HTN lecture Flashcards
1) Define HTN
2) The lifetime risk of developing hypertension among those 55 years of age and older who are normotensive is higher than _____%
3) Higher incidence in men before age 65; higher incidence in women after age _____.
4) What group is disproportionally affected?
1) ≥130/80 mm Hg
2) 90%
3) 74
4) African Americans / Black Americans
What makes up 90% of all HTN cases?
Primary HTN
(Idiopathic)
Use of a monoamine oxidase inhibitor (isocarboxazid, phenelzine, tranylcypromine) with tyramine-containing foods or certain drugs can cause what?
Secondary HTN
What are 2 foods/ food products that can lead to secondary HTN?
Sodium + Licorice
List drugs that can lead to secondary HTN
1) Amphetamines
2) Antivascular endothelin growth factor agents
3) Corticosteroids
4) Calcineurin inhibitors
5) Decongestants
6) Ethanol
7) Ergot alkaloids
8) Estrogen/ estrogen OCPs
9) Nonsteroidal anti-inflammatory drugs
10) Testosterone
11) Antidepressants: desvenlafaxine, venlafaxine, bupropion (have norepinephrine activity)
Define systolic and diastolic BP
1) Systolic BP: cardiac contraction; peak value; 1/3 of cardiac cycle
2) Diastolic BP: cardiac chamber filling;
What 2 factors make up BP?
Cardiac output (CO) * total peripheral resistance (TPR)
Define:
1) Normal BP
2) Elevated
3) Stage 1 HTN
4) Stage 2 HTN
1) <120/ <80
2) 120-129/ <80
3) 130-139/ 80-89
4) >/=140/ >/=190
Define hypertensive crisis (quantitatively)
> 180/120 mm Hg
Starting at a BP of 115/75 mm Hg, the risk of CV disease doubles with every ___________mmHg increase
20/10
Patients are considered to have ______________ hypertension when their SBP values are elevated (i.e., ≥130 mm Hg) and DBP values are not
isolated systolic
A wider than normal pulse pressure (SBP minus DBP) is believed to reflect the extent of ________________ disease in older patients and is a measure of increased arterial stiffness
atherosclerotic
What is the most influential contributor to the homeostatic regulation of BP? What does this do?
RAAS; regulates sodium, potassium, and blood volume
RAAS: Where do the following act?
1) Ca+ channel blockers (2 places)
2) Thiazides (2 places)
3) Mineralocorticoids
1) Heart (effects contractility and CO) and vasoconstriction (increasing total peripheral resistance)
-Both are after angiotensin II
2) Directly increase total peripheral resistance + directly encourages sodium/ water reabsorption (^blood vol.)
3) Directly increases aldosterone synthesis (encouraging sodium/ water reabsorption)
Angiotensin II:
1) Pressor effects include what 3 things?
2) What does Ang. II stimulate? What does this lead to?
1) Direct vasoconstriction, stimulation of catecholamine release from the adrenal medulla, and centrally mediated increases in sympathetic nervous system activity
2) Aldosterone synthesis from the adrenal cortex, leading to sodium and water reabsorption that increases plasma volume, TPR, and ultimately BP
1) What does natriuretic hormone do?
2) What does this allow to work?
1) Inhibits sodium and potassium ATPase and thus interferes with sodium transport across cell membranes
2) ANP and BNP are going to lower blood pressure
Neuronal regulation:
1) The α and β presynaptic receptors of the adrenergic system play a role in negative and positive feedback to what?
2) Stimulation of presynaptic α-receptors (α2) exerts a _____________________on norepinephrine release
Stimulation of presynaptic β-receptors ___________ norepinephrine release
1) The norepinephrine-containing vesicles
2) negative inhibition
3) facilitates
True or false: Norepinephrine effects both the effector cell membrane and the cell that released it
True
List 2 vascular endothelial mechanisms. What do these influence?
