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Pharm 2 > HTN Lecture > Flashcards

HTN Lecture Flashcards

1
Q

Resistant HTN?

A

PT fails to achieve BP goal despite use of 3 meds (ideally 1 is diuretic)

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2
Q

Isolated HTN?

A

SBP > 140 AND DBP > 90 (widening pulse pressure)

Indicative of arterial stiffness and increased CV risk

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3
Q

Large determinants of SBP? DBP?

A

CO largely determines SBP (SV, HR, venous capacitance)

Total peripheral resistance largely determines DBP

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4
Q

MAP?

A

2/3DBP + 1/3SBP

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5
Q

Cardiac output affected by?

A 
Blood volume (Na, mineralcorticoids, ANP)
Cardiac factors (HR, contractility)
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6
Q

Total peripheral resistance (TPR) affected by?

A

Humoral (Constristrictors: (CATLE) catecholamine, angiotensin 2, thromboxane, leukotrienes, endothelin; Dilators: (PKN) prostaglandins, kinins, NO)

Neural ( alpha, beta adrenergic)

Local factors (ionic/pH/hyhpoxia)

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7
Q

Inhibit Na, Cl reabsorption in the DCT ( = Na, Cl, water elimination)

Over time, volume normalizes but decrease in peripheral reistsance keeps BP lower

A

Thiazide/thiazide like diuretics

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8
Q

Best tolerated med for HTN

Not effective for pts w/ poor KF *****(CrCl < 30 ml/min or SCr > 2.5 mg/dL)

A

Thiazide (hydrochorothiazide)/thiazide like diuretics

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9
Q

Non-thiazides?

A

Metolazone (**use for when KF < 30)

Indapamide

Chlorothalidone

MIC the “thigh guy”

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10
Q

Thiazides most effective when combined with?

A

ACEI or ARB

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11
Q

Inhibit conversion of angiotensin 1 to angiotensin 2, causing?

A

ACEI

Reduces:

vascular smooth muscle constriction

aldosterone synthesis/release

Na reabsorption (thus increasing excretion)

HR

ADH release

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12
Q

ACEI also increases availability of?

A

Bradykinin, which is a vasodilator

ACE itself is responsible for breakdown of bradykinin

BUT bradykinin is involved in production of prostacyclin/NO (a humoral dilator)

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13
Q

Despite bradykinin’s vasodilator effects, it also has some negative effects…?

A

angioedema/dry cough (adverse effects of ACEI)

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14
Q

ACEI reduced efficacy in what pop?

A

African-Americans (however, effective when combined with CCBs/diuretics)

Those with renal insufficiency

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15
Q

Considerations/Adverse events for ACEI?

A

taste disturbances

hyperkalemia

increase in BUN (up to 20% acceptable)

Renal artery stenosis

SHOULD MONITOR K, SCr, BUN @ baseline, 2 weeks

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16
Q

Mixing ACEI w/ what can increase rsk of arrythmias/deaht?

A

K-sparing diuretics/K supps

Increase in SK levels -> arrhythmias

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17
Q

Drug induced acute injury death?

A

RENAL TRIFECTA

Diuretics (concentrate blood urine)

ACEI/ARB (dilates afferent arteriole)

NSAIDS (inhibits prostaglandins/bradykinins -> constriction of afferent renal arteriole)

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18
Q

ACEI end in?

Only IV only ACEI?

A

-pril

Enalaprilat

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19
Q

ARBs act on what receptor?

A

Antagonize angiotensin2 at the AT1 receptor (which predominates in the vasculature) thus prevents vasoconstriction

Allows blocks aldosterone secretio (reducing salt/water retention)

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20
Q

ARBs/ACEIs are similar, except?

A

ARBs are generally more expensive (which is why they’re reserved for those who can’t tolerate ACEIs)

However, ARBs don’t significantly affect bradykinin (no cough/angioedema

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21
Q

Considerations/Adverse events for ARBs?

A

hyperkalemia

increase in SCr/BUN (up to 20% acceptable)

Renal artery stenosis

Caution w/ K-sparing diuretics/K supps (Increase in SK levels -> arrhythmias)

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22
Q

ARBs end in?

A

-sartan

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23
Q

Both ACEIs/ARBs?

A

Cat D (pregnancy)

Renal stenosis

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24
Q

Directly inhibits renin (thus reducing Angiotensin 1,2 and aldosterone)

A

Aliskiren

(not routinely combined w/ ACEI/ARBs)

ADE: diarrhea, cough/angioedema, hyperkalemia, incraesed BUN/SCr

Hypersensitivity to sulfonamide

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25
Q

Alpha1 adrenergic blocking agents?

A

Rarely used as 1st step for HTN

HTN monotherapy is discouraged

BUT can use for BPH & HTN

(or can be used in resistant HTN w/ other meds)

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26
Q

Uroselective Alpha1A antagonists?

