Hypertension Flashcards by Emery Frey

patient specific factor: stable ischemic heart disease

first-line:
-beta-blockers
-ACEi/ARBs

-DHP CCBs can be used if still uncontrolled

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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

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preferred HTN agents for pregnancy

methyldopa
nifedipine
labetalol

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contraindicated HTN agents for pregnancy

ACEi
ARBs
direct renin inhibitors

*thiazides

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patient specific factor: black patients

thiazide or CCB (if no HF or CKD)

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when should you dose thiazide diuretics?

morning, to avoid nocturnal diuresis

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do not initiate aldosterone antagonist with K+ > _______ mEq/L

> 5 mEq/L

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when should you dose aldosterone antagonists?

morning/afternoon, to avoid nocturnal diuresis

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adverse effects of aldosterone antagonists

hyperkalemia
hyponatremia
gynecomastia (spironolactone)

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when should you dose ACE inhibitors and ARBs?

PM, ensure BP dipping overnight

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drug interactions of aldosterone antagonists

ACEi
ARBs
Renin inhibitors
NSAIDS

because they all increase risk of hyperkalemia

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three contraindications for both ACEi and ARBs

pregnancy
concomitant use of aliskiren in patients with DM
history of angioedema due to ACEi or ARB

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what two HTN drug classes are often preferred over other first-line agents in the presence of other comorbidities?

ACEi/ARBs

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what type of CCB is a more potent vasodilator: dihydropyridines or non-DHPs?

dihydropyridines

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DHP CCB drug interactions

-grapefruit juice
-CYP3A4 inducers/inhibitors

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two patient populations with additional benefit from non-dihydropyridine CCBs:

supraventricular tachyarrhythmias (Afib)
Pts w/ angina that cannot tolerate BBs

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drugs interactions of non-DHP CCBs:

grapefruit juice
beta blockers (increases risk of heart block)
CYP3A4 substrates

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what is a dose-dependent side effect of dihydropyridine CCBs?

peripheral edema

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What CCB would be used in the setting of heart failure?

amlodipine

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When would a beta blocker be first line for HTN?

if a compelling indication is present i.e. heart failure or CAD

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Patients with these specific comorbidities may benefit from using a beta blocker:

tachyarrhythmias
tremors
migraines
thyrotoxicosis

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beta blockers decrease _______ ________

cardiac output

(because decrease in heart rate and force of contraction)

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Three beta blockers with intrinsic sympathomimetic activity (ISA)

acebutolol
penbutolol
pindolol

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beta blockers with mixed alpha/beta effects

carvedilol
labetalol

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beta blockers can mask S/Sx of _______________

hypoglycemia (i.e. rapid heartbeat and tremors)

minoxidil is _____ potent than hydralazine

a patient must be taking these two antihypertensive agents in order to start hydralazine or minoxidil

1. diuretic 2. 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

1. nighttime dosing for one antihypertensive, other than diuretics 2. assess adherence 3. assess diet, exercise, smoking cessation 4. rule out white coat HTN 5. 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?

1. nitroglycerin 2. sodium nitroprusside 3. 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?

1. advanced functional class 2. poor exercise capacity 3. high right atrial pressure 4. right ventricular dysfunction 5. 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?

1. decreased nitric oxide synthase 2. decreased prostacyclin production 3. increased thromboxane production 4. 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:

1. riociguat 2. 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?

1. anticoagulation (typically not with prostacyclins) 2. 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