HTN - Kaakeh Flashcards
List the risk factors for HTN: \_\_\_\_ Na+ intake \_\_\_\_\_\_ ethnicity \_\_\_\_\_\_\_ \_\_\_\_\_ K+ intake excess \_\_\_\_\_\_ intake \_\_\_\_\_\_\_\_\_ (FH)
HIGH Na+; African American; Obesity; low K+; excess alcohol; genetic predisposition
Tobacco use - HTN or CVD risk factor?
CVD
Each increment of ___/___ mmHg doubles the risk of CVD across the entire BP range starting from ___/___ mmHg
20/10;
from 115/75
What are CVD risk factors?
- HTN
- Tobacco use
- Overweight
- Dyslipidemia
- Diabetes Mellitus
- Age
- FH
- Physical Inactivity
- Microalbuminuria or GFR < 60
How to be classified with normal Adult BP
Sys < 120 AND Dias < 80
How to be classified with Pre-HTN Adult BP
Sys : 120 - 139 OR Dias 80-89
How to be classified with stage 1 HTN Adult BP
sys: 140 - 159 OR Dias 90-99
How to be classified with stage 2 Adult BP
sys > 160 OR dias > 100
Lowering BP helps lower the incidence of what 3 things
stroke; MI; HF
what are some prescription drugs that can elevate BP
NSAIDs Corticosteroids Estrogens/OCs; Progesterone; Androgen Sympathomimetic Amines Erythropoietin Ketoconazole
what are the 2 determinanys of BP
cardiac output & peripheral resistance
is it primary or secondary cause of HTN?
drug induced
secondary
is it primary or secondary cause of HTN? Humoral abnormality (RAAS, natriuretic hormone, insulin resistance)
primary
is it primary or secondary cause of HTN?
vascular endothelial mechanisms abnormality
primary
is it primary or secondary cause of HTN? neuronal mechanisms (alpha and beta) abnormality
primary
is it primary or secondary cause of HTN?food substances
secondary
is it primary or secondary cause of HTN?
Obstructive sleep apnea
secondary
is it primary or secondary cause of HTN?
CKD
Secondary
is it primary or secondary cause of HTN?
Peripheral autoregulation abnormality
primary
is it primary or secondary cause of HTN?
primary aldosteronism
secondary
is it primary or secondary cause of HTN?
renovascular disease
secondary
is it primary or secondary cause of HTN?
Chronic steroid therapy & Cushings Syndrome
secondary
is it primary or secondary cause of HTN?
Pheochromocytoma
secondary
is it primary or secondary cause of HTN?
electrolyte disturbances
primary
is it primary or secondary cause of HTN?
Coarctation of the aorta
secondary
is it primary or secondary cause of HTN?
thyroid/parathyroid disease
secondary
what food substances can cause HTN
sodium; licorice; ethanol
Illicit Drugs that may elevate BP
ketamine
ectasy
cocaine
Possible symptoms of primary aldosteronism
HA, muscle cramps, polyuria
Primary Aldosteronism:
______kalemia
______natremia
metabolic _______
HYPOkalemia; HYPERnatremia; alkalosis
what types of patients should be tested for primary aldosteronism?
- drug resistant HTN
- mod - severe HTN
- Adrenal tumors
- HTN of FH of HTN before age 40
- if pt has HTN and has 1st degree relative with PA
BP = _____ x _____
CO x TPR
TPR = total peripheral resistance
CO = _____ x _____
HR x SV
What meds can be used to control SV (stroke volume)
diuretics
what meds can be used to control HR (heart rate)
beta blockers; some CCBs
what meds can be used to control TPR (total peripheral resistance)
- ACEIs
- ARBs
- Hydralazine
- Sympatholytics
how to treat primary aldosteronism
surgically remove adrenal tumorl
pretreat w/ 3 - 4 wks of spironolactone 100 mg - 400 mg PO QD
What is the normal range for MAP
70 - 100 mmHG
what value of MAP is needed to perfuse/sustain perfusion of organs
60 mmHg
what 5 areas of the body can be damaged by HTN
- brain
- heart
- eyes
- kidneys
- vasculature
what can happen to the brain if HTN is persistent
stroke; hemorrhage; TIA
what can happen to the heart if HTN is persistent
LVH (left ventricle hypertrophy); CHD; CHF
what can happen to the eyes if HTN is persistent
Retinopathy; AV nicking
what can happen to the kidneys if HTN is persistent
Renal failure; Proteinuria; CKD
how is eye damaged measured (when talk about HTN..?)
with KW values ( KW 1 - 4; KW 4 = most damage)
Initial add on treatment for someone that has CKD (regardless of race or DM)
ACEI or ARB
5 different NON-PHARM life modifications that can be done to help control BP
- weight reduction
- DASH eating plan
- Dietary Na reduction
- Aerobic physical activity
- Moderation of alcohol consumption
DASH diet: what is there Na restriction recommendation?