1) Bradykinin
2) Nitric oxide
ACEis/ ARBs and whether they cause a cough
What is an electrolyte counseling point? Describe
1) Excess sodium increases BP
2) DASH diet limits salt to 2,300 milligrams (mg) a day
The average of _____ or more BP measurements taken during ______ or more clinical encounters is required to diagnose hypertension and Rx a med
two; two
1) When measuring BP, patients should ideally refrain from ____________ and ___________ ingestion for 30 minutes
2) Only measure after a _____ minute period of rest.
1) nicotine and caffeine
2) 5
Approximately 15% to 20% of patients have ____________ hypertension, where BP values rise in a clinical setting but are normal in nonclinical environments as measured with home or ambulatory BP monitors
white coat
With _____________ hypertension, home BP is much higher than the in-office BP measurement
masked
__________________ is a falsely elevated BP measurement and may be seen in those with CKD [due to calcified brachial arteries]
Pseudohypertension
In institutionalized older patients, those with a high disease burden and comorbidities, or limited life expectancy, you should consider a modified ideal SBP of what?
<150mmHg; <140mmHg if tolerated (relaxed goals)
1) The 2017 ACC/AHA guideline recommends a goal BP of __________ mmHg for the management of hypertension in most patients
2) <_______ mmHg for patients with HTN + CKD
1) <130/80
2) 120mmHg
List 4 lifestyle modifications to help with BP
1) DASH diet
2) Reduced salt intake
3) Physical activity
4) Moderation of alcohol intake (<2 drinks/ day for men, <1 for women)
How do you determine if you should Tx stage 1 HTN?
If the pt has clinical ASCVD, diabetes, CKD, or a 10 year ASCVD risk score >/= 10%
What are the options for stage 1 HTN?
1) Lifestyle modifications (if no risks) (reassess in 3-6 mo)
2) Medication: monotherapy with an ACEi, ARB, CCB, or thiazide diuretic (reassess in 1 month)
What therapy should be reserved to either treat a specific compelling indication or used in combination with one or more of those mentioned above first-line antihypertensive agents for patients without a compelling indication?
β-Blocker
What are the ACE inhibitors and what does each end in?
end in -pril
1) Benazepril
2) Captopril
3) Enalapril
4) Fosinopril
5) Lisinopril
6) Moexipril
7) Perindopril
8) Quinapril
9) Ramipril
10) Trandolapril
What are the ARBs and what does each end in?
end in -sartan
1) Azilsartan
2) Candesartan
3) Eprosartan
4) Irbesartan
5) Losartan
6) Telmisartan
7) Olmesartan
8) Valsartan
List the 2 main groups of CCBs and the members of each
1) Dihydropiridines
-Amlodipine (main oral one)
-Felodipine
2) Nondihydropiridines
-Diltiazem
-Verapamil
List 4 groups of diuretics and members of each
1) Thiazide: Chlorathalidone & Hydrochlorothiazide
2) Loop (for edema): Furosemide (Lasix)
3) Potassium sparing: Amiloride & Triamterene (both are weaker)
4) Mineralcorticoid receptor agonist: spironolactone
Beta blockers:
1) What do they all end in?
2) What are the 3 groups?
1) -lol
2) Cardioselective, nonselective, and mixed alpha & beta blockers
1) What do alpha1 blockers end in?
2) What are direct renin inhibitors (aliskiren) similar to?
3) Give examples of central alpha2 agonists
4) What are 2 examples of direct arterial vasodilators?
1) -zosin
2) ACEis and ARBs
3) Clonidine + methyldopa
4) Monoxidil and hydralazine
The The ALLHAT trial found that ________________ had statistically fewer secondary endpoints that amlodipine (HF) and lisinopril
(combined CV disease, HF, and stroke)
Chlorthalidone
Clinical trial data and meta-analyses cumulatively suggest that treatment with a _____________ may not reduce CV events to the extent other drugs do
β-blocker
1) What beta blocker has a short half life and is hydrophilic
2) List the 2 preferred β-blockers
1) Atenolol
2) Metoprolol and carvedilol
1) Heart failure with reduced ejection fraction (HFrEF) as well as HFpEF are compelling indications for what drug class?
2) What are 3 other compelling indications for this drug class?
