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Pharmacology 2 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

ACE inhibitor means …

A

Angiotensin converting enzyme inhibitor

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2
Q

MOA
ACE inhibitor

A
  • block angiotensin I conversion to angiotensin II
  • inhibit breakdown of bradykinin (contribute to vasodilation)
  • reduce sodium retention
  • reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)

ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP

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3
Q

Indication
ACE inhibitors

A

Hypertension

Chronic heart failure with reduced ejection fraction as part of standard treatment

Diabetic nephropathy

Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)

Post MI

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4
Q

Adverse reactions
ACE inhibitors

A
  • hypotension
  • headache
  • dizziness
  • cough (dry / non productive)
  • hyperkalaemia
  • fatigue
  • nausea
  • renal impairment
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5
Q

Practice points

A

*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*

When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

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6
Q

Drug class and indication

Captopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)

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7
Q

Drug Class and indication

Enalapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction

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8
Q

Drug class and indication

Enalapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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9
Q

Drug class and indication

Fosinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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10
Q

Drug class and indication

Fosinopril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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11
Q

Drug class and indication

Lisinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment

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12
Q

Drug class and indication

Perindopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure

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13
Q

Drug class and indication

Perindopril with amlodipine

A

ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease

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14
Q

Drug class and indication

Perindopril with indapamide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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15
Q

Drug class and indication

Quinapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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16
Q

Drug class and indication

Quinapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* hypertension

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17
Q

Drug class and indication

Ramipril

A

ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors

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18
Q

Drug class and indication

Ramipril with felodipine

A

ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension

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19
Q

Drug class and indication

Trandolapril

A

ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction

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20
Q

Generic names of ACE inhibitors

A

Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril

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21
Q

Drug interactions
ACE inhibitor

A

Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).

Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.

ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.

Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.

Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.

ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.

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22
Q

SARTANs a.k.a. …

A

angiotensin receptor agonists (ARA)

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23
Q

MOA
sartans / ARA

A

Competitively block binding of angiotensin II to type 1 angiotensin (AT1) receptors. They reduce angiotensin II-induced vasoconstriction, sodium reabsorption and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.

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24
Q

Indication
sartans / ARAs

A
  • Hypertension
  • Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
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25
Q

Adverse effects
sartans

A

dizziness, headache, hyperkalaemia

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26
Q

Precautions / contradictions
sartans / ARAs

A

Peripheral vascular disease or atherosclerosis—patients may be more likely to have renal artery stenosis.

Volume or sodium depletion—Monitor combination w/ diuretics (both affect sodium and BP)

Black African or Caribbean descent

Treatment with drugs that can increase potassium concentration,

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27
Q

Practice points
sartans / ARAs

A
  • stop K+ and K+ sparing diuretics
  • review use of NSAIDs
  • check renal function
  • used when ACE inhibitors are not tolerated for HTN and chronic heart failure

You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.

when starting a sartan:
stop potassium supplements and potassium-sparing diuretics
in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan
review use of NSAIDs (including selective COX‑2 inhibitors)
start with a low dose
check renal function and electrolytes before starting a sartan and review after 1–2 weeks
unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they:
cause less cough than ACE inhibitors
may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence)
maximum antihypertensive effect occurs about 4–6 weeks after starting treatment
encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

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28
Q

Drug class and indication

Candesartan

A

sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors

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29
Q

Drug class and indication

Candesartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

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30
Q

Drug class and indication

Eprosartan

A

sartan / ARA
Hypertension

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31
Q

Drug class and indication

Eprosartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

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32
Q

Drug class and indication

Irbesartan

A

sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)

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33
Q

Drug class and indication

Irbesartan with hydrochlorothiazide

A

sartan /ARA + thiazide diuretic
Hypertension

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34
Q

Drug class and indication

Losartan

A

sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)

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35
Q

Drug class and indication

Olmesartan

A

sartan / ARA
Hypertension

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36
Q

Drug class and indication

Olmesartan with amlodipine

A

sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension

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37
Q

Drug class and interaction

Olmesartan with amlodipine and hydrochlorothiazide

A

sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic
Hypertension

38
Q

Drug class and interaction

Olmesartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

39
Q

Drug class and indication

Telmisartan

A

sartan / ARA
* Hypertension
* Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA

