HTN 2 - olenik Flashcards
what are the first line agents for HTN?
thiazides
CCBs
ACEi
ARBs
what are the results of ALLHAT trial?
chlorthalidone is better than amlodipine and lisinopril-based therapy in preventing stroke, heart attack, and heart failure
what are the key takeaways of ALLHAT trial?
thiazide diuretics should be first line
for pts who cannot take diuretic –> prescribe a CCB or ACEi
patients with HTN should take 1+ drugs
what are the preferred combination therapy for HTN?
ACEi/CCB
ARB/CCB
ACEi/diuretic
ARB/diuretic
what is an acceptable combination therapy for HTN?
CCB/diuretic
how should HTN be treated in stable ischemic heart disease?
beta blockers or ACEi/ARBs
use dihydropyridine CCBs if still uncontrolled
what is the role of beta blockers in treatment of HTN in stable ischemic heart disease?
reduce CV events and anginal symptoms
what is the goal BP in stable ischemic heart disease?
under 130/80
what is the treatment of HTN in heart failure with reduced ejection fraction (HFrEF)?
ARNI + evidence based beta blocker + mineralocorticoid antagonist + SGLTis
may add other agents like a loop diuretic for persistent fluid overload
what is an ARNI?
angiotensin receptor/neprilysin inhibitor
what are drugs to avoid in heart failure?
nondihydropyridine CCBs
what is the treatment order of HTN in heart failure with preserved ejection fracture (HFpEF)?
- SGLT2 inhibitor
- add other agents depending on patient-specific factors
how is HTN treated in CKD?
if CKD stage 1 or 2 with albuminuria (>300 mg/day) OR CKD stage 3, ACEi (or ARB if intolerant)
if not, use first line agents
what is the goal BP in CKD?
under 130/80
how is HTN treated in post kidney transplantation?
dihydropyridine CCBs to improve GFR and kidney survival
how is HTN treated in cerebrovascular disease for secondary stroke prevention?
ACEi/ARBs
thiazide
both if BP is over 140/90
what is the goal BP in cerebrovascular disease?
under 140/90
how is HTN treated in DM?
any first-line agent unless there is albuminuria, then ACEi/ARBs
how is albuminuria classified?
over 300mg/day or over 300mg/g albumin to creatinine ratio
what is the preferred anti-HTN agents in pregnancy?
methyldopa
nifedipine
labetolol
what HTN meds are CI in pregnancy?
ACEi
ARBs
direct renin inhibitors
how is HTN treated in black adults without HF or CKD (including those with DM)?
thiazide or CCB (better at lowering BP and reducing CV events)
how is HTN treated in atrial fibrillation?
ARB to prevent recurrence
how is HTN treated in aortic disease?
BB to help improve survival
what HTN drugs are thiazides?
chlorothalidone
hydrochlorothalidone
indapamide
metolazone
what classes of diuretics are used in HTN?
thiazide
loop
aldosterone antagonists
potassium-sparing
what loop diuretics are used in HTN?
furosemide
torsemide
bumetanide
what aldosterone antagonists are used in HTN?
spironolactone
eplerenone
what potassium-sparing diuretics are used in HTN?
amiloride
triamterene
what happens after initially introducing diuretics?
diuresis –> reduced stroke
volume –> increased PVR
what happens long-term after introducing diuretics?
stroke volume returns to normal and decreases the PVR to go below pre-treatment levels
what is the most potent thiazide diuretic?
chlorothalidone
what are the clinical pearls of thiazides?
more effective than loops with CrCl over 30 mL/min
dose in the morning to avoid nocturnal diuresis
how often should thiazides be taken?
once a day
what are the SE of thiazides?
low K
low Mg
high Ca
hyperuricemia
hyperglycemia
hyperlipidemia
sexual dysfunction
increase in TG/cholesterol
what drug-drug interaction is important to note in thiazides?
lithium –> causes toxicity with concurrent use
what is the CI of thiazides?
sulfa allergy
anuria
what is the indication of loop diuretics?
heart failure
not first line for HTN but more effective than thiazides when CrCl is under 30 mL/min
what are the clinical pearls of loop diuretics?
dose in the morning/afternoon to avoid nocturnal diuresis
high-ceiling dose response curve (may need higher doses in severely reduced renal function or fluid overload –> switching to another loop or from oral to IV can help)
how often should loop diuretics be taken?
1-2x daily
QD for torsemide
what is SE of loop diuretics?
low K
low Mg
low Ca
hyperuricemia
ototoxicity
what is CI of loop diuretics?
sulfa allergy
what is the preferred add-on agent in resistant HTN?
spironolactone
what are the clinical pearls of aldosterone antagonists?
dose in the morning/afternoon to avoid nocturnal diuresis
don’t use if potassium is greater than 5 mEq/L
what should be done if the pt develops gynecomastia?
switch from spironolactone to eplerenone
what is another name for aldosterone antagonists?
mineralocorticoid receptor antagonists
how often should aldosterone antagonists be dosed?
1-2x per day
under what conditions should an aldosterone antagonist be held or reduced?
if potassium is greater than 5/5 mEq/L or SCr increases by over 25%
what is SE of aldosterone antagonists?
high K
hyponatremia
gynecomastia (spironolactone 10%)
what are the drug-drug interactions of aldosterone antagonists?
ACEi
ARBs
renin inhibitors
NSAIDs
increase risk of hyperkalemia
what are CIs of aldosterone antagonists?
concomitant use of potassium sparing diuretics
what are the CIs of eplerenone?
impaired renal function
T2DM with proteinuria
what are the lab values for impaired renal function?
CrCl under 50 mL or
SCr greater than 2 for men or over 1.8 for women
what is the purpose of potassium-sparing diuretics in HTN?
used in combination with thiazides to minimize hypokalemia (minimal BP effects)
what are the clinical pearls of potassium-sparing diuretics?
use with caution in patients with DM or CKD (GFR under 45)
dose in morning to avoid nocturnal diuresis
how often should potassium-sparing diuretics be taken?
1-2x daily
what is SE of potassium-sparing diuretics?
high K
increased uric acid
hyperglucemia
what are the monitoring parameters of diuretics
electrolytes and renal function
at baseline
1-2 weeks after initiation
3-4 months after initiation (loop/aldosterone only)
every 5-12 months
what are the clinical pearls of diuretics?
nocturnal diuresis
thiazides are first-line for most HTN pts
spironolactone is first-line for resistant HTN
potassium-sparing is not monotherapy
pts with sulfa allergy cannot take
check CrCl when choosing class
monitor potassium and other electrolytes
