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HTN Flashcards

1
Q

Risks of high blood pressure

A
  1. increased morbidity and mortality from HTN mediated organ damage (HMOD)
  2. BP and TOD (every 20mmhg increase in SBP and 10 mmHG DBP 2x risk)
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2
Q

HMOD from HTN

A
  1. heart disease (CAD: angina, MI) (systolic heart failure) (LVH)
  2. brain disease (CVA, TIA, hemorrhagic stroke, dementia)
  3. PAD
  4. CKD
  5. eye disease (retinopathy)
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3
Q

Prescription induced causes of HTN

A
  1. Amphetamines: Ritalin, Adderall
  2. Corticosteroids: prednisone
  3. NSAIDS: ibuprofen, naproxen, high dose aspirin
  4. Estrogen-containing oral contraceptives
  5. Anabolic steroids: androgens/ test
  6. Calcineurin inhibitors: tacrolimus, cyclosporine
  7. SNRIs: venlafaxine (Effexor) or desvenlafaxine (Pristiq)
  8. Oral decongestants: pseudoephedrine, phenylephrine
  9. Abruptly stopping beta blocker therapy
  10. Abrupt central acting alpha-agonist therapy
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4
Q

Non-prescription drug induced causes of HTN

A
  1. Drug abuse: cocaine, nicotine, narcotic, PCP
  2. Dietary supps/ food:
    Sodium intake
    Ethanol intake
    Dietary supplements
    Tyramine-containing foods (wine, aged cheese)
    MOA inhibitors (antidepressants)
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5
Q

Dietary supplements that can lead to HTN

A

St johns wort; herbal ecstasy, bitter orange, guarana, kava, high dose licorice

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6
Q

First line medications

A

ACE (prils)
ARBS (sartans)
Thiazide diuretics
CCB: dhp (ipines), non-dhp (diltiazem, verapamil)

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7
Q

ACEs drug names

A
  • PRIL
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8
Q

ARBS drug names

A
  • sartan
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9
Q

Thiazide diuretic drug names

A

Hydrocholorothiazide
Chlorothiazide
Chlorothalidone
Indapamide
Metolazone

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10
Q

CCB drug names

A

DHP:
-dipine

non-DHP:
Verapamil
Diltiazem

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11
Q

Direct renin inhibitor drug name

A

Alskiren

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12
Q

DRI rationale

A

Other drugs affecting RAAS system cause compensatory increase in renin production

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13
Q

DRI side effects

A

hyperkalemia, hypotension

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14
Q

DRI treatment guidelines

A
  1. Avoid combination with DRI, ACE, ARB (dual RAAS blockage)
  2. minimal BP benefits in combination
  3. Significantly increased risk in combination (Scr, K+)
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15
Q

ACE side effects

A

hypotension, hyperkalemia, dry cough

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16
Q

ARB side effects

A

Hypotension, Hyperkalemia

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17
Q

ACE/ARB/DRI adverse effects

A
  1. dizziness/ hypotension (especially if hypovolemic
  2. Hyperkalemia
  3. Non-productive dry cough (ACE only)
  4. Increased SCr (limited rise <30% okay)
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18
Q

ACE/ARB/DRI very rare risks

A
  1. Hepatotoxicity
  2. Neutropenia
  3. Angioedema (increased in African Americans): ACE>ARB>DRI
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19
Q

ACE/ARB/DRI contraindications

A

Hypersensitivity, pregnancy, bilateral renal stenosis

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20
Q

ACE/ARB/DRI warnings/ precautions

A
  1. Avoid dual RAAS therapy
  2. Precautions:
    Volume depletion/ dehydration
    Pre-existing hyperkalemia
    Women of child bearing age
    Risk of acute renal injury
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21
Q

ACE/ARB/DRI drug interaction potential

A
  1. Any drugs with potential for hyperkalemia:
    K+ sparing diuretic
    aldosterone antagonist
    Dual RAAS
    Rx potassium supplements
    OTC salt substitutes (No salt, Nu salt)
  2. Diuretics: risk of dizziness/ hypotension
  3. Lithium: Li toxicity with concomitant ACE
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22
Q

ACE/ARB/DRI monitoring

A
  1. 1-2 weeks for initial impact, 4 weeks for full BP lowering impact
  2. Safety: Scr, K+ (BMP or CMP)
    acceptable: SCr < 30-35%
    unacceptable SCr> 30-35% (AKI)
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23
Q