40
Q

Drug class and indication

Telmisartan with amlodipine

A

sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension

41
Q

Drug class and indication

Telmisartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

42
Q

Drug class and indication

Valsartan

A

Sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
* Left ventricular failure/dysfunction after MI, when clinically stable

43
Q

Drug class and indication

Valsartan with hydrochlorothiazide

A

Sartan / ARA + Thiazide diuretic
Hypertension

44
Q

Generic names of Sartans / ARA

A

Candesartan
Candesartan with hydrochlorothiazide
Eprosartan
Eprosartan with hydrochlorothiazide
Irbesartan
Irbesartan with hydrochlorothiazide
Losartan
Olmesartan
Olmesartan with amlodipine
Olmesartan with amlodipine and hydrochlorothiazide
Olmesartan with hydrochlorothiazide
Telmisartan
Telmisartan with amlodipine
Telmisartan with hydrochlorothiazide
Valsartan
Valsartan with hydrochlorothiazide

45
Q

Tripple Whammy

A

NSAID + Sartan + ACE

Sounds like satan ate enough said

46
Q

Generic names: Thiazide diuretics and Thiazide-related diuretics

A

Thiazide
Hydrochlorothiazide
Thiazide-related
Chlortalidone
Indapamide

47
Q

Indication
Thiazide and related diuretics

A
  • Hypertension
  • Oedema associated with heart failure or hepatic cirrhosis
  • Nephrogenic diabetes insipidus
48
Q

MOA
Thiazide and related diuretics

A

Inhibit reabsorption of sodium and chloride in the proximal (diluting) segment of the distal convoluted tubule, increased potassium excretion.

When used in recommended low doses for hypertension, thiazides lower BP mostly by a vasodilator effect.

49
Q

Precautions
Thiazide and related diuretics

A

Gout—may be aggravated by diuretic-induced hyperuricaemia

Heart failure with significant oedema—hyponatraemia may occur, particularly if higher doses are used with a salt-restricted diet and/or potassium-sparing diuretics and excess water intake.

Conditions or drugs that may cause hypokalaemia—further increases risk of hypokalaemia; monitor potassium concentration.

Conditions or drugs that cause volume depletion—further increases risk of renal impairment and hypotension (particularly in patients with heart failure); monitor renal function and BP (sitting and standing).

50
Q

Adverse effects
Thiazide and related diuretics

A

Effects on electrolytes, blood glucose and lipids are dose-dependent.

dizziness, weakness, muscle cramps, polyuria, orthostatic hypotension, electrolyte disturbances (eg hyponatraemia, hypokalaemia, hyperuricaemia, hypochloraemic alkalosis, hypomagnesaemia, hypercalcaemia)

51
Q

Nursing considerations
Thiazide and related diuretics

A

You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy.

most adverse effects are dose-related; start with a low dose and increase slowly

Heart failure
* may be given with loop diuretics to relieve symptoms of fluid retention; seek specialist advice
* start with a low dose and adjust according to clinical response; use small, intermittent doses with careful monitoring of renal function, electrolytes, BP and volume status
* advise patients to report any dizziness, thirst, or increased fluid loss due to diarrhoea, vomiting or excessive sweating
Diuretic-induced hypokalaemia
* reduce risk by using a low dose
* is less likely when also taking an ACE inhibitor, sartan or potassium-sparing diuretic
* potassium supplements may be used to treat mild hypokalaemia (each potassium chloride 600 mg tablet contains 8 mmol potassium; daily potassium replacement requirement is around 20–60 mmol (3–8 tablets))

52
Q

Drug interactions
Thiazide and related diuretics

A

ACE inhibitors + thiazide diuretics = hypotension
sartans + thiazide diuretics = Hypotension
loop diuretics + thiazide diuretics = hypokalemia + hypotension

NSAIDs + thiazide diuretics = reduced renal function

Hydrochlorothiazide is a thiazide diuretic; chlortalidone and indapamide are related to the thiazide diuretics and behave in the same way.

Thiazide diuretics cause hypotension; administration with other drugs* with this effect may result in additional hypotension.

