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NRS 271B > HTN & HF > Flashcards

HTN & HF Flashcards

1
Q

When to reassess BP

A
  • If normal:
    • 1 year
  • if elevated (120-129/<80):
    • 3-6months
  • if stage 1: (130/80- 139/89)
    • ASCVD ≥ 10% = 1 month
    • ASCVD <10% =3-6 months
  • if stage 2: (≥ 140/90)
    • 1 month
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2
Q

Isolated Systolic HTN (ISH)

A

SBP > 160, but DBP <90

mostly in elderly (>60yo)

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3
Q

Masked HTN

A

BP consistently high at home, but normal in office

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4
Q

Malignant HTN

A

mod-severe HTN leads to:

  • retinopathy
  • encephalopathy
  • nephrosclerosis
  • DBP > 120 usually, but can happen at 100 mmHg
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5
Q

Hypertensive Emergency vs Urgency

A
  • Emergency:
    • DBP > 120, with evidence of acute organ damage; can be life-threatening
  • Urgency:
    • DBP > 120 mmHg, asymptomatic, no evidence of acute organ damage
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6
Q

Major Causes of Secondary HTN

A
  • Medications:
    • oral contraceptives (high in estrogen)
    • NSAIDS, TCA, & SSRIs
    • Glucocorticoids
    • decongestants
    • EPO
    • Cyclosporin
    • Stimulants
  • illicit drugs: cocaine, meth
  • primary aldosteronism: HTN + HypoK + metabolic alkalosis
  • Obstructive Sleep Apnea
  • Endocrine disorders
  • Pheochromocytoma: catecholamine secreting tumor
  • Renal Vascular Stenosis
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7
Q

Complications of HTN

A
  • LVH
  • HF
  • Ischemic Stroke
  • Intra-cerebral Hemorrhage
  • MI
  • Ischemic Heart disease
  • CKD & ESRD
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8
Q

Thiazides

A
  • The med names:
    • Hydrochlorothiazide,Chlorothiazide, Chlorthalidone (x2 as potent as HCTZ), Metolazone (10x as potent as HCTZ), Indapamide (10x as potent as HCTZ), Methyclothiazide
  • MOA: act on the distal convoluted tubule and inhibit Na+ reabsorption via the NaCl pump
  • SEs:
    • dose related
    • hypoK+ and hypoMg, hyper Ca2+
    • hyperuricemia → gout flare
    • hyperglycemia
    • increase TGs → decrease efficacy of fibrates
    • limited efficacy when CrCl <30mL/min
      *
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9
Q

Loop Diuretics

A
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10
Q

Loop Diuretics

A

40mg furosemide = 20 mg torsemide = 1 mg bumetanide

ethacrynic acid = indicated in pts with sulfa allergy

  • SEs:
    • HypoNa, HypoK, Hypo Mg, HypoCa
    • potential sulfa allergy contra-indication → use ethacrynic acid
  • torsemide and bumetanide have a greater bioavailability and duration than furosemide
  • 40mg furosemide IV → response in 30min - 1 hour (output ≥ 1mL/kg/hr)
  • can double dose if AKI pt with fluid overload is not initially responsive → if still not responsive then add thiazide
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11
Q

K+ Sparing Diuretic

A

Amiloride & Triamterene

  • MOA:
    • inhibits the sodium potassium exchange in the distal tubule by selectively blocking sodium transport
  • often used together with K+ wasting diuretics
  • have modest diuresis
  • contribute to hyperK+
  • DDI:
    • ACE, ARB, K-supplementation, NSAIDs
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12
Q

Aldosterone Antagonist

A

Spironolactone & Eplerenone

  • Indications:
    • Used together with thiazide or loop diuretic
    • low dose + ACE-I or ARB for resistant HTN
  • SEs:
    • gynecomastia
    • hyperK+
    • eplerenone minimally affects androgens and progesterone compared to spironolactone
  • Contraindications:
    • CrCl <50ml/min for HTN
    • Scr >1.8 in females
    • Scr >2 in males
    • DM with microalbuminuria
    • K >5.5 mg/dL
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13
Q

Selective Beta-blocker with positive intrinsic sympathomimetic activity

A

Acebutolol

can increase HTN due to the sympathetic activation

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14
Q

Indications for Dihydropyridines

A

HTN

Angina Pectoris

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15
Q

Indications for Verapamil & Diltiazem

A

Non-dihydropyridines

  • HTN
  • Angina
  • Supraventricular arrhythmias
    • A. Fib/Flutter
    • Paroxysmal Supraventricular Tachycardia (PSVT)
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16
Q

How do Nifedipine, Diltiazem, & Verapamil affect Vasodilation, depression of cardiac contractility, depression of SA node/ AV node