2300 mg/day
what is the DASH LOWER Na+ restriction recommendation?
1500 mg/day
what groups of patients should be using the LOWER Na+ restriction value?
if pt is over 51 YO has diagnosed HTN has DM has CKD or is African American
per JNC 8 -
what is the preferred thiazide
Chlorthalidone (longer 1/2 life and more potent)
HCTZ (cheap af tho)
per JNC 8 -
what is the preferred ACEI
enalapril (BID)
Lisinopril (QD)
Special Indications for HTN:
If a pt has CAD (coronary artery disease) what is their standard pharmacotherapy
Beta blocker then add ACEI or ARB
THEN CCB
THEN Thiazide
Special Indications for HTN:
standard pharmacotherapy for post MI pts
Beta blocker then add ACEI or ARB
Special Indications for HTN:
standard pharmacotherapy for pt who has HF w/ reduced ejection fraction
Diuretic w/ ACE or ARB
THEN beta blocker
THEN aldosterone antagonist
Special Indications for HTN:
Recurrent stroke prevention pt - what is their standard pharmacotherapy
Thiazide or Thiazide w/ ACEI
If a pt is in stage 1 HTN (and no compelling indications)
how should drug therapy be initiated?
Monotherapy of the 4 first line agents
OR
2 drug combo of ACEI (or) ARB with CCB (or) thiazide
If a pt is in stage 2 HTN (and no compelling indications)
how should drug therapy be initiated?
Two drug combo:
ACEi or ARB with CCB
OR
ACEi or ARB with thiazide
JNC8 Treatment Strategies aka wtf to do:
If goal BP not met after 1 month of treatment…..
- increase dose of initial drug (maximize if tolerated)
or - add 2nd drug - CAN add 2nd drug before achieving max dose of initial drug (watch for ADEs)
JNC8 Treatment Strategies aka wtf to do:
May consider start w/ 2 drugs at the same time if…..
if SBP > 160 and/or DBP > 100
OR
if SBP > 20 and/or DBP > 10 ABOVE goal
JNC8 Treatment Strategies aka wtf to do:
If goal BP not met w/ 2 meds….
add/titrate 3rd medication
*DO NOT use ACEI and ARB together tho - possible kidney failure
JNC8 Treatment Strategies aka wtf to do:
when to start using other classes of drugs (aka when to use drugs other than the 4 first line agents)
- Goal BP NOT met with 3 meds
- Contraindication ot thiazide, ACEi/ARB, or CCB
what drug classes are known to be 2nd line therapy
- Loops/K+ sparing diuretics
- Beta-blockers
- Vasodilators (hydralazine)
- alpha blockers
- Direct renin inhbitors
4 classes of diuretics
- loops
- thiazides
- K+ sparing
- Aldosterone antagonists
What drugs are apart of the thiazide diuretic class?
- chlorthalidone
- HCTZ
- indapamide
- metolazone
What drugs are apart of the loop diuretic class?
bumetanide; furosemide; torsemide
What drugs are apart of the K+ sparing diuretic class?
amiloride; triamterene
What drugs are apart of the aldosterone antagonist diuretic class?
eplerenone; spironolactone
which diuretic can cause DM?
thiazides
which diuretic can help with osteoporosis?
thiazides - because they cause hypercalcemia/slow demineralization in osteoporosis
what are the clinical indications for diuretics
- HTN
- Edema
- CHF
- kidney disease
- Hepatic cirrhosis
- Hypercalcemia
- diabetes insipidus
which diuretic can cause a flare of gout?
thiazide
______ diuretics are more effective than ______ diuretics unless CrCl < 30 mL/min
thiazide; loop
T or F: Thiazides have a contraindication for sulfa allergy
True!
