HTN & HF Meds

Question 1

Medications for hypertension (classes)

Answer 1

Diuretics, RAAS agents, Adrenergic Agents, Calcium channel blockers, vasodilators

Question 2

Med classes for heart failure

Answer 2

Same for hypertension, cardiac glycosides, neprilysin inhibitor/ARB combo

Question 3

Action of diuretic

Answer 3

Block sodium and chloride reabsorption in kidney, preventing passive reabsorption of water, excretion of sodium, chloride and water.

Question 4

Classes of diuretics

Answer 4

Loop - action at loop of henle

Thiazides - Action at distal convoluted tubule

Potassium Sparing - action at late distal convoluted tube and collection ducts

Osmotic - inhibits passive water reabsorption

Question 5

Furosemide (LASIX)

Answer 5

Class: Loop Diuretic
Indication: volume overload, edema. Sometimes for HTN, mostly HF
MoA: Loop Diuretic
CV effect: decreases volume, preload and afterload

ADE: Volume depletion (diuresis), dehydration, 4 HYPOS: hypotension, hypokalemia, hypomagnesemia, hypokalemia, HYPERglycemia, ototoxicity
Interactions: anti hyper sensitive, digoxin, NSAIDS, aminoglycoside antibiotic. CAUTION with sulfa allergy.

CONSIDERATIONS:
Low doses - eat K+ rich foods to avoid hypokalemia
High doses - supplement potassium (risk of dysrhythmias)
Frequent urination

Question 6

Hydrochlorothiazide (HydroDiuril)

Answer 6

CLASS: Thiazides Diuretic
INDICATION: Hypertension, mild/moderate edema. Less frequent use in HF than furosemide
MoA: Thiazides diuretic
CV EFFECTS: decrease blood volume, preload and afterload
ADE: volume depletion, dehydration, hyperglycemia. 5 HYPOS: Hypokalemia, hypotension, hyponatremia, hypomagnesemia, hypocalcemia
INTERACTIONS: antihypersensitives, NSAIDs, *caution sulfa allergy

Question 7

Spironolactone (Aldactone)

Answer 7

CLASS: Potassium sparing diuretic, aldosterone antagonist
INDICATION: HTN, edema, HF
MECHANISM: blocks aldosterone action at late distal tubule & collecting ducts, (excretion of salt and fluid, retention of potassium). Can block aldosterone effects in HF (remodeling, fibrosis, etc)
ONSET: 24-72 hours (transcription)
ADE: hyperkalemia, endocrine effects (menstrual irregularities)
INTERACTIONS: antihypersensitives, ACE-Inhibitors and ARBs

Question 8

Lisinopril (Prinivil, Zestril)

Answer 8

CLASS: ACE inhibitor
INDICATION: HTN, HF, MI, nephropathy
MECHANISM: ACE inhibitor, blocks conversion of ang-I to ang-II by inhibiting ACE
CV EFFECTS: vasodilation, decrease after load, preload and Na+ reabsorption, decreased cardiac remodeling
ADE: hypotension, hyperkalemia, cough (bradykinin inflammation), dysegeusia, angioedema, rash
INTERACTIONS: diuretics or anti-hypertensives, K+ supplements and K+ sparing diuretics

CONSIDERATIONS:
NOT for use during pregnancy. Is the only ACEI that is NOT a prodrug.

Question 9

Losartan (Cozaar)

Answer 9

CLASS: Ang-II receptor blocker
INDICATION: hypertension, HF, diabetic nephropathy
MOA: Blocks type-1 Ang-II receptor in blood vessels, heart, adrenals
CV EFFECT: Dilation of arterioles and veins, prevents cardiac remodeling, decreases aldosterone release, decrease blood volume and preload/afterload
DISTRO: 98% protein bound, first pass effect
ADE: Hypotension, angioedema (rarer), rash. Less incidence of cough
INTERACTIONS: diuretics or antihypertensives, K+ supplements, grapefruit juice
CONTRAINDICATION: pregnancy, bilateral renal artery stenosis

Question 10

Prazoisin (Minipress)

Answer 10

CLASS: Alpha-1 receptor antagonists
INDICATION: Hypertension
MOA: alpha-1 adrenergic blocker/antagonist… dilates arterioles and veins
ADE: Orthostatic hypotension (blood pooling in extremities), Reflex tachycardia
CONSIDERATION: All alpha blockers can cause “first dose” effect due to sever postural hypotension. Dosing should start low and slow

Question 11

Metoprolol (Lopressor)

Answer 11

CLASS: Beta-1 receptor antagonists (selective beta blocker)
INDICATION: HTN, HF, Angina, MI
MOA: beta-1 adrenergic blocker/antagonist. Cardioselective
CV EFFECT: lower HR and contractility (low bp), decreases AV conduction, reducing workload and oxygen demand of the heart
ADE: bradycardia, hypotension, fatigue, decreased CO, heart block, dizziness. Can mask symptoms of hypoglycemia
INTERACTIONS: antihypertensives
CONTRA: bradycardia and AV block (1st degree).