1) Beta blockers
2) Stable ischemic heart disease + Diabetes mellitus + CKD
A ____________, either in combination with an ACEi or as monotherapy, is an evidence-based antihypertensive regimen for patients with a history of stroke or transient ischemic attack
thiazide
Data demonstrate reductions in CV morbidity and mortality in older patients with isolated systolic hypertension, especially with __________ and long-acting ______________ CCBs
thiazides; dihydropyridine
HTN in older ppl:
1) Define orthostatic hypotension
2) What 2 things should generally be used with caution in older patients bc of dizziness risk?
1) A significant drop in BP when standing and can be associated with dizziness and/or fainting
2) Centrally acting agents and α1-blockers
Gestational hypertension is defined as new-onset hypertension arising after _____ weeks of gestation
20
1) Define preeclampsia
2) Define eclampsia
1) HTN in assoc. with another factor (pulm. edema, thrombocytopenia, etc)
2) The onset of convulsions in preeclampsia
Resistant hypertension is defined as failure to achieve goal BP with the use of three or more antihypertensive drugs with __________________ MOAs
complementary
1) What type of β-blockers can safely be used in patients with asthma or COPD?
2) Centrally acting agents are associated with higher rates of __________ dysfunction and should be avoided in men with ____________ dysfunction
1) Cardioselective β-blockers
2) sexual; erectile
1) What 2 groups are most effective at lowering BP in African Americans / Black Americans and should be used first-line in the absence of a compelling indication?
2) Why?
1) CCBs and thiazides
2) Black patients have a higher frequency of salt sensitivity than White patients
Black pts have a higher risk of ________________ from an ACEi compared to other populations
angioedema
The 2017 ACC / AHA HTN guidelines and UptoDate both recommend ________________ as the best 4th line option for resistant HTN.
spironolactone
Dr. Lewis says he sees lots of people on beta-blockers due to another indication (e.g., post MI or stable ischemic heart disease) or patients using alternative 4th line drugs like ____________ blockers
alpha
CCBs, inhibitors of RAS, and chlorthalidone comprise a common 3-drug regimen. Considerable evidence indicates that the addition of _________________ to multidrug regimens provides substantial BP reduction when compared with placebo
spironolactone
There is clinical trial evidence that the addition of ______________ or _____________ is effective in achieving BP control in patients resistant to usual combination therapy.
hydralazine or minoxidil
Chlorthalidone + hydrochlorothiazide (both are thiazides):
1) Which has more data to support use?
2) Which is more commonly found in combination tablets?
1) Chlorthalidone
2) HCTZ (hydrochlorothiazide)
Clinicians may consider using a __________ diuretic, even in place of a thiazide, for patients with resistant hypertension who have very compromised kidney function (estimated GFR <30 mL/min)
loop
Angiotensin-converting enzyme inhibitors (ACEi):
1) What is the MOA?
2) ACEi is a first-line option for patients with ___________ and hypertension because of demonstrated CV disease and kidney benefits
1) Blocks ACE in lungs
2) diabetes
1) Angioedema occurs in less than 1% of pts on ACEis and can include _________ edema.
2) A history of angioedema precludes the use of what?
1) laryngeal
2) Another ACEi (it is a contraindication)(can still use ARBs)
Why can hyperkalemia be a SE of ACEis?
1) Because they decrease aldosterone, an increase in potassium serum concentrations can occur
2) Patients with CKD or those taking potassium supplements, potassium-sparing diuretics, mineralocorticoid receptor antagonists, ARBs, or a direct renin inhibitor are at highest risk for hyperkalemia
3) Monitoring of serum potassium and creatinine values within 4 weeks of starting or increasing the dose of an ACEi can often identify
1) With ACEis, AKIs occur in less than ___% of patients
2) Why do ACEis decrease GFR?
