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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
Q

CCB DHP adverse effects

A
  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
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26
Q

CCB NON-DHP adverse effects

A
  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
Q

CCB contraindications

A
  1. pregnancy/ lactation
  2. hepatic/ renal dysfunction
    amlodipine: hepatic clearance
    diltiazem: renal clearance
    verapamil, nifedipine: renal and hepatic clearance
28
Q

NON-DHP subclass contraindications:

A
  1. concomitant beta blocker
  2. cardiac conduction abnormalities: AV block
  3. Systolic heart failure/ LV dysfunction
29
Q

DHP contraindications

A
  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
Q

CCB drug interaction potential

A
  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
Q

Non first line medication classes:

A
  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
Q

Loop diuretic drug names

A

Furosemide
Torsemide
Bumetanide
Ethacrynic acid (no sulfa group)

33
Q

K+ sparing diuretics/ aldosterone antagonist drug names

A

Spironolactone
Eplerenone

34
Q

Beta blocker drug names

A
  1. non selective: propranolol, nadolol, pindolol, timolol
  2. B1 selective (BEAM): Bisoprolol, Esmolol, Acebutolol, Atenolol, Metoprolol
35
Q

Alpha- antagonist drug names

A

For HTN: Prazosin, Terazosin, Doxazosin
Not for HTN: Tamsulosin, Silodosin, Alfuzosin

36
Q

Central alpha-2 agonist drug names and uses

A

Clonidine (used for HTN emergencies/ urgencies)
Methyldopa: used in pregnancy
Guanfacine: low dose outpatient

37
Q

Direct vasodilator drug names and uses

A

Hydralazine: hair growth
Minoxidil

38
Q

Loop diuretics considerations

A
  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
Q

K+ sparing diuretics consideration

A
  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
Q

Diuretic metabolic serum electrolyte considerations

A

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
Q

Diuretic warnings

A

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
Q

Diuretic interaction potential

A

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
Q

Beta Blocker considerations

A
  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
Q

Beta blocker adverse effects

A
  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
Q

Beta Blocker adverse effects in DM

A
  1. Hyperglycemia (non-selective BB)
  2. Hypoglycemia (non-selective BB)
46
Q

Beta blocker warnings

A
  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
Q

Sympatholytics drug names

A

Central alpha-2 agonists: clonidine, methyldopa, guanfacine
Alpha-1 antagonists: prazosin, doxazosin, terazosin

48
Q

central alpha-2 agonist considerations

A

clonidine in HTN urgency/ last line resistant HTN
methyldopa: can be used in pregnancy but adverse effects on liver or anemia

49
Q

Central alpha-2 agonists adverse effects

A
  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
Q

Adverse Affects of Methyldopa:

A
  1. Systemic Lupus erythematosus
  2. Rare hemolytic anemia
  3. Hepatic Dysfunction
51
Q

Central Alpha-2 agonist warnings

A
  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
Q

Central Alpha-2 agonist interactions

A
  1. Abrupt discontinuation of clonidine with concomitant BB results in rebound HTN
  2. Bradycardia risk increased with other drugs that lower HR
53
Q

Alpha-1 antagonist considerations

A

No comorbid benefit for any disease state related to HTN
OK for symptomatic relief of BPH

54
Q

Direct Vasodilators adverse class effects

A
  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
Q

Hydralazine adverse effects

A
  1. common nausea, vomiting, diarrhea, anorexia
  2. rare hepatotoxicity, rare drug induced lupus, drug fever, leukopenia
56
Q

Minoxidil adverse effects

A
  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
Q

Direct vasodilator warnings

A
  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
Q

First line HTN drugs

A

ACE, ARB, Thiazide, CCB

59
Q

Heart Failure drugs for HTN

A

ACE, ARB, BB (first line), Diuretics

60
Q

DM drugs for HTN

61
Q

CKD drugs for HTN

62
Q

ACS drugs for HTN

A

BB, ACE, ARB

63
Q

Pregnancy drugs for HTN

A

Labetalol, Nifedipine, Hydralazine, Methyldopa

64
Q

African American HTN

A

Thiazides, CCB, ARB

Pharm (3 decks)

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