HTN Flashcards
What is HTN?
Elevation in pressure from normal
What is systolic vs diastolic?
Cardiac contraction and after contraction when the cardiac chambers are filling
What is MAP? Who do you calculate it?
Average pressure throughout cardiac cycle of contraction
MAP=1/3 SBP + 2/3 DBP
MAP= CO x PVR
CO=HR x SV
How does increasing CO lead to high BP?
How does increasing PVR lead to high BP?
What are the infrarenals of the RAAS?
- Renal purfusion pressure
- Catecholamines
- Angiotensin II
What are the extrarenals of RAAS?
Na+, K+, Cl-
Describe the presynaptic regulations of HTN?
Describe the postsynaptic regulations of HTN?
Describe the endothelial mechanisms?
Vasodilating substances → prostacyclin, bradykinin, nitric oxide
Vasoconstricting substances → angiotensin IIand endothelin I
What are the consequences of HTN?
- Stroke
- MI
- HF
- Angina
- Vision loss
- Kidney failure
What are some modifiable risk factors?
- Smoking
- DM
- Obesity/Physical inactivity
- DIet
- High cholesterol
What is normotensive?
What is elevated BP?
What is Stage 1 BP?
What is Stage 2 BP?
What is HTN crisis number?
What is essentinal HTN?
No underlying cause
What is secondary HTN?
Identifiable cause
What is resistant HTN?
≥130/80 mm Hg with concurrent use of 3 antiHTN meds of different classes
What is masked HTN?
Elevated BP at home despite office BP lower than 140/90
What is white coat HTN?
Normal BP at home but elevated in office
What are the environmental causes of essential HTN?
- Obesity
- Sodium intake
- Potassium intake
- PE
- Alcohol intake
What are common causes of secondary HTN?
- Renal disease
- Renovascular disease
- Aldosteronism
- Obstructive sleep apnea
- Drugs or alcohol
What are some med that can cause elevated BP?
- Alcohol
- Amphetamines
- Antidepressants
- Caffeine
- Decongestants
- Oral contraceptives
- NSAIDs
- Recreational drugs
- Systemic corticosteroids
What are the clinical presentations of HTN?
- Asymptomatic
- Elevated BP
- Require 2 or more measurements taken during 2 or more clinical encounters is required for diagnose
What are the clinical evals of HTN?
- Comprehensive med hisotry
- Physical examination
- Laba and diagnostics
What are the goals of evaluation?
- Identify secondary causes
- Identify CV risks and cormorbidity
- Assess for the presence or absence of HTN associated complications
What are some historical features to be aware of in primary HTN? Secondary?
P: Lifestyle factors, family history
S: Obstructive sleep apnea, weight
What are goals for HTN according to ACC/AHA? Alone? DM? CKD? Elderly?
What are the ACC/AHA goals of HTN? Why is it not used as often?
- Each patient is unique
- Balance benefit and harm
Insurance don’t abide by it
What is the purpose of trials of HTN?
Reducing morbidity and mortality of disease states and medications
What is the algorithm for normal BP?
What is the algorithm for elevated BP?
What is the algorithm for stage 1 HTN?
What is the algorithm for stage 2 HTN?
What needs to be considered when someone reaches stage 2?
2 antiHTN of different classes
Those ≥160/100 should be treated promptly
What are some non-pharm strategies for HTN?
- Weightloss
- DASH
- Sodium reduction
- Potassium supplements
- Increased physical activity
- Reduction in alcohol consumption
What are the weight loss goals?
IBW, expect about 1 mmHg for every 1 kg reduction in body weight (max: 5)
What consists of the DASH diet?
fruits, veggies, whole grains, low-fat dairy
What is the goal for Na+ intake?
<1500 mg/d
What is the goal for potassium supplements?
3500-5000 mg/d
What is the alcohol intake rec?
Men: ≤2
Women: ≤1
Who would respond more to sodium reduction?
- Blacks
- Older people
Most fast foods are processed and have high sodium
What are strategies for reducing sodium?
