Hypertension Flashcards
What causes primary, essential HTN? What are the risk factors?
- Cause is unknown
- Combination risk factors include; obesity, sedentary lifestyle, excessive salt intake, smoking, family hx, diabetes and dyslipidemia
What causes secondary HTN?
- Caused by renal disease (CKD)
Screening and diagnosis of HTN
Screening:
* BP assessments; should be based on average of at least two readings on two separate occasions
- Self-monitoring is preferred
Diagnosis:
* Normal: SBP <120 mmHg and DBP <80
- Elevated: SBP 120-129 and DBP <80
- HTN:
^^ stage 1: SBP 130-139 or DBP 80-89
^^ stage 2: SBP >=140 or DBP >=90
Name drugs that can increase BP
- Amphetamines and ADHD drugs
- Cocaine
- Decongestants (pseudoephedrine, phenylephrine)
- Erythropoiesis-stimulating agents
- Immunosuppressants (cyclosporine)
- NSAIDs
- Systemic steroids
Natural products for HTN
- Fish oil
- Coenzyme Q10
- L-arginine
- Garlic
HTN guideline recommendations: requirements to start treatment
Stage 1 HTN [SBP 130-139 or DBP 80-89] and;
* Clinical CVD (stroke, HF or CHD)
* 10-year ASCVD risk >=10%
Stage 2 HTN [SBP >=140 or DBP >=90]
BP GOAL: <130/80 mmHg for all patients
HTN guideline recommendations: initial drug selection
- Non-black: thiazide, CCB, ACE inhibitor or ARB
- Black: thiazide or CCB
- CKD (all races): ACE inhibitor or ARB
- Diabetes with albuminuria (all races): ACE inhibitor or ARB
- Diabetes with CAD (all races): ACE inhibitor or ARB
Notes:
– Start 2 first line drugs in Stage 2 HTN when average SBP and DBP >20 mmHg above goal (e.g., 150/90)
– Check BP every month and titrate medication if not at goal
Pregnancy and HTN
- Fetal toxicity (BW): ACE inhibitors, ARBs and aliskiren
- Aspirin recommended after the first trimester for preeclampsia
Pregnant patients with chronic HTN should receive treatment if [SBP >=160 or DBP >=105]:
* Labetalol and Nifedipine XR
- Methyldopa is also recommended but may be less effective at BP lowering
Thiazide-type diuretics - MOA
- Inhibit sodium reabsorption in the distal convoluted tubules, causing increased excretion of Na, Cl, water and K
Thiazide-type diuretics - drugs, dosages, safety/SEs/monitoring
Chlorthalidone: 12.5-25 mg daily
Hydrochlorothiazide: 12.5-50 mg daily
CIs:
* Hypersensitivity to sulfonamide-derived drugs
SEs:
* Decreased electrolytes; K, Mg, Na
* Increased electrolytes; Ca, UA, LDL, TG, BG
* Photosensitivity, impotence
Monitoring:
* Electrolytes
* Renal function
Notes:
– Thiazides are not effective when CrCl <30
– Take early in the day to avoid nocturia
– Chlorothiazide is the only medication available IV
Thiazide-type diuretic - DDIs
- NSAIDs can cause Na and water retention
- Thiazide diuretics can decrease lithium clearance and increase the risk of lithium toxicity
Dihydropyridine (CCBs) - MOA, indication
- Used for HTN, chronic stable angina and Prinzmetal’s angina
- They inhibit Ca ions from entering vascular smooth muscle, causing peripheral arterial vasodilation
Dihydropyridine (CCBs) - drugs (brand/generic)
- Amlodipine (Norvasc)
- Nicardipine IV (Cardene IV)
- Nifedipine ER (Adalat CC, Procardia XL)
Dihydropyridine - drug effects
Dihydropyridine
Warnings:
* Hypotension
* Nifedipine IR: do not use for chronic HTN or acute BP reduction (profound hypotension, MI and/or death occurred)
SEs:
* Peripheral edema/headache/flushing/palpitations/reflex tachycardia/gingival hyperplasia
Monitoring:
* Peripheral edema
Notes:
– Amlodipine is considered the safest if it is used to lower BP in HF with reduced ejection fraction
– Nifedipine ER is a DOC in pregnancy and is used Raynaud’s (blue fingers)