A

Diltiazem & Verapamil = decrease velocity

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17
Q

ACE-Inhibitors

A
  • meds that end in “pril” → most common: captopril, enalapril, lisinopril
  • Dosing: initiate at a low dose with gradual titration to target doses (or max tolerated dose)
  • SEs: (Caused by increased Bradykinin)
    • CHAD has a cough
    • Cough, Hyperkalemia, Hyperuremia (monitor serum creatinine→ only allow increase of 30% or creatinine > 3mg/dL; and BUN)
    • Angioedema, Dose 1 syncope/hypotension
  • Contraindications:
    • Pregnancy
    • Bilateral Renal Artery Stenosis
    • K > 5.5 mEq/L
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18
Q

ARBs

A

Angiotensin-2 Receptor Blockers

end in “sartan” → Losartan, Valsartan, Candesartan

  • Only Losartan & Valsartan = approved for Heart Failure
  • Dosing: initiate at a low dose with gradual titration to target doses (or max tolerated dose)
  • SEs: Same as ACE-I WITHOUT the cough
    • Hyperkalemia, Hyperuremia (monitor serum creatinine & BUN)
    • angioedema, dose 1 hypotension/syncope
  • Contraindications:
    • Pregnancy
    • Hypersensitivity
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19
Q

Renin Inhibitors

A
  • Aliskiren (Tekturna)
    • first in class
    • MOA: directly blocks renin → reduce plasma renin activity
    • monitor serum K+, kidney fxn – similar to ACEI/ARBs
    • caution with renal dysfxn & stenosis
    • Pregnancy Cat. D – may cause harm to fetus
  • Aliskiren/amlodipine/ HCTZ
  • Aliskiren/Amlodipine
  • Aliskiren/ HCTZ
20
Q

Alpha-1 Blockers

A
  • Doxazosin, Prazosin, Terazosin
  • Indications:
    • Benign Prostatic Hyperplasia
  • SEs:
    • syncope, dizziness, palpitations
  • Contraindications:
    • Hypersensitivity
21
Q

Direct Vasodilators

A
  • Isosorbide dinitrate, hydralazine, minoxidil
  • Indications:
    • heart failure with elevated BP
      • (isosorbide dinitrate + hydralazine in African Americans)
  • SEs:
    • Edema (minoxidil)
    • Tachycardia
    • Lupus-like syndrome (hydralazine)
  • Contraindications:
    • hypersensitivity, pheochromocytoma, acute closure glaucoma, head trauma or cerebral hemorrhage
22
Q

Central Alpha-2 Agonists

A
  • Methyldopa, clonidine, guanabenz, guanfacine (also used for ADHD)
  • SEs:
    • hepatotoxicity, hemolytic anemia, peripheral edema (methyldopa)
    • Orthostatic Hypotension (methyldopa, clonidine)
    • Dry mouth, muscle weakness (clonidine)
    • Abrupt D/c of clonidine → severe rebound HTN
      • beta-blocker + clonidine → taper BB off first then clonidine
23
Q

Drug Class Recommendations for Heart Failure

A
  • Diuretic, aldosterone antagonist, Beta-Blocker, ACE-I, ARB, Direct Vasodilator
24
Q

