HTN Flashcards
When does CVD risk double?
- Beginning at 115/75
- For each increment of 20/10
Primary HTN accounts for how many cases?
90-95%
What controls BP?
- SNS
- RAAS
- Plasma volume
Neural MOA
Overactive SNS
Renal MOA
Renal sodium retention
Vascular MOA
- Inflammation
- Oxidative stress
- Vascular remodeling
Hormonal (RAAS) MOA
- Aldosterone
- Angiotensin II
- Renin
- Prorenin activate pathways damaging vascular health
Secondary HTN indications
- Young age of onset
- Diastolic HTN at age older than 50
- Poor response to generally effective therapy
HEENT eval
- Narrowing of arterial diameter
- Cotton wool spots
- Hemorrhages
- Papilledema
- Exudates (3+)
Abdomen eval
- Renal masses
- Renal bruits
- Femoral pulses
Neuro eval
- Visual disturbance
- Focal weakness
- Confusion
Cardio eval
- Left ventricular hypertrophy
- S4 gallop
- Edema
Screening according to USPSTF?
Adults 18+
At what value do we dx HTN?
Depends on what guideline we are following
- Based on avg of 2 or more BP readings at 2 or more office visits
JNC 7 BP goal for general population
140/90
JNC 7 BP goal for pts w/ diabetes
130/80
JNC 8 recommendations
- < 140/90 for ALL adults up to age 59
- < 150/90 for age 60+
ADA recommendations
- < 140/90
- Risk-based individualization
Special considerations
- White coat HTN: 20-25% of stage 1 HTN in office
- Masked HTN: 10%, increased cardiovascular risk
When do you initiate anti-hypertensives according to ACC/AHA?
- Stage 2
- Stage 1 w/ 1 or more of the following:
1. Established ASCVD
2. Type 2 DM
3. CKD
4. 10 year calculated ASCVD risk of 10%
What is BP goal according to ACC/AHA?
- < 130/80 if on meds
- < 140/90 for low-risk stage 1 who don’t qualify for meds
What caution should you be aware of in pts > 60 yo?
Not to lower DBP < 55-60
*Associated w/ increased risk of MI & stroke
Non-pharmacologic tx
- Salt restriction
- DASH diet
- Alcohol reduction
- Weight loss
- Exercise
- Smoking cessation
Pharmacologic tx
- Diuretics
- Calcium channel blockers
- ACE Inhibitors
- Beta blockers
- Direct renin inhibitor
- Central alpha agonists
- Alpha blockers
What are the types of diuretics?
- Thiazide (ex. hydrochlorothiazide)
- Loop (ex. Furosemide)
- Potassium sparing (ex. Triamterene)
- Aldosterone antagonists (ex. Spironolactone)
Diuretics: MOA
Inhibits sodium reabsorption in the nephron, increasing sodium & water excretion
Diuretics: Important notes
- Controls BP in 50%
- Can be used in combo w/ other agents
- More potent in blacks, elderly, obese, smokers
Hydrochlorothiazide side effects
- Hypokalemia
- Hypomagnesemia
- Hypercalcemia
- Hyponatremia
- Sexual dysfunction
- Hyperuricemia (gout)
- Glucose disturbance
- Dyslipidemia
Hydrochlorothiazide contraindications
Hypersensitivity to sulfonamide derived drugs
Furosemide (Lasix) side effects
- Hypokalemia* Should supplement potassium
- Hyponatremia
- Hypomagnesemia
- Hypocalcemia
- Sexual dysfunction
- Hypercholesterolemia
- Glucose disturbance
Furosemide contraindications
- Poor antihypertensive
- Reserved for pts w/ kidney disease or fluid retention
Triamterene (Dyrenium) side effects
- Hyperkalemia (esp w/ CKD, DM)
- Nephrolithiasis
- Renal dysfunction
Triamterene contraindications
- Weak antihypertensives
- Caution combining w/ ACE-I, ARB, DRI, K supplements
- Hepatic disease
- Renal failure
- Hyperkalemia
Spironolactone (Aldactone, Aldactazide) side effects
- Hyperkalemia
- Gynecomastia
Spironolactone contraindications
- Renal impairment
- DM w/ proteinuria
- Hyperkalemia
Calcium channel blockers: MOA
Inhibition of calcium influx into myocardial & vascular smooth muscle cells
- Decreased calcium inhibits the contractile process –> vasodilation
- Increased efficacy in blacks, elderly
Types of calcium channel blockers
- Non-dihydropyridines (verapamil, diltiazem) *Cardiac depressants
- Dihydropyridines *Selective vasodilators
Calcium channel blocker medication names end w/ what?
- dipine
Non-DHP side effects
- Bradycardia
- Constipation
- Gingival hyperplasia
- Worsening HF
DHP side effects
- Peripheral edema
- Headache
- Flushing
Non-DHP contraindications
- Acute MI
- AV block
- Cardiogenic shock
- HF
- Hypotension
- Sick sinus syndrome
- Ventricular dysfunction or Vtach
- WPW syndrome
DHP contraindications
- Acute MI
- In urgent/emergent HTN, immediate release nifedipine is contraindicated
ACE inhibitors: MOA
- Inhibit RAAS system
- Stimulate bradykinin (vasodilator effect)
- Less effective in blacks, elderly, predominant systolic HTN
ACE-I medication names end w/ what?
-pril
ACE-I side effects
- Cough
- Hyperkalemia
- Angioedema
- Acute renal failure
ACE-I contraindications
- Pregnancy
- Angioedema
- Renal artery stenosis
ARBs: MOA
Inhibit RAAS system
*Helpful in pts w/ CKD, diabetes, HF
ARBs medication names end w/ what?
-sartan
ARBs side effects
- Hyperkalemia
- Angioedema
- Acute renal failure
ARBs contraindications
- Pregnancy
- Renal artery stenosis
Direct renin inhibitors MOA
Inhibit enzyme activity of renin, reducing activity of angiotensin I/II & aldosterone
Example of DRI
Aliskiren (Tekturna)
DRI side effects
- Hyperkalemia
- Renal impairment
- Hypersensitivity rxns
DRI contraindications
- Use w/ ACE-I or ARB
- Pregnancy
Beta blockers MOA
Blocks activity of catecholamines at β adrenoreceptors –> decreased CO, some decreased PVR, & decreased renin activity
Types of beta blockers
- Cardioselective (β1 receptors)
- Noncardioselective (β1 & β2 receptors)
