HTN Flashcards
BP = SV x cardiac output
CO= stroke (blood) volume x HR
BP usually decreases at night and increases in early AM
BP readings for dx should be based on two separate readings on two separate occasions
normal bp
< 120 mmHg AND < 80 mmHg
elevated BP
120-129 mmHg AND < 80 mmHg
stage 1 HTN BP
130-139 mmHg OR 80-89 mmHg
stage 2 HTN BP
at least 140 mmHg OR at least 90 mmHg
lifestyle management of HTN
weight loss 1 kg of weight decreases by 1 mmHg
heart healthy diet (DASH, high fruit, fiber, and low fat dairy, veggies)
adequate potassium intake or supplementation (unless CI)
reduce sodium intake < 1500 mg daily
routine physical activity
limiting alcohol consumption
control BG and BP
make sure to use the bathroom before taking BP
drugs that increase BP
amphetamines and ADHD drugs
cocaine
decongestants
ESA’s
Immunosuppressants (ex: cyclosporine)
NSAIDs
systemic steroids
natural products for HTN
fish oil
coenzyme Q10
L-arginine
garlic
never combine ACEi and ARB
to minimize SE, we can add a second drug to a pts therapy before they reach max titration on their first drug
when do we initiate HTN therapy
if pt is in stage 2 OR
if pt is in stage 1 AND and all of the following: the clinical CVD (stroke, HF, or coronary artery disease) or 10 yr ascvd risk is at least 10%
BP goal for all pts
< 130/80 mmHg
initial therapy for black pts
Thiazide
DHP CCB
initial therapy for non black pts
thiazide
DHP CCB
ACEi or ARB
therapy for HTN pts with CKD
ACE or ARB helps slow progression of ESRD
therapy for HTN pt with diabetes with albuminuria
ACE or ARB
when should we initiate two first line drugs
when HTN stage 2 avg. SBP and DBP are > 20/10 mmHg above above goal (150/90 mmHg)
how often to monitor for HTN pts
check BP monthly and titrate meds to goal
avoid these HTN meds in pregnancy
ACE inhibitors
ARBS
Direct renin inhibitor (aliskiren)
all have boxed warning for fetal toxicity
pts at risk of preeclampsia (occurs after 20 wks= HTN and proteinuria)
- overweight
- renal disease
- DM
- HTN
low dose ASA recommended AFTER 1ST TRIMESTER to prevent
Pregnant pts w/ chronic HTN should receive HTN drug treatment when
SBP >/= 160 mmHg
DBP is >/= 105 mmHg
use labetolol AND nifedipine ER are first
Methyldopa is less effective but an option
bp goal for pregnant pts is 120-160 mmHg/80-110 mmHg
ACE Inhibitor/ARB + diuretic combos
lisinopril/HCTZ (zestoretic)
losartan/HCTZ (hyzaar)
olmesartan/HCTZ (Benicar HCT)
valsartan/HCTZ (Diovan HCT)
ACE Inhibitor/ARB + CCB combos
Benazepril/amlodipine (lotrel)
valsartan/amlodipine (exforge)
Beta blocker + diuretic combos
atenolol/Chlorthalidone (tenoretic)
bisoprolol/HCTZ (Ziac)
K+ sparing + thiazide type diuretic combo
Triamterene/HCTZ (Maxzide, Maxzide 25, Dyazide)
thiazide diuretic MOA
inhibit sodium reabsorption in distal convoluted tubules, so that sodium, chloride, and K+ are peed out more
chlorthalidone 12.5 -25 mg daily (max: 100 mg)
HCTZ (microzide) 12.5 - 50 mg daily (max: 100 mg)
take early in the day to avoid nocturia
chlorothiazide is IV
metolazone
indapamide
CI: sulfonamide hypersensitivity
warning: severe renal disease, progressive liver disease, can precipitate or exacerbate systemic lupus erythmatosus, gout, DM, or acute angle glaucoma.