ADE’s of thiazides?
hypokalemia/hypomagnesemia
hypercalcemia/hyperuricemia
hyperglycemia/hyperlipidemia
sexual dysfunction
what are the contraindications for thiazides?
sulfa allergy
Anuria (aka hella renal dysfunction - do not use if CrCl < 30 mL/min)
Loop diuretics - sulfa allergy - yes or no?
yes - sulfa allergy is an issue
ADEs of Loop Diuretics
- hypokalemia/hypomagnesemia/hypocalcemia
- hyperuricemia
- ototoxicity
what are the K+ sparing diuretics
Amiloride; triamterene
who are K+ sparing diuretics used for?
pts that have had diuretic induced hypokalemia
K+ sparing diuretics should be avoided in what types of pts?
CKD or diabetic pts
What diuretics are aldosterone antagonists
spironolactone; eplerenone
Due to increased risk of hyperkalemia, _________ is contraindicated in CrCl < 50 ml/min and pts with T2DM and proteinuria
eplerenone
diuretic drug interactions
- NSAIDs
- Digitalis toxicity
- Lithium toxicity
- Corticosteroids
What are the diuretic monitoring parameters?
- BP
- BUN/SCr
- Serum electrolytes
- Cholesterol/triglycerides
- skin rash
- uric acid
Indications for ACEIs
- HTN
- Left ventricular systolic dysfunction
- MI
- diabetic nephropathy
Indications for ARBs
HTN
CHF
Progressive renal impairment (diabetes)
Contraindications for Angiotensin Inhbitors (ACEI/ARBs/Renin inhibitor)
- Pregnancy/Nursing mothers
- Hx of angioedema
- Bilateral renal artery stenosis
- Pre-existing kidney dysfunction
- Hyperkalemia
for ACE inhibitors: monitoring serum _____ & ____ within _____ of initiation of dose increase
K+; SCr; 4 weeks
Reduce the starting dose for ACE inhibitors/ARBs by ______% if the patients have a _________ risk
50%; hypotension;
What types of patients may need a 50% decrease in their starting dose for their ACEI/ARB
- pts also taking a diuretic
- Volume depletion
- Elderly patients
(everyone who has hypotension risk)
what types of patients are at a higher risk of hyperkalemia when starting an ACEI/ARB
CKD patients
or
pts on other K+ sparing medications (K+ sparing diuretics/aldosterone antagonists)
what are the compelling indications for Angiotension Inhibitors (ACEIs/ARBs)
DM - type 1 w/ proteinuria
HF
Post MI w/ Systolic Dysfucntion
when is it appropriate to have someone on both an ARB and ACEI
if the pt has severe forms of nephrotic syndrome
Indications for CCBs
- HTN
- Angina
- Arrhytmias
- (other: bipolar; HA; pulmonary HTN; diabetes)
Contraindications for CCBs
Preexisting bradycardia
Conduction defects
HF due to systolic dysfunction
______ is a contraindication to non-DHPs
Heart block
what are CCB Drug interactions
non-DHPs and BETA blockers (low HR!!)
Increase CCB effect: Grapefruit juice; Cimetidine; ranitidine
Decrease CCB effect: Rifampin; Phenobarbital
what drugs will increase CCB effect
grapefruit juice, cimetidine, ranititinde
what drugs will decrease CCB effect
rifampin; phenobarbital
monitoring for CCBs
BP
HR
Edema
Constipation
potentially favorable effects of Beta Blockers…
- shown to reduce mortality in pts w/ HF
- useful in the tx of atrial tachyarrhytmias/fibrilation
- migraines
- thyrotoxicosis (short term)
- essential tremor
- perioperative HTN
Potentially unfavorable effects of Beta Blockers
- Asthma/Reactive airway disease
- Renal insufficiency
- Diabetes
- HF exacerbation
- 2nd/3rd Degree heart block
frequent side effects of direct arterial vasodilators are ________
fluid retention; reflex tachycardia
Contraindication for Direct Arterial Vasodilator
Dissecting aortic aneurysm (bc reflex tachycardia issue with direct vasodilators…)
Which drug can have SLE side effects
Hydralazine (lupus like side effects - rash)
which drugs are preferred for pregnant women (bc safety of fetus)
Methyldopa
BBs
Vasodilators
