can be used for hypertensive emergencies
Enalaprilat IV push
Clonidine oral
What drug used in hyoertensive emergency is most likely to cause bradycardia
B blockers
is hydralazine available as IV?
No
What drugs to use to treat Acute decompensated HF with pumlonary edema? What drugs to avoid
Nitrate class (nitroglycerin or nitroprusside)
Nicardipine and clevdipine are acceptable alternatives
Avoid BB and non DHP CCBs
How to treat Aortic dissection with hypertensive emergency
Initiate BB then vasodilator (nicardipine, clevdipine, Nitroprusside
How to treat acute coronary syndrome with hypertensive emergency
Esmolol, labetalol, nitroglycerin, nicradipine, SNP
Avoid BB if reduced HR (<60), heart block or airway disease
What drugs should we avoid in AKI
SNP and Enalaprilat
What BB does not cause a decrease in BP
Esmolol
If patient has hypertensive emergency and stroke how to treat
Nicardipine, clevdipine, labetalol
If patient has eclampsia /severe pre eclampsia how to treat
Hydralazine, labetalol, nicardipine
