Hypertension Flashcards
patient specific factor: stable ischemic heart disease
first-line:
-beta-blockers
-ACEi/ARBs
-DHP CCBs can be used if still uncontrolled
patient specific factor: chronic kidney disease
-CKD stage 1 or 2 AND albuminuria: ACEi (or ARBs)
-CKD stage 3 or higher: ACEi (or ARBs)
-post kidney transplantation: DHP CCBs
preferred HTN agents for pregnancy
methyldopa
nifedipine
labetalol
contraindicated HTN agents for pregnancy
ACEi
ARBs
direct renin inhibitors
*thiazides
patient specific factor: black patients
thiazide or CCB (if no HF or CKD)
when should you dose thiazide diuretics?
morning, to avoid nocturnal diuresis
do not initiate aldosterone antagonist with K+ > _______ mEq/L
> 5 mEq/L
when should you dose aldosterone antagonists?
morning/afternoon, to avoid nocturnal diuresis
adverse effects of aldosterone antagonists
hyperkalemia
hyponatremia
gynecomastia (spironolactone)
when should you dose ACE inhibitors and ARBs?
PM, ensure BP dipping overnight
drug interactions of aldosterone antagonists
ACEi
ARBs
Renin inhibitors
NSAIDS
because they all increase risk of hyperkalemia
three contraindications for both ACEi and ARBs
- pregnancy
- concomitant use of aliskiren in patients with DM
- history of angioedema due to ACEi or ARB
what two HTN drug classes are often preferred over other first-line agents in the presence of other comorbidities?
ACEi/ARBs
what type of CCB is a more potent vasodilator: dihydropyridines or non-DHPs?
dihydropyridines
DHP CCB drug interactions
-grapefruit juice
-CYP3A4 inducers/inhibitors
two patient populations with additional benefit from non-dihydropyridine CCBs:
- supraventricular tachyarrhythmias (Afib)
- Pts w/ angina that cannot tolerate BBs
drugs interactions of non-DHP CCBs:
- grapefruit juice
- beta blockers (increases risk of heart block)
- CYP3A4 substrates
what is a dose-dependent side effect of dihydropyridine CCBs?
peripheral edema
What CCB would be used in the setting of heart failure?
amlodipine
When would a beta blocker be first line for HTN?
if a compelling indication is present i.e. heart failure or CAD
Patients with these specific comorbidities may benefit from using a beta blocker:
tachyarrhythmias
tremors
migraines
thyrotoxicosis
beta blockers decrease _______ ________
cardiac output
(because decrease in heart rate and force of contraction)
Three beta blockers with intrinsic sympathomimetic activity (ISA)
acebutolol
penbutolol
pindolol
beta blockers with mixed alpha/beta effects
carvedilol
labetalol
beta blockers can mask S/Sx of _______________
hypoglycemia
(i.e. rapid heartbeat and tremors)
minoxidil is _____ potent than hydralazine
more
a patient must be taking these two antihypertensive agents in order to start hydralazine or minoxidil
- diuretic
- beta blocker
*for minoxidil: maximum therapeutic doses of diuretic and two other antihypertensives should be used before this drug is added
what is one side effect unique to hydralazine?
lupus-like syndrome/rash
what is one side effect unique to minoxidil?
hair growth
Boxed warning for minoxidil
-may cause pericarditis and pericardial effusion that may progress to tamponade
-may increase oxygen demand and exacerbate angina pectoris
alpha-1 blockers are associated with ____________ ___________
orthostatic hypotension
central alpha-2 agonists are last line due to ________ ___________
adverse effects
i.e. CNS depression, dizziness, fatigue, anticholinergic effects, bradycardia
Oral -> Transdermal Patch clonidine regimen:
Day 1: place patch, 100% of oral dose
Day 2: 50% of oral dose
Day 3: 25% of oral dose
Day 4: Patch ONLY
Patch -> Oral clonidine regimen:
start oral clonidine no sooner than 8 hours after patch removal
Monitoring parameters: ACEi/ARBs
BUN/SCr
Potassium
Monitoring parameters: CCBs
Heart rate
(just for non-DHP CCBs)
Monitoring parameters: Aldosterone antagonists
BUN/SCr
Potassium
Monitoring parameters: Diuretics
BUN/SCr
Electrolytes: K, Mg, Na
Uric acid (thiazides)
Monitoring parameters: beta blockers
Heart rate
Considerations before diagnosing resistant HTN
- nighttime dosing for one antihypertensive, other than diuretics
- assess adherence
- assess diet, exercise, smoking cessation
- rule out white coat HTN
- D/c interfering substances (i.e. ibuprofen)
Define resistant HTN
failure to attain goal BP while adherent to at least 3 agents at maximum dose, including a diuretic, or when 4+ agents are needed
Risk factors for resistant HTN
older age
obesity
CKD
diabetes
African American
Management of resistant HTN: STEP 1
-maximize lifestyle interventions
-optimize 3-drug regimen (ACEi/ARB, CCB, and diuretic)
Management of resistant HTN: STEP 2
substitute optimized thiazide-like diuretic (chlorthalidone, indapamide)
*d/c HCTZ
Management of resistant HTN: STEP 3
Add mineralocorticoid receptor antagonist – spironolactone preferred
(eplerenone if pt develops gynecomastia with spir.)
