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HTN Flashcards

1
Q

What is the lifetime risk of developing HTN?

A

90%

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2
Q

What is the prevalence of HTN in adult?

A

1 in 3

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3
Q

HTN is a risk factor for developing what?

A

Heart disease
Stroke
Heart failure
Renal disease

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4
Q

What are some of the pathophysiologic mechanisms behind HTN?

A

Sex, Environment (stress), Genetics, CNS (sympathetic), Cardiac (CO), Renal (Na+ retention), G.I (obesity, nutrients, alcohol), Endocrine (insulin, aldosterone), Age, Endothelium (NO, endothelin)

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5
Q

List risk factors for HTN

A 
Cigarette smoking
Obesity ( BMI > 30)
Physical inactivity
Dyslipidemia
DM
Renal dysfunction (may also be an end result)
Age: MEN > 55, WOMEN > 65 
Family h/o premature CVD: men < 55, women < 65
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6
Q

Differentiate between Essential & Secondary HTN

A

Essential accounts for 90% of cases; has a hereditary component

Secondary accounts for < 10%; common causes are chronic kidney dz, renovascular dz, pregnancy, medications, etc.

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7
Q

Differentiate between Systolic & Diastolic BP

A

Systolic: represents cardiac contraction

Diastolic: represents nadir, filling of the heart

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8
Q

Define Cardiac Output (CO) and Total Peripheral Resistance (TPR)

A

CO: AMOUNT of blood pumped out by the ventricles (represents SBP)

TPR: sum of peripheral resistance in peripheral vasculature (represents DBP)

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9
Q

How would you calculate BP if given CO & TPR

A

BP = CO x TPR

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10
Q

What is the mechanism behind increasing peripheral resistance?

A

Functional Vascular Constriction/ Structural Vascular Hypertrophy (narrows the vessel as well)

  • -> overactivity of sympathetic NS
  • -> Genetic components
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11
Q

What is the mechanism behind increased CO?

A

Increased preload

–> increased fluid volume
–> excess Na+ intake
–> renal Na+ retention
water follows Na+

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12
Q

What are possible mechanisms behind venous constriction?

A
  • ->Excess RAAS stimulation (constriction = more H2O, Na+ = increased BP)
  • -> Sympathetic NS overactivity
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13
Q

What are the new JNC 8 goals for BP?

  • Pts > 60
  • Pts < 60
  • Pts w/ DM and CKD
  • Pts w/ DM (per ADA)
A
  • Pts > 60 goal: < 150/90
  • Pts < 60 goal: < 140/90
  • Pts w/ DM & CKD goal: < 140/90
  • Pts w/ DM (per ADA) goal: <140/ 80
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14
Q

What are some of the lifestyle modifications suggested to lower BP?

A

Smoking cessation
Weight loss (overweight/ obese pts)
DASH diet (fruits, veggies, whole grains)
Dietary Sodium restriction
Increased physical activity
Limit alcohol intake to < 1-2 drinks/ day

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15
Q

What is the most effective lifestyle modification used to lower BP? By how much?

Recommendations?

A

Losing weight: could reduce systolic BP by 5-20 mm Hg PER 10- kg wt loss

Recommendation is to maintain a BMI between 18.5-24.9

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16
Q

What is a DASH diet pattern? How does it affect BP?

A

A diet rich in fruits, veggies & low-fat dairy products with reduced saturated & total fat

May reduce systolic BP 8-14 mmHg

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17
Q

What is the ideal Sodium intake for a pt with HTN?

A

Ideally, 65 mmol/day (1.5g/ day sodium or 3.8g/day NaCl)

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18
Q

What are the four first line options for treating HTN?

A

Thiazides, Calcium Channel Blockers (CCBs), ACE-Inhibitors, ARBs (Angiotensin II receptor blocker)

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19
Q

Which two medication classes should not be used in African American pts to treat HTN?

A

ACE-I & ARBs

1st line would be a Thiazide or CCB

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20
Q

Which two medication classes are recommended for treating HTN in a pt with DM or CKD?

A

ACE-I & ARBs: DO NOT USE THEM TOGETHER!

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21
Q

Which medication class should be used to treat HTN in a pt with a cardiac history (i.e. M.I., CHF)?

A

Beta-Blockers

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22
Q

What is the 1st option in the treatment approach to HTN?

A

Start with 1 DRUG and MAX THE DOSE; then add on 2nd agent if not at goal and MAX THE DOSE PRN; add on a 3rd agent if still not at goal –> referral to specialist if still not at goal after 3rd drug

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23
Q

What is the 2nd option in the treatment approach to HTN?

