HTN Flashcards
1st line medications
thiazide-type diuretics, CCBs, ACEIs, ARBs
pts of AA descent
CCBs or thiazides
80% higher stroke mortality
50% higher HD mortality
320% higher HTN-related, ESRD
pts w/ HTN and CKD
ACEIs or ARBs seperately
pts> 75 yo w/ impaired renal fc and HTN
CCBs and thiazide diuretics
hypertensive emergency
HTN presentation with evidence of life-threatening, end-organ damage
damage: unstable angina, acute MI, acute retinopathy, encephalopathy, nephropathy, LV failure, dissecting aneurysm, AMS, intracranial bleed
goal tx: substantial BP reduction - reduce MAP by 25% in 1-2 hrs
then titrate towards goal - 160/100 over first 6 hrs
ex: nitroprusside, labetalol, NTG, nicradipine, hydralazine, diazoxide
hypertensive urgency
BP>220/125 w/o life-threatening, end-organ damage
OR HTN with end-organ damage (non-life threatening)
oral agents used w/o damage -> CCB, alpha-agonist, ACEI
goal - partial BP reduction, relief of xs’x
BP goals
> 60 yo w/o DM or CKD, 150/90
<60 yo or have DM or have CKD, 140/90
important BP effect on CV risk <60 yo
DBP
important BP effect on CV risk >60 yo
SBP
lifestyle changes for BP
DASH eating plan, wt loss, exercise 30 min most days of the week, reduce NA intake to <2.4 g/day, limit EtOH, limit fat intake, get enough K+, Ca+, Mg+, stop smoking, limit caffeine
when to use ambulatory BP measurement
white coat syndrome, apparent drug resistance, hypotensive symptoms w/ anti-hypertensive, autonomic dysfunction
helps improve patient’s adherence to Tx and can help reduce cost
Medical Hx for HTN
known duration, any past meds
personal hx/symptoms of CHD, CHF, CVA, PVD, DM
family hx
symptoms - weight change, lack of physical activity, smoking/tobacco
diet: sodium alcohol, saturated fat, caffeine
All prescribe meds, OTC, herbals, illicit drugs
psychosocial and environmental factors
Labs and tests for HTN
urinalysis CBC CMP EKG chest x-ray
primary HTN
95% of cases no clear cause genetics and environmental 10-15% whites 20-30% AA onset btwn 25-55 yo uncommon <20 yo
HTN post stroke
don’t reduce BP rapidly because increased pressure required for brain perfusion S/P CVA
avoid clonidine, hydralazine, and other centrally acting meds
ischemic - withhold tx
hemorrhagic - MAP < 130 mm HG due to risk of expanding CVA
thiazide diuretics - facts
aka loop diuretics
act on kidneys
best proven efficiency except w/ CHR, S/P MI, DM, CKD
good until Creatinine clearance <20 ml/min and some loop diuretics work lower with sodium restriction
avoid in pts w/ gout, high lipids, orthostatic hypotension
adverse side effects: electrolyte abnormalities - hyponatremia, hyperkalemia, increase in uric acid, glucose, LDL and TGs
loop diuretics: shorter acting, more volume depletion/ electrolyte (only use w/ impaired renal function)
thiazide diuretics - drugs
clorthalidone & HCTZ
furosemide& bumetanide ðacrynic acid
CCBs - facts
calcium channel blockers
cause peripheral vasodilation w/o reflex tachycardia and fluid retention comparitively
prevent CHD, major CV events, total mortality
non-dihydropyridines & dihydropyridines - more sx’s of vasodilation
SE: HA, peripheral edema, bradycardia, constipation (verapamil in elderly pts)
CCBS - dihydropyridines
nifedipine, felodipine, amlodipine
CCBs- non-dihydropyridines
diltiazem, verapamil
ACEIs and ARBs - facts
most effect w/ normal renin levels, contra-indicated when low
drug of choice for diabetic pts w/ HTN (not severe)
teratogenic
contraindicated in b/l renal artery stenosis and severe CHF - can worsen azotemia -> acute renal failure
SE: hyperkalemia, kidney dysfunction, angioedema (rare for ARBs)
