HTN Flashcards
1
Q
alpha 2 agonists
A
clonidine, methyldopa
MOA
- agonist for pre-synaptic alpha 2 receptors
- decrease NE release
- decrease alpha 1 = decrease TPR
- decrease B1 = decrease contractility and HR
- no reflex tachy
SE
- dizziness/orthostatic hypotension
- sedation
- depression
- insomnia
- nausea/vomiting/constipation
- dry mouth
- sexual dysfunction
Precautions
- contraindicated in severe bradycardia/heart block
- may exacerbate depression
- may cause hyperglycaemia in diabetes
- safety in pregnancy unknown/may impair breastfeeding
2
Q
Alpha 1 antagonists
A
prazosine
MOA
-decrease TPR (arteriolar and venous)
SE
- reflex tachy
- orthostatic hypotension
- urinary incontinence
3
Q
Beta blockers
A
Beta 1 selective (abnormal beat medication)
- atenolol
- > renal elimination
- bisoprolol
- > renal/hepatic elimination
- metoprolol
- > hepatic elimination
Non selective beta (propranolol is promiscuous)
- propanolol
- > hepatic elimination
Non selective beta/alpha (AB..C)
- carvedilol
- > hepatic
- labetolol
- > hepatic
MOA
- B1
- > decreased chronotropyat SA/dronotropy at AV/inotropy
- B2
- > inhibit renin release
- A1
- > vasculature muscle relaxation
SE
- bradycardia/hypotension/orthostatic hypotension
- transient worsening of HF
- nausea/diarrhoea
- bronchospasm/dyspnoea
- cold extremities
- fatigue/sedation/dizzines
- sexual dysfunction is rare
Precautions
- contraindications
- > shock
- > bradycardia or heart block
- > severe or poorly controlled asthma
- > combination with verpamil/diltiazam
- may exacerbate PAD
- may mask signs of hypoglycaemia in diabetics
- hepatic disease
- > except atenolol
- pregnancy and breast feeding
- > labetolol preferred
4
Q
dihydropyridine calcium channel blockers
A
nephidepine, amlodopine
MOA (HTN)
- peripheral smooth muscle relaxation
- > decrease TPR
SE
- contraindicated in CCF
- AV block (beta blockers, digoxin)
- constipation
- flushing
- headache
- hypotension
- reflex tachy
- nephidepine
- > gingival hyperplasia
5
Q
ACEI and ARB
A
ACEI
- captopril
- ramipril
MOA
- inhibit angiotensin converting enzyme
- > decrease formation of angiotensin II
- > prevent vasoconstrictive effect
- decrease aldosterone levels
- > decrease Na and water retention
ARB
-losartan
MOA
- block AT1 receptors
- > prevent aldosterone release from zona glomerulosa of adrenal cortex
- > prevent vasoconstrictive effect of angiotensin II
SE
- renal failure
- hypotension
- headache/dizziness
- hyperkalaemia
- cough
- > increase in bradykinin
- > more ACEI than ARB
- angioedema
Precautions
- volume/Na depletion
- > worsen and hypotension
- drugs causing hyperkalaemia
- renal impairment
- > hyperkalaemia
- > may worsen kidney function
- pregnancy
- > teratogenic
- breastfeeding
- > limited evidence
6
Q
Loop diuretics
A
furosemide
MOA
- inhibit Na/K/2Cl symporter in thick ascending limb
- > decrease K leak = loss of positive luminal charge
- > decreased paracellular reabsorption Ca/Mg
- diuresis
- also increases prostaglandins
- > decreases TPR
SE
- hypersensitivity (sulfide)
- hypokalaemia and alkalosis (hyperaldosterone)
- hypocalcaemia and hypomagnesaemia
- hyperuricaemia (competes secretion in proximal tubule)
- ototoxicity
7
Q
Thiazides
A
hydrochlorothiazide, metolazone, indapamide
MOA
- inhibit Na/Cl co transporter in distal convoluted tubule
- > excretion of Na/Cl = diuresis
- decrease Na entry into tubule cell
- > increase action of Na/Ca antiporter on basolateral
- > increase Ca reabsorption at apical membrane
- open Ca dependent K channels (predominant effect at low doses)
- > hyperpolarisation of arteriolar smooth muscle cells
- > vasodilation = decrease TPR
SE
- hypersensitivity (sulfide)
- hypokalaemia and alkalosis
- hypercalcaemia
- hyperuricaemia
- insulin resistance
- > hyperglycaemia
- > hyperlipidaemia
8
Q
Spironolactone
A
MOA
- competitively antagonises aldosterone at mineralocorticoid receptor on principle cells of collecting duct
- > decreases Na reabsorption
- > decrease K and H secretion
SE
- hyperkalaemia
- acidosis
- gynecamastia and breast discomfort
9
Q
Indication for different HTN drugs
A
ACEI/ARB
- cardioprotective (HFrEF)
- renoprotective (diabetic nephropathy)
- avoid in bilateral renal stenosis
Dihydropyridine Ca blocker
-angina + HTN
Thiazides
-avoid in young due to diabetes risk
Beta blockers
- not first line
- useful post MI and stable angina
10
Q
CVD risk modification non pharm
A
General
- provided to everyone for primary/secondary prevention
- 5 A’s approach to lifestyle modification
- consider risks outside of those included in absolute CVD risk
- consider contributing conditions (sleep apnea, insomnia, depression)
Smoking cessation
Nutrition
- benefit seperate from improved BP and lipids
- Mediterranean diet (fewer processed carbohydrates, fish 3x weekly, olive oil, high vegetables)
- reduce salt
Alcohol
- small intake not recommended
- limit alcohol intake
Exercise
- 30 mins moderate intensity most days
- includes resistance at least two days
- can be accomplished over 10 min bouts
- substitute sitting for standing
Weight loss
- Improves BP, glycaemic control, lipids
- not associated with decreased CVD morbidity/mortality
- waist circumference best measure
11
Q
management of absolute CVD risk
A
high risk (>15%)
- liftesyle modification
- lipid and BP lowering drugs
- goal is to improve modifiable risks, not improve CVD absolute score (should not be reassessed)
medium risk (10-15%)
- lifestyle modification
- balance benefits and risks of drug therapy
- begin drug therapy after failure of lifestyle modification
- begin BP or lipid if significant CVD risk factor present
low risk (<10%)
- lifestyle modification
- lipid and BP not offered generally
- individual risk factors can be managed pharmaceutically
12
Q
pharm management HTN
A
Indication
- high CVD absolute risk
- 160/90mmHg
Pathway
- monotherapy
- > ACEI/ARB.dihydropyridine Ca blocker/thiazide
- review after 3 months
- > add second if target not reached
- begin with dual therapy
- > ACEI/ARB + thiazide/beta blocker/dihydropyridine
- > dihydropyridine Ca blocker + beta blocker
- > ACEI/ARB + dihydropyridine + thiazide
- increase one till maximum dose, then the other
Second line
- beta blockers
- K sparing
- Ca channel blockers
- alpha 1 antagonists
- alpha 2 agonists
13
Q
long term stemi management
A
Pharm
- dual antiplatelet for 12 months (cease P2Y12, continue aspirin indefinitely)
- high intensity statin
- beta blocker (metoprolol, atenolol)
- ACEI (max dose)
- oral anticoagulation for complications (eg. AF)
Non pharm
- cardiovascular risk management
- smoking, diet, exercise, weight loss, alcohol