They also cause hypokalaemia; additional potassium loss may occur if they are given with other drugs* that reduce potassium concentration; monitor potassium concentration and give potassium supplements if necessary. See also Prolonged QT interval.

High doses of thiazide diuretics can increase blood glucose concentration

53
Q

Two kinds of Calcium channel blockers

A

Dihydropyridines
Non-dihydropyridines

54
Q

suffix
Dihydropyridines Calcium channel blocker

A

Pine

55
Q

Generic names of Dihydropyridines Calcium channel blocker

A

Amlodipine
Amlodipine with atorvastatin
Amlodipine with valsartan
Amlodipine with valsartan and hydrochlorothiazide
Clevidipine
Felodipine
Lercanidipine
Lercanidipine with enalapril
Nifedipine
Nimodipine

56
Q

Generic names of Non-dihydropyridines Calcium channel blockers

A

Diltiazem
Verapamil
Trandolapril with verapamil

57
Q

Indication
Calcium channel blockers

A

Hypertension
Angina

58
Q

MOA
Calcium channel blockers

A

Block inward current of calcium into cells in vascular smooth muscle, myocardium and cardiac conducting system via L‑type calcium channels.

Act on coronary arteriolar smooth muscle to reduce vascular resistance and myocardial oxygen requirements, relieving angina symptoms.

Dihydropyridines act mainly on arteriolar smooth muscle to reduce peripheral vascular resistance and BP. They have minimal effect on myocardial cells.

Non-dihydropyridines: diltiazem and verapamil act on cardiac and arteriolar smooth muscle. They reduce cardiac contractility, heart rate and conduction, with verapamil having the greater effect. Diltiazem has a greater effect on arteriolar smooth muscle than verapamil.

59
Q

Precautions
Calcium channel blockers

A

Myasthenia-like neuromuscular disease—calcium channel blockers may increase risk of muscle weakness and respiratory depression (most case reports with verapamil).

Peritoneal dialysis—cloudy peritoneal fluid (with no signs of infection) has been reported, mostly with lercanidipine; it is not clear if this is a class effect.

60
Q

Adverse effects
Calcium channel blockers

A

Most listed adverse effects occur with all calcium channel blockers.

Adverse effects vary between the calcium channel blockers according to their relative effects on vascular, myocardial and conducting tissue.

Dihydropyridines have more pronounced vasodilatory effects than diltiazem and verapamil. Verapamil, and to a lesser extent, diltiazem, reduce cardiac contractility, heart rate and conduction.
Peripheral oedema
Dihydropyridines commonly cause peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention); this does not respond to treatment with diuretics, which may put patient at risk of volume depletion.

61
Q

Practice points
Calcium channel blockers

A

vasodilatory adverse effects usually subside with continued treatment (may require dose reduction)

62
Q

Drug class and indication

Amlodipine

A

Dihydropyridine Calcium channel blocker
Hypertension
Angina

63
Q

Drug class and indication

Amlodipine with atorvastatin

A

Dihydropyridine Calcium channel blocker + statin / HMG-CoA reductase inhibitors
Hypertension or angina, in patients with hypercholesterolaemia or multiple cardiovascular risk factors

64
Q

Drug class and indication

Amlodipine with valsartan

A

Dihydropyridine Calcium channel blocker + sartan (ARA)
Hypertension

Sartan a.k.a. angiotensin II antagonists and angiotensin receptor antago

65
Q

Drug class and indication

Amlodipine with valsartan and hydrochlorothiazide

A

Dihydropyridine Calcium channel blocker + Sartan (ARA / ARB/ angiotensin II receptor blocker + Thiazide diuretic
Hypertension

66
Q

Drug class and Indication

Clevidipine

A

Dihydropyridine calcium channel blocker
Hypertension (short-term use when oral treatment not appropriate)

67
Q

Drug class and indication

Felodipine

A

Dihydropyridine calcium channel blocker
Hypertension

68
Q

Drug class and indication

Lercanidipine

A

Dihydropyridine calcium channel blocker
Hypertension

69
Q

Drug class and Indication

Lercanidipine with enalapril

A

Dihydropyridine calcium channel blocker + ACE inhibitor
Hypertension

70
Q

Drug class and indication

Nifedipine

A

Dihydropyridine calcium channel blocker
Hypertension
Angina

71
Q

Drug class and indication

Diltiazem

A

Non-Dihydropyridine calcium channel blocker
Angina
Hypertension (controlled release tablet)