Management of resistant HTN: STEP 4
ASSESS HR FIRST
-add BB if HR > 70 bpm
-central alpha-2 agonist (clonidine patch or guanfacine) if BB is contraindicated or if HR < 70 bpm
Management of resistant HTN: STEPS 5 + 6
*must be on diuretic and BB to move on to these steps
step 5: add hydralazine
step 6: substitute hydralazine for minoxidil
Hypertensive emergency: BP goal at Hour 1
reduce BP by max of 25%
Hypertensive emergency: BP goal at Hours 2 - 6
Reduce BP < 160/110
Hypertensive emergency: BP goal at Hours 6 - 48
Reduce BP to goal
what allergy is contraindicated with clevidipine IV?
soy and egg
nicardipine IV has a _______ onset and _______duration of action than clevidipine
slower
longer
what are the 3 vasodilators used for hypertensive emergencies?
- nitroglycerin
- sodium nitroprusside
- hydralazine
which vasodilator (IV) is not titratable?
hydralazine
what class of drugs interacts with nitrates and should not be taken together?
PDE-5 inhibitors (sildenafil, tadalafil, etc)
what two beta blockers are used IV for hypertensive emergency?
labetalol and esmolol
labetalol decreases 1) ? and 2) ?
heart rate and blood pressure
why is esmolol used as an adjuct for BP reduction and not monotherapy?
it’s only used to decrease heart rate during crisis
which hypertensive crisis drugs should be avoided with acute kidney injuries?
use caution with sodium nitroprusside
avoid enalaprilat
pulmonary hypertension is defined as a mean pulmonary artery pressure (MPAP) > ________ at rest
> 20 mmHg
what is the gold standard for diagnosis of pulmonary arterial hypertension (PAH)?
right heart catheterization (used to measure pressure in heart and lungs)
what are 5 negative predictors of PAH?
- advanced functional class
- poor exercise capacity
- high right atrial pressure
- right ventricular dysfunction
- low cardiac output
In PAH, the left heart becomes _________ and the right heart becomes ______________
left = smaller
right = larger
what are the four components of endothelial dysfunction in the progression of PAH?
- decreased nitric oxide synthase
- decreased prostacyclin production
- increased thromboxane production
- increased endothelin 1 production
= VASOCONSTRICTION
Guideline recommendation for treatment naive FC II and low-risk FC III – COMBINATION THERAPY
(not candidates for CCBs)
ambrisentan and tadalafil
Guideline recommendation for treatment naive FC II and low-risk FC III – MONOTHERAPY
(not candidates for CCBs)
endothelin receptor antagonist (ERA)
OR
riociguat
OR
PDE-5 inhibitor
What are the three therapeutic pathways targeted for treatment of PAH?
1) Nitric oxide pathway
2) Endothelin pathway
3) Prostacyclin pathway
What are the drugs associated with the nitric oxide pathway?
PDE-5 inhibitors: sildenafil, tadalafil
soluble guanylate cyclase stimulator: riociguat
What are the drugs associated with the endothelin pathway?
endothelin receptor antagonists (ERAs): bosentan, ambrisentan, macitentan
What are the drugs associated with the prostacyclin pathway? Which functional class are these drugs reserved for?
prostacyclins:
epoprostenol (IV)
iloprost (inhaled)
***treprostinil (IV, SQ, inh, oral)
IP prostacyclin receptor agonist:
selexipag
these are reserved for high risk FC III and FC IV
sildenafil is dosed ____x daily while tadalafil is dosed _______x daily
sildenafil = three
tadalafil = once
Which ERA may cause LFT abnormalities?
Bosentan (Tracleer)
Which ERA may cause peripheral edema?
Ambrisentan (Letairis)
Ambrisentan is selective for _________ (ETa or ETb)
ETa receptors
How long after starting an ERA is improvement likely seen?
8-10 weeks
PDE-5 inhibitors should not be used in combination with these two drugs:
- riociguat
- nitrates
What did the AMBITION trial prove?
Ambrisentan + tadalafil were more effective than monotherapy and is now used as first-line
Guideline recommendation for high risk FC III and FC IV who are candidates for parenteral prostanoids
First-line: SC treprostinil
IV treprostinil, IV epoprostenol
Guideline recommendation for high risk FC III and FC IV who are NOT candidates for parenteral prostanoids
Inhaled prostanoid + ERA + PDE-5i (or riociguat in place of PDE-5i)
What adverse effects do all prostacyclins have in common?
inhibition of platelet aggregation
thrombocytopenia (more w/ epo)
hypotension
headache
flushing
What side effects are more common with inhaled prostacyclins?
gastric effects - N/V/D
IV prostacyclins ________ be co-infused with other fluids
CANNOT
What are two adjunct therapies that may be used during PAH treatment?
- anticoagulation (typically not with prostacyclins)
- diuretics to maintain euvolemia
Which PAH drugs can cause birth defects and are listed in REMS?
ERAs (i.e. bosentan, ambrisentan)
riociguat
Elevated BP classification:
120-129
AND
< 80
HTN Stage 1 classification:
130-139
OR
80-89
HTN Stage 2 classification:
> 140
OR
90
ACC/AHA treatment strategy:
Elevated BP:
Non-pharm treatment
Reassess in 3-6 months
ACC/AHA treatment strategy:
Stage 1 HTN and ASCVD > 10% or a specific comorbidity:
Non-pharm Tx and 1 medication
Reassess in 1 month
ACC/AHA treatment strategy:
Stage 2 HTN:
Non-pharm Tx and 2 medications
Reassess in 1 month
HTN patients at goal should have a follow-up every ___ - ___ months
3-6 months
