HTN Medications Flashcards
1
Q
ACE inhibitors
A
- example: “pril” ending: captopril
- mechanism: Block conversion of ang I to ang II by binding to active site of ACE
- effects: Lowers blood pressure by altering peripheral arterial resistance and intravascular volume, promotes Na loss; reduced aldosterone secretion; slow progression of kidney damage; may increase BUN and creatinine in serum due to decreased glomerular filtration (stabilizes over time)
- adverse reactions: dry cough with bronchospasm and nasal discharge (dose-dependent) due to bradykinin increase; hyperkalemia (minimized by combining RAAS drugs); angioedema, more common in Afro Am patients; neutropenia, rashes, worsening renal function with bilateral renal artery stenosis
- precautions: Do not use in pregnant women or women who may become pregnant
- notes: Have shown decrease in rate of progression of kidney disease at all levels of achieved bp
2
Q
Angiotensin receptor blockers
A
- example: “sartan” ending
- mechanism: selective blockade at At1 receptor.
- effects: Reduced effect of ang II on its receptor–> vasodilation, sodium and fluid loss
- adverse reactions: cough and angioedema, but less common than with ACE-I’s. Hyperkalemia, increase in serum creatinine
- precautions: Do not use in pregnant women or women who may become pregnant
- notes: Similar efficacy as monotherapy as compared to ACE-Is but improved side effect profile
3
Q
Aldosterone antagonists
A
- example spironolactone, eplerenone
- mechanism: Mineralcorticoid receptor antagonist
- effects: Decrease in: fluid retention, sodium reabsorption, vasoconstriction, endothelial dysfunction, hypertrophy of vascular smooth muscle cells
- adverse reactions: Sexual side effects: breast tenderness, gynecomastia, erectile dysfunction in men; menstrual abnormalities in women due to binding to progesterone/ androgen receptors
- precautions: Do not use in pregnant women or women who may become pregnant
- notes: Particularly good for resistant hypertension and in obese patients; may also be helpful in treating heart failure
4
Q
Direct renin inhibitors
A
ex aliskiren
- mechanism: Directly block the rate limiting step of RAAS cascade- conversion of angiotensinogen to angiotensin.
- effects: Vasodilation, sodium and fluid loss
- adverse events: Diarrhea (dose dependent)
- precautions: Do not use in pregnant women or women who may become pregnant. Do not combine with ACE-Is or ARBs in patients with renal impairment
- notes: do not cause negative feedback compensation (ACE-Is and ARBs have feedback that increases renin excretion)
5
Q
Potassium sparing diuretics
A
- ex amiloride, triamterene
- mechanism: Mineralcorticoid receptor antagonist
- effects: Increase urinary sodium excretion by directly blocking epithelial sodium channels
- adverse reactions: Hyperkalemia; depletion ofsodium,folic acidandcalcium, nausea, vomiting, diarrhea, headache, dizziness, fatigue, and dry mouth. Serious side effects may include heart palpitations, tingling/numbness, fever, chills, sore throat, rash, and back pain
- precautions: Do not use in pregnant women or women who may become pregnant.
Weak and ineffective for monotherapy, most useful when combined with hydrochlorothiazide.
6
Q
Loop diuretics
A
- ex furosemide
- mechanism: Venodilators and natriuretic agents
- effects: Reduced: preload, extracellular fluid volume, blood pressure
- adverse events: Volume depletion, hypokalemia, low serum magnesium, erectile dysfunction, increased urinary calcium excretion (can worsen osteoposis), ototoxicity
- precautions: Hypotension, gout, renal failure, on lithium therapy, hypokalemia
- notes: Especially effective in setting of decompensated heart failure and/or chronic kidney disease
7
Q
Thiazide diuretics
A
- ex hydrochlorothiazide, chlorthalidone
- mechanism: Venodilators and natriuretic agents
- effects: Reduced: preload, extracellular fluid volume, blood pressure
- adverse events: Volume depletion, hypotension, orthostasis, hypokalemia, hypomagnesemia, hyperglycemia, hypercholesterolemia, hyperuricemia, erectile dysfunction
precautions: Hypotension, gout, renal failure, on lithium therapy, hypokalemia
nots: low cost, additive effect when combined with other drugs. Greater risk of diabetes incidence.