NOT EFFECTIVE in CrCl < 30 ml/min (metolazone may work though)
Drug interactions:
they decrease lithium renal clearance and can increase risk of lithium toxicity (avoid with lithium products). also avoid with dofetilide serum concentrations because it could lead to an increased risk of QT prolongation
SE:
decreased K+, Na, Mg (may supplement with K+, or L+ rich foods)
increased Ca, UA, LDL< TG, and BG
photosensitivity
impotence (inability to achieve orgasm), dizziness, rash
monitor: BG in DM, electrolytes, renal fx, BP fluid status
NSAIDS cause sodium and water retention and can decrease effectiveness of HTN meds- avoid
long acting CCBs
nifedipine (DHP CCB) and
Diltiazem (non DHP CCB)
generic names of CCB’s end in “pine”
amlodipine (norvasc) 2.5 - 10 mg daily
nicardipine IV (cardene) 5 mg/hr
nifedipine ER (adalat CC, procardia XL) 30 -90 mg daily - IR form is procardia brand name
Contraindications: avoid nicardipine in advanced aortic stenosis
warnings: hypotension esp. in pts with severe aortic stenosis, worsening angina, MI, hepatic impairment, use with caution in HF
never use nifedipine IR for chronic HTN or acute BP reduction in non pregnant adults d/t profound HTN, MI, and death
SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia
Monitor: peripheral edema, BP, HR
Amlodipine safest if a CCB is needed in HFreF
nifedipine ER is drug of choice in pregnancy . it does leave a ghost tablet
DHP CCBs help prevent peripheral vasoconstriction in raynauds
clevidipine (cleviprex 1- 21 mg/hr) a few different facts: Contraindicated if allergic to soy beans, soy products or eggs, defective lipid emtabolism, or severe aortic stenosis . comes as a 20% lipid emulsion and gives 2 kcal/mL. milky white color. strict aseptic technique required, and max time after vial puncture is 12 hrs!!~**
warning for reflex tachycardia, infections, and hypotension
SE: hypertriglyceridemia, HA, atrial fibrillation, nausea
random: how many lipid calories in propofol
1.1 kcal/ml
non DHP CCBs
verapamil and diltiazem (cardiazem, tiazac)
verapamil (Calan SR, Verelan)
- used to control HR in certain arrhythmias, and help with HTN and angina by preventing Ca ions from entering vascular smooth muscle in heart, they help control tachycardia in afib
they have a negative inotropic effect (decreased force of ventricular contraction) and negative chronotropic effect decreases the HR
warnings: HF, bradycardia, hypotension, increased LFTs, use with caution with other drugs that decrease HR like BBs, diigoxin, clonidine, amiodarone, and dexmedetomidine (precedex), DO NOT USE WITH GRAPEFRUIT JUICE, these drugs are major substrates and inhibitors of CYP450. Also should decrease dose of simvastatin or lovastatin if using concurrently
SE: edema, constipation(more with verapamil), gingival hyperplasia, HA, dizziness
monitor: BP, HR, ECG, LFTs
IV: PO conversions are not 1:1
Angiotensin 2 causes vasoconstriction and increased release of aldosterone = sodium and water retention
RAAAS inhibitors inhibit the effect of angiotensin 2
these drugs are ACEi’s an ARBs’ and aliskiren which should never be used together bc of renal impairment , hypotension, and hyperkalemia
- all of these have increased risk of hyperkalemia. be mindful of other things contributing to hyperkalemia.
ACEi’s:
Acei’s block conversion of Angiotensin 1 to ang 2 and block degredation of bradykinin (reason for vasodilatory effects that contribute to cough
lisinopril (prinivil, zestril) 5-40 mg daily
benazapril (lotensin) 5- 40 mg daily
enalapril (vasotec, vasotec IV) 5-20 mg daily or BID
enaprilat (vasotec IV)
Quinapril (accupril)
Ramipril (altace)
once daily drugs can be used BID if needed
BOXED warning: injury/death to fetus, in 2nd and third trimesters.