Clevidipine - drug effects
Clevidipine
CIs:
* Allergy to soybeans, soy products or eggs
Warnings:
* Hypotension, reflex tachycardia, infections
SEs:
* Hypertriglyceridemia
Notes:
– A lipid emulsion (provides 2 kcal/mL) (milky-white)
– Use strict aseptic technique (max time after vial puncture is 12 hrs)
Non-Dihydropyridine (CCBs) - MOA and indication
- Verapamil and diltiazem are used to control HR in certain arrhythmias (Afib)
- They are more selective for the myocardium than DHP CCBs
- The decrease in BP is due to negative inotropic (decreased force of ventricular contraction) and negative chronotropic (decreased HR) effects
- Non-Dihydropyridine - drug effects
- All CCBs - DDIs
1) Non-Dihydropyridines:
* Diltiazem (Cardizem, Tiazac), Verapamil (Calan SR)
* Warnings: HF (worsen sx), bradycardia
- SEs: edema, constipation(more with verapamil), gingival hyperplasia
2) DDIs: All CCBs
* Use caution with BBs, digoxin, clonidine, amiodarone
- All CCBs are major substrates of CYP450 3A4. Do not use with grapefruit juice
- Diltiazem and verapamil are substrates and inhibitors of P-gp and moderate inhibitors of CYP3A4. Pts should use lower doses of simvastatin and lovastatin
ACE Inhibitors - MOA
- They block the conversion of Ang I to Ang II, resulting in decreased vasoconstriction and aldosterone secretion
- They block the degradation of bradykinin
ACE Inhibitors - drugs (brand/generic)
- Benazepril (Lotensin)
- Enalapril (Vasotec), Enalaprilat(Vasotec IV)
- Lisinopril (Privinil, Zestril)
- Quinapril (Accupril)
- Ramipril (Altace)
ACE Inhibitors - drug effects
BW:
* Teratogenic
CIs:
* Do not use with hx of angioedema
* Do not use within 36 hrs of entresto
Warnings:
* Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis
SEs:
* Cough, hyperkalemia, increased SCr, hypotension
Monitoring:
* BP, K, renal function
ARBs - MOA, drug effects
They block Ang II from binding to the AT1 receptor on vascular smooth muscle, preventing vasoconstriction
* Irbesartan (Avapro)
* Losartan (Cozaar)
* Olmesartan (Benicar)
* Valsartan (Diovan)
Drug effects: same profile as ACE Inhibitors except:
* Less cough
* Less angioedema
* No washout period required
* Olmesartan: spure-like enteropathy (warning)
Aliskiren - CIs
- CIs: Do not use with ACE inhibitors or ARBs in patients with diabetes
RAAS inhibitors - DDIs
- All RAAS inhibitors increase the risk of hyperkalemia
- Do not use more than 1 RAAS inhibitor together
- ACE inhibitors and ARBs can decrease lithium clearance and increase the risk of lithium toxicity
Potassium-sparing diuretics - MOA
- Often used in combination with hydrochlorothiazide (maxzide) to counteract the mild K losses seen with thiazide diuretics
- Commonly used in HF
- Spironolactone is non-selective aldosterone receptor antagonist (also blocks androgen)
- Eplerenone is selective and does not exhibit endocrine side effects
Potassium-sparing diuretics - drug effects and DDIs
Spironolactone (Aldactone)
Triamterene + HCTZ (Dyazide, Maxzide)
Eplerenone (Inspra)
Drug effects:
BW:
* Hyperkalemia (K>5.5)
CIs:
* Hyperkalemia
* Severe renal impairment
* Addison’s disease
SEs:
* Hyperkalemia, increased SCr, dizziness
* Spironolactone: gynecomastia, breast tenderness, impotence
Monitoring:
* BP, K, renal function, fluid status, s/sx of HF
DDIs:
* Other potassium sparing drugs
* Decreases lithium renal clearance and increases lithium toxicity
BBs - MOA
- No longer first-line unless pt has post-MI, stable ischemic heart disease, HF
- Bisoprolol, carvedilol or metoprolol succinate treats chronic HF.
