HTN and Lipidemia Flashcards
What is the definition of HTN
SBP is 140 mmHg or higher and/or DBP is 90 mm Hg or higher
following repeated examination (2-3 office visits 1-4 week intervals, out of office BP measurements preferred)
When can HTN be diagnosed at a single office visit
if BP is 180/110 mm Hg or higher and evidence of CVD
idiopathic form of HTN, genetic predisposition, environmental factors
primary HTN
form of HTN with identifiable cause - suspect in patients who are below 30 years of age, resistant HTN and/or malignant HTN
secondary HTN
malignant HTN
hypertensive emergency characterized by presence of severe BP elevation (usually >200/120 mm Hg) and advanced retinopathy, defined as bilateral presence of flame‐shaped hemorrhages, cotton wool spots, or papilledema.
common causes of secondary HTN
renovascular disease, OSA, hypothyroidism/hyperthyroidism, cushing syndrome, primary aldosteroism, pheochromocytoma (adrenal tumor), coarctation of aorta, drug or alcohol induced
screening for secondary HTN
drug resistant HTN? new onset of hTN? adding more hypertensives to previously controlled? below 30 years of age? malignant Htn? disproportionate target organ damage for degree of HTN (retinopathy, stroke, LVH, pulmonary edema, etc)? onset of diastolic HTN in older adults? unprovoked or excessive hypokalemia
common medication/substances that can cause secondary HTN
alcohol, amphetamines, antidepressants (MAOIs, TCA, SNRI) caffeine, NSAIDS, atypical antipsychotics (clozapine, olanzapine), st johns wort, decongestants, immunosuppressants (cyclosporine), oral contraceptives, cocaine, bath salts, corticosteroids, nicotine replacement therapy, withdrawal (beta blocker withdrawal, etc)
First 4 classes of drugs for HTN treatment (no compelling indications, no sign of organ issues)
ACE inhibitors, ARBs, DHP-CCBs, thiazide direutics
Step 1 of treatment of essential HTN
ACE/ARB and a CCB
Step 2 treatment of essential HTN
increase dose of ACE and CCB
Step 3 treatment of essential HTN
ACE/ ARB, CCB at increased dosages and add thiazide
Step 4 treatment of essential HTN
ACE/ARB, CCB, thiazide, add spironolactone or other agents depending on comorbities
blood pressure goals
< 130 / 80 mmHg (except for elderly patients) – control within 3 month of pharmacological intervention
What meds to start for HTN in patients with heart failure
ACE/ARB, spirnolactone, and beta blocker
What meds to start for HTN in patients with MI/CAD
ACE/ARB, beta blocker (add CCB for angina)what
what meds to start for HTN in patients with DM
ACE/ARB for first line reduce albuminuria (renal protector)
What meds to start for HTN for patients with CKD
ACE/ARB reduce albuminuria
Considerations for ethnicity in treating HTN
black populations need to be started on two agents right away given resistance to HTN treatment; thiazide and CCB (or CCB and ARBs but consider angioedema)
first choices for HTN treatment in pregnant patients
CCB (nifedipine)
beta blockers (in first trimester)
ACE inhibitors (prils) - MOA
prevent conversion of angiotensin I to II (which stimulates aldosterone and increases Na and water absorption and vasoconstriction ) – decreased Na/H2o retention and decreased peripheral resistance
ACE inhibitor& ARBs - side effects
dry cough - more so with ACE (1-2 weeks after initaiton - can switch to ARBs)
monitor for hypokalemia (especially on potassium sparing diuretics, RAS)
risk of ARF in patients with RAS
do not use WITH arbs/direct renin inhibitors
contraindicated in patients with history of angioedema with ACEI
avoid in pregnancy
ARBs (sartans) - MOA
directly inhibit angiotensin II
calcium channel blockers
inhibit L type calcium channel in cells
CCB: Dihydropyridines (-dipines)
potent vasodilator, do not affect cardiac contractility
pedal edema common side effect
avoid in heart failure /reduced EF as it causes refractory tachycardia (except for amolodipine and felodipine)
Which DHP -CCB can be used in HF patients
amlodopine and felodipine
Nondihydropyridines CCB (diltiazem, verapimil)
directly affect cardiac muscle
reduce proteinuria
constipation common side effect
causes bradycardia, reduces CO
nondihydropyridines CCB (diltiazem, verapamil) are contraindicated in which patients
not used in heart failure / low EF/ sick sinus syndrome and heart blocks
Thiazide diuretics (Chlorathidone **, HCTZ, indapamide, metolazone)
decrease water and sodium reabsorption
monitor for hyponatremia and hypokalemia
use with caution in gout
why use thiazide with ACE inhibitors
ACE inhibitors retain potassium so counteracts hypokalemia affect of thiazide
aldosterone antagonists (spironolactone)
preferred agents in primary aldoesteronism
add ons for stage IV HTN, and HF
monitor for hyperkalemia
gynecomastia and impotence***
beta blockers - indications, MOA, SEs
reserved for post MI/CHF/AF/pregnancy
reduce heart and contractility
not first line for HTN
SEs - fatigue, bradycardia, increase glucose (can mask hypoglycemic awareness)
cardioselective B blockers (only work on beta 1)
beta 1 - those with asthma/COPD
atenolol, betaxolol, bisoprolol, metoprolol
combined alpha and beta blockers
carvedilol and labetolol (often used in ICU settings) - very hypertensive patients
Non cardioselective beta blockers
nadolol, propranolol
beta blockers for HF
metoprolol, labetolol, bisoprolol
direct renin inhibitors (aliskiren)
SEs - RAS, hyperkalemia
avoid in pregnancy
do not use in combination with ACEI or ARBs
Vasodilators (-zosin)
add ons for BPH with HTN
specifically for orthostasis so prescribed overnight
hydralazine (vasodilator)
stimulates nO production in endothelial cells
SEs- fluid retention, reflex tachycardia (not good for patients with cardiac issues/HF)
minoxidil (vasodilator)
SEs- reflex tachycardia, fluid retention
**used with resistant HTN, use with diuretic and beta blocker
Clonidine
last line treatment for HTN
resistant HTN
CNS side effects - need to wean to avoid HTN crisism
methyldopa
for pregnant patients
Loop direutics (-mides) when preferred?