Warning: fatal risk of angioedema - CI if history, bilateral renal artery stenosis (avoid use),
DO NOT USE IN PREGNANCY,
DO NOT USE w/in 36 hours of sacubitril/valsartan (entresto)
don’t use aliskiren in diabetes
SE: cough , hyperkalemia, increase Scr, hypotension/dizziness, HA
monitor
BP, K, renal function, s&sx of angioedema
ARBS moa - block ang 2 from binding to angiotensin type 2 and prevent vasoconstriction
same safety as acei’s
less cough than ACEi’s
less angioedema
no washout period required with entresto
warning: olmesartan : sprue like enteropathy, severe, chronic diarrhea, with substanial weight loss. - can occur months to years after starting.
irbesartan (avapro)
losartan (cozaar)
olmesartan (benicar)
valsartan (diovan)
azilsartan (edarbi) - this one needs to be kept in original container to protect from light.
direct renin inhibitor : aliskiren (tekturna)
by inhibiting renin, angiotensinogen doesnt convert to angiotensin 1
take with or without food, but be consistent with choice.
AVOID HIGH FAT FOODS.
same safety as acei’s
never use with acei’s or arb’s in DM patients.
Tekturna, tablets need to be protected from moisture
ACEi’s and arbs and diuretics decrease lithium renal clearance and increase risk of tox.
K sparing diuretics
often in combo with HCTZ to counteract K+ losses
they have minimal BP lowing effects
BOXED WARNING: on amiloride and triamterene: HYPERKALEMIA > 5.5 meq/l is more likely in pts with DM, renal impairment, or elderly
spironolactone (aldactone) 25 - 100 mg daily
Triamterene + HCTZ (dyazide, maxzide)
amiloride
eplerenone (inspra)
SE: hyperkalemia, increase SCr, dizziness,
spironolactone can cause gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
eplerenone increases TG’s, avoid it with strong CYp 3a4 inhibitors (clarithromycin, ritonavir, ketoconazole, itraconazole)
preferred add on drugs in resistant HTN
ARBs, spironolactone, and eplerenone
commonly used in HF
beta blockers aren’t recommended as 1st line for HTN unless pt has other condition that requires it.
ex: HF: carvedilol, metoprolol, or bisoprolol
MOA: decrease BP by blocking beta 1/2 adrenergic receptors, decreasing HR and heart contractility
carvedilol and labetolol - alpha 1 blockers (decrease peripheral vasoconstriction) and lower BP
if a pt has a lung condition/asthma disease we should do a beta 1 selective agent.
BETA 1 SELECTIVE AGENTS (AMEBBA)
atenolol (tenormin) 25-100 mg/day
esmolol (brevibloc) injection
metoprolol tartrate (lopressor, comes in IV and tab- take with food or immediately after eating)
metoprolol succinate (Toprol, toprol XL-take XL with food or immediately after eating) IR: 100-450 mg daily in divided doses, XL: 25-100 mg daily max: 400, can split XL dose in half
boxed warning: dont DC abruptly esp. if CAD or IHD, gradually taper over 1-2 weeks to avoid probs.
CI: severe bradycardia, 2nd or 3rd AV block or sinus syndrome (unless permanent pace maker is in place)overt HF or cardiogenic shock.
warning: caution with DM pts, can mask hypoglycemia and sx, or hyperglycemia
caution in bronchospastic pts
caution in raynauds/other peripheral diseases
SE: bradycardia
fatigue, hypotention, dizziness, impotense (less than thiazides), depression
monitor HR on BBs (decrease dose if HR < 55 bpm)
titrate doses every 1-2 weeks as tolerated
when switching from tartrate to succinate, use same daily dose
alpha receptors: vasoconstriction/contraction
(a1 - vasculature, a2 - brain and periphery)
beta receptors: vasodilation/bronchodilation
(b1 - heart, b2 - lungs)
Beta 1 selective drugs = AMEBBA to prevent lung issues
atenolol
metoprolol
esmolol
bisoprolol
betaxolol
acebutolol
can give anyone with copd/asthma these
nebivolol (bystolic) is a beta 1 selective blocker with nitric oxide dependent vasodilation
CI: severe liver impairment
SE: fatigue, nausea, increased TG, decreased HDL
NO causes peripheral vasodilation
non selective BB’s
propranolol (inderal LA, inderal XL)
nadolol (Corgard)
same safety as B1’s
propranolol is lipophilic and crosses BBB, leads to more CNS effects. useful for migraine prophylaxis.
also used in portal HTN
non selective BBs
carvedilol (coreg)
labetalol (PO or IV)
CI: severe hepatic impairment
warning: intraoperative floppy iris syndrome in pts previously treated on alpha 1 blocker
SE: edema, weight gain.