A

Start with 1 DRUG, and ADD 2ND DRUG if not at goal (prior to maxing out 1st drug); MAX THE DOSE ON BOTH DRUGS; if not at goal, add 3rd agent

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24
Q

What is the 3rd option in the treatment approach to HTN?

A

Start with 2 DRUGS from the beginning IF SBP > 160 and/or DBP > 100; MAX OUT BOTH DRUG DOSES; if not at goal, add 3rd agent

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25
Give examples of the 3 Thiazide Diuretics, what is the MOA?
- Hydrochlorothiazide (HCTZ), chlorthalidone, metolazone | - Inhibits Na+ reabsorption in the DISTAL TUBULE (better at lower BP than regular diuretics
26
Which is the most common Thiazide diuretics? Least common?
HCTZ = MC Metolazone is rarely used; potent diuretic
27
What is the place in therapy for a Thiazide diuretic? What is the typical dose?
One of the FIRST LINE drug classes in treating HTN 25mg (can start at 12.5 mg); any dose >25 mg will NOT be more effective, may show more ADEs
28
What are some adverse effects of Thiazide diuretics?
- Orthostatic hypotension; - Electrolyte abnormalities (DECREASED K+, Na+; INCREASED Ca++, uric acid, glucose) --> avoid with gout or kidney dz; - Photosensitivity (recommend SPF >30) - Increase in urination (initially) --> TAKE IN THE AM
29
What precautions should you adhere to when prescribing Thiazide diuretics?
-Use caution in pts with SULFA ALLERGY (anaphylactic) -INEFFECTIVE IN PTS WITH SEVERE RENAL DZ: CrCl < 30 mL/min -- won't even get into DCT to work -AVOID in pts taking Lithium (may increase [Lithium] d/t similar structure)
30
Give examples of Loop Diuretics | What is the MOA?
Furosemide (Lasix), Bumetanide, Torsemide - Inhibits active transport of Na+, Cl- & K+ in thick ASCENDING LIMB of Loop of Henle --> ion excretion - Collecting duct EXCRETES MORE H2O in response
31
What is the most potent of the loop diuretics? The least? Give equivalence doses
MOST --> Torsemide (1 mg) = Bumetanide (20 mg) = Furosemide (40 mg) <-- LEAST
32
What is the place in therapy of Loop Diuretics?
- CHF (preferred) - Edema (both peripheral & pulmonary) - HTN (not 1st line)
33
What are some adverse effects of Loop Diuretics? | Precautions?
- Electrolyte abnormalities (DECREASED: K+, Na+, Ca++, Mg; INCREASED: uric acid --> gout!!) - Dehydration - Ototoxicity (esp if combined w/ another agent) - Increase in SCr - Caution in sulfa-allergic pts - Nephrotoxicity
34
What are the two subcategories of Potassium-Sparing Diuretics?
Aldosterone Receptor Blockers | Potassium Sparing Drugs
35
Give 2 examples of Aldosterone Receptor Blockers; what is the MOA of this class?
- Spironolactone; Eplerenon | - MOA: COMPETES WITH ALDOSTERONE: prevents Na+ reabsorption & K+ excretion
36
Give 2 examples of Potassium Sparing Drugs; what is the MOA of this class?
- Triamterene; Amiloride | - BLOCKS Na+ reabsorption & K+ excretion INDEPENDENT OF ALDOSTERONE
37
What is the place in therapy for Potassium Sparing Drugs? Specifically Spironolactone?
- HTN (not 1st line), often in COMBO WITH THIAZIDE | - Spironolactone is used for End Stage (Class III-IV) Heart Failure
38
What are some potential adverse effects of Potassium Sparing Drugs? Spironolactone specifically?
- HYPERKALEMIA: caution in pts w/ renal failure; pts using salt-substitute; AVOID putting too much stress on the heart - Spironolactone: gynecomastia, menstrual irregularities
39
Give some examples of ACE- Inhibitors
Benazepril; Captopril; Enalapril; Fosinopril; Lisinopril; Moexipril; Perindopril; Quinapril; Ramipril; Trandolapril
40
What is the MOA of ACE-Is?
- Inhibits ACE to block production of ATII - Inhibits BREAKDOWN of Bradykinin (vasodilator) - ->lowers BP; inflammatory mediator - Dilates the EFFERENT ARTERIOLE of the kidney --> increases blood flow (renin would do the opposite)
41
What is the place in therapy of ACE-Is?
- One of the FIRST LINE classes for HTN (except in AAs) - FIRST LINE OPTION for CKD (& DM) --> KIDNEY PROTECTIVE - Used in CHF