1) 1%
2) Inhibition of angiotensin II vasoconstriction on the efferent arteriole
-Either modest elevations of ≤30% (for baseline creatinine values ≤3 mg/dL) or absolute increases <1 mg/dL do not warrant changes
True or false: Angiotensin-converting enzyme inhibitors (ACEi) are teratogenic
True
Name a group of meds that can ↑ lithium serum concentrations and cause hyperkalemia
ACEis
True or false: Unlike an ACEi, an ARB does not block the breakdown of bradykinin
True
For patients with type 2 diabetes and CKD, the progression of kidney disease has been shown to be significantly reduced with ________ therapy
ARB
What has the lowest incidence of side effects compared with other antihypertensive agents?
ARBs
What 2 groups of meds can cause hyperkalemia and are teratogenic?
ACEis and ARBs
____________ is superior to lisinopril in African American / Black population
Amlodipine
What group of Ca+ channel blockers may also treat supraventricular tachyarrhythmias?
Nondihydropyridines (verapamil and diltiazem)
1) Negative inotropy precipitating or causing systolic HF can occur with Ca+ channel blockers, except for what?
2) What has increased risk of this compared to diltiazem?
1) Amlodipine or felodipine
2) Verapamil
Baroreceptor-mediated reflex tachycardia can occur due to what 2 things?
Beta blockers and Ca+ channel blockers
Constipation and peripheral edema are 2 side effects of what group?
Calcium channel blockers
Calcium channel blockers
1) ______________ and ____________ moderate cytochrome P450 3A4 isoenzyme system inhibitors
2) List 2 things they interact with
1) Verapamil and diltiazem
2) Lovastatin, simvastatin
Verapamil and diltiazem have lots of formulations are usually not AB-rated by the FDA as interchangeable on a milligram-per-milligram basis due to different biopharmaceutical release mechanisms, but the clinical significance of these differences is likely __________
negligible
Diuretics:
1) The preferred one for HTN that is considered a first-line therapy option in most patients is what group?
2) Which are more potent agents for inducing diuresis?
3) Which are very weak and often used to counteract the potassium-wasting properties of the other diuretic agents?
4) Which 2 groups are very weak?
1) Thiazides
2) Loop
3) Potassium-sparing
4) Potassium-sparing + Mineralocorticoid receptor antagonist
Side effects of thiazides and loops include what 2 things?
1) Hypercalcemia
2) Hyperuricemia
What diuretics may cause hypocalcemia?
Loop
Side effects for potassium-sparring diuretics:
1) Which is second line? Why?
2) What is this med contraindicated in?
3) Which is first line? What is a side effect of this med?
1) Eplerenone is more likely to cause hyperkalemia
2) Eplerenone is contraindicated for patients with impaired kidney function or type 2 diabetes with proteinuria
3) Spironolactone may cause gynecomastia in up to 10% of patients
True or false: Diuretics are not inherently teratogenic, but are not first line therapies.
True
1) Which group of meds has negative chronotropic and inotropic effects that reduce CO?
2) Which group of these do not reduce CO, yet they lower BP and decrease peripheral resistance?
1) β-Blockers
2) β-blockers with ISA (intrinsic agonist)
1) Name a nonselective beta blocker that is commonly used for anxiety and migraine prevention
2) Name a mixed alpha/ beta blocker that can be used in pregnancy
1) Propranolol
2) Labetalol
Beta blockers:
1) Atenolol and nadolol may need to be dose reduced for pts with what?
2) Which is most lipophilic?
1) Moderate-to-severe CKD
2) Propranolol
Which group of drugs can have negative effects on the heart? (ex: bradycardia, atrioventricular conduction abnormalities (e.g., second- or third-degree heart block), and the development of acute HF)
β-Blockers
Abrupt cessation of _____________ therapy can produce cardiac ischemia (aka, angina or chest pain), a CV event, or even death
β-blocker
Which beta blocker causes vasodilation due to increasing nitric oxide instead of blocking α1-receptors?
(hints: has no proven long-term clinical benefits, but lower risk of β-blocker–associated fatigue, erectile dysfunction, and metabolic side effects (e.g., hyperglycemia))
Nebivolol
Selective α1-receptor blockers:
1) List 2 of these
2) What is the main takeaway of their MOA?
1) Doxazosin and prazosin
2) Results in vasodilation
Which meds should be given at night to avoid feeling the “First-dose” phenomenon that is characterized by transient dizziness or faintness, palpitations, and even syncope within 1 to 3 hours of the first dose?