72
Q

Drug class and indication

Verapamil

A

Non-dihydropyridine calcium channel blocker
SVT
AF or atrial flutter (ventricular rate control)
Hypertension
Angina

73
Q

Drug class and indication

Trandolapril with verapamil

A

ACE inhibitor + Non-dihydropyridine calcium channel blocker
Hypertension

74
Q

Suffix:

Beta-blocker

A

lol

75
Q

Drug class

lol

A

Beta-blockers

76
Q

Indication
Beta-blocker

A

Hypertension
Angina
Tachyarrhythmias
MI
Chronic heart failure with reduced ejection fraction as part of standard treatment
Prevention of migraine

77
Q

MOA
Beta-blocker

A

Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.

Beta-blockers reduce heart rate, BP and cardiac contractility; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.

78
Q

Precautions / adverse effects
Beta-blockers

A

Shock (cardiogenic and hypovolaemic)—contraindicated.

Hyperthyroidism—beta-blockers may mask clinical signs, eg tachycardia.

Phaeochromocytoma—beta-blockers may aggravate hypertension; an alpha-blocker should be given first.

History of anaphylactic reactions—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis.

Myasthenic symptoms—may worsen.

CARDIACContraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure.
Respiratory contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD

Myasthenic symptoms (muscle weakness)

79
Q

Adverse effects
Beta-blockers

A
  • bradycardia,
  • hypotension,
  • orthostatic hypotension
  • bronchospasm,
  • dyspnoea,
  • fatigue, dizziness
  • Mask Hypoglycemia

Can mask signs of hypoglycemia in diabetics

80
Q

Counselling / practice points
Beta-blockers

A

Counselling
This medicine may cause dizziness or tiredness
Do not stop taking this medicine suddenly

Practice points
beta-blockers are not usually recommended first line for uncomplicated essential hypertension; they are associated with reduced protection against stroke in the elderly
**when stopping treatment, reduce dosage gradually

81
Q

Drug class and indication

Atenolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI

82
Q

Drug class and indication

Bisoprolol

A

Beta-blocker
Chronic heart failure with reduced ejection fraction as part of standard treatment

83
Q

Drug class and Indication

Carvedilol

A

Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment

84
Q

Drug class and indication

Labetalol

A

Beta-blocker
Hypertension
Hypertensive emergency

85
Q

Drug class and Indication

Metoprolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Prevention of migraine
Chronic heart failure with reduced ejection fraction as part of standard treatment

86
Q

Drug class and Indication

Nebivolol

A

Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment

87
Q

Drug class and indication

Propranolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
Tetralogy of Fallot, seek specialist advice
MI
Prevention of migraine
Essential tremor
Phaeochromocytoma (with an alpha-blocker)

88
Q

Generic drug names
Beta-blockers

A

Atenolol
Bisoprolol
Carvedilol
Esmolol
Labetalol
Metoprolol
Nebivolol
Propranolol
Sotalol

89
Q

Pathophysiology
Hypertension

A

The pathophysiology of hypertension involves the impairment of renal pressure natriuresis, the feedback system in which high blood pressure induces an increase in sodium and water excretion by the kidney that leads to a reduction of the blood pressure.

90
Q

Signs and symptoms
Hypertension

A
  • Early morning headache
  • Nosebleeds
  • Irregular heart rhythms
  • Vision changes
  • Buzzing in ears
91
Q

Rationale for drug use
Hypertension

A

Reduce premature cardiovascular morbidity and mortality and microvascular disease affecting the brain, kidneys and retinas

92
Q

Drug choice
Hypertension

A

For uncomplicated hypertension, unless there is a contraindication or a specific indication for another drug, first consider:

  • an ACE inhibitor (or sartan) or
  • a dihydropyridine calcium channel blocker or
  • if 65 or older, a thiazide diuretic (low dosage).

Pharmacology 2 (41 decks)

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