A

Used for BPH ONLY not HTN

Tamsulosin
Silodosin

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27
Q

Alpha1 antagonists?

A

Terazosin
Doxazosin
Prazosin (***Not for BPH, BUT for PTSD)

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28
Q

Alpha1 antagonists adverse effects?

A

Orthostatic HOTN

Reflex tachycardia -> angina

Edema (prazosin esp.) which may require a diuretic

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29
Q

A2 agonists

A

Reduction in sympathetic outflow

Best used with agents that have other MOA (diueretics, ACEI)

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30
Q

Can be combined with other meds for tough HTN

Also for ADHD, Tourette’s

Offlabel = etoh w/drawal, mania, restless legs, smoking cessation

A

Clonidine

caution with olds and abrupt w/drawal

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31
Q

First line for pregnanc HTN?

Requires TID/QID?

A

Methyldopa

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32
Q

B blockers for HTN?

A

antagonizes B1 receptors causing decreased CO, also reduces renin secretion

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33
Q

B blockers for hyperthyroidism?

A

propranol/esmolol

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34
Q

post-MI DOC?

A

B blocker

Also beneficial in:

Angina (reduce myocardial Oxygen)
CHF 
MI (DOC)
Glaucoma
Pheochromocytoma
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35
Q

“Cardioselective” (B1) blockers have less effect on?

A

Asthma/diabetes

36
Q

Beta blocker w/ ISA?

A

Good option for pts who need beta blocker but can’t handle bradycardia

***AVOID USE POST-MI

37
Q

ISA Beta blockers?

A

Acebutolol
Pindolol
Penbutolol

38
Q

Beta blockers that cross the BBB well (i.e., high lipid solubility)? Resulting in?

A

Propranolol
Bisoprolol

Drowsiness, confusion, nightmares, depression

39
Q

Precautions w/ Beta blockers?

A

DM: ***** mask symptoms of hypoglycemia

Asthma: non-cardioselectives can make bronchoconstriction worse

Can disrupt lipid metabolism

Decreased libido

40
Q

Beta blockers combined with non-dihydropyridine CCBs may produce?

A

bradycardia

NonDHP CCB = verapmil, diltiazem

41
Q

Mainly used in pts w/ HF and HTN

mixed Alpha1-nonspecific Beta blocker

A

Carvedilol

take w/ food, only tabs

42
Q

mixed Alpha1-nonspecific Beta blocker

2nd line agent for pregnancy (offlabel)

SEVERE HTN

A

Labetalol

43
Q

B1 selective antagonists?

A 
Betaxolol
Bisoprolol
Atenolol
Acebutolol (ISA)
Metoprolol
44
Q

Non-selective antagonist (beta1,2)

A

Propanolol
Nadolol
Timolol

Pindolol (ISA)
Penbutolol (ISA)

45
Q

blocks transport of catecholamines, resulting in depletion and impairment of sympathetic function

adjunctive therapy with other HTN meds

A

Central monoamine-depleting agent

Reserpine

46
Q

Blocks inward movement of calcium through L channels of ARTERIAL smooth muscle and CARDIAC cells of coronary system (obvs a CCB)… what two categories?

A

Dihydropyridines (DHPs) [end in -pine]

Non-DHPs [more selective for myocardium & neg inotrope]

47
Q

Preferred in pts w/ fast HRs and those who have A Fib who can’t tolerate beta blockers

A

Non DHP CCBs

Verapamil

Diltiazem

48
Q

***least selective CCB (so effects on both cardiac/vascular smooth muscle)

Angina, SVTs, Tachyarrhythmias,

***migraines/cluster HAs

A

verapamil (non-DHP)

49
Q

CCB w/ less pronounced neg inotropic effects

significant effects on both cardiac/arterial smooth muscle

SVTs/tachyarrhythmias

A

Diltiazem (non-DHP CCB)

50
Q

More efficacious in HTN of African AMerican population?

A

CCB

51
Q

Caution in HF?

A

CCB

Amlodipine has increased risk of HF vs diuretic

52
Q

adverse effects…

HOTN -> peripheral edema

High dose -> excessive vasodilation & reflex tachy

Gingival enlargement (which particular drug?)

A

Dihydropyridines (CCBs)

big gums = Nifedipine

53
Q

Verapamil/diltiazem can increase presence of what drug?

A

digoxin

54
Q

Verapamil/diltiazem may increase negative inotropic effects of beta blockers -> bracycardia BUT….