Diuretics for HTN

A

Thiazide
Loop
K sparing/ Aldosterone antagonist

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24
Q

Thiazide drug considerations

A
  1. synergistic BP lowering with ACE, ARB, DRI or BB
  2. Metolazone: very potent , not used for HTN in general population
  3. avoid CrCl <30 ml/min
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25
CCB DHP adverse effects
1. dose related peripheral EDEMA (avoid in patients with heart failure 2. dose related headache 3. less common: dose-related dizziness/ orthostasis flushing, nausea/ anorexia, GERD, gingival hyperplasia reflex tachycardia
26
CCB NON-DHP adverse effects
1. Bradycardia 2. potential cardiac conduction abnormalities (AV block) 3. Systolic heart failure (negative inotropic effects) 4. Constipation (verapamil) 5. less common: nausea, GERD, headache, dizziness, flushing
27
CCB contraindications
1. pregnancy/ lactation 2. hepatic/ renal dysfunction amlodipine: hepatic clearance diltiazem: renal clearance verapamil, nifedipine: renal and hepatic clearance
28
NON-DHP subclass contraindications:
1. concomitant beta blocker 2. cardiac conduction abnormalities: AV block 3. Systolic heart failure/ LV dysfunction
29
DHP contraindications
1. short-acting/ immediate release nifedipine for HTN (lead to reflex tachycardia/ rebound HTN, increased risk of MI/CVA) 2. Nifedipine XL- avoid in systolic heart failure/ LV dysfunction 3. Migraines
30
CCB drug interaction potential
1. Avoid NON-DHP + beta blocker for HTN (risk of bradycardia/ AV block 2. major P450 interactions verapamil, diltiazem & nifedipine are 3A4 inhibs/ substrates: increase erythromycin, increase digoxin, interaction with simvastatin, should not ingest with >1L/day grapefruit juice
31
Non first line medication classes:
1. Loop diuretics 2. K+ sparing diuretics/ aldosterone antagonist 3. Beta blockers 4. Central alpha-2 agonist 5. Alpha- 1 antagonist 6. Direct vasodilators
32
Loop diuretic drug names
Furosemide Torsemide Bumetanide Ethacrynic acid (no sulfa group)
33
K+ sparing diuretics/ aldosterone antagonist drug names
Spironolactone Eplerenone
34
Beta blocker drug names
1. non selective: propranolol, nadolol, pindolol, timolol 2. B1 selective (BEAM): Bisoprolol, Esmolol, Acebutolol, Atenolol, Metoprolol
35
Alpha- antagonist drug names
For HTN: Prazosin, Terazosin, Doxazosin Not for HTN: Tamsulosin, Silodosin, Alfuzosin
36
Central alpha-2 agonist drug names and uses
Clonidine (used for HTN emergencies/ urgencies) Methyldopa: used in pregnancy Guanfacine: low dose outpatient
37
Direct vasodilator drug names and uses
Hydralazine: hair growth Minoxidil
38
Loop diuretics considerations
1. CKD with CrCl <30 ml/min: more effective than THZ for HTN population 2. Systolic heart failure: more effective than THZ with concomitant edema
39
K+ sparing diuretics consideration
1. Limit hypokalemia 2. Use in combo with THZ, weak Anti-hypertensive effect alone 3. Increased hyperkalemia risk with concomitant ACE,ARB,DRI 4. CrCL <50 ml/min Eplerenone: more expensive than spironolactone spironolactone: gynecomastia risk for men, effective add-on in resistant HTN
40
Diuretic metabolic serum electrolyte considerations
hyponatremia hypokalemia (loop> THZ) hyperkalemia (K+ sparing) hypomagnesemia (Loop> THZ) hypercalcemia (THZ) hypocalcemia (Loop) hyperuricemia (THZ>loop) hyperglycemia (high dose THZ or LOOP) hyperlipidemia (high dose THZ or LOOP)
41
Diuretic warnings
Anuria Ototoxicity: loop diuretics Dehydration (hypovolemia) Hypotension Electrolyte imbalance CKD hepatic disease gout (THZ > loop) hyperglycemia (high dose THZ or LOOP) hyperlipidemia (high dose THZ or LOOP) child bearing age/ lactation
42
Diuretic interaction potential
Anything that increases K levels (KCL, ACE,ARB,DRI,K sparing/ aldosterone antagonist) Digoxin (LOOP> THZ): increased toxicity/ arrhythmias lithium: toxicity Cholestyramine: 85% reduction of HCTZ absorption Eplerenone: hyperkalemia with grapefruit juice