- Carvedilol and labetalol block alpha-1
- BBs with intrinsic sympathomimetic activity (ISA) (acebutolol) are not recommended in post-MI
Beta-1 selective blockers - drugs (brand/generic)
- Atenolol (Tenormin)
- Esmolol (Brevibloc) - injection
- Metoprolol tartrate (Lopressor)
- Metoprolol succinate ER (Toprol XL)
Beta-1 selective blockers - drug effects
Drug effects:
BW:
* Do not discontinue abruptly
Warnings:
* Caution in pts with diabetes; can worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms
- Caution with bronchospastic diseases
- Caution with raynaud’s
SEs:
* Bradycardia, fatigue, hypotension, dizziness, depression, impotence
- Exacerbate Raynaud’s
Notes:
– Lopressor and Toprol XL should be taken with or immediately with following food
– Metoprolol tartrate IV is not equivalent to PO (IV:PO ration is 1:2.5)
Name beta-1 selective blocker with nitric oxide-dependent vasodilation
Nebivolol (Bystolic)
Beta-1 and beta-2 blockers (non-selective) - drugs (brand/generic)
which one has high lipid solubility? what is it useful for?
- Propranolol (Inderal LA/XL)
- Nadolol (Corgard)
Propranolol has high lipid solubility so associated with more CNS side effects, but this makes it useful for migrane prophylaxis
Non-selective beta-blocker and alpha-1 blocker - drugs (brand/generic), drug effects
Carvedilol (Coreg, Coreg CR)
* Take it with food
* Dosing conversions are not 1:1
Labetalol
* SEs: dizziness
* DOC in pregnancy
BBs- DDIs
- BBs can enhance the hypoglycemic effects of insulin and SUs and mask some sx of hypoglycemia (except hunger and sweating)
- BBs can decrease insulin secretion, causing hyperglycemia
- Use in caution with diltiazem, verapamil, digoxin, clonidine, amiodarone
Centrally acting alpha 2 adrenergic agonists - drugs (brand/generic), drug effects
Clonidine (Catapres, Catapres-TTS patch)
Guanfacine ER (Intuniv)
Methyldopa
Drug effects:
CIs:
* Methyldopa: concurrent use with MAO inhibitors
Warnings:
* Do not discontinue abruptly (can cause rebound hypertension)
- Hemolytic anemia with methyldopa
SEs:
* Dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, impotence
- Clonidine patch: skin rash, pruritus, erythema
- Methyldopa: DILE
Notes:
– Apply clonidine patch weekly and remove before MRI
– Methyldopa is DOC in pregnancy
Direct vasodilators - drugs and drug effects
Hydralazine
Warnings: DILE
SEs: Peripheral edema/headache/flushing/palpitations/reflex tachycardia
Minoxidil - OTC topical for hair growth
BW: Potent antihypertensive
SEs: Fluid retention, tachycardia, hair growth
Hypertensive Crises
BP >=180/120 mmHg
Hypertensive emergency: patient has acute target organ damage (encephalopathy, stroke, acute kidney injury, ACS)
* Tx with IV meds
* Decrease BP by no more than 25% within the first hour
Hypertensive urgency: no evidence of acute target organ damage
* Tx with any PO med that has short onset of action
* Decrease BP gradually over 24-48 hrs
Key IV medications for hypertensive crises
- Chlorothiazide
- Clevidipine
- Diltiazem
- Enalaprilat
- Esmolol
- Hydralazine
- Labetalol
- Metoprolol tartrate
- Nicardipine
- Nitroglycerin
- Nitroprusside
- Propranolol
- Verapamil