A

Dihydropyridines can be combined with beta

DHPs end in -pine

55
Q

Directly relax smooth muscle in arteries (decreases vasc resistance/BP)

Increases renin concentration, so you need a diuertic to reduce Na/H20

May precipitaet angina/MI/cardiac failure

A

DIrect arterial vasodilators

LAME (4th line)

Effective when combined with diueretics, betas, sympatholytics

56
Q

Reserved for severe HTN or pts who fail triple therapy

HTN emergency

Pregnancy HTN (cat C)

Combined with nitrates to treat both hTN/HF in African Americans

A

Hydralazine (DIrect arterial vasodilator)

can cause lupus erythematosis-like syndrome

57
Q

Can use if hydralazine isn’t effective

Hypertrichosis

A

Minoxidl (DIrect arterial vasodilator)

58
Q

What stages warrant drug tx?

A

Stage 1, 2 HTN

59
Q

BP of 120-129…. therapy?

A

Nonpharmacologic

reassess in 3-6 mos

60
Q

Stage 1 HTN (130-139/80-89)… What’s a decision point?

A

ASCVD risk… if >10 (use a BP-lowering med)

If risk <10, use a non-pharmacologic approach

61
Q

Stage 2 HTN (140/90)?

A

BP-lowering meds regardless of ASCVD risk

62
Q

Stage 1 HTN… single drug?

A

Upon initiation of tx, A single HTN is reasonable in adults with stage 1 w/ dosage titration/addition of other agents

63
Q

Stage 2 HTN… tx?

A

2 first line agents of different classes is rec’d

64
Q

In black adults w/ HTN but w/o HF/CKD (including those w/ DM) initial HTN tx should be?

A

thiazide-type diuretic or CCB

65
Q

Pregnancy HTN tx?

A

methyldopa
Labetalol
Nifedipine

66
Q

DM & HTN?

A

All first line drugs are useful/effective

ACEI/ARBs may be considered in presence of albuminuria

67
Q

Adults w/ stroke & prior TIA?

A

NOT A CCB

68
Q

Albuminura >300 mg/d (creatinine >300)?

A

Start w/ an ACEI

If less than 300, usual “first-line”

69
Q

HTN urgency vs emergency?

A

Urgency > 180 but no indication of end organ damage

Emergency > 180 w/ EVIDENCE OF END ORGAN DAMAGE (ssx - stroke, LOC, crushing chest pn, eye/kdiney damage, unstable angina, pulm edema, eclampsia)

70
Q

African American w/ HTN (w/w/o DM) but w/o HF or CKD…. first line med?

A

thiazide type or CCB

71
Q

Oral or IV in HTN urgency?

A

Oral

72
Q

HTN urgency… timelines?

A

Slow… over 24-48 hrs (reduce MAP by no more than 25%)

73
Q

HTN urgency mgmt? (3x drugs…)

A

Clonidine

Captopril (use this over clonidine if pt has HF)

Labetalol (consider if pregnant)

74
Q

HTN emergency… similar to HTN urgency, you should only reduce MAP by 25% in first hour UNLESS?

A

Pt has compelling condition (aortic dissection, preeclampsia/eclampsia, pheochromocytoma crisis), wherein you should reduce to 140 or 120 (aortic dissection)

IV is preferred

75
Q

Vasodilators for HTN emergency?

A

Sodium Nitroprusside (DOC, except CKD, hepatic fx, aortic dissection)

Nitroglycerin (preferred in pts w/ pulmonary congestion)

Hydralazine

Fenoldopam (dope agonist)

76
Q

ACEI for HTN Emer?

A

Enalaprilat (only IV ACEI as well, hint)

77
Q

CCB for HTN emer?

A

Nicardipine (strong cerebral effects, consider w/ intracerebral hemorrhage/stroke)

Clevidipine

78
Q

Adrenergic inhibitors for HTN emer?

A

Esmolol

Labetalol

79
Q

HTN emergency and Useful in severe tachy, increased CO, severe post op HTN

BUT

Avoid in pts w/ decompensated HF, already on a beta, or have brady

A

esmolol

80
Q

Useful in HTN urgency/emer

Doesn’t cause reflex tachy, so preferred in CAD, acute dissection, end stage renal disease, acute intracerebral hemorrhage, acute ischemic stroke (doesn’t reduce cerebral blood flow), MI

A

labetalol

81
Q

Adverse…

Cyanide toxicity, methemoglobinemia

CI in renal/hep fx

Caution in increased ICP

A

Sodium nitroprusside

82
Q

Adverse…

tachyphylaxis

methemglobinemia

Increased ICP (Caution)

A

Nitroglycerin

83
Q

Adverse…

Reflex tachy

Caution in angina/MI, incerased ICP, aortic dissection

A

hydralazine

84
Q

Adverse…

Long half life….

CI = pregnancy, renal artery stenosis, angioedema

A

Enalaprilat (ACEI)

85
Q

HTN emer agent… caution in Angina/MI, acute HF

A

Nicardipine (CCB)

86
Q

HTN Emer agents…

Caution in acute HF, asthma, heart block

(hint they’re both adrenergic inhibitors)

A

esmolol (beta blocker)

labetalol (beta blocker)

Pharm 2 (5 decks)

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