42
What is the typical dose frequency of an ACE-I? | What are some signs to monitor for in a pt taking an ACE-I?
- Often once daily, sometimes b.i.d - Monitor for INC. K+ & SCr w/in 4 wks of initiation or dose increase (likely to see benign inc in SCr < 30% from baseline) --> should then decrease otherwise d/c - ANGIOEDEMA: swollen lips, face, tongue, throat --> immediate d/c
43
What are some adverse effects of ACE-Is?
- COUGH: persistent, dry/non-productive; present in 20%, (d/t increased Bradykinin) - Angioedema (rare) - Hyperkalemia: esp in pts w/ CKD or DM - Other: neutropenia, agranulocytosis, proteinuria, glomerulonephritis, acute renal failure
44
What are some ABSOLUTE CONTRAINDICATIONS for ACE-Is?
- Pregnancy: Category C/D - Angioedema with other ACE-Is - Renal Artery Stenosis (B/L) --> increased risk of renal toxicity
45
What are some potential drug interactions with ACE-Is?
- Potassium supplements - Potassium-sparing diuretics --> both inc. K+ - NSAIDs: can inc. BP by itself; blocks prostaglandins which normally help DILATE the AFFERENT arteriole of the kidney --> constriction of arteriole = poor renal perfusion
46
What is the typical dose frequency of an ACE-I?
- All can be dosed ONCE DAILY EXCEPT Captopril (dosed b.i.d or t.i.d) - Most may be dosed > QD for increased efficacy
47
What is the special consideration of Enalapril?
It is a prodrug of Enalaprilat --> only ACE-I that can be given IV
48
What is the MC used ACE-I? What is the typical dose?
Lisinopril | Usually 10-40 mg DAILY
49
What are some special considerations of Captopril?
Must be dosed b.i.d. -- t.i.d | Absorption is DECREASED 30-40% when given with food
50
Give examples of Angiotensin II Receptors Blockers (ARBs)
``` Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan ```
51
What is the MOA of ARBs?
INHIBITS Angiotensin II at its receptor site --> does NOT inhibit breakdown of Bradykinin
52
What is the place in therapy for ARBs? What is the typical dose frequency?
- One of the FIRST LINE drugs for HTN - FIRST LINE option for CKD - Used in CHF -Often once daily
53
What should you monitor when a pt is taking an ARB?
Potassium (increase) Angioedema
54
What are some potential adverse effects of ARBs?
- Hypotension/ orthostatic hypotension - Angioedema - Hyperkalemia - Dizziness - Cough? (not as freq as with ACE-I)
55
What are some ABSOLUTE CONTRAINDICATIONS when prescribing an ARB?
- PREGNANCY: Category C/D - Caution in pts with renal artery stenosis - CAN be used if pt experienced angioedema with an ACE-I --> not recommended though
56
What are some potential Drug Interactions with ARBs?
- Potassium supplements, potassium-sparing diuretics | - NSAIDs
57
What is the name & MOA of the Renin Inhibitor anti-HTN med?
- Aliskiren | - First ORAL agent that directly inhibits Renin
58
What is the role in therapy of a Renin Inhibitor? | Potential adverse effects?
- Role is unclear -- new agent: can be used as monotherapy or in combination (NOT w/ ACE or ARB) - ADEs are similar to ACE-IS; SHOULD NOT BE USED IN PREGNANCY
59
What are the 3 MC Beta-Blockers? | Dose frequency?
Atenolol: QD Metoprolol Succinate: QD (E.R) Metoprolol Tartrate: B.I.D. (I.R) Dose depends on the B-blocker
60
What is the place in therapy for Beta-blockers?
- NOT a 1st line for treating HTN - Reserved for pts w/ significant cardiac hx - -> Heart failure - -> Post-M.I - -> High CAD - -> CKD
61
What is the MOA of B-blockers?
B-1 receptors (heart), B-2 receptors (lung) | -Blocking B-1 receptors = dec. effects of Epi/ NorEpi = dec. heart rate, BP
62
What are the 4 main categories of B-blockers?
- Cardioselectivity (dose-dependent) - Mixed alpha & Beta blockers - ISA (Intrinsic sympathomimetic activity) --> not as common; suggested for pts who experience bradycardia regardless of dose - Non-specific
63
Which drugs are considered Cardioselective B-Blockers?
``` AMEBBA!! -Atenolol Metoprolol Esmolol Bisoprolol Betaxolol Acebutolol ```
