HTN Day 1 Flashcards
What are the risk factors for HTN
Cigarette smoking Obesity (BMI>30) Sedentary life style Dyslipidemia DM Renal Dysfunction Age: men>55, women>65 Fam Hx
Essential HTN makes up what percent of HTN cases
90%
Hereditary component
Secondary HTN makes up what percent of HTN cases and what are the common causes?
<10% of cases
Chronic Kidney Disease
Renovascular disease
Systolic BP
number that represents cardiac contraction
Diastolic BP (DBP):
Number that represents nadir (lowest point)…filling of the heart
Cardiac Output:
Amount of blood pumped out by the ventricles (represent the SBP)
Total Peripheral Resistance (TPR):
Sum of peripheral resistance in peripheral vasculature (represents DBP)
BP=
CO X TPR
What are the mechanisms of pathogenesis for HTN
Increased peripheral resistance
Increases CO
How does Increased peripheral resistance contribute to HTN
functional vascular constriction/vascular hypertrophy:
- Over activity of sympathetic nervous system
- Genetic component
How does Cardiac output cause HTN
Increased preload via:
Increased fluid volume
Excess sodium intake
Renal sodium retention
how does venous constriction cause increase cardiac output with HTN
excess RAAS stimulation
Sympathetic nervous system over activity
JNC8 BP goal:Patients ≥60 years old goal?
<150/90
JNC8 BP goal:Patients <60 years old goal?
<140/90
JNC8 BP goal:Patients with DM and CKD?
<140/90
Patient with DM according to ADA BP goal?
<140/80
Majority of patients will require how many medications to reach goal?
at least two
What are non-pharmacological therapy to treat HTN
smoking cessation weight loss DASH diet sodium reduction Increase physical activity limit alcohol intake to no more than 1-2/day
What is the most effective non pharmacological treatment to reduce blood pressure
weight loss
What are the 1st line options for HTN treatment
Thiazides, CCB’s, ACE-I, ARB’s
What would be best choice for a black patient
Thiazides or CCB
What would be the best treatment for DM or chronic kidney disease
ACE or ARB
What would be the best treatment option for a patient with cardiac history
beta-blocker
What is the treatment approach 1st option
Start with 1 drug and max the dose and then add on a 2nd agent if still not at goal, and then add on a 3rd agent once the 2nd drug is maxed out if pt. still not at goa
What is the treatment approach 2nd option
Start with 1 drug and if not at goal add a 2nd drug prior to maxing out the dose on the first. Then max the dose on both drugs and if not at goal add a 3rd agent
What is the treatment approach 3rd option
Start with 2 drugs from the beginning if the SBP >160 and/or the DBP >100. Max out the drug doses and add on a 3rd agent if needed.
What drugs are part of the the thiazide diuretics
HCTZ, chlorthalidone, metolzone (most potent diuretic)
what is the MOA for Thiazide diuretics
Inhibits sodium reabsorption in the distal tubule.
what are the adverse effects of Thiazide diuretics
Orthostatic hypotensionElectrolyte abnormalities: ↓ K, ↓ Na, ↑ Ca, ↑ uric acid, ↑ glucose
What are the allergy precautions with thiazide diuretics
Caution in sulfa allergic patients
Ineffective in patients with severe renal disease
Avoid in patients taking lithium– may increase serum lithium concentrations
What are the loop diuretics
Furosemide (Lasix™)
Bumetanide (Bumex™)
Torsemide (Demadex )
what is the MOA for loop diuretics
Inhibits active transport of sodium, chloride and potassium in thick ascending limb of Loop of Henle, causing excretion of these ions
Collecting duct excretes more water in response
What are loop diuretics used in therapy of
CHF
Edema both pulm and peripheral
HTN
what are the adverse effects of loop diuretics
Electrolytes abnormalities: ↓ K, ↓Na, ↓ Ca, ↓ Mg, ↑ uric acid
Increase in SCr
Dehydration
Ototoxicity
What are the precautions with loop diuretics
sulfa allergies
nephrotoxicity
What drugs are aldosterone receptor blockers:
spironolactone
eplerenone
what is the MOA for aldosterone receptor blockers:
Competes with aldosterone, prevents sodium reabsorption and potassium excretion
what are potassium sparing drugs
Triamterene
Amiloride
what is the MOA for potassium sparing drugs
blocks sodium reabsorption and potassium excretion, effect independent of aldosterone
What potassium sparing drugs is used for class IV heart failure
spironolactone
what are the adverse effects with potassium sparing diuretics
hyperkalemia ( need to watch with patients who have renal failure)
what are the adverse effects of spironolactone?