Drug Class Recommendations for Post-MI

A
  • Aldosterone antagonist, BB, ACE-I
25
Drug Class Recommendations for **High Coronary Disease Risk**
Diuretic, Beta-Blocker, CCB, ACE-I
26
Drug Class Recommendation for **Diabetes**
Diuretic, Beta-blocker, CCB, ACE-I/ARB
27
Drug Class Recommendation for **Chronic Kidney Disease**
ACE-I, ARB
28
Tx of HTN + Diabetes
1. ACE-I/ARB +/- CCB or thiazide 2. Thiazide, CCB, ACE-I, or ARB
29
Tx of HTN + nonblack, no comorbidities
* Thiazide, CCB, ACE-I, or ARB
30
Tx of HTN + African American & no co-morbidities
* Thiazide or CCB
31
Tx of HTN + CKD
ACEI or ARB +/- CCB or thiazide
32
Tx of HTN + Stroke Hx
* ACE-I or ARB +/- CCB or thiazide
33
Tx of HTN + Heart failure
ACE-I or ARB + BB
34
Tx of HTN + CAD
ACEI or ARB + BB
35
When to have BP of pt re-checked after initiation of HTN therapy and what to do if not at goal
* Reassess in 2-3 weeks * if not at goal: assess adherence to drugs, lifestyle changes * Increase dose, or add thiazide, CCB, ACE-I, or ARB * monitor q 2-3 weeks and increase dose/add agent until controlled
36
Tx of Chronic HTN in pregnancy
**Methyldopa** = first line therapy * labetalol * Beta-blockers
37
Compensatory Mechanisms of Heart Failure
* **Frank-Starling Law**: ability to change force of contraction and thus stroke volume in response to changes in venous return * **Neurohormonal Activation** * **Ventricular Remodeling**
38
ACCF/AHA Stages of HF: Structural Changes and Symptoms
* _Stage A_: * At high risk for HF but **without** **structural heart** disease **or symptoms** of HF * _Stage B:_ * **Structural heart disease** but **without signs or symptoms** of HF * _Stage C_: * **Structural heart disease** **with** **prior or current symptoms** of HF * _Stage D_: * **Refractory HF** requiring specialized interventions
39
Stage A Heart Failure Tx
High risk but no structural changes or s/sxs * HTN & lipid disorders should be controlled * Other conditions should be managed such as: * obesity, DM, tobacco use, & known cardiotoxic agents
40
Stage B Heart Failure Tx
**Structural heart disease** but **without** **signs or symptoms** of HF * in all pts with a recent or remote hx of MI or ACS and reduced EF * **ACE-I** * to prevent symptomatic HF and reduce mortality * **Beta-Blockers** * **Statins** * to prevent symptomatic HF and cardiovascular events * **Non-dihydropyridine CCBs** with negative inotropic effects: * **May be harmful in asymptomatic patients with low LVEF and no sxs of HF after MI**
41
What med classes do we give to ALL pts with reduced EF even if they do not have a hx of MI?
**ACE-I & Beta-blockers**
42
Effects of RAAS inhibitors
* **Decrease** ventricular remodeling * **Decrease** myocardial fibrosis * **Decrease** myocyte apoptosis * **Decrease** cardiac hypertrophy * **Decrease** NE release * **Decrease** vasoconstriction * **Decrease** Na/H20 absorption * **Increase** vasodilation
43
Stage C Heart Failure Tx (HFrEF Stage C)
* ACE-I or ARB **_and_** Beta-blocker * For all volume overload NYHA class II-IV pts: **Loop diuretics** * For persistently symptomatic African Americans, NYHA class III-IV add: **hydralazine + long-acting nitrates** * For NYHA class II-IV patients add: **Aldosterone Antagonists (eplerenone, spironolactone)** Provided estimated creatinine \> 30mL/min and K+ \< 5.0 mEg/dL
44
Hydralazine/Isosorbide Dinitrate
* _MOA_: * **hydralazine**: direct **arterial vasodilator** (decreases afterload) * **Isosorbide Dinitrate**: **venodilator** (decreases preload) * _Clinical Considerations_: * Benefits in AAs * decreased rate of the first hospitalization for HF * improved quality of life score * useful in pts unable to tolerate RAAS inhibitors * _SEs_: * headache, dizziness & GI complaints → all due to vasodilation in periphery
45
Digoxin
* _MOA_: **inhibits the Na-K ATPase** * leads to **positive inotropic** (contractility) effects * **parasympathomimetic actions** (increased vagal tone), decreased RAAS output * _Dosing_: 125-250 mcg/day * loading dose not required for managing HF * _Adverse Effects_: * CNS (dizziness, HA, confusion), GI intolerance (N/V) * toxicity can occur at any level (frequently \>2ng/mL) * _Monitoring_: * electrolytes (Ca, Mg, K), vital signs (BP&HR), digoxin serum levels * _Indications_: * symptom improvement
46
Stage D Advanced (or End-Stage) Heart Failure Tx
* tx s/sxs of fluid retention * evaluate need for cardiac transplant or medical intervention (LV assist device) * **consider use of positive inotropes IV** in outpatient setting **Positive Inotropic Therapy**: * **_Dobutamine_** (Dobutrex): * _MOA_: stimulates Beta receptors on heart * mild chronotropic, vasodilative & arrhythmogenic effect * **_Milrinone_** (Primacor): * _MOA_: inhibits the cAMP phosphodiesterase III isoenzyme * increased intracellular ionized Ca2+ and heart contractile forces * arrhythmogenic effects
47
Sacubitril-Valsartan (Entresto)
* _MOA_: **Neprilysin** **(****enzyme that breaks down BNP****)** **inhibitor** and angiotensin receptor blocker * Increased levels of vasoactive peptides, including natriuretic peptides, bradykinin, and adrenomedullin * _Clinical Considerations_: * mortality benefiting therapy * reduced cardiovascular-related hospitalization * fetal-toxicity – d/c as soon as pregnancy is detected * _Contraindicated_: * Hx of angioedema; concomitant use of ACEI or aliskiren

NRS 271B (10 decks)

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