SE of ACEIs only: cough, dizziness, hypotension
ACEIs
angiotensin converting enzyme inhibitors
benazepril
enalapril
ARBs
angiotensin I Receptor Blocker
losartan, valsartan
aldosterone antagonists
save K+, lose Na+
SE: hyponatremia, hyperkalemia, metabolic acidosis, gynecomastia ( breast enlargement in men)
drugs: spironolactone
amiloride
BBs
beta-blockers
non-cardio selective
drugs: atenolol, metoprolol, carvedilol
SD: bronchospasm, fatigue, sleep disturbance, nightmare, bradycardia, AV blocks, worsen CHR, impotence, incr. in TG, lowering of HDL, mask hyopglycemia warning signs, decrease CO
alpha-adrenergic antagonists
drugs: prazosin, terazosin, doxazosin
SE: syncope, postural hypotension, dizziness, paplitations, sexual dysfunction
used to treat BPH as well
centrally-acting alpha agonist agents
aka central sympatholytics
stimulate alpha adrenergic receptors in CNS and inhibit sympathetic outflow
result: decr. peripheral resistance and lowers BP
clonidine, methyldopa
SE: sedation, dry mouth, HA, bradyarrhythias, sexual dysfunction
arteriolar dilators
direct vasodilators by relaxing vascular smooth m.
hydralazine, minoxidil
SE: alone - reflex teachycardia, increased heart contractility and fluid retention
giver w/ diuretic or BB in pts with resistant HTN
resistant HTN
adherent pts with HTN who fail to respond to Rx w/ appropriate 3-drug regimen, including a diuretic
exclude secondary causes including aldosterone - ARBs
send to nephrologist/HTN specialist
secondary HTN
identifiable cause of HTN - 5%
include: renal parencymal disease, CKD, primary aldosteronism, sleep apnea, drug-induced, renal artery stenosis, cushing’s syndrome, long-term steroid use, pheochromocytoma, aorta coarctation, thyroid or parathyroid disease
consider when - age, hx, pe, severity suggests it, BP respond poorly to meds, initially well-controlled with marked increases, stage 2 HTN, sudden onset,
primary aldosteronism
unprovoked, marked hypokalemia
hyperparathyroidism
hypercalcemia
elevated creatinine or abnormal urinalysis
renal parenchymal disease
drug considerations
start low, go slow one-daily long-acting dose ideal - better adherence, may lower cost, smoother control, less risk due to increase in BP when waking combine with other meds: BPH - alpha-antagonist CAD - beta-blocker S/P MI - beta blocker
pts > 55 yo
diuretic or CCB
half the dose when elderly
higher risk for hypotension, orthostatic changes in BP
HTN in pregnancy
before 20 weeks -> chronic hypertension
goal- minimize risk to mother while avoiding therapy that may compromise fetal well-being
after 20 wks and with incr. proteinuria - pre-elampsia
cure- deliver fetus and placenta
eclampsia- pre-eclampsia progresses rapidly to a convulsive state
HTN & LVH
anti-hypertensives, wt reduction, decreasing Na - reduce LV mass and wall thickness
ACEI + diuretic should be considered
HTN & CHF
ACEIs - reduced episode, and M&M s/p MI
preop considreations
BP >180/110 is a risk for peri-operative ischemia events
- don’t clear for elective surgery until lowered
those w/o prior tx - cardioselective BB decrease MA risk and lessen tachycardia perioperatively
hypotension and shock
SBP <100 mmHg plus diminished perfusion - low urine output, cold extremities, confusion
tx- successive IVF boluses with NS if hypovolemia
consider pressors - DA w/ nitroprusside or dobutamine
if not hypovolemia, high mortality rate
orthostatic hypotension
SBP falls >20 , DBP falls >10
supine 10+ min
then have pt stand up and repeat BP and HR w/in 3 minutes
causes: drugs, prolonged bedrest, bleeding, ANS diseases