64
Which drugs are considered mixed a/B Blockers?
- Carvedilol | - Labetalol
65
Which B-blockers are considered to have ISA?
``` CAPP!! -Carteolol Acebutolol* Penbutolol Pindolol ```
66
Which B-Blockers are non-specific?
Nadolol Propranolol Timolol
67
What is a consideration when prescribing Carvedilol?
TAKE WITH FOOD
68
Which B-blockers can be used in heart failure?
Metoprolol succinate, carvedilol, bisoprolol
69
Other than HTN, what else may Propranolol be prescribed for?
D/t lipophilicity, may help w/ migraines; may also be given PRN for someone w/ stage fright
70
What are some common ADEs of B-Blockers?
Initial: B-blocker Blues: tired, fatigued, depressed, "different" feeling in chest (d/t change in heart beat; body will adjust in ~1 mo) Other: sexual dysfunction (doesn't go away); REBOUND HTN IF SUDDENLY D/C'd --> 2-3x UNL d/t upregulation
71
What are some relative contraindications to B-Blockers?
- Asthma & COPD (bronchospasm) esp if non-selective; doesn't allow SABA to work - DM: masks the hypoglycemic response (except sweating) - Severe peripheral vascular dz: decreased output can worsen symptoms - Heart block - Severe ACUTE heart failure - Pregnancy: category C
72
Which B-blocker is OKAY to use in pregnancy?
Labetolol
73
What is Sotalol (Betapace) used for?
A B-Blocker used only as a Class III anti-arrhythmic agent
74
A 45 y.o male comes in for his 3rd BP reading: previously it's been 136/78; 155/88; 160/84 He is on ASA 81mg PO QD; Ventolin inhaler PRN; Zocor 40mg PO QHS - What is his BP goal? - Which meds are most appropriate to start him on?
75
If the pt was prescribed HCTZ: - How often do we dose? - Side effects? - Monitoring? - Counseling?
- CrCl has to be >30 mL/min - 25 mg max QD - Caution with sulfa allergy; orthostatic hypotension - Monitor DEC Na+ K+ INC Ca++ uric acid - Take in the AM; wear SPF 30
76
If the pt was prescribed an ACE-I or an ARB: - How often do we dose? - Side effects? - Monitoring? - Counseling?
- QD - Cough d/t INC bradykinin (switch to ARB if bothersome); potential angioedema; dizziness & hypotension w/ ARBs - INC SCr by 30%; INC K+ (no supplements) - Not for use with NSAIDs
77
``` Which of the following is NOT a potential adverse effect associated with furosemide therapy? A. Hypokalemia B. Hyperuricemia C. Hyperglycemia D. Hypercalcemia E. Ototoxicity ```
D. Hypercalcemia (mostly with thiazides) A. Hypokalemia B. Hyperuricemia C. Hyperglycemia E. Ototoxicity
78
``` Which of the following is a Direct Renin Inhibitor? A. Aliskiren B. Perindopril C. Eprosartan D. Enalaprilat ```
A. Aliskiren B. Perindopril - ACE-I C. Eprosartan - ARB D. Enalaprilat - ACE-I
79
This is an important counseling point for lisinopril: A. This med will increase urination B. If you have DM, you may need to monitor your BGL more frequently C. Take extra meds if you miss a dose D. Do NOT use salt substitutes while taking this med
D. Do NOT use salt substitutes while taking this med A. This med will increase urination B. If you have DM, you may need to monitor your BGL more frequently C. Take extra meds if you miss a dose
80
``` Which of the following is a B-1 selective B-Blocker? A. Bisoprolol B. Carvedilol C. Pindolol D. Labetalol E. Nadolol ```
A. Bisoprolol (AMEBBA) B. Carvedilol -- a & B C. Pindolol -- ISA (CAPP) D. Labetalol -- a & B E. Nadolol -- non-specific
81
For which medication classes should a pt AVOID taking salt substitutes?
ACE-Is, ARBs & K-sparing diuretics
82
Which medication class should not be used with ACE-Is and ARBs?
Renin Inhibitors
83
What are 2 contraindications for ACE-Is and ARBs?
Pregnancy | Renal Artery Stenosis
84
With which medication classes should you be cautious when a pt has a sulfa drug allergy?
Thiazides, Loop diuretics
85
What is the typical dosing frequency of an ACE-I?
Once daily EXCEPT Captopril b.i.d - t.i.d

Pharm II (5 decks)

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