43
Beta Blocker considerations
1. Inferior protection from HMOD vs 1st line anti-HTN 2. Not as protective when used as Monotherapy but do not increase CV events
44
Beta blocker adverse effects
1. Bradycardia 2. Exercise intolerance 3. Bronchospasm (risk with asthma/ COPD) - higher risk with non-selective or alpha/beta > cardioselective agent 4. hypotension and dizziness/ orthostatic hypotension (carvedilol/ labetalol w/c both work on A and B receptors) 5. Diarrhea- especially alpha/ beta blockers 6. Dyslipidemia- less impact with B1 selective, no impact w/ alpha beta 7. weight gain 8. erectile dysfunction 9. depression
45
Beta Blocker adverse effects in DM
1. Hyperglycemia (non-selective BB) 2. Hypoglycemia (non-selective BB)
46
Beta blocker warnings
1. avoid abrupt withdrawal (rebound HTN/ CAD exacerbation) 2. asthma/ COPD 3. Orthostatic hypotension 4. Bradycardia/ cardiac conduction abnormalities 5. PAD 6. Heart failure 7. uncontrolled DM 8. CKD 9. Hepatic disease (propranolol, metoprolol, carvedilol)
47
Sympatholytics drug names
Central alpha-2 agonists: clonidine, methyldopa, guanfacine Alpha-1 antagonists: prazosin, doxazosin, terazosin
48
central alpha-2 agonist considerations
clonidine in HTN urgency/ last line resistant HTN methyldopa: can be used in pregnancy but adverse effects on liver or anemia
49
Central alpha-2 agonists adverse effects
1. Sodium/ water retention 2. orthostatic hypotension/ dizziness 3. anticholinergic: sedation, dry-mouth, constipation, urinary retention, blurry vision 4. CNS depression: increase effects of alcohol, barbiturates, sedatives 5. bradycardia (consider any drugs that can cause AV block: nonDHP, CCB, BB, digoxin) 6. Headache 7. CNS stimulation: excitability/ restlessness 8. Erectile Dysfunction 9. Rebound HTN if not tapered off
50
Adverse Affects of Methyldopa:
1. Systemic Lupus erythematosus 2. Rare hemolytic anemia 3. Hepatic Dysfunction
51
Central Alpha-2 agonist warnings
1. Elderly 2. Heart Failure 3. renal impairment 4. Avoid abrupt withdrawal 5. Methyldopa: liver disease, use with diuretic therapy in non-pregnant patients
52
Central Alpha-2 agonist interactions
1. Abrupt discontinuation of clonidine with concomitant BB results in rebound HTN 2. Bradycardia risk increased with other drugs that lower HR
53
Alpha-1 antagonist considerations
No comorbid benefit for any disease state related to HTN OK for symptomatic relief of BPH
54
Direct Vasodilators adverse class effects
1. Na/ H2O retention: hypernatremia, edema, heart failure 2. Reflex tachycardia: palpitations, chest pain, angina, tachyarrhythmia 3. Headache 4. CNS depression 5. Hypotension, dizziness
55
Hydralazine adverse effects
1. common nausea, vomiting, diarrhea, anorexia 2. rare hepatotoxicity, rare drug induced lupus, drug fever, leukopenia
56
Minoxidil adverse effects
1. Black Box for pleural effusion that can lead to cardiac tamponade and angina pectoris exacerbation: only for HTN not responsive to maximum therapeutic doses of diuretic and 2 other HTN agents 2. reversible hypertrichosis/ hirsutism (rogaine)
57
Direct vasodilator warnings
1. Compensatory increased HR: should use with concomitant beta blocker, avoid with tachyarrhythmia 2. Compensatory increased sodium/ water retention: use with concomitant diuretic 3. Avoid if: Heart failure, recent MI/ angina, CNS depression, CVA/TIA, pregnancy or lactation, CKD
58
First line HTN drugs
ACE, ARB, Thiazide, CCB
59
Heart Failure drugs for HTN
ACE, ARB, BB (first line), Diuretics
60
DM drugs for HTN
ACE, ARB
61
CKD drugs for HTN
ACE, ARB
62
ACS drugs for HTN
BB, ACE, ARB
63
Pregnancy drugs for HTN
Labetalol, Nifedipine, Hydralazine, Methyldopa
64
African American HTN
Thiazides, CCB, ARB

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