symptomatic CHF
replaces thiazide
moderated to severe CKD with GFR of less than 30
Pharmacological approach to refractory HTN
HTN maintained on 4 meds; rule out reasons for secondary HTN
maximize direuetic therapy –>
add mineralcorticosteroid receptor antagonist (i.e. spirnolactone)
add other agents with different mechanisms of action (SVR, preload, contractility/HR with beta blocker or CCB, etc)
use loop diuretics with CKD or patients on minoxidil
HTN emergency vs HTN urgency
elevated HTn (SBP >180, DBP >120) with signs of TOD
urgency - severe elevation in bP without acute TOD
Reduction of HBP in aortic dissection
rapid reduction in BP to SBP <120 mm Hg within 20 minutes; beta blockade first –> esmolol, labetalol
Reduction of HBP in acute pulmonary edema
clevidipine, nitro, nitroprusside –> BETA BLOCKERS CONTRINDICATED!!; diuretics
Reduction of HBP in ACS
esmolol, labetalol, nicardipine, nitro
Reduction of. HBP in acute renal failure
acute hypertensive hephrosclerosis
proteinura, hematura, elevated creat
clevidipine, fenoldopam, nicardipine
Reduction of HBP in eclampsia
rapid lowering of SBP <140 in 1st hour
hydralazine, labetalol, nicardipine
CONTRAINDICATED - ACE/ARB/ Renin I/ SNP
Reduction of HBP in acute ICH (less than 6 hours from onset)
reasonable to streat SBP > 220 with continous IV infusion with close BP monitoring
Keep SBP < 150
labetalol, nicardipine, clevidipine
Management of HBP in acute ischemic stroke
bp is NOT lowered unless it is >185/100 in candidiates for reperfusion tx or 220/120 for those who are not candidates
labetalol, nicardipine, clevidipine
Management of HBP in phemochromocytoma
rapid lowering of SBP <140 1st hour
clevidipine, nicardipine, phentolamine
management of HBP due to ingestion of cocaine, amphetamines, tyramine with MAOIs
phentolamine, nitroprusside
beta blockers contraindicated due to unopposed alphra-adrenergic vasoconstriction
Management of HBP due to severe autonomic dysfunction (guillian barre, acute spinal cord injury)
nitroprusside, phentolamine
Beta blockers contraindicated
Management of HBP due to HTN agent withdrawal
happens usually with beta blockers and clonidine
treatment includes reinstating agent, short acting IV initially
who goes straight to high intensity statin regimen
hx of heart disease, 40-75 years, LDL >190, dx DM or risk of CAD; risk greater than 7.5 % on 10 year risk
what should someone on statins avoid
grapefruit juice - can decrease breakdown of statins in blood and lead to higher side effects
initial labs before statin therapy
lipid panel, lft’s, bmp ; lipid panel every 6 weeks after therapy and adjusting dosage and then every 4 months
what HTN medication for those with renal disease/kidney dysfunction
ACE/ARB
lovaza (omega 3 fatty acid) - dose? when to take? indication? caution?
4 g daily or BID with meals
for severe (OTC fish oils
hypertriglyceridemia
caution in those with fish or shellfish allergy, heptic impairment, bleeding risk
fibrates (gemfibrozil, fenofibrate, clofibrate) - indications?
hypertriglyceridemia, hyper cholesteremia, mixed disylipidemia
what drug should be added to statin therapy for high risk patients before considering a pck 9 inhibitor
ezetimbie
when should a lipid panel be repeated after initiating therapy? how often are the panels repeated until levels are controlled? when control is achieved, how often do you repeat lipid panel
4-6 weeks repeat
every 3-4 months
every 6-12 months after control achieved
PCSK9 inhibitors
alirocumab, evolocumab