gynecomastia
menstrual irregularities
what are the benefits of eplerenone
more selective
less side effects
more expensive
What do you need to educate your patients about using potassium sparing diuretics?
people who are using salt substitutes have potassium in them which can cause hyperkalemia affecting the heart
What drugs are part of the ACE inhibitors
anything that ends in -pril Captopril Enalapril Lisinopril Ramipril
what is the MOA for ACE-I
inhibits ACE to block the production of AT II
Inhibits the breakdown of bradykinin
What are the benefits of ACE-I and
Disadvantages
lowers BP
Dilate the efferent arteriole of kidney
Inflammatory mediator
What are ACE-I used for?
One of the first line drug classes in HTN
First line option for CKD (chronic kidney disease)
Used in CHF
In practice use for DM
What do you need to monitor with ACE-I?
Serum K+ & SCr within 4 weeks of initiation or dose increase. You will likely see a benign increase in Scr (<30% from baseline)
what are the adverse effects with ACE-I
Cough due to increased bradykinin
Angioedemia
Hyperkalemia: esp in patients with DM or CKD
Neutropenia, agranulocytosis, proteinuria, glomerulonephritis, acute renal failure
what are the contraindications with ACE-I?
pregnancy-childbearing age
angioedema
renal artery stenosis
what are the drug interactions with ACE-I?
potassium supplements
Potassium sparing diuretics
NSAIDs
how often is captpril dosed?
dosed 2-3 times daily
Which of the ACE-I is a prodrug and only available IV?
Enalapril
Which is the most commonly used ACE-I and what are the doses?
Lisinopril
10-40mg daily
What decreases the absorption of captopril and by how much
when given with food and by 30-40%
what drugs are part of the ARB drug class?
anything that ends in -sartan candesartan eprosartan irbesartan losartan valsartan
what is the MOA for ARB
Inhibits angiotensin II at its receptor sites
Does NOT inhibit the breakdown of bradykinin
What is ARB used for therapy in?
One of the first line drug classes in HTN
First line option for CKD
Used in CHF
what do you need to monitor with ARB?
potassium
angioedema
what are the adverse effects of ARB’s?
Hypotension/orthostatic hypotension Angioedema Hyperkalemia Dizziness Cough
What are ARB’s contraindicated with?
Pregnancy
Caution in pt’s with renal artery stenosis
ARB’s can be used in patients who have angioedema with an ACE but use caution
what are the drug interactions for ARBs?
potassium supplements
potassium sparing diuretics
NSAID
what drug is a renin inhibitor
Aliskiren
What is aliskiren contraindicated with?
ACE or ARB because it causes kidney damage
What drugs are part of the beta blocker drug class
atenolol- dosed once a day
Metoprolol succinate- dosed once a day
metoprolol tartrate- dosed twice a day
Beta blockers Reserved for patients that have significant history of what?
cardiac history Heart failure Post MI High coronary artery disease CKD
what is the MOA for beta blockers?
Beta-1 receptors; located in heart and beta-2 receptors are located in the lungs
Beta-blockers block beta-1 receptors thus decreasing the effects of epinephrine, and nor-epinephrine which therefore decrease BP and HR
What are the 4 categories of beta blockers
Cardioselectivity
Mixed α and β blockers
what drugs are part of the Cardioselective category?
AMEBBA Atenolol metoprolol esmolol bisoprolol betaxaolol acebutolol
what drugs are part of the Mixed α and β blockers category?
Carvedilol
labetalol
what drugs are part of the ISA category?
CAPP Carteolol- take with food Acebutolol Penbutolol Pindolol
what drugs are part of the non specific category?
Nadolol
propanolol-migrane tx
Timolol
What beta blockers are used for heart failure?
Bisoprolol
Carvedilol
metoprolol succinate
what are common adverse effects of beta blockers
“beta blocker blues”
Tire, fatigued, depressed, tight chest due to change in heart beat
Sexual dysfunction, rebound HTN
what are relative contraindications of beta blockers?
Asthma & COPD Diabetes (masks hypoglycemia) Severe peripheral vascular dz heart block severe acute heart failure Pregnancy
what class does sotalol belong too
class III anti-arrhythmic (beta-blockers)