- Fresh foods
- Use food labels
- Sub
- Control
How do you calculate heart rate reserve?
Max HR- resting HR
Usually 220-age
What are the types of physical activity?
Aerobic
Dynamic resistance
Isometric resistance
What is aerobic?
Brisk walking, swimming, rowing, jumping rope, cycling, running
What is dynamic resistance?
Concentric and eccentric contractions (joint movement)
Bicep curls, tricep dip, squats
What is isometric resistance?
Contracting a muscle for a prescribed amount of time
Planking, wall sit
What is considered a standard drink?
12 fl oz (beer) = 1.5 fl ox (double shot) = 5 fl oz (wine)
What are alternative strategies for HTN (limited evidence)?
- Probiotics
- Increased protein and fiber
- Ca2+ supplements
What is 1st line diuretic for HTN?
Thiazides
What are the adrenergic HTN drugs?
- Non selective a atangonist
- alpha 1 blocker
- beta blockers
- centrally acting
What are the vasodilators for HTN?
CCB
Direct acting VD
K+ channel openers
What is the initial med for non-black?
- TZD
- CCB (DHP)
- ACEI
- ARB
What is the initial med for blacks?
TZD or CCB
How do we decide med for basic HTN patients?
What is the MOA of thiazides?
- Inhibit reabsorption of Na+ in the DCT
- Increases the excretion of sodium and water and potassium
What are the thiazides used for HTN?
- Chlorthalidone (stronger and higher efficacy)
- HCTZ
- Indapamide
- Metolazone (not really used)
What are some pearls to know about TZD?
- first line of HTN
- PO QAM to avoid nocturnal diuresis
- May worsen gout
- Decreased efficacy withCrCl <30mL/min
- Sulfonamide allergy
What is the MOA of CCB? what the difference between the two classes?
Blocks inward flow of Ca2+ through L channels of arterial smooth muscle
DHP: dilate arteries not veins
Non-DHP: reduce HR and contractility, not used for HTN
What are some pearls for DHP?
- Peripheral edema on arterial and increased venous pressure → edema
- Nifedipine may cause yo-yoing
- Avoid use in patients with patients with HFrEF (amlodipine or felodipine)
- Potent peripheral VD
What are some Non-DHP pearls?
- ER products for HTN (not commonly used)
- Avoid use in HFrEF
- Avoid with beta blockers
- For arterial tachyarrhythmia
- CYP3A4 substrates and moderate inhibitors DDI
What are the DHP drugs?
What are the nonDHP?
What is the MOA of ACEI?
- Block the conversion of angiotensin II
- Increase bradykinin blocking breakdown
Coughing, angioedema
ACEI drugs?
ACEi Pearls?
- Strong rec for: stroke, CAD, HF, CKD, DM, albuminuria
- Reduce proteinuria
- DDI with ARB or renin inhibitor
- Hyperkalemia
- Angioedema
- Fetal toxicity
- Reduce dose 50% who are on diuretic or elderly
- Reno-protective
What is the MOA of ARBS?
Blocks angiotensin II receptor (AT1) → vasodilation
Types of ARBs?
ARB pearls?
- No increased production of BK
- DDI with renin inhibitors and ACEis?
- hyperkalemia
- Risk for AKI
- Angioedema
- Fetal toxicity
- Reduce dose 50% who are on diuretic or elderly
What need to be considered in black patients with HTN?
- Most require ≥2 AHTN med to achieve BP control
- TZD and CCBs are more effective
- ACEi are less effective and higher risk of angioedema
What are some thing to be aware of for HTN geriatrics?
Less intensive BP control
High burden of comorbidity and limited life expectancy
TZD and geriatrics?
Increased SIADH (electrolyte abnormalities)
CCB and geriatrics?
Greater hypotensive response
Constipation
No CNS effect
ACEis and getriatrics?
Favorable side effect profiles, hyperkalemia
Beta blockers and geriatrics?
Less hemodynamic response and more bradycardia
What are some thing to be aware of for HTN pregnancies?