8
Q
Dihydropurine calcium channel blockers
A
- ex amlodipine
- mechanism: Decrease calcium entry through L type calcium channels, causing decreased nerve excitation, cardiac/ vascular smooth muscle contraction, hormone secretion
- effects: Decreased peripheral resistance; increased renal blood flow- dilation of afferent arterioles and increased glomerular filtration pressure (facilitates natriuresis)
- adverse reactions: Can cause reflex tachycardia. Arteriolar dilation–> headache, flushing, tachycardia, peripheral edema; gingival overgrowth
- precautions: Vasodilation may worsen ischemic symptoms for patients with angina; can worsen proteinuria in patients with nephropathy
9
Q
Non-dihydropyridine Calcium Channel Blockers
A
ex verapamil, diltiazem
- mechanism: Decrease calcium entry through L type calcium channels, causing decreased nerve excitation, cardiac/ vascular smooth muscle contraction, hormone secretion
- effects: Decreased peripheral resistance; increased renal blood flow- dilation of afferent arterioles and increased glomerular filtration pressure (facilitates natriuresis)
- adverse events: Can reduce atrial and atrioventricular conduction rates esp AV node- may cause profound slowing of heart rate in patients with conduction disease; constipation is common; gingival swelling
- precautions: SA or AV conduction disturbances. Bradycardia and heart block more common when together with B blockers or digoxin
10
Q
B blockers
A
- example: pindolol (intrinsic sympathomimetic activity- partial agonist); carvedilol and propranolol (non-selective); atenolol and metoprolol (selective)
- mechanism: Inhibit effects of catecholamines, decrease sympathetic nervous activity.
- effects: Decreased cardiac output, inhibit renin secretion, inhibit norepinephrine release; reductiosn in heart rate due to decreased automaticity
- adverse reactions: Bronchospasm, bradycardia, dizziness, erectile dysfunction, sedation, fatigue, sleep disturbance, hallucinations, depression, increased serum trigylcerides, decreased HDL cholesterol.
- precautions: Not sole agent for first line therapy but good for people with history of MI, CAD, arrhythmia
- notes: Also reduces ventricular hypertrophy, stroke, heart failure, coronary events, mortality. Two types: non-selective B blockers block both B1 and B2; selective B blockers block B1 only
11
Q
Direct vasodilators
A
- examples: Hydralazine, minoxidil Vasodilators, smooth muscle relaxation
- effects: Decreased peripheral resistance
- adverse reactions: Can cause pseudotolerance- compensatory responses by increased sympathetic nervous activity. Lupus like reaction, pericardial effusion, elevated pulmonary artery pressure, fluid retention
- precautions: Metabolism by N-acetyltransferase so genetic variation.
- notes: Should be administered with diuretics and B blockers to reduce pseudotolerance
12
Q
a-Adrenergic blockers
A
- examples: Doxazosin, terazosin
- effects: Block receptor site for norepinephrine Decreased arteriolar resistance
- adverse reactions: Nasal congestion, dizziness, postural hypotension, fluid retention
- notes: Typically used as part of multiple medication anti-HTN regimen, may be added for pateints with BPH to decrase urinary symptoms
13
Q
Central Sympathetolytics (a2 agonists)
A
- examples: clonidine, methyldopa
- mechanism: Reduced sympathetic outflow to heart and blood vessels
- effects: Vasodilation
- adverse reactions: Sedation, dry mouth, erectile dysfunction, rebound hypertension, skin hypersensitivity, Coombs positive hemolytic anemia, elevated LFTs
- notes: Methyldopa used to treat HTN in pregnancy. No abrupt discontinuation
14
Q
What is the appropriate medication combination in heart failure
A
ARB (or ACEI) + β-blocker + diuretic + spironolactone;
Add dihydropyridine for improved BP control if needed
15
Q
What is the appropriate medication combination for post-MI/ CAD
A
1st: ACEI (or ARB)
2nd: CCB or thiazide diuretic
* some patients will need a β-blocker based on LV function