BBW!!! Taper taper taper.

Question 12

Carvedilol (Coreg)

Answer 12

CLASS: Mixed beta-1 and alpha-1 antagonists
INDICATION: HF, HTN
MOA: mixed beta-1 and alpha-1 blockade. Beta: decrease HR, AV conduction contractility, renin release. Alpha: vasodilation
CONSIDER: food decreases rate of absorption but not the extent. Give with food to decrease postural hypotension
ADE: Bradycardia, dizziness, fatigue, postural hypotension.
INTERACTIONS: antihypertensives (additive), increases serum concentration of drugs that are P-glycoproteins substrates

Question 13

Clonidine (Catapres)

Answer 13

CLASS:  alpha-2 agonist
INDICATION:  HTN, other
MOA: Central NS alpha-2 activation
ADE:  bradycardia, decreased CO, hypotension, drowsiness, constipation, rebound HTN if not tapered, nightmares, CNS effects. Hallucinations at high doses (think CNS) 
INTERACTIONS:  anti-hypertensives 
CONTRA:  pregnancy

Question 14

Verapamil (Isoptin)

Answer 14

CLASS: non-dihydropyridine calcium channel antagonists
INDICATION: angina, hypertension, dysrythmias
MOA: blocks Ca2+ channels in vascular smooth muscle, myocardium and SA/AV nodes
CONSIDER: pay attention when given IV!!! Extensive first pass effect
ADE: constipation, hypotension, bradycardia, edema, dizziness, headache, flushing, AV block
INTERACTIONS: digoxin, beta blockers, antihypertensives (additive), grapefruit, dabigatran (p-gly substrate)
CAUTION: cardiac conduction disturbances, heart block

Question 15

Nifedipine (procardia)

Answer 15

CLASS: Dihydropyridine calcium channel antagonist
INDICATION: Angina, hypertension
MOA: blocks calcium channels in vascular smooth muscle cells (first pass effect!)
ADE: reflex tachycardia, peripheral edema, dizziness, headache, flushing (vasodilation), rash.
INTERACTION: beta blockers, grapefruit. Loses selectivity at high doses (TOXIC)

Question 16

Hydralazine (apresoline)

Answer 16

CLASS: Vasodilator
INDICATION: HTN, HF, (short term)
MOA: direct acting vasodilator - stimulates release of NO from endothelium, acting on arterioles NOT veins.
ADE: hypotension, reflex tachycardia, fluid retention, headache, dizziness, fatigue (hypotension), systemic lupus erthematosus - like reaction RARE.
CONSIDER: less likely to cause orthostatic or postural hypotension because it does not venodilate

Question 17

Sacubitril/Valsartan (Entresto)

Answer 17

CLASS: ARNI
MOA: combo of neprilysin inhibitor and ARB.
INDICATION: reduce risk of CV death and hospitalization for HF patients with NYHA class 2 IV HF and reduced ejection fraction
ADE: hypotension, hyperkalemia, cough, dizziness, renal failure
INTERACTIONS: ACEIs and ARBs (additive), NSAIDs (renal), K+ sparing diuretics, lithium

BBW! Pregnancy, Hx of ACEI or ARB angioedema. Must discontinue all ACE inhibitors 36 hours before starting the drug

Question 18

Digoxin (Lanoxin)

Answer 18

CLASS: cardiac glycoside
INDICATION: HF, a-fib,
MOA: inhibits sodium potassium pump in CV tissues, increases contractility (positive inotrope). Increases arterial pressure, decreases HR, renin and preload
CONSIDER: narrow therapeutic range.
ADE: Cardia dysrhthmias (SA and AV effects, especially with hypokalemia), fatigue, visual disturbances, GI probs - 1st sign of toxicity
CAUTION: hypokalemia (competes with K+ for pump receptors)
INTERACTIONS: Diuretics, ACEI, ARBs, beta blockers, CCBs, MANY others

NOTE: Digoxin Immune Fab can blue used to revers effects of toxicity or overdose. Digoxin improves symptoms but does not prolong life.