- BP decline 1st trimester than slowly rises
- ARB and ACEi are fetotoxic
- Nifedipine, labetalol, methyldopa, hydralazine
- Preeclampsia are risk facotrs
What are comorbidities of HTN?
- Stable ischemic heart disease
- A fib
- HF
- PAD
- CKD
- DM
- CVD
- Metabolic syndrome
HTN treatment for stable ischemic heart disease?
GDMT w/ beta blocker (not for HTN but for disease state)
What is the guideline for HFrEF?
Find optimal regimen for HF not HTN
ACEi or ARB, ARNI, MCR antagonists, diuretics, GDMT beta blockers
Don’t use Non-DHP
Goal: <130/80
What is the guideline for HfpEF?
Goal: <130/80
ACEi or ARB, beta blocker, MRA
Volume overload treatment with diuretics
How does HTN effect CKD?
Major contributor to decline in GFR
30% of patients have masked HTN
Guidelines for CKD?
What is the difference between acute intracerbral hemorrhage and ischemic stroke? Secondary stroke prevention?
Hem: Increased BP → pressure in vessels → leakage in brain
Stroke: Lack of O2 → damage → treatment is permissive HTN
Secondary: management of stroke
How do you treat PAD with HTN?
Normal patient
How do you treat DM with HTN?
- First line
- With albuminuria: ACEi/ARB
What is metabolic syndrome? What is the treatment?
Metabolic dysregulation by visceral fat accumulation, insulin resistance, hyperinsulinemia, hyperlipidemia
Thiazides due to increased insulin resistance
Don’t use beta blockers → deterioration of glucose tolerance and dyslipidemia
What is the most common cormorbidie associated with HTN?
A fib
What is the goal for Afib HTN?
Control HTN to aid a fib prevention
ARB
What is the standard for clinical monitoring of HTN?
- Reevaluation 2-4 weeks after initiating or changing therapy
- Once at goal → monitor every 3-6 months
Self monitoring and ABP can be used in combo
How do we monitor ADRs?
Pharmacist must know common side effects and lab parameters
How do you lab monitoring for HTN?
- 2-4 weeks after agent initiation or dose increase
- Every 6-12 months for stable patients
- More intensive follow up for aldosterone antagonists → K+ and renal function evaluation within 3 days then again for 1 week
What are the signs and symptoms of HTN to look out for?
- Ischemic chest pain
- Vision
- One side weakness
- Slurred speech
- Loss of balance
Ey exam
Proteinurina
Recommendations for non adherence?
- Focus on clinical outcomes
- Empowerment
- Implement a team
- Advocate for health policy reform
Preferred HTN combos?
- ACEI/CCB
- ARB/CCB
- ACEi/thiazide
- ARB/thiazide
How do you diagnose resistant HTN?
- Failure to achieve BP control with 3 meds
- BP control but requires ≥4 meds
Risk factors of resistant HTN?
- Older
- Obesity
- CKD
- Black
- DM
Common 3 drug regimen?
CCB, RAAS inhibitors, Chlorthalidone
What are recommended combo with spironolactone?
Hydralazine or minoxidil
What is the treatment algorithm for resistant HTN?
Confirm resistance → Exclude pseudo resistance → Identify and reverse lifestyle factors → discontinue substances → screen for secondary causes → pharm treatment → refer to specialist
What diuretics are more potent than HCTZ?
Chlorthalidone and indapimide
What can be used in place of thiazides if patient has decreased renal function?
Loops
What are guidelines for alpha-1 blockers?
Sodium and H2O retention
First dose phenomenon
What are guidelines for central a2 blockers?
Significant CNS activity
Induce HTN crisis
What are guidelines for renin inhibitors?
DDI with RAAS inhibitors
Long acting
What are guidelines for loop?
HF, CKD
What are guidelines for K+ sparing?
Avoid CKD
For thiazide induced hypokalemia
Overall algorithm for HTN?
Overall algorithm for HTN with cormorbidieis?