Selective α1-receptor blockers (Doxazosin and prazosin)
Selective α1-receptor blocker:
1) It can cross the blood–brain barrier; what does this cause? What does this allow for?
2) What is a weird side effect?
1) May cause central nervous system side effects such as lassitude, vivid dreams, and depression
-Prazosin commonly used in psychiatry (e.g., PTSD or nightmares)
2) Priapism
Name a direct renin inhibitor and its MOA
Bocks the RAAS at its point of activation, which results in reduced plasma renin activity and BP lowering
Central α2-adrenergic agonists:
1) Give 3 examples
2) What’s the MOA?
1) Clonidine, guanfacine and methyldopa
2) Reduces sympathetic outflow from the vasomotor center in the brain and increases vagal tone
Central α2-adrenergic agonists:
1) Which is used for resistant hypertension or hypertensive crisis?
2) Which is good for pregnancy-induced hypertension?
3) Which 2 are used to treat ADHD?
1) Clonidine
2) Methyldopa
3) Clonidine and guanfacine
Central α2-adrenergic agonists: list 4 side effects
1) Anticholinergic (especially clonidine)
2) Depression
3) Highest incidence of orthostatic hypotension and dizziness of all antihypertensive drugs
4) Rebound hypertension with abrupt discontinuation
Which group of meds can cause rebound HTN with abrupt discontinuation?
Central α2-adrenergic agonists
What are 2 groups of meds you shouldn’t “cold turkey”?
1) Central α2-adrenergic agonists
2) Beta blockers
Central α2-adrenergic agonists
1) What are 2 clonidine side effects? What may exacerbate these?
2) What are 2 rare side effects of methyldopa?
1) Nervousness, agitation; may be exacerbated by concomitant β-blocker use
2) Hepatitis or hemolytic anemia (both are rare)
Direct arterial vasodilators:
1) List 2
2) What is their MOA?
1) Hydralazine and minoxidil
2) Directly relax arteriolar smooth muscle resulting in vasodilation
Direct arterial vasodilators:
They’re not first or second line Txs; pts receiving hydralazine or minoxidil for chronic therapy should first receive both a _____________ and a ___________
thiazide and a β-blocker
Direct arterial vasodilators
1) What is a (weird) side effect of Hydralazine? Who is more prone to this?
2) List 2 side effects of minoxidil (hint: one is obvious)
1) Lupus-like syndrome
“Slow acetylators” are especially prone to develop drug-induced lupus
2) Hypertrichosis (hirsutism; reversible on discontinuation)
Pericardial effusion and a nonspecific T-wave change on the electrocardiogram (rare)
Combination therapy: Combination of two antihypertensive drugs is recommended for patients with stage 2 HTN particularly if BP is >_________mm Hg away from goal
20/10
Hypertensive urgencies and emergencies are characterized by the presence of very elevated BP, typically >___________mm Hg
180/120
Hypertensive urgencies: Acute administration of a short-acting oral antihypertensive, like ____________, followed by careful observation
Clonidine
1) Hypertensive emergencies require immediate BP reduction with __________ agent
2) Give 2 examples of appropriate emergency Txs
1) parenteral
2) Nitroprusside or Nitroglycerin
Nitroprusside (for HTN emergencies):
1) What is the MOA?
2) Serum thiocyanate levels should be monitored when infusions are continued for longer than ______ hours
1) Direct acting vasodilator
2) 72
Nitroglycerin (for HTN emergency): What are 2 side effects?
Associated with tolerance when used over 24 to 48 hours
Severe headache
Evaluation of Therapeutic Outcomes:
1) Laboratory monitoring should typically occur 4 weeks after starting a new agent or dose increase, and then every _____ to _____ months in stable patients
2) Patients treated with a mineralocorticoid receptor antagonist (eplerenone or spironolactone) should have what 2 things assessed? When?
1) 6 to 12
2) K+ concentrations and kidney function; within 3 days of initiation and again at 1 week [to detect potential hyperkalemia]