Take all forms of carvedilol with food. to decrease rate of absorption and risk of orthostatic HTN. dose conversions aren’t 1:1 (3.125 mg coreg BID = coreg CR 10 mg daily- CR has less bioavalability)
labetolols also causes SE: dizziness, fatigue, and nausea. This is the drug of choice in pregnancy. IV form common in hospital pts
beta blockers can decrease insulin secretion and cause hypperglycemia, but they can mask sx of hypo too, so monitor in DM
use BB’s in caution with other drugs that decrease HR - diltiazem, verapamil, digoxin, clonidine, amiodarone, and dexmedetomidine (precedex)
carvedilol, propranolol, metoprolol CYP 2D6 substrates
carvedilol and propranolol are inhibitors of pgp
centrally acting alpha 2 agonists act in the brain by reducing sympathetic outflow or NE which decreases DV and HR
clonidine (catapres, Catapress TTS patch) - 0.1-0.2 mg po BID, max is 2.4 mg day OR weekly patch TTS
clonidine is also called Kapvay when used for ADHD
guanfacine ER (intuniv) - for adhd
methyldopa
clonidine commonly used in resistant HTN and in pts who can’t swallow /dementia (patch)
CI: methyldopa and MAOi’s and active liver disease
warnings- dont DC abruptly, causes rebound HTN, sweating, anxiety, tremors, must taper gradually over 2-4 days
SE: dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, impotence, HA, depression, behavioral changes
clonidine patch can cause redness, rash, ithing
methyldopa can cause hypersensitivity reactions (Drug induced lupus eryth. (DILE), increased prolactin .preferred in pregnancy
Monitor bp, hr, mental status
clonidine patch should be removed before MRI.
Direct vasodilators
hydralazine and minoxidil
has direct effect on the arterioles and little effect on veins. results in a decreased SVR and decreased BP
hydralazine (PO or inj.)
PO:; 10-50 mg daily max 300 mg/day
IM, IV : 10 -20 mg q4-6 h prn
contraindicated in mitral valvular rheumatic disease (CAD)
warnings: DILE (drug induced lupus erythmatosus)
SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia, N/V
monitor HR, ANA titer, BP
minoxidil (topically this is rogaine, the men and womens otc hair product) 5-40 mg daily in 1 or 2 divided doses
boxed warning: potent antihypertensive , can cause pericardial effusion and angina exacerbations - give with beta blocker and loop diuretic
contraindicated in someone with pheochromocytoma.
SE: fluid retention, tachycardia, hair growth
alpha 1 blockers inhibit the alpha 1 receptor and cause peripheral vasodilation of arterioles and veins.
doxazosin
prazosin
terazosin
NOT RECOMMENDED FOR HTN. JUST FOR BPH + HTN
HTN crisis = BP > 180/120 mmHg
HTN emergency = acute organ damage evidence (tx w/ THREE IV MEDS) with goal of decreasing to 25% in ONE HOUR and in 2-6 hrs, goal : < 160/100 mmHg
IV HTN meds:
chlorthiazide, clevipine, diltiazem, enalaprilat, asmolol, hydralazine, labetolol, metoprolol tartrate, nicardipine, nitroglycerin
nitroprusside, propranolol, verapamil
HTN urgency = no evidence of acute organ damage treat with ORAL MEDICATION W/ SHORT ONSET (15-30 MIN like labetolol). Goal = BP decrease gradually over 1-2 days
take thiazides early in day (no later than 4 pm) to avoid nocturia
SE: sexual dysfunction, hyperglycemia, photosensitivity
NEVER ABRUPTLY DC BETA BLOCKERS!!! it can cause a heart attack because of the rapid rejuvenation of the agonist substrate
always caution in DM for signs of masking hypoglycemia and causing hyperglycemia
cause also cause sexual dysfunction
COREG (carvedilol) needs to be taken with food
lopressor (tartrate)/toprol XL (succinate ER) - take with food.
CCB
can cause peripheral edema
gingival hyperplasia
aladat (nifedipine) should be taken on empty stomach
aladat and procardia (nicardipine ER PO forms) both can leave ghost tabs in stool
ACEi, ARBs and aliskiren
should all be avoided in pregnancy
they cause angioedema
ACEi’s dry